[Note: Instructions for Plans are provided within the bracketed and italicized text

Transcription

1 2014 Formulary (List of Covered Drugs) Central Health Medicare Plan (HMO), Central Health Medi- Medi Plan (HMO SNP), & Central Health Premier Plan (HMO) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN This formulary was updated 10/28/2014. For more recent information or other questions, please contact Central Health Medicare Plan at , or for TTY users, , 7 days a week, 8:00 AM to 8:00 PM (PST), or visit The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan. Limitations, copayments, and restrictions may apply. Benefits, formulary, pharmacy network, premium, and/or copayments/co-insurance may change on January 1 of each year. Central Health Medicare Plan is an HMO plan with a Medicare contract. Enrollment in Central Health Medicare Plan depends on contract renewal. This information is available for free in other languages. Please call our customer service number at , TTY , 7 days a week, 8:00 AM to 8:00 PM (PT). Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details. H5649_112713_1085_CF Accepted HPMS Approved Formulary File submission ID and version number: 14560v17 1

2 Esta información es disponible gratuitamente en otros lenguajes. Favor de llamar al número de servicio al cliente al , TTY , los 7 días de la semana, 8:00 AM a 8:00 PM (Tiempo Pacifico). Favor de llamar si usted necesita esta información en otro formato. 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 Central Health Medicare Plan. When it refers to plan or our plan, it means Central Health Medicare Plan. This document includes a list of the drugs (formulary) for our plan which is current as of 10/28/2014. 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, premium and/or copayments/coninsurance may change on January 1, What is the Central Health Medicare Plan Formulary? A formulary is a list of covered drugs selected by Central Health Medicare 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. Central Health Medicare Plan will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Central Health Medicare 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 2014 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2014 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder 2

3 of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If we remove drugs from our formulary, add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of 10/28/2014. To get updated information about the drugs covered by Central Health Medicare Plan, please contact us. Our contact information appears on the front and back cover pages. In the event of non-maintenance changes to the formulary throughout the plan year, Central Health Medicare Plan may make changes via errata sheets mailed to you. Additionally, you may visit our Web site for a link to the errata sheets. How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 26. 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 26. 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 197. 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. 3

4 What are generic drugs? Central Health Medicare 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: Central Health Medicare Plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Central Health Medicare Plan before you fill your prescriptions. If you don t get approval, Central Health Medicare Plan may not cover the drug. Quantity Limits: For certain drugs, Central Health Medicare Plan limits the amount of the drug that Central Health Medicare Plan will cover. For example, Central Health Medicare Plan provides 60 capsules per prescription for CELEBREX. This may be in addition to a standard one-month or three-month supply. Step Therapy: In some cases, Central Health Medicare Plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Central Health Medicare Plan may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Central Health Medicare Plan will then cover Drug B. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 26. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask Central Health Medicare 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 the Central Health Medicare Plan formulary? on page 5 for information about how to request an exception. 4

5 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 Member Services and ask if your drug is covered. If you learn that Central Health Medicare Plan does not cover your drug, you have two options: You can ask Member Services for a list of similar drugs that are covered by Central Health Medicare 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 Central Health Medicare Plan. You can ask Central Health Medicare 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 Central Health Medicare Plan Formulary? You can ask Central Health Medicare 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 your drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Central Health Medicare 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, Central Health Medicare Plan will only approve your request for an exception if the alternative drugs included on the plan s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you request a formulary, tiering or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber. 5

6 What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with a 91-day transition supply, consistent with the dispensing increment, (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception. Exceptions are available for beneficiaries who have experienced a change in the level of care they are receiving which requires them to transition from one facility or treatment center to another. Examples of situations in which beneficiaries would be eligible for the one-time temporary fill exception when they are outside of the three month effective date into the Part D program are as follows: 6 1. Beneficiary was discharged from the hospital and was provided a discharge list of medications based upon the formulary of the hospital; 2. Beneficiaries who end their skilled nursing facility Medicare Part A stay (where payments include all pharmacy charges) and who need to revert back to their Part D plan formulary; 3. Beneficiaries who give up Hospice Status to revert back to standard Medicare Part A and B benefits; 4. Beneficiaries who are discharged from Chronic Psychiatric Hospitals with medication regimens that are highly individualized. All of these situations would warrant a temporary one-time fill exception irrespective of whether the beneficiary is in their first ninety (90) days of program enrollment.

7 For more information For more detailed information about your Central Health Medicare Plan prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about Central Health Medicare Plan, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at MEDICARE ( ) 24 hours a day/7 days a week. TTY users should call Or, visit 7

8 Central Health Medicare Plan Formulary The formulary that begins on page 26 provides coverage information about the drugs covered by Central Health Medicare Plan. If you have trouble finding your drug in the list, turn to the Index that begins on page 197. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., CELEBREX) and generic drugs are listed in lower-case italics (e.g., lisinopril). The information in the Requirements/Limits column tells you if Central Health Medicare Plan has any special requirements for coverage of your drug. We provide additional coverage for drugs in Tiers 1 and 2 through the coverage gap. Please refer to our Evidence of All drugs in the five formulary tiers are available through mail order. Please check with the mail order pharmacy for any limitations and/or exclusions. 8 *We provide additional coverage of this drug in the coverage gap for Medicare Members in Plan 001, 002 & 004. ** We provide additional coverage of this drug in the coverage gap for Medicare Members in Plan 001. Please refer to our Evidence of Coverage for more information about this coverage.

9 How much will I pay for Central Health Medicare Plan covered drugs? The amount you pay depends on which drug tier your drug is in and whether you are receiving any extra help paying for your prescription drugs. If you are a member of Central Health Medicare Plan (HMO), see below for the copayment or coinsurance for each drug tier while you are in the Initial Coverage Stage: Network Network Mail Order Pharmacy Pharmacy Drug Tier (90-day (30-day (90-day supply) supply) supply) Tier 1 Preferred Generics $0 $0 $0 Tier 2 Non-Preferred Generics $5 $15 $10 Tier 3 Preferred Brands $25 $75 $50 Tier 4 Non-Preferred Brands $50 $150 $100 Tier 5 Specialty Drugs 33% 33% 33% If you are a member of Central Health Medi-Medi Plan (HMO SNP) or Central Health Premier Plan (HMO), the amount you pay depends on whether you are receiving extra help from Medicare to pay for your prescription drugs. See below for the copayment or coinsurance for each drug tier while you are in the Initial Coverage Stage: Extra Help Program Receiving Extra Help No Extra Help Drug Tier Tier 1 Preferred Generics Tier 2 Non-Preferred Generics Tier 3 Preferred Brands Tier 4 Non-Preferred Brands Tier 5 Specialty Drugs Network Pharmacy (30-day supply) Network Pharmacy (30-day supply) $0 $0 $0, $3.60, $6.35, or 15% 25% 9

10 Formulario 2014 (Lista de Medicamentos Cubiertos) Central Health Medicare Plan (HMO), Central Health Medi- Medi Plan (HMO SNP), & Central Health Premier Plan (HMO) FAVOR DE LEER: ÉSTE DOCUMENTO CONTIENE INFORMACIÓN ACERCA DE LOS MEDICAMENTOS CUBIERTOS EN ÉSTE PLAN Este formulario fue actualizado el 10/28/2014. Para información más reciente u otras preguntas, favor de ponerse en contacto con nuestro Departamento de Servicio al Miembro al o, para usuarios de TTY deben llamar al , los 7 días a la semana, de 8:00 AM a 8:00 PM (Tiempo Pacifico), o visite el sitio web La información de beneficios proveída aquí es un resumen breve, no es una descripción completa de los beneficios. Para más información, póngase en contacto con el plan. Limitaciones, copagos, y restricciones tal vez apliquen. Los beneficios, el formulario, la red de farmacias, primas y /o co-pagos / co-seguros quizás cambien en Enero 1 de cada año. Central Health Medicare Plan es una HMO plan con un contrato de Medicare. La inscripción a Central Health Medicare Plan depende en la renovación del contrato. Las primas, los co-pagos, el co-seguro, y los deducibles tal vez varíen basado en el nivel de Ayuda Adicional que usted reciba. Para más detalles, póngase en contacto con el plan. H5649_112713_1085_CF_S Accepted Last Updated: 10/28/2014 HPMS Approved Formulary File submission ID and version number: 14560v17 10

11 Nota para los miembros existentes: Éste formulario a cambiado desde el año pasado. Favor de revisar éste documento para asegurarse que todavía contiene los medicamentos que usted toma. Cuando esta lista de medicamentos (formulario) se refiere a nosotros, o nuestro, esto significa que nos estamos refiriendo a Central Health Medicare Plan. Cuando se refiere al plan o a nuestro plan, esto significa que nos estamos refiriendo a Central Health Medicare Plan. Este documento incluye una lista de los medicamentos (formulario) para nuestro plan que es actualizada a 10/28/2014. Para conseguir un formulario actualizado, favor de ponerse en contacto con nosotros. Nuestra información de contacto, junto con la fecha de la ultima vez que se actualizo el formulario, aparece en las portadas del formulario. Usted tiene que utilizar las farmacias dentro de la red para acezar su beneficio de medicamentos recetados. Los beneficios, el formulario, la red de farmacias, las primas y /o co-pagos / coseguro tal vez cambien a partir de Enero 1, Esta información es disponible gratuitamente en otros lenguajes. Favor de llamar al número de servicio al cliente al , TTY , los 7 días de la semana, 8:00 AM a 8:00 PM (Tiempo Pacifico). Favor de llamar si usted necesita esta información en otro formato. This information is available for free in other languages. Please call our customer service number at , TTY , 7 days a week, 8:00 AM to 8:00 PM (PT). Que es el Formulario de Central Health Medicare Plan? Un formulario es una lista de medicamentos seleccionados que son cubiertos por Central Health Medicare Plan, que representa la receta que los terapéuticos creen necesaria como parte de un programa de tratamiento de calidad. Por lo general, Central Health Medicare Plan cubre los medicamentos en la lista de nuestro formulario, siempre y cuando el medicamento sea médicamente necesario, la receta es surtida en una farmacia en la red de Central Health Medicare Plan, y bajo otras reglas del plan. Para más información en como surtir sus recetas, favor de revisar su Evidencia de Cobertura. Puede cambiar la (lista de medicamentos) del Formulario? Por lo general, si usted está tomando un medicamento de nuestro formulario en el 2014 que estaba cubierto al principio del año, no descontinuaremos ni reduciremos la cobertura del medicamento durante la cobertura del año 2014, solo y cuando un medicamento genérico nuevo y más barato sea disponible o cuando nueva información adversa acerca de la seguridad o efectividad de un medicamento sea disponible. Otro tipo de cambio, como removiendo un medicamento de nuestro formulario, no afectara a los miembros que estén actualmente tomando 11

12 el medicamento. Este permanecerá disponible al mismo costo compartido para los miembros que lo estén tomando por el resto de la cobertura del año. Creemos que es importante que usted tenga acceso continuo de la cobertura por el resto del año a los medicamentos en el formulario que estaban disponibles cuando escogió nuestro plan, excepto en los casos que usted puede ahorrar dinero adicional o mejorar la seguridad de sus medicamentos. Si removemos medicamentos de nuestro formulario o agregamos autorización previa, limite de cantidad y /o restricciones en terapia de pasos de un medicamento o se mueve el medicamento a un nivel de costo-compartido mas alto, debemos notificar el cambio a los miembros afectados cuando menos 60 días antes que el cambio entre en efecto, o al tiempo que el miembro pida surtir el medicamento, en ese tiempo el miembro recibirá un suministro del medicamento para 60 días. Si la Administración de Comida y Medicamentos cree que un medicamento en nuestro formulario es inseguro o los fabricantes del medicamento quitan el medicamento del mercado, nosotros inmediatamente quitaremos el medicamento de nuestro formulario y notificaremos a los miembros que toman el medicamento. Éste formulario es efectivo a partir de 08/14/2013. Para obtener información actualizada acerca de los medicamentos cubiertos por Central Health Medicare Plan, favor de ponerse en contacto con nosotros. Nuestra información de contacto aparece en las portadas del formulario. En el evento de que haya cambios al formulario durante el año del plan que no son de mantenimiento, Central Health Medicare Plan puede hacer cambios y enviárselos por correo. También puede ir a nuestra página en la Internet para revisar los cambios. Cómo uso el Formulario? Hay dos maneras de encontrar su medicamento dentro del formulario: Condición Médica El formulario empieza en la página 26. Los medicamentos en éste formulario están en grupo de categoría dependiendo que clase de condición médica se ha estado tratando. Por ejemplo, medicamentos usados para tratar una condición del Corazón, están en la lista bajo la categoría, CARDIOVASCULAR AGENTS. Si usted sabe para que es usado su medicamento, busque el nombre de la categoría en la lista que comienza en la página 26. Luego busque bajo el nombre de la categoría por su medicamento. Lista Alfabética Si usted no esta seguro/a en cual categoría buscar, debe buscar su medicamento en el índice que comienza en la página 197. El índice provee una lista alfabética de todos los medicamentos incluidos en este documento. Ambos medicamentos, los de nombre-de-marca y genéricos están en la lista del índice. Busque en el índice y encuentre su medicamento. Al lado de su medicamento, va a ver el número de la página donde puede encontrar la información de cobertura. Vea la página de la lista en el índice y encuentre el nombre de su medicamento en la primera columna de la lista. 12

13 Que son medicamentos genéricos? Central Health Medicare Plan cubre ambos medicamentos de nombre-de-marca y medicamentos genéricos. Un medicamento genérico esta aprobado por la Administración de Comida y Medicamentos (FDA) por tener los mismos ingredientes activos que los medicamentos de marca. Por lo general, los medicamentos genéricos cuestan menos que los medicamentos de marca. Hay alguna restricción en mi cobertura? Algunos medicamentos que son cubiertos pueden tener requisitos adicionales o límite de cobertura. Estos requisitos y límites pueden incluir: Autorización Previa: Central Health Medicare Plan requiere que usted o su medico obtengan autorización previa para ciertos medicamentos. Esto significa que usted necesita obtener aprobación de Central Health Medicare Plan antes de surtir sus recetas. Si usted no obtiene aprobación, Central Health Medicare Plan podría no cubrir el medicamento. Límite de Cantidad: Para algunos medicamentos, Central Health Medicare Plan limita la cantidad del medicamento que Central Health Medicare Plan cubrirá. Por ejemplo, Central Health Medicare Plan provee 60 cápsulas por receta de CELEBREX. Esto puede ser adicional a lo normal de un mes o tres meses del suministro. Terapia de Pasos: En algunos casos, Central Health Medicare Plan requiere que usted pruebe ciertos medicamentos para tratar su condición médica antes que cubramos otro medicamento para la misma condición. Por ejemplo, si el Medicamento A y el Medicamento B, ambos tratan su condición médica, Central Health Medicare Plan pudiese no cubrir el medicamento B a menos que pruebe el medicamento A primero. Si el Medicamento A no le funciona, entonces Central Health Medicare Plan le cubrirá el Medicamento B. Usted puede enterarse si su medicamento tiene requisitos adicionales o limites buscando en el formulario que empieza en la página 26. Usted puede obtener más información acerca de las restricciones aplicadas a ciertos medicamentos cubiertos por solo ir a nuestra página Web. Nuestra información de contacto, junto con la fecha más reciente que se actualizo el formulario, aparece en las portadas de este formulario. Usted puede solicitar a Central Health Medicare Plan que haga una excepción a estas restricciones o limites o por una lista de otros medicamentos similares que quizás puedan tratar su condición de salud. Vea en la sección, Cómo solicito una excepción al Formulario de Central Health Medicare Plan? en la página 14 para información de como solicitar una excepción. 13

14 Que pasa sí mi medicamento no esta en el Formulario? Si su medicamento no esta incluido en este formulario, debe comunicarse primero al Departamento de Servicios al Miembro y preguntar sí su medicamento esta cubierto. Si usted se entera que Central Health Medicare Plan no cubre su medicamento, usted tiene dos opciones: Puede solicitarle al Departamento de Servicios al Miembro una lista de medicamentos similares que son cubiertos por Central Health Medicare Plan. Cuando reciba la lista, muéstresela a su doctor y pídale que le recete un medicamento similar que si este cubierto por Central Health Medicare Plan. Puede solicitar a Central Health Medicare Plan que haga una excepción y cubra su medicamento. Vea la siguiente información para ver como solicitar una excepción. Cómo solicito una excepción al Formulario de Central Health Medicare Plan? Usted puede solicitar a Central Health Medicare Plan que haga una excepción a nuestras reglas de cobertura. Hay varios tipos de excepciones que puede solicitar que hagamos. Puede solicitar que cubramos su medicamento aunque no este en nuestro formulario. Si es aprobado, este medicamento será cubierto a un nivel de costo compartido predeterminado, y usted no podrá pedirnos que cubramos el medicamento a un nivel de costo compartido más bajo. Usted nos puede pedir que cubramos un medicamento del formulario a un nivel de costo compartido más bajo si este medicamento no está en el nivel de especialidad. Si es aprobado, esto bajara la cantidad que usted tendrá que pagar por su medicamento. Por lo general, Central Health Medicare Plan solo aprobaría su petición para una excepción si el medicamento alternativo incluido en el formulario del plan, el medicamento de nivel mas bajo, o las restricciones adicionales no serian tan efectivos para tratar su condición y /o podría causarle que tenga efectos médicos adversos. Usted debe comunicarse con nosotros para solicitar una decisión de cobertura inicial del formulario, nivel o excepción de utilización restringida. Cuando usted solicite un formulario, nivel o excepción de utilización restringida, debe de mandar una declaración de su medico que apoye su solicitud. Por lo general, tomaremos una decisión en las siguientes 72 horas de haber recibido la declaración de apoyo de su medico. Usted puede solicitar que se agilice su excepción (rápido) si usted o su doctor creen que su salud puede dañarse seriamente por esperar hasta 72 horas por una decisión. Si su solicitud rápida es concedida, debemos darle una decisión no mas tarde de 24 horas después que obtengamos la declaración de apoyo de su médico. 14

15 Que hago antes de hablar con mi doctor acerca de cambiar mis medicamentos o solicitar una excepción? Como un miembro nuevo o continuo en nuestro plan, usted puede estar tomando medicamentos que no están en nuestro formulario. O, puede estar tomando un medicamento que esta en nuestro formulario pero su habilidad para obtenerlo es limitada. Por ejemplo, usted puede necesitar nuestra autorización previa antes de surtir su receta. Usted debe hablar con su doctor para decidir si debe cambiar a un medicamento apropiado que este cubierto o solicitar una excepción al formulario para que podamos cubrir el medicamento que usted toma. Mientras habla con su doctor para determinar el curso de acción correcto para usted, podemos cubrir su medicamento en algunos casos durante los primeros 90 días que usted es miembro de nuestro plan. Por cada uno de sus medicamentos que no están en nuestro formulario o si su habilidad para obtener sus medicamentos es limitada, nosotros cubriremos un suministro temporal de 30-días (a menos que usted tenga una receta escrita por menos días) cuando usted va a una farmacia en la red. Después de su primer suministro de 30-días, nosotros no pagaremos por estos medicamentos, aun si usted ha sido miembro del plan por menos de 90 días. Si usted es residente de un establecimiento de cuidado a largo plazo, nosotros le permitiremos surtir su receta hasta que nosotros le hemos proveído con un suministro de transición de 91 días, consistente con el incremento de dispensación, (a menos que usted tenga una receta escrita por menos días). Nosotros cubriremos más de un suministro de estos medicamentos por los primeros 90 días que usted es miembro de nuestro plan. Si usted necesita un medicamento que no esta en nuestro formulario o si su habilidad para obtener sus medicamentos es limitada, pero ya pasaron los primeros 90 días de membresía en nuestro plan, nosotros cubriremos un suministro de emergencia de 31-días de ese medicamento (a menos que usted tenga una receta escrita por menos días) mientras espera por una excepción del formulario. Excepciones son disponibles para beneficiarios que han experimentado un cambio en el nivel de cuidado que están recibiendo cual les requiere que cambien de una facilidad o centro de tratamiento a otro. Ejemplos de situaciones en cual los beneficiarios serian elegibles una vez para la excepción de suministro, una vez, cuando estén fuera del día efectivo de tres meses del programa de la Parte D son como lo siguiente: 1. El beneficiario es dado de alta del hospital y es proveído una lista de dado de alta de medicamentos basado en el formulario del hospital; 2. Los beneficiarios que terminan su estadía de Medicare Parte A en un establecimiento de cuidado medico continuo (donde los pagos incluyen todos los cobros de la farmacia) y necesita volver a su formulario del plan de la Parte D; 3. Los beneficiarios que dan por vencido el Estado de Hospicio para volver a los beneficios normales de la Parte A y la Parte B de Medicare; 4. Los beneficiarios que son dados de alta de Hospitales Psiquiátricos Crónicos con regímenes de medicamento que son altamente individualizados. Todas estas situaciones merecen una excepción de un suministro independiente de que el beneficiario este en los primeros 90 días del programa de inscripción. 15

16 Para más información Para más información detallada de su cobertura de medicamentos recetados de Central Health Medicare Plan, favor de revisar su Evidencia de Cobertura y otros materiales del plan. Si tiene preguntas acerca de Central Health Medicare Plan, favor de ponerse en contacto con nosotros. Nuestra información de contacto, junto con la fecha más reciente que se actualizo el formulario, aparece en las portadas de este formulario. Si usted tiene preguntas generales acerca de su cobertura de medicamentos recetados de Medicare, favor de llamar a Medicare al MEDICARE ( ) las 24 horas al día / los 7 días a la semana. Usuarios TTY deben llamar al O, visite Formulario de Central Health Medicare Plan El formulario en la página 26 provee información de cobertura de algunos de los medicamentos cubiertos por Central Health Medicare Plan. Si usted tiene problemas para encontrar su medicamento en la lista, vea el índice que empieza en la página 197. La primera columna en la lista menciona el nombre del medicamento. Medicamentos de marca están escritos en mayúsculas (ej., CELEBREX) y medicamentos genéricos están escritos en minúsculas itálicas (ej., lisinopril). La información en la columna de Requisitos / Limites le notifica si Central Health Medicare Plan tiene algún requisito especial para la cobertura de sus medicamentos. Ofrecemos cobertura adicional para medicamentos en los Niveles 1 y 2 a través de la brecha de cobertura. Consulte nuestra Evidencia de Cobertura para obtener más información sobre esta cobertura. Todos los medicamentos en los cinco niveles del formulario están disponibles a través de pedidos por correo. Compruebe por favor con la farmacia de pedidos por correo de las limitaciones y / o exclusiones. 16

17 Cuánto pagare por los Medicamentos Cubiertos por Central Health Medicare Plan? La cantidad que usted paga depende en cual nivel de medicamento esta su medicamento y si usted esta recibiendo ayuda adicional para pagar sus medicamentos recetados. Si usted es un miembro de Central Health Medicare Plan (HMO), vea debajo para el co-pago o co-seguro de cada nivel de medicamento mientras usted esta en la Etapa de Cobertura Inicial: Nivel de Medicamento Farmacia Dentro de la Red (Suplemento de 30 días) Farmacia Dentro de la Red (Suplemento de 90 días) Orden por Correo (Suplemento de 90 días) Nivel 1 Genéricos Preferidos $0 $0 $0 Nivel 2 Genéricos No-Preferidos $5 $15 $10 Nivel 3 Marcas Preferidas $25 $75 $50 Nivel 4 Marcas No-Preferidas $50 $150 $100 Nivel 5 Medicamentos de Especialidad 33% 33% 33% Si usted es un miembro de Central Health Medi-Medi Plan (HMO SNP) o Central Health Premier Plan (HMO), la cantidad que usted paga depende de si usted esta recibiendo ayuda adicional de Medicare para pagar por sus medicamentos recetados. Vea debajo para el co-pago o co-seguro de cada nivel de medicamento mientras usted esta en la Etapa de Cobertura Inicial: Programa de Ayuda Adicional Con Ayuda Adicional Sin Ayuda Adicional Nivel de Medicamento Nivel 1 Genéricos Preferidos Nivel 2 Genéricos No-Preferidos Nivel 3 Marcas Preferidas Farmacia Dentro de la Red (Suplemento de 30 días) Farmacia Dentro de la Red (Suplemento de 30 días) $0 $0 Nivel 4 Marcas No-Preferidas Nivel 5 Medicamentos de Especialidad $0, $3.60, $6.35, o 15% 25% 17

18 中心健保聯邦紅藍卡計劃 (HMO) 以及, 中心健保聯邦紅藍白卡 計劃 (HMO SNP), & 中心健保特選計劃 (HMO) 2014 處方集 ( 含保藥品目錄 ) 請閱讀 : 以下目錄包含計劃含保的藥品資訊本處方集最近更新日期為 10/28/2014 有關更新修訂或其他資訊, 請聯絡中心健保 : 或聽障 / 語障專線 , 一週七天, 上午 8:00 到下午 8:00( 太平洋時間 ) 或上網 上述文字內容只是福利摘要, 並非完整福利解說 請與計劃聯繫以獲得更多資訊 福利可能有條件限制及共付額 福利內容 處方集 合約藥局 保費 及 / 或共付 額 / 共同保險在每年的 1 月 1 日起可能會有所更動 中心健保聯邦健保計劃是個與聯邦醫療保險簽約的健康管理組織 HMO 計劃 中心 健保聯邦健保計劃登記資格取決於續訂合約與否 以上的資訊有其他免費語言版本 請致電會員服務中心 , 聽障 / 語障專線 , 一週七天, 上午 8:00 到下午 8:00( 太平洋時間 ) H5649_112713_1085_CF_C Accepted Last Updated: 10/28/2014 HPMS Approved Formulary File submission ID and version number: 14560v17 18

19 保費 共付額 共同保險 以及自付扣除額可能因您的額外補助等級不同而有變動 詳情請與計劃聯繫 This information is available for free in other languages. Please call our customer service number at , TTY , 7 days a week, 8:00 AM to 8:00 PM (PT). 現有會員請注意 : 本含保藥品處方目錄內容與去年相較己有更動, 請仔細查閱您正 在使用的藥品是否仍然在處方集內 本藥品目錄由中心健保聯邦醫療保險公司所提供, 中心健保聯邦醫療保險公司在福 利說明書中稱之為 我們 或 我們的 中心健保聯邦保險計劃則稱之為 計劃 或是 本計劃 會員必須使用合約藥局領取處方藥以獲得福利 福利內容 處方集 合約藥局 保 費 及 / 或共付額 / 共同保險可能於 2015 年 1 月 1 日以後有所更改 何謂 中心健保藥品處方集? 本藥品處方集是由中心健保的專業醫藥團隊在經過仔細的研究和比較後, 得出的一個相信能提供會員高品質的藥品目錄 處方集內的藥物只要是有醫療上的需要 且在中心健保的簽約藥局內配領藥物 並符合其他的規定, 中心健保都會含保給付在藥品處方集內的藥物 如欲了解更多有關取得藥物的訊息, 請參閱福利說明 (Evidence of Coverage) 處方藥品 ( 藥品目錄 ) 內容會改變嗎? 一般而言, 如果我們 2014 年的藥品目錄已含保您目前使用的藥品, 除非在市場上有更新 更加安全 有效及經濟的藥品問世, 我們將不會減少或取消您已經在 2014 年使用的藥品 如果您正在使用的藥品在藥品目錄內被移除, 您使用該藥品的福利將不被影響 會員將仍然可在同一年度內給付原來自付的費用至到保障年度結束 我們認為當會員加入中心健保時, 在同一年度內可以持續使用原來的處方是一件至關重要 19

20 的事 除非我們可以提供更加經濟及安全的類似藥方, 我們不會隨意改變您已經在使用的處方 如果我們從處方集內刪除藥品, 或增添了藥品的事先批准 數量限制及 / 或階段性療法的程序限制, 或轉至更高的給付層級等, 正在使用被修改藥品的會員將會在處方集更正生效前 60 天收到書面通知, 或在修改生效之前預先得到 60 天的藥物準備量 若本處方集內有食品及藥品管理局 (Food and Drug Administration) 認為不安全的藥品或藥廠將某種藥品從市場上收回, 我們會馬上將此藥品從處方集中移除, 並立即通知正在使用此藥品的會員停止用藥 本處方集目錄是 08/14/2013 份更新版本 如果您需要更新的版本, 請聯係我們的會員服務 我們的聯係信息位于本目錄的封面以及封底部分 若是在這一年當中處方集內有任何變更時, 中心健保可能藉由郵寄勘誤通知給您 除此之外, 您也可經由我們的網站連結取得勘誤表 如何使用這本處方集? 有兩種方法可查閱藥品 : 以醫療狀況分類處方集目錄內第 26 頁開始的藥品是根據疾病狀況來分類 比如說, 治療心臟疾病的藥品會被歸類在 CARDIOVASCULAR AGENTS 類別內 只要您知道您需要服用的藥品是被歸類在那些病情, 您便可以在從第 26 頁開始的藥品目錄由該病情分類選項下找到您需要服用的藥品 以字母順序排列如果您不清楚您的藥品是屬於那一種類別, 您可以利用第 197 頁的索引以藥品名字母排列順序方式來找尋您所需的藥品 索引依照字母順序排列出處方集所有的藥物, 包括名牌藥品及一般藥品 在藥品名稱的旁邊, 找出有關該藥品保障資訊的頁數 翻到該藥品的頁數後, 在第一欄可找到您的藥品 20

21 什麼是一般藥品 (generic drugs)? 中心健保含保一般藥品 (generic drugs) 及品牌藥品 (brand name drugs) 一般藥品與品牌藥品具有相同的作用成份, 也都經過 食品及藥品管理局 (FDA) 核准 通常, 一般藥品價格上比名牌藥品較低 藥品保障方面有那些限制? 以下簡列藥品保障方面的一些限制 : 事先核准 (PriorAuthorization): 有些特定處方藥品是中心健保需要您或您的家庭醫師先取得事先核准的 這表示您需要經過中心健保事先的核准才能去藥局領取該特定藥品 如果沒有事先核准, 中心健保將有權不給付該藥物的費用 藥量限制 (QuantityLimits): 中心健保會限制有些處方藥品的藥量 譬如中心健保給予處方藥 CELEBREX 的處方藥量限定在每一處方 6 錠為限 這則與一般一個月或三個月的用藥劑量有所不同 階段性藥品療法 (StepTherapy): 有些情況下, 中心健保會在提供某種藥物前先要求您使用其他具有相同療效的藥物來治療您的疾病 譬如說, 處方藥 A 與處方藥 B 對同一病況均有療效 中心健保可能會要求您先使用 A 藥品 如果 A 藥品對您的病況沒有幫助, 中心健保則會同意您使用 B 藥品 您可以在目錄第 26 頁查詢您使用的藥品是否有特殊的要求或限制 您也可以上網到 查詢更多有關特定處方藥品的限制 您可以在本目錄的封面和封底部分找到我們的聯係方式以及我們最後一次修訂本目錄的日期 如有需要, 您可以和中心健保提出要求例外修改您目前使用藥品的限制, 或者您可以向中心健保索取一份可能治療您目前病情的相似藥品名錄 中心健保會以個案方式特別處理 詳情請參閱第 22 頁 如何向中心健保申請例外含保藥品? 部份 如果我使用的處方藥不在處方集內怎麼辦? 如果您使用的處方藥不在這本處方集之內, 請先聯絡會員服務中心, 以確認您使用的藥物確實不在計劃的含保範圍之內 如果您發現您目前使用的藥品不在中心健保的含保範圍之內, 您有以下兩項選擇 : 21

22 請向會員服務中心索取一份和您目前使用的藥品有相似藥性的含保藥品名單 將此名單交給您的醫師; 您的醫師會幫助您選擇適當的藥品 如有需要, 您可以要求中心健保例外含保給付您所使用的非含保藥品 詳細情形請參照以下的說明 如何向中心健保申請例外含保藥品? 您可以向中心健保針對含保條例申請例外含保 例外含保可分為下列幾種情形 : 如您發現您使用的藥品不在處方集內, 您可以向我們提出例外含保給付您所使用的非含保藥品 您可以要求我們取消對於您的藥品限制 例如, 對於某一些藥品, 中心健保聯邦毉療保險計劃會限制其給藥數量 如果您所需要的藥品有此藥量限制, 您可以要求我們取消其限制 一般而言, 中心健保只有在含保藥品 低給付層級藥品 或其他使用限制無法有效的治療您的病況或會造成嚴重副作用情形時, 才會同意例外含保的申請 您應該與我們聯絡以提出對處方集 藥品層級 或藥品限制例外含保的含保範圍確認 當您提出以上的申請時, 請同時提出醫師的證明報告 一般而言, 中心健保會在收到醫師報告的 72 小時之內對您提出的申請作出決定 如果您的狀況緊急, 您可以要求提出緊急例外申請 若是該要求經核准, 本計劃在收到醫師報告的 24 小時之內便會作出回應 在我諮詢醫師有關是否該做藥品的轉換或申請例外含保之前, 我該做些什麼? 不論您是新進會員或是現有會員, 您都有可能在使用一些不在計劃處方集內的藥品 或者是, 您所使用的藥品在處方集內, 但在使用上有限制 例如 : 您可能需要得 22

23 到本計劃的事先核准才可以領取處方藥 如果您有上述的問題時, 您可以向您的醫生諮詢是否該轉換到別種合適的含保藥品, 或是向本計劃提出例外含保的要求 在這個諮詢的過程同時, 在某些狀況下本計劃在您成為會員的前 90 天內會受保您正在使用的藥品 如果您目前使用的藥品不在計劃處方集內 或藥品使用上有所限制, 只要您使用簽約藥局取藥, 本計劃將會提供您暫時性的 30 天藥量 ( 除非您的處方限定較少的劑量 ) 提供您 30 天份藥量後, 本計劃將不會再給付您使用的該項藥品費用, 即使您加入計劃成為會員時間少於 90 天 如果您是住在長期療養院所之內的病患 ; 本計劃將支付 91 天份的臨時劑量, 每月劑量相同 ( 除非您的處方限定較少的劑量 ) 本計劃會提供新會員前 90 天內不只一次重新調配的藥品供給 如果您使用的藥品不在本計劃處方集內 或是在藥品使用上有限制, 但是您參加計劃己超過 90 天, 我們將在您申請例外含保的同時, 提供 31 天份緊急供給藥量 ( 除非您的處方限定較少的劑量 ) 例外含保亦適用於某些因療程有所變動而可能需要由某醫療機構, 轉換到另一機構的受益人 以下為當療程有所變動時, 即使會員加入 D 部份藥物處方保險超過三個月卻符合取得一次暫時性藥物的例子 : 受益人於出院後, 由醫院所開出的處方藥 受益人結束在聯邦健保 A 部份專業護理院的治療 ( 藥物費用已涵蓋於護理院支付款項內 ) 並需要恢復使用 D 部份處方藥物 受益人中止了安寧照護的狀況, 並恢復到原本的 A 部份及 B 部份計劃福利 受益人從慢性精神科醫院出院後, 仍需使用特殊的個人處方藥物治療以上特殊情形, 不論是否成為會員在 90 天內, 皆符合可領取一次暫時例外含保處方藥品 更多資訊 如需更多中心健保含保藥品資訊, 請參閱福利說明及其他文件 如果您對中心健保有疑問, 請聯絡我們的會員服務中心 您可以在本目錄的封面和封底部分找到我們的聯係方式以及本目錄最后一次修訂的日期 23

24 如果您對一般有關於聯邦醫療保險 (Medicare) 處方藥品計劃有疑問, 請撥打 Medi care 每週 7 天, 每天 24 小時免費電話 MEDICARE ( ) 詢問 聽障或語障人士請致電 或上網到 中心健保處方集 第 26 頁開始的處方集提供部分中心健保含保的藥品資訊 如果您找不到您需要的藥品, 請翻到第 197 頁索引查尋 處方集內的第一欄為藥品名稱 (Drug Name) 在本目錄內名牌藥品以英文正楷大寫標示( 譬如 : CELEBREX), 一般藥品以英文斜體小寫標示 ( 譬如 :lisinopril), 以示區分 在特殊限制藥品欄目 (Requirements/Limits) 內會告知您中心健保是否對您使用的處方藥品有特殊限制 我們在保障缺口階段針對第 1 及第 2 等級藥品提供額外保障 詳情請查閱福利說明書 所有 5 個等級的藥品均可經由郵購取得 相關限制及規定請與郵購藥局聯繫 加入中心健保之後, 我的藥品部分負擔費用為何? 您的自付費用會因為您使用的藥品層級和您是否獲得藥品額外補助而有所不同 如果您是中心健保聯邦紅藍卡計劃 (HMO) 的會員, 當您在藥品保障初始階段時, 請參閱下表以了解您在不同藥品給付層級應該自付的費用 : 藥品層級 (Drug Tier) 網路藥局 (30 天份藥量 ) 網路藥局 (90 天份藥量 ) 郵寄藥品 (90 天份藥量 ) 層級一 : 優先一般藥 $0 $0 $0 層級二 : 非優先一般藥 $5 $15 $10 層級三 : 優先名牌藥 $25 $75 $50 層級四 : 非優先名牌藥 $50 $150 $100 層級五 : 特殊用藥 33% 33% 33% 24

25 如果您是中心健保聯邦紅藍白卡計劃 (HMOSNP) 或中心健保特選計劃 (HMO) 的會員, 當您在藥品保障初始階段時, 您的自付費用會因您是否獲得藥品額外補助而有所不同 請參閱下表以了解您在不同藥品給付層級應該自付的費用 : 藥品額外補助獲得藥品額外補助沒有藥品額外補助 藥品層級 (Drug Tier) 網路藥局 (30 天份藥量 ) 網路藥局 (30 天份藥量 ) 層級一 : 優先一般藥 層級二 : 非優先一般藥 $0 $0 層級三 : 優先名牌藥 層級四 : 非優先名牌藥 $0,$3.60,$6.35 或 15% 25% 層級五 : 特殊用藥 25

26 ANALGESICS Analgesics, Other butalbital-acetaminophen tab mg 2** butalbital-acetaminophen tab mg 2** butalbital-acetaminophencaffeine cap mg 2** butalbital-acetaminophencaffeine soln mg/15ml 2** butalbital-acetaminophencaffeine tab mg 2** butalbital-acetaminophencaffeine tab mg 2** butalbital-aspirin-caffeine cap mg 2** butalbital-aspirin-caffeine tab mg 2** Nonsteroidal Anti-Inflammatory Drugs CELEBREX CAP100MG 3 Quantity limitation 60 per 30 days; Step therapy protocols apply CELEBREX CAP200MG 3 Quantity limitation 60 per 30 days; Step therapy protocols apply Quantity limitation 60 per 30 days; CELEBREX CAP400MG 3 CELEBREX CAP50MG 3 diclofenac potassium tab 50 mg 1* diclofenac sodium tab delayed release 25 mg 1* diclofenac sodium tab delayed release 50 mg 1* diclofenac sodium tab delayed release 75 mg 1* diclofenac sodium tab sr 24hr 100 mg 1* diflunisal tab 500 mg 1* etodolac cap 200 mg 1* etodolac cap 300 mg 1 etodolac tab 400 mg 1* Step therapy protocols apply Quantity limitation 60 per 30 days; Step therapy protocols apply 26 *We provide additional coverage of this drug in the coverage gap for Medicare

27 etodolac tab 500 mg 1* etodolac tab sr 24hr 400 mg 1* etodolac tab sr 24hr 500 mg 1* etodolac tab sr 24hr 600 mg 1* fenoprofen calcium tab 600 mg 2** flurbiprofen tab 100 mg 1* flurbiprofen tab 50 mg 1* ibuprofen susp 100 mg/5ml 1* ibuprofen tab 400 mg 1* ibuprofen tab 600 mg 1* ibuprofen tab 800 mg 1* indomethacin cap 25 mg 1* indomethacin cap 50 mg 1* indomethacin cap cr 75 mg 1* ketoprofen cap 50 mg 1* ketoprofen cap 75 mg 1* ketoprofen cap sr 24hr 200 mg 1* meclofenamate sodium cap 100 mg 1* meclofenamate sodium cap 50 mg 1* meloxicam tab 15 mg 1* Quantity limitation 30 per 30 days meloxicam tab 7.5 mg 1* Quantity limitation 30 per 30 days nabumetone tab 500 mg 1* nabumetone tab 750 mg 1* naproxen sodium tab 275 mg 1* naproxen sodium tab 550 mg 1* naproxen susp 125 mg/5ml 1* naproxen tab 250 mg 1* naproxen tab 375 mg 1* naproxen tab 500 mg 1* naproxen tab ec 375 mg 1* naproxen tab ec 500 mg 1* oxaprozin tab 600 mg 1* piroxicam cap 10 mg 1* piroxicam cap 20 mg 1* sulindac tab 150 mg 1* sulindac tab 200 mg 1* tolmetin sodium cap 400 mg 1* tolmetin sodium tab 200 mg 1* tolmetin sodium tab 600 mg 1* 27 *We provide additional coverage of this drug in the coverage gap for Medicare

28 Opioid Analgesics, Long-Acting Quantity limitation 30 per 30 days; AVINZA CAP120MG 4 Step therapy protocols apply AVINZA CAP30MG 4 Quantity limitation 30 per 30 days; Step therapy protocols apply AVINZA CAP45MG 4 AVINZA CAP60MG 4 Quantity limitation 30 per 30 days; Step therapy protocols apply AVINZA CAP75MG 4 AVINZA CAP90MG 4 Quantity limitation 30 per 30 days; Step therapy protocols apply Quantity limitation 120 per 30 days; This medication requires prior fentanyl citrate lollipop 1200 mcg 2** fentanyl citrate lollipop 1600 mcg 2** fentanyl citrate lollipop 200 mcg 2** fentanyl citrate lollipop 400 mcg 2** Quantity limitation 120 per 30 days; This medication requires prior Quantity limitation 120 per 30 days; This medication requires prior Quantity limitation 120 per 30 days; This medication requires prior Quantity limitation 120 per 30 days; This medication requires fentanyl citrate lollipop 600 mcg 2** prior 28 *We provide additional coverage of this drug in the coverage gap for Medicare

29 Quantity limitation 120 per 30 days; This medication requires prior fentanyl citrate lollipop 800 mcg 2** fentanyl td patch 72hr 100 mcg/hr 2** Quantity limitation 30 per 30 days fentanyl td patch 72hr 12 mcg/hr 2** Quantity limitation 30 per 30 days fentanyl td patch 72hr 25 mcg/hr 2** Quantity limitation 30 per 30 days fentanyl td patch 72hr 50 mcg/hr 2** Quantity limitation 30 per 30 days fentanyl td patch 72hr 75 mcg/hr 2** Quantity limitation 30 per 30 days KADIAN CAP10MG CR 3 KADIAN CAP200MG CR 3 LAZANDA SPR100MCG 5 Quantity limitation 60 per 30 days; Step therapy protocols apply Quantity limitation 60 per 30 days; Step therapy protocols apply Quantity limitation 30 per 30 days; LAZANDA SPR400MCG 5 Quantity limitation 30 per 30 days; levorphanol tartrate tab 2 mg 1* Quantity limitation 240 per 30 days METHADONE INJ10MG/ML 4 29 *We provide additional coverage of this drug in the coverage gap for Medicare

30 methadone hcl conc 10 mg/ml 1* methadone hcl soln 10 mg/5ml 2** methadone hcl soln 5 mg/5ml 2** methadone hcl tab 10 mg 1* Quantity limitation 180 per 30 days methadone hcl tab 5 mg 1* Quantity limitation 180 per 30 days morphine sulfate inj pf 0.5 mg/ml 4 morphine sulfate inj pf 1 mg/ml 4 morphine sulfate tab 15 mg 1* Quantity limitation 180 per 30 days morphine sulfate tab 30 mg 1* Quantity limitation 180 per 30 days morphine sulfate tab cr 100 mg 1* Quantity limitation 120 per 30 days morphine sulfate tab cr 15 mg 1* Quantity limitation 120 per 30 days morphine sulfate tab cr 200 mg 1* Quantity limitation 120 per 30 days morphine sulfate tab cr 30 mg 1* Quantity limitation 120 per 30 days morphine sulfate tab sr 12hr 60 mg 1* Quantity limitation 120 per 30 days oxycodone hcl cap 5 mg 1* Quantity limitation 120 per 30 days oxycodone hcl conc 20 mg/ml 1* oxycodone hcl tab 10 mg 1* oxycodone hcl tab 15 mg 1* oxycodone hcl tab 20 mg 1 oxycodone hcl tab 30 mg 1* oxycodone hcl tab 5 mg 1* Quantity limitation 120 per 30 days oxymorphone er 1 oxymorphone hcl tab 10 mg 1* oxymorphone hcl tab 5 mg 1* oxymorphone hcl tab sr 12hr 15 mg 1* oxymorphone hcl tab sr 12hr 7.5 1* 30 *We provide additional coverage of this drug in the coverage gap for Medicare

31 mg tramadol hcl tab sr 24hr 100 mg 2** Quantity limitation 30 per 30 days tramadol hcl tab sr 24hr 200 mg 2** Quantity limitation 30 per 30 days tramadol hcl tab sr 24hr biphasic release 300 mg 2** Opioid Analgesics, Short-Acting acetaminophen w/ codeine soln mg/5ml 1* acetaminophen w/ codeine tab mg 1* Quantity limitation 400 per 30 days acetaminophen w/ codeine tab mg 1* Quantity limitation 400 per 30 days acetaminophen w/ codeine tab mg 1* Quantity limitation 400 per 30 days acetaminophen-caffeinedihydrocodeine tab mg 1* butalbital-acetaminophen-caff w/ cod cap mg 2** Quantity limitation 360 per 30 days butalbital-aspirin-caff w/ codeine cap mg 1* Quantity limitation 180 per 30 days butorphanol tartrate nasal soln 10 mg/ml 1* Quantity limitation 10 per 30 days hydrocodone-acetaminophen cap mg 1* Quantity limitation 240 per 30 days hydrocodone-acetaminophen soln mg/15ml 2** hydrocodone-acetaminophen soln mg/15ml 2** Quantity limitation 3600 per 30 days hydrocodone-acetaminophen soln mg/15ml 2** Quantity limitation 3600 per 30 days hydrocodone-acetaminophen tab mg 2** Quantity limitation 360 per 30 days hydrocodone-acetaminophen tab mg 2** Quantity limitation 360 per 30 days hydrocodone-acetaminophen tab mg 4 hydrocodone-acetaminophen tab mg 2** Quantity limitation 240 per 30 days hydrocodone-acetaminophen tab mg 2** Quantity limitation 180 per 30 days 31 *We provide additional coverage of this drug in the coverage gap for Medicare

32 hydrocodone-acetaminophen tab mg 2** Quantity limitation 180 per 30 days hydrocodone-acetaminophen tab mg 2** Quantity limitation 150 per 30 days hydrocodone-acetaminophen tab mg 2** Quantity limitation 240 per 30 days hydrocodone-acetaminophen tab mg 2** Quantity limitation 360 per 30 days hydrocodone-acetaminophen tab mg 2** Quantity limitation 360 per 30 days hydrocodone-acetaminophen tab mg 4 hydrocodone-acetaminophen tab mg 1* Quantity limitation 240 per 30 days hydrocodone-acetaminophen tab mg 2** Quantity limitation 240 per 30 days hydrocodone-acetaminophen tab mg 2** Quantity limitation 360 per 30 days hydrocodone-acetaminophen tab mg 2** Quantity limitation 360 per 30 days hydrocodone-acetaminophen tab mg 4 hydrocodone-acetaminophen tab mg 2** Quantity limitation 240 per 30 days hydrocodone-acetaminophen tab mg 2** Quantity limitation 180 per 30 days hydrocodone-acetaminophen tab mg 2** Quantity limitation 150 per 30 days hydrocodone-ibuprofen tab mg 2** Quantity limitation 480 per 30 days hydromorphone hcl tab 2 mg 1* Quantity limitation 120 per 30 days hydromorphone hcl tab 4 mg 1* Quantity limitation 120 per 30 days hydromorphone hcl tab 8 mg 1* Quantity limitation 120 per 30 days nalbuphine hcl inj 10 mg/ml 4 nalbuphine hcl inj 20 mg/ml 4 32 *We provide additional coverage of this drug in the coverage gap for Medicare

33 oxycodone w/ acetaminophen cap mg 1* Quantity limitation 240 per 30 days oxycodone w/ acetaminophen soln mg/5ml 1* Quantity limitation 1800 per 30 days oxycodone w/ acetaminophen tab mg 1* Quantity limitation 360 per 30 days oxycodone w/ acetaminophen tab mg 1* oxycodone w/ acetaminophen tab mg 1* oxycodone w/ acetaminophen tab mg 1* Quantity limitation 360 per 30 days oxycodone w/ acetaminophen tab mg 1* Quantity limitation 360 per 30 days oxycodone w/ acetaminophen tab mg 1* Quantity limitation 240 per 30 days oxycodone-aspirin tab mg 1* Quantity limitation 360 per 30 days oxycodone-ibuprofen tab mg 1* SUBOXONE MIS12-3MG 4 tramadol hcl tab 50 mg 2** Quantity limitation 240 per 30 days tramadol-acetaminophen tab mg 2** Quantity limitation 240 per 30 days ANESTHETICS Local Anesthetics lidocaine hcl gel 2% 1* lidocaine hcl local preservative free (pf) inj 0.5% 4 lidocaine hcl local preservative 4 33 *We provide additional coverage of this drug in the coverage gap for Medicare

34 free (pf) inj 1% lidocaine hcl soln 4% 1* lidocaine-prilocaine cream % 1* ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS Alcohol Deterrents/Anti-craving CAMPRAL TAB333MG 4 disulfiram tab 250 mg 2** disulfiram tab 500 mg 2** Opioid Antagonists buprenorphine hcl inj 0.3 mg/ml (base equiv) 4 buprenorphine hcl sl tab 2 mg (base equiv) 1* buprenorphine hcl sl tab 8 mg (base equiv) 1* buprenorphine hcl-naloxone hcl sl tab mg (base equiv) 2** buprenorphine hcl-naloxone hcl sl tab 8-2 mg (base equiv) 2** naloxone hcl inj 1 mg/ml 4 naltrexone hcl tab 50 mg 1* SUBOXONE MIS2-0.5MG 4 Quantity limitation 90 per 30 days 34 *We provide additional coverage of this drug in the coverage gap for Medicare

35 SUBOXONE MIS4-1MG 4 SUBOXONE MIS8-2MG 4 Quantity limitation 90 per 30 days Smoking Cessation Agents bupropion hcl (smoking deterrent) tab sr 12hr 150 mg 2** Quantity limitation 90 per 30 days Quantity limitation 60 per 30 days; CHANTIX PAK0.5& 1MG 4 CHANTIX TAB0.5MG 4 Quantity limitation 60 per 30 days; Quantity limitation 60 per 30 days; CHANTIX TAB1MG 4 NICOTROL NS SPR10MG/ML 3 Quantity limitation 40 per 30 days ANTIBACTERIALS Aminoglycosides GENTAMICIN CRE0.1% 1* GENTAMICIN OIN0.1% 1* gentamicin sulfate inj 40 mg/ml 2** gentamicin sulfate iv soln 10 mg/ml 2** 35 *We provide additional coverage of this drug in the coverage gap for Medicare

36 gentamicin sulfate ophth oint 0.3% 1* gentamicin sulfate ophth soln 0.3% 1* neomycin sulfate tab 500 mg 1* paromomycin sulfate cap 250 mg 1* streptomycin sulfate for inj 1 gm 2** TOBI NEB300/5ML 5 tobramycin sulfate inj 10 mg/ml 4 tobramycin sulfate inj 80 mg/2ml (40 mg/ml) 4 tobramycin sulfate ophth soln 0.3% 1* Antibacterials Other bacitracin intramuscular for soln 4 36 *We provide additional coverage of this drug in the coverage gap for Medicare

37 50000 unit bacitracin ophth oint 500 unit/gm 1* chloramphenicol sodium succinate for iv inj 1 gm 2** CLEOCIN SUP100MG 4 clindamycin hcl cap 150 mg 1* clindamycin hcl cap 300 mg 1* clindamycin hcl cap 75 mg 1* clindamycin phosphate foam 1% 1* clindamycin phosphate gel 1% 1* clindamycin phosphate in d5w iv soln 300 mg/50ml 4 clindamycin phosphate in d5w iv soln 600 mg/50ml 4 clindamycin phosphate in d5w iv soln 900 mg/50ml 4 clindamycin phosphate iv soln 600 mg/4ml 4 clindamycin phosphate lotion 1% 1* clindamycin phosphate soln 1% 1* clindamycin phosphate swab 1% 1* clindamycin phosphate vaginal cream 2% 1* clindamycin sol75mg/5ml 2 colistimethate sodium for inj 150 mg 4 37 *We provide additional coverage of this drug in the coverage gap for Medicare

38 methenamine hippurate tab 1 gm 1* METROGEL GEL1% 4 metronidazole cream 0.75% 1* metronidazole gel 0.75% 1* metronidazole lotion 0.75% 1* metronidazole tab 250 mg 1* metronidazole tab 500 mg 1* metronidazole vaginal gel 0.75% 1* MONUROL PAKGRANULES 4 mupirocin calcium cream 2% 1* mupirocin oint 2% 1* neomycin-polymyxin b gu irrigation soln 1* nitrofurantoin macrocrystalline cap 50 mg 2** nitrofurantoin monohydrate macrocrystalline cap 100 mg 2** nitrofurantoin susp 25 mg/5ml 2** SULFAMYLON CRE85MG/GM 4 trimethoprim tab 100 mg 1* TYGACIL INJ50MG 4 vancomycin hcl for inj 10 gm 4 vancomycin hcl for inj 1000 mg 4 vancomycin hcl for inj 500 mg 4 38 *We provide additional coverage of this drug in the coverage gap for Medicare

39 ZYVOX SOL2MG/ML 5 ZYVOX SUS100MG/5M 5 ZYVOX TAB600MG 5 Beta-lactam, Cephalosporins cefaclor cap 250 mg 1* cefaclor cap 500 mg 1* cefaclor monohydrate tab sr 12hr 500 mg 1* cefadroxil cap 500 mg 1* cefadroxil for susp 250 mg/5ml 1* cefadroxil for susp 500 mg/5ml 1* cefadroxil tab 1 gm 1* cefazolin in d5w inj 1 gm/50ml 4 Quantity limitation 56 per 28 days; cefazolin sodium for inj 1 gm 4 39 *We provide additional coverage of this drug in the coverage gap for Medicare

40 cefazolin sodium for inj 10 gm 4 cefazolin sodium for inj 500 mg 4 cefdinir cap 300 mg 1* cefdinir for susp 125 mg/5ml 1* cefdinir for susp 250 mg/5ml 1* cefepime hcl for inj 1 gm 4 cefepime hcl for inj 2 gm 4 cefoxitin sodium for inj 1 gm 4 40 *We provide additional coverage of this drug in the coverage gap for Medicare

41 cefoxitin sodium for inj 10 gm 4 cefoxitin sodium for inj 2 gm 4 cefoxitin sodium iv for soln 1 gm and dextrose 4% 4 cefoxitin sodium iv for soln 2 gm and dextrose 2.2% 4 cefpodoxime proxetil for susp 100 mg/5ml 1* cefpodoxime proxetil for susp 50 mg/5ml 1* cefpodoxime proxetil tab 100 mg 1* cefpodoxime proxetil tab 200 mg 1* cefprozil for susp 125 mg/5ml 1* cefprozil for susp 250 mg/5ml 1* cefprozil tab 250 mg 1* cefprozil tab 500 mg 1* ceftriaxone sodium for inj 10 gm 4 ceftriaxone sodium for inj 250 mg 4 41 *We provide additional coverage of this drug in the coverage gap for Medicare

42 ceftriaxone sodium for inj 500 mg 4 ceftriaxone sodium for iv soln 1 gm 4 ceftriaxone sodium for iv soln 2 gm 4 cefuroxime axetil tab 250 mg 1* cefuroxime axetil tab 500 mg 1* cefuroxime sodium for inj 1.5 gm 4 cefuroxime sodium for inj 7.5 gm 4 cefuroxime sodium for inj 750 mg 4 cephalexin cap 250 mg 1* 42 *We provide additional coverage of this drug in the coverage gap for Medicare

43 cephalexin cap 500 mg 1* cephalexin for susp 125 mg/5ml 1* cephalexin for susp 250 mg/5ml 1* cephalexin tab 250 mg 1* cephalexin tab 500 mg 1* SUPRAX SUS100/5ML 4 SUPRAX SUS200/5ML 4 SUPRAX SUS500/5ML 4 Beta-lactam, Other AZACTAM/DEX INJ1GM 3 AZACTAM/DEX INJ2GM 3 INVANZ INJ1GM 4 Beta-lactam, Penicillins amoxicillin & k clavulanate chew tab mg 1* amoxicillin & k clavulanate chew tab mg 1* amoxicillin & k clavulanate for susp mg/5ml 1* amoxicillin & k clavulanate for susp mg/5ml 1* amoxicillin & k clavulanate for susp mg/5ml 1* amoxicillin & k clavulanate for susp mg/5ml 1* amoxicillin & k clavulanate tab 1* mg amoxicillin & k clavulanate tab mg 1* amoxicillin & k clavulanate tab mg 1* 43 *We provide additional coverage of this drug in the coverage gap for Medicare

44 amoxicillin & k clavulanate tab sr 12hr mg 2** amoxicillin (trihydrate) cap 250 mg 1* amoxicillin (trihydrate) cap 500 mg 1* amoxicillin (trihydrate) chew tab 125 mg 1* amoxicillin (trihydrate) chew tab 250 mg 1* amoxicillin (trihydrate) for susp 125 mg/5ml 1* amoxicillin (trihydrate) for susp 200 mg/5ml 1* amoxicillin (trihydrate) for susp 250 mg/5ml 1* amoxicillin (trihydrate) for susp 400 mg/5ml 1* amoxicillin (trihydrate) tab 500 mg 1* amoxicillin (trihydrate) tab 875 mg 1* ampicillin & sulbactam sodium for inj 2-1 gm 4 ampicillin & sulbactam sodium for iv soln 10-5 gm 4 ampicillin cap 250 mg 1* ampicillin cap 500 mg 1* ampicillin for susp 125 mg/5ml 1* ampicillin for susp 250 mg/5ml 1* ampicillin sodium for inj 1 gm 4 44 *We provide additional coverage of this drug in the coverage gap for Medicare

45 ampicillin sodium for inj 125 mg 4 ampicillin sodium for iv soln 10 gm 4 dicloxacillin sodium cap 250 mg 1* dicloxacillin sodium cap 500 mg 1* nafcillin sodium for inj 1 gm 4 nafcillin sodium for inj 10 gm 4 PENICILL GK/INJDEX 2MU 4 45 *We provide additional coverage of this drug in the coverage gap for Medicare

46 PENICILL GK/INJDEX 3MU 4 penicillin g potassium for inj unit 4 penicillin g procaine intramuscular susp unit/ml 4 penicillin g sodium for inj unit 4 penicillin v potassium for soln 125 mg/5ml 1* penicillin v potassium for soln 250 mg/5ml 1* penicillin v potassium tab 250 mg 1* penicillin v potassium tab 500 mg 1* piperacillin sodium-tazobactam sodium for inj gm 4 46 *We provide additional coverage of this drug in the coverage gap for Medicare

47 piperacillin sodium-tazobactam sodium for inj gm 4 Macrolides azithromycin for susp 100 mg/5ml 2** Quantity limitation 30 per 5 days azithromycin for susp 200 mg/5ml 2** Quantity limitation 90 per 5 days azithromycin iv for soln 500 mg 4 azithromycin tab 250 mg 2** Quantity limitation 6 per 5 days azithromycin tab 500 mg 2** Quantity limitation 6 per 5 days azithromycin tab 600 mg 2** Quantity limitation 6 per 5 days clarithromycin for susp 125 mg/5ml 2** clarithromycin for susp 250 mg/5ml 2** clarithromycin tab 250 mg 2** Quantity limitation 28 per 14 days clarithromycin tab 500 mg 2** Quantity limitation 28 per 14 days clarithromycin tab sr 24hr 500 mg 2** Quantity limitation 28 per 14 days ERYTHROCIN INJ500MG 4 ERYTHROM ETHTAB400MG 2** erythromycin gel 2% 2** erythromycin ophth oint 5 mg/gm 2** erythromycin pads 2% 2** erythromycin soln 2% 2** erythromycin stearate tab 250 mg 2** 47 *We provide additional coverage of this drug in the coverage gap for Medicare

48 erythromycin tab 250 mg 2** erythromycin tab 500 mg 2** erythromycin tab delayed release 250 mg 2** erythromycin tab delayed release 333 mg 2** erythromycin tab delayed release 500 mg 2** KETEK TAB300MG 4 KETEK TAB400MG 4 ZMAX SUS2GM 3 Quantity limitation 60 per 30 days Quinolones AVELOX INJ 4 BESIVANCE SUS0.6% 4 CILOXAN OIN0.3% OP 4 ciprofloxacin hcl ophth soln 0.3% 1* ciprofloxacin hcl tab 100 mg (base equiv) 2** ciprofloxacin hcl tab 250 mg (base equiv) 2** ciprofloxacin hcl tab 500 mg (base equiv) 2** ciprofloxacin hcl tab 750 mg (base equiv) 2** ciprofloxacin-ciprofloxacin hcl tab sr 24hr 1000 mg(base eq) 2** ciprofloxacin-ciprofloxacin hcl tab sr 24hr 500 mg (base eq) 2** levofloxacin iv soln 25 mg/ml 2** 48 *We provide additional coverage of this drug in the coverage gap for Medicare

49 levofloxacin ophth soln 0.5% 2** levofloxacin oral soln 25 mg/ml 1* levofloxacin tab 250 mg 1* Quantity limitation 14 per 14 days levofloxacin tab 500 mg 1* Quantity limitation 14 per 14 days levofloxacin tab 750 mg 1* Quantity limitation 14 per 14 days NOROXIN TAB400MG 4 ofloxacin ophth soln 0.3% 2** ofloxacin otic soln 0.3% 2** ofloxacin tab 200 mg 2** ofloxacin tab 300 mg 2** ofloxacin tab 400 mg 2** VIGAMOX DRO0.5% 4 Sulfonamides silver sulfadiazine cream 1% 1* sulfacetamide sodium lotion 10% (acne) 1* sulfacetamide sodium ophth oint 10% 1* sulfacetamide sodium ophth soln 10% 1* sulfadiazine tab 500 mg 1* sulfamethoxazole-trimethoprim iv soln mg/5ml 4 sulfamethoxazole-trimethoprim susp mg/5ml 1* sulfamethoxazole-trimethoprim tab mg 1* sulfamethoxazole-trimethoprim tab mg 1* Tetracyclines demeclocycline hcl tab 150 mg 1* demeclocycline hcl tab 300 mg 1* doxycycline hyclate cap 100 mg 1* doxycycline hyclate cap 50 mg 1* doxycycline hyclate for inj *We provide additional coverage of this drug in the coverage gap for Medicare

50 mg doxycycline hyclate tab 100 mg 1* doxycycline hyclate tab 20 mg 1* doxycycline hyclate tab delayed release 100 mg 1* doxycycline hyclate tab delayed release 150 mg 1* doxycycline hyclate tab delayed 1* release 75 mg doxycycline monohydrate cap 1* 75 mg doxycycline monohydrate tab 50 1* mg doxycycline monohydrate tab 75 1* mg minocycline hcl cap 100 mg 1* minocycline hcl cap 50 mg 1* minocycline hcl cap 75 mg 1* minocycline hcl tab 100 mg 1* minocycline hcl tab 50 mg 1* minocycline hcl tab 75 mg 1* minocycline hcl tab sr 24hr 135 1* mg minocycline hcl tab sr 24hr 45 1* mg minocycline hcl tab sr 24hr 90 mg 1* ORACEA CAP40MG 4 ANTICONVULSANTS Anticonvulsants, Other levetiracetam inj 500 mg/5ml (100 mg/ml) 4 levetiracetam oral soln 100 1* mg/ml levetiracetam tab 1000 mg 1* levetiracetam tab 250 mg 1* levetiracetam tab 500 mg 1* levetiracetam tab 750 mg 1* levetiracetam tab sr 24hr 500 1* mg 50 *We provide additional coverage of this drug in the coverage gap for Medicare

51 levetiracetam tab sr 24hr 750 mg 1* Calcium Channel Modifying Agents CELONTIN CAP300MG 4 ethosuximide cap 250 mg 1* ethosuximide soln 250 mg/5ml 1* LYRICA CAP100MG 3 LYRICA CAP150MG 3 LYRICA CAP200MG 3 LYRICA CAP225MG 3 LYRICA CAP25MG 3 LYRICA CAP300MG 3 LYRICA CAP50MG 3 LYRICA CAP75MG 3 LYRICA SOL20MG/ML 3 zonisamide cap 100 mg 1* zonisamide cap 25 mg 1* zonisamide cap 50 mg 1* Gamma-aminobutyric Acid (GABA) Augmenting Agents divalproex sodium cap sprinkle 1* 125 mg divalproex sodium tab delayed 1* release 125 mg divalproex sodium tab delayed 1* release 250 mg divalproex sodium tab delayed 1* release 500 mg FYCOMPA TAB2MG 4 Quantity limitation 120 per 30 days FYCOMPA TAB4MG 4 Quantity limitation 90 per 30 days FYCOMPA TAB6MG 4 Quantity limitation 60 per 30 days FYCOMPA TAB8MG 4 Quantity limitation 30 per 30 days FYCOMPA TAB10MG 4 Quantity limitation 30 per 30 days FYCOMPA TAB12MG 4 Quantity limitation 30 per 30 days gabapentin cap 100 mg 1* Quantity limitation 360 per 30 days gabapentin cap 300 mg 1* Quantity limitation 360 per 30 days gabapentin cap 400 mg 1* Quantity limitation 270 per 30 days gabapentin oral soln 250 mg/5ml 1* gabapentin tab 600 mg 1* Quantity limitation 180 per 30 days gabapentin tab 800 mg 1* Quantity limitation 120 per 30 days GABITRIL TAB12MG 4 GABITRIL TAB16MG 4 51 *We provide additional coverage of this drug in the coverage gap for Medicare

52 primidone tab 250 mg 1* primidone tab 50 mg 1* Quantity limitation 180 per 30 days; This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at hours a day- seven days a week. TTY users should SABRIL POW500MG 5 SABRIL TAB500MG 5 STAVZOR CAP125MG 4 STAVZOR CAP250MG 4 STAVZOR CAP500MG 4 valproate sodium inj 100 mg/ml 4 valproate sodium syrup 250 1* mg/5ml (base equiv) valproic acid cap 250 mg 1* Glutamate Reducing Agents felbamate susp 600 mg/5ml 2** felbamate tab 400 mg 2** felbamate tab 600 mg 2** lamotrigine tab 100 mg 1* lamotrigine tab 150 mg 1* lamotrigine tab 200 mg 1* lamotrigine tab 25 mg 1* lamotrigine tab chewable dispersible 25 mg 1* lamotrigine tab chewable dispersible 5 mg 1* topiramate sprinkle cap 15 mg 2** topiramate sprinkle cap 25 mg 2** topiramate tab 100 mg 2** call 1- Quantity limitation 180 per 30 days; This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call hours a day- seven days a week. TTY users should call 1-52 *We provide additional coverage of this drug in the coverage gap for Medicare

53 topiramate tab 200 mg 2** topiramate tab 25 mg 2** topiramate tab 50 mg 2** TROKENDI XR 4 Sodium Channel Agents APTIOM TAB200MG 4 Quantity limitation 180 per 30 days APTIOM TAB400MG 4 Quantity limitation 90 per 30 days APTIOM TAB600MG 4 Quantity limitation 60 per 30 days APTIOM TAB800MG 4 Quantity limitation 30 per 30 days Quantity limitation 2400 per 30 days BANZEL SUS40MG/ML 4 BANZEL TAB200MG 4 Quantity limitation 240 per 30 days BANZEL TAB400MG 4 Quantity limitation 240 per 30 days carbamazepine cap sr 12hr 100 mg 2** carbamazepine cap sr 12hr 200 mg 2** carbamazepine cap sr 12hr 300 mg 2** carbamazepine chew tab 100 mg 2** carbamazepine susp 100 mg/5ml 2** carbamazepine tab 200 mg 1* carbamazepine tab 200 mg 2** carbamazepine tab sr 12hr 200 mg 2** carbamazepine tab sr 12hr 400 mg 2** fosphenytoin sodium inj 100 mg/2ml (phenytoin equiv) 4 oxcarbazepine susp 300 mg/5ml (60 mg/ml) 1* oxcarbazepine tab 150 mg 1* oxcarbazepine tab 300 mg 1* oxcarbazepine tab 600 mg 1* 53 *We provide additional coverage of this drug in the coverage gap for Medicare

54 OXTELLAR XR TAB150MG 4 Quantity limitation 480 per 30 days OXTELLAR XR TAB300MG 4 Quantity limitation 240 per 30 days OXTELLAR XR TAB600MG 4 Quantity limitation 120 per 30 days PEGANONE TAB250MG 4 phenytoin chew tab 50 mg 1* phenytoin sodium extended cap 100 mg 1* phenytoin sodium extended cap 200 mg 2** phenytoin sodium extended cap 300 mg 2** phenytoin sodium inj 50 mg/ml 4 phenytoin susp 125 mg/5ml 1* POTIGA TAB200MG 4 Quantity limitation 180 per 30 days POTIGA TAB300MG 4 Quantity limitation 120 per 30 days POTIGA TAB400MG 4 Quantity limitation 90 per 30 days POTIGA TAB50MG 4 Quantity limitation 720 per 30 days VIMPAT INJ200MG/20 4 Quantity limitation 1200 per 30 days Quantity limitation 1200 per 30 days VIMPAT SOL10MG/ML 4 VIMPAT TAB100MG 4 Quantity limitation 60 per 30 days VIMPAT TAB150MG 4 Quantity limitation 60 per 30 days VIMPAT TAB200MG 4 Quantity limitation 60 per 30 days VIMPAT TAB50MG 4 Quantity limitation 60 per 30 days Cholinesterase Inhibitors donepezil hydrochloride orally disintegrating tab 10 mg 2** Quantity limitation 30 per 30 days donepezil hydrochloride orally disintegrating tab 5 mg 2** Quantity limitation 30 per 30 days donepezil hydrochloride tab 10 mg 2** Quantity limitation 30 per 30 days donepezil hydrochloride tab 5 mg 2** Quantity limitation 30 per 30 days EXELON DIS13.3/ *We provide additional coverage of this drug in the coverage gap for Medicare

55 EXELON DIS4.6MG/24 3 EXELON DIS9.5MG/24 3 EXELON SOL2MG/ML 3 Quantity limitation 180 per 30 days galantamine hydrobromide cap sr 24hr 16 mg 2** Quantity limitation 30 per 30 days galantamine hydrobromide cap sr 24hr 24 mg 2** Quantity limitation 30 per 30 days galantamine hydrobromide cap sr 24hr 8 mg 2** Quantity limitation 30 per 30 days galantamine hydrobromide oral soln 4 mg/ml 2** Quantity limitation 180 per 30 days galantamine hydrobromide tab 12 mg 2** galantamine hydrobromide tab 4 mg 2** galantamine hydrobromide tab 8 mg 2** rivastigmine tartrate cap 1.5 mg 1* Quantity limitation 60 per 30 days rivastigmine tartrate cap 3 mg 1* Quantity limitation 60 per 30 days rivastigmine tartrate cap 4.5 mg 1* Quantity limitation 60 per 30 days rivastigmine tartrate cap 6 mg 1* Quantity limitation 60 per 30 days N-methyl-D-aspartate (NMDA) Receptor Antagonist NAMENDA SOL10MG/5ML 3 Quantity limitation 360 per 30 days NAMENDA TAB10MG 3 Quantity limitation 60 per 30 days NAMENDA TAB5-10MG 3 Quantity limitation 60 per 30 days NAMENDA TAB5MG 3 Quantity limitation 60 per 30 days ANTIDEPRESSANTS Antidepressants Other ABILIFY INJ9.75MG 4 ABILIFY SOL1MG/ML 4 Quantity limitation 900 per 30 days ABILIFY TAB10MG 4 Quantity limitation 90 per 30 days ABILIFY TAB15MG 4 Quantity limitation 60 per 30 days ABILIFY TAB20MG 4 Quantity limitation 60 per 30 days ABILIFY TAB2MG 4 Quantity limitation 450 per 30 days ABILIFY TAB30MG 4 Quantity limitation 30 per 30 days 55 *We provide additional coverage of this drug in the coverage gap for Medicare

56 ABILIFY TAB5MG 4 Quantity limitation 180 per 30 days ABILIFY DISCTAB10MG 4 Quantity limitation 90 per 30 days ABILIFY DISCTAB15MG 4 Quantity limitation 60 per 30 days ABILIFY MAININJ300MG 4 APLENZIN TAB174MG 4 Quantity limitation 30 per 30 days APLENZIN TAB348MG 4 Quantity limitation 30 per 30 days APLENZIN TAB522MG 4 Quantity limitation 30 per 30 days BRINTELLIX TAB10MG 4 Quantity limitation 60 per 30 days BRINTELLIX TAB20MG 4 Quantity limitation 30 per 30 days BRINTELLIX TAB5MG 4 Quantity limitation 120 per 30 days bupropion hcl tab 100 mg 2** Quantity limitation 120 per 30 days bupropion hcl tab 75 mg 2** Quantity limitation 180 per 30 days bupropion hcl tab sr 12hr 100 mg 2** Quantity limitation 120 per 30 days bupropion hcl tab sr 12hr 150 mg 2** Quantity limitation 90 per 30 days bupropion hcl tab sr 12hr 200 mg 2** Quantity limitation 60 per 30 days bupropion hcl tab sr 24hr 150 mg 1* bupropion hcl tab sr 24hr 300 mg 1* FORFIVO XL TAB450MG 4 Quantity limitation 30 per 30 days maprotiline hcl tab 25 mg 1* maprotiline hcl tab 50 mg 1* maprotiline hcl tab 75 mg 1* mirtazapine orally disintegrating tab 15 mg 1* Quantity limitation 30 per 30 days mirtazapine orally disintegrating tab 30 mg 1* Quantity limitation 30 per 30 days mirtazapine orally disintegrating tab 45 mg 1* Quantity limitation 30 per 30 days mirtazapine tab 15 mg 1* Quantity limitation 30 per 30 days mirtazapine tab 30 mg 1* Quantity limitation 30 per 30 days mirtazapine tab 45 mg 1* Quantity limitation 30 per 30 days mirtazapine tab 7.5 mg 1* Quantity limitation 30 per 30 days nefazodone hcl tab 100 mg 1* nefazodone hcl tab 150 mg 1* nefazodone hcl tab 200 mg 1* nefazodone hcl tab 250 mg 1* nefazodone hcl tab 50 mg 1* 56 *We provide additional coverage of this drug in the coverage gap for Medicare

57 olanzapine-fluoxetine hcl cap mg 2** olanzapine-fluoxetine hcl cap mg 2** olanzapine-fluoxetine hcl cap 3-25 mg 2** olanzapine-fluoxetine hcl cap 6-25 mg 2** olanzapine-fluoxetine hcl cap 6-50 mg 2** perphenazine-amitriptyline tab 2-10 mg 1* perphenazine-amitriptyline tab 2-25 mg 1* perphenazine-amitriptyline tab 4-10 mg 1* perphenazine-amitriptyline tab 4-25 mg 1* perphenazine-amitriptyline tab 4-50 mg 1* trazodone hcl tab 100 mg 1* trazodone hcl tab 150 mg 1* trazodone hcl tab 300 mg 1* trazodone hcl tab 50 mg 1* VIIBRYD KIT 4 VIIBRYD TAB10MG 4 Quantity limitation 120 per 30 days VIIBRYD TAB20MG 4 Quantity limitation 60 per 30 days VIIBRYD TAB40MG 4 Quantity limitation 30 per 30 days Monoamine Oxidase Inhibitors EMSAM DIS12MG/24H 4 Quantity limitation 30 per 30 days EMSAM DIS6MG/24HR 4 Quantity limitation 30 per 30 days EMSAM DIS9MG/24HR 4 Quantity limitation 30 per 30 days MARPLAN TAB10MG 4 phenelzine sulfate tab 15 mg 2** tranylcypromine sulfate tab 10 mg 1* Serotonin/ Norepinephrine Reuptake Inhibitors citalopram hydrobromide oral soln 10 mg/5ml 1* citalopram hydrobromide tab 10 mg (base equiv) 1* Quantity limitation 30 per 30 days 57 *We provide additional coverage of this drug in the coverage gap for Medicare

58 citalopram hydrobromide tab 20 mg (base equiv) 1* Quantity limitation 30 per 30 days citalopram hydrobromide tab 40 mg (base equiv) 1* Quantity limitation 30 per 30 days CYMBALTA CAP20MG 4 Quantity limitation 180 per 30 days CYMBALTA CAP30MG 4 Quantity limitation 120 per 30 days CYMBALTA CAP60MG 4 Quantity limitation 60 per 30 days DESVENLAFAXINE TAB100MG ER 4 Quantity limitation 120 per 30 days DESVENLAFAXINE TAB50MG ER 4 Quantity limitation 240 per 30 days duloxetine cap20mg 2 Quantity limitation 180 per 30 days duloxetine cap30mg 2 Quantity limitation 120 per 30 days duloxetine cap60mg 2 Quantity limitation 60 per 30 days escitalopram oxalate soln 5 mg/5ml (base equiv) 2** Quantity limitation 620 per 30 days escitalopram oxalate tab 10 mg (base equiv) 2** Quantity limitation 60 per 30 days escitalopram oxalate tab 20 mg (base equiv) 2** Quantity limitation 30 per 30 days escitalopram oxalate tab 5 mg (base equiv) 2** Quantity limitation 120 per 30 days FETZIMA CAP120 4 Quantity limitation 30 per 30 days FETZIMA CAP20 4 Quantity limitation 180 per 30 days FETZIMA CAP40 4 Quantity limitation 120 per 30 days FETZIMA CAP80 4 Quantity limitation 30 per 30 days FETZIMA CAPTITRATION 4 Quantity limitation 28 per 28 days fluoxetine hcl cap 10 mg 1* Quantity limitation 30 per 30 days fluoxetine hcl cap 20 mg 1* fluoxetine hcl cap 40 mg 1* Quantity limitation 60 per 30 days fluoxetine hcl solution 20 mg/5ml 1* fluoxetine hcl tab 10 mg 1* Quantity limitation 30 per 30 days fluoxetine hcl tab 20 mg 1* fluvoxamine maleate tab 100 mg 2** Quantity limitation 90 per 30 days fluvoxamine maleate tab 25 mg 2** Quantity limitation 360 per 30 days fluvoxamine maleate tab 50 mg 2** Quantity limitation 180 per 30 days KHEDEZLA TAB100MG ER 4 Quantity limitation 120 per 30 days KHEDEZLA TAB50MG ER 4 Quantity limitation 240 per 30 days paroxetine hcl tab 10 mg 2** Quantity limitation 90 per 30 days paroxetine hcl tab 20 mg 2** Quantity limitation 60 per 30 days paroxetine hcl tab 30 mg 2** Quantity limitation 60 per 30 days 58 *We provide additional coverage of this drug in the coverage gap for Medicare

59 paroxetine hcl tab 40 mg 2** Quantity limitation 45 per 30 days paroxetine hcl tab sr 24hr 12.5 mg 2** Quantity limitation 150 per 30 days paroxetine hcl tab sr 24hr 25 mg 2** Quantity limitation 90 per 30 days paroxetine hcl tab sr 24hr 37.5 mg 2** Quantity limitation 60 per 30 days PAXIL SUS10MG/5ML 4 PRISTIQ TAB100MG 4 Quantity limitation 30 per 30 days PRISTIQ TAB50MG 4 Quantity limitation 240 per 30 days sertraline hcl oral conc 20 mg/ml 1* Quantity limitation 300 per 30 days sertraline hcl tab 100 mg 1* Quantity limitation 60 per 30 days sertraline hcl tab 25 mg 1* Quantity limitation 240 per 30 days sertraline hcl tab 50 mg 1* Quantity limitation 120 per 30 days venlafaxine hcl cap sr 24hr 150 mg (base equivalent) 2** Quantity limitation 60 per 30 days venlafaxine hcl cap sr 24hr 37.5 mg (base equivalent) 2** Quantity limitation 180 per 30 days venlafaxine hcl cap sr 24hr 75 mg (base equivalent) 2** Quantity limitation 90 per 30 days Tricyclics amitriptyline hcl tab 10 mg 1* amitriptyline hcl tab 100 mg 1* amitriptyline hcl tab 150 mg 1* amitriptyline hcl tab 25 mg 1* amitriptyline hcl tab 50 mg 1* amitriptyline hcl tab 75 mg 1* amoxapine tab 100 mg 1* amoxapine tab 150 mg 1* amoxapine tab 25 mg 1* amoxapine tab 50 mg 1* clomipramine hcl cap 25 mg 1* clomipramine hcl cap 50 mg 1* clomipramine hcl cap 75 mg 1* desipramine hcl tab 10 mg 1* desipramine hcl tab 100 mg 1* desipramine hcl tab 150 mg 1* desipramine hcl tab 25 mg 1* desipramine hcl tab 50 mg 1* desipramine hcl tab 75 mg 1* doxepin hcl cap 10 mg 1* doxepin hcl cap 100 mg 1* 59 *We provide additional coverage of this drug in the coverage gap for Medicare

60 doxepin hcl cap 150 mg 1* doxepin hcl cap 25 mg 1* doxepin hcl cap 50 mg 1* doxepin hcl cap 75 mg 1* doxepin hcl conc 10 mg/ml 1* imipramine hcl tab 10 mg 1* imipramine hcl tab 25 mg 1* imipramine hcl tab 50 mg 1* nortriptyline hcl cap 10 mg 1* nortriptyline hcl cap 25 mg 1* nortriptyline hcl cap 50 mg 1* nortriptyline hcl cap 75 mg 1* nortriptyline sol10mg/5ml 1 protriptyline hcl tab 10 mg 1* protriptyline hcl tab 5 mg 1* trimipramine maleate cap 100 mg 2** trimipramine maleate cap 25 mg 2** trimipramine maleate cap 50 mg 2** ANTIEMETICS Antiemetics, Other chlorpromazine hcl inj 25 mg/ml 4 chlorpromazine hcl tab 10 mg 1* chlorpromazine hcl tab 100 mg 1* chlorpromazine hcl tab 200 mg 1* chlorpromazine hcl tab 25 mg 1* chlorpromazine hcl tab 50 mg 1* diphenhydramine hcl inj 50 mg/ml 4 meclizine hcl tab 12.5 mg 1* meclizine hcl tab 25 mg 1* metoclopramide hcl inj 5 mg/ml 4 60 *We provide additional coverage of this drug in the coverage gap for Medicare

61 metoclopramide hcl soln 5 mg/5ml (10 mg/10ml) 1* metoclopramide hcl tab 10 mg 1* metoclopramide hcl tab 5 mg 1* perphenazine tab 16 mg 1* perphenazine tab 2 mg 1* perphenazine tab 4 mg 1* perphenazine tab 8 mg 1* prochlorperazine edisylate inj 5 mg/ml 4 prochlorperazine maleate tab 10 mg 1* prochlorperazine maleate tab 5 mg 1* prochlorperazine suppos 25 mg 1* promethazine hcl inj 25 mg/ml 4 promethazine hcl inj 50 mg/ml 4 promethazine hcl suppos 12.5 mg 2** promethazine hcl suppos 25 mg 2** promethazine hcl suppos 50 mg 2** Emetogenic Therapy Adjuncts ALOXI INJ0.25MG/5 4 Quantity limitation 150 per 30 days; This medication requires prior 61 *We provide additional coverage of this drug in the coverage gap for Medicare

62 Quantity limitation 50 per 30 days; ANZEMET INJ20MG/ML 4 ANZEMET TAB100MG 4 Quantity limitation 30 per 30 days; ANZEMET TAB50MG 4 dronabinol cap 10 mg 4 dronabinol cap 2.5 mg 4 dronabinol cap 5 mg 4 EMEND CAP125MG 3 EMEND CAP40MG 3 Quantity limitation 30 per 30 days; Quantity limitation 30 per 30 days; Quantity limitation 30 per 30 days; 62 *We provide additional coverage of this drug in the coverage gap for Medicare

63 EMEND CAP80MG 3 Quantity limitation 30 per 30 days; EMEND PAK80 & Quantity limitation 30 per 30 days; granisetron hcl tab 1 mg 1* Quantity limitation 60 per 30 days ondansetron hcl oral soln 4 mg/5ml 1* Quantity limitation 450 per 30 days ondansetron hcl tab 24 mg 1* Quantity limitation 60 per 30 days ondansetron hcl tab 4 mg 1* Quantity limitation 60 per 30 days ondansetron hcl tab 8 mg 1* Quantity limitation 60 per 30 days ondansetron orally disintegrating tab 4 mg 1* Quantity limitation 60 per 30 days ondansetron orally disintegrating tab 8 mg 1* Quantity limitation 60 per 30 days ANTIFUNGALS Antifungals ABELCET INJ5MG/ML 5 amphotericin b for inj 50 mg 4 63 *We provide additional coverage of this drug in the coverage gap for Medicare

64 CANCIDAS INJ50MG 5 CANCIDAS INJ70MG 5 ciclopirox gel 0.77% 1* ciclopirox olamine cream 0.77% (base equiv) 1* ciclopirox olamine susp 0.77% (base equiv) 1* ciclopirox shampoo 1% 1* ciclopirox solution 8% 1* clotrimazole cream 1% 1* clotrimazole soln 1% 1* clotrimazole troche 10 mg 1* econazole nitrate cream 1% 1* ERAXIS INJ100MG 4 EXELDERM CRE1% 4 EXELDERM SOL1% 4 fluconazole for susp 10 mg/ml 1* fluconazole for susp 40 mg/ml 1* fluconazole in dextrose inj 400 mg/200ml 2** 64 *We provide additional coverage of this drug in the coverage gap for Medicare

65 fluconazole tab 100 mg 1* fluconazole tab 150 mg 1* Quantity limitation 2 per 7 days fluconazole tab 200 mg 1* fluconazole tab 50 mg 1* flucytosine cap 250 mg 2** flucytosine cap 500 mg 2** griseofulvin microsize susp 125 mg/5ml 4 itraconazole cap 100 mg 1* ketoconazole cream 2% 1* ketoconazole shampoo 2% 1* ketoconazole tab 200 mg 1* miconazole nitrate vaginal suppos 200 mg 1* Quantity limitation 3 per 3 days NAFTIN CRE1% 4 NAFTIN GEL1% 4 NATACYN SUS5% OP 3 NOXAFIL SUS40MG/ML 5 nystatin cream unit/gm 1* nystatin oint unit/gm 1* nystatin susp unit/ml 1* nystatin tab unit 1* nystatin topical powder 1* nystatin-triamcinolone cream unit/gm-% 1* nystatin-triamcinolone oint unit/gm-% 1* OXISTAT CRE1% 4 OXISTAT LOT1% 4 terbinafine hcl tab 250 mg 1* terconazole vaginal cream 0.4% 1* Quantity limitation 45 per 7 days terconazole vaginal cream 0.8% 1* terconazole vaginal suppos 80 mg 1* Quantity limitation 3 per 3 days VFEND SUS40MG/ML 5 65 *We provide additional coverage of this drug in the coverage gap for Medicare

66 voriconazole tab 200 mg 2** voriconazole tab 50 mg 2** ZAZOLE CRE0.4% 4 Quantity limitation 45 per 7 days ZOLINZA CAP100MG 5 ANTIGOUT AGENTS Antigout Agents allopurinol tab 100 mg 1* allopurinol tab 300 mg 1* colchicine w/ probenecid tab mg 1* COLCRYS TAB0.6MG 4 Quantity limitation 120 per 30 days probenecid tab 500 mg 1* ULORIC TAB40MG 4 Step therapy protocols apply ULORIC TAB80MG 4 Step therapy protocols apply ANTIMIGRAINE AGENTS Ergot Alkaloids dihydroergotamine mesylate inj 1 mg/ml 3 ergotamine w/ caffeine suppos mg 1* MIGRANAL SPR4MG/ML 4 Quantity limitation 16 per 30 days Prophylactic divalproex sodium tab sr 24 hr 250 mg 1* divalproex sodium tab sr 24 hr 500 mg 1* timolol maleate tab 10 mg 1* timolol maleate tab 20 mg 1* timolol maleate tab 5 mg 1* Serotonin (5-HT) 1b/1d Receptor Agonists 66 *We provide additional coverage of this drug in the coverage gap for Medicare

67 AXERT TAB12.5MG 4 Quantity limitation 12 per 30 days AXERT TAB6.25MG 4 Quantity limitation 12 per 30 days naratriptan hcl tab 1 mg (base equiv) 1* Quantity limitation 9 per 30 days naratriptan hcl tab 2.5 mg (base equiv) 1* Quantity limitation 9 per 30 days RELPAX TAB20MG 3 Quantity limitation 6 per 30 days RELPAX TAB40MG 3 Quantity limitation 6 per 30 days rizatriptan benzoate orally disintegrating tab 10 mg 2** rizatriptan benzoate orally disintegrating tab 5 mg 2** rizatriptan benzoate tab 10 mg 2** rizatriptan benzoate tab 5 mg 2** sumatriptan succinate inj 6 mg/0.5ml 4 Quantity limitation 6 per 30 days sumatriptan succinate inj 6 mg/0.5ml 4 sumatriptan succinate tab 100 mg 2** Quantity limitation 9 per 30 days sumatriptan succinate tab 25 mg 2** Quantity limitation 9 per 30 days sumatriptan succinate tab 50 mg 2** Quantity limitation 9 per 30 days ANTIMYASTHENIC AGENTS Parasympathomimetics GUANIDINE TAB125MG 4 MESTINON SYP60MG/5ML 4 MESTINON TABTIMESPAN 4 pyridostigmine bromide tab 60 mg 1* ANTIMYCOBACTERIALS Antimycobacterials, Other dapsone tab 100 mg 3 dapsone tab 25 mg 3 MYCOBUTIN CAP150MG 4 Antituberculars aminosalicylic acid cr granules packet 4 gm 4 CAPASTAT SULINJ1GM 4 67 *We provide additional coverage of this drug in the coverage gap for Medicare

68 ethambutol hcl tab 100 mg 1* ethambutol hcl tab 400 mg 1* isoniazid syrup 50 mg/5ml 1* isoniazid tab 100 mg 1* isoniazid tab 300 mg 1* PRIFTIN TAB150MG 4 rifampin cap 150 mg 1* rifampin cap 300 mg 1* rifampin for inj 600 mg 4 RIFATER TAB 4 TRECATOR TAB250MG 4 ANTINEOPLASTICS Alkylating Agents CEENU CAP10MG 4 CEENU CAP40MG 4 CYCLOPHOSPH CAP25MG 4 CYCLOPHOSPH CAP50MG 4 cyclophosphamide tab 25 mg 1* cyclophosphamide tab 50 mg 1* cycloserine cap 250 mg 1* EMCYT CAP140MG 4 HEXALEN CAP50MG 5 LEUKERAN TAB2MG 3 LOMUSTINE CAP100MG 4 LOMUSTINE CAP10MG 4 LOMUSTINE CAP40MG 4 MATULANE CAP50MG 4 ZANOSAR INJ1GM 4 68 *We provide additional coverage of this drug in the coverage gap for Medicare

69 Antiangiogenic Agents REVLIMID CAP2.5MG 5 REVLIMID CAP20MG 5 REVLIMID CAP10MG 5 REVLIMID CAP15MG 5 REVLIMID CAP25MG 5 This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at hours a day- seven days This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at hours a day- seven days This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at hours a day- seven days This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at hours a day- seven days This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at *We provide additional coverage of this drug in the coverage gap for Medicare

70 hours a day- seven days REVLIMID CAP5MG 5 THALOMID CAP100MG 5 THALOMID CAP150MG 5 THALOMID CAP200MG 5 THALOMID CAP50MG 5 Antiestrogens/Modifiers FARESTON TAB60MG 4 SOLTAMOX SOL10MG/5ML 4 tamoxifen citrate tab 10 mg (base equivalent) 1* tamoxifen citrate tab 20 mg (base equivalent) 1* Antimetabolites DACOGEN INJ50MG 5 This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at hours a day- seven days decitabine inj50mg 5 DROXIA CAP200MG 4 DROXIA CAP300MG 4 DROXIA CAP400MG 4 gemcitabine hcl for inj 1 gm 4 70 *We provide additional coverage of this drug in the coverage gap for Medicare

71 hydroxyurea cap 500 mg 1* mercaptopurine tab 50 mg 1* TABLOID TAB40MG 4 Antineoplastics, Other AFINITOR TAB10MG 5 Quantity limitation 60 per 30 days AFINITOR TAB2.5MG 5 Quantity limitation 60 per 30 days AFINITOR TAB5MG 5 Quantity limitation 60 per 30 days AFINITOR TAB7.5MG 5 Quantity limitation 60 per 30 days AFINITOR DISTAB2MG 5 Quantity limitation 150 per 30 days AFINITOR DISTAB3MG 5 Quantity limitation 90 per 30 days AFINITOR DISTAB5MG 5 Quantity limitation 60 per 30 days ALIMTA INJ500MG 5 amifostine crystalline for inj 500 mg 5 azacitidine 5 ARRANON INJ5MG/ML 5 71 *We provide additional coverage of this drug in the coverage gap for Medicare

72 BELEODAQ INJ500MG 5 bleomycin sulfate for inj 30 unit 4 DOCEFREZ INJ20MG 5 DOCEFREZ INJ80MG 5 docetaxel for inj conc 80 mg/4ml (20 mg/ml) 4 ELITEK INJ1.5MG 5 72 *We provide additional coverage of this drug in the coverage gap for Medicare

73 FASLODEX INJ250MG 5 FUSILEV INJ50MG 4 HALAVEN INJ1MG/2ML 5 ISTODAX INJ10MG 5 JAKAFI TAB10MG 5 JAKAFI TAB15MG 5 Quantity limitation 60 per 30 days; This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at hours a day- seven days Quantity limitation 60 per 30 days; This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at hours a day- seven days 73 *We provide additional coverage of this drug in the coverage gap for Medicare

74 JAKAFI TAB20MG 5 Quantity limitation 60 per 30 days; This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at hours a day- seven days JAKAFI TAB25MG 5 Quantity limitation 60 per 30 days; This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at hours a day- seven days JAKAFI TAB5MG 5 Quantity limitation 60 per 30 days; This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at hours a day- seven days JEVTANA INJ60/1.5ML 5 leucovorin calcium for inj 100 mg 4 74 *We provide additional coverage of this drug in the coverage gap for Medicare

75 leucovorin calcium for inj 350 mg 4 leucovorin calcium tab 10 mg 2** leucovorin calcium tab 15 mg 2** leucovorin calcium tab 25 mg 2** leucovorin calcium tab 5 mg 2** MESNEX TAB400MG 4 mitoxantrone hcl inj conc 25 mg/12.5ml (2 mg/ml) 4 ONTAK INJ150/ML 5 POMALYST CAP1MG 5 POMALYST CAP2MG 5 POMALYST CAP3MG 5 POMALYST CAP4MG 5 PROLEUKIN INJ22MU 5 SYNRIBO INJ3.5MG 5 75 *We provide additional coverage of this drug in the coverage gap for Medicare

76 TAFINLAR CAP50MG 5 Quantity limitation 180 per 30 days TAFINLAR CAP75MG 5 Quantity limitation 120 per 30 days TRISENOX SOL10MG/10M 4 VELCADE INJ3.5MG 5 VIDAZA INJ100MG 5 Quantity limitation 240 per 30 days; This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at hours a day- seven days a week. TTY users should call 1- ZELBORAF TAB240MG 5 ZYDELIG TAB100MG 5 Quantity limitation 90 per 30 days ZYDELIG TAB150MG 5 Quantity limitation 60 per 30 days Aromatase Inhibitors, 3rd Generation anastrozole tab 1 mg 1* Quantity limitation 30 per 30 days exemestane tab 25 mg 2** letrozole tab 2.5 mg 2** Quantity limitation 30 per 30 days 76 *We provide additional coverage of this drug in the coverage gap for Medicare

77 Enzyme Inhibitors ETOPOPHOS INJ100MG 4 etoposide inj 20 mg/ml 4 etoposide inj 20 mg/ml 3 topotecan hcl for inj 4 mg 4 Molecular Target Inhibitors BOSULIF TAB100MG 5 Quantity limitation 120 per 30 days BOSULIF TAB500MG 5 Quantity limitation 30 per 30 days CAPRELSA TAB100MG 5 Quantity limitation 60 per 30 days; This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at hours a day- seven days CAPRELSA TAB300MG 5 Quantity limitation 30 per 30 days; 77 *We provide additional coverage of this drug in the coverage gap for Medicare

78 This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at hours a day- seven days COMETRIQ KIT100MG 5 Quantity limitation 56 per 28 days COMETRIQ KIT140MG 5 Quantity limitation 112 per 28 days COMETRIQ KIT60MG 5 Quantity limitation 84 per 28 days GILOTRIF TAB20MG 5 Quantity limitation 30 per 30 days GILOTRIF TAB30MG 5 Quantity limitation 30 per 30 days GILOTRIF TAB40MG 5 Quantity limitation 30 per 30 days GLEEVEC TAB100MG 5 Quantity limitation 90 per 30 days GLEEVEC TAB400MG 5 Quantity limitation 60 per 30 days ICLUSIG TAB15MG 5 Quantity limitation 60 per 30 days ICLUSIG TAB45MG 5 Quantity limitation 30 per 30 days IMBRUVICA CAP140MG 5 Quantity limitation 30 per 30 days INLYTA TAB1MG 4 INLYTA TAB5MG 4 MEKINIST TAB0.5MG 5 Quantity limitation 120 per 30 days MEKINIST TAB2MG 5 Quantity limitation 30 per 30 days Quantity limitation 120 per 30 days; This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at hours a day- seven days a week. TTY users should call 1- NEXAVAR TAB200MG 5 SPRYCEL TAB100MG 5 SPRYCEL TAB140MG 5 SPRYCEL TAB20MG 5 SPRYCEL TAB50MG 5 SPRYCEL TAB70MG 5 SPRYCEL TAB80MG 5 STIVARGA TAB40MG 5 Quantity limitation 84 per 28 days SUTENT CAP12.5MG 5 SUTENT CAP25MG 5 78 *We provide additional coverage of this drug in the coverage gap for Medicare

79 SUTENT CAP37.5MG 5 SUTENT CAP50MG 5 TARCEVA TAB100MG 5 TARCEVA TAB150MG 5 TARCEVA TAB25MG 5 TASIGNA CAP150MG 5 TASIGNA CAP200MG 5 TYKERB TAB250MG 5 This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at hours a day- seven days VOTRIENT TAB200MG 5 XALKORI CAP200MG 5 Quantity limitation 60 per 30 days; This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at hours a day- seven days Quantity limitation 60 per 30 days; This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at hours a day- seven days XALKORI CAP250MG 5 ZYKADIA CAP150MG 5 Quantity limitation 150 per 30 days Monoclonal Antibodies ARZERRA CON100/5ML 5 79 *We provide additional coverage of this drug in the coverage gap for Medicare

80 AVASTIN INJ 5 ERIVEDGE CAP150MG 4 HERCEPTIN INJ440MG 5 KADCYLA INJ100MG 4 PERJETA INJ420/14ML 5 RITUXAN INJ500MG 5 YERVOY INJ50MG 5 ZALTRAP INJ100/4ML 5 80 *We provide additional coverage of this drug in the coverage gap for Medicare

81 Retinoids PANRETIN GEL0.1% 5 RETIN-A MICRGEL0.04% 4 RETIN-A MICRGEL0.08% 4 RETIN-A MICRGEL0.1% 4 TARGRETIN CAP75MG 5 TARGRETIN GEL1% 5 Quantity limitation 60 per 30 days tretinoin cap 10 mg 1* tretinoin cream 0.025% 1* tretinoin cream 0.05% 1* tretinoin cream 0.1% 1* tretinoin gel 0.01% 1* tretinoin gel 0.025% 1* ANTIPARASITICS Anthelmintics ALBENZA TAB200MG 3 BILTRICIDE TAB600MG 4 STROMECTOL TAB3MG 4 Antiprotozoals ALINIA SUS100MG/5M 4 ALINIA TAB500MG 4 atovaquone-proguanil hcl tab mg 2** chloroquine phosphate tab 250 mg 1* chloroquine phosphate tab 500 mg 1* DARAPRIM TAB25MG 4 hydroxychloroquine sulfate tab 200 mg 1* mefloquine hcl tab 250 mg 1* MEPRON SUS 3 81 *We provide additional coverage of this drug in the coverage gap for Medicare

82 NEBUPENT INH300MG 4 PENTAM 300 INJ300MG 4 PRIMAQUINE TAB26.3MG 4 Pediculicides/Scabicides EURAX CRE10% 4 EURAX CRE10% EURAX LOT10% 4 EURAX LOT10% lindane lotion 1% 1* lindane lotion 1% lindane shampoo 1% 1* lindane shampoo 1% malathion lotion 0.5% 2** malathion lotion 0.5% permethrin cream 5% 1* permethrin cream 5% ANTIPARKINSON AGENTS Anticholinergics benztropine mesylate tab 0.5 mg 1* benztropine mesylate tab 1 mg 1* benztropine mesylate tab 2 mg 1* trihexyphenidyl hcl elixir 0.4 mg/ml 1* trihexyphenidyl hcl tab 2 mg 1* trihexyphenidyl hcl tab 5 mg 1* Antiparkinson Agents, Other amantadine hcl cap 100 mg 1* amantadine hcl syrup 50 mg/5ml 2** amantadine hcl tab 100 mg 1* COMTAN TAB200MG 3 Quantity limitation 240 per 30 days CYCLOSET TAB0.8MG 4 Quantity limitation 180 per 30 days TASMAR TAB100MG 4 Dopamine Agonists This prescription may be available only at certain pharmacies. For more information consult your APOKYN INJ10MG/ML 5 Pharmacy Directory or call 82 *We provide additional coverage of this drug in the coverage gap for Medicare

83 Member Services at hours a day- seven days ; This medication requires prior authorization. To obtain an exception please call hours a dayseven days a week. TTY users should call 1- bromocriptine mesylate cap 5 mg 1* bromocriptine mesylate tab 2.5 mg 1* pramipexole dihydrochloride tab mg 2** Quantity limitation 90 per 30 days pramipexole dihydrochloride tab 0.25 mg 2** Quantity limitation 90 per 30 days pramipexole dihydrochloride tab 0.5 mg 2** Quantity limitation 90 per 30 days pramipexole dihydrochloride tab 0.75 mg 2 Quantity limitation 90 per 30 days pramipexole dihydrochloride tab 1 mg 2** Quantity limitation 90 per 30 days pramipexole dihydrochloride tab 1.5 mg 2** Quantity limitation 90 per 30 days ropinirole hydrochloride tab 0.25 mg 1* ropinirole hydrochloride tab 0.5 mg 1* ropinirole hydrochloride tab 1 mg 1* ropinirole hydrochloride tab 2 mg 1* ropinirole hydrochloride tab 3 mg 1* ropinirole hydrochloride tab 4 mg 1* ropinirole hydrochloride tab 5 mg 1* Dopamine Precursors/L-Amino Acid Decarboxylase Inhibitors carbidopa & levodopa orally 1* 83 *We provide additional coverage of this drug in the coverage gap for Medicare

84 disintegrating tab mg carbidopa & levodopa orally disintegrating tab mg 1* carbidopa & levodopa orally disintegrating tab mg 1* carbidopa & levodopa tab mg 1* carbidopa & levodopa tab mg 1* carbidopa & levodopa tab mg 1* carbidopa & levodopa tab cr mg 1* carbidopa & levodopa tab cr mg 1* LODOSYN TAB25MG 4 Monoamine Oxidase B (MAO-B) Inhibitors AZILECT TAB0.5MG 4 AZILECT TAB0.5MG AZILECT TAB1MG 4 AZILECT TAB1MG selegiline hcl cap 5 mg 1* selegiline hcl cap 5 mg selegiline hcl tab 5 mg 1* selegiline hcl tab 5 mg ANTIPSYCHOTICS 1st Generation/Typical fluphenazine decanoate inj 25 mg/ml 4 fluphenazine hcl elixir 2.5 mg/5ml 1* fluphenazine hcl inj 2.5 mg/ml 4 fluphenazine hcl oral conc 5 mg/ml 1* fluphenazine hcl tab 1 mg 1* fluphenazine hcl tab 10 mg 1* fluphenazine hcl tab 2.5 mg 1* fluphenazine hcl tab 5 mg 1* haloperidol decanoate im soln 100 mg/ml 4 84 *We provide additional coverage of this drug in the coverage gap for Medicare

85 haloperidol decanoate im soln 50 mg/ml 4 haloperidol lactate inj 5 mg/ml 4 haloperidol lactate oral conc 2 mg/ml 1* haloperidol tab 0.5 mg 1* haloperidol tab 1 mg 1* haloperidol tab 10 mg 1* haloperidol tab 2 mg 1* haloperidol tab 20 mg 1* haloperidol tab 5 mg 1* loxapine succinate cap 10 mg 1* loxapine succinate cap 25 mg 1* loxapine succinate cap 5 mg 1* loxapine succinate cap 50 mg 1* ORAP TAB1MG 4 ORAP TAB2MG 4 thioridazine hcl tab 10 mg 2** thioridazine hcl tab 100 mg 2** thioridazine hcl tab 25 mg 2** thioridazine hcl tab 50 mg 2** thiothixene cap 1 mg 1* thiothixene cap 10 mg 1* thiothixene cap 2 mg 1* thiothixene cap 5 mg 1* trifluoperazine hcl tab 1 mg 1* trifluoperazine hcl tab 10 mg 1* trifluoperazine hcl tab 2 mg 1* trifluoperazine hcl tab 5 mg 1* 2nd Generation/Atypical FANAPT PAK 4 Quantity limitation 60 per 30 days FANAPT TAB10MG 4 Quantity limitation 90 per 30 days FANAPT TAB12MG 4 Quantity limitation 60 per 30 days FANAPT TAB1MG 4 Quantity limitation 720 per 30 days FANAPT TAB2MG 4 Quantity limitation 360 per 30 days FANAPT TAB4MG 4 Quantity limitation 180 per 30 days 85 *We provide additional coverage of this drug in the coverage gap for Medicare

86 FANAPT TAB6MG 4 Quantity limitation 120 per 30 days FANAPT TAB8MG 4 Quantity limitation 90 per 30 days GEODON INJ20MG 4 INVEGA TAB1.5MG 4 Quantity limitation 240 per 30 days INVEGA TAB3MG 4 Quantity limitation 120 per 30 days INVEGA TAB6MG 4 Quantity limitation 60 per 30 days INVEGA TAB9MG 4 Quantity limitation 60 per 30 days INVEGA SUST INJ117/ INVEGA SUST INJ156MG/ML 5 INVEGA SUST INJ234/1.5 5 INVEGA SUST INJ39/ INVEGA SUST INJ78/0.5ML 4 LATUDA TAB120MG 4 Quantity limitation 30 per 30 days LATUDA TAB20MG 4 Quantity limitation 120 per 30 days LATUDA TAB40MG 4 Quantity limitation 60 per 30 days LATUDA TAB60MG 4 Quantity limitation 60 per 30 days LATUDA TAB80MG 4 Quantity limitation 30 per 30 days Quantity limitation 30 per 30 days; olanzapine for im inj 10 mg 4 olanzapine orally disintegrating tab 10 mg 2** Quantity limitation 60 per 30 days olanzapine orally disintegrating tab 15 mg 2** Quantity limitation 60 per 30 days olanzapine orally disintegrating tab 20 mg 2** Quantity limitation 30 per 30 days olanzapine orally disintegrating tab 5 mg 2** Quantity limitation 120 per 30 days olanzapine tab 10 mg 2** Quantity limitation 60 per 30 days olanzapine tab 15 mg 2** Quantity limitation 60 per 30 days olanzapine tab 2.5 mg 2** Quantity limitation 240 per 30 days olanzapine tab 20 mg 2** Quantity limitation 30 per 30 days olanzapine tab 5 mg 2** Quantity limitation 120 per 30 days olanzapine tab 7.5 mg 2** Quantity limitation 90 per 30 days quetiapine fumarate tab 100 mg 2** Quantity limitation 240 per 30 days quetiapine fumarate tab 200 mg 2** Quantity limitation 120 per 30 days 86 *We provide additional coverage of this drug in the coverage gap for Medicare

87 quetiapine fumarate tab 25 mg 2** Quantity limitation 960 per 30 days quetiapine fumarate tab 300 mg 2** Quantity limitation 90 per 30 days quetiapine fumarate tab 400 mg 2** Quantity limitation 60 per 30 days quetiapine fumarate tab 50 mg 2** Quantity limitation 480 per 30 days RISPERDAL INJ12.5MG 4 RISPERDAL INJ25MG 4 RISPERDAL INJ37.5MG 4 RISPERDAL INJ50MG 4 risperidone orally disintegrating tab 0.25 mg 2** Quantity limitation 1920 per 30 days risperidone orally disintegrating tab 0.5 mg 2** Quantity limitation 960 per 30 days risperidone orally disintegrating tab 1 mg 2** Quantity limitation 480 per 30 days risperidone orally disintegrating tab 2 mg 2** Quantity limitation 240 per 30 days risperidone orally disintegrating tab 3 mg 2** Quantity limitation 180 per 30 days risperidone orally disintegrating tab 4 mg 2** Quantity limitation 120 per 30 days risperidone soln 1 mg/ml 1* Quantity limitation 480 per 30 days Quantity limitation 1920 per 30 days risperidone tab 0.25 mg 1* risperidone tab 0.5 mg 1* Quantity limitation 960 per 30 days risperidone tab 1 mg 1* Quantity limitation 480 per 30 days risperidone tab 2 mg 1* Quantity limitation 240 per 30 days risperidone tab 3 mg 1* Quantity limitation 180 per 30 days risperidone tab 4 mg 1* Quantity limitation 120 per 30 days SEROQUEL XR TAB150MG 4 Quantity limitation 30 per 30 days SEROQUEL XR TAB200MG 4 Quantity limitation 30 per 30 days SEROQUEL XR TAB300MG 4 Quantity limitation 60 per 30 days SEROQUEL XR TAB400MG 4 Quantity limitation 60 per 30 days SEROQUEL XR TAB50MG 4 Quantity limitation 60 per 30 days ziprasidone hcl cap 20 mg 2** Quantity limitation 240 per 30 days ziprasidone hcl cap 40 mg 2** Quantity limitation 120 per 30 days ziprasidone hcl cap 60 mg 2** Quantity limitation 90 per 30 days ziprasidone hcl cap 80 mg 2** Quantity limitation 60 per 30 days Treatment Resistent clozapine tab 100 mg 1* Quantity limitation 120 per 30 days clozapine tab 200 mg 1* Quantity limitation 120 per 30 days clozapine tab 25 mg 1* Quantity limitation 120 per 30 days 87 *We provide additional coverage of this drug in the coverage gap for Medicare

88 clozapine tab 50 mg 1* Quantity limitation 120 per 30 days FAZACLO TAB100/ODT 4 Quantity limitation 270 per 30 days FAZACLO TAB150MG 4 Quantity limitation 180 per 30 days FAZACLO TAB200MG 4 Quantity limitation 120 per 30 days FAZACLO TAB25MG ODT 4 Quantity limitation 270 per 30 days FAZACLO TAB12.5/ODT 4 Quantity limitation 270 per 30 days VERSACLOZ SUS50MG/ML 4 Quantity limitation 540 per 30 days ANTISPASTICITY AGENTS Antispasticity Agents baclofen tab 10 mg 1* baclofen tab 20 mg 1* dantrolene sodium cap 100 mg 1* dantrolene sodium cap 25 mg 1* dantrolene sodium cap 50 mg 1* tizanidine hcl cap 2 mg 1* tizanidine hcl cap 4 mg 1* tizanidine hcl cap 6 mg 1* tizanidine hcl tab 2 mg 1* tizanidine hcl tab 4 mg 1* ANTIVIRALS Anti-cytomegalovirus (CMV) Agents foscarnet sodium inj 24 mg/ml 4 ganciclovir sodium for inj 500 mg 4 VALCYTE SOL50MG/ML 5 VALCYTE TAB450MG 5 ZIRGAN GEL0.15% 3 Antihepatitis Agents BARACLUDE SOL.05MG/ML 4 BARACLUDE TAB0.5MG 5 Quantity limitation 600 per 30 days; This medication requires prior Quantity limitation 30 per 30 days; 88 *We provide additional coverage of this drug in the coverage gap for Medicare

89 BARACLUDE TAB1MG 5 EPIVIR HBV SOL5MG/ML 4 EPIVIR HBV TAB100MG 4 HEPSERA TAB10MG 5 INCIVEK TAB375MG 5 INFERGEN INJ15MCG 5 INTRON-A INJ10MU 4 INTRON-A INJ18MU 4 PEGASYS INJ 5 PEGASYS INJ180MCG/M 5 PEGASYS INJPROCLICK 5 PEG-INTRON KIT120 RP 5 Quantity limitation 30 per 30 days; Quantity limitation 2 per 28 days; Quantity limitation 4 per 28 days; Quantity limitation 4 per 28 days; PEG-INTRON KIT150 RP 5 89 *We provide additional coverage of this drug in the coverage gap for Medicare

90 PEG-INTRON KIT50MCG 5 Quantity limitation 5 per 28 days; PEG-INTRON KIT50MCG RP 5 Quantity limitation 4 per 28 days; Quantity limitation 4 per 28 days; PEG-INTRON KIT80MCG RP 5 REBETOL SOL40MG/ML 4 ribavirin cap 200 mg 1* ribavirin tab 200 mg 1* ribavirin tab 400 mg 1* ribavirin tab 400 mg & ribavirin tab 600 mg dose pack 1* ribavirin tab 600 mg 1* Quantity limitation 30 per 30 days; SOVALDI TAB400MG 5 90 *We provide additional coverage of this drug in the coverage gap for Medicare

91 TYZEKA TAB600MG 5 Quantity limitation 360 per 30 days; This medication requires prior VICTRELIS CAP200MG 5 VIRAZOLE INH6GM 4 Antiherpetic Agents acyclovir cap 200 mg 1* acyclovir oint 5% 1* acyclovir sodium for inj 500 mg 4 acyclovir susp 200 mg/5ml 1* acyclovir tab 400 mg 1* acyclovir tab 800 mg 1* DENAVIR CRE1% 4 Quantity limitation 1.5 per 28 days famciclovir tab 125 mg 1* Quantity limitation 21 per 10 days famciclovir tab 250 mg 1* Quantity limitation 60 per 30 days famciclovir tab 500 mg 1* Quantity limitation 21 per 7 days trifluridine ophth soln 1% 1* valacyclovir hcl tab 1 gm 2** Quantity limitation 30 per 30 days valacyclovir hcl tab 500 mg 2** Quantity limitation 30 per 30 days ZOVIRAX CRE5% 4 Quantity limitation 10 per 30 days ZOVIRAX OIN5% 4 Quantity limitation 30 per 30 days Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors EDURANT TAB25MG 5 Quantity limitation 30 per 30 days INTELENCE TAB25MG 4 INTELENCE TAB100MG 5 Quantity limitation 120 per 30 days INTELENCE TAB200MG 5 nevirapine sus50mg/5ml 2 nevirapine tab 200 mg 2** nevirapine tab 400 mg er 2 RESCRIPTOR TAB100 MG 4 RESCRIPTOR TAB200MG 4 91 *We provide additional coverage of this drug in the coverage gap for Medicare

92 SUSTIVA CAP200MG 4 SUSTIVA CAP50MG 4 SUSTIVA TAB600MG 4 VIRAMUNE SUS50MG/5ML 3 VIRAMUNE XR TAB100MG 3 VIRAMUNE XR TAB400MG 3 Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors abacavir sulfate tab 300 mg (base equiv) 2** abacavir/lamivudine/zidovudine 2 ATRIPLA TAB 5 COMPLERA TAB 5 Quantity limitation 30 per 30 days didanosine delayed release capsule 125 mg 1* didanosine delayed release capsule 200 mg 1* didanosine delayed release capsule 250 mg 1* didanosine delayed release capsule 400 mg 1* EMTRIVA CAP200MG 4 EMTRIVA SOL10MG/ML 4 EPIVIR SOL10MG/ML 4 EPZICOM TAB lamivudine tab 100 mg 2** lamivudine tab 150 mg 2** lamivudine tab 300 mg 2** lamivudine-zidovudine tab mg 1* RETROVIR INJ10MG/ML 4 stavudine cap 15 mg 1* stavudine cap 20 mg 1* stavudine cap 30 mg 1* stavudine cap 40 mg 1* stavudine for oral soln 1 mg/ml 1* STRIBILD TAB 4 TRIZIVIR TAB 5 TRUVADA TAB VIDEX SOL2GM 4 VIREAD POW40MG/GM 4 VIREAD TAB150MG 4 92 *We provide additional coverage of this drug in the coverage gap for Medicare

93 VIREAD TAB200MG 4 VIREAD TAB250MG 4 VIREAD TAB300MG 4 ZIAGEN SOL20MG/ML 3 zidovudine cap 100 mg 1* zidovudine syrup 10 mg/ml 1* zidovudine tab 300 mg 1* Anti-HIV Agents, Other FUZEON INJ90MG 3 ISENTRESS CHW100MG 5 ISENTRESS CHW25MG 5 ISENTRESS POW100MG 4 ISENTRESS TAB400MG 5 SELZENTRY TAB150MG 5 SELZENTRY TAB300MG 5 TIVICAY TAB50MG 5 Quantity limitation 60 per 30 days Anti-HIV Agents, Protease Inhibitors APTIVUS CAP250MG 5 APTIVUS SOL 5 Quantity limitation 300 per 30 days CRIXIVAN CAP200MG 4 CRIXIVAN CAP400MG 4 INVIRASE CAP200MG 4 INVIRASE TAB500MG 5 KALETRA SOL 3 KALETRA TAB100-25MG 4 KALETRA TAB200-50MG 4 LEXIVA SUS50MG/ML 4 LEXIVA TAB700MG 4 NORVIR CAP100MG 4 NORVIR SOL80MG/ML 4 NORVIR TAB100MG 4 PREZISTA SUS100MG/ML 4 PREZISTA TAB150MG 4 PREZISTA TAB400MG 5 PREZISTA TAB600MG 5 PREZISTA TAB75MG 4 PREZISTA TAB800MG 4 REYATAZ CAP100MG 3 REYATAZ CAP150MG 3 REYATAZ CAP200MG 3 REYATAZ CAP300MG 3 93 *We provide additional coverage of this drug in the coverage gap for Medicare

94 VIRACEPT TAB250MG 5 VIRACEPT TAB625MG 5 Anti-influenza Agents RELENZA MISDISKHALE 3 Quantity limitation 60 per 180 days rimantadine hydrochloride tab 100 mg 1* TAMIFLU CAP30MG 3 Quantity limitation 84 per 180 days TAMIFLU CAP45MG 3 Quantity limitation 42 per 180 days TAMIFLU CAP75MG 3 Quantity limitation 42 per 180 days TAMIFLU SUS6MG/ML 3 Quantity limitation 900 per 180 days ANXIOLYTICS Anxiolytics, Other alprazolam orally disintegrating tab 0.25 mg 2** Quantity limitation 120 per 30 days alprazolam orally disintegrating tab 0.5 mg 2** Quantity limitation 120 per 30 days alprazolam orally disintegrating tab 1 mg 2** Quantity limitation 120 per 30 days alprazolam orally disintegrating tab 2 mg 2** Quantity limitation 120 per 30 days alprazolam tab 0.25 mg 2** Quantity limitation 120 per 30 days alprazolam tab 0.5 mg 2** Quantity limitation 120 per 30 days alprazolam tab 1 mg 2** Quantity limitation 120 per 30 days alprazolam tab 2 mg 2** Quantity limitation 120 per 30 days alprazolam tab sr 24hr 0.5 mg 2** Quantity limitation 90 per 30 days alprazolam tab sr 24hr 1 mg 2** Quantity limitation 90 per 30 days alprazolam tab sr 24hr 2 mg 2** Quantity limitation 90 per 30 days alprazolam tab sr 24hr 3 mg 2** Quantity limitation 90 per 30 days buspirone hcl tab 10 mg 1* buspirone hcl tab 15 mg 1* buspirone hcl tab 30 mg 1* buspirone hcl tab 5 mg 1* buspirone hcl tab 7.5 mg 1* clonazepam orally disintegrating tab mg 2** clonazepam orally disintegrating tab 0.25 mg 2** clonazepam orally disintegrating tab 0.5 mg 2** 94 *We provide additional coverage of this drug in the coverage gap for Medicare

95 clonazepam orally disintegrating tab 1 mg 2** clonazepam orally disintegrating tab 2 mg 2** clonazepam tab 0.5 mg 2** clonazepam tab 1 mg 2** clonazepam tab 2 mg 2** clorazepate dipotassium tab 15 mg 2** Quantity limitation 90 per 30 days clorazepate dipotassium tab 3.75 mg 2** Quantity limitation 90 per 30 days clorazepate dipotassium tab 7.5 mg 2** Quantity limitation 90 per 30 days DIASTAT ACUDIAL GEL 20MG 4 DIASTAT ACUDIAL GEL 10MG 4 Quantity limitation 30 per 30 days DIASTAT PEDIATRIC GEL 2.5MG 4 Quantity limitation 30 per 30 days DIAZEPAM GEL10MG 4 Quantity limitation 30 per 30 days DIAZEPAM GEL2.5MG 4 Quantity limitation 30 per 30 days DIAZEPAM GEL20MG 4 diazepam conc 5 mg/ml 2** Quantity limitation 240 per 30 days Quantity limitation 1200 per 30 days diazepam soln 1 mg/ml 2** diazepam tab 10 mg 2** Quantity limitation 180 per 30 days diazepam tab 2 mg 2** Quantity limitation 90 per 30 days diazepam tab 5 mg 2** Quantity limitation 240 per 30 days lorazepam conc 2 mg/ml 2** lorazepam tab 0.5 mg 2** Quantity limitation 90 per 30 days lorazepam tab 1 mg 2** Quantity limitation 90 per 30 days lorazepam tab 2 mg 2** Quantity limitation 90 per 30 days meprobamate tab 200 mg 2** meprobamate tab 400 mg 2** ONFI SUS2.5MG/ML 4 ONFI TAB10MG 4 Quantity limitation 60 per 30 days ONFI TAB20MG 4 Quantity limitation 60 per 30 days ONFI TAB5MG 4 Quantity limitation 60 per 30 days PHENOBARB TAB64.8MG 2** Quantity limitation 90 per 30 days PHENOBARB TAB97.2MG 2** Quantity limitation 60 per 30 days phenobarbital elixir 20 mg/5ml 2** phenobarbital tab 100 mg 2** Quantity limitation 1500 per 30 days 95 *We provide additional coverage of this drug in the coverage gap for Medicare

96 phenobarbital tab 15 mg 2** phenobarbital tab 16.2 mg 2** Quantity limitation 360 per 30 days phenobarbital tab 30 mg 2** Quantity limitation 195 per 30 days phenobarbital tab 32.4 mg 2** Quantity limitation 180 per 30 days phenobarbital tab 60 mg 2** temazepam cap 15 mg 1* Quantity limitation 30 per 30 days temazepam cap 22.5 mg 1* Quantity limitation 30 per 30 days temazepam cap 30 mg 1* Quantity limitation 30 per 30 days temazepam cap 7.5 mg 1* Quantity limitation 30 per 30 days BIPOLAR AGENTS Bipolar Agents, Other SAPHRIS SUB10MG 4 Quantity limitation 60 per 30 days SAPHRIS SUB5MG 4 Quantity limitation 120 per 30 days Mood Stabilizers lithium carbonate cap 150 mg 1* lithium carbonate cap 300 mg 1* lithium carbonate cap 600 mg 1* lithium carbonate tab 300 mg 1* lithium carbonate tab cr 300 mg 1* lithium carbonate tab cr 450 mg 1* LITHIUM CITRSOL8MEQ/5ML 4 BLOOD GLUCOSE REGULATORS Antidiabetic Agents acarbose tab 100 mg 1* acarbose tab 25 mg 1* acarbose tab 50 mg 1* Quantity limitation 2.4 per 30 days; BYETTA INJ10MCG 4 Step therapy protocols apply Quantity limitation 2.4 per 30 days; BYETTA INJ5MCG 4 Step therapy protocols apply glimepiride tab 1 mg 1* Quantity limitation 60 per 30 days glimepiride tab 2 mg 1* Quantity limitation 60 per 30 days glimepiride tab 4 mg 1* Quantity limitation 60 per 30 days glipizide tab 10 mg 1* Quantity limitation 120 per 30 days glipizide tab 5 mg 1* Quantity limitation 240 per 30 days glipizide tab sr 24hr 10 mg 1* Quantity limitation 60 per 30 days glipizide tab sr 24hr 2.5 mg 1* Quantity limitation 240 per 30 days glipizide tab sr 24hr 5 mg 1* Quantity limitation 120 per 30 days glipizide-metformin hcl tab mg 1* Quantity limitation 240 per 30 days 96 *We provide additional coverage of this drug in the coverage gap for Medicare

97 glipizide-metformin hcl tab mg 1* Quantity limitation 120 per 30 days glipizide-metformin hcl tab mg 1* Quantity limitation 120 per 30 days glyburide micronized tab 1.5 mg 1* Quantity limitation 120 per 30 days glyburide micronized tab 3 mg 1* Quantity limitation 60 per 30 days glyburide micronized tab 6 mg 1* Quantity limitation 30 per 30 days glyburide tab 1.25 mg 1* Quantity limitation 480 per 30 days glyburide tab 2.5 mg 1* Quantity limitation 240 per 30 days glyburide tab 5 mg 1* Quantity limitation 120 per 30 days glyburide-metformin tab mg 1* Quantity limitation 240 per 30 days glyburide-metformin tab mg 1* Quantity limitation 120 per 30 days glyburide-metformin tab mg 1* Quantity limitation 120 per 30 days GLYSET TAB100MG 4 Quantity limitation 90 per 30 days GLYSET TAB25MG 4 Quantity limitation 90 per 30 days GLYSET TAB50MG 4 Quantity limitation 90 per 30 days Quantity limitation 60 per 30 days; JANUMET TAB Step therapy protocols apply Quantity limitation 60 per 30 days; Step therapy protocols apply JANUMET TAB50-500MG 4 JANUMET XR TAB Quantity limitation 60 per 30 days JANUMET XR TAB Quantity limitation 60 per 30 days JANUMET XR TAB50-500MG 4 Quantity limitation 60 per 30 days JANUVIA TAB100MG 4 Quantity limitation 30 per 30 days JANUVIA TAB25MG 4 Quantity limitation 30 per 30 days JANUVIA TAB50MG 4 Quantity limitation 30 per 30 days JUVISYNC TAB100-10MG 4 Quantity limitation 30 per 30 days JUVISYNC TAB100-20MG 4 Quantity limitation 30 per 30 days JUVISYNC TAB100-40MG 4 Quantity limitation 30 per 30 days JUVISYNC TAB50-10MG 4 Quantity limitation 30 per 30 days JUVISYNC TAB50-20MG 4 Quantity limitation 30 per 30 days JUVISYNC TAB50-40MG 4 Quantity limitation 30 per 30 days metformin hcl tab 1000 mg 1* Quantity limitation 90 per 30 days metformin hcl tab 500 mg 1* Quantity limitation 150 per 30 days metformin hcl tab 850 mg 1* Quantity limitation 90 per 30 days metformin hcl tab sr 24hr 500 mg 1* Quantity limitation 120 per 30 days metformin hcl tab sr 24hr 750 1* Quantity limitation 90 per 30 days 97 *We provide additional coverage of this drug in the coverage gap for Medicare

98 mg nateglinide tab 120 mg 2** Quantity limitation 90 per 30 days nateglinide tab 60 mg 2** Quantity limitation 90 per 30 days pioglitazone hcl tab 15 mg (base equiv) 2** Quantity limitation 30 per 30 days pioglitazone hcl tab 30 mg (base equiv) 2** Quantity limitation 30 per 30 days pioglitazone hcl tab 45 mg (base equiv) 2** Quantity limitation 30 per 30 days pioglitazone hcl-glimepiride tab 30-2 mg 2** Quantity limitation 30 per 30 days pioglitazone hcl-glimepiride tab 30-4 mg 2** Quantity limitation 30 per 30 days pioglitazone hcl-metformin hcl tab mg 2** Quantity limitation 30 per 30 days pioglitazone hcl-metformin hcl tab mg 2** Quantity limitation 90 per 30 days PRANDIMET TAB1-500MG 4 Quantity limitation 150 per 30 days PRANDIMET TAB2-500MG 4 Quantity limitation 150 per 30 days PRANDIN TAB0.5MG 4 Quantity limitation 120 per 30 days PRANDIN TAB1MG 4 Quantity limitation 120 per 30 days PRANDIN TAB2MG 4 Quantity limitation 240 per 30 days Quantity limitation 10.8 per 30 SYMLINPEN 60INJ1000MCG 4 days SYMLNPEN 120INJ1000MCG 4 Quantity limitation 10.8 per 30 days tolazamide tab 250 mg 1* tolazamide tab 500 mg 1* tolbutamide tab 500 mg 1* Blood Glucose Regulators ALCOHOL PREPPAD 3 GAUZE PADS & DRESSING 3 INSULIN NEEDLE 3 INSULIN PEN NEEDLE 3 INSULIN SYRINGE 3 Glycemic Agents GLUCAGEN INJHYPOKIT 3 Quantity limitation 30 per 30 days GLUCAGON KIT1MG 3 Quantity limitation 2 per 30 days PROGLYCEM SUS50MG/ML 4 Insulins APIDRA INJSOLOSTAR 3 Quantity limitation 30 per 30 days 98 *We provide additional coverage of this drug in the coverage gap for Medicare

99 APIDRA INJU Quantity limitation 30 per 30 days HUMALOG INJ100/ML 3 HUMALOG KWIKINJ100/ML 3 HUMALOG MIX INJ50/50 3 Quantity limitation 30 per 30 days HUMALOG MIX INJ50/50KWP 3 Quantity limitation 30 per 30 days HUMALOG MIX INJ75/25KWP 3 Quantity limitation 30 per 30 days HUMALOG MIX SUS75/25 3 Quantity limitation 30 per 30 days HUMULIN INJ70/30 3 Quantity limitation 30 per 30 days HUMULIN N INJU Quantity limitation 30 per 30 days HUMULIN N PNINJU Quantity limitation 30 per 30 days HUMULIN PEN INJ70/30 3 Quantity limitation 30 per 30 days HUMULIN R INJU Quantity limitation 30 per 30 days HUMULIN R INJU Quantity limitation 30 per 30 days LANTUS INJ100/ML 3 Quantity limitation 30 per 30 days LANTUS INJSOLOSTAR 3 Quantity limitation 30 per 30 days LEVEMIR INJ 3 Quantity limitation 30 per 30 days LEVEMIR INJFLEXPEN 3 Quantity limitation 30 per 30 days NOVOLIN INJ70/30 3 Quantity limitation 30 per 30 days NOVOLIN N INJU Quantity limitation 30 per 30 days NOVOLIN R INJU Quantity limitation 30 per 30 days NOVOLOG INJ100/ML 3 Quantity limitation 30 per 30 days NOVOLOG INJFLEXPEN 3 Quantity limitation 30 per 30 days NOVOLOG MIX INJ70/30 3 Quantity limitation 30 per 30 days NOVOLOG MIX INJFLEXPEN 3 Quantity limitation 30 per 30 days BLOOD PRODUCTS/MODIFIERS/ VOLUME EXPANDERS Anticoagulants COUMADIN INJ5 MG 3 enoxaparin sodium inj 100 mg/ml 4 Quantity limitation 28 per 30 days; 99 *We provide additional coverage of this drug in the coverage gap for Medicare

100 Quantity limitation 22.4 per 30 days; This medication requires prior enoxaparin sodium inj 120 mg/0.8ml 4 enoxaparin sodium inj 150 mg/ml 4 enoxaparin sodium inj 30 mg/0.3ml 4 enoxaparin sodium inj 300 mg/3ml 4 enoxaparin sodium inj 40 mg/0.4ml 4 enoxaparin sodium inj 60 mg/0.6ml 4 enoxaparin sodium inj 80 mg/0.8ml 4 Quantity limitation 28 per 30 days; Quantity limitation 8.4 per 30 days; Quantity limitation 11.2 per 30 days; This medication requires prior Quantity limitation 16.8 per 30 days; This medication requires prior Quantity limitation 22.4 per 30 days; This medication requires prior 100 *We provide additional coverage of this drug in the coverage gap for Medicare

101 fondaparinux sodium inj 10 mg/0.8ml 5 fondaparinux sodium inj 2.5 mg/0.5ml 4 fondaparinux sodium inj 5 mg/0.4ml 5 fondaparinux sodium inj 7.5 mg/0.6ml 5 FRAGMIN INJ10000/ML 5 FRAGMIN INJ12500UNT 5 Quantity limitation 24 per 30 days; Quantity limitation 15 per 30 days; Quantity limitation 12 per 30 days; Quantity limitation 18 per 30 days; Quantity limitation 20 per 30 days; Quantity limitation 20 per 30 days; 101 *We provide additional coverage of this drug in the coverage gap for Medicare

102 Quantity limitation 20 per 30 days; FRAGMIN INJ15000UNT 5 FRAGMIN INJ18000UNT 5 Quantity limitation 20 per 30 days; FRAGMIN INJ2500/0.2 4 Quantity limitation 20 per 30 days; FRAGMIN INJ25000/ML 4 Quantity limitation 20 per 30 days; FRAGMIN INJ5000/0.2 4 Quantity limitation 20 per 30 days; FRAGMIN INJ7500/0.3 5 Quantity limitation 20 per 30 days; 102 *We provide additional coverage of this drug in the coverage gap for Medicare

103 HEP SOD/NACLINJ25000UNT 4 HEP SOD/NACLINJ25000UNT 4 heparin sodium (porcine) 2 unit/ml in sodium chloride 0.9% 4 heparin sodium (porcine) 40 unit/ml in d5w 4 heparin sodium (porcine) inj 1000 unit/ml 4 heparin sodium (porcine) inj unit/ml *We provide additional coverage of this drug in the coverage gap for Medicare

104 heparin sodium (porcine) inj unit/ml 4 heparin sodium (porcine) inj 5000 unit/ml 4 PRADAXA CAP150MG 4 Quantity limitation 60 per 30 days; Quantity limitation 60 per 30 days; PRADAXA CAP75MG 4 warfarin sodium tab 1 mg 1* warfarin sodium tab 10 mg 1* warfarin sodium tab 2 mg 1* warfarin sodium tab 2.5 mg 1* warfarin sodium tab 3 mg 1* warfarin sodium tab 4 mg 1* warfarin sodium tab 5 mg 1* warfarin sodium tab 6 mg 1* warfarin sodium tab 7.5 mg 1* XARELTO TAB10MG 4 Quantity limitation 30 per 30 days 104 *We provide additional coverage of this drug in the coverage gap for Medicare

105 XARELTO TAB15MG 4 Quantity limitation 30 per 30 days XARELTO TAB20MG 4 Quantity limitation 30 per 30 days Blood Formation Modifiers anagrelide hcl cap 0.5 mg 1* anagrelide hcl cap 1 mg 1* ARANESP INJ100MCG 4 Quantity limitation 4 per 28 days; ARANESP INJ150MCG 5 Quantity limitation 1.2 per 28 days; ARANESP INJ200MCG 5 Quantity limitation 4 per 28 days; ARANESP INJ25MCG 4 Quantity limitation 4 per 28 days; Quantity limitation 4 per 28 days; ARANESP INJ300MCG 5 Quantity limitation 1.6 per 28 days; ARANESP INJ40MCG *We provide additional coverage of this drug in the coverage gap for Medicare

106 Quantity limitation 4 per 28 days; ARANESP INJ500MCG 5 ARANESP INJ60MCG 4 Quantity limitation 4 per 28 days; EPOGEN INJ10000/ML 4 EPOGEN INJ2000/ML 4 Quantity limitation 12 per 28 days; EPOGEN INJ20000/ML 4 EPOGEN INJ3000/ML 3 Quantity limitation 12 per 28 days; 106 *We provide additional coverage of this drug in the coverage gap for Medicare

107 Quantity limitation 12 per 28 days; EPOGEN INJ4000/ML 4 LEUKINE INJ250MCG 4 LEUKINE INJ500 MCG 4 methylergonovine maleate tab 0.2 mg 2** NEULASTA INJ6MG/0.6M 5 NEUMEGA INJ5MG 5 NEUPOGEN INJ300/0.5 5 Quantity limitation 2 per 30 days; Quantity limitation 21 per 21 days; 107 *We provide additional coverage of this drug in the coverage gap for Medicare

108 NEUPOGEN INJ480/0.8 5 NEUPOGEN INJ480MCG 5 PROCRIT INJ10000/ML 4 PROCRIT INJ2000/ML 4 Quantity limitation 12 per 28 days; PROCRIT INJ20000/ML 5 PROCRIT INJ3000/ML 4 Quantity limitation 12 per 28 days; PROCRIT INJ4000/ML 4 Quantity limitation 12 per 28 days; 108 *We provide additional coverage of this drug in the coverage gap for Medicare

109 PROCRIT INJ40000/ML 5 This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at hours a day- seven days PROMACTA TAB12.5MG 5 PROMACTA TAB25MG 5 Quantity limitation 90 per 30 days; This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at hours a day- seven days ; This medication requires prio PROMACTA TAB50MG 5 Quantity limitation 90 per 30 days; This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at hours a day- seven days ; This medication requires prio PROMACTA TAB75MG 5 This prescription may be available only at certain pharmacies. For more information consult your 109 *We provide additional coverage of this drug in the coverage gap for Medicare

110 Pharmacy Directory or call Member Services at hours a day- seven days Coagulants CYKLOKAPRON INJ100MG/ML 3 tranexamic acid inj 100 mg/ml 4 Platelet Modifying Agents AGGRENOX CAP25-200MG 4 cilostazol tab 100 mg 1* cilostazol tab 50 mg 1* clopidogrel bisulfate tab 300 mg (base equiv) 2** Quantity limitation 30 per 30 days clopidogrel bisulfate tab 75 mg (base equiv) 2** Quantity limitation 30 per 30 days EFFIENT TAB10MG 4 Quantity limitation 30 per 30 days EFFIENT TAB5MG 4 Quantity limitation 30 per 30 days ERWINAZE INJ10000UNT 5 ONCASPAR INJ750/ML 5 ticlopidine hcl tab 250 mg 1* CARDIOVASCULAR AGENTS Alpha-adrenergic Agonists *We provide additional coverage of this drug in the coverage gap for Medicare

111 clonidine hcl tab 0.1 mg 1* clonidine hcl tab 0.2 mg 1* clonidine hcl tab 0.3 mg 1* clonidine hcl td patch weekly 0.1 mg/24hr 2** Quantity limitation 4 per 28 days clonidine hcl td patch weekly 0.2 mg/24hr 2** Quantity limitation 4 per 28 days clonidine hcl td patch weekly 0.3 mg/24hr 2** Quantity limitation 4 per 28 days guanfacine hcl tab 1 mg 1* guanfacine hcl tab 2 mg 1* methyldopa & hydrochlorothiazide tab mg 1* methyldopa & hydrochlorothiazide tab mg 1* methyldopa tab 250 mg 1* methyldopa tab 500 mg 1* methyldopate hcl inj 250 mg/5ml 4 midodrine hcl tab 10 mg 1* midodrine hcl tab 2.5 mg 1* midodrine hcl tab 5 mg 1* Alpha-adrenergic Blocking Agents doxazosin mesylate tab 1 mg 1* Quantity limitation 30 per 30 days doxazosin mesylate tab 2 mg 1* Quantity limitation 30 per 30 days doxazosin mesylate tab 4 mg 1* Quantity limitation 30 per 30 days doxazosin mesylate tab 8 mg 1* Quantity limitation 60 per 30 days prazosin hcl cap 1 mg 1* prazosin hcl cap 2 mg 1* prazosin hcl cap 5 mg 1* RESERPINE TAB0.1MG 4 RESERPINE TAB0.25MG 4 terazosin hcl cap 1 mg 1* Quantity limitation 30 per 30 days terazosin hcl cap 10 mg 1* Quantity limitation 60 per 30 days 111 *We provide additional coverage of this drug in the coverage gap for Medicare

112 terazosin hcl cap 2 mg 1* Quantity limitation 30 per 30 days terazosin hcl cap 5 mg 1* Quantity limitation 30 per 30 days Angiotensin II Receptor Antagonists BENICAR TAB20MG 4 Quantity limitation 30 per 30 days BENICAR TAB40MG 4 Quantity limitation 30 per 30 days BENICAR TAB5MG 4 Quantity limitation 30 per 30 days BENICAR HCT TAB Quantity limitation 30 per 30 days BENICAR HCT TAB Quantity limitation 30 per 30 days BENICAR HCT TAB40-25MG 4 Quantity limitation 30 per 30 days candesartan cilexetilhydrochlorothiazide tab mg 2** Quantity limitation 30 per 30 days candesartan cilexetilhydrochlorothiazide tab mg 2** Quantity limitation 30 per 30 days candesartan cilexetilhydrochlorothiazide tab mg 2** Quantity limitation 30 per 30 days eprosartan mesylate tab 600 mg 1* irbesartan tab 150 mg 2** irbesartan tab 300 mg 2** irbesartan tab 75 mg 2** irbesartan-hydrochlorothiazide tab mg 2** irbesartan-hydrochlorothiazide tab mg 2** losartan potassium & hydrochlorothiazide tab mg 1* Quantity limitation 30 per 30 days losartan potassium & hydrochlorothiazide tab mg 1* Quantity limitation 30 per 30 days losartan potassium & hydrochlorothiazide tab mg 1* Quantity limitation 30 per 30 days losartan potassium tab 100 mg 1* Quantity limitation 30 per 30 days losartan potassium tab 25 mg 1* Quantity limitation 30 per 30 days losartan potassium tab 50 mg 1* Quantity limitation 30 per 30 days Quantity limitation 30 per 30 days; TEKAMLO TAB150-10MG 4 Step therapy protocols apply TEKAMLO TAB150-5MG 4 Quantity limitation 30 per 30 days; 112 *We provide additional coverage of this drug in the coverage gap for Medicare

113 Step therapy protocols apply Quantity limitation 30 per 30 days; TEKAMLO TAB300-10MG 4 Step therapy protocols apply TEKAMLO TAB300-5MG 4 Quantity limitation 30 per 30 days; Step therapy protocols apply TEKTURNA TAB150MG 4 Quantity limitation 30 per 30 days; Step therapy protocols apply TEKTURNA TAB300MG 4 Quantity limitation 30 per 30 days; Step therapy protocols apply Quantity limitation 30 per 30 days; TEKTURNA HCTTAB Step therapy protocols apply TEKTURNA HCTTAB150-25MG 4 Quantity limitation 30 per 30 days; Step therapy protocols apply TEKTURNA HCTTAB Quantity limitation 30 per 30 days; Step therapy protocols apply TEKTURNA HCTTAB300-25MG 4 Quantity limitation 30 per 30 days; Step therapy protocols apply valsartan-hydrochlorothiazide tab mg 2** Quantity limitation 30 per 30 days valsartan-hydrochlorothiazide tab mg 2** Quantity limitation 30 per 30 days valsartan-hydrochlorothiazide tab mg 2** Quantity limitation 30 per 30 days valsartan-hydrochlorothiazide tab mg 2** Quantity limitation 30 per 30 days valsartan-hydrochlorothiazide tab mg 2** Quantity limitation 30 per 30 days Angiotensin-converting Enzyme (ACE) Inhibitors benazepril & hydrochlorothiazide tab mg 1* benazepril & hydrochlorothiazide tab mg 1* benazepril & hydrochlorothiazide tab mg 1* benazepril & hydrochlorothiazide tab mg 1* benazepril hcl tab 10 mg 1* benazepril hcl tab 20 mg 1* benazepril hcl tab 40 mg 1* benazepril hcl tab 5 mg 1* captopril & hydrochlorothiazide 1* 113 *We provide additional coverage of this drug in the coverage gap for Medicare

114 tab mg captopril & hydrochlorothiazide tab mg 1* captopril & hydrochlorothiazide tab mg 1* captopril & hydrochlorothiazide tab mg 1* captopril tab 100 mg 1* captopril tab 12.5 mg 1* captopril tab 25 mg 1* captopril tab 50 mg 1* enalapril maleate & hydrochlorothiazide tab mg 1* enalapril maleate & hydrochlorothiazide tab mg 1* enalapril maleate tab 10 mg 1* enalapril maleate tab 2.5 mg 1* enalapril maleate tab 20 mg 1* enalapril maleate tab 5 mg 1* fosinopril sodium & hydrochlorothiazide tab mg 1* fosinopril sodium & hydrochlorothiazide tab mg 1* fosinopril sodium tab 10 mg 1* fosinopril sodium tab 20 mg 1* fosinopril sodium tab 40 mg 1* lisinopril & hydrochlorothiazide tab mg 1* lisinopril & hydrochlorothiazide tab mg 1* lisinopril & hydrochlorothiazide tab mg 1* lisinopril tab 10 mg 1* lisinopril tab 2.5 mg 1* lisinopril tab 20 mg 1* lisinopril tab 30 mg 1* lisinopril tab 40 mg 1* 114 *We provide additional coverage of this drug in the coverage gap for Medicare

115 lisinopril tab 5 mg 1* moexipril hcl tab 15 mg 1* moexipril hcl tab 7.5 mg 1* moexipril-hydrochlorothiazide tab mg 1* moexipril-hydrochlorothiazide tab mg 1* moexipril-hydrochlorothiazide tab mg 1* quinapril hcl tab 10 mg 1* quinapril hcl tab 20 mg 1* quinapril hcl tab 40 mg 1* quinapril hcl tab 5 mg 1* quinapril-hydrochlorothiazide tab mg 1* quinapril-hydrochlorothiazide tab mg 1* quinapril-hydrochlorothiazide tab mg 1* ramipril cap 1.25 mg 1* Quantity limitation 60 per 30 days ramipril cap 10 mg 1* Quantity limitation 60 per 30 days ramipril cap 2.5 mg 1* Quantity limitation 60 per 30 days ramipril cap 5 mg 1* Quantity limitation 60 per 30 days trandolapril tab 1 mg 1* trandolapril tab 2 mg 1* trandolapril tab 4 mg 1* Antiarrhythmics acebutolol hcl cap 200 mg 1* acebutolol hcl cap 400 mg 1* amiodarone hcl tab 100 mg 1* amiodarone hcl tab 200 mg 1* amiodarone hcl tab 400 mg 1* disopyramide phosphate cap 100 mg 1* disopyramide phosphate cap 150 mg 1* flecainide acetate tab 100 mg 1* flecainide acetate tab 150 mg 1* flecainide acetate tab 50 mg 1* mexiletine hcl cap 150 mg 1* mexiletine hcl cap 200 mg 1* 115 *We provide additional coverage of this drug in the coverage gap for Medicare

116 mexiletine hcl cap 250 mg 1* Quantity limitation 60 per 30 days; MULTAQ TAB400MG 4 procainamide hcl inj 100 mg/ml 4 propafenone hcl tab 150 mg 1* propafenone hcl tab 225 mg 1* propafenone hcl tab 300 mg 1* quinidine gluconate tab cr 324 mg 1* quinidine sulfate tab 200 mg 1* quinidine sulfate tab 300 mg 1* quinidine sulfate tab cr 300 mg 1* sotalol hcl (afib/afl) tab 120 mg 1* sotalol hcl tab 120 mg 1* sotalol hcl tab 160 mg 1* sotalol hcl tab 240 mg 1* sotalol hcl tab 80 mg 1* TIKOSYN CAP125MCG 4 TIKOSYN CAP250MCG 4 TIKOSYN CAP500MCG 4 Beta-adrenergic Blocking Agents atenolol & chlorthalidone tab mg 1* atenolol & chlorthalidone tab mg 1* atenolol tab 100 mg 1* atenolol tab 25 mg 1* atenolol tab 50 mg 1* betaxolol hcl tab 10 mg 1* betaxolol hcl tab 20 mg 1* 116 *We provide additional coverage of this drug in the coverage gap for Medicare

117 bisoprolol & hydrochlorothiazide tab mg 1* bisoprolol & hydrochlorothiazide tab mg 1* bisoprolol & hydrochlorothiazide tab mg 1* bisoprolol fumarate tab 10 mg 1* bisoprolol fumarate tab 5 mg 1* carvedilol tab 12.5 mg 1* Quantity limitation 60 per 30 days carvedilol tab 25 mg 1* Quantity limitation 60 per 30 days carvedilol tab mg 1* Quantity limitation 60 per 30 days carvedilol tab 6.25 mg 1* Quantity limitation 60 per 30 days COREG CR CAP10MG 3 Quantity limitation 30 per 30 days COREG CR CAP20MG 3 Quantity limitation 30 per 30 days COREG CR CAP40MG 3 Quantity limitation 30 per 30 days COREG CR CAP80MG 3 Quantity limitation 30 per 30 days INNOPRAN XL CAP120MG 4 INNOPRAN XL CAP80MG 4 labetalol hcl tab 100 mg 1* labetalol hcl tab 200 mg 1* labetalol hcl tab 300 mg 1* LEVATOL TAB20MG 4 metoprolol & hydrochlorothiazide tab mg 1* metoprolol & hydrochlorothiazide tab mg 1* metoprolol & hydrochlorothiazide tab mg 1* metoprolol succinate tab sr 24hr 100 mg 1* Quantity limitation 30 per 30 days metoprolol succinate tab sr 24hr 200 mg 1* Quantity limitation 60 per 30 days metoprolol succinate tab sr 24hr 25 mg 1* Quantity limitation 30 per 30 days metoprolol succinate tab sr 24hr 50 mg 1* Quantity limitation 30 per 30 days metoprolol tartrate inj 1 mg/ml *We provide additional coverage of this drug in the coverage gap for Medicare

118 metoprolol tartrate tab 100 mg 1* metoprolol tartrate tab 25 mg 1* metoprolol tartrate tab 50 mg 1* nadolol & bendroflumethiazide tab 40-5 mg 1* nadolol & bendroflumethiazide tab 80-5 mg 1* nadolol tab 20 mg 1* nadolol tab 40 mg 1* nadolol tab 80 mg 1* pindolol tab 10 mg 1* pindolol tab 5 mg 1* propranolol & hydrochlorothiazide tab mg 1* propranolol & hydrochlorothiazide tab mg 1* propranolol hcl cap sr 24hr 120 mg 1* propranolol hcl cap sr 24hr 160 mg 1* propranolol hcl cap sr 24hr 60 mg 1* propranolol hcl cap sr 24hr 80 mg 1* propranolol hcl inj 1 mg/ml 4 propranolol hcl oral soln 20 mg/5ml 1* propranolol hcl oral soln 40 1* 118 *We provide additional coverage of this drug in the coverage gap for Medicare

119 mg/5ml propranolol hcl tab 10 mg 1* propranolol hcl tab 20 mg 1* propranolol hcl tab 40 mg 1* propranolol hcl tab 60 mg 1* propranolol hcl tab 80 mg 1* Calcium Channel Blocking Agents amlodipine besylate tab 10 mg 1* Quantity limitation 30 per 30 days amlodipine besylate tab 2.5 mg 1* Quantity limitation 30 per 30 days amlodipine besylate tab 5 mg 1* Quantity limitation 30 per 30 days amlodipine besylate-benazepril hcl cap mg 1* Quantity limitation 30 per 30 days amlodipine besylate-benazepril hcl cap mg 1* Quantity limitation 30 per 30 days amlodipine besylate-benazepril hcl cap mg 1* Quantity limitation 30 per 30 days amlodipine besylate-benazepril hcl cap 5-10 mg 1* Quantity limitation 30 per 30 days amlodipine besylate-benazepril hcl cap 5-20 mg 1* Quantity limitation 30 per 30 days amlodipine besylate-benazepril hcl cap 5-40 mg 1* Quantity limitation 30 per 30 days diltiazem hcl cap sr 12hr 120 mg 1* diltiazem hcl cap sr 12hr 60 mg 1* diltiazem hcl cap sr 12hr 90 mg 1* diltiazem hcl cap sr 24hr 180 mg 1* diltiazem hcl cap sr 24hr 240 mg 1* diltiazem hcl coated beads cap sr 24hr 120 mg 1* diltiazem hcl coated beads cap sr 24hr 180 mg 1* diltiazem hcl coated beads cap sr 24hr 240 mg 1* diltiazem hcl coated beads cap sr 24hr 300 mg 1* diltiazem hcl extended release beads cap sr 24hr 120 mg 1* diltiazem hcl extended release beads cap sr 24hr 180 mg 1* diltiazem hcl extended release beads cap sr 24hr 240 mg 1* 119 *We provide additional coverage of this drug in the coverage gap for Medicare

120 diltiazem hcl extended release beads cap sr 24hr 300 mg 1* diltiazem hcl extended release beads cap sr 24hr 360 mg 1* diltiazem hcl extended release beads cap sr 24hr 420 mg 1* diltiazem hcl tab 120 mg 1* diltiazem hcl tab 30 mg 1* diltiazem hcl tab 60 mg 1* diltiazem hcl tab 90 mg 1* felodipine tab sr 24hr 10 mg 1* felodipine tab sr 24hr 2.5 mg 1* felodipine tab sr 24hr 5 mg 1* isradipine cap 2.5 mg 1* isradipine cap 5 mg 1* nicardipine hcl cap 20 mg 1* nicardipine hcl cap 30 mg 1* nifedipine tab sr 24hr 30 mg 1* nifedipine tab sr 24hr 60 mg 1* nifedipine tab sr 24hr 90 mg 1* nifedipine tab sr 24hr osmotic 30 mg 1* nifedipine tab sr 24hr osmotic 60 mg 1* nifedipine tab sr 24hr osmotic 90 mg 1* nimodipine cap 30 mg 1* nisoldipine tab sr 24hr 17 mg 1* nisoldipine tab sr 24hr 20 mg 1* nisoldipine tab sr 24hr 25.5 mg 1* nisoldipine tab sr 24hr 30 mg 1* nisoldipine tab sr 24hr 34 mg 1* nisoldipine tab sr 24hr 40 mg 1* nisoldipine tab sr 24hr 8.5 mg 1* verapamil hcl cap sr 24hr 100 mg 1* verapamil hcl cap sr 24hr 120 mg 1* verapamil hcl cap sr 24hr 180 mg 1* verapamil hcl cap sr 24hr 200 1* 120 *We provide additional coverage of this drug in the coverage gap for Medicare

121 mg verapamil hcl cap sr 24hr 240 mg 1* verapamil hcl cap sr 24hr 300 mg 1* verapamil hcl cap sr 24hr 360 mg 1* verapamil hcl iv soln 2.5 mg/ml 4 verapamil hcl tab 120 mg 1* verapamil hcl tab 40 mg 1* verapamil hcl tab 80 mg 1* verapamil hcl tab cr 120 mg 1* verapamil hcl tab cr 180 mg 1* verapamil hcl tab cr 240 mg 1* Cardiovascular Agents, Other DIGOXIN SOL50MCG/ML 4 digoxin inj 0.25 mg/ml 4 digoxin tab mg 1* digoxin tab 0.25 mg 1* pentoxifylline tab cr 400 mg 1* RANEXA TAB1000MG 3 Quantity limitation 120 per 30 days RANEXA TAB500MG 3 Quantity limitation 120 per 30 days Diuretics, Carbonic Anhydrase Inhibitors acetazolamide cap sr 12hr 500 mg 1* acetazolamide sodium for inj 500 mg 4 acetazolamide tab 125 mg 1* acetazolamide tab 250 mg 1* methazolamide tab 25 mg 1* methazolamide tab 50 mg 1* Diuretics, Loop amiloride & hydrochlorothiazide tab 5-50 mg 1* amiloride hcl tab 5 mg 1* 121 *We provide additional coverage of this drug in the coverage gap for Medicare

122 bumetanide tab 0.5 mg 1* bumetanide tab 1 mg 1* bumetanide tab 2 mg 1* furosemide inj 10 mg/ml 4 furosemide oral soln 10 mg/ml 1* furosemide oral soln 8 mg/ml 1* furosemide tab 20 mg 1* furosemide tab 40 mg 1* furosemide tab 80 mg 1* torsemide tab 10 mg 1* torsemide tab 100 mg 1* torsemide tab 20 mg 1* torsemide tab 5 mg 1* Diuretics, Potassium-sparing eplerenone tab 25 mg 1* eplerenone tab 50 mg 1* spironolactone tab 100 mg 1* spironolactone tab 25 mg 1* spironolactone tab 50 mg 1* Diuretics, Thiazide chlorothiazide tab 250 mg 1* chlorothiazide tab 500 mg 1* chlorthalidone tab 25 mg 1* chlorthalidone tab 50 mg 1* hydrochlorothiazide cap 12.5 mg 1* hydrochlorothiazide tab 12.5 mg 2** hydrochlorothiazide tab 25 mg 1* hydrochlorothiazide tab 50 mg 1* indapamide tab 1.25 mg 1* indapamide tab 2.5 mg 1* methyclothiazide tab 5 mg 1* metolazone tab 10 mg 1* metolazone tab 2.5 mg 1* metolazone tab 5 mg 1* spironolactone & 1* 122 *We provide additional coverage of this drug in the coverage gap for Medicare

123 hydrochlorothiazide tab mg triamterene & hydrochlorothiazide cap mg 1* triamterene & hydrochlorothiazide tab mg 1* triamterene & hydrochlorothiazide tab mg 1* Dyslipidemics, Fibric Acid Derivatives fenofibrate micronized cap 134 mg 2** Quantity limitation 30 per 30 days fenofibrate micronized cap 200 mg 2** Quantity limitation 30 per 30 days fenofibrate micronized cap 67 mg 2** Quantity limitation 30 per 30 days fenofibrate tab 160 mg 2** Quantity limitation 30 per 30 days fenofibrate tab 54 mg 2** Quantity limitation 30 per 30 days gemfibrozil tab 600 mg 1* Dyslipidemics, HMG CoA Reductase Inhibitors atorvastatin calcium tab 10 mg (base equivalent) 1* Quantity limitation 30 per 30 days atorvastatin calcium tab 20 mg (base equivalent) 1* Quantity limitation 30 per 30 days atorvastatin calcium tab 40 mg (base equivalent) 1* Quantity limitation 30 per 30 days atorvastatin calcium tab 80 mg (base equivalent) 1* Quantity limitation 30 per 30 days Quantity limitation 30 per 30 days; CRESTOR TAB10MG 4 Step therapy protocols apply CRESTOR TAB20MG 4 Quantity limitation 30 per 30 days; Step therapy protocols apply Quantity limitation 30 per 30 days; CRESTOR TAB40MG 4 Step therapy protocols apply Quantity limitation 30 per 30 days; Step therapy protocols apply CRESTOR TAB5MG 4 lovastatin tab 10 mg 1* Quantity limitation 30 per 30 days lovastatin tab 20 mg 1* Quantity limitation 30 per 30 days lovastatin tab 40 mg 1* Quantity limitation 60 per 30 days 123 *We provide additional coverage of this drug in the coverage gap for Medicare

124 pravastatin sodium tab 10 mg 1* Quantity limitation 30 per 30 days pravastatin sodium tab 20 mg 1* Quantity limitation 30 per 30 days pravastatin sodium tab 40 mg 1* Quantity limitation 60 per 30 days pravastatin sodium tab 80 mg 1* Quantity limitation 30 per 30 days simvastatin tab 10 mg 1* Quantity limitation 30 per 30 days simvastatin tab 20 mg 1* Quantity limitation 30 per 30 days simvastatin tab 40 mg 1* Quantity limitation 30 per 30 days simvastatin tab 5 mg 1* Quantity limitation 30 per 30 days simvastatin tab 80 mg 1* Quantity limitation 30 per 30 days Dyslipidemics, Other cholestyramine light powder 4 gm/dose 2** cholestyramine light powder packets 4 gm 2** colestipol hcl granules 5 gm 2** colestipol hcl tab 1 gm 2** LOVAZA CAP1GM 4 niacin (antihyperlipidemic) tab 500 mg 1* NIASPAN TAB1000 ER 3 Quantity limitation 60 per 30 days NIASPAN TAB500MG ER 3 Quantity limitation 60 per 30 days NIASPAN TAB750MG ER 3 Quantity limitation 60 per 30 days SIMCOR TAB Quantity limitation 60 per 30 days SIMCOR TAB Quantity limitation 60 per 30 days SIMCOR TAB500-20MG 3 Quantity limitation 60 per 30 days SIMCOR TAB500-40MG 3 Quantity limitation 60 per 30 days SIMCOR TAB750-20MG 3 Quantity limitation 60 per 30 days VYTORIN TAB10-10MG 4 Quantity limitation 30 per 30 days; Step therapy protocols apply VYTORIN TAB10-20MG 4 Quantity limitation 30 per 30 days; Step therapy protocols apply Quantity limitation 30 per 30 days; VYTORIN TAB10-40MG 4 Step therapy protocols apply Quantity limitation 30 per 30 days; Step therapy protocols apply VYTORIN TAB10-80MG 4 WELCHOL PAK3.75GM 4 WELCHOL TAB625MG 4 ZETIA TAB10MG 4 Quantity limitation 30 per 30 days Vasodilators, Direct-acting Arterial hydralazine hcl inj 20 mg/ml *We provide additional coverage of this drug in the coverage gap for Medicare

125 hydralazine hcl tab 10 mg 1* hydralazine hcl tab 100 mg 1* hydralazine hcl tab 25 mg 1* hydralazine hcl tab 50 mg 1* minoxidil tab 10 mg 1* minoxidil tab 2.5 mg 1* Vasodilators, Direct-acting Arterial/Venous isosorbide dinitrate sl tab 2.5 mg 1* isosorbide dinitrate tab 10 mg 1* isosorbide dinitrate tab 20 mg 1* isosorbide dinitrate tab 30 mg 1* isosorbide dinitrate tab 5 mg 1* isosorbide dinitrate tab cr 40 mg 1* isosorbide mononitrate tab 10 mg 1* isosorbide mononitrate tab 20 mg 1* isosorbide mononitrate tab sr 24hr 120 mg 1* isosorbide mononitrate tab sr 24hr 30 mg 1* isosorbide mononitrate tab sr 24hr 60 mg 1* NITRO-DUR DIS0.3MG/HR 4 NITRO-DUR DIS0.8MG/HR 4 nitroglycerin iv soln 5 mg/ml 4 nitroglycerin td patch 24hr 0.1 mg/hr 1* nitroglycerin td patch 24hr 0.2 mg/hr 1* 125 *We provide additional coverage of this drug in the coverage gap for Medicare

126 nitroglycerin td patch 24hr 0.4 mg/hr 1* nitroglycerin td patch 24hr 0.6 mg/hr 1* NITROLINGUALSPRPUMPSPR A 4 NITROSTAT SUB0.3MG 3 NITROSTAT SUB0.4MG 3 NITROSTAT SUB0.6MG 3 CENTRAL NERVOUS SYSTEM AGENTS Attention Deficit Hyperactivity Disorder Agents, Amphetamines amphetaminedextroamphetamine cap sr 24hr 10 mg 2** Quantity limitation 30 per 30 days amphetaminedextroamphetamine cap sr 24hr 15 mg 2** Quantity limitation 30 per 30 days amphetaminedextroamphetamine cap sr 24hr 20 mg 2** Quantity limitation 60 per 30 days amphetaminedextroamphetamine cap sr 24hr 25 mg 2** Quantity limitation 60 per 30 days amphetaminedextroamphetamine cap sr 24hr 30 mg 2** Quantity limitation 60 per 30 days amphetaminedextroamphetamine cap sr 24hr 5 mg 2** Quantity limitation 30 per 30 days amphetaminedextroamphetamine tab 10 mg 2** amphetaminedextroamphetamine tab 12.5 mg 2** amphetaminedextroamphetamine tab 15 mg 2** amphetaminedextroamphetamine tab 20 mg 2** amphetaminedextroamphetamine tab 30 mg 2** amphetaminedextroamphetamine tab 5 mg 2** 126 *We provide additional coverage of this drug in the coverage gap for Medicare

127 amphetaminedextroamphetamine tab 7.5 mg 2** dextroamphetamine sulfate tab 10 mg 2** dextroamphetamine sulfate tab 5 mg 2** INTUNIV TAB1MG 4 INTUNIV TAB2MG 4 INTUNIV TAB3MG 4 INTUNIV TAB4MG 4 STRATTERA CAP100MG 3 Quantity limitation 60 per 30 days STRATTERA CAP10MG 3 Quantity limitation 60 per 30 days STRATTERA CAP18MG 3 Quantity limitation 60 per 30 days STRATTERA CAP25MG 3 Quantity limitation 60 per 30 days STRATTERA CAP40MG 3 Quantity limitation 60 per 30 days STRATTERA CAP60MG 3 Quantity limitation 60 per 30 days STRATTERA CAP80MG 3 Quantity limitation 60 per 30 days Attention Deficit Hyperactivity Disorder Agents, Non-amphetamines dexmethylphenidate hcl tab 10 mg 2** Quantity limitation 90 per 30 days dexmethylphenidate hcl tab 2.5 mg 2** Quantity limitation 90 per 30 days dexmethylphenidate hcl tab 5 mg 2** Quantity limitation 90 per 30 days methylphenidate hcl tab 10 mg 2** methylphenidate hcl tab 20 mg 2** methylphenidate hcl tab 5 mg 2** methylphenidate hcl tab cr 20 mg 2** Central Nervous System, Other NUEDEXTA CAP20-10MG 4 Quantity limitation 60 per 30 days RILUTEK TAB50MG 3 XENAZINE TAB12.5MG 5 This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at hours a day- seven days ; This medication requires prior authorization. To 127 *We provide additional coverage of this drug in the coverage gap for Medicare

128 obtain an exception please call hours a dayseven days a week. TTY users should call 1- This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at hours a day- seven days ; This medication requires prior authorization. To obtain an exception please call hours a dayseven days a week. TTY users XENAZINE TAB25MG 5 should call 1- Multiple Sclerosis Agents AVONEX KIT30MCG 5 AVONEX PREFLKIT30MCG 5 BETASERON INJ0.3MG 3 COPAXONE KIT20MG/ML 5 Quantity limitation 4 per 28 days; Quantity limitation 4 per 28 days; Quantity limitation 15 per 30 days; 128 *We provide additional coverage of this drug in the coverage gap for Medicare

129 GILENYA CAP0.5MG 5 REBIF INJ22/0.5 5 Quantity limitation 12 per 30 days; REBIF INJ44/0.5 5 Quantity limitation 12 per 30 days; Quantity limitation 6 per 30 days; REBIF TITRTNSOLPACK 5 This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at hours a day- seven days ; This medication requires prior authorization. To obtain an exception please call hours a day- TYSABRI INJ 5 seven days a week. TTY users 129 *We provide additional coverage of this drug in the coverage gap for Medicare

130 should call 1- DENTAL AND ORAL AGENTS Dental and Oral Agents chlorhexidine gluconate soln 0.12% 1* chlorhexidine gluconate soln 0.12% 1* lidocaine hcl viscous soln 2% 1* pilocarpine hcl tab 5 mg 1* pilocarpine hcl tab 7.5 mg 1* triamcinolone acetonide dental paste 0.1% 1* DERMATOLOGICAL AGENTS Dermatological Agents 8-MOP CAP10MG 3 adapalene cream 0.1% 1* adapalene gel 0.1% 1* benzoyl peroxide-erythromycin gel 5-3% 2** calcipotriene cream 0.005% 2** calcipotriene oint 0.005% 2** calcipotriene soln 0.005% (50 mcg/ml) 2** clotrimazole w/ betamethasone cream % 1* 130 *We provide additional coverage of this drug in the coverage gap for Medicare

131 clotrimazole w/ betamethasone lotion % 1* DIFFERIN GEL0.3% 4 DIFFERIN LOT0.1% 4 ELIDEL CRE1% 3 fluorouracil cream 5% 1* Quantity limitation 30 per 30 days; imiquimod cream 5% 2 authorization for new starts only. To obtain an exception please call hours a dayseven days a week. TTY users should call 1- lactic acid (ammonium lactate) cream 12% 1* lactic acid (ammonium lactate) lotion 12% 1* lidocaine oint 5% 1* LIDODERM DIS5% 4 Quantity limitation 90 per 30 days OXSORALEN-ULCAP10MG 4 podofilox soln 0.5% 1* authorization for new starts only. To obtain an exception please call hours a dayseven days a week. TTY users should call 1- Quantity limitation 30 per 30 days; authorization for new starts only. To obtain an exception please call hours a day- PROTOPIC OIN0.03% 4 seven days a week. TTY users 131 *We provide additional coverage of this drug in the coverage gap for Medicare

132 should call 1- Quantity limitation 30 per 30 days; authorization for new starts only. To obtain an exception please call hours a dayseven days a week. TTY users PROTOPIC OIN0.1% 4 should call 1- SANTYL OIN250/GM 3 Quantity limitation 30 per 30 days selenium sulfide lotion 2.5% 1* SOLARAZE GEL3% W/W 3 Quantity limitation 100 per 30 days; This medication requires prior SORIATANE CAP10MG 4 Quantity limitation 60 per 30 days SORIATANE CAP17.5MG 4 Quantity limitation 60 per 30 days SORIATANE CAP25MG 4 Quantity limitation 60 per 30 days TAZORAC CRE0.05% 4 TAZORAC CRE0.1% 4 TAZORAC GEL0.05% 4 TAZORAC GEL0.1% 4 VOLTAREN GEL1% 4 Step therapy protocols apply ENZYME REPLACEMENTS/ MODIFIERS Enzyme Replacements/ Modifiers ADAGEN INJ250/ML 5 This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at hours a day- seven days ; This medication requires prior authorization. To obtain an exception please call hours a dayseven days a week. TTY users should call 1- ALDURAZYME INJ2.9MG/5M *We provide additional coverage of this drug in the coverage gap for Medicare

133 BUPHENYL POW 4 BUPHENYL TAB500MG 4 CEREZYME INJ200UNIT 5 CREON CAP12000UNT 3 CREON CAP24000UNT 3 CREON CAP3000UNIT 3 CREON CAP36000UNT 3 CREON CAP6000UNIT 3 CYSTADANE POW 4 CYSTAGON CAP150MG 4 CYSTAGON CAP50MG 4 This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at hours a day- seven days This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at hours a day- seven days ELAPRASE INJ6MG/3ML 5 FABRAZYME INJ35MG *We provide additional coverage of this drug in the coverage gap for Medicare

134 KUVAN TAB100MG 5 This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at hours a day- seven days ; This medication requires prior authorization. To obtain an exception please call hours a dayseven days a week. TTY users should call 1- MYOZYME INJ50MG 5 This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at hours a day- seven days ; This medication requires prior authorization. To obtain an exception please call hours a dayseven days a week. TTY users NAGLAZYME INJ1MG/ML 5 should call 1- This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call ORFADIN CAP10MG 5 Member Services at *We provide additional coverage of this drug in the coverage gap for Medicare

135 hours a day- seven days ; This medication requires prior authorization. To obtain an exception please call hours a dayseven days a week. TTY users should call 1- This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at hours a day- seven days ; This medication requires prior authorization. To obtain an exception please call hours a dayseven days a week. TTY users ORFADIN CAP2MG 5 ORFADIN CAP5MG 5 PANCREAZE CAP10500UNT 4 PANCREAZE CAP16800UNT 4 PANCREAZE CAP21000UNT 4 PANCREAZE CAP4200UNIT 4 ZAVESCA CAP100MG 4 should call 1- This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at hours a day- seven days ; This medication requires prior authorization. To obtain an exception please call hours a dayseven days a week. TTY users should call 1- This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call 135 *We provide additional coverage of this drug in the coverage gap for Medicare

136 Member Services at hours a day- seven days ZENPEP CAP10000UNT 4 ZENPEP CAP15000UNT 4 ZENPEP CAP20000UNT 4 ZENPEP CAP25000UNT 4 ZENPEP CAP3000UNIT 4 ZENPEP CAP5000UNIT 4 GASTROINTESTINAL AGENTS Antispasmodics, Gastrointestinal atropine sulfate inj 0.1 mg/ml 4 CANTIL TAB25MG 4 dicyclomine hcl cap 10 mg 2** dicyclomine hcl oral soln 10 mg/5ml 2** dicyclomine hcl tab 20 mg 2** glycopyrrolate tab 1 mg 1* glycopyrrolate tab 2 mg 1* methscopolamine bromide tab 2.5 mg 1* methscopolamine bromide tab 5 mg 1* Gastrointestinal Agents, Other HELIDAC MIS 4 loperamide hcl cap 2 mg 2** peg 3350-kcl-sod bicarb-nacl for soln 420 gm 1* RELISTOR KIT12/0.6ML *We provide additional coverage of this drug in the coverage gap for Medicare

137 ursodiol cap 300 mg 1* ursodiol tab 250 mg 1* ursodiol tab 500 mg 1* Histamine2 (H2) Receptor Antagonists cimetidine hcl soln 300 mg/5ml 1* cimetidine tab 200 mg 1* cimetidine tab 300 mg 1* cimetidine tab 400 mg 1* cimetidine tab 800 mg 1* famotidine for susp 40 mg/5ml 1* famotidine in nacl 0.9% iv soln 20 mg/50ml 4 famotidine inj 10 mg/ml 4 famotidine tab 20 mg 1* famotidine tab 40 mg 1* nizatidine cap 150 mg 2** nizatidine cap 300 mg 2** nizatidine oral soln 15 mg/ml 2** ranitidine hcl cap 150 mg 1* ranitidine hcl cap 300 mg 1* ranitidine hcl inj 150 mg/6ml (25 mg/ml) 4 ranitidine hcl syrup 15 mg/ml (75 mg/5ml) 1* ranitidine hcl tab 150 mg 1* 137 *We provide additional coverage of this drug in the coverage gap for Medicare

138 ranitidine hcl tab 300 mg 1* Irritable Bowel Syndrome Agents AMITIZA CAP24MCG 4 Quantity limitation 60 per 30 days AMITIZA CAP8MCG 4 Quantity limitation 60 per 30 days LOTRONEX TAB0.5MG 3 Quantity limitation 60 per 30 days LOTRONEX TAB1MG 3 Quantity limitation 60 per 30 days Laxatives lactulose (encephalopathy) solution 10 gm/15ml 1* lactulose solution 10 gm/15ml 1* polyethylene glycol 3350 oral powder 2** Protectants misoprostol tab 100 mcg 2** misoprostol tab 200 mcg 2** sucralfate tab 1 gm 2** Proton Pump Inhibitors lansoprazole cap delayed release 15 mg 2** Quantity limitation 30 per 30 days lansoprazole cap delayed release 30 mg 2** Quantity limitation 30 per 30 days omeprazole cap delayed release 10 mg 2** Quantity limitation 60 per 30 days omeprazole cap delayed release 20 mg 2** Quantity limitation 60 per 30 days omeprazole cap delayed release 40 mg 2** Quantity limitation 30 per 30 days pantoprazole sodium ec tab 20 mg (base equiv) 2** Quantity limitation 30 per 30 days pantoprazole sodium ec tab 40 mg (base equiv) 2** Quantity limitation 30 per 30 days PROTONIX INJ40MG 4 GENITOURINARY AGENTS Antispasmodics, Urinary ENABLEX TAB15MG 3 Quantity limitation 30 per 30 days 138 *We provide additional coverage of this drug in the coverage gap for Medicare

139 ENABLEX TAB7.5MG 3 Quantity limitation 30 per 30 days flavoxate hcl tab 100 mg 1* oxybutynin chloride syrup 5 mg/5ml 1* oxybutynin chloride tab 5 mg 1* oxybutynin chloride tab sr 24hr 10 mg 1* Quantity limitation 90 per 30 days oxybutynin chloride tab sr 24hr 15 mg 1* Quantity limitation 60 per 30 days oxybutynin chloride tab sr 24hr 5 mg 1* Quantity limitation 180 per 30 days OXYTROL DIS3.9MG/24 4 tolterodine tartrate tab 1 mg 2** tolterodine tartrate tab 2 mg 2** TOVIAZ TAB4MG 3 Quantity limitation 8 per 28 days; Step therapy protocols apply Quantity limitation 30 per 30 days; Step therapy protocols apply Quantity limitation 30 per 30 days; Step therapy protocols apply TOVIAZ TAB8MG 3 trospium chloride cap sr 24hr 60 mg 1* trospium chloride tab 20 mg 1* Quantity limitation 60 per 30 days Benign Prostatic Hypertrophy Agents alfuzosin hcl tab sr 24hr 10 mg 2** Quantity limitation 30 per 30 days Quantity limitation 30 per 30 days; Step therapy protocols apply AVODART CAP0.5MG 3 finasteride tab 5 mg 2** Quantity limitation 30 per 30 days tamsulosin hcl cap 0.4 mg 1* Quantity limitation 60 per 30 days Genitourinary Agents, Other bethanechol chloride tab 10 mg 1* bethanechol chloride tab 25 mg 1* bethanechol chloride tab 5 mg 1* bethanechol chloride tab 50 mg 1* DEPEN TITRA TAB250MG 4 potassium citrate tab cr 10 meq (1080 mg) 1* potassium citrate tab cr 5 meq (540 mg) 1* Phosphate Binders calcium acetate (phosphate binder) cap 667 mg (169 mg ca) 1* 139 *We provide additional coverage of this drug in the coverage gap for Medicare

140 FOSRENOL CHW1000MG 4 FOSRENOL CHW500MG 4 FOSRENOL CHW750MG 4 HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (Adrenal) Glucocorticoids/Mineralocorticoids alclometasone dipropionate cream 0.05% 1* alclometasone dipropionate oint 0.05% 1* amcinonide cream 0.1% 1* amcinonide lotion 0.1% 1* amcinonide oint 0.1% 1* betamethasone dipropionate augmented cream 0.05% 1* betamethasone dipropionate augmented gel 0.05% 1* betamethasone dipropionate augmented lotion 0.05% 1* betamethasone dipropionate augmented oint 0.05% 1* betamethasone dipropionate cream 0.05% 1* betamethasone dipropionate lotion 0.05% 1* betamethasone dipropionate oint 0.05% 1* betamethasone valerate cream 0.1% 1* betamethasone valerate lotion 0.1% 1* betamethasone valerate oint 0.1% 1* CAPEX SHA0.01% 4 clobetasol propionate emollient base cream 0.05% 1* clobetasol propionate foam 0.05% 1* clobetasol propionate gel 0.05% 1* clobetasol propionate lotion 1* 140 *We provide additional coverage of this drug in the coverage gap for Medicare

141 0.05% clobetasol propionate oint 0.05% 1* clobetasol propionate shampoo 0.05% 1* clobetasol propionate soln 0.05% 1* desonide cream 0.05% 1* desonide lotion 0.05% 1* desonide oint 0.05% 1* desoximetasone cream 0.05% 1* desoximetasone gel 0.05% 1* desoximetasone oint 0.25% 1* diflorasone diacetate cream 0.05% 1* diflorasone diacetate oint 0.05% 1* fludrocortisone acetate tab 0.1 mg 1* fluocinolone acetonide cream 0.01% 1* fluocinolone acetonide cream 0.025% 1* fluocinolone acetonide oint 0.025% 1* fluocinolone acetonide soln 0.01% 1* fluocinonide emulsified base cream 0.05% 1* fluocinonide gel 0.05% 1* fluocinonide oint 0.05% 1* fluocinonide soln 0.05% 1* fluticasone propionate cream 0.05% 1* fluticasone propionate lotion 0.05% 1* fluticasone propionate oint 0.005% 1* halobetasol propionate cream 0.05% 1* halobetasol propionate oint 0.05% 1* HALOG CRE0.1% *We provide additional coverage of this drug in the coverage gap for Medicare

142 HALOG OIN0.1% 4 hydrocortisone cream 1% 1* hydrocortisone cream 2.5% 1* hydrocortisone lotion 2.5% 1* hydrocortisone oint 1% 1* hydrocortisone oint 2.5% 1* hydrocortisone tab 10 mg 1* hydrocortisone tab 20 mg 1* hydrocortisone tab 5 mg 1* hydrocortisone valerate cream 0.2% 1* hydrocortisone valerate oint 0.2% 1* methylprednisolone acetate inj susp 40 mg/ml 4 methylprednisolone acetate inj susp 80 mg/ml 4 methylprednisolone sodium succinate for inj 125 mg 4 methylprednisolone sodium succinate for inj 40 mg *We provide additional coverage of this drug in the coverage gap for Medicare

143 methylprednisolone tab 16 mg 1* methylprednisolone tab 32 mg 1* methylprednisolone tab 4 mg 1* methylprednisolone tab 4 mg dose pack 1* methylprednisolone tab 8 mg 1* mometasone furoate cream 0.1% 1* mometasone furoate oint 0.1% 1* mometasone furoate solution 0.1% (lotion) 1* prednicarbate cream 0.1% 1* prednicarbate oint 0.1% 1* prednisolone sod phosph oral soln 6.7 mg/5ml (5 mg/5ml base) 1* prednisolone sod phosphate oral soln 15 mg/5ml (base equiv) 1* triamcinolone acetonide cream 0.025% 1* triamcinolone acetonide cream 0.1% 1* triamcinolone acetonide cream 0.5% 1* triamcinolone acetonide lotion 0.025% 1* triamcinolone acetonide lotion 0.1% 1* triamcinolone acetonide oint 0.025% 1* triamcinolone acetonide oint 0.1% 1* triamcinolone acetonide oint 0.5% 1* urea-hc acetate cream 1% 1* HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (PITUITARY) Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) desmopressin acetate inj *We provide additional coverage of this drug in the coverage gap for Medicare

144 mcg/ml DRUG NAME DRUG TIER REQUIREMENTS/LIMITS desmopressin acetate tab 0.1 mg 1* desmopressin acetate tab 0.2 mg 1* GENOTROPIN INJ0.2MG 4 GENOTROPIN INJ0.4MG 4 GENOTROPIN INJ0.6MG 4 GENOTROPIN INJ0.8MG 4 GENOTROPIN INJ1.2MG 4 GENOTROPIN INJ1.4MG *We provide additional coverage of this drug in the coverage gap for Medicare

145 GENOTROPIN INJ1.6MG 4 GENOTROPIN INJ1.8MG 4 GENOTROPIN INJ12MG 5 GENOTROPIN INJ1MG 4 GENOTROPIN INJ2MG 4 GENOTROPIN INJ5MG 5 HUMATROPE INJ12MG *We provide additional coverage of this drug in the coverage gap for Medicare

146 HUMATROPE INJ24MG 5 HUMATROPE INJ5MG 5 HUMATROPE INJ6MG 5 INCRELEX INJ40MG/4ML 5 NORDITROPIN INJ10/1.5ML 5 NORDITROPIN INJ15/1.5ML 5 NORDITROPIN INJ30/3ML 5 NORDITROPIN INJ5/1.5ML 5 This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at hours a day- seven days ; This medication requires prior authorization. To obtain an exception please call hours a dayseven days a week. TTY users should call 1- NUTROPIN INJ10MG *We provide additional coverage of this drug in the coverage gap for Medicare

147 NUTROPIN AQ INJ10MG/2ML 5 NUTROPIN AQ INJ20MG/2ML 5 NUTROPIN AQ INJNUSPIN 5 5 SAIZEN INJ5MG 5 SAIZEN INJ8.8MG 5 SEROSTIM INJ4MG 5 SEROSTIM INJ5MG 5 SEROSTIM INJ6MG 5 SOMATULINE INJ120/.5ML *We provide additional coverage of this drug in the coverage gap for Medicare

148 SOMATULINE INJ60/0.2ML 5 SOMATULINE INJ90/0.3ML 5 STIMATE SOL1.5MG/ML 4 ZORBTIVE INJ8.8MG 5 HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (SEX HORMONES/MODIFIERS) Anabolic Steroids oxandrolone tab 10 mg 1* oxandrolone tab 2.5 mg 1* Androgens ANDROGEL GEL1%(50MG) 4 Quantity limitation 300 per 30 days ANDROGEL GEL1.62% 4 ANDROXY TAB10MG 4 danazol cap 100 mg 3 danazol cap 200 mg 3 danazol cap 50 mg 3 TESTIM GEL1%(50MG) 4 testosterone enanthate im in oil 200 mg/ml *We provide additional coverage of this drug in the coverage gap for Medicare

149 Estrogens ALORA DIS0.025MG 3 Quantity limitation 8 per 28 days ALORA DIS0.05MG 3 Quantity limitation 8 per 28 days ALORA DIS0.075MG 3 Quantity limitation 8 per 28 days ALORA DIS0.1MG 3 Quantity limitation 8 per 28 days COMBIPATCH DIS.05/.14 4 COMBIPATCH DIS.05/.25 4 desogest-eth estrad & eth estrad tab /0.01 mg(21/5) 1* desogest-ethin est tab / / mg-mg 1* desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg 1* DUAVEE TAB Quantity limitation 300 per 30 days esterified estrogens tab 0.3 mg 4 esterified estrogens tab mg 4 esterified estrogens tab 1.25 mg 4 esterified estrogens tab 2.5 mg 4 ESTRACE VAG CRE0.1MG/GM 4 estradiol tab 0.5 mg 1* estradiol tab 1 mg 1* estradiol tab 2 mg 1* ESTRING MIS2MG 4 Quantity limitation 1 per 90 days estropipate tab 0.75 mg 2** estropipate tab 1.5 mg 2** estropipate tab 3 mg 2** ethynodiol diacetate & ethinyl estradiol tab 1 mg-35 mcg 1* ethynodiol diacetate & ethinyl estradiol tab 1 mg-50 mcg 1* levonorgestrel & ethinyl estradiol (91-day) tab mg 1* levonorgestrel & ethinyl estradiol tab 0.1 mg-20 mcg 1* levonorgestrel & ethinyl estradiol 1* 149 *We provide additional coverage of this drug in the coverage gap for Medicare

150 tab 0.15 mg-30 mcg levonorgestrel-eth estra tab / / mgmcg 1* norethindrone & ethinyl estradiol tab 0.4 mg-35 mcg 1* norethindrone & ethinyl estradiol tab 0.5 mg-35 mcg 1* norethindrone & ethinyl estradiol tab 1 mg-35 mcg 1* norethindrone ace & ethinyl estradiol tab 1 mg-20 mcg 1* norethindrone ace & ethinyl estradiol tab 1.5 mg-30 mcg 1* norethindrone ace & ethinyl estradiol-fe tab 1 mg-20 mcg 1* norethindrone ace & ethinyl estradiol-fe tab 1.5 mg-30 mcg 1* norethindrone acetate-ethinyl estradiol tab 1 mg-5 mcg 2** norethindrone ac-ethinyl estradfe tab 1-20/1-30/1-35 mg-mcg 1* norethindrone-eth estradiol tab / /1-35 mg-mcg 1* norethindrone-eth estradiol tab /1-35 mg-mcg (10/11) 1* norethindrone-eth estradiol tab /1-35/ mg-mcg 1* norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg 1* norgestimate-eth estrad tab / / mgmcg 1* norgestrel & ethinyl estradiol tab 0.3 mg-30 mcg 1* norgestrel & ethinyl estradiol tab 0.5 mg-50 mcg 1* NUVARING MIS 4 ORTHO EVRA DISWEEK 4 PREFEST TAB 3 PREMARIN TAB0.3MG *We provide additional coverage of this drug in the coverage gap for Medicare

151 PREMARIN TAB0.45MG 3 PREMARIN TAB0.625MG 3 PREMARIN TAB0.9MG 3 PREMARIN TAB1.25MG 3 PREMARIN VAGCRE0.625MG 3 PREMPHASE TAB 3 PREMPRO TAB PREMPRO TAB PREMPRO TAB PREMPRO TAB Progestins CRINONE GEL4% VAG 4 CRINONE GEL8% VAG 4 medroxyprogesterone acetate im susp 150 mg/ml 4 Quantity limitation 1 per 90 days medroxyprogesterone acetate tab 10 mg 1* medroxyprogesterone acetate tab 2.5 mg 1* medroxyprogesterone acetate tab 5 mg 1* MEGACE ES SUS625/5ML 4 megestrol acetate susp 40 mg/ml 1* megestrol acetate tab 20 mg 1* megestrol acetate tab 40 mg 1* norethindrone acetate tab 5 mg 1* norethindrone tab 0.35 mg 1* norethindrone tab 0.35 mg 1* Selective Estrogen Receptor Modifying Agents EVISTA TAB60MG 3 Quantity limitation 30 per 30 days HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (THYROID) Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) LEVOTHROID TAB100MCG 1* LEVOTHROID TAB112MCG 1* LEVOTHROID TAB125MCG 1* LEVOTHROID TAB137MCG 1* LEVOTHROID TAB150MCG 1* 151 *We provide additional coverage of this drug in the coverage gap for Medicare

152 LEVOTHROID TAB175MCG 1* LEVOTHROID TAB200MCG 1* LEVOTHROID TAB25MCG 1* LEVOTHROID TAB300MCG 1* LEVOTHROID TAB50MCG 1* LEVOTHROID TAB75MCG 1* LEVOTHROID TAB88MCG 1* levothyroxine sodium tab 100 mcg 1* levothyroxine sodium tab 112 mcg 1* levothyroxine sodium tab 125 mcg 1* levothyroxine sodium tab 137 mcg 1* levothyroxine sodium tab 150 mcg 1* levothyroxine sodium tab 175 mcg 1* levothyroxine sodium tab 200 mcg 1* levothyroxine sodium tab 25 mcg 1* levothyroxine sodium tab 300 mcg 1* levothyroxine sodium tab 50 mcg 1* levothyroxine sodium tab 75 mcg 1* levothyroxine sodium tab 88 mcg 1* liothyronine sodium tab 25 mcg 2** liothyronine sodium tab 5 mcg 2** liothyronine sodium tab 50 mcg 2** SYNTHROID TAB100MCG 3 SYNTHROID TAB112MCG 3 SYNTHROID TAB125MCG 3 SYNTHROID TAB137MCG 3 SYNTHROID TAB150MCG 3 SYNTHROID TAB175MCG 3 SYNTHROID TAB200MCG *We provide additional coverage of this drug in the coverage gap for Medicare

153 SYNTHROID TAB25MCG 3 SYNTHROID TAB300MCG 3 SYNTHROID TAB50MCG 3 SYNTHROID TAB75MCG 3 SYNTHROID TAB88MCG 3 HORMONAL AGENTS, SUPPRESSANT (ADRENAL) Hormonal Agents, Suppressant (Adrenal) LYSODREN TAB500MG 3 HORMONAL AGENTS, SUPPRESSANT (PARATHYROID) Hormonal Agents, Suppressant (Parathyroid) SENSIPAR TAB30MG 3 SENSIPAR TAB60MG 3 SENSIPAR TAB90MG 3 HORMONAL AGENTS, SUPPRESSANT (PITUITARY) Hormonal Agents, Suppressant (Pituitary) cabergoline tab 0.5 mg 1 leuprolide acetate inj kit 5 mg/ml 4 LUPR DEP-PEDINJ11.25MG 4 LUPRON DEPOTINJ22.5MG 4 LUPRON DEPOTINJ3.75MG 4 LUPRON DEPOTINJ30MG 4 LUPRON DEPOTINJ45MG 5 LUPRON DEPOTINJ7.5MG 4 octreotide acetate inj 100 mcg/ml (0.1 mg/ml) 4 octreotide acetate inj 1000 mcg/ml (1 mg/ml) *We provide additional coverage of this drug in the coverage gap for Medicare

154 octreotide acetate inj 200 mcg/ml (0.2 mg/ml) 4 octreotide acetate inj 50 mcg/ml (0.05 mg/ml) 4 octreotide acetate inj 500 mcg/ml (0.5 mg/ml) 5 SANDOSTATIN KITLAR 10MG 5 SANDOSTATIN KITLAR 20MG 5 SANDOSTATIN KITLAR 30MG 5 Quantity limitation 5 per 28 days; Quantity limitation 5 per 28 days; Quantity limitation 5 per 28 days; 154 *We provide additional coverage of this drug in the coverage gap for Medicare

155 This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at hours a day- seven days ; This medication requires prior authorization. To obtain an exception please call hours a dayseven days a week. TTY users SOMAVERT INJ10MG 5 should call 1- SOMAVERT INJ15MG 5 This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at hours a day- seven days ; This medication requires prior authorization. To obtain an exception please call hours a dayseven days a week. TTY users should call 1- SOMAVERT INJ20MG 5 This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at hours a day- seven days ; This medication requires prior authorization. To obtain an exception please call hours a dayseven days a week. TTY users should call 1- SYNAREL SOL2MG/ML *We provide additional coverage of this drug in the coverage gap for Medicare

156 HORMONAL AGENTS, SUPPRESSANT (SEX HORMONES/MODIFIERS) Antiandrogens bicalutamide tab 50 mg 2 Quantity limitation 30 per 30 days flutamide cap 125 mg 1* NILANDRON TAB150MG 4 Quantity limitation 120 per 30 days; This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at hours a day- seven days a week. TTY users should XTANDI CAP40MG 5 ZYTIGA TAB250MG 5 call 1- Quantity limitation 120 per 30 days; This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at hours a day- seven days a week. TTY users should call 1- HORMONAL AGENTS, SUPPRESSANT (THYROID) Antithyroid Agents methimazole tab 10 mg 1* methimazole tab 5 mg 1* propylthiouracil tab 50 mg 1* methimazole tab 10 mg 1* IMMUNOLOGICAL AGENTS Immune Suppressants ASTAGRAF XL CAP0.5MG *We provide additional coverage of this drug in the coverage gap for Medicare

157 ASTAGRAF XL CAP1MG 4 ASTAGRAF XL CAP5MG 5 azathioprine tab 100 mg 4 azathioprine tab 50 mg 1* azathioprine tab 75 mg 4 CELLCEPT SUS200MG/ML *We provide additional coverage of this drug in the coverage gap for Medicare

158 CELLCEPT IV INJ500MG 4 cyclosporine cap 100 mg 1* cyclosporine cap 25 mg 1* cyclosporine iv soln 50 mg/ml 4 cyclosporine modified cap 100 mg 1* cyclosporine modified cap 25 mg 1* 158 *We provide additional coverage of this drug in the coverage gap for Medicare

159 cyclosporine modified cap 50 mg 1* cyclosporine modified oral soln 100 mg/ml 1* ENBREL INJ25/0.5ML 5 ENBREL INJ25MG 5 ENBREL INJ50MG/ML 5 HUMIRA KIT20MG/0.4 5 Quantity limitation 8 per 28 days; Quantity limitation 16 per 28 days; Quantity limitation 8 per 28 days; Quantity limitation 8 per 28 days; 159 *We provide additional coverage of this drug in the coverage gap for Medicare

160 Quantity limitation 8 per 28 days; HUMIRA KIT40MG/0.8 5 Quantity limitation 8 per 28 days; HUMIRA PEN KITCROHNS 5 KINERET INJ 5 methotrexate sodium for inj 1 gm 4 methotrexate sodium inj pf 25 mg/ml 4 methotrexate sodium tab 10 mg (base equiv) 4 methotrexate sodium tab 15 mg (base equiv) 4 methotrexate sodium tab 2.5 mg 1* 160 *We provide additional coverage of this drug in the coverage gap for Medicare

161 (base equiv) methotrexate sodium tab 5 mg (base equiv) 4 methotrexate sodium tab 7.5 mg (base equiv) 4 mycophenolate mofetil cap 250 mg 2** mycophenolate mofetil tab 500 mg 2** mycophenolictab180mg dr 2. mycophenolictab360mg dr 2. MYFORTIC TAB180MG 4 MYFORTIC TAB360MG 4 NULOJIX INJ250MG 5 ORENCIA INJ125MG/ML 5 ORENCIA INJ250MG *We provide additional coverage of this drug in the coverage gap for Medicare

162 PROGRAF INJ5MG/ML 4 RAPAMUNE SOL1MG/ML 3 RAPAMUNE TAB0.5MG 3 RAPAMUNE TAB1MG 3 RAPAMUNE TAB2MG 3 REMICADE INJ100MG *We provide additional coverage of this drug in the coverage gap for Medicare

163 SANDIMMUNE SOL100MG/ML 3 SIMPONI INJ50MG 5 SIMULECT INJ20MG 5 sirolimus tab 0.5 mg 2** tacrolimus cap 0.5 mg 2** tacrolimus cap 1 mg 2** 163 *We provide additional coverage of this drug in the coverage gap for Medicare

164 tacrolimus cap 5 mg 2** Quantity limitation 60 per 30 days; ZORTRESS TAB0.25MG 4 ZORTRESS TAB0.5MG 5 Quantity limitation 60 per 30 days; Quantity limitation 60 per 30 days; ZORTRESS TAB0.75MG 5 Immunizing Agents, Passive CARIMUNE NF INJ3GM 5 GAMASTAN S/DINJ *We provide additional coverage of this drug in the coverage gap for Medicare

165 GAMMAGARD INJ2.5GM/25 5 THYMOGLOBULNINJ25MG 5 Immunomodulators ACTIMMUNE INJ2MU/0.5 5 ARCALYST INJ220MG 5 leflunomide tab 10 mg 1* Quantity limitation 30 per 30 days leflunomide tab 20 mg 1* Quantity limitation 30 per 30 days RIDAURA CAP3MG 4 SYLATRON KIT296MCG 5 Quantity limitation 1 per 28 days SYLATRON KIT444MCG 5 Quantity limitation 1 per 28 days SYLATRON KIT888MCG 5 Quantity limitation 1 per 28 days Vaccines ACTHIB INJ 4 ADACEL INJ 4 BOOSTRIX INJ 4 CERVARIX INJ 4 COMVAX INJ 4 DAPTACEL INJ 4 DIPHTHERIA/TETANUS INJ 4 ENGERIX-B INJ10/0.5ML *We provide additional coverage of this drug in the coverage gap for Medicare

166 ENGERIX-B INJ20MCG/ML 4 GARDASIL INJ 4 HAVRIX INJ1440UNIT 1* HAVRIX INJ720UNIT 1* IMOVAX RABIEINJ2.5/ML 4 INFANRIX INJ 4 IPOL INJINACTIVE 4 IXIARO INJ 4 MENACTRA INJ 4 MENOMUNE INJA/C/Y/W 4 MENVEO INJ 4 M-M-R II INJLIVE 4 PEDVAX HIB INJ 4 PROQUAD INJ 4 RABAVERT INJ 4 RECOMBIVA HBINJ5MCG/0.5ML 4 RECOMBIVA HBINJ10MCG/ML *We provide additional coverage of this drug in the coverage gap for Medicare

167 RECOMBIVA-HBINJ40MCG/ML 4 ROTATEQ SUS 1* TET/DIP TOX INJ2-2 LF 1* TETANUS TOX INJ5LF ADS 1* TWINRIX INJ 4 TYPHIM VI INJ 4 VAQTA INJ25/0.5ML 1* VAQTA INJ50UNT/ML 1* VARIVAX INJ 1* YF-VAX INJ 4 ZOSTAVAX INJ 1* INFLAMMATORY BOWEL DISEASE AGENTS Aminosalicylates balsalazide disodium cap 750 mg 1* CANASA SUP1000MG 4 DELZICOL CAP400MG 3 DIPENTUM CAP250MG 4 LIALDA TAB1.2GM 4 mesalamine rectal enema 4 gm & cleanser wipe kit 1* PENTASA CAP250MG CR 4 PENTASA CAP500MG CR 4 Glucocorticoids budesonide cap sr 24hr 3 mg 1* CELESTONE SOL0.6MG/5 4 cortisone acetate tab 25 mg 1* dexamethasone conc 1 mg/ml 1* dexamethasone elixir 0.5 mg/5ml 1* dexamethasone sodium *We provide additional coverage of this drug in the coverage gap for Medicare

168 phosphate inj 4 mg/ml dexamethasone tab 0.5 mg 1* dexamethasone tab 0.75 mg 1* dexamethasone tab 1 mg 1* dexamethasone tab 1.5 mg 1* dexamethasone tab 2 mg 1* dexamethasone tab 4 mg 1* dexamethasone tab 6 mg 1* hydrocortisone enema 100 mg/60ml 1* hydrocortisone rectal cream 1% 1* hydrocortisone rectal cream 2.5% 1* prednisone conc 5 mg/ml 1* prednisone oral soln 5 mg/5ml 2** prednisone tab 1 mg 1* prednisone tab 10 mg 1* prednisone tab 2.5 mg 1* prednisone tab 20 mg 1* prednisone tab 5 mg 1* prednisone tab 50 mg 1* Sulfonamides sulfasalazine tab 500 mg 1* sulfasalazine tab delayed release 500 mg 1* METABOLIC BONE DISEASE AGENTS Metabolic Bone Disease Agents ACTONEL TAB150MG 4 Quantity limitation 1 per 28 days; Step therapy protocols apply ACTONEL TAB35MG 4 Quantity limitation 4 per 28 days; Step therapy protocols apply ACTONEL TAB5MG 4 Quantity limitation 31 per 31 days; Step therapy protocols apply alendronate sodium tab 10 mg 1* Quantity limitation 120 per 30 days alendronate sodium tab 35 mg 1* Quantity limitation 5 per 30 days alendronate sodium tab 40 mg 1* Quantity limitation 30 per 30 days alendronate sodium tab 5 mg 1* Quantity limitation 240 per 30 days alendronate sodium tab 70 mg 1* Quantity limitation 5 per 30 days Quantity limitation 1 per 30 days; BONIVA INJ3MG/3ML *We provide additional coverage of this drug in the coverage gap for Medicare

169 calcitonin (salmon) nasal soln 200 unit/act 2** calcitriol cap 0.25 mcg 1* calcitriol cap 0.5 mcg 1* calcitriol inj 1 mcg/ml 4 calcitriol oral soln 1 mcg/ml 1* etidronate disodium tab 200 mg 1* etidronate disodium tab 400 mg 1* FORTEO SOL600/2.4 5 HECTOROL CAP0.5MCG 4 HECTOROL CAP1MCG 4 HECTOROL CAP2.5MCG 4 HECTOROL INJ4MCG/2ML 4 ibandronate sodium tab 150 mg (base equivalent) 2** Quantity limitation 1 per 28 days pamidronate disodium iv soln 3 mg/ml 2** 169 *We provide additional coverage of this drug in the coverage gap for Medicare

170 pamidronate disodium iv soln 6 mg/ml 2** pamidronate disodium iv soln 9 mg/ml 2** PROLIA SOL60MG/ML 4 XGEVA INJ 5 ZEMPLAR CAP1MCG 3 ZEMPLAR CAP2MCG *We provide additional coverage of this drug in the coverage gap for Medicare

171 ZEMPLAR CAP4MCG 3 ZEMPLAR INJ2MCG/ML 3 ZEMPLAR INJ5MCG/ML 3 zoledronic acid inj conc for iv infusion 4 mg/5ml 2** zoledronic acid iv soln 5 mg/100ml 2** OPHTHALMIC AGENTS Ophthalmic Agents, Other bacitracin-polymyxin b ophth oint 1* bacitracin-polymyxin-neomycinhc ophth oint 1% 1* BLEPHAMIDE SUSOP *We provide additional coverage of this drug in the coverage gap for Medicare

172 naphazoline hcl ophth soln 0.1% 1* neomycin-bacitrac zn-polymyx 5(3.5)mg-400unt-10000unt op oin 1* neomycin-polymyxin b- gramicidin ophth soln 1* neomycin-polymyxindexamethasone ophth oint 0.1% 1* neomycin-polymyxindexamethasone ophth susp 0.1% 1* neomycin-polymyxin-hc ophth susp 1* polymyxin b-trimethoprim ophth soln unit/ml-0.1% 1* PRED-G SUSOP 4 PRED-G S.O.POINOP 4 proparacaine hcl ophth soln 0.5% 1* RESTASIS EMU0.05% 4 sulfacetamide sodiumprednisolone ophth oint % 4 sulfacetamide sodiumprednisolone ophth soln (0.25)% 1* TOBRADEX OIN % 4 tobramycin-dexamethasone ophth susp % 1* Ophthalmic Anti-allergy Agents ALOCRIL SOL2% 4 ALOMIDE SOL0.1% OP 4 azelastine hcl ophth soln 0.05% 1* cromolyn sodium ophth soln 4% 1* PATANOL SOL0.1% OP 4 Ophthalmic Antiglaucoma Agents Quantity limitation 60 per 30 days; 172 *We provide additional coverage of this drug in the coverage gap for Medicare

173 apraclonidine hcl ophth soln 0.5% (base equivalent) 1* AZOPT SUS1% OP 4 betaxolol hcl ophth soln 0.5% 1* BETIMOL SOL0.25% 4 BETIMOL SOL0.5% 4 BETOPTIC-S SUS0.25% OP 4 brimonidine tartrate ophth soln 0.15% 1* brimonidine tartrate ophth soln 0.2% 1* carteolol hcl ophth soln 1% 1* dorzolamide hcl ophth soln 2% 1* dorzolamide hcl-timolol maleate ophth soln mg/ml 1* IOPIDINE SOL1% OP 4 levobunolol hcl ophth soln 0.5% 1* metipranolol ophth soln 0.3% 1* PHOSPHOLINE SOL0.125%OP 4 PILOPINE HS GEL4% OP 4 timolol maleate ophth gel forming soln 0.25% 1* timolol maleate ophth gel forming soln 0.5% 1* timolol maleate ophth soln 0.25% 1* timolol maleate ophth soln 0.5% 1* Ophthalmic Anti-inflammatories ALREX SUS0.2% 4 bromfenac sodium ophth soln 0.09% (base equivalent) 1 dexamethasone sodium phosphate ophth soln 0.1% 1* diclofenac sodium ophth soln 0.1% 1* FLAREX SUS0.1% OP 4 flurbiprofen sodium ophth soln 0.03% 1* FML OIN0.1% OP 4 FML FORTE SUS0.25% OP 4 ketorolac tromethamine ophth 1* 173 *We provide additional coverage of this drug in the coverage gap for Medicare

174 soln 0.4% ketorolac tromethamine ophth soln 0.5% 1* LOTEMAX SUS0.5% 4 MAXIDEX SUS0.1% OP 4 NEVANAC SUS0.1% 4 PRED MILD SUS0.12% OP 4 prednisolone acetate ophth susp 1% 1* prednisolone sodium phosphate ophth soln 1% 1* VEXOL SUS1% OP 4 Ophthalmic Prostaglandin and Prostamide Analogs latanoprost ophth soln 0.005% 2** Quantity limitation 5 per 30 days LUMIGAN SOL0.01% 4 Quantity limitation 7.5 per 30 days OTIC AGENTS Otic Agents acetic acid otic soln 2% 1* CIPRO HC SUSOTIC 3 CIPRODEX SUS % 4 COLY-MYCIN SSUSOTIC 4 hydrocortisone w/ acetic acid otic soln 1-2% 1* neomycin-polymyxin-hc otic soln 1% 1* neomycin-polymyxin-hc otic susp 3.5 mg/ml unit/ml- 1% 1* RESPIRATORY TRACT AGENTS Antihistamines azelastine hcl nasal spray 137 mcg/spray (1 mg/ml) 1* Quantity limitation 30 per 30 days clemastine fumarate tab 2.68 mg 1* cyproheptadine hcl syrup 2 mg/5ml 2** cyproheptadine hcl tab 4 mg 2** levocetirizine dihydrochloride tab 5 mg 2** Anti-inflammatories, Inhaled Corticosteroids 174 *We provide additional coverage of this drug in the coverage gap for Medicare

175 ASMANEX 120 AER220MCG 4 Quantity limitation 2 per 30 days ASMANEX 30 AER110MCG 4 Quantity limitation 2 per 30 days ASMANEX 30 AER220MCG 4 Quantity limitation 2 per 30 days ASMANEX 60 AER220MCG 4 Quantity limitation 2 per 30 days BECONASE AQ SUS0.042% 4 Quantity limitation 50 per 30 days FLOVENT DISKAER100MCG 3 Quantity limitation 120 per 30 days FLOVENT DISKAER250MCG 3 Quantity limitation 300 per 30 days FLOVENT DISKAER50MCG 3 Quantity limitation 120 per 30 days FLOVENT HFA AER110MCG 3 Quantity limitation 24 per 30 days FLOVENT HFA AER220MCG 3 Quantity limitation 24 per 30 days Quantity limitation 21.2 per 30 days FLOVENT HFA AER44MCG 3 flunisolide nasal soln 0.025% 1* Quantity limitation 50 per 30 days flunisolide nasal soln 29 mcg/act (0.025%) 1* Quantity limitation 50 per 30 days fluticasone propionate nasal susp 50 mcg/act 1* Quantity limitation 16 per 30 days PULMICORT INH180MCG 3 Quantity limitation 2 per 30 days PULMICORT INH90MCG 3 Quantity limitation 2 per 30 days QVAR AER40MCG 4 QVAR AER80MCG 4 Quantity limitation 21.9 per 30 days Quantity limitation 21.9 per 30 days Quantity limitation 17.2 per 30 days RHINOCORT SUSAQUA 3 triamcinolone acetonide nasal inhal 55 mcg/act 2** Quantity limitation 33 per 30 days VERAMYST SPR27.5MCG 3 Quantity limitation 20 per 30 days Antileukotrienes montelukast sodium chew tab 4 mg (base equiv) 2** Quantity limitation 30 per 30 days montelukast sodium chew tab 5 mg (base equiv) 2** Quantity limitation 30 per 30 days montelukast sodium oral granules packet 4 mg (base equiv) 2** Quantity limitation 30 per 30 days montelukast sodium tab 10 mg (base equiv) 2** Quantity limitation 30 per 30 days zafirlukast tab 10 mg 1* Quantity limitation 60 per 30 days zafirlukast tab 20 mg 1* Quantity limitation 60 per 30 days ZYFLO CR TAB600MG 4 Quantity limitation 120 per 30 days 175 *We provide additional coverage of this drug in the coverage gap for Medicare

176 Bronchodilators, Anticholinergic Quantity limitation 25.8 per 30 ATROVENT HFAAER17MCG 3 days ipratropium bromide nasal soln 0.03% (21 mcg/spray) 1* Quantity limitation 30 per 30 days ipratropium bromide nasal soln 0.06% (42 mcg/spray) 1* Quantity limitation 30 per 30 days SPIRIVA CAPHANDIHLR 3 Quantity limitation 90 per 30 days Bronchodilators, Phosphodiesterase Inhibitors (Xanthines) dyphylline tab 200 mg 2** dyphylline tab 400 mg 2** theophylline tab sr 12hr 100 mg 1* theophylline tab sr 12hr 200 mg 1* theophylline tab sr 12hr 300 mg 1* theophylline tab sr 12hr 450 mg 1* theophylline tab sr 24hr 400 mg 1* theophylline tab sr 24hr 600 mg 1* Bronchodilators, Sympathomimetic ADVAIR DISKUAER100/50 4 Quantity limitation 60 per 30 days ADVAIR DISKUAER250/50 4 Quantity limitation 60 per 30 days ADVAIR DISKUAER500/50 4 Quantity limitation 60 per 30 days ADVAIR HFA AER115/21 4 Quantity limitation 12 per 30 days ADVAIR HFA AER230/21 4 Quantity limitation 12 per 30 days ADVAIR HFA AER45/21 4 Quantity limitation 12 per 30 days albuterol sulfate soln nebu 0.083% (2.5 mg/3ml) 1* albuterol sulfate soln nebu 0.5% (5 mg/ml) 1* albuterol sulfate soln nebu 0.63 mg/3ml (base equiv) 1* albuterol sulfate soln nebu 1.25 mg/3ml (base equiv) 1* albuterol sulfate syrup 2 mg/5ml 1* albuterol sulfate tab 2 mg 1* albuterol sulfate tab 4 mg 1* albuterol sulfate tab sr 12hr 4 mg 1* albuterol sulfate tab sr 12hr 8 mg 1* ARCAPTA CAP75MCG 3 Quantity limitation 30 per 30 days COMBIVENT AER 3 Quantity limitation 29.4 per *We provide additional coverage of this drug in the coverage gap for Medicare

177 days COMBIVENT AERRESPIMAT 3 EPIPEN 2-PAKINJ0.3MG 4 Quantity limitation 1 per 30 days EPIPEN-JR INJ2-PAK 4 Quantity limitation 1 per 30 days FORADIL CAPAEROLIZE 4 Quantity limitation 60 per 30 days metaproterenol sulfate syrup 10 mg/5ml 1* metaproterenol sulfate tab 10 mg 1* metaproterenol sulfate tab 20 mg 1* PROAIR HFA AER 4 Quantity limitation 17 per 30 days PROVENTIL AERHFA 4 Quantity limitation 13.4 per 30 days SEREVENT DISAER50MCG 3 Quantity limitation 60 per 30 days SYMBICORT AER Quantity limitation 10.2 per 30 days SYMBICORT AER Quantity limitation 6.9 per 30 days terbutaline sulfate inj 1 mg/ml 4 terbutaline sulfate tab 2.5 mg 1* terbutaline sulfate tab 5 mg 1* VENTOLIN HFAAER 3 Quantity limitation 36 per 30 days XOPENEX HFA AER 3 Quantity limitation 30 per 30 days Mast Cell Stabilizers cromolyn sodium soln nebu 20 mg/2ml 2** Pulmonary Antihypertensives ADCIRCA TAB20MG 5 Quantity limitation 60 per 30 days; 177 *We provide additional coverage of this drug in the coverage gap for Medicare

178 This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at hours a day- seven days ; This medication requires prior authorization. To obtain an exception please call hours a dayseven days a week. TTY users LETAIRIS TAB10MG 5 should call 1- LETAIRIS TAB5MG 5 This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at hours a day- seven days ; This medication requires prior authorization. To obtain an exception please call hours a dayseven days a week. TTY users should call 1- This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at hours a day- seven days ; This medication requires prior authorization. To obtain an exception please call hours a day- REMODULIN INJ10MG/ML 5 seven days a week. TTY users 178 *We provide additional coverage of this drug in the coverage gap for Medicare

179 should call 1- REMODULIN INJ1MG/ML 5 This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at hours a day- seven days ; This medication requires prior authorization. To obtain an exception please call hours a dayseven days a week. TTY users should call 1- REMODULIN INJ2.5MG/ML 5 This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at hours a day- seven days ; This medication requires prior authorization. To obtain an exception please call hours a dayseven days a week. TTY users should call 1- REMODULIN INJ5MG/ML 5 This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at hours a day- seven days ; This medication requires prior authorization. To obtain an exception please call hours a dayseven days a week. TTY users should call 1- This prescription may be available TRACLEER TAB125MG 5 only at certain pharmacies. For 179 *We provide additional coverage of this drug in the coverage gap for Medicare

180 more information consult your Pharmacy Directory or call Member Services at hours a day- seven days ; This medication requires prior authorization. To obtain an exception please call hours a dayseven days a week. TTY users should call 1- This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at hours a day- seven days ; This medication requires prior authorization. To obtain an exception please call hours a dayseven days a week. TTY users TRACLEER TAB62.5MG 5 should call 1- Respiratory Tract Agents, Other acetylcysteine inhal soln 10% 2** acetylcysteine inhal soln 20% 2** ARALAST NP INJ400MG 5 This prescription may be available only at certain pharmacies. For more information please call *We provide additional coverage of this drug in the coverage gap for Medicare

181 hours a dayseven days a week. TTY users should call ; This medication requires prior authorization for new starts only. DALIRESP TAB500MCG 4 Quantity limitation 30 per 30 days PULMOZYME SOL1MG/ML 5 tetrahydrozoline hcl nasal soln 0.05% 4 tetrahydrozoline hcl nasal soln 0.1% 4 XOLAIR SOL150MG 5 ZEMAIRA INJ1000MG 4 This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at hours a day- seven days ; This medication requires prior authorization. To obtain an exception please call hours a dayseven days a week. TTY users should call 1- This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at hours a day- seven days ; This medication requires prior authorization. To obtain an exception please call hours a dayseven days a week. TTY users should call *We provide additional coverage of this drug in the coverage gap for Medicare

182 SKELETAL MUSCLE RELAXANTS Skeletal Muscle Relaxants carisoprodol tab 350 mg 2** cyclobenzaprine hcl tab 10 mg 2** cyclobenzaprine hcl tab 5 mg 2** SLEEP DISORDER AGENTS GABA Receptor Modulators zaleplon cap 10 mg 1* Quantity limitation 60 per 30 days zaleplon cap 5 mg 1* Quantity limitation 30 per 30 days zolpidem tartrate tab 10 mg 2** Quantity limitation 30 per 30 days zolpidem tartrate tab 5 mg 2** Quantity limitation 30 per 30 days zolpidem tartrate tab cr 12.5 mg 2** Quantity limitation 30 per 30 days zolpidem tartrate tab cr 6.25 mg 2** Quantity limitation 30 per 30 days Sleep Disorders, Other NUVIGIL TAB150MG 4 Quantity limitation 30 per 30 days NUVIGIL TAB250MG 4 Quantity limitation 30 per 30 days NUVIGIL TAB50MG 4 Quantity limitation 30 per 30 days ROZEREM TAB8MG 4 Quantity limitation 30 per 30 days; Step therapy protocols apply XYREM SOL500MG/ML 4 This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at hours a day- seven days 182 *We provide additional coverage of this drug in the coverage gap for Medicare

183 ; This medication requires prior authorization. To obtain an exception please call hours a dayseven days a week. TTY users should call 1- THERAPEUTIC NUTRIENTS/MINERALS/ELECTROLYTES Electrolyte/Mineral Modifiers EXJADE TAB125MG 4 EXJADE TAB500MG 5 levocarnitine oral soln 1 gm/10ml (10%) 1* levocarnitine tab 330 mg 1* sodium polystyrene sulfonate oral susp 15 gm/60ml 1* This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at hours a day- seven days ; This medication requires prior authorization. To obtain an exception please call hours a dayseven days a week. TTY users should call 1- This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at hours a day- seven days ; This medication requires prior authorization. To obtain an exception please call hours a dayseven days a week. TTY users should call *We provide additional coverage of this drug in the coverage gap for Medicare

184 SYPRINE CAP250MG 4 Electrolyte/Mineral Replacement AMINOSYN INJ8.5/LYTE 4 AMINOSYN II INJ10% 4 AMINOSYN II INJ7% 4 AMINOSYN II INJ8.5% 4 AMINOSYN II INJ8.5/LYTE 4 AMINOSYN M INJ3.5% *We provide additional coverage of this drug in the coverage gap for Medicare

185 AMINOSYN-HBCINJ7% 4 AMINOSYN-PF INJ10% 4 AMINOSYN-PF INJ7% 4 D10W/NACL INJ0.2% 4 D10W/NACL INJ0.45% 4 D5W/NACL INJ0.225% *We provide additional coverage of this drug in the coverage gap for Medicare

186 dextrose 2.5% w/ sodium chloride 0.45% 4 dextrose 5% in lactated ringers 4 dextrose 5% w/ sodium chloride 0.2% 4 dextrose 5% w/ sodium chloride 0.33% 4 dextrose 5% w/ sodium chloride 0.45% 4 dextrose 5% w/ sodium chloride 0.9% *We provide additional coverage of this drug in the coverage gap for Medicare

187 dextrose inj 10% 4 dextrose inj 5% 4 fat emulsion iv soln 20% 4 FREAMINE IIIINJ8.5% 4 kcl 10 meq/l (0.075%) in dextrose 5% & nacl 0.45% inj 4 kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.2% inj *We provide additional coverage of this drug in the coverage gap for Medicare

188 kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.33% inj 4 kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.45% inj 4 kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.9% inj 4 kcl 20 meq/l (0.15%) in nacl 0.45% inj 4 kcl 20 meq/l (0.15%) in nacl 0.9% inj 4 kcl 30 meq/l (0.224%) in dextrose 5% & nacl 0.45% inj *We provide additional coverage of this drug in the coverage gap for Medicare

189 kcl 40 meq/l (0.3%) in dextrose 5% & nacl 0.45% inj 4 kcl 40 meq/l (0.3%) in dextrose 5% & nacl 0.9% inj 4 KCL/D5W/NACLINJ0.15/0.2 4 lactated ringer's solution 4 magnesium sulfate inj 50% 4 potassium chloride 20 meq/l (0.15%) in d5w lactated ringers *We provide additional coverage of this drug in the coverage gap for Medicare

190 potassium chloride 20 meq/l (0.15%) in dextrose 5% inj 4 potassium chloride 40 meq/l (0.3%) in dextrose 5% inj 4 potassium chloride cap cr 10 meq 1* potassium chloride cap cr 8 meq 2** potassium chloride inj 2 meq/ml 4 potassium chloride microencapsulated crys cr tab 10 meq 1* potassium chloride microencapsulated crys cr tab 15 meq 1* potassium chloride microencapsulated crys cr tab 20 meq 1* potassium chloride tab cr 10 meq 1* potassium chloride tab cr 8 meq (600 mg) 1* prenatal vitamin min fa 1* sodium chloride inj 0.45% *We provide additional coverage of this drug in the coverage gap for Medicare

191 sodium chloride inj 2.5 meq/ml (14.6%) 4 sodium chloride inj 3% 4 sodium chloride inj 5% 4 sodium chloride irrigation soln 0.9% 1* sodium chloride iv soln 0.9% 4 sodium fluoride 2.2mg 1* TPN ELECTROLINJ *We provide additional coverage of this drug in the coverage gap for Medicare

192 TROPHAMINE INJ10% 4 CAVERJECT INJ 20MCG, 40MCG ENHANCED COVERAGE DRUGS 4 Quantity limitation - 6 injections per 30 days; This medication is available for members who are enrolled in the Medicare Plan 001,Medi-Medi Plan 002, or the Premier Plan 004. This prescription drug is not normally covered in a Medicare Prescription Drug Plan. The amount you pay when you fill a prescription for this drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug. Medicare Plan 001 members are covered up to $150. Medi-Medi Plan 002 and Premier Plan 004 members are covered up to $300 for Medicare excluded drugs in our formulary. CIALIS 10MG AND 20MG 4 Quantity limitation - 6 tablets per 30 days; This medication is available for members who are enrolled in the Medicare Plan 001,Medi-Medi Plan 002, or the Premier Plan 004. This prescription drug is not normally covered in a Medicare Prescription 192 *We provide additional coverage of this drug in the coverage gap for Medicare

193 Drug Plan. The amount you pay when you fill a prescription for this drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug. Medicare Plan 001 members are covered up to $150. Medi-Medi Plan 002 and Premier Plan 004 members are covered up to $300 for Medicare excluded drugs in our formulary. EDEX KIT 20 MCG 4 Quantity limitation - 6 injections per 30 days; This medication is available for members who are enrolled in the Medicare Plan 001,Medi-Medi Plan 002, or the Premier Plan 004. This prescription drug is not normally covered in a Medicare Prescription Drug Plan. The amount you pay when you fill a prescription for this drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug. Medicare Plan 001 members are covered up to $150. Medi-Medi Plan 002 and Premier Plan 004 members are covered up to $300 for Medicare excluded drugs in our formulary. folic acid 1mg 1 This medication is available for members who are enrolled in the 193 *We provide additional coverage of this drug in the coverage gap for Medicare

194 Medicare Plan 001,Medi-Medi Plan 002, or the Premier Plan 004. This prescription drug is not normally covered in a Medicare Prescription Drug Plan. The amount you pay when you fill a prescription for this drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug. Medicare Plan 001 members are covered up to $150. Medi-Medi Plan 002 and Premier Plan 004 members are covered up to $300 for Medicare excluded drugs in our formulary. LEVITRA 2.5MG, 5MG,10MG, 20MG 4 This medication is available for members who are enrolled in the Medicare Plan 001,Medi-Medi Plan 002, or the Premier Plan 004. This prescription drug is not normally covered in a Medicare Prescription Drug Plan. The amount you pay when you fill a prescription for this drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug. Medicare Plan 001 members are covered up to $150. Medi-Medi Plan 002 and Premier Plan 004 members are covered up to $300 for Medicare excluded drugs in our formulary. 194 *We provide additional coverage of this drug in the coverage gap for Medicare

195 MUSE SUPPPOSITORY 50MCG, 100MCG, 125MCG, 250MCG 4 This medication is available for members who are enrolled in the Medicare Plan 001,Medi-Medi Plan 002, or the Premier Plan 004. This prescription drug is not normally covered in a Medicare Prescription Drug Plan. The amount you pay when you fill a prescription for this drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug. Medicare Plan 001 members are covered up to $150. Medi-Medi Plan 002 and Premier Plan 004 members are covered up to $300 for Medicare excluded drugs in our formulary. VIAGRA 100MG, 25MG, 50MG, 4 Quantity limitation - 6 tablets per 30 days; This medication is available for members who are enrolled in the Medicare Plan 001,Medi-Medi Plan 002, or the Premier Plan 004. This prescription drug is not normally covered in a Medicare Prescription Drug Plan. The amount you pay when you fill a prescription for this drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug. Medicare Plan 001 members are covered up to $150. Medi-Medi 195 *We provide additional coverage of this drug in the coverage gap for Medicare

196 Plan 002 and Premier Plan 004 members are covered up to $300 for Medicare excluded drugs in our formulary. 196 *We provide additional coverage of this drug in the coverage gap for Medicare

197 Index of Drugs Therapeutic Classes and Categories Therapeutic Categories are listed in Bold Therapeutic Classes are also listed in Bold 1st Generation/Typical nd Generation/Atypical MOP CAP10MG abacavir sulfate tab 300 mg (base equiv) abacavir/lamivudine/zidovudine ABELCET INJ5MG/ML ABILIFY INJ9.75MG ABILIFY SOL1MG/ML ABILIFY TAB10MG ABILIFY TAB15MG ABILIFY TAB20MG ABILIFY TAB2MG ABILIFY TAB30MG ABILIFY TAB5MG ABILIFY DISCTAB10MG ABILIFY DISCTAB15MG ABILIFY MAININJ300MG acarbose tab 100 mg acarbose tab 25 mg acarbose tab 50 mg acebutolol hcl cap 200 mg acebutolol hcl cap 400 mg acetaminophen w/ codeine soln mg/5ml acetaminophen w/ codeine tab mg acetaminophen w/ codeine tab mg acetaminophen w/ codeine tab mg acetaminophen-caffeine-dihydrocodeine tab mg acetazolamide cap sr 12hr 500 mg acetazolamide sodium for inj 500 mg121 acetazolamide tab 125 mg acetazolamide tab 250 mg acetic acid otic soln 2% acetylcysteine inhal soln 10% acetylcysteine inhal soln 20% ACTHIB INJ ACTIMMUNE INJ2MU/ ACTONEL TAB150MG ACTONEL TAB35MG ACTONEL TAB5MG acyclovir cap 200 mg acyclovir oint 5% acyclovir sodium for inj 500 mg acyclovir susp 200 mg/5ml acyclovir tab 400 mg acyclovir tab 800 mg ADACEL INJ ADAGEN INJ250/ML adapalene cream 0.1% adapalene gel 0.1% ADCIRCA TAB20MG ADVAIR DISKUAER100/ ADVAIR DISKUAER250/ ADVAIR DISKUAER500/ ADVAIR HFA AER115/ ADVAIR HFA AER230/ ADVAIR HFA AER45/ AFINITOR TAB10MG AFINITOR TAB2.5MG AFINITOR TAB5MG AFINITOR TAB7.5MG AFINITOR DISTAB2MG AFINITOR DISTAB3MG AFINITOR DISTAB5MG AGGRENOX CAP25-200MG ALBENZA TAB200MG albuterol sulfate soln nebu 0.083% (2.5 mg/3ml) albuterol sulfate soln nebu 0.5% (5 mg/ml) albuterol sulfate soln nebu 0.63 mg/3ml (base equiv) albuterol sulfate soln nebu 1.25 mg/3ml (base equiv) albuterol sulfate syrup 2 mg/5ml

198 albuterol sulfate tab 2 mg albuterol sulfate tab 4 mg albuterol sulfate tab sr 12hr 4 mg albuterol sulfate tab sr 12hr 8 mg alclometasone dipropionate cream 0.05% alclometasone dipropionate oint 0.05% Alcohol Deterrents/Anti-craving ALCOHOL PREPPAD ALDURAZYME INJ2.9MG/5M alendronate sodium tab 10 mg alendronate sodium tab 35 mg alendronate sodium tab 40 mg alendronate sodium tab 5 mg alendronate sodium tab 70 mg alfuzosin hcl tab sr 24hr 10 mg ALIMTA INJ500MG ALINIA SUS100MG/5M ALINIA TAB500MG Alkylating Agents allopurinol tab 100 mg allopurinol tab 300 mg ALOCRIL SOL2% ALOMIDE SOL0.1% OP ALORA DIS0.025MG ALORA DIS0.05MG ALORA DIS0.075MG ALORA DIS0.1MG ALOXI INJ0.25MG/ Alpha-adrenergic Agonists Alpha-adrenergic Blocking Agents alprazolam orally disintegrating tab 0.25 mg alprazolam orally disintegrating tab 0.5 mg alprazolam orally disintegrating tab 1 mg alprazolam orally disintegrating tab 2 mg alprazolam tab 0.25 mg alprazolam tab 0.5 mg alprazolam tab 1 mg alprazolam tab 2 mg alprazolam tab sr 24hr 0.5 mg alprazolam tab sr 24hr 1 mg alprazolam tab sr 24hr 2 mg alprazolam tab sr 24hr 3 mg ALREX SUS0.2% amantadine hcl cap 100 mg amantadine hcl syrup 50 mg/5ml amantadine hcl tab 100 mg amcinonide cream 0.1% amcinonide lotion 0.1% amcinonide oint 0.1% amifostine crystalline for inj 500 mg amiloride & hydrochlorothiazide tab 5-50 mg amiloride hcl tab 5 mg Aminoglycosides Aminosalicylates aminosalicylic acid cr granules packet 4 gm AMINOSYN INJ8.5/LYTE AMINOSYN II INJ10% AMINOSYN II INJ7% AMINOSYN II INJ8.5% AMINOSYN II INJ8.5/LYTE AMINOSYN M INJ3.5% AMINOSYN-HBCINJ7% AMINOSYN-PF INJ10% AMINOSYN-PF INJ7% amiodarone hcl tab 100 mg amiodarone hcl tab 200 mg amiodarone hcl tab 400 mg AMITIZA CAP24MCG AMITIZA CAP8MCG amitriptyline hcl tab 10 mg amitriptyline hcl tab 100 mg amitriptyline hcl tab 150 mg amitriptyline hcl tab 25 mg amitriptyline hcl tab 50 mg amitriptyline hcl tab 75 mg amlodipine besylate tab 10 mg amlodipine besylate tab 2.5 mg amlodipine besylate tab 5 mg amlodipine besylate-benazepril hcl cap mg amlodipine besylate-benazepril hcl cap mg

199 amlodipine besylate-benazepril hcl cap mg amlodipine besylate-benazepril hcl cap 5-10 mg amlodipine besylate-benazepril hcl cap 5-20 mg amlodipine besylate-benazepril hcl cap 5-40 mg amoxapine tab 100 mg amoxapine tab 150 mg amoxapine tab 25 mg amoxapine tab 50 mg amoxicillin & k clavulanate chew tab mg amoxicillin & k clavulanate chew tab mg amoxicillin & k clavulanate for susp mg/5ml amoxicillin & k clavulanate for susp mg/5ml amoxicillin & k clavulanate for susp mg/5ml amoxicillin & k clavulanate for susp mg/5ml amoxicillin & k clavulanate tab mg amoxicillin & k clavulanate tab mg amoxicillin & k clavulanate tab mg amoxicillin & k clavulanate tab sr 12hr mg amoxicillin (trihydrate) cap 250 mg amoxicillin (trihydrate) cap 500 mg amoxicillin (trihydrate) chew tab 125 mg amoxicillin (trihydrate) chew tab 250 mg amoxicillin (trihydrate) for susp 125 mg/5ml amoxicillin (trihydrate) for susp 200 mg/5ml amoxicillin (trihydrate) for susp 250 mg/5ml amoxicillin (trihydrate) for susp 400 mg/5ml amoxicillin (trihydrate) tab 500 mg amoxicillin (trihydrate) tab 875 mg amphetamine-dextroamphetamine cap sr 24hr 10 mg amphetamine-dextroamphetamine cap sr 24hr 15 mg amphetamine-dextroamphetamine cap sr 24hr 20 mg amphetamine-dextroamphetamine cap sr 24hr 25 mg amphetamine-dextroamphetamine cap sr 24hr 30 mg amphetamine-dextroamphetamine cap sr 24hr 5 mg amphetamine-dextroamphetamine tab 10 mg amphetamine-dextroamphetamine tab 12.5 mg amphetamine-dextroamphetamine tab 15 mg amphetamine-dextroamphetamine tab 20 mg amphetamine-dextroamphetamine tab 30 mg amphetamine-dextroamphetamine tab 5 mg amphetamine-dextroamphetamine tab 7.5 mg amphotericin b for inj 50 mg ampicillin & sulbactam sodium for inj 2-1 gm ampicillin & sulbactam sodium for iv soln 10-5 gm ampicillin cap 250 mg ampicillin cap 500 mg ampicillin for susp 125 mg/5ml ampicillin for susp 250 mg/5ml ampicillin sodium for inj 1 gm ampicillin sodium for inj 125 mg ampicillin sodium for iv soln 10 gm Anabolic Steroids anagrelide hcl cap 0.5 mg anagrelide hcl cap 1 mg ANALGESICS Analgesics, Other anastrozole tab 1 mg

200 ANDROGEL GEL1%(50MG) ANDROGEL GEL1.62% Androgens ANDROXY TAB10MG ANESTHETICS Angiotensin II Receptor Antagonists Angiotensin-converting Enzyme (ACE) Inhibitors Anthelmintics ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS Antiandrogens Antiangiogenic Agents Antiarrhythmics ANTIBACTERIALS Antibacterials, Other Anticholinergics Anticoagulants ANTICONVULSANTS Anticonvulsants, Other Anti-cytomegalovirus (CMV) Agents ANTIDEPRESSANTS Antidepressants, Other Antidiabetic Agents ANTIEMETICS Antiemetics, Other Antiestrogens/Modifiers ANTIFUNGALS ANTIGOUT AGENTS Antihepatitis Agents Antiherpetic Agents Antihistamines Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors 91 Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors Anti-HIV Agents, Other Anti-HIV Agents, Protease Inhibitors Anti-inflammatories, Inhaled Corticosteroids Anti-influenza Agents Antileukotrienes Antimetabolites ANTIMIGRAINE AGENTS ANTIMYASTHENIC AGENTS ANTIMYCOBACTERIALS Antimycobacterials, Other ANTINEOPLASTICS Antineoplastics, Other ANTIPARASITICS ANTIPARKINSON AGENTS Antiparkinson Agents, Other Antiprotozoals ANTIPSYCHOTICS Antispasmodics, Gastrointestinal 136 Antispasmodics, Urinary ANTISPASTICITY AGENTS Antithyroid Agents Antituberculars ANTIVIRALS ANXIOLYTICS Anxiolytics, Other ANZEMET INJ20MG/ML ANZEMET TAB100MG ANZEMET TAB50MG APIDRA INJSOLOSTAR APIDRA INJU APLENZIN TAB174MG APLENZIN TAB348MG APLENZIN TAB522MG APOKYN INJ10MG/ML apraclonidine hcl ophth soln 0.5% (base equivalent) APTIOM TAB200MG APTIOM TAB400MG APTIOM TAB600MG APTIOM TAB800MG APTIVUS CAP250MG APTIVUS SOL ARALAST NP INJ400MG ARANESP INJ100MCG ARANESP INJ150MCG ARANESP INJ200MCG ARANESP INJ25MCG ARANESP INJ300MCG ARANESP INJ40MCG ARANESP INJ500MCG ARANESP INJ60MCG

201 ARCALYST INJ220MG ARCAPTA CAP75MCG Aromatase Inhibitors, 3rd Generation ARRANON INJ5MG/ML ARZERRA CON100/5ML ASMANEX 120 AER220MCG ASMANEX 30 AER110MCG ASMANEX 30 AER220MCG ASMANEX 60 AER220MCG ASTAGRAF XL CAP0.5MG ASTAGRAF XL CAP1MG ASTAGRAF XL CAP5MG atenolol & chlorthalidone tab mg atenolol & chlorthalidone tab mg atenolol tab 100 mg atenolol tab 25 mg atenolol tab 50 mg atorvastatin calcium tab 10 mg (base equivalent) atorvastatin calcium tab 20 mg (base equivalent) atorvastatin calcium tab 40 mg (base equivalent) atorvastatin calcium tab 80 mg (base equivalent) atovaquone-proguanil hcl tab mg ATRIPLA TAB atropine sulfate inj 0.1 mg/ml ATROVENT HFAAER17MCG Attention Deficit Hyperactivity Disorder Agents, Amphetamines Attention Deficit Hyperactivity Disorder Agents, Nonamphetamines AVASTIN INJ AVELOX INJ AVINZA CAP120MG AVINZA CAP30MG AVINZA CAP45MG AVINZA CAP60MG AVINZA CAP75MG AVINZA CAP90MG AVODART CAP0.5MG AVONEX KIT30MCG AVONEX PREFLKIT30MCG AXERT TAB12.5MG AXERT TAB6.25MG azacitidine AZACTAM/DEX INJ1GM AZACTAM/DEX INJ2GM azathioprine tab 100 mg azathioprine tab 50 mg azathioprine tab 75 mg azelastine hcl nasal spray 137 mcg/spray (1 mg/ml) azelastine hcl ophth soln 0.05% AZILECT TAB0.5MG AZILECT TAB1MG azithromycin for susp 100 mg/5ml azithromycin for susp 200 mg/5ml azithromycin iv for soln 500 mg azithromycin tab 250 mg azithromycin tab 500 mg azithromycin tab 600 mg AZOPT SUS1% OP bacitracin intramuscular for soln unit bacitracin ophth oint 500 unit/gm bacitracin-polymyxin b ophth oint bacitracin-polymyxin-neomycin-hc ophth oint 1% baclofen tab 10 mg baclofen tab 20 mg balsalazide disodium cap 750 mg BANZEL SUS40MG/ML BANZEL TAB200MG BANZEL TAB400MG BARACLUDE SOL.05MG/ML BARACLUDE TAB0.5MG BARACLUDE TAB1MG BECONASE AQ SUS0.042% BELEODAQ INJ500MG benazepril & hydrochlorothiazide tab mg benazepril & hydrochlorothiazide tab mg

202 benazepril & hydrochlorothiazide tab mg benazepril & hydrochlorothiazide tab mg benazepril hcl tab 10 mg benazepril hcl tab 20 mg benazepril hcl tab 40 mg benazepril hcl tab 5 mg BENICAR TAB20MG BENICAR TAB40MG BENICAR TAB5MG BENICAR HCT TAB BENICAR HCT TAB BENICAR HCT TAB40-25MG Benign Prostatic Hypertrophy Agents benzoyl peroxide-erythromycin gel 5-3% benztropine mesylate tab 0.5 mg benztropine mesylate tab 1 mg benztropine mesylate tab 2 mg BESIVANCE SUS0.6% Beta-adrenergic Blocking Agents. 116 Beta-lactam, Cephalosporins Beta-lactam, Other Beta-lactam, Penicillins betamethasone dipropionate augmented cream 0.05% betamethasone dipropionate augmented gel 0.05% betamethasone dipropionate augmented lotion 0.05% betamethasone dipropionate augmented oint 0.05% betamethasone dipropionate cream 0.05% betamethasone dipropionate lotion 0.05% betamethasone dipropionate oint 0.05% betamethasone valerate cream 0.1% betamethasone valerate lotion 0.1% 140 betamethasone valerate oint 0.1% BETASERON INJ0.3MG betaxolol hcl ophth soln 0.5% betaxolol hcl tab 10 mg betaxolol hcl tab 20 mg bethanechol chloride tab 10 mg bethanechol chloride tab 25 mg bethanechol chloride tab 5 mg bethanechol chloride tab 50 mg BETIMOL SOL0.25% BETIMOL SOL0.5% BETOPTIC-S SUS0.25% OP bicalutamide tab 50 mg BILTRICIDE TAB600MG BIPOLAR AGENTS Bipolar Agents, Other bisoprolol & hydrochlorothiazide tab mg bisoprolol & hydrochlorothiazide tab mg bisoprolol & hydrochlorothiazide tab mg bisoprolol fumarate tab 10 mg bisoprolol fumarate tab 5 mg bleomycin sulfate for inj 30 unit BLEPHAMIDE SUSOP Blood Formation Modifiers Blood Formation Products BLOOD GLUCOSE REGULATORS.. 96 BLOOD PRODUCTS/MODIFIERS/ VOLUME EXPANDERS BONIVA INJ3MG/3ML BOOSTRIX INJ BOSULIF TAB100MG BOSULIF TAB500MG brimonidine tartrate ophth soln 0.15% brimonidine tartrate ophth soln 0.2% 173 BRINTELLIX TAB10MG BRINTELLIX TAB20MG BRINTELLIX TAB5MG bromfenac sodium ophth soln 0.09% (base equivalent) bromocriptine mesylate cap 5 mg bromocriptine mesylate tab 2.5 mg Bronchodilators, Anticholinergic Bronchodilators, Phosphodiesterase Inhibitors (Xanthines)

203 Bronchodilators, Sympathomimetic budesonide cap sr 24hr 3 mg bumetanide tab 0.5 mg bumetanide tab 1 mg bumetanide tab 2 mg BUPHENYL POW BUPHENYL TAB500MG buprenorphine hcl inj 0.3 mg/ml (base equiv) buprenorphine hcl sl tab 2 mg (base equiv) buprenorphine hcl sl tab 8 mg (base equiv) buprenorphine hcl-naloxone hcl sl tab mg (base equiv) buprenorphine hcl-naloxone hcl sl tab 8-2 mg (base equiv) bupropion hcl (smoking deterrent) tab sr 12hr 150 mg bupropion hcl tab 100 mg bupropion hcl tab 75 mg bupropion hcl tab sr 12hr 100 mg bupropion hcl tab sr 12hr 150 mg bupropion hcl tab sr 12hr 200 mg bupropion hcl tab sr 24hr 150 mg bupropion hcl tab sr 24hr 300 mg buspirone hcl tab 10 mg buspirone hcl tab 15 mg buspirone hcl tab 30 mg buspirone hcl tab 5 mg buspirone hcl tab 7.5 mg butalbital-acetaminophen tab mg butalbital-acetaminophen tab mg butalbital-acetaminophen-caff w/ cod cap mg butalbital-acetaminophen-caffeine cap mg butalbital-acetaminophen-caffeine soln mg/15ml butalbital-acetaminophen-caffeine tab mg butalbital-acetaminophen-caffeine tab mg butalbital-aspirin-caff w/ codeine cap mg butalbital-aspirin-caffeine cap mg butalbital-aspirin-caffeine tab mg butorphanol tartrate nasal soln 10 mg/ml BYETTA INJ10MCG BYETTA INJ5MCG cabergoline tab 0.5 mg calcipotriene cream 0.005% calcipotriene oint 0.005% calcipotriene soln 0.005% (50 mcg/ml) calcitonin (salmon) nasal soln 200 unit/act calcitriol cap 0.25 mcg calcitriol cap 0.5 mcg calcitriol inj 1 mcg/ml calcitriol oral soln 1 mcg/ml calcium acetate (phosphate binder) cap 667 mg (169 mg ca) Calcium Channel Blocking Agents 119 Calcium Channel Modifying Agents 51 CAMPRAL TAB333MG CANASA SUP1000MG CANCIDAS INJ50MG CANCIDAS INJ70MG candesartan cilexetilhydrochlorothiazide tab mg candesartan cilexetilhydrochlorothiazide tab mg candesartan cilexetilhydrochlorothiazide tab mg. 112 CANTIL TAB25MG CAPASTAT SULINJ1GM CAPEX SHA0.01% CAPRELSA TAB100MG CAPRELSA TAB300MG captopril & hydrochlorothiazide tab mg captopril & hydrochlorothiazide tab mg

204 captopril & hydrochlorothiazide tab mg captopril & hydrochlorothiazide tab mg captopril tab 100 mg captopril tab 12.5 mg captopril tab 25 mg captopril tab 50 mg carbamazepine cap sr 12hr 100 mg carbamazepine cap sr 12hr 200 mg carbamazepine cap sr 12hr 300 mg carbamazepine chew tab 100 mg carbamazepine susp 100 mg/5ml carbamazepine tab 200 mg carbamazepine tab sr 12hr 200 mg carbamazepine tab sr 12hr 400 mg carbidopa & levodopa orally disintegrating tab mg carbidopa & levodopa orally disintegrating tab mg carbidopa & levodopa orally disintegrating tab mg carbidopa & levodopa tab mg. 84 carbidopa & levodopa tab mg. 84 carbidopa & levodopa tab mg. 84 carbidopa & levodopa tab cr mg carbidopa & levodopa tab cr mg CARDIOVASCULAR AGENTS... 3, 110 Cardiovascular Agents, Other CARIMUNE NF INJ3GM carisoprodol tab 350 mg carteolol hcl ophth soln 1% carvedilol tab 12.5 mg carvedilol tab 25 mg carvedilol tab mg carvedilol tab 6.25 mg CAVERJECT CAVERJECT INJ 20MCG, 40MCG CEENU CAP10MG CEENU CAP40MG cefaclor cap 250 mg cefaclor cap 500 mg cefaclor monohydrate tab sr 12hr 500 mg cefadroxil cap 500 mg cefadroxil for susp 250 mg/5ml cefadroxil for susp 500 mg/5ml cefadroxil tab 1 gm cefazolin in d5w inj 1 gm/50ml cefazolin sodium for inj 1 gm cefazolin sodium for inj 10 gm cefazolin sodium for inj 500 mg cefdinir cap 300 mg cefdinir for susp 125 mg/5ml cefdinir for susp 250 mg/5ml cefepime hcl for inj 1 gm cefepime hcl for inj 2 gm cefoxitin sodium for inj 1 gm cefoxitin sodium for inj 10 gm cefoxitin sodium for inj 2 gm cefoxitin sodium iv for soln 1 gm and dextrose 4% cefoxitin sodium iv for soln 2 gm and dextrose 2.2% cefpodoxime proxetil for susp 100 mg/5ml cefpodoxime proxetil for susp 50 mg/5ml cefpodoxime proxetil tab 100 mg cefpodoxime proxetil tab 200 mg cefprozil for susp 125 mg/5ml cefprozil for susp 250 mg/5ml cefprozil tab 250 mg cefprozil tab 500 mg ceftriaxone sodium for inj 10 gm ceftriaxone sodium for inj 250 mg ceftriaxone sodium for inj 500 mg ceftriaxone sodium for iv soln 1 gm ceftriaxone sodium for iv soln 2 gm cefuroxime axetil tab 250 mg cefuroxime axetil tab 500 mg cefuroxime sodium for inj 1.5 gm cefuroxime sodium for inj 7.5 gm cefuroxime sodium for inj 750 mg CELEBREX CAP100MG CELEBREX CAP200MG CELEBREX CAP400MG CELEBREX CAP50MG CELESTONE SOL0.6MG/ CELLCEPT SUS200MG/ML

205 CELLCEPT IV INJ500MG CELONTIN CAP300MG CENTRAL NERVOUS SYSTEM AGENTS Central Nervous System, Other cephalexin cap 250 mg cephalexin cap 500 mg cephalexin for susp 125 mg/5ml cephalexin for susp 250 mg/5ml cephalexin tab 250 mg cephalexin tab 500 mg CEREZYME INJ200UNIT CERVARIX INJ CHANTIX PAK0.5& 1MG CHANTIX TAB0.5MG CHANTIX TAB1MG chloramphenicol sodium succinate for iv inj 1 gm chlorhexidine gluconate soln 0.12%. 130 chloroquine phosphate tab 250 mg chloroquine phosphate tab 500 mg chlorothiazide tab 250 mg chlorothiazide tab 500 mg chlorpromazine hcl inj 25 mg/ml chlorpromazine hcl tab 10 mg chlorpromazine hcl tab 100 mg chlorpromazine hcl tab 200 mg chlorpromazine hcl tab 25 mg chlorpromazine hcl tab 50 mg chlorthalidone tab 25 mg chlorthalidone tab 50 mg cholestyramine light powder 4 gm/dose cholestyramine light powder packets 4 gm Cholinesterase Inhibitors CIALIS CIALIS 10MG AND 20MG ciclopirox gel 0.77% ciclopirox olamine cream 0.77% (base equiv) ciclopirox olamine susp 0.77% (base equiv) ciclopirox shampoo 1% ciclopirox solution 8% cilostazol tab 100 mg cilostazol tab 50 mg CILOXAN OIN0.3% OP cimetidine hcl soln 300 mg/5ml cimetidine tab 200 mg cimetidine tab 300 mg cimetidine tab 400 mg cimetidine tab 800 mg CIPRO HC SUSOTIC CIPRODEX SUS % ciprofloxacin hcl ophth soln 0.3% ciprofloxacin hcl tab 100 mg (base equiv) ciprofloxacin hcl tab 250 mg (base equiv) ciprofloxacin hcl tab 500 mg (base equiv) ciprofloxacin hcl tab 750 mg (base equiv) ciprofloxacin-ciprofloxacin hcl tab sr 24hr 1000 mg(base eq) ciprofloxacin-ciprofloxacin hcl tab sr 24hr 500 mg (base eq) citalopram hydrobromide oral soln 10 mg/5ml citalopram hydrobromide tab 10 mg (base equiv) citalopram hydrobromide tab 20 mg (base equiv) citalopram hydrobromide tab 40 mg (base equiv) clarithromycin for susp 125 mg/5ml clarithromycin for susp 250 mg/5ml clarithromycin tab 250 mg clarithromycin tab 500 mg clarithromycin tab sr 24hr 500 mg clemastine fumarate tab 2.68 mg CLEOCIN SUP100MG clindamycin hcl cap 150 mg clindamycin hcl cap 300 mg clindamycin hcl cap 75 mg clindamycin phosphate foam 1% clindamycin phosphate gel 1% clindamycin phosphate in d5w iv soln 300 mg/50ml clindamycin phosphate in d5w iv soln 600 mg/50ml

206 clindamycin phosphate in d5w iv soln 900 mg/50ml clindamycin phosphate iv soln 600 mg/4ml clindamycin phosphate lotion 1% clindamycin phosphate soln 1% clindamycin phosphate swab 1% clindamycin phosphate vaginal cream 2% clindamycin sol75mg/5ml clobetasol propionate emollient base cream 0.05% clobetasol propionate foam 0.05% clobetasol propionate gel 0.05% clobetasol propionate lotion 0.05% clobetasol propionate oint 0.05% clobetasol propionate shampoo 0.05% clobetasol propionate soln 0.05% clomipramine hcl cap 25 mg clomipramine hcl cap 50 mg clomipramine hcl cap 75 mg clonazepam orally disintegrating tab mg clonazepam orally disintegrating tab 0.25 mg clonazepam orally disintegrating tab 0.5 mg clonazepam orally disintegrating tab 1 mg clonazepam orally disintegrating tab 2 mg clonazepam tab 0.5 mg clonazepam tab 1 mg clonazepam tab 2 mg clonidine hcl tab 0.1 mg clonidine hcl tab 0.2 mg clonidine hcl tab 0.3 mg clonidine hcl td patch weekly 0.1 mg/24hr clonidine hcl td patch weekly 0.2 mg/24hr clonidine hcl td patch weekly 0.3 mg/24hr clopidogrel bisulfate tab 300 mg (base equiv) clopidogrel bisulfate tab 75 mg (base equiv) clorazepate dipotassium tab 15 mg clorazepate dipotassium tab 3.75 mg. 95 clorazepate dipotassium tab 7.5 mg clotrimazole cream 1% clotrimazole soln 1% clotrimazole troche 10 mg clotrimazole w/ betamethasone cream % clotrimazole w/ betamethasone lotion % clozapine tab 100 mg clozapine tab 200 mg clozapine tab 25 mg clozapine tab 50 mg Coagulants colchicine w/ probenecid tab mg COLCRYS TAB0.6MG colestipol hcl granules 5 gm colestipol hcl tab 1 gm colistimethate sodium for inj 150 mg.. 37 COLY-MYCIN SSUSOTIC COMBIPATCH DIS.05/ COMBIPATCH DIS.05/ COMBIVENT AER COMBIVENT AERRESPIMAT COMETRIQ KIT100MG COMETRIQ KIT140MG COMETRIQ KIT60MG COMPLERA TAB COMTAN TAB200MG COMVAX INJ COPAXONE KIT20MG/ML COREG CR CAP10MG COREG CR CAP20MG COREG CR CAP40MG COREG CR CAP80MG cortisone acetate tab 25 mg COUMADIN INJ5 MG CREON CAP12000UNT CREON CAP24000UNT CREON CAP3000UNIT CREON CAP36000UNT CREON CAP6000UNIT

207 CRESTOR TAB10MG CRESTOR TAB20MG CRESTOR TAB40MG CRESTOR TAB5MG CRINONE GEL4% VAG CRINONE GEL8% VAG CRIXIVAN CAP200MG CRIXIVAN CAP400MG cromolyn sodium ophth soln 4% cromolyn sodium soln nebu 20 mg/2ml cyclobenzaprine hcl tab 10 mg cyclobenzaprine hcl tab 5 mg CYCLOPHOSPH CAP25MG CYCLOPHOSPH CAP50MG cyclophosphamide tab 25 mg cyclophosphamide tab 50 mg cycloserine cap 250 mg CYCLOSET TAB0.8MG cyclosporine cap 100 mg cyclosporine cap 25 mg cyclosporine iv soln 50 mg/ml cyclosporine modified cap 100 mg cyclosporine modified cap 25 mg cyclosporine modified cap 50 mg cyclosporine modified oral soln 100 mg/ml CYKLOKAPRON INJ100MG/ML CYMBALTA CAP20MG CYMBALTA CAP30MG CYMBALTA CAP60MG cyproheptadine hcl syrup 2 mg/5ml cyproheptadine hcl tab 4 mg CYSTADANE POW CYSTAGON CAP150MG CYSTAGON CAP50MG D10W/NACL INJ0.2% D10W/NACL INJ0.45% D5W/NACL INJ0.225% DACOGEN INJ50MG DALIRESP TAB500MCG danazol cap 100 mg danazol cap 200 mg danazol cap 50 mg dantrolene sodium cap 100 mg dantrolene sodium cap 25 mg dantrolene sodium cap 50 mg dapsone tab 100 mg dapsone tab 25 mg DAPTACEL INJ DARAPRIM TAB25MG decitabine inj50mg DELZICOL CAP400MG demeclocycline hcl tab 150 mg demeclocycline hcl tab 300 mg DENAVIR CRE1% DENTAL AND ORAL AGENTS DEPEN TITRA TAB250MG DERMATOLOGICAL AGENTS desipramine hcl tab 10 mg desipramine hcl tab 100 mg desipramine hcl tab 150 mg desipramine hcl tab 25 mg desipramine hcl tab 50 mg desipramine hcl tab 75 mg desmopressin acetate inj 4 mcg/ml desmopressin acetate tab 0.1 mg desmopressin acetate tab 0.2 mg desogest-eth estrad & eth estrad tab /0.01 mg(21/5) desogest-ethin est tab / / mg-mg desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg desonide cream 0.05% desonide lotion 0.05% desonide oint 0.05% desoximetasone cream 0.05% desoximetasone gel 0.05% desoximetasone oint 0.25% DESVENLAFAXINE TAB100MG ER.. 58 DESVENLAFAXINE TAB50MG ER dexamethasone conc 1 mg/ml dexamethasone elixir 0.5 mg/5ml dexamethasone sodium phosphate inj 4 mg/ml dexamethasone sodium phosphate ophth soln 0.1% dexamethasone tab 0.5 mg dexamethasone tab 0.75 mg dexamethasone tab 1 mg dexamethasone tab 1.5 mg

208 dexamethasone tab 2 mg dexamethasone tab 4 mg dexamethasone tab 6 mg dexmethylphenidate hcl tab 10 mg dexmethylphenidate hcl tab 2.5 mg dexmethylphenidate hcl tab 5 mg dextroamphetamine sulfate tab 10 mg dextroamphetamine sulfate tab 5 mg 127 dextrose 2.5% w/ sodium chloride 0.45% dextrose 5% in lactated ringers dextrose 5% w/ sodium chloride 0.2% dextrose 5% w/ sodium chloride 0.33% dextrose 5% w/ sodium chloride 0.45% dextrose 5% w/ sodium chloride 0.9% dextrose inj 10% dextrose inj 5% DIASTAT ACUDIAL GEL 10MG DIASTAT ACUDIAL GEL 20MG DIASTAT PEDIATRIC GEL 2.5MG DIAZEPAM GEL10MG DIAZEPAM GEL2.5MG DIAZEPAM GEL20MG diazepam conc 5 mg/ml diazepam soln 1 mg/ml diazepam tab 10 mg diazepam tab 2 mg diazepam tab 5 mg diclofenac potassium tab 50 mg diclofenac sodium ophth soln 0.1% diclofenac sodium tab delayed release 25 mg diclofenac sodium tab delayed release 50 mg diclofenac sodium tab delayed release 75 mg diclofenac sodium tab sr 24hr 100 mg 26 dicloxacillin sodium cap 250 mg dicloxacillin sodium cap 500 mg dicyclomine hcl cap 10 mg dicyclomine hcl oral soln 10 mg/5ml. 136 dicyclomine hcl tab 20 mg didanosine delayed release capsule 125 mg didanosine delayed release capsule 200 mg didanosine delayed release capsule 250 mg didanosine delayed release capsule 400 mg DIFFERIN GEL0.3% DIFFERIN LOT0.1% diflorasone diacetate cream 0.05% diflorasone diacetate oint 0.05% diflunisal tab 500 mg DIGOXIN SOL50MCG/ML digoxin inj 0.25 mg/ml digoxin tab mg digoxin tab 0.25 mg dihydroergotamine mesylate inj 1 mg/ml diltiazem hcl cap sr 12hr 120 mg diltiazem hcl cap sr 12hr 60 mg diltiazem hcl cap sr 12hr 90 mg diltiazem hcl cap sr 24hr 180 mg diltiazem hcl cap sr 24hr 240 mg diltiazem hcl coated beads cap sr 24hr 120 mg diltiazem hcl coated beads cap sr 24hr 180 mg diltiazem hcl coated beads cap sr 24hr 240 mg diltiazem hcl coated beads cap sr 24hr 300 mg diltiazem hcl extended release beads cap sr 24hr 120 mg diltiazem hcl extended release beads cap sr 24hr 180 mg diltiazem hcl extended release beads cap sr 24hr 240 mg diltiazem hcl extended release beads cap sr 24hr 300 mg diltiazem hcl extended release beads cap sr 24hr 360 mg diltiazem hcl extended release beads cap sr 24hr 420 mg diltiazem hcl tab 120 mg

209 diltiazem hcl tab 30 mg diltiazem hcl tab 60 mg diltiazem hcl tab 90 mg DIPENTUM CAP250MG diphenhydramine hcl inj 50 mg/ml DIPHTHERIA/TETANUS INJ disopyramide phosphate cap 100 mg disopyramide phosphate cap 150 mg disulfiram tab 250 mg disulfiram tab 500 mg Diuretics, Carbonic Anhydrase Inhibitors Diuretics, Loop Diuretics, Potassium-sparing Diuretics, Thiazide divalproex sodium cap sprinkle 125 mg divalproex sodium tab delayed release 125 mg divalproex sodium tab delayed release 250 mg divalproex sodium tab delayed release 500 mg divalproex sodium tab sr 24 hr 250 mg divalproex sodium tab sr 24 hr 500 mg DOCEFREZ INJ20MG DOCEFREZ INJ80MG docetaxel for inj conc 80 mg/4ml (20 mg/ml) donepezil hydrochloride orally disintegrating tab 10 mg donepezil hydrochloride orally disintegrating tab 5 mg donepezil hydrochloride tab 10 mg donepezil hydrochloride tab 5 mg Dopamine Agonists Dopamine Precursors/L-Amino Acid Decarboxylase Inhibitors dorzolamide hcl ophth soln 2% dorzolamide hcl-timolol maleate ophth soln mg/ml doxazosin mesylate tab 1 mg doxazosin mesylate tab 2 mg doxazosin mesylate tab 4 mg doxazosin mesylate tab 8 mg doxepin hcl cap 10 mg doxepin hcl cap 100 mg doxepin hcl cap 150 mg doxepin hcl cap 25 mg doxepin hcl cap 50 mg doxepin hcl cap 75 mg doxepin hcl conc 10 mg/ml doxycycline hyclate cap 100 mg doxycycline hyclate cap 50 mg doxycycline hyclate for inj 100 mg doxycycline hyclate tab 100 mg doxycycline hyclate tab 20 mg doxycycline hyclate tab delayed release 100 mg doxycycline hyclate tab delayed release 150 mg doxycycline hyclate tab delayed release 75 mg doxycycline monohydrate cap 75 mg. 50 doxycycline monohydrate tab 50 mg.. 50 doxycycline monohydrate tab 75 mg.. 50 dronabinol cap 10 mg dronabinol cap 2.5 mg dronabinol cap 5 mg DROXIA CAP200MG DROXIA CAP300MG DROXIA CAP400MG DRUG NAME DUAVEE TAB duloxetine cap20mg duloxetine cap30mg duloxetine cap60mg dyphylline tab 200 mg dyphylline tab 400 mg Dyslipidemics Dyslipidemics, Fibric Acid Derivatives Dyslipidemics, HMG CoA Reductase Inhibitors Dyslipidemics, Other econazole nitrate cream 1% EDEX KIT EDEX KIT 20 MCG

210 EDURANT TAB25MG EFFIENT TAB10MG EFFIENT TAB5MG ELAPRASE INJ6MG/3ML Electrolyte/Mineral Modifiers Electrolyte/Mineral Replacement ELIDEL CRE1% ELITEK INJ1.5MG EMCYT CAP140MG EMEND CAP125MG EMEND CAP40MG EMEND CAP80MG EMEND PAK80 & Emetogenic Therapy Adjuncts EMSAM DIS12MG/24H EMSAM DIS6MG/24HR EMSAM DIS9MG/24HR EMTRIVA CAP200MG EMTRIVA SOL10MG/ML ENABLEX TAB15MG ENABLEX TAB7.5MG enalapril maleate & hydrochlorothiazide tab mg enalapril maleate & hydrochlorothiazide tab mg enalapril maleate tab 10 mg enalapril maleate tab 2.5 mg enalapril maleate tab 20 mg enalapril maleate tab 5 mg ENBREL INJ25/0.5ML ENBREL INJ25MG ENBREL INJ50MG/ML ENGERIX-B INJ10/0.5ML ENGERIX-B INJ20MCG/ML ENHANCED COVERAGE DRUGS enoxaparin sodium inj 100 mg/ml enoxaparin sodium inj 120 mg/0.8ml 100 enoxaparin sodium inj 150 mg/ml enoxaparin sodium inj 30 mg/0.3ml enoxaparin sodium inj 300 mg/3ml enoxaparin sodium inj 40 mg/0.4ml enoxaparin sodium inj 60 mg/0.6ml enoxaparin sodium inj 80 mg/0.8ml Enzyme Inhibitors ENZYME REPLACEMENTS/ MODIFIERS EPIPEN 2-PAKINJ0.3MG EPIPEN-JR INJ2-PAK EPIVIR SOL10MG/ML EPIVIR HBV SOL5MG/ML EPIVIR HBV TAB100MG eplerenone tab 25 mg eplerenone tab 50 mg EPOGEN INJ10000/ML EPOGEN INJ2000/ML EPOGEN INJ20000/ML EPOGEN INJ3000/ML EPOGEN INJ4000/ML eprosartan mesylate tab 600 mg EPZICOM TAB ERAXIS INJ100MG Ergot Alkaloids ergotamine w/ caffeine suppos mg ERIVEDGE CAP150MG ERWINAZE INJ10000UNT ERYTHROCIN INJ500MG ERYTHROM ETHTAB400MG erythromycin gel 2% erythromycin ophth oint 5 mg/gm erythromycin pads 2% erythromycin soln 2% erythromycin stearate tab 250 mg erythromycin tab 250 mg erythromycin tab 500 mg erythromycin tab delayed release 250 mg erythromycin tab delayed release 333 mg erythromycin tab delayed release 500 mg escitalopram oxalate soln 5 mg/5ml (base equiv) escitalopram oxalate tab 10 mg (base equiv) escitalopram oxalate tab 20 mg (base equiv) escitalopram oxalate tab 5 mg (base equiv) esterified estrogens tab 0.3 mg esterified estrogens tab mg esterified estrogens tab 1.25 mg

211 esterified estrogens tab 2.5 mg ESTRACE VAG CRE0.1MG/GM estradiol tab 0.5 mg estradiol tab 1 mg , 150 estradiol tab 2 mg ESTRING MIS2MG Estrogens estropipate tab 0.75 mg estropipate tab 1.5 mg estropipate tab 3 mg ethambutol hcl tab 100 mg ethambutol hcl tab 400 mg ethosuximide cap 250 mg ethosuximide soln 250 mg/5ml ethynodiol diacetate & ethinyl estradiol tab 1 mg-35 mcg ethynodiol diacetate & ethinyl estradiol tab 1 mg-50 mcg etidronate disodium tab 200 mg etidronate disodium tab 400 mg etodolac cap 200 mg etodolac cap 300 mg etodolac tab 400 mg etodolac tab 500 mg etodolac tab sr 24hr 400 mg etodolac tab sr 24hr 500 mg etodolac tab sr 24hr 600 mg ETOPOPHOS INJ100MG etoposide inj 20 mg/ml EURAX CRE10% EURAX LOT10% EVISTA TAB60MG EXELDERM CRE1% EXELDERM SOL1% EXELON DIS13.3/ EXELON DIS4.6MG/ EXELON DIS9.5MG/ EXELON SOL2MG/ML exemestane tab 25 mg EXJADE TAB125MG EXJADE TAB500MG FABRAZYME INJ35MG famciclovir tab 125 mg famciclovir tab 250 mg famciclovir tab 500 mg famotidine for susp 40 mg/5ml famotidine in nacl 0.9% iv soln 20 mg/50ml famotidine inj 10 mg/ml famotidine tab 20 mg famotidine tab 40 mg FANAPT PAK FANAPT TAB10MG FANAPT TAB12MG FANAPT TAB1MG FANAPT TAB2MG FANAPT TAB4MG FANAPT TAB6MG FANAPT TAB8MG FARESTON TAB60MG FASLODEX INJ250MG fat emulsion iv soln 20% FAZACLO TAB100/ODT FAZACLO TAB12.5/ODT FAZACLO TAB150MG FAZACLO TAB200MG FAZACLO TAB25MG ODT felbamate susp 600 mg/5ml felbamate tab 400 mg felbamate tab 600 mg felodipine tab sr 24hr 10 mg felodipine tab sr 24hr 2.5 mg felodipine tab sr 24hr 5 mg fenofibrate micronized cap 134 mg fenofibrate micronized cap 200 mg fenofibrate micronized cap 67 mg fenofibrate tab 160 mg fenofibrate tab 54 mg fenoprofen calcium tab 600 mg fentanyl citrate lollipop 1200 mcg fentanyl citrate lollipop 1600 mcg fentanyl citrate lollipop 200 mcg fentanyl citrate lollipop 400 mcg fentanyl citrate lollipop 600 mcg fentanyl citrate lollipop 800 mcg fentanyl td patch 72hr 100 mcg/hr fentanyl td patch 72hr 12 mcg/hr fentanyl td patch 72hr 25 mcg/hr fentanyl td patch 72hr 50 mcg/hr fentanyl td patch 72hr 75 mcg/hr FETZIMA CAP FETZIMA CAP

212 FETZIMA CAP FETZIMA CAP FETZIMA CAPTITRATION finasteride tab 5 mg FLAREX SUS0.1% OP flavoxate hcl tab 100 mg flecainide acetate tab 100 mg flecainide acetate tab 150 mg flecainide acetate tab 50 mg FLOVENT DISKAER100MCG FLOVENT DISKAER250MCG FLOVENT DISKAER50MCG FLOVENT HFA AER110MCG FLOVENT HFA AER220MCG FLOVENT HFA AER44MCG fluconazole for susp 10 mg/ml fluconazole for susp 40 mg/ml fluconazole in dextrose inj 400 mg/200ml fluconazole tab 100 mg fluconazole tab 150 mg fluconazole tab 200 mg fluconazole tab 50 mg flucytosine cap 250 mg flucytosine cap 500 mg fludrocortisone acetate tab 0.1 mg flunisolide nasal soln 0.025% flunisolide nasal soln 29 mcg/act (0.025%) fluocinolone acetonide cream 0.01% 141 fluocinolone acetonide cream 0.025% fluocinolone acetonide oint 0.025% fluocinolone acetonide soln 0.01% fluocinonide emulsified base cream 0.05% fluocinonide gel 0.05% fluocinonide oint 0.05% fluocinonide soln 0.05% fluorouracil cream 5% fluoxetine hcl cap 10 mg fluoxetine hcl cap 20 mg fluoxetine hcl cap 40 mg fluoxetine hcl solution 20 mg/5ml fluoxetine hcl tab 10 mg fluoxetine hcl tab 20 mg fluphenazine decanoate inj 25 mg/ml. 84 fluphenazine hcl elixir 2.5 mg/5ml fluphenazine hcl inj 2.5 mg/ml fluphenazine hcl oral conc 5 mg/ml fluphenazine hcl tab 1 mg fluphenazine hcl tab 10 mg fluphenazine hcl tab 2.5 mg fluphenazine hcl tab 5 mg flurbiprofen sodium ophth soln 0.03% flurbiprofen tab 100 mg flurbiprofen tab 50 mg flutamide cap 125 mg fluticasone propionate cream 0.05% 141 fluticasone propionate lotion 0.05% fluticasone propionate nasal susp 50 mcg/act fluticasone propionate oint 0.005% fluvoxamine maleate tab 100 mg fluvoxamine maleate tab 25 mg fluvoxamine maleate tab 50 mg FML OIN0.1% OP FML FORTE SUS0.25% OP folic acid folic acid 1mg fondaparinux sodium inj 10 mg/0.8ml fondaparinux sodium inj 2.5 mg/0.5ml fondaparinux sodium inj 5 mg/0.4ml. 101 fondaparinux sodium inj 7.5 mg/0.6ml FORADIL CAPAEROLIZE FORFIVO XL TAB450MG FORTEO SOL600/ foscarnet sodium inj 24 mg/ml fosinopril sodium & hydrochlorothiazide tab mg fosinopril sodium & hydrochlorothiazide tab mg fosinopril sodium tab 10 mg fosinopril sodium tab 20 mg fosinopril sodium tab 40 mg fosphenytoin sodium inj 100 mg/2ml (phenytoin equiv) FOSRENOL CHW1000MG

213 FOSRENOL CHW500MG FOSRENOL CHW750MG FRAGMIN INJ10000/ML FRAGMIN INJ12500UNT FRAGMIN INJ15000UNT FRAGMIN INJ18000UNT FRAGMIN INJ2500/ FRAGMIN INJ25000/ML FRAGMIN INJ5000/ FRAGMIN INJ7500/ FREAMINE IIIINJ8.5% furosemide inj 10 mg/ml furosemide oral soln 10 mg/ml furosemide oral soln 8 mg/ml furosemide tab 20 mg furosemide tab 40 mg furosemide tab 80 mg FUSILEV INJ50MG FUZEON INJ90MG FYCOMPA TAB10MG FYCOMPA TAB12MG FYCOMPA TAB2MG FYCOMPA TAB4MG FYCOMPA TAB6MG FYCOMPA TAB8MG GABA Receptor Modulators gabapentin cap 100 mg gabapentin cap 300 mg gabapentin cap 400 mg gabapentin oral soln 250 mg/5ml gabapentin tab 600 mg gabapentin tab 800 mg GABITRIL TAB12MG GABITRIL TAB16MG galantamine hydrobromide cap sr 24hr 16 mg galantamine hydrobromide cap sr 24hr 24 mg galantamine hydrobromide cap sr 24hr 8 mg galantamine hydrobromide oral soln 4 mg/ml galantamine hydrobromide tab 12 mg 55 galantamine hydrobromide tab 4 mg.. 55 galantamine hydrobromide tab 8 mg.. 55 GAMASTAN S/DINJ Gamma-aminobutyric Acid (GABA) Augmenting Agents GAMMAGARD INJ2.5GM/ ganciclovir sodium for inj 500 mg GARDASIL INJ GASTROINTESTINAL AGENTS Gastrointestinal Agents, Other GAUZE PADS & DRESSING gemcitabine hcl for inj 1 gm gemfibrozil tab 600 mg GENITOURINARY AGENTS Genitourinary Agents, Other GENOTROPIN INJ0.2MG GENOTROPIN INJ0.4MG GENOTROPIN INJ0.6MG GENOTROPIN INJ0.8MG GENOTROPIN INJ1.2MG GENOTROPIN INJ1.4MG GENOTROPIN INJ1.6MG GENOTROPIN INJ1.8MG GENOTROPIN INJ12MG GENOTROPIN INJ1MG GENOTROPIN INJ2MG GENOTROPIN INJ5MG GENTAMICIN CRE0.1% GENTAMICIN OIN0.1% gentamicin sulfate inj 40 mg/ml gentamicin sulfate iv soln 10 mg/ml gentamicin sulfate ophth oint 0.3% gentamicin sulfate ophth soln 0.3% GEODON INJ20MG GILENYA CAP0.5MG GILOTRIF TAB20MG GILOTRIF TAB30MG GILOTRIF TAB40MG GLEEVEC TAB100MG GLEEVEC TAB400MG glimepiride tab 1 mg glimepiride tab 2 mg glimepiride tab 4 mg glipizide tab 10 mg glipizide tab 5 mg glipizide tab sr 24hr 10 mg glipizide tab sr 24hr 2.5 mg glipizide tab sr 24hr 5 mg

214 glipizide-metformin hcl tab mg glipizide-metformin hcl tab mg glipizide-metformin hcl tab mg.. 97 GLUCAGEN INJHYPOKIT GLUCAGON KIT1MG Glucocorticoids , 167 Glucocorticoids/Mineralocorticoids Glutamate Pathway Modifiers Glutamate Reducing Agents glyburide micronized tab 1.5 mg glyburide micronized tab 3 mg glyburide micronized tab 6 mg glyburide tab 1.25 mg glyburide tab 2.5 mg glyburide tab 5 mg glyburide-metformin tab mg. 97 glyburide-metformin tab mg glyburide-metformin tab mg Glycemic Agents glycopyrrolate tab 1 mg glycopyrrolate tab 2 mg GLYSET TAB100MG GLYSET TAB25MG GLYSET TAB50MG granisetron hcl tab 1 mg griseofulvin microsize susp 125 mg/5ml guanfacine hcl tab 1 mg guanfacine hcl tab 2 mg GUANIDINE TAB125MG HALAVEN INJ1MG/2ML halobetasol propionate cream 0.05%141 halobetasol propionate oint 0.05% HALOG CRE0.1% HALOG OIN0.1% haloperidol decanoate im soln 100 mg/ml haloperidol decanoate im soln 50 mg/ml haloperidol lactate inj 5 mg/ml haloperidol lactate oral conc 2 mg/ml. 85 haloperidol tab 0.5 mg haloperidol tab 1 mg haloperidol tab 10 mg haloperidol tab 2 mg haloperidol tab 20 mg haloperidol tab 5 mg HAVRIX INJ1440UNIT HAVRIX INJ720UNIT HECTOROL CAP0.5MCG HECTOROL CAP1MCG HECTOROL CAP2.5MCG HECTOROL INJ4MCG/2ML HELIDAC MIS HEP SOD/NACLINJ25000UNT heparin sodium (porcine) 2 unit/ml in sodium chloride 0.9% heparin sodium (porcine) 40 unit/ml in d5w heparin sodium (porcine) inj 1000 unit/ml heparin sodium (porcine) inj unit/ml heparin sodium (porcine) inj unit/ml heparin sodium (porcine) inj 5000 unit/ml HEPSERA TAB10MG HERCEPTIN INJ440MG HEXALEN CAP50MG Histamine2 (H2) Receptor Antagonists HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (Adrenal) HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (PITUITARY) HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (SEX HORMONES/MODIFIERS) HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (THYROID) HORMONAL AGENTS, SUPPRESSANT (ADRENAL) HORMONAL AGENTS, SUPPRESSANT (PARATHYROID)

215 HORMONAL AGENTS, SUPPRESSANT (PITUITARY) HORMONAL AGENTS, SUPPRESSANT (SEX HORMONES/MODIFIERS) HORMONAL AGENTS, SUPPRESSANTS (THYROID) HUMALOG INJ100/ML HUMALOG KWIKINJ100/ML HUMALOG MIX INJ50/ HUMALOG MIX INJ50/50KWP HUMALOG MIX INJ75/25KWP HUMALOG MIX SUS75/ HUMATROPE INJ12MG HUMATROPE INJ24MG HUMATROPE INJ5MG HUMATROPE INJ6MG HUMIRA KIT20MG/ HUMIRA KIT40MG/ HUMIRA PEN KITCROHNS HUMULIN INJ70/ HUMULIN N INJU HUMULIN N PNINJU HUMULIN PEN INJ70/ HUMULIN R INJU HUMULIN R INJU hydralazine hcl inj 20 mg/ml hydralazine hcl tab 10 mg hydralazine hcl tab 100 mg hydralazine hcl tab 25 mg hydralazine hcl tab 50 mg hydrochlorothiazide cap 12.5 mg hydrochlorothiazide tab 12.5 mg hydrochlorothiazide tab 25 mg hydrochlorothiazide tab 50 mg hydrocodone-acetaminophen cap mg hydrocodone-acetaminophen soln mg/15ml hydrocodone-acetaminophen soln mg/15ml hydrocodone-acetaminophen tab mg hydrocodone-acetaminophen tab mg hydrocodone-acetaminophen tab mg hydrocodone-acetaminophen tab mg hydrocodone-acetaminophen tab mg hydrocodone-acetaminophen tab mg hydrocodone-acetaminophen tab mg hydrocodone-acetaminophen tab mg hydrocodone-acetaminophen tab mg hydrocodone-acetaminophen tab mg hydrocodone-acetaminophen tab mg hydrocodone-acetaminophen tab mg hydrocodone-acetaminophen tab mg hydrocodone-acetaminophen tab mg hydrocodone-acetaminophen tab mg hydrocodone-acetaminophen tab mg hydrocodone-acetaminophen tab mg hydrocodone-acetaminophen tab mg hydrocodone-ibuprofen tab mg hydrocortisone cream 1% hydrocortisone cream 2.5% hydrocortisone enema 100 mg/60ml 168 hydrocortisone lotion 2.5% hydrocortisone oint 1% hydrocortisone oint 2.5% hydrocortisone rectal cream 1% hydrocortisone rectal cream 2.5% hydrocortisone tab 10 mg hydrocortisone tab 20 mg hydrocortisone tab 5 mg hydrocortisone valerate cream 0.2%

216 hydrocortisone valerate oint 0.2% hydrocortisone w/ acetic acid otic soln 1-2% hydromorphone hcl tab 2 mg hydromorphone hcl tab 4 mg hydromorphone hcl tab 8 mg hydroxychloroquine sulfate tab 200 mg hydroxyurea cap 500 mg ibandronate sodium tab 150 mg (base equivalent) ibuprofen susp 100 mg/5ml ibuprofen tab 400 mg ibuprofen tab 600 mg ibuprofen tab 800 mg ICLUSIG TAB15MG ICLUSIG TAB45MG IMBRUVICA CAP140MG imipramine hcl tab 10 mg imipramine hcl tab 25 mg imipramine hcl tab 50 mg imiquimod cream 5% Immune Suppressants Immunizing Agents, Passive IMMUNOLOGICAL AGENTS Immunomodulators IMOVAX RABIEINJ2.5/ML INCIVEK TAB375MG INCRELEX INJ40MG/4ML indapamide tab 1.25 mg indapamide tab 2.5 mg indomethacin cap 25 mg indomethacin cap 50 mg indomethacin cap cr 75 mg INFANRIX INJ INFERGEN INJ15MCG INFLAMMATORY BOWEL DISEASE AGENTS INLYTA TAB1MG INLYTA TAB5MG INNOPRAN XL CAP120MG INNOPRAN XL CAP80MG INSULIN NEEDLE INSULIN PEN NEEDLE INSULIN SYRINGE Insulins INTELENCE TAB100MG INTELENCE TAB200MG INTELENCE TAB25MG INTRON-A INJ10MU INTRON-A INJ18MU INTUNIV TAB1MG INTUNIV TAB2MG INTUNIV TAB3MG INTUNIV TAB4MG INVANZ INJ1GM INVEGA TAB1.5MG INVEGA TAB3MG INVEGA TAB6MG INVEGA TAB9MG INVEGA SUST INJ117/ INVEGA SUST INJ156MG/ML INVEGA SUST INJ234/ INVEGA SUST INJ39/ INVEGA SUST INJ78/0.5ML INVIRASE CAP200MG INVIRASE TAB500MG IOPIDINE SOL1% OP IPOL INJINACTIVE ipratropium bromide nasal soln 0.03% (21 mcg/spray) ipratropium bromide nasal soln 0.06% (42 mcg/spray) irbesartan tab 150 mg irbesartan tab 300 mg irbesartan tab 75 mg irbesartan-hydrochlorothiazide tab mg irbesartan-hydrochlorothiazide tab mg Irritable Bowel Syndrome Agents. 138 ISENTRESS CHW100MG ISENTRESS CHW25MG ISENTRESS POW100MG ISENTRESS TAB400MG isoniazid syrup 50 mg/5ml isoniazid tab 100 mg isoniazid tab 300 mg isosorbide dinitrate sl tab 2.5 mg isosorbide dinitrate tab 10 mg isosorbide dinitrate tab 20 mg isosorbide dinitrate tab 30 mg

217 isosorbide dinitrate tab 5 mg isosorbide dinitrate tab cr 40 mg isosorbide mononitrate tab 10 mg isosorbide mononitrate tab 20 mg isosorbide mononitrate tab sr 24hr 120 mg isosorbide mononitrate tab sr 24hr 30 mg isosorbide mononitrate tab sr 24hr 60 mg isradipine cap 2.5 mg isradipine cap 5 mg ISTODAX INJ10MG itraconazole cap 100 mg IXIARO INJ JAKAFI TAB10MG JAKAFI TAB15MG JAKAFI TAB20MG JAKAFI TAB25MG JAKAFI TAB5MG JANUMET TAB JANUMET TAB50-500MG JANUMET XR TAB JANUMET XR TAB JANUMET XR TAB50-500MG JANUVIA TAB100MG JANUVIA TAB25MG JANUVIA TAB50MG JEVTANA INJ60/1.5ML JUVISYNC TAB100-10MG JUVISYNC TAB100-20MG JUVISYNC TAB100-40MG JUVISYNC TAB50-10MG JUVISYNC TAB50-20MG JUVISYNC TAB50-40MG KADCYLA INJ100MG KADIAN CAP10MG CR KADIAN CAP200MG CR KALETRA SOL KALETRA TAB100-25MG KALETRA TAB200-50MG kcl 10 meq/l (0.075%) in dextrose 5% & nacl 0.45% inj kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.2% inj kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.33% inj kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.45% inj kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.9% inj kcl 20 meq/l (0.15%) in nacl 0.45% inj kcl 20 meq/l (0.15%) in nacl 0.9% inj 188 kcl 30 meq/l (0.224%) in dextrose 5% & nacl 0.45% inj kcl 40 meq/l (0.3%) in dextrose 5% & nacl 0.45% inj kcl 40 meq/l (0.3%) in dextrose 5% & nacl 0.9% inj KCL/D5W/NACLINJ0.15/ KETEK TAB300MG KETEK TAB400MG ketoconazole cream 2% ketoconazole shampoo 2% ketoconazole tab 200 mg ketoprofen cap 50 mg ketoprofen cap 75 mg ketoprofen cap sr 24hr 200 mg ketorolac tromethamine ophth soln 0.4% ketorolac tromethamine ophth soln 0.5% KHEDEZLA TAB100MG ER KHEDEZLA TAB50MG ER KINERET INJ KUVAN TAB100MG labetalol hcl tab 100 mg labetalol hcl tab 200 mg labetalol hcl tab 300 mg lactated ringer's solution lactic acid (ammonium lactate) cream 12% lactic acid (ammonium lactate) lotion 12% lactulose (encephalopathy) solution 10 gm/15ml lactulose solution 10 gm/15ml lamivudine tab 100 mg lamivudine tab 150 mg lamivudine tab 300 mg

218 lamivudine-zidovudine tab mg lamotrigine tab 100 mg lamotrigine tab 150 mg lamotrigine tab 200 mg lamotrigine tab 25 mg lamotrigine tab chewable dispersible 25 mg lamotrigine tab chewable dispersible 5 mg lansoprazole cap delayed release 15 mg lansoprazole cap delayed release 30 mg LANTUS INJ100/ML LANTUS INJSOLOSTAR latanoprost ophth soln 0.005% LATUDA TAB120MG LATUDA TAB20MG LATUDA TAB40MG LATUDA TAB60MG LATUDA TAB80MG Laxatives LAZANDA SPR100MCG LAZANDA SPR400MCG leflunomide tab 10 mg leflunomide tab 20 mg LETAIRIS TAB10MG LETAIRIS TAB5MG letrozole tab 2.5 mg leucovorin calcium for inj 100 mg leucovorin calcium for inj 350 mg leucovorin calcium tab 10 mg leucovorin calcium tab 15 mg leucovorin calcium tab 25 mg leucovorin calcium tab 5 mg LEUKERAN TAB2MG LEUKINE INJ250MCG LEUKINE INJ500 MCG leuprolide acetate inj kit 5 mg/ml LEVATOL TAB20MG LEVEMIR INJ LEVEMIR INJFLEXPEN levetiracetam inj 500 mg/5ml (100 mg/ml) levetiracetam oral soln 100 mg/ml levetiracetam tab 1000 mg levetiracetam tab 250 mg levetiracetam tab 500 mg levetiracetam tab 750 mg levetiracetam tab sr 24hr 500 mg levetiracetam tab sr 24hr 750 mg LEVITRA LEVITRA 2.5MG, 5MG,10MG, 20MG levobunolol hcl ophth soln 0.5% levocarnitine oral soln 1 gm/10ml (10%) levocarnitine tab 330 mg levocetirizine dihydrochloride tab 5 mg levofloxacin iv soln 25 mg/ml levofloxacin ophth soln 0.5% levofloxacin oral soln 25 mg/ml levofloxacin tab 250 mg levofloxacin tab 500 mg levofloxacin tab 750 mg levonorgestrel & ethinyl estradiol (91- day) tab mg levonorgestrel & ethinyl estradiol tab 0.1 mg-20 mcg levonorgestrel & ethinyl estradiol tab 0.15 mg-30 mcg levonorgestrel-eth estra tab / / mg-mcg levorphanol tartrate tab 2 mg LEVOTHROID TAB100MCG LEVOTHROID TAB112MCG LEVOTHROID TAB125MCG LEVOTHROID TAB137MCG LEVOTHROID TAB150MCG LEVOTHROID TAB175MCG LEVOTHROID TAB200MCG LEVOTHROID TAB25MCG LEVOTHROID TAB300MCG LEVOTHROID TAB50MCG LEVOTHROID TAB75MCG LEVOTHROID TAB88MCG levothyroxine sodium tab 100 mcg levothyroxine sodium tab 112 mcg levothyroxine sodium tab 125 mcg levothyroxine sodium tab 137 mcg

219 levothyroxine sodium tab 150 mcg levothyroxine sodium tab 175 mcg levothyroxine sodium tab 200 mcg levothyroxine sodium tab 25 mcg levothyroxine sodium tab 300 mcg levothyroxine sodium tab 50 mcg levothyroxine sodium tab 75 mcg levothyroxine sodium tab 88 mcg LEXIVA SUS50MG/ML LEXIVA TAB700MG LIALDA TAB1.2GM lidocaine hcl gel 2% lidocaine hcl local preservative free (pf) inj 0.5% lidocaine hcl local preservative free (pf) inj 1% lidocaine hcl soln 4% lidocaine hcl viscous soln 2% lidocaine oint 5% lidocaine-prilocaine cream %.. 34 LIDODERM DIS5% lindane lotion 1% lindane shampoo 1% liothyronine sodium tab 25 mcg liothyronine sodium tab 5 mcg liothyronine sodium tab 50 mcg lisinopril & hydrochlorothiazide tab mg lisinopril & hydrochlorothiazide tab mg lisinopril & hydrochlorothiazide tab mg lisinopril tab 10 mg lisinopril tab 2.5 mg lisinopril tab 20 mg lisinopril tab 30 mg lisinopril tab 40 mg lisinopril tab 5 mg lithium carbonate cap 150 mg lithium carbonate cap 300 mg lithium carbonate cap 600 mg lithium carbonate tab 300 mg lithium carbonate tab cr 300 mg lithium carbonate tab cr 450 mg LITHIUM CITRSOL8MEQ/5ML Local Anesthetics LODOSYN TAB25MG LOMUSTINE CAP100MG LOMUSTINE CAP10MG LOMUSTINE CAP40MG loperamide hcl cap 2 mg lorazepam conc 2 mg/ml lorazepam tab 0.5 mg lorazepam tab 1 mg lorazepam tab 2 mg losartan potassium & hydrochlorothiazide tab mg losartan potassium & hydrochlorothiazide tab mg losartan potassium & hydrochlorothiazide tab mg losartan potassium tab 100 mg losartan potassium tab 25 mg losartan potassium tab 50 mg LOTEMAX SUS0.5% LOTRONEX TAB0.5MG LOTRONEX TAB1MG lovastatin tab 10 mg lovastatin tab 20 mg lovastatin tab 40 mg LOVAZA CAP1GM loxapine succinate cap 10 mg loxapine succinate cap 25 mg loxapine succinate cap 5 mg loxapine succinate cap 50 mg LUMIGAN SOL0.01% LUPR DEP-PEDINJ11.25MG LUPRON DEPOTINJ22.5MG LUPRON DEPOTINJ3.75MG LUPRON DEPOTINJ30MG LUPRON DEPOTINJ45MG LUPRON DEPOTINJ7.5MG LYRICA CAP100MG LYRICA CAP150MG LYRICA CAP200MG LYRICA CAP225MG LYRICA CAP25MG LYRICA CAP300MG LYRICA CAP50MG

220 LYRICA CAP75MG LYRICA SOL20MG/ML LYSODREN TAB500MG Macrolides magnesium sulfate inj 50% malathion lotion 0.5% maprotiline hcl tab 25 mg maprotiline hcl tab 50 mg maprotiline hcl tab 75 mg MARPLAN TAB10MG Mast Cell Stabilizers MATULANE CAP50MG MAXIDEX SUS0.1% OP meclizine hcl tab 12.5 mg meclizine hcl tab 25 mg meclofenamate sodium cap 100 mg.. 27 meclofenamate sodium cap 50 mg medroxyprogesterone acetate im susp 150 mg/ml medroxyprogesterone acetate tab 10 mg medroxyprogesterone acetate tab 2.5 mg medroxyprogesterone acetate tab 5 mg mefloquine hcl tab 250 mg MEGACE ES SUS625/5ML megestrol acetate susp 40 mg/ml megestrol acetate tab 20 mg megestrol acetate tab 40 mg MEKINIST TAB0.5MG MEKINIST TAB2MG meloxicam tab 15 mg meloxicam tab 7.5 mg MENACTRA INJ MENOMUNE INJA/C/Y/W MENVEO INJ meprobamate tab 200 mg meprobamate tab 400 mg MEPRON SUS mercaptopurine tab 50 mg MESNEX TAB400MG MESTINON SYP60MG/5ML MESTINON TABTIMESPAN METABOLIC BONE DISEASE AGENTS metaproterenol sulfate syrup 10 mg/5ml metaproterenol sulfate tab 10 mg metaproterenol sulfate tab 20 mg metformin hcl tab 1000 mg metformin hcl tab 500 mg metformin hcl tab 850 mg metformin hcl tab sr 24hr 500 mg metformin hcl tab sr 24hr 750 mg METHADONE INJ10MG/ML methadone hcl conc 10 mg/ml methadone hcl soln 10 mg/5ml methadone hcl soln 5 mg/5ml methadone hcl tab 10 mg methadone hcl tab 5 mg methazolamide tab 25 mg methazolamide tab 50 mg methenamine hippurate tab 1 gm methimazole tab 10 mg methimazole tab 5 mg methotrexate sodium for inj 1 gm methotrexate sodium inj pf 25 mg/ml 160 methotrexate sodium tab 10 mg (base equiv) methotrexate sodium tab 15 mg (base equiv) methotrexate sodium tab 2.5 mg (base equiv) methotrexate sodium tab 5 mg (base equiv) methotrexate sodium tab 7.5 mg (base equiv) methscopolamine bromide tab 2.5 mg methscopolamine bromide tab 5 mg 136 methyclothiazide tab 5 mg methyldopa & hydrochlorothiazide tab mg methyldopa & hydrochlorothiazide tab mg methyldopa tab 250 mg methyldopa tab 500 mg methyldopate hcl inj 250 mg/5ml methylergonovine maleate tab 0.2 mg methylphenidate hcl tab 10 mg

221 methylphenidate hcl tab 20 mg methylphenidate hcl tab 5 mg methylphenidate hcl tab cr 20 mg methylprednisolone acetate inj susp 40 mg/ml methylprednisolone acetate inj susp 80 mg/ml methylprednisolone sodium succinate for inj 125 mg methylprednisolone sodium succinate for inj 40 mg methylprednisolone tab 16 mg methylprednisolone tab 32 mg methylprednisolone tab 4 mg methylprednisolone tab 4 mg dose pack methylprednisolone tab 8 mg metipranolol ophth soln 0.3% metoclopramide hcl inj 5 mg/ml metoclopramide hcl soln 5 mg/5ml (10 mg/10ml) metoclopramide hcl tab 10 mg metoclopramide hcl tab 5 mg metolazone tab 10 mg metolazone tab 2.5 mg metolazone tab 5 mg metoprolol & hydrochlorothiazide tab mg metoprolol & hydrochlorothiazide tab mg metoprolol & hydrochlorothiazide tab mg metoprolol succinate tab sr 24hr 100 mg metoprolol succinate tab sr 24hr 200 mg metoprolol succinate tab sr 24hr 25 mg metoprolol succinate tab sr 24hr 50 mg metoprolol tartrate inj 1 mg/ml metoprolol tartrate tab 100 mg metoprolol tartrate tab 25 mg metoprolol tartrate tab 50 mg METROGEL GEL1% metronidazole cream 0.75% metronidazole gel 0.75% metronidazole lotion 0.75% metronidazole tab 250 mg metronidazole tab 500 mg metronidazole vaginal gel 0.75% mexiletine hcl cap 150 mg mexiletine hcl cap 200 mg mexiletine hcl cap 250 mg miconazole nitrate vaginal suppos 200 mg midodrine hcl tab 10 mg midodrine hcl tab 2.5 mg midodrine hcl tab 5 mg MIGRANAL SPR4MG/ML minocycline hcl cap 100 mg minocycline hcl cap 50 mg minocycline hcl cap 75 mg minocycline hcl tab 100 mg minocycline hcl tab 50 mg minocycline hcl tab 75 mg minocycline hcl tab sr 24hr 135 mg minocycline hcl tab sr 24hr 45 mg minocycline hcl tab sr 24hr 90 mg minoxidil tab 10 mg minoxidil tab 2.5 mg mirtazapine orally disintegrating tab 15 mg mirtazapine orally disintegrating tab 30 mg mirtazapine orally disintegrating tab 45 mg mirtazapine tab 15 mg mirtazapine tab 30 mg mirtazapine tab 45 mg mirtazapine tab 7.5 mg misoprostol tab 100 mcg misoprostol tab 200 mcg mitoxantrone hcl inj conc 25 mg/12.5ml (2 mg/ml) M-M-R II INJLIVE moexipril hcl tab 15 mg moexipril hcl tab 7.5 mg moexipril-hydrochlorothiazide tab mg moexipril-hydrochlorothiazide tab mg

222 moexipril-hydrochlorothiazide tab mg Molecular Target Inhibitors mometasone furoate cream 0.1% mometasone furoate oint 0.1% mometasone furoate solution 0.1% (lotion) Monoamine Oxidase B (MAO-B) Inhibitors Monoamine Oxidase Inhibitors Monoclonal Antibodies montelukast sodium chew tab 4 mg (base equiv) montelukast sodium chew tab 5 mg (base equiv) montelukast sodium oral granules packet 4 mg (base equiv) montelukast sodium tab 10 mg (base equiv) MONUROL PAKGRANULES Mood Stabilizers morphine sulfate inj pf 0.5 mg/ml morphine sulfate inj pf 1 mg/ml morphine sulfate tab 15 mg morphine sulfate tab 30 mg morphine sulfate tab cr 100 mg morphine sulfate tab cr 15 mg morphine sulfate tab cr 200 mg morphine sulfate tab cr 30 mg morphine sulfate tab sr 12hr 60 mg MULTAQ TAB400MG Multiple Sclerosis Agents mupirocin calcium cream 2% mupirocin oint 2% MUSE SUPPPOSITORY MUSE SUPPPOSITORY 50MCG, 100MCG, 125MCG, 250MCG MYCOBUTIN CAP150MG mycophenolate mofetil cap 250 mg mycophenolate mofetil tab 500 mg mycophenolictab180mg dr mycophenolictab360mg dr MYFORTIC TAB180MG MYFORTIC TAB360MG MYOZYME INJ50MG nabumetone tab 500 mg nabumetone tab 750 mg nadolol & bendroflumethiazide tab 40-5 mg nadolol & bendroflumethiazide tab 80-5 mg nadolol tab 20 mg nadolol tab 40 mg nadolol tab 80 mg nafcillin sodium for inj 1 gm nafcillin sodium for inj 10 gm NAFTIN CRE1% NAFTIN GEL1% NAGLAZYME INJ1MG/ML nalbuphine hcl inj 10 mg/ml nalbuphine hcl inj 20 mg/ml naloxone hcl inj 1 mg/ml naltrexone hcl tab 50 mg NAMENDA SOL10MG/5ML NAMENDA TAB10MG NAMENDA TAB5-10MG NAMENDA TAB5MG naphazoline hcl ophth soln 0.1% naproxen sodium tab 275 mg naproxen sodium tab 550 mg naproxen susp 125 mg/5ml naproxen tab 250 mg naproxen tab 375 mg naproxen tab 500 mg naproxen tab ec 375 mg naproxen tab ec 500 mg naratriptan hcl tab 1 mg (base equiv). 67 naratriptan hcl tab 2.5 mg (base equiv) NATACYN SUS5% OP nateglinide tab 120 mg nateglinide tab 60 mg NEBUPENT INH300MG nefazodone hcl tab 100 mg nefazodone hcl tab 150 mg nefazodone hcl tab 200 mg nefazodone hcl tab 250 mg nefazodone hcl tab 50 mg neomycin sulfate tab 500 mg neomycin-bacitrac zn-polymyx 5(3.5)mg-400unt-10000unt op oin

223 neomycin-polymyxin b gu irrigation soln neomycin-polymyxin b-gramicidin ophth soln neomycin-polymyxin-dexamethasone ophth oint 0.1% neomycin-polymyxin-dexamethasone ophth susp 0.1% neomycin-polymyxin-hc ophth susp. 172 neomycin-polymyxin-hc otic soln 1% 174 neomycin-polymyxin-hc otic susp 3.5 mg/ml unit/ml-1% NEULASTA INJ6MG/0.6M NEUMEGA INJ5MG NEUPOGEN INJ300/ NEUPOGEN INJ480/ NEUPOGEN INJ480MCG NEVANAC SUS0.1% nevirapine sus50mg/5ml nevirapine tab 200 mg nevirapine tab 400 mg er NEXAVAR TAB200MG niacin (antihyperlipidemic) tab 500 mg NIASPAN TAB1000 ER NIASPAN TAB500MG ER NIASPAN TAB750MG ER nicardipine hcl cap 20 mg nicardipine hcl cap 30 mg NICOTROL NS SPR10MG/ML nifedipine tab sr 24hr 30 mg nifedipine tab sr 24hr 60 mg nifedipine tab sr 24hr 90 mg nifedipine tab sr 24hr osmotic 30 mg 120 nifedipine tab sr 24hr osmotic 60 mg 120 nifedipine tab sr 24hr osmotic 90 mg 120 NILANDRON TAB150MG nimodipine cap 30 mg nisoldipine tab sr 24hr 17 mg nisoldipine tab sr 24hr 20 mg nisoldipine tab sr 24hr 25.5 mg nisoldipine tab sr 24hr 30 mg nisoldipine tab sr 24hr 34 mg nisoldipine tab sr 24hr 40 mg nisoldipine tab sr 24hr 8.5 mg NITRO-DUR DIS0.3MG/HR NITRO-DUR DIS0.8MG/HR nitrofurantoin macrocrystalline cap 50 mg nitrofurantoin monohydrate macrocrystalline cap 100 mg nitrofurantoin susp 25 mg/5ml nitroglycerin iv soln 5 mg/ml nitroglycerin td patch 24hr 0.1 mg/hr 125 nitroglycerin td patch 24hr 0.2 mg/hr 125 nitroglycerin td patch 24hr 0.4 mg/hr 126 nitroglycerin td patch 24hr 0.6 mg/hr 126 NITROLINGUALSPRPUMPSPRA NITROSTAT SUB0.3MG NITROSTAT SUB0.4MG NITROSTAT SUB0.6MG nizatidine cap 150 mg nizatidine cap 300 mg nizatidine oral soln 15 mg/ml N-methyl-D-aspartate (NMDA) Receptor Antagonist Nonsteroidal Anti-Inflammatory Drugs NORDITROPIN INJ10/1.5ML NORDITROPIN INJ15/1.5ML NORDITROPIN INJ30/3ML NORDITROPIN INJ5/1.5ML norethindrone & ethinyl estradiol tab 0.4 mg-35 mcg norethindrone & ethinyl estradiol tab 0.5 mg-35 mcg norethindrone & ethinyl estradiol tab 1 mg-35 mcg norethindrone ace & ethinyl estradiol tab 1 mg-20 mcg norethindrone ace & ethinyl estradiol tab 1.5 mg-30 mcg norethindrone ace & ethinyl estradiol-fe tab 1 mg-20 mcg norethindrone ace & ethinyl estradiol-fe tab 1.5 mg-30 mcg norethindrone acetate tab 5 mg norethindrone acetate-ethinyl estradiol tab 1 mg-5 mcg norethindrone ac-ethinyl estrad-fe tab 1-20/1-30/1-35 mg-mcg norethindrone tab 0.35 mg

224 norethindrone-eth estradiol tab / /1-35 mg-mcg norethindrone-eth estradiol tab /1-35 mg-mcg (10/11) norethindrone-eth estradiol tab /1-35/ mg-mcg norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg norgestimate-eth estrad tab / / mg-mcg norgestrel & ethinyl estradiol tab 0.3 mg- 30 mcg norgestrel & ethinyl estradiol tab 0.5 mg- 50 mcg NOROXIN TAB400MG nortriptyline hcl cap 10 mg nortriptyline hcl cap 25 mg nortriptyline hcl cap 50 mg nortriptyline hcl cap 75 mg nortriptyline sol10mg/5ml NORVIR CAP100MG NORVIR SOL80MG/ML NORVIR TAB100MG NOVOLIN INJ70/ NOVOLIN N INJU NOVOLIN R INJU NOVOLOG INJ100/ML NOVOLOG INJFLEXPEN NOVOLOG MIX INJ70/ NOVOLOG MIX INJFLEXPEN NOXAFIL SUS40MG/ML NUEDEXTA CAP20-10MG NULOJIX INJ250MG NUTROPIN INJ10MG NUTROPIN AQ INJ10MG/2ML NUTROPIN AQ INJ20MG/2ML NUTROPIN AQ INJNUSPIN NUVARING MIS NUVIGIL TAB150MG NUVIGIL TAB250MG NUVIGIL TAB50MG nystatin cream unit/gm nystatin oint unit/gm nystatin susp unit/ml nystatin tab unit nystatin topical powder nystatin-triamcinolone cream unit/gm-% nystatin-triamcinolone oint unit/gm-% octreotide acetate inj 100 mcg/ml (0.1 mg/ml) octreotide acetate inj 1000 mcg/ml (1 mg/ml) octreotide acetate inj 200 mcg/ml (0.2 mg/ml) octreotide acetate inj 50 mcg/ml (0.05 mg/ml) octreotide acetate inj 500 mcg/ml (0.5 mg/ml) ofloxacin ophth soln 0.3% ofloxacin otic soln 0.3% ofloxacin tab 200 mg ofloxacin tab 300 mg ofloxacin tab 400 mg olanzapine for im inj 10 mg olanzapine orally disintegrating tab 10 mg olanzapine orally disintegrating tab 15 mg olanzapine orally disintegrating tab 20 mg olanzapine orally disintegrating tab 5 mg olanzapine tab 10 mg olanzapine tab 15 mg olanzapine tab 2.5 mg olanzapine tab 20 mg olanzapine tab 5 mg olanzapine tab 7.5 mg olanzapine-fluoxetine hcl cap mg olanzapine-fluoxetine hcl cap mg olanzapine-fluoxetine hcl cap 3-25 mg57 olanzapine-fluoxetine hcl cap 6-25 mg57 olanzapine-fluoxetine hcl cap 6-50 mg57 omeprazole cap delayed release 10 mg omeprazole cap delayed release 20 mg

225 omeprazole cap delayed release 40 mg ONCASPAR INJ750/ML ondansetron hcl oral soln 4 mg/5ml ondansetron hcl tab 24 mg ondansetron hcl tab 4 mg ondansetron hcl tab 8 mg ondansetron orally disintegrating tab 4 mg ondansetron orally disintegrating tab 8 mg ONFI SUS2.5MG/ML ONFI TAB10MG ONFI TAB20MG ONFI TAB5MG ONTAK INJ150/ML OPHTHALMIC AGENTS Ophthalmic Agents, Other Ophthalmic Anti-allergy Agents Ophthalmic Antiglaucoma Agents 172 Ophthalmic Anti-inflammatories Ophthalmic Prostaglandins and Prostamide Analogs Opioid Analgesics, Long-Acting Opioid Analgesics, Short-Acting Opioid Antagonists ORACEA CAP40MG ORAP TAB1MG ORAP TAB2MG ORENCIA INJ125MG/ML ORENCIA INJ250MG ORFADIN CAP10MG ORFADIN CAP2MG ORFADIN CAP5MG ORTHO EVRA DISWEEK OTIC AGENTS oxandrolone tab 10 mg oxandrolone tab 2.5 mg oxaprozin tab 600 mg oxcarbazepine susp 300 mg/5ml (60 mg/ml) oxcarbazepine tab 150 mg oxcarbazepine tab 300 mg oxcarbazepine tab 600 mg OXISTAT CRE1% OXISTAT LOT1% OXSORALEN-ULCAP10MG OXTELLAR XR TAB150MG OXTELLAR XR TAB300MG OXTELLAR XR TAB600MG oxybutynin chloride syrup 5 mg/5ml. 139 oxybutynin chloride tab 5 mg oxybutynin chloride tab sr 24hr 10 mg oxybutynin chloride tab sr 24hr 15 mg oxybutynin chloride tab sr 24hr 5 mg 139 oxycodone hcl cap 5 mg oxycodone hcl conc 20 mg/ml oxycodone hcl tab 10 mg oxycodone hcl tab 15 mg oxycodone hcl tab 20 mg oxycodone hcl tab 30 mg oxycodone hcl tab 5 mg oxycodone w/ acetaminophen cap mg oxycodone w/ acetaminophen soln mg/5ml oxycodone w/ acetaminophen tab mg oxycodone w/ acetaminophen tab mg oxycodone w/ acetaminophen tab mg oxycodone w/ acetaminophen tab mg oxycodone w/ acetaminophen tab mg oxycodone w/ acetaminophen tab mg oxycodone-aspirin tab mg 33 oxycodone-ibuprofen tab mg oxymorphone er oxymorphone hcl tab 10 mg oxymorphone hcl tab 5 mg oxymorphone hcl tab sr 12hr 15 mg oxymorphone hcl tab sr 12hr 7.5 mg.. 30 OXYTROL DIS3.9MG/ pamidronate disodium iv soln 3 mg/ml pamidronate disodium iv soln 6 mg/ml

226 pamidronate disodium iv soln 9 mg/ml PANCREAZE CAP10500UNT PANCREAZE CAP16800UNT PANCREAZE CAP21000UNT PANCREAZE CAP4200UNIT PANRETIN GEL0.1% pantoprazole sodium ec tab 20 mg (base equiv) pantoprazole sodium ec tab 40 mg (base equiv) Parasympathomimetics paromomycin sulfate cap 250 mg paroxetine hcl tab 10 mg paroxetine hcl tab 20 mg paroxetine hcl tab 30 mg paroxetine hcl tab 40 mg paroxetine hcl tab sr 24hr 12.5 mg paroxetine hcl tab sr 24hr 25 mg paroxetine hcl tab sr 24hr 37.5 mg PATANOL SOL0.1% OP PAXIL SUS10MG/5ML Pediculicides/Scabicides PEDVAX HIB INJ peg 3350-kcl-sod bicarb-nacl for soln 420 gm PEGANONE TAB250MG PEGASYS INJ PEGASYS INJ180MCG/M PEGASYS INJPROCLICK PEG-INTRON KIT120 RP PEG-INTRON KIT150 RP PEG-INTRON KIT50MCG PEG-INTRON KIT50MCG RP PEG-INTRON KIT80MCG RP PENICILL GK/INJDEX 2MU PENICILL GK/INJDEX 3MU penicillin g potassium for inj unit penicillin g procaine intramuscular susp unit/ml penicillin g sodium for inj unit penicillin v potassium for soln 125 mg/5ml penicillin v potassium for soln 250 mg/5ml penicillin v potassium tab 250 mg penicillin v potassium tab 500 mg PENTAM 300 INJ300MG PENTASA CAP250MG CR PENTASA CAP500MG CR pentoxifylline tab cr 400 mg PERJETA INJ420/14ML permethrin cream 5% perphenazine tab 16 mg perphenazine tab 2 mg perphenazine tab 4 mg perphenazine tab 8 mg perphenazine-amitriptyline tab 2-10 mg perphenazine-amitriptyline tab 2-25 mg perphenazine-amitriptyline tab 4-10 mg perphenazine-amitriptyline tab 4-25 mg perphenazine-amitriptyline tab 4-50 mg phenelzine sulfate tab 15 mg PHENOBARB TAB64.8MG PHENOBARB TAB97.2MG phenobarbital elixir 20 mg/5ml phenobarbital tab 100 mg phenobarbital tab 15 mg phenobarbital tab 16.2 mg phenobarbital tab 30 mg phenobarbital tab 32.4 mg phenobarbital tab 60 mg phenytoin chew tab 50 mg phenytoin sodium extended cap 100 mg phenytoin sodium extended cap 200 mg phenytoin sodium extended cap 300 mg phenytoin sodium inj 50 mg/ml phenytoin susp 125 mg/5ml Phosphate Binders PHOSPHOLINE SOL0.125%OP pilocarpine hcl tab 5 mg

227 pilocarpine hcl tab 7.5 mg PILOPINE HS GEL4% OP pindolol tab 10 mg pindolol tab 5 mg pioglitazone hcl tab 15 mg (base equiv) pioglitazone hcl tab 30 mg (base equiv) pioglitazone hcl tab 45 mg (base equiv) pioglitazone hcl-glimepiride tab 30-2 mg pioglitazone hcl-glimepiride tab 30-4 mg pioglitazone hcl-metformin hcl tab mg pioglitazone hcl-metformin hcl tab mg piperacillin sodium-tazobactam sodium for inj gm piperacillin sodium-tazobactam sodium for inj gm piroxicam cap 10 mg piroxicam cap 20 mg Platelet Modifying Agents podofilox soln 0.5% polyethylene glycol 3350 oral powder polymyxin b-trimethoprim ophth soln unit/ml-0.1% POMALYST CAP1MG POMALYST CAP2MG POMALYST CAP3MG POMALYST CAP4MG potassium chloride 20 meq/l (0.15%) in d5w lactated ringers potassium chloride 20 meq/l (0.15%) in dextrose 5% inj potassium chloride 40 meq/l (0.3%) in dextrose 5% inj potassium chloride cap cr 10 meq potassium chloride cap cr 8 meq potassium chloride inj 2 meq/ml potassium chloride microencapsulated crys cr tab 10 meq potassium chloride microencapsulated crys cr tab 15 meq potassium chloride microencapsulated crys cr tab 20 meq potassium chloride tab cr 10 meq potassium chloride tab cr 8 meq (600 mg) potassium citrate tab cr 10 meq (1080 mg) potassium citrate tab cr 5 meq (540 mg) POTIGA TAB200MG POTIGA TAB300MG POTIGA TAB400MG POTIGA TAB50MG PRADAXA CAP150MG PRADAXA CAP75MG pramipexole dihydrochloride tab mg pramipexole dihydrochloride tab 0.25 mg pramipexole dihydrochloride tab 0.5 mg pramipexole dihydrochloride tab 0.75 mg pramipexole dihydrochloride tab 1 mg 83 pramipexole dihydrochloride tab 1.5 mg PRANDIMET TAB1-500MG PRANDIMET TAB2-500MG PRANDIN TAB0.5MG PRANDIN TAB1MG PRANDIN TAB2MG pravastatin sodium tab 10 mg pravastatin sodium tab 20 mg pravastatin sodium tab 40 mg pravastatin sodium tab 80 mg prazosin hcl cap 1 mg prazosin hcl cap 2 mg prazosin hcl cap 5 mg PRED MILD SUS0.12% OP PRED-G SUSOP PRED-G S.O.POINOP prednicarbate cream 0.1% prednicarbate oint 0.1% prednisolone acetate ophth susp 1%

228 prednisolone sod phosph oral soln 6.7 mg/5ml (5 mg/5ml base) prednisolone sod phosphate oral soln 15 mg/5ml (base equiv) prednisolone sodium phosphate ophth soln 1% prednisone conc 5 mg/ml prednisone oral soln 5 mg/5ml prednisone tab 1 mg prednisone tab 10 mg prednisone tab 2.5 mg prednisone tab 20 mg prednisone tab 5 mg prednisone tab 50 mg PREFEST TAB PREMARIN TAB0.3MG PREMARIN TAB0.45MG PREMARIN TAB0.625MG PREMARIN TAB0.9MG PREMARIN TAB1.25MG PREMARIN VAGCRE0.625MG PREMPHASE TAB PREMPRO TAB PREMPRO TAB PREMPRO TAB PREMPRO TAB prenatal vitamin min fa PREZISTA SUS100MG/ML PREZISTA TAB150MG PREZISTA TAB400MG PREZISTA TAB600MG PREZISTA TAB75MG PREZISTA TAB800MG PRIFTIN TAB150MG PRIMAQUINE TAB26.3MG primidone tab 250 mg primidone tab 50 mg PRISTIQ TAB100MG PRISTIQ TAB50MG PROAIR HFA AER probenecid tab 500 mg procainamide hcl inj 100 mg/ml prochlorperazine edisylate inj 5 mg/ml 61 prochlorperazine maleate tab 10 mg.. 61 prochlorperazine maleate tab 5 mg prochlorperazine suppos 25 mg PROCRIT INJ10000/ML PROCRIT INJ2000/ML PROCRIT INJ20000/ML PROCRIT INJ3000/ML PROCRIT INJ4000/ML PROCRIT INJ40000/ML Progestins PROGLYCEM SUS50MG/ML PROGRAF INJ5MG/ML PROLEUKIN INJ22MU PROLIA SOL60MG/ML PROMACTA TAB12.5MG PROMACTA TAB25MG PROMACTA TAB50MG PROMACTA TAB75MG promethazine hcl inj 25 mg/ml promethazine hcl inj 50 mg/ml promethazine hcl suppos 12.5 mg promethazine hcl suppos 25 mg promethazine hcl suppos 50 mg propafenone hcl tab 150 mg propafenone hcl tab 225 mg propafenone hcl tab 300 mg proparacaine hcl ophth soln 0.5% Prophylactic propranolol & hydrochlorothiazide tab mg propranolol & hydrochlorothiazide tab mg propranolol hcl cap sr 24hr 120 mg propranolol hcl cap sr 24hr 160 mg propranolol hcl cap sr 24hr 60 mg propranolol hcl cap sr 24hr 80 mg propranolol hcl inj 1 mg/ml propranolol hcl oral soln 20 mg/5ml propranolol hcl oral soln 40 mg/5ml propranolol hcl tab 10 mg propranolol hcl tab 20 mg propranolol hcl tab 40 mg propranolol hcl tab 60 mg propranolol hcl tab 80 mg propylthiouracil tab 50 mg PROQUAD INJ Protectants Proton Pump Inhibitors PROTONIX INJ40MG

229 PROTOPIC OIN0.03% PROTOPIC OIN0.1% protriptyline hcl tab 10 mg protriptyline hcl tab 5 mg PROVENTIL AERHFA PULMICORT INH180MCG PULMICORT INH90MCG Pulmonary Antihypertensives PULMOZYME SOL1MG/ML pyridostigmine bromide tab 60 mg quetiapine fumarate tab 100 mg quetiapine fumarate tab 200 mg quetiapine fumarate tab 25 mg quetiapine fumarate tab 300 mg quetiapine fumarate tab 400 mg quetiapine fumarate tab 50 mg quinapril hcl tab 10 mg quinapril hcl tab 20 mg quinapril hcl tab 40 mg quinapril hcl tab 5 mg quinapril-hydrochlorothiazide tab mg quinapril-hydrochlorothiazide tab mg quinapril-hydrochlorothiazide tab mg quinidine gluconate tab cr 324 mg quinidine sulfate tab 200 mg quinidine sulfate tab 300 mg quinidine sulfate tab cr 300 mg Quinolones QVAR AER40MCG QVAR AER80MCG RABAVERT INJ ramipril cap 1.25 mg ramipril cap 10 mg ramipril cap 2.5 mg ramipril cap 5 mg RANEXA TAB1000MG RANEXA TAB500MG ranitidine hcl cap 150 mg ranitidine hcl cap 300 mg ranitidine hcl inj 150 mg/6ml (25 mg/ml) ranitidine hcl syrup 15 mg/ml (75 mg/5ml) ranitidine hcl tab 150 mg ranitidine hcl tab 300 mg RAPAMUNE SOL1MG/ML RAPAMUNE TAB0.5MG RAPAMUNE TAB1MG RAPAMUNE TAB2MG REBETOL SOL40MG/ML REBIF INJ22/ REBIF INJ44/ REBIF TITRTNSOLPACK RECOMBIVA HBINJ10MCG/ML RECOMBIVA HBINJ5MCG/0.5ML RECOMBIVA-HBINJ40MCG/ML RELENZA MISDISKHALE RELISTOR KIT12/0.6ML RELPAX TAB20MG RELPAX TAB40MG REMICADE INJ100MG REMODULIN INJ10MG/ML REMODULIN INJ1MG/ML REMODULIN INJ2.5MG/ML REMODULIN INJ5MG/ML RESCRIPTOR TAB100 MG RESCRIPTOR TAB200MG RESERPINE TAB0.1MG RESERPINE TAB0.25MG RESPIRATORY TRACT AGENTS Respiratory Tract Agents, Other RESTASIS EMU0.05% RETIN-A MICRGEL0.04% RETIN-A MICRGEL0.08% RETIN-A MICRGEL0.1% Retinoids RETROVIR INJ10MG/ML REVLIMID CAP10MG REVLIMID CAP15MG REVLIMID CAP2.5MG REVLIMID CAP20MG REVLIMID CAP25MG REVLIMID CAP5MG REYATAZ CAP100MG REYATAZ CAP150MG REYATAZ CAP200MG REYATAZ CAP300MG RHINOCORT SUSAQUA ribavirin cap 200 mg

230 ribavirin tab 200 mg ribavirin tab 400 mg ribavirin tab 400 mg & ribavirin tab 600 mg dose pack ribavirin tab 600 mg RIDAURA CAP3MG rifampin cap 150 mg rifampin cap 300 mg rifampin for inj 600 mg RIFATER TAB RILUTEK TAB50MG rimantadine hydrochloride tab 100 mg 94 RISPERDAL INJ12.5MG RISPERDAL INJ25MG RISPERDAL INJ37.5MG RISPERDAL INJ50MG risperidone orally disintegrating tab 0.25 mg risperidone orally disintegrating tab 0.5 mg risperidone orally disintegrating tab 1 mg risperidone orally disintegrating tab 2 mg risperidone orally disintegrating tab 3 mg risperidone orally disintegrating tab 4 mg risperidone soln 1 mg/ml risperidone tab 0.25 mg risperidone tab 0.5 mg risperidone tab 1 mg risperidone tab 2 mg risperidone tab 3 mg risperidone tab 4 mg RITUXAN INJ500MG rivastigmine tartrate cap 1.5 mg rivastigmine tartrate cap 3 mg rivastigmine tartrate cap 4.5 mg rivastigmine tartrate cap 6 mg rizatriptan benzoate orally disintegrating tab 10 mg rizatriptan benzoate orally disintegrating tab 5 mg rizatriptan benzoate tab 10 mg rizatriptan benzoate tab 5 mg ropinirole hydrochloride tab 0.25 mg.. 83 ropinirole hydrochloride tab 0.5 mg ropinirole hydrochloride tab 1 mg ropinirole hydrochloride tab 2 mg ropinirole hydrochloride tab 3 mg ropinirole hydrochloride tab 4 mg ropinirole hydrochloride tab 5 mg ROTATEQ SUS ROZEREM TAB8MG SABRIL POW500MG SABRIL TAB500MG SAIZEN INJ5MG SAIZEN INJ8.8MG SANDIMMUNE SOL100MG/ML SANDOSTATIN KITLAR 10MG SANDOSTATIN KITLAR 20MG SANDOSTATIN KITLAR 30MG SANTYL OIN250/GM SAPHRIS SUB10MG SAPHRIS SUB5MG Selective Estrogen Receptor Modifying Agents selegiline hcl cap 5 mg selegiline hcl tab 5 mg selenium sulfide lotion 2.5% SELZENTRY TAB150MG SELZENTRY TAB300MG SENSIPAR TAB30MG SENSIPAR TAB60MG SENSIPAR TAB90MG SEREVENT DISAER50MCG SEROQUEL XR TAB150MG SEROQUEL XR TAB200MG SEROQUEL XR TAB300MG SEROQUEL XR TAB400MG SEROQUEL XR TAB50MG SEROSTIM INJ4MG SEROSTIM INJ5MG SEROSTIM INJ6MG Serotonin (5-HT) 1b/1d Receptor Agonists Serotonin/ Norepinephrine Reuptake Inhibitors sertraline hcl oral conc 20 mg/ml sertraline hcl tab 100 mg sertraline hcl tab 25 mg

231 sertraline hcl tab 50 mg silver sulfadiazine cream 1% SIMCOR TAB SIMCOR TAB SIMCOR TAB500-20MG SIMCOR TAB500-40MG SIMCOR TAB750-20MG SIMPONI INJ50MG SIMULECT INJ20MG simvastatin tab 10 mg simvastatin tab 20 mg simvastatin tab 40 mg simvastatin tab 5 mg simvastatin tab 80 mg sirolimus tab 0.5 mg SKELETAL MUSCLE RELAXANTS 182 SLEEP DISORDER AGENTS Sleep Disorders, Other Smoking Cessation Agents Sodium Channel Agents Sodium Channel Inhibitors sodium chloride inj 0.45% sodium chloride inj 2.5 meq/ml (14.6%) sodium chloride inj 3% sodium chloride inj 5% sodium chloride irrigation soln 0.9%. 191 sodium chloride iv soln 0.9% sodium fluoride 2.2mg sodium polystyrene sulfonate oral susp 15 gm/60ml SOLARAZE GEL3% W/W SOLTAMOX SOL10MG/5ML SOMATULINE INJ120/.5ML SOMATULINE INJ60/0.2ML SOMATULINE INJ90/0.3ML SOMAVERT INJ10MG SOMAVERT INJ15MG SOMAVERT INJ20MG SORIATANE CAP10MG SORIATANE CAP17.5MG SORIATANE CAP25MG sotalol hcl (afib/afl) tab 120 mg sotalol hcl tab 120 mg sotalol hcl tab 160 mg sotalol hcl tab 240 mg sotalol hcl tab 80 mg SOVALDI TAB400MG SPIRIVA CAPHANDIHLR spironolactone & hydrochlorothiazide tab mg spironolactone tab 100 mg spironolactone tab 25 mg spironolactone tab 50 mg SPRYCEL TAB100MG SPRYCEL TAB140MG SPRYCEL TAB20MG SPRYCEL TAB50MG SPRYCEL TAB70MG SPRYCEL TAB80MG stavudine cap 15 mg stavudine cap 20 mg stavudine cap 30 mg stavudine cap 40 mg stavudine for oral soln 1 mg/ml STAVZOR CAP125MG STAVZOR CAP250MG STAVZOR CAP500MG STIMATE SOL1.5MG/ML STIVARGA TAB40MG STRATTERA CAP100MG STRATTERA CAP10MG STRATTERA CAP18MG STRATTERA CAP25MG STRATTERA CAP40MG STRATTERA CAP60MG STRATTERA CAP80MG streptomycin sulfate for inj 1 gm STRIBILD TAB STROMECTOL TAB3MG SUBOXONE MIS12-3MG SUBOXONE MIS2-0.5MG SUBOXONE MIS4-1MG SUBOXONE MIS8-2MG sucralfate tab 1 gm sulfacetamide sodium lotion 10% (acne) sulfacetamide sodium ophth oint 10% 49 sulfacetamide sodium ophth soln 10% 49 sulfacetamide sodium-prednisolone ophth oint %

232 sulfacetamide sodium-prednisolone ophth soln (0.25)% sulfadiazine tab 500 mg sulfamethoxazole-trimethoprim iv soln mg/5ml sulfamethoxazole-trimethoprim susp mg/5ml sulfamethoxazole-trimethoprim tab mg sulfamethoxazole-trimethoprim tab mg SULFAMYLON CRE85MG/GM sulfasalazine tab 500 mg sulfasalazine tab delayed release 500 mg Sulfonamides... 49, 168 sulindac tab 150 mg sulindac tab 200 mg sumatriptan succinate inj 6 mg/0.5ml. 67 sumatriptan succinate tab 100 mg sumatriptan succinate tab 25 mg sumatriptan succinate tab 50 mg SUPRAX SUS100/5ML SUPRAX SUS200/5ML SUPRAX SUS500/5ML SUSTIVA CAP200MG SUSTIVA CAP50MG SUSTIVA TAB600MG SUTENT CAP12.5MG SUTENT CAP25MG SUTENT CAP37.5MG SUTENT CAP50MG SYLATRON KIT296MCG SYLATRON KIT444MCG SYLATRON KIT888MCG SYMBICORT AER SYMBICORT AER SYMLINPEN 60INJ1000MCG SYMLNPEN 120INJ1000MCG SYNAREL SOL2MG/ML SYNRIBO INJ3.5MG SYNTHROID TAB100MCG SYNTHROID TAB112MCG SYNTHROID TAB125MCG SYNTHROID TAB137MCG SYNTHROID TAB150MCG SYNTHROID TAB175MCG SYNTHROID TAB200MCG SYNTHROID TAB25MCG SYNTHROID TAB300MCG SYNTHROID TAB50MCG SYNTHROID TAB75MCG SYNTHROID TAB88MCG SYPRINE CAP250MG TABLOID TAB40MG tacrolimus cap 0.5 mg tacrolimus cap 1 mg tacrolimus cap 5 mg TAFINLAR CAP50MG TAFINLAR CAP75MG TAMIFLU CAP30MG TAMIFLU CAP45MG TAMIFLU CAP75MG TAMIFLU SUS6MG/ML tamoxifen citrate tab 10 mg (base equivalent) tamoxifen citrate tab 20 mg (base equivalent) tamsulosin hcl cap 0.4 mg TARCEVA TAB100MG TARCEVA TAB150MG TARCEVA TAB25MG TARGRETIN CAP75MG TARGRETIN GEL1% TASIGNA CAP150MG TASIGNA CAP200MG TASMAR TAB100MG TAZORAC CRE0.05% TAZORAC CRE0.1% TAZORAC GEL0.05% TAZORAC GEL0.1% TEKAMLO TAB150-10MG TEKAMLO TAB150-5MG TEKAMLO TAB300-10MG TEKAMLO TAB300-5MG TEKTURNA TAB150MG TEKTURNA TAB300MG TEKTURNA HCTTAB TEKTURNA HCTTAB150-25MG TEKTURNA HCTTAB TEKTURNA HCTTAB300-25MG temazepam cap 15 mg

233 temazepam cap 22.5 mg temazepam cap 30 mg temazepam cap 7.5 mg terazosin hcl cap 1 mg terazosin hcl cap 10 mg terazosin hcl cap 2 mg terazosin hcl cap 5 mg terbinafine hcl tab 250 mg terbutaline sulfate inj 1 mg/ml terbutaline sulfate tab 2.5 mg terbutaline sulfate tab 5 mg terconazole vaginal cream 0.4% terconazole vaginal cream 0.8% terconazole vaginal suppos 80 mg TESTIM GEL1%(50MG) testosterone enanthate im in oil 200 mg/ml TET/DIP TOX INJ2-2 LF TETANUS TOX INJ5LF ADS Tetracyclines tetrahydrozoline hcl nasal soln 0.05% tetrahydrozoline hcl nasal soln 0.1% 181 THALOMID CAP100MG THALOMID CAP150MG THALOMID CAP200MG THALOMID CAP50MG theophylline tab sr 12hr 100 mg theophylline tab sr 12hr 200 mg theophylline tab sr 12hr 300 mg theophylline tab sr 12hr 450 mg theophylline tab sr 24hr 400 mg theophylline tab sr 24hr 600 mg THERAPEUTIC NUTRIENTS/MINERALS/ELECTROL YTES thioridazine hcl tab 10 mg thioridazine hcl tab 100 mg thioridazine hcl tab 25 mg thioridazine hcl tab 50 mg thiothixene cap 1 mg thiothixene cap 10 mg thiothixene cap 2 mg thiothixene cap 5 mg THYMOGLOBULNINJ25MG ticlopidine hcl tab 250 mg TIKOSYN CAP125MCG TIKOSYN CAP250MCG TIKOSYN CAP500MCG timolol maleate ophth gel forming soln 0.25% timolol maleate ophth gel forming soln 0.5% timolol maleate ophth soln 0.25% timolol maleate ophth soln 0.5% timolol maleate tab 10 mg timolol maleate tab 20 mg timolol maleate tab 5 mg TIVICAY TAB50MG tizanidine hcl cap 2 mg tizanidine hcl cap 4 mg tizanidine hcl cap 6 mg tizanidine hcl tab 2 mg tizanidine hcl tab 4 mg TOBI NEB300/5ML TOBRADEX OIN % tobramycin sulfate inj 10 mg/ml tobramycin sulfate inj 80 mg/2ml (40 mg/ml) tobramycin sulfate ophth soln 0.3% tobramycin-dexamethasone ophth susp % tolazamide tab 250 mg tolazamide tab 500 mg tolbutamide tab 500 mg tolmetin sodium cap 400 mg tolmetin sodium tab 200 mg tolmetin sodium tab 600 mg tolterodine tartrate tab 1 mg tolterodine tartrate tab 2 mg topiramate sprinkle cap 15 mg topiramate sprinkle cap 25 mg topiramate tab 100 mg topiramate tab 200 mg topiramate tab 25 mg topiramate tab 50 mg topotecan hcl for inj 4 mg torsemide tab 10 mg torsemide tab 100 mg torsemide tab 20 mg torsemide tab 5 mg TOVIAZ TAB4MG

234 TOVIAZ TAB8MG TPN ELECTROLINJ TRACLEER TAB125MG TRACLEER TAB62.5MG tramadol hcl tab 50 mg tramadol hcl tab sr 24hr 100 mg tramadol hcl tab sr 24hr 200 mg tramadol hcl tab sr 24hr biphasic release 300 mg tramadol-acetaminophen tab mg trandolapril tab 1 mg trandolapril tab 2 mg trandolapril tab 4 mg tranexamic acid inj 100 mg/ml tranylcypromine sulfate tab 10 mg trazodone hcl tab 100 mg trazodone hcl tab 150 mg trazodone hcl tab 300 mg trazodone hcl tab 50 mg Treatment Resistent TRECATOR TAB250MG tretinoin cap 10 mg tretinoin cream 0.025% tretinoin cream 0.05% tretinoin cream 0.1% tretinoin gel 0.01% tretinoin gel 0.025% triamcinolone acetonide cream 0.025% triamcinolone acetonide cream 0.1% 143 triamcinolone acetonide cream 0.5% 143 triamcinolone acetonide dental paste 0.1% triamcinolone acetonide lotion 0.025% triamcinolone acetonide lotion 0.1%. 143 triamcinolone acetonide nasal inhal 55 mcg/act triamcinolone acetonide oint 0.025% 143 triamcinolone acetonide oint 0.1% triamcinolone acetonide oint 0.5% triamterene & hydrochlorothiazide cap mg triamterene & hydrochlorothiazide tab mg triamterene & hydrochlorothiazide tab mg Tricyclics trifluoperazine hcl tab 1 mg trifluoperazine hcl tab 10 mg trifluoperazine hcl tab 2 mg trifluoperazine hcl tab 5 mg trifluridine ophth soln 1% trihexyphenidyl hcl elixir 0.4 mg/ml trihexyphenidyl hcl tab 2 mg trihexyphenidyl hcl tab 5 mg trimethoprim tab 100 mg trimipramine maleate cap 100 mg trimipramine maleate cap 25 mg trimipramine maleate cap 50 mg TRISENOX SOL10MG/10M TRIZIVIR TAB TROKENDI XR TROPHAMINE INJ10% trospium chloride cap sr 24hr 60 mg 139 trospium chloride tab 20 mg TRUVADA TAB TWINRIX INJ TYGACIL INJ50MG TYKERB TAB250MG TYPHIM VI INJ TYSABRI INJ TYZEKA TAB600MG ULORIC TAB40MG ULORIC TAB80MG urea-hc acetate cream 1% ursodiol cap 300 mg ursodiol tab 250 mg ursodiol tab 500 mg Vaccines valacyclovir hcl tab 1 gm valacyclovir hcl tab 500 mg VALCYTE SOL50MG/ML VALCYTE TAB450MG valproate sodium inj 100 mg/ml valproate sodium syrup 250 mg/5ml (base equiv) valproic acid cap 250 mg valsartan-hydrochlorothiazide tab mg

235 valsartan-hydrochlorothiazide tab mg valsartan-hydrochlorothiazide tab mg valsartan-hydrochlorothiazide tab mg valsartan-hydrochlorothiazide tab mg vancomycin hcl for inj 10 gm vancomycin hcl for inj 1000 mg vancomycin hcl for inj 500 mg VAQTA INJ25/0.5ML VAQTA INJ50UNT/ML VARIVAX INJ Vasodilators, Direct-acting Arterial , 125 Vasodilators, Direct-acting Arterial/Venous VELCADE INJ3.5MG venlafaxine hcl cap sr 24hr 150 mg (base equivalent) venlafaxine hcl cap sr 24hr 37.5 mg (base equivalent) venlafaxine hcl cap sr 24hr 75 mg (base equivalent) VENTOLIN HFAAER VERAMYST SPR27.5MCG verapamil hcl cap sr 24hr 100 mg verapamil hcl cap sr 24hr 120 mg verapamil hcl cap sr 24hr 180 mg verapamil hcl cap sr 24hr 200 mg verapamil hcl cap sr 24hr 240 mg verapamil hcl cap sr 24hr 300 mg verapamil hcl cap sr 24hr 360 mg verapamil hcl iv soln 2.5 mg/ml verapamil hcl tab 120 mg verapamil hcl tab 40 mg verapamil hcl tab 80 mg verapamil hcl tab cr 120 mg verapamil hcl tab cr 180 mg verapamil hcl tab cr 240 mg VERSACLOZ SUS50MG/ML VEXOL SUS1% OP VFEND SUS40MG/ML VIAGRA VIAGRA 100MG, 25MG, 50MG, VICTRELIS CAP200MG VIDAZA INJ100MG VIDEX SOL2GM VIGAMOX DRO0.5% VIIBRYD KIT VIIBRYD TAB10MG VIIBRYD TAB20MG VIIBRYD TAB40MG VIMPAT INJ200MG/ VIMPAT SOL10MG/ML VIMPAT TAB100MG VIMPAT TAB150MG VIMPAT TAB200MG VIMPAT TAB50MG VIRACEPT TAB250MG VIRACEPT TAB625MG VIRAMUNE SUS50MG/5ML VIRAMUNE XR TAB100MG VIRAMUNE XR TAB400MG VIRAZOLE INH6GM VIREAD POW40MG/GM VIREAD TAB150MG VIREAD TAB200MG VIREAD TAB250MG VIREAD TAB300MG VOLTAREN GEL1% voriconazole tab 200 mg voriconazole tab 50 mg VOTRIENT TAB200MG VYTORIN TAB10-10MG VYTORIN TAB10-20MG VYTORIN TAB10-40MG VYTORIN TAB10-80MG warfarin sodium tab 1 mg warfarin sodium tab 10 mg warfarin sodium tab 2 mg warfarin sodium tab 2.5 mg warfarin sodium tab 3 mg warfarin sodium tab 4 mg warfarin sodium tab 5 mg warfarin sodium tab 6 mg warfarin sodium tab 7.5 mg WELCHOL PAK3.75GM WELCHOL TAB625MG XALKORI CAP200MG XALKORI CAP250MG

236 XARELTO TAB10MG XARELTO TAB15MG XARELTO TAB20MG XENAZINE TAB12.5MG XENAZINE TAB25MG XGEVA INJ XOLAIR SOL150MG XOPENEX HFA AER XTANDI CAP40MG XYREM SOL500MG/ML YERVOY INJ50MG YF-VAX INJ zafirlukast tab 10 mg zafirlukast tab 20 mg zaleplon cap 10 mg zaleplon cap 5 mg ZALTRAP INJ100/4ML ZANOSAR INJ1GM ZAVESCA CAP100MG ZAZOLE CRE0.4% ZELBORAF TAB240MG ZEMAIRA INJ1000MG ZEMPLAR CAP1MCG ZEMPLAR CAP2MCG ZEMPLAR CAP4MCG ZEMPLAR INJ2MCG/ML ZEMPLAR INJ5MCG/ML ZENPEP CAP10000UNT ZENPEP CAP15000UNT ZENPEP CAP20000UNT ZENPEP CAP25000UNT ZENPEP CAP3000UNIT ZENPEP CAP5000UNIT ZETIA TAB10MG ZIAGEN SOL20MG/ML zidovudine cap 100 mg zidovudine syrup 10 mg/ml zidovudine tab 300 mg ziprasidone hcl cap 20 mg ziprasidone hcl cap 40 mg ziprasidone hcl cap 60 mg ziprasidone hcl cap 80 mg ZIRGAN GEL0.15% ZMAX SUS2GM zoledronic acid inj conc for iv infusion 4 mg/5ml zoledronic acid iv soln 5 mg/100ml ZOLINZA CAP100MG zolpidem tartrate tab 10 mg zolpidem tartrate tab 5 mg zolpidem tartrate tab cr 12.5 mg zolpidem tartrate tab cr 6.25 mg ZOMIG... 4 zonisamide cap 100 mg zonisamide cap 25 mg zonisamide cap 50 mg ZORBTIVE INJ8.8MG ZORTRESS TAB0.25MG ZORTRESS TAB0.5MG ZORTRESS TAB0.75MG ZOSTAVAX INJ ZOVIRAX CRE5% ZOVIRAX OIN5% ZYDELIG TAB100MG ZYDELIG TAB150MG ZYFLO CR TAB600MG ZYKADIA CAP150MG ZYTIGA TAB250MG ZYVOX SOL2MG/ML ZYVOX SUS100MG/5M ZYVOX TAB600MG

237 This formulary was updated 10/28/2014. For more recent information or other questions, please contact Central Health Medicare Plan at , or for TTY users, , 7 days a week, 8:00 AM to 8:00 PM (PST), or visit 237

238 Este formulario fue actualizado el 10/28/2014. Para información más reciente u otras preguntas, favor de ponerse en contacto con nuestro Departamento de Servicio al Miembro al o, para usuarios de TTYdeben llamar al , los 7 días a la semana, de 8:00 AM a 8:00 PM (Tiempo Pacifico), o visite el sitio web 238

239 本處方集最近更新日期為 10/28/2014 有關更新修訂或其他資訊, 請聯絡中心健保 : 或聽障 / 語障專線 , 一週七天, 上午 8:00 到下午 8:00( 太平洋時間 ) 或上網 239