VillageCareMAX Full Advantage FIDA 計劃 206 年涵蓋藥品目錄 ( 處方一覽表 ) 這是參與者可在 VillageCareMAX Full Advantage FIDA 計劃中獲得藥品的清單 VillageCareMAX Full Advantage FIDA 計

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1 H9345_MBR6_03c CMS Approved VillageCareMAX Full Advantage FIDA 計劃 (Medicare-Medicaid Plan, 即 醫療保險 紐約州衛生署計劃 ) 206 年給付藥品目錄 ( 處方一覽表 ) 該給付藥品清單已在 09/0/206 更新 欲了解更多最新信息或其他問題, 請撥打 VillageCareMAX 全部優勢 FIDA 計劃服務熱線 , 聽障者電話 (TTY) 用戶請撥打 7, 辦公時間為上午 8 時到下午 8 時, 每週 7 天 或訪問 Formulary ID: , Version 8

2 VillageCareMAX Full Advantage FIDA 計劃 206 年涵蓋藥品目錄 ( 處方一覽表 ) 這是參與者可在 VillageCareMAX Full Advantage FIDA 計劃中獲得藥品的清單 VillageCareMAX Full Advantage FIDA 計劃是一項管理式醫療計劃, 與醫療保險部門及紐約州衛生署簽訂合約, 以全面整合雙重優勢 (FIDA - 全面整合雙重優勢 ) 方案來為參與者同時提供兩項計劃的福利 給付藥品清單以及 / 可能會在一年之中作出更改 當我們作出的變更會影響到您之前, 我們會向您發送通知 福利可能會在每年的 0 月 0 日作出更改 您可上網 ( 查看 VillageCareMAX Full Advantage FIDA 計劃的最新給付藥品清單, 或撥打 VillageCareMAX Full Advantage FIDA 計劃參與者服務熱線 隨時核查 聽障者電話 (TTY) 用戶請撥打 7 請注意可能存在的局限性和限制 若需要進一步的資訊, 請撥打 VillageCareMAX Full Advantage FIDA 計劃參與者服務熱線或閱讀 VillageCareMAX Full Advantage FIDA 參與者手冊 對於任何給付藥品都無需承擔自付額 ( 被保險人用於就醫或配藥所支付的小額費用 ) 您還可以免費索取大字版, 點字或語音等格式, 請撥打免付費專線 和 7, 上午 8 時至晚上 8 時, 每週 7 天 You can get this information for free in other languages. Call and TTY users should call 7, during the hours of 8:00 am to 8:00 pm, 7 days a week. The call is free. Puede obtener esta información gratis en Español.Llame a Servicios del Participante al durante las horas de 8:00 am a 8:00pm, 7 días de la semana. Usuarios de TTY llamar al 7.La llamada es gratuita. Lei puo ottenere questi informazioni in Italiano gratuitamente. Chiama il Servizio Partecipanti a durante il periodo da 8AM a 8PM, 7 giorni alla settimana. TTY utilizzatori dovressi chiamare 7. La chiamata è gratis. Ou ka jwenn enfòmasyon sa a gratis nan kreyòl Ayisyen. Rele sèvis patisipan nan pandan lè 8:00 am jiska 8:00 pm, 7 jou pà semèn. Itilisatè ATS yo dwe rele nan 7. Apèl sa a gratis. 如果您有任何疑問, 請撥打 VillageCareMAX Full Advantage FIDA 計劃免費專線 , 上午 8 時至晚上 8 時, 每週 7 天 若需要進一步的資訊, 請上網 : ii

3 Вы можете получить эту информацию бесплатно на русском языке. Звоните в Отдел обслуживания участников плана по телефону с 8:00 до 20:00, без выходных. Пользователи TTY звоните по телефону 7. Звонок бесплатный. 您可免費獲得到以上的中文資訊, 請致電參與者服務電話 , 辦公時間為上午 8 時到下午 8 時, 每週 7 天 聽障者電話服務專線 (TTY) 用戶請撥打 7 該電話為免付費通話 한국어로된정보를무료로얻을수있습니다. 주 7 일오전 8 시에서오후 8 시사이에 번 (TTY 사용자는 7 번 ) 으로문의해주십시오. 통화는무료입니다. 紐約州備有參與者申訴方案稱為獨立消費者倡權網路 (ICAN), 可為參與者提供 VillageCareMAX Full Advantage FIDA 計劃的免費 保密協助 若需要使用參與者申訴服務 (ICAN), 請撥打免付費電話 : , 或造訪網站 如果您有任何疑問, 請撥打 VillageCareMAX Full Advantage FIDA 計劃免費專線 , 上午 8 時至晚上 8 時, 每週 7 天 若需要進一步的資訊, 請上網 : iii

4 常見問題 (FAQ) 您可在此處查找有關給付藥品清單疑問的答案 您可以閱讀所有的常見問題瞭解更多資訊, 也可以查找問題和答案. 給付藥品清單上有什麼處方藥? ( 此處我們將給付藥品清單簡稱為 藥品清單 ) 從給付藥品清單第一頁開始的所有藥品均為 VillageCareMAX Full Advantage FIDA 計劃給付藥品 這些藥品在我們藥房網路中的所有藥店內有售 如果一個藥房與我們簽署了合作為您提供服務的合約, 那麼這個藥房就在我們網路中 我們將這個藥房稱為 網路藥房 如果符合以下情況,VillageCareMAX Full Advantage FIDA 計劃將給付藥品清單上的所有藥品 : 您的醫生或其他處方開立者認為您需要這些藥品來獲得好轉或保持健康, 您需要此藥品治療病情, 且 您在 VillageCareMAX Full Advantage FIDA 計劃網路藥房內補藥 在獲得某些藥品的過程中,VillageCareMAX Full Advantage FIDA 計劃可能會採取額外的步驟 ( 詳見下文中的問題 5) 在某些情況下, 您在獲得某種藥品前可能必須先進行其它步驟, 比如先嘗試其它藥品等 您也可以前往我們的網站 或者撥打參與者服務熱線 獲得最新的藥品清單 聽障者電話 (TTY) 用戶請撥打 7 2. 藥品清單是否會不斷變化? 是 VillageCareMAX Full Advantage FIDA 計劃可能會隨時增加或減少藥品清單上的藥品 一般來說, 藥品清單只會在以下情況下更改 : 出現了一種與藥品清單上現有藥品效果一樣好的新藥, 或者 我們瞭解到清單上的某種藥品不安全 我們也有可能會更改有關藥品的規定 比如說, 我們可能會 : 如果您有任何疑問, 請撥打 VillageCareMAX Full Advantage FIDA 計劃免費專線 , 上午 8 時至晚上 8 時, 每週 7 天 若需要進一步的資訊, 請上網 : iv

5 要求或取消要求某種藥物的事先許可 ( 事先許可即在您獲得某種藥品前, 來自 VillageCareMAX Full Advantage FIDA 計劃部門或者您的跨學科專業團隊 (Interdisciplinary Team,IDT) 的許可 ) 增加或更改您可獲得某種藥品的數量 ( 被稱為 限量 ) 增加或更改某種藥品的階段療法限制 ( 階段療法是指您在獲得某種藥品前必須先嘗試另一種藥品 ) ( 有關這些藥品規定的進一步資訊請參閱第 vi 頁 ) 當您正在使用的某種藥物被從藥品清單中移除時, 我們會通知您 當我們對某種藥品的給付規定進行更改時, 也會通知您 有關藥品清單更改時狀況的進一步資訊請查看下文中的問題 3 4 和 7 您可隨時上網 ( 查看 VillageCareMAX Full Advantage FIDA 計劃的最新藥品清單 您也可撥打參與者服務熱線 核查現行的藥品清單 聽障者電話 (TTY) 用戶請撥打 7 3. 當出現了一種與藥品清單上現有藥品效果一樣好且更便宜的新藥時, 會如何處理? 如果出現了一種與藥品清單上現有藥品效果一樣好且更便宜的新藥 : 當您下次補藥時, 您的藥師可能會給您比較便宜的那一款藥品 如果您和您的處方提供者認為便宜的那一款藥品不適合您, 那麼您的處方提供者可致電藥師, 請他 / 她繼續給您現在正在服用的這種藥品 VillageCareMAX Full Advantage FIDA 計劃部門可能會決定將比較貴的那一款藥品從藥品清單中移除 如果您正在服用的某種藥品因為存在效果同樣好且比較便宜的藥品上市而從藥品清單上被移除, 我們將會在將其從藥品清單上移除前至少 60 天 或者在您補藥時通知您 因此您可以在藥品清單更改前獲得 60 天劑量的該藥品 當您正在使用的某種藥物自藥品清單中移除時,VillageCareMAX Full Advantage FIDA 計劃部門會寄信通知您 我們的網站上列有關於藥品清單的最新資訊 如有任何疑問, 您可以隨時上網 ( 查看或者撥打參與者服務熱線諮詢 我們的電話號碼為 聽障者電話 (TTY) 用戶請撥打 7 我們的營業時間為每週 7 天, 上午 8:00 至晚上 8:00 如果您有任何疑問, 請撥打 VillageCareMAX Full Advantage FIDA 計劃免費專線 , 上午 8 時至晚上 8 時, 每週 7 天 若需要進一步的資訊, 請上網 : v

6 4. 當我們發現某種藥品不安全時, 會如何處理? 如果美國食品藥物管理局 (FDA) 指出您正在服用的藥品不安全, 我們會直接將其從藥品清單上移除 我們也會寄信和致電給您, 讓您得知這種不安全藥物已從藥品清單上移除 如果您正在服用某種已由 FDA 確認為不安全的藥物, 請與您的醫生談一談 您的醫生可以開立另一種藥物來取代不再供應的藥物 5. 藥品給付是否存在任何限制或局限性? 或者說, 如要獲得某些藥品, 是否要求採取某些行動? 是的, 部分藥品具有給付規定或限量規定 在某些情況下, 在獲得藥品前您或您的醫生或其他處方開立者必須先進行其它步驟 例如 : 獲得事先許可 ( 或事先授權 ): 對於某些藥品, 在您獲得藥品前, 您或您的醫生或其他處方開立者必須先獲得來自 VillageCareMAX Full Advantage FIDA 計劃部門或者您的多專業團隊 (Interdisciplinary Team,IDT) 的許可 若您未獲得許可, 則 VillageCareMAX Full Advantage FIDA 計劃將不會為您給付此藥品 數量限制 : 某些情況下,VillageCareMAX Full Advantage FIDA 計劃會限制您可獲得藥品的數量 階段療法 : 某些情況下,VillageCareMAX Full Advantage FIDA 計劃會要求您進行階段療法 也就是說, 在病情治療過程中, 您將必須以某種特定順序嘗試不同藥品 您可能得在獲得某種藥品前, 先嘗試另一種藥品 若您的醫生認為第一種藥品對您無效, 那麼我們將為您給付第二種藥品 您可以在從開始自第一頁的表格中瞭解您的藥品是否有任何附加要求或限制 您也可以上網 ( 瞭解更多資訊 我們已在網站上公佈了一些文件來說明我們的事先授權和階段步驟療法限制 您也可以要求我們寄送一份至貴府 對於這些限制, 您可以請求 規則豁免 有關規則豁免的進一步資訊, 請查看問題 如果您在護理機構或其它長照機構中, 且需要某種不在藥品清單上的藥品或者無法輕易獲得所需藥品, 我們可以向您提供幫助 無論您是否為 VillageCareMAX Full Advantage FIDA 計劃的新參與者, 我們都將為您提供所需藥品的 3 天緊急藥品供應給付 ( 除非您已持有需用藥天數少於此天數的處方 ) 這可以讓您有充分的時間和您的醫生或其他處方開立者溝通 他或她可以幫您確認在藥品清單上是否有可取代的相似藥品, 或者是否能夠請求規則豁免 有關規則豁免的進一步資訊請查看問題 如果您有任何疑問, 請撥打 VillageCareMAX Full Advantage FIDA 計劃免費專線 , 上午 8 時至晚上 8 時, 每週 7 天 若需要進一步的資訊, 請上網 : vi

7 6. 您將如何得知您所需藥品是否有限制, 或者在獲得藥品前是否要求採取某些行動? 第 頁上的給付藥品清單中, 有一欄為 使用時的必要行動 限制或局限性 7. 如果我們更改了有關如何給付某些藥品的規定 ( 例如, 如果我們對某種藥品增加了事先授權 ( 許可 ) 限量 及 / 或階段療法限制等場合 ), 會發生什麼情況? 如果我們對某種藥品增加了事先授權 ( 許可 ) 限量及 / 或階段步驟療法限制, 我們將通知您 我們將會在增加限制前至少 60 天 或者在您補藥時通知您 因此您可以在藥品清單更改前獲得 60 天劑量的該藥品 這可以讓您有充分時間與您的醫生或其它處方提供者商量下一步行動 8. 您如何在藥品清單上查找某種藥品? 有兩種查找藥品的方法 : 您可以按照首字母順序檢索 ( 如果您知道如何拼寫該藥品的英文名稱 ), 或者 根據醫療狀況查找 如果您要按照首字母順序進行檢索, 請查看第 I- 頁中的首字母順序排列部分 然後在清單中查找您所需藥品的名稱 如果您要按照醫療狀況查找, 請找到第 頁中的 根據醫療狀況分類的藥品清單 部分 在該部分, 藥物將根據它們被用於治療的醫療的類型被分類 例如, 如果您有心臟問題, 則應在心血管問題分類中查找 您將在該分類裡找到治療心臟病的藥物 9. 如果您要服用的藥品未列在藥品清單上, 該怎麼辦? 如果您未在藥品清單上找到所需藥品, 請撥打參與者服務熱線 並諮詢相關情況 聽障者電話 (TTY) 用戶請撥打 7 如果您得知 VillageCareMAX Full Advantage FIDA 計劃不會給付該藥品, 您可以採取以下行動之一 : 向參與者服務熱線工作人員索取一份您想服用藥品的相似藥品清單 然後將這份清單給您的醫生或其它處方提供者過目 他或她可以為您開立與您想服用藥品的相似藥品處方, 或者 您可以向本計劃工作人員或您的跨學科專業團隊 (IDT) 請求規則豁免, 來給付您的藥品 有關規則豁免的進一步資訊請查看問題 如果您有任何疑問, 請撥打 VillageCareMAX Full Advantage FIDA 計劃免費專線 , 上午 8 時至晚上 8 時, 每週 7 天 若需要進一步的資訊, 請上網 : vii

8 0. 如果您是 VillageCareMAX Full Advantage FIDA 計劃的新成員, 且無法在藥品清單上找到您所需藥品或在獲取藥品的過程中出現了問題, 該怎麼辦? 我們能幫助您 在您成為 VillageCareMAX Full Advantage FIDA 計劃參與者的前 90 天中, 我們必須根據需要為您提供最多 90 天的臨時藥品供應服務 這可以讓您有充分的時間和您的醫生或其他處方提供者溝通 他或她可以幫您確認在藥品清單上是否有可取代的相似藥品, 或者是否能夠請求規則豁免 如符合以下情況, 我們將為您提供最多 90 天的臨時藥品供應服務 : 您正在使用不在我們藥品清單中的藥品 ; 或者 根據健康計劃規定, 您無法獲得您的處方提供者要求的藥品數量 ; 或 此藥品要求來自 VillageCareMAX Full Advantage FIDA 計劃或者您的跨學科專業團隊 (IDT) 的事先許可 ; 或 您正在服用的藥品屬於階段療法限制藥品 如果您生活在護理機構或其它長照機構中, 您可根據處方領取多達 98 天劑量的藥品 您可以在該計劃的頭 90 天內多次補藥 這可以讓您的處方開立者有足夠的時間將您使用的藥品更改為藥品清單上的藥品, 或者請求規則豁免 VillageCareMAX Full Advantage FIDA 計劃擁有一個過渡流程來確保向新進和目前的 D 部分 ( 聯邦醫療保險處方藥計劃 ) 成員提供持續的藥品給付服務 有時候, 您會經歷諸如入住或搬出長照機構 住院或出院等照護等級方面的變化 在這些情況下, VillageCareMAX Full Advantage FIDA 計劃將向您提供一次性的非處方藥物緊急供應 非處方藥品同時包括不在本計劃處方一覽表上的 D 部分藥品, 以及列於本計劃處方一覽表中 但根據本計劃使用管理規定需要獲得事先許可或進行階段療法的 D 部分藥品 如您有任何問題, 請致電參與者服務中心 您可在每週 7 天, 上午 8:00 至晚上 8:00 間撥打 聽障者電話 (TTY) 用戶請撥打 7. 您是否可以請求規則豁免來報銷藥品? 是 您可以向 VillageCareMAX Full Advantage FIDA 計劃部門或您的跨學科專業團隊 (IDT) 請求規則豁免來給付不在藥品清單上的藥品 你也可以請求 VillageCareMAX Full Advantage FIDA 計劃部門或者您的 IDT 來更改有關您所需藥品的規定 如果您有任何疑問, 請撥打 VillageCareMAX Full Advantage FIDA 計劃免費專線 , 上午 8 時至晚上 8 時, 每週 7 天 若需要進一步的資訊, 請上網 : viii

9 例如,VillageCareMAX Full Advantage FIDA 計劃會限制可給付藥品量 如果您所需藥品有限量規定, 您可以要求我們或您的 IDT 團隊更改數量限制並給付更多藥品 其它例子 : 您可以要求我們或您的 IDT 取消階段療法限制或事先許可要求 2. 獲得規則豁免需要多長時間? 首先,VillageCareMAX Full Advantage FIDA 計劃部門或您的跨學科專業團隊 (IDT) 必須從您的處方提供者收到支援您規則豁免請求的聲明 在我們受到聲明之後, 您將在 72 小時內收到有關您規則豁免請求的判定 如果您或者您的處方提供者認為花費 72 小時等待決定將對您的健康產生傷害, 您可以要求加急 此為更快的判定 如果您的處方提供者支援您的請求, 您將在收到您的處方提供者支援聲明的 24 小時內獲得判定 3. 您需如何請求規則豁免? 如需請求規則豁免, 請致電您的醫療管理人員 您的醫療管理人員將和您及您的處方提供者一起幫您請求規則豁免 4. 什麼是仿學名藥? 學名藥是指由與品牌藥品相同成分製成的藥品 它們通常比品牌藥品價格更低廉且並無廣為人知的品名 學名藥由食品藥物管理局 (FDA) 審查核准 VillageCareMAX Full Advantage FIDA 計劃可同時給付品牌藥和學名藥 5. 什麼是 OTC 藥品? OTC 的意思是 成藥 當由您的處方提供者開立此類藥物的處方時,VillageCareMAX Full Advantage FIDA 計劃也可給付部分非處方 (OTC) 藥品 您可閱讀 VillageCareMAX Full Advantage FIDA 計劃藥品清單查看可給付的非處方藥品 非處方藥品位於第 4 級中 如果您有任何疑問, 請撥打 VillageCareMAX Full Advantage FIDA 計劃免費專線 , 上午 8 時至晚上 8 時, 每週 7 天 若需要進一步的資訊, 請上網 : ix

10 6. VillageCareMAX Full Advantage FIDA 計劃是否可給付非藥物類非處方產品? 當由您的處方提供者開立此類藥物的處方時,VillageCareMAX Full Advantage FIDA 計劃也可報銷部分非藥物類非處方產品 樣例包括 : 紗布墊 酒精棉 / 墊 胰島素注射器和針頭等非處方類糖尿病用品 您可閱讀 VillageCareMAX Full Advantage FIDA 計劃藥品清單查看可報銷的非處方藥品 您可閱讀 VillageCareMAX Full Advantage FIDA 計劃藥品清單查看可報銷的非藥物類非處方產品 7. 你們的自付醫療費用如何計算? 您無需為藥品清單上的藥品承擔自付款 8. 什麼是藥品? 在 VillageCareMAX Full Advantage FIDA 計劃處方一覽表中, 您可以看到共有 4 種藥品等級 類別 的藥品為由醫療保險部門給付的學名藥 類別 2 的藥品為由醫療保險部門給付的品牌藥和專科用藥 類別 3 的藥品為由紐約衛生署給付的非 D 部分藥品和品牌藥 類別 4 的藥品為由紐約衛生署給付的非處方 (OTC) 藥品 作為我們計劃的成員, 您無需為這四類藥品承擔任何自付款 如果您有任何疑問, 請撥打 VillageCareMAX Full Advantage FIDA 計劃免費專線 , 上午 8 時至晚上 8 時, 每週 7 天 若需要進一步的資訊, 請上網 : x

11 給付藥品清單 下文第 頁中的給付藥品清單向您提供了有關可由 VillageCareMAX Full Advantage FIDA 計劃給付藥品的資訊 如果您無法在清單中找到所需藥品, 請使用由第 I- 頁開始的索引 圖表中的第一列為藥品名稱 品牌藥品為大寫 ( 例如 : 立普妥 [LIPITOR]), 而學名藥為小寫斜體 ( 例 : 布洛芬 [ibuprofen]) 必要行動 限制或局限性一欄中資訊可讓您瞭解 VillageCareMAX Full Advantage FIDA 計劃是否對給付您的藥物設立任何規定 描述指南 此藥品清單採用以下縮寫和符號 : 縮寫 / 符號 描述 解釋說明 使用管理限制 在領取藥物前, 您 ( 或您的醫師 ) 需要獲得來自 VillageCareMAX Full PA Advantage FIDA 計劃的事先授權 若事先授權限制無事先許可, 則 VillageCareMAX Full Advantage FIDA 計劃可能不會報銷此 藥品 根據醫療保險部門的 Part B 或 Part D 保險計劃, 此藥品可能需要支付款項 在領取藥品前, 您 ( 或您的醫師 ) 需要 Part B 和 Part D 保險獲得來自 VillageCareMAX Full 計劃測定的事先授權 Advantage FIDA 計劃的事先授權來確 定此藥品是否可根據醫療保險部門的 Part D 保險計劃報銷 若無事先許可, 則 VillageCareMAX Full Advantage FIDA 計劃可能不會報銷此藥品 此藥已被 CMS 認為是潛在有害的, 因 PA-HRM 此,65 歲或以的上 Medicare 醫療保險高風險藥物的事先授權參加者要得到 VillageCareMAX Full 限制 Advantage FIDA 計劃的事先許可高風 險服藥的要求之後才得到此處方藥 若 如果您有任何疑問, 請撥打 VillageCareMAX Full Advantage FIDA 計劃免費專線 , 上午 8 時至晚上 8 時, 每週 7 天 若需要進一步的資訊, 請上網 : xi

12 縮寫 / 符號 描述 解釋說明無事先許可, 則 VillageCareMAX Full Advantage FIDA 計劃可能不會報銷此藥品 PA NSO 僅針對新開方藥品的事先授權限制 如果您是新成員或您之前未服用過此藥品, 在領取藥物前, 您 ( 或您的醫師 ) 需獲得來自 VillageCareMAX Full Advantage FIDA 計劃的事先授權 若無事先許可, 則 VillageCareMAX Full Advantage FIDA 計劃可能不會報銷此藥品 VillageCareMAX Full Advantage FIDA QL 計劃限制了此藥品每次按處方領取的報數量限制規定銷數量, 或者特定時間框架內的數量 ST 階段療法限制 在 VillageCareMAX Full Advantage FIDA 計劃為此藥物提供報銷之前, 您必須首先嘗試另一種藥品來治療您的病情 在其它藥品對您無效的情況下, 才可報銷此藥品 其它保險相關縮寫 此藥方可能僅可在某些特定藥房中領取 藥品 欲知更多資訊, 請查看您的藥劑 目錄或在每天上午 8:00 至晚上 8:00 LA 藥品獲取限制間, 每週 7 天撥打我們的會員服務熱線 此為免費電話 聽障 者電話 TTY 用戶請撥打 7 您也許能夠獲得大多數的藥物多於 對 月的供應通過郵購處方以降低成本的份 NM 非郵購藥品額 如藥物無法通過郵購, 您處方的要 求 / 限制列中記下 NM * 非 Part D 藥品 此藥品不是可由醫療保險部門報銷的 Part D 藥品, 或者 OTC 藥品或產品 如果您有任何疑問, 請撥打 VillageCareMAX Full Advantage FIDA 計劃免費專線 , 上午 8 時至晚上 8 時, 每週 7 天 若需要進一步的資訊, 請上網 : xii

13 注 : 所有類別 3 和類別 4 中的藥品均為非 Part D 藥品 這些藥品具有不同的申訴規定 申訴是一種在您認為有錯誤存在的情況下請求審核並更改保險決定的正式途徑 例如, VillageCareMAX Full Advantage FIDA 計劃或您的跨學科專業團隊 (IDT) 可能會規定您所需藥品不在受保範圍內, 或者決定不再由醫療保險部門或紐約州衛生署報銷此藥品 如果您或您的醫生或其他處方提供者不同意這項決定, 則您可進行申訴 如需有關如何申訴的指導, 請撥打參與者服務熱線 或獨立消費者倡權網路 (ICAN) 的電話 您也可以通過閱讀參與者手冊來瞭解如何就某項決策進行申訴 藥品名單 - 按醫療狀況的類型分類 在本節中藥物將根據它們被用於治療的醫療狀況的類型被分類 例如, 如果您有心臟問題, 則應在心血管問題分類中查找 您將在該分類裡找到治療心臟病的藥物. 如果您有任何疑問, 請撥打 VillageCareMAX Full Advantage FIDA 計劃免費專線 , 上午 8 時至晚上 8 時, 每週 7 天 若需要進一步的資訊, 請上網 : xiii

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15 Table of Contents Analgesics... 3 Anesthetics... 4 Anti-Addiction/Substance Abuse Treatment Agents... 5 Antianxiety Agents... 6 Antibacterials... 7 Anticancer Agents Anticholinergic Agents Anticonvulsants Antidementia Agents Antidepressants Antidiabetic Agents Antifungals... 5 Antihistamines Anti-Infectives (Skin And Mucous Membrane) Antimigraine Agents... 6 Antimycobacterials... 6 Antinausea Agents Antiparasite Agents Antiparkinsonian Agents Antipsychotic Agents Antivirals (Systemic) Blood Products/Modifiers/Volume Expanders Caloric Agents Cardiovascular Agents Central Nervous System Agents... 0 Contraceptives VillageCareMAX Full Advantage FIDA Plan 206 Formulary Formulary ID: Version: 8 Effective: October 0, 206

16 Cough And Cold Products... Dental And Oral Agents Dermatological Agents Devices... 3 Disinfectants (For Non-Dermatologic Use) Enzyme Replacement/Modifiers Eye, Ear, Nose, Throat Agents Gastrointestinal Agents... 4 Genitourinary Agents Heavy Metal Antagonists Hormonal Agents, Stimulant/Replacement/Modifying Immunological Agents... 6 Inflammatory Bowel Disease Agents Irrigating Solutions... 7 Metabolic Bone Disease Agents... 7 Miscellaneous Therapeutic Agents Ophthalmic Agents Replacement Preparations Respiratory Tract Agents Skeletal Muscle Relaxants Sleep Disorder Agents Vasodilating Agents Vitamins And Minerals VillageCareMAX Full Advantage FIDA Plan 206 Formulary Formulary ID: Version: 8 Effective: October 0, 206 2

17 Analgesics Analgesics, Miscellaneous acephen 20 mg suppository outer 20 mg * acephen 325 mg suppository outer 325 mg * acephen 650 mg suppository outer 650 mg * acetaminophen 20 mg suppos outer 20 mg * acetaminophen 60 mg rapid tab 60 mg * acetaminophen 60 mg/5 ml elx 60 mg/5 ml * acetaminophen 325 mg liqui-gel 325 mg * acetaminophen 650 mg suppos 650 mg * acetaminophen 80 mg rapid tab children's 80 mg * acetaminophen 80 mg/0.8 ml drp infants 80 mg/0.8 ml * acetaminophen-codeine 20 mg-2 mg/5 ml solution 20-2 mg/5 ml acetaminophen-codeine oral solution 300 mg-30 mg /2.5 ml acetaminophen-codeine oral tablet mg, mg acetaminophen-codeine oral tablet mg ALLZITAL ORAL TABLET MG ascomp with codeine oral capsule mg (Acetaminophen) (Acetaminophen) (Acetaminophen) (Acetaminophen) (Acetaminophen) (Acetaminophen) (Acetaminophen) (Acetaminophen) (Acetaminophen) (Acetaminophen) (Acetaminophen with Codeine) (Acetaminophen with Codeine) (Tylenol-Codeine No.3) (Tylenol-Codeine No.3) (Fiorinal with Codeine #3) $0 $0 $0 $0 $0 $0 QL (360 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (240 per 30 days) QL (360 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (2700 per 30 days) QL (2700 per 30 days) QL (360 per 30 days) QL (80 per 30 days) PA-HRM; QL (80 per 30 days); AGE (Max 64 Years) 3

18 BELBUCA BUCCAL FILM 50 MCG, 300 MCG, 450 MCG, 600 MCG, 75 MCG, 750 MCG, 900 MCG buprenorphine hcl injection syringe 0.3 mg/ml butalbital compound w/codeine oral capsule mg butalbital-acetaminop-caf-cod oral capsule mg, mg butalbital-acetaminophen oral tablet mg butalbital-acetaminophen-caff oral capsule mg butalbital-acetaminophen-caff oral tablet mg butalbital-aspirin-caffeine oral capsule mg BUTRANS TRANSDERMAL PATCH WEEKLY 0 MCG/HOUR, 5 MCG/HOUR, 20 MCG/HOUR, 5 MCG/HOUR, 7.5 MCG/HOUR (Buprenorphine HCl) (Fiorinal with Codeine #3) (Fioricet with Codeine) $0 $0 $0 (Tencon) $0 (Esgic) $0 (Esgic) $0 (Fiorinal) $0 capacet oral capsule mg (Esgic) $0 child non-aspirin 60 mg/5 ml children's 60 mg/5 ml * child pain-fever 60 mg/5 ml a/f,gluten/f,cherry 60 mg/5 ml * child tactinal 80 mg tab chw 80 mg * (Acetaminophen) (Infants' Tylenol) (Acetaminophen) ST; QL (60 per 30 days) PA-HRM; QL (80 per 30 days); AGE (Max 64 Years) PA-HRM; QL (80 per 30 days); AGE (Max 64 Years) PA-HRM; QL (80 per 30 days); AGE (Max 64 Years) PA-HRM; QL (80 per 30 days); AGE (Max 64 Years) PA-HRM; QL (80 per 30 days); AGE (Max 64 Years) PA-HRM; QL (80 per 30 days); AGE (Max 64 Years) QL (4 per 28 days) PA-HRM; QL (80 per 30 days); AGE (Max 64 Years) QL (240 per 30 days) QL (240 per 30 days) QL (30 per 30 days) 4

19 children's mapap 80 mg rapid 80 QL (30 per 30 days) (Acetaminophen) mg * children's silapap elixir 60 mg/5 ml (Tylenol Sore QL (240 per 30 days) * Throat) codeine sulfate oral tablet 5 mg, 30 QL (80 per 30 days) (Codeine Sulfate) $0 mg, 60 mg cvs child non-asa 80 mg tb chw 80 QL (30 per 30 days) (Acetaminophen) mg * cvs non-aspirin jr tab chew 60 mg QL (30 per 30 days) (Acetaminophen) * cvs pain relief adult liquid 500 (Tylenol Sore QL (20 per 30 days) mg/5 ml * Throat) endocet oral tablet mg, 2.5- QL (360 per 30 days) (Xolox) $0 325 mg, mg, mg endodan oral tablet mg (Percodan) $0 QL (360 per 30 days) fentanyl citrate buccal lozenge on a handle,200 mcg,,600 mcg, 200 (Actiq) $0 PA; QL (20 per 30 days) mcg, 400 mcg, 600 mcg, 800 mcg fentanyl transdermal patch 72 hour 00 mcg/hr, 2 mcg/hr, 25 mcg/hr, 37.5 mcg/hour, 50 mcg/hr, 62.5 mcg/hour, 75 mcg/hr, 87.5 mcg/hour (Duragesic) $0 QL (0 per 30 days) feverall 20 mg suppository QL (30 per 30 days) (Acetaminophen) children's, outer 20 mg * feverall 325 mg suppository junior QL (30 per 30 days) (Acetaminophen) str, outer 325 mg * feverall 650 mg suppository adult, QL (30 per 30 days) (Acetaminophen) outer 650 mg * hydrocodone-acetaminophen oral QL (2700 per 30 days) solution mg/5 ml(5 ml), mg/5 ml, mg/5 ml (Hycet) $0 hydrocodone-acetaminophen oral tablet mg, mg, mg (Norco) $0 (includes Vicodin, Vicodin ES and Vicodin HP); QL (390 per 30 days) 5

20 hydrocodone-acetaminophen oral QL (360 per 30 days) tablet mg, mg, (Norco) $0 mg, mg hydrocodone-ibuprofen oral tablet QL (50 per 30 days) mg, mg, mg, mg (Ibudone) $0 hydromorphone (pf) injection solution 0 mg/ml (Dilaudid-HP) $0 hydromorphone (pf) injection solution 4 mg/ml (Dilaudid) $0 hydromorphone injection solution 2 (Hydromorphone mg/ml HCl) $0 hydromorphone injection syringe 2 (Hydromorphone mg/ml HCl) $0 hydromorphone oral liquid mg/ml (Dilaudid) $0 QL (200 per 30 days) hydromorphone oral tablet 2 mg, 4 QL (80 per 30 days) (Dilaudid) $0 mg hydromorphone oral tablet 8 mg (Dilaudid) $0 QL (240 per 30 days) HYSINGLA ER ORAL TABLET,ORAL ONLY,EXT.REL.24 HR 00 MG, 20 MG, 20 MG, 30 MG, 40 MG, 60 MG, 80 MG QL (30 per 30 days) junior mapap 60 mg rapid tab 60 QL (30 per 30 days) (Acetaminophen) mg * LAZANDA NASAL SPRAY,NON- AEROSOL 00 MCG/SPRAY, 300 MCG/SPRAY, 400 MCG/SPRAY PA; QL (30 per 30 days) lorcet (hydrocodone) oral tablet 5- QL (360 per 30 days) (Norco) $0 325 mg lorcet hd oral tablet mg (Norco) $0 QL (360 per 30 days) lorcet plus oral tablet mg (Norco) $0 QL (360 per 30 days) mapap 60 mg/5 ml elixir 60 mg/5 (Tylenol Sore QL (240 per 30 days) ml * Throat) mapap 60 mg/5 ml suspension 60 QL (240 per 30 days) (Infants' Tylenol) mg/5 ml * mapap 325 mg tablet 325 mg * (Tylenol) QL (360 per 30 days) 6

21 mapap 500 mg capsule 500 mg * (Acetaminophen) QL (240 per 30 days) mapap 500 mg tablet 500 mg * (Tylenol) QL (240 per 30 days) mapap 500 mg/5 ml liquid 500 (Tylenol Sore QL (20 per 30 days) mg/5 ml * Throat) mapap 80 mg tablet chew 80 mg * (Acetaminophen) QL (30 per 30 days) mapap arthritis er 650 mg cplt 650 QL (80 per 30 days) (Tylenol Arthritis) mg * margesic oral capsule mg (Esgic) $0 PA-HRM; QL (80 per 30 days); AGE (Max 64 Years) methadone injection solution 0 mg/ml (Methadone HCl) $0 methadone oral solution 0 mg/5 QL (800 per 30 days) (Methadone HCl) $0 ml, 5 mg/5 ml methadone oral tablet 0 mg, 5 mg (Diskets) $0 QL (360 per 30 days) methadose oral tablet,soluble 40 mg (Diskets) $0 QL (90 per 30 days) morphine (pf) in 0.9 % nacl intravenous pt controlled analgesia (Morphine Sulfate/0.9% $0 syring 50 mg/25 ml (2 mg/ml) Nacl/PF) morphine 0 mg/ml carpuject 0 mg/ml (Morphine Sulfate) $0 morphine 2 mg/ml carpuject outer, latex-f, p/f 2 mg/ml (Morphine Sulfate) $0 morphine 4 mg/ml carpuject 4 mg/ml (Morphine Sulfate) $0 morphine 8 mg/ml syringe 8 mg/ml (Morphine Sulfate) $0 morphine concentrate oral solution QL (200 per 30 days) (Morphine Sulfate) $0 00 mg/5 ml (20 mg/ml) morphine concentrate oral syringe (Morphine Sulfate) $0 20 mg/ml morphine in dextrose 5 % injection pt controlled analgesia syring 00 mg/50 ml (2 mg/ml), 50 mg/25 ml (2 mg/ml) morphine injection solution 5 mg/ml, 8 mg/ml (Morphine Sulfate/D5W) $0 (Morphine Sulfate) $0 7

22 morphine injection syringe 0 mg/ml (Morphine Sulfate) $0 morphine intramuscular pen injector 0 mg/0.7 ml (Morphine Sulfate) $0 morphine intravenous cartridge 5 mg/ml (Morphine Sulfate) $0 morphine intravenous solution 25 mg/ml, 50 mg/ml (Morphine Sulfate) $0 morphine intravenous syringe 0 mg/ml, 2 mg/ml, 4 mg/ml, 8 mg/ml (Morphine Sulfate) $0 morphine oral solution 0 mg/5 ml (Morphine Sulfate) $0 QL (700 per 30 days) morphine oral solution 20 mg/5 ml QL (300 per 30 days) (Morphine Sulfate) $0 (4 mg/ml) MORPHINE ORAL TABLET 5 QL (80 per 30 days) MG, 30 MG morphine oral tablet extended QL (20 per 30 days) (MS Contin) $0 release 00 mg, 30 mg, 60 mg morphine oral tablet extended QL (80 per 30 days) (MS Contin) $0 release 5 mg, 200 mg morphine rectal suppository 0 mg, 20 mg, 30 mg, 5 mg (Morphine Sulfate) $0 non-aspirin x-str 67 mg/5 ml 500 (Tylenol Sore QL (20 per 30 days) mg/5 ml * Throat) nortemp 80 mg/0.8 ml drop 80 QL (30 per 30 days) (Acetaminophen) mg/0.8 ml * NUCYNTA ER ORAL TABLET QL (60 per 30 days) EXTENDED RELEASE 2 HR 00 MG, 50 MG, 200 MG, 250 MG, 50 MG NUCYNTA ORAL TABLET 00 QL (8 per 30 days) MG, 50 MG, 75 MG oxycodone oral concentrate 20 QL (80 per 30 days) (Oxycodone HCl) $0 mg/ml oxycodone oral solution 5 mg/5 ml (Oxycodone HCl) $0 QL (300 per 30 days) oxycodone oral tablet 0 mg, 5 mg, QL (80 per 30 days) (Roxicodone) $0 20 mg, 30 mg, 5 mg 8

23 oxycodone oral tablet,oral only,ext.rel.2 hr 0 mg, 5 mg, 20 mg, 30 mg, 40 mg, 60 mg oxycodone oral tablet,oral only,ext.rel.2 hr 80 mg oxycodone-acetaminophen oral solution mg/5 ml oxycodone-acetaminophen oral tablet mg, mg, mg, mg oxycodone-acetaminophen oral tablet mg oxycodone-acetaminophen oral tablet mg oxycodone-aspirin oral tablet mg OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.2 HR 0 MG, 5 MG, 20 MG, 30 MG, 40 MG, 60 MG (Oxycontin) $0 (Oxycontin) (Oxycodone HCl/Acetaminophe n) $0 (Xolox) $0 (Xolox) $0 (Xolox) $0 (Percodan) $0 QL (60 per 30 days) QL (20 per 30 days) QL (800 per 30 days) QL (360 per 30 days) QL (80 per 30 days) QL (240 per 30 days) QL (360 per 30 days) QL (60 per 30 days) OXYCONTIN ORAL QL (20 per 30 days) TABLET,ORAL ONLY,EXT.REL.2 HR 80 MG oxymorphone oral tablet 0 mg, 5 QL (80 per 30 days) (Opana) $0 mg oxymorphone oral tablet extended QL (60 per 30 days) release 2 hr 0 mg, 5 mg, 20 mg, 5 mg, 7.5 mg (Opana ER) $0 oxymorphone oral tablet extended QL (20 per 30 days) (Opana ER) $0 release 2 hr 30 mg, 40 mg pain relief 500 mg capsule 500 mg * (Acetaminophen) QL (240 per 30 days) pain reliever er 650 mg caplet 8 QL (80 per 30 days) (Tylenol Arthritis) hour, caplet 650 mg * pharbetol 325 mg tablet regular QL (360 per 30 days) (Tylenol) strength 325 mg * 9

24 pharbetol 500 mg caplet extra-str, QL (240 per 30 days) (Tylenol) caplet 500 mg * pv non-aspirin 500 mg softgel exstr,liq filled 500 mg * QL (240 per 30 days) (Acetaminophen) q-pap 60 mg/5 ml solution a/f, (Tylenol Sore QL (240 per 30 days) cherry 60 mg/5 ml * Throat) q-pap 325 mg tablet 325 mg * (Tylenol) QL (360 per 30 days) q-pap 80 mg/0.8 ml drops 80 mg/0.8 QL (30 per 30 days) (Acetaminophen) ml * q-pap ex-str 500 mg tablet aspirin QL (240 per 30 days) (Tylenol) free 500 mg * ra jr acetaminophen 60 mg tab QL (30 per 30 days) (Acetaminophen) rapid melts 60 mg * reprexain oral tablet mg, QL (50 per 30 days) (Ibudone) $ mg, mg (Oxycodone QL (800 per 30 days) roxicet oral solution mg/5 ml HCl/Acetaminophe n) $0 silapap infant's drops infant's 80 QL (30 per 30 days) (Acetaminophen) mg/0.8 ml * sm arthritis pain er 650 mg caplet QL (80 per 30 days) (Tylenol Arthritis) 650 mg * sm pain rel jr str tab chew 60 mg * (Acetaminophen) QL (30 per 30 days) sm pain reliever 80 mg tab QL (30 per 30 days) (Acetaminophen) children's 80 mg * tactinal 325 mg tablet 325 mg * (Tylenol) QL (360 per 30 days) tactinal 500 mg tablet extra-strength QL (240 per 30 days) (Tylenol) 500 mg * PA-HRM; QL (80 per tencon oral tablet mg (Tencon) $0 30 days); AGE (Max 64 Years) tramadol oral tablet 50 mg (Ultram) $0 QL (240 per 30 days) tramadol-acetaminophen oral tablet QL (240 per 30 days) (Ultracet) $ mg 0

25 vicodin es oral tablet mg (Norco) $0 (includes Vicodin, Vicodin ES and Vicodin HP); QL (390 per 30 days) vicodin hp oral tablet mg (Norco) $0 (includes Vicodin, Vicodin ES and Vicodin HP); QL (390 per 30 days) vicodin oral tablet mg (Norco) $0 (includes Vicodin, Vicodin ES and Vicodin HP); QL (390 per 30 days) xylon 0 oral tablet mg (Ibudone) $0 QL (50 per 30 days) zebutal oral capsule mg (Esgic) $0 Nonsteroidal Anti- Inflammatory Agents ADVIL 00 MG TABLET JR STRENGTH,COATED 00 MG * ADVIL 200 MG TABLET 200 MG * ADVIL JR STR 00 MG TAB CHEW TB CHEW,8 HOUR,GRAPE 00 MG * aspirin 300 mg suppository 300 mg (Aspirin) * aspirin 325 mg tablet 325 mg * (Ecotrin) aspirin 600 mg suppository 600 mg (Aspirin) * aspirin 8 mg chewable tablet 8 (Bayer Chewable mg * Aspirin) aspirin buffered 325 mg tab 325 mg (Aspirin/Calcium * Carbonate/Mag) aspirin ec 325 mg tablet 325 mg * (Ecotrin) aspirin ec 500 mg tablet 500 mg * (Ecotrin) PA-HRM; QL (80 per 30 days); AGE (Max 64 Years)

26 aspirin ec 8 mg tablet low dose 8 mg * (Ecotrin) aspir-low ec 8 mg tablet 8 mg * (Ecotrin) bufferin 325 mg tablet coated 325 (Aspirin/Calcium mg * Carbonate/Mag) CALDOLOR INTRAVENOUS RECON SOLN 400 MG/4 ML (00 MG/ML) celecoxib oral capsule 00 mg, 200 mg, 400 mg, 50 mg (Celebrex) $0 CHILDREN'S ADVIL 00 MG/5 ML A/F (OTC) 00 MG/5 ML * choline,magnesium salicylate oral (Choline Sal/Mag liquid 500 mg/5 ml Salicylate) $0 cvs ibuprofen 200 mg softgel liquid filled,softge 200 mg * (Advil) diclofenac potassium oral tablet 50 (Diclofenac mg Potassium) $0 diclofenac sodium oral tablet extended release 24 hr 00 mg (Voltaren-XR) $0 diclofenac sodium oral (Diclofenac tablet,delayed release (dr/ec) 25 mg, Sodium) 50 mg, 75 mg $0 diclofenac sodium topical gel 3 % (Voltaren) $0 diclofenac-misoprostol oral tablet,ir,delayed rel,biphasic (Arthrotec 50) $0 mg-mcg, mg-mcg diflunisal oral tablet 500 mg (Diflunisal) $0 ecpirin ec 325 mg tablet 325 mg * (Ecotrin) etodolac oral capsule 200 mg, 300 mg (Etodolac) $0 etodolac oral tablet 400 mg, 500 mg (Etodolac) $0 etodolac oral tablet extended release 24 hr 400 mg, 500 mg, 600 (Etodolac) $0 mg fenoprofen oral capsule 200 mg (Nalfon) $0 QL (60 per 30 days) 2

27 fenoprofen oral tablet 600 mg (Fenoprofen Calcium) $0 FLECTOR TRANSDERMAL PA PATCH 2 HOUR.3 % flurbiprofen oral tablet 00 mg, 50 mg (Flurbiprofen) $0 gnp ibuprofen jr str 00 mg tb 00 mg * (Advil) ibuprofen 00 mg/5 ml susp children's (otc) 00 mg/5 ml * (Children'S Advil) ibuprofen 200 mg tablet 200 mg * (Advil) ibuprofen oral suspension 00 mg/5 ml (Ibuprofen) $0 ibuprofen oral tablet 400 mg, 600 mg, 800 mg (Ibuprofen) $0 indomethacin oral capsule 25 mg (Indomethacin) $0 QL (240 per 30 days) indomethacin oral capsule 50 mg (Indomethacin) $0 QL (20 per 30 days) indomethacin oral capsule, extended QL (60 per 30 days) (Indomethacin) $0 release 75 mg indomethacin sodium intravenous (Indomethacin recon soln mg Sodium) $0 infant ibuprofen 50 mg/.25 ml d/f,a/f,non-staining 50 mg/.25 ml * (Infants' Motrin) INFANTS' MOTRIN 50 MG/.25 ML D/F, BERRY FLAVOR 50 3 $0 MG/.25 ML * ketoprofen oral capsule 50 mg, 75 mg (Ketoprofen) $0 ketoprofen oral capsule,ext rel. pellets 24 hr 200 mg (Ketoprofen) $0 ketorolac oral tablet 0 mg (Ketorolac QL (20 per 30 days) $0 Tromethamine) mefenamic acid oral capsule 250 mg (Ponstel) $0 meloxicam oral suspension 7.5 mg/5 ml (Mobic) $0 meloxicam oral tablet 5 mg, 7.5 mg (Mobic) $0 3

28 nabumetone oral tablet 500 mg, 750 mg (Nabumetone) $0 naproxen oral suspension 25 mg/5 ml (Naprosyn) $0 naproxen oral tablet 250 mg, 375 mg, 500 mg (Naprosyn) $0 naproxen oral tablet,delayed release (Ec-Naprosyn) (dr/ec) 375 mg, 500 mg $0 naproxen sodium oral tablet 275 mg, 550 mg (Anaprox) $0 piroxicam oral capsule 0 mg, 20 mg (Feldene) $0 ra aspirin tri-buffered tb 325 mg * (Aspirin/Calcium Carbonate/Mag) sm ibuprofen ib 00 mg tablet junior (Advil) strength 00 mg * st. joseph aspirin 8 mg chew (Bayer Chewable orange 8 mg * Aspirin) st. joseph aspirin ec 8 mg tb enteric coated 8 mg * (Ecotrin) sulindac oral tablet 50 mg, 200 mg (Sulindac) $0 tolmetin oral capsule 400 mg (Tolmetin Sodium) $0 tolmetin oral tablet 200 mg, 600 mg (Tolmetin Sodium) $0 VOLTAREN TOPICAL GEL % $0 wal-profen 200 mg softgel softgel 200 mg * (Advil) Anesthetics Local Anesthetics glydo mucous membrane jelly in applicator 2 % (Lidocaine HCl) $0 lidocaine (pf) injection solution 5 mg/ml (.5 %), 40 mg/ml (4 %), 5 (Xylocaine-MPF) $0 mg/ml (0.5 %) lidocaine 2% viscous soln 2 % (Xylocaine) $0 lidocaine hcl injection solution 0 mg/ml ( %), 20 mg/ml (2 %) (Xylocaine) $0 4

29 lidocaine hcl mucous membrane gel 2 % (Lidocaine HCl) $0 lidocaine hcl mucous membrane solution 2 %, 4 % (40 mg/ml) (Xylocaine) $0 lidocaine topical adhesive patch,medicated 5 % (Lidoderm) $0 lidocaine topical ointment 5 % (Lidocaine) $0 lidocaine-prilocaine topical cream % (EMLA) $0 Anti-Addiction/Substance Abuse Treatment Agents Anti-Addiction/Substance Abuse Treatment Agents acamprosate oral tablet,delayed (Acamprosate release (dr/ec) 333 mg Calcium) $0 buprenorphine hcl sublingual tablet (Buprenorphine 2 mg, 8 mg HCl) $0 (Buprenorphine buprenorphine-naloxone sublingual HCl/Naloxone tablet mg, 8-2 mg HCl) $0 bupropion hcl sr 50 mg tablet f/c 50 mg (Zyban) $0 CHANTIX CONTINUING MONTH BOX ORAL TABLET MG CHANTIX ORAL TABLET 0.5 MG, MG CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK 0.5 MG ()- MG (42) disulfiram oral tablet 250 mg, 500 mg (Antabuse) $0 naloxone injection solution 0.4 mg/ml (Naloxone HCl) $0 naloxone injection syringe 0.4 mg/ml, mg/ml (Naloxone HCl) $0 naltrexone oral tablet 50 mg (Revia) $0 PA PA; QL (90 per 30 days) PA; QL (90 per 30 days) QL (68 per 84 days) QL (68 per 84 days) QL (53 per 28 days) 5

30 NARCAN NASAL SPRAY,NON- AEROSOL 4 MG/ACTUATION NICODERM CQ 4 MG/24HR PATCH 4 MG/24 HR * NICODERM CQ 2 MG/24HR PATCH 2 MG/24 HR * NICODERM CQ 7 MG/24HR PATCH 7 MG/24 HR * nicorelief 2 mg gum 2 mg * (Nicorette) nicorelief 4 mg gum 4 mg * (Nicorette) nicorette 2 mg chewing gum white ice mint 2 mg * (Nicorette) nicotine 4 mg/24hr patch outer (otc) 4 mg/24 hr * (Nicoderm Cq) nicotine 2 mg chewing gum sugar free 2 mg * (Nicorette) nicotine 2 mg lozenge mint, 3 quittube 2 mg * (Nicorette) nicotine 2 mg/24hr patch step (otc) 2 mg/24 hr * (Nicoderm Cq) nicotine 22 mg/24hr patch week starter kit 22 mg/24 hr * (Nicoderm Cq) nicotine 4 mg chewing gum 4 mg * (Nicorette) nicotine 4 mg lozenge mint, 3 quittube 4 mg * (Nicorette) nicotine 7 mg/24hr patch (otc) 7 mg/24 hr * (Nicoderm Cq) NICOTROL INHALATION CARTRIDGE 0 MG ZUBSOLV SUBLINGUAL TABLET MG, MG, MG, MG, MG Antianxiety Agents Benzodiazepines alprazolam oral tablet 0.25 mg, 0.5 mg, mg, 2 mg (Xanax) $0 QL (4 per 30 days) QL (68 per 365 days) QL (68 per 365 days) QL (80 per 365 days) QL (68 per 365 days) QL (68 per 365 days) QL (80 per 365 days) QL (008 per 90 days) PA; QL (90 per 30 days) QL (20 per 30 days) 6

31 chlordiazepoxide hcl oral capsule (Chlordiazepoxide QL (20 per 30 days) $0 0 mg, 25 mg, 5 mg HCl) clonazepam oral tablet 0.5 mg, mg (Klonopin) $0 QL (90 per 30 days) clonazepam oral tablet 2 mg (Klonopin) $0 QL (300 per 30 days) clonazepam oral tablet,disintegrating 0.25 mg, 0.25 mg, 0.5 mg, mg (Clonazepam) $0 QL (90 per 30 days) clonazepam oral QL (300 per 30 days) (Clonazepam) $0 tablet,disintegrating 2 mg clorazepate dipotassium oral tablet QL (20 per 30 days) (Tranxene T-Tab) $0 5 mg clorazepate dipotassium oral tablet QL (60 per 30 days) (Tranxene T-Tab) $ mg, 7.5 mg diazepam injection syringe 5 mg/ml (Diazepam) $0 QL (0 per 28 days) diazepam intensol oral concentrate QL (200 per 30 days) (Diazepam) $0 5 mg/ml diazepam oral solution 5 mg/5 ml ( QL (200 per 30 days) (Diazepam) $0 mg/ml) diazepam oral tablet 0 mg, 2 mg, 5 QL (20 per 30 days) (Valium) $0 mg diazepam rectal kit mg, 2.5 mg, mg (Diastat) $0 lorazepam oral tablet 0.5 mg, mg, QL (90 per 30 days) (Ativan) $0 2 mg ONFI ORAL SUSPENSION 2.5 PA NSO; QL (480 per MG/ML 30 days) Antibacterials Aminoglycosides BETHKIS INHALATION SOLUTION FOR NEBULIZATION 300 MG/4 ML gentamicin in nacl (iso-osm) intravenous piggyback 00 mg/00 ml, 00 mg/50 ml, 60 mg/50 ml, 70 mg/50 ml, 80 mg/00 ml, 80 mg/50 ml, 90 mg/00 ml (Gentamicin In Nacl, Iso-Osm) $0 7

32 gentamicin injection solution 40 (Gentamicin mg/ml Sulfate) $0 gentamicin ped 20 mg/2 ml vial (Gentamicin latex-free, sdv 20 mg/2 ml Sulfate/PF) $0 gentamicin sulfate (pf) intravenous (Gentamicin solution 80 mg/8 ml Sulfate/PF) $0 neomycin oral tablet 500 mg (Neomycin Sulfate) $0 streptomycin intramuscular recon (Streptomycin soln gram Sulfate) $0 TOBI PODHALER INHALATION CAPSULE, W/INHALATION DEVICE 28 MG tobramycin in % nacl inhalation solution for nebulization (Tobi) $0 300 mg/5 ml tobramycin in 0.9 % nacl (Tobramycin/Sodiu intravenous piggyback 60 mg/50 ml, m Chloride) 80 mg/00 ml $0 tobramycin sulfate injection solution 0 mg/ml, 40 mg/ml Antibacterials, Miscellaneous bacitracin intramuscular recon soln 50,000 unit chloramphenicol sod succinate intravenous recon soln gram clindamycin 75 mg/5 ml soln 75 mg/5 ml clindamycin hcl oral capsule 50 mg, 300 mg, 75 mg clindamycin in 5 % dextrose intravenous piggyback 300 mg/50 ml, 600 mg/50 ml, 900 mg/50 ml clindamycin pediatric oral recon soln 75 mg/5 ml clindamycin phosphate injection solution 50 mg/ml (Tobramycin Sulfate) $0 (Bacitracin) $0 (Chloramphenicol Sod Succ) $0 (Cleocin Palmitate) $0 (Cleocin HCl) $0 (Cleocin Phosphate In D5w) $0 (Cleocin Palmitate) $0 (Cleocin Phosphate) $0 QL (224 per 28 days) 8

33 clindamycin phosphate intravenous (Cleocin solution 600 mg/4 ml Phosphate) $0 colistin (colistimethate na) injection (Coly-Mycin M recon soln 50 mg Parenteral) $0 CUBICIN INTRAVENOUS RECON SOLN 500 MG linezolid intravenous parenteral solution 600 mg/300 ml (Zyvox) $0 linezolid oral suspension for reconstitution 00 mg/5 ml (Zyvox) $0 linezolid oral tablet 600 mg (Zyvox) $0 methenamine hippurate oral tablet gram (Hiprex) $0 metronidazole in nacl (iso-os) (Metronidazole/So intravenous piggyback 500 mg/00 dium Chloride) ml $0 metronidazole oral capsule 375 mg (Flagyl) $0 metronidazole oral tablet 250 mg, 500 mg (Flagyl) $0 nitrofurantoin macrocrystal oral capsule 00 mg, 25 mg, 50 mg nitrofurantoin monohyd/m-cryst oral capsule 00 mg (Macrodantin) $0 (Macrobid) $0 PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (20 per 30 days); AGE (Max 64 Years) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (20 per 30 days); AGE (Max 64 Years) 9

34 nitrofurantoin monohyd/m-cryst oral capsule 00 mg (75/25) (Macrobid) $0 polymyxin b sulfate injection recon (Polymyxin B soln 500,000 unit Sulfate) $0 SYNERCID INTRAVENOUS RECON SOLN 500 MG trimethoprim oral tablet 00 mg (Trimethoprim) $0 vancomycin hcl g/200 ml bag (Vancomycin Hcl gram/200 ml In Dextrose 5 %) $0 vancomycin intravenous recon soln,000 mg, 0 gram, 750 mg (Vancomycin HCl) $0 vancomycin intravenous recon soln (Vancomycin Hcl 500 mg In Dextrose 5 %) $0 vancomycin oral capsule 25 mg, 250 mg (Vancocin HCl) $0 XIFAXAN ORAL TABLET 200 MG XIFAXAN ORAL TABLET 550 MG ZYVOX ORAL SUSPENSION FOR RECONSTITUTION 00 MG/5 ML Cephalosporins cefaclor oral capsule 250 mg, 500 mg (Cefaclor) $0 cefaclor oral suspension for reconstitution 25 mg/5 ml, 250 (Cefaclor) $0 mg/5 ml, 375 mg/5 ml cefadroxil oral capsule 500 mg (Cefadroxil) $0 PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (20 per 30 days); AGE (Max 64 Years) PA; QL (9 per 30 days) PA 20

35 cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 (Cefadroxil) $0 mg/5 ml cefadroxil oral tablet gram (Cefadroxil) $0 cefazolin in dextrose (iso-os) intravenous piggyback gram/50 ml, 2 gram/50 ml cefazolin injection recon soln gram, 0 gram, 500 mg (Cefazolin Sodium/Dextrose, Iso) $0 (Cefazolin Sodium) $0 cefdinir oral capsule 300 mg (Cefdinir) $0 cefdinir oral suspension for reconstitution 25 mg/5 ml, 250 (Cefdinir) $0 mg/5 ml cefditoren pivoxil oral tablet 200 mg, 400 mg (Spectracef) $0 CEFEPIME 2 GM INJECTION 2 GRAM/00 ML CEFEPIME IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK GRAM/50 ML, 2 GRAM/50 ML cefepime injection recon soln gram, 2 gram (Maxipime) $0 cefotaxime injection recon soln gram, 0 gram, 2 gram, 500 mg (Claforan) $0 cefoxitin in dextrose, iso-osm intravenous piggyback 2 gram/50 ml (Cefoxitin Sodium/Dextrose, Iso) $0 cefoxitin intravenous recon soln gram, 0 gram, 2 gram (Cefoxitin Sodium) $0 cefpodoxime oral suspension for (Cefpodoxime reconstitution 00 mg/5 ml, 50 mg/5 Proxetil) ml $0 cefpodoxime oral tablet 00 mg, 200 (Cefpodoxime mg Proxetil) $0 cefprozil oral suspension for reconstitution 25 mg/5 ml, 250 mg/5 ml (Cefprozil) $0 2

36 cefprozil oral tablet 250 mg, 500 mg (Cefprozil) $0 ceftazidime injection recon soln 2 gram, 6 gram (Fortaz) $0 ceftibuten oral capsule 400 mg (Cedax) $0 ceftibuten oral suspension for reconstitution 80 mg/5 ml (Cedax) $0 ceftriaxone gm piggyback 50ml (Ceftriaxone galaxycontainer gram/50 ml Na/Dextrose, Iso) $0 ceftriaxone gm vial 0's, fliptop,l/f gram (Rocephin) $0 ceftriaxone 2 gm piggyback 50ml (Ceftriaxone galaxycontainer 2 gram/50 ml Na/Dextrose, Iso) $0 ceftriaxone injection recon soln 0 gram, 250 mg, 500 mg (Rocephin) $0 ceftriaxone intravenous recon soln (Ceftriaxone gram, 2 gram Na/Dextrose, Iso) $0 cefuroxime axetil oral tablet 250 mg, 500 mg (Ceftin) $0 cefuroxime sodium injection recon soln.5 gram, 750 mg (Zinacef) $0 cefuroxime sodium intravenous recon soln 7.5 gram (Zinacef) $0 cephalexin oral capsule 250 mg, 500 mg, 750 mg (Keflex) $0 cephalexin oral suspension for reconstitution 25 mg/5 ml, 250 (Cephalexin) $0 mg/5 ml cephalexin oral tablet 250 mg, 500 mg (Cephalexin) $0 MEFOXIN IN DEXTROSE (ISO- OSM) INTRAVENOUS PIGGYBACK GRAM/50 ML, 2 GRAM/50 ML SUPRAX ORAL TABLET,CHEWABLE 00 MG, 200 MG 22

37 tazicef injection recon soln 2 gram, 6 gram (Fortaz) $0 TEFLARO INTRAVENOUS RECON SOLN 400 MG, 600 MG Macrolides azithromycin intravenous recon soln 500 mg (Zithromax) $0 azithromycin oral packet gram (Zithromax) $0 azithromycin oral suspension for reconstitution 00 mg/5 ml, 200 (Zithromax) $0 mg/5 ml azithromycin oral tablet 250 mg, 250 mg (6 pack), 600 mg (Zithromax) $0 azithromycin oral tablet 500 mg (Zithromax) $0 clarithromycin oral suspension for reconstitution 25 mg/5 ml, 250 (Biaxin) $0 mg/5 ml clarithromycin oral tablet 250 mg, 500 mg (Biaxin) $0 clarithromycin oral tablet extended release 24 hr 500 mg (Clarithromycin) $0 DIFICID ORAL TABLET 200 MG QL (20 per 0 days) e.e.s. 400 oral tablet 400 mg (Erythromycin Ethylsuccinate) $0 e.e.s. granules oral suspension for reconstitution 200 mg/5 ml (Eryped 200) $0 ery-tab oral tablet,delayed release (Erythromycin (dr/ec) 250 mg, 500 mg Base) $0 ERY-TAB ORAL TABLET,DELAYED RELEASE (DR/EC) 333 MG erythrocin (as stearate) oral tablet (Erythromycin 250 mg Stearate) $0 ERYTHROCIN INTRAVENOUS RECON SOLN,000 MG, 500 MG erythromycin ethylsuccinate oral (Erythromycin tablet 400 mg Ethylsuccinate) $0 23

38 erythromycin oral capsule,delayed release(dr/ec) 250 mg erythromycin oral tablet 250 mg, 500 mg Miscellaneous B-Lactam Antibiotics aztreonam injection recon soln gram CAYSTON INHALATION SOLUTION FOR NEBULIZATION 75 MG/ML imipenem-cilastatin intravenous recon soln 250 mg, 500 mg INVANZ INJECTION RECON SOLN GRAM meropenem intravenous recon soln 500 mg meropenem iv gm vial outer, latexfree gram Penicillins amoxicillin oral capsule 250 mg, 500 mg amoxicillin oral suspension for reconstitution 25 mg/5 ml, 200 mg/5 ml, 250 mg/5 ml, 400 mg/5 ml amoxicillin oral tablet 500 mg, 875 mg amoxicillin oral tablet,chewable 25 mg, 250 mg amoxicillin-pot clavulanate oral suspension for reconstitution mg/5 ml, mg/5 ml, mg/5 ml, mg/5 ml amoxicillin-pot clavulanate oral tablet mg, mg, mg (Erythromycin Base) (Erythromycin Base) $0 $0 (Azactam) $0 (Primaxin) $0 (Merrem) $0 (Merrem) $0 (Amoxicillin) $0 (Amoxicillin) $0 (Amoxicillin) $0 (Amoxicillin) $0 (Augmentin) $0 (Augmentin) $0 LA 24

39 amoxicillin-pot clavulanate oral tablet extended release 2 hr, mg amoxicillin-pot clavulanate oral tablet,chewable mg, mg ampicillin 2 gm vial 0's, latex-free 2 gram ampicillin oral capsule 250 mg, 500 mg ampicillin oral suspension for reconstitution 25 mg/5 ml, 250 mg/5 ml ampicillin sodium injection recon soln gram, 0 gram, 25 mg ampicillin sodium intravenous recon soln 2 gram ampicillin-sulbactam injection recon soln.5 gram, 5 gram, 3 gram BICILLIN C-R INTRAMUSCULAR SYRINGE,200,000 UNIT/ 2 ML(600K/600K),,200,000 UNIT/ 2 ML(900K/300K) BICILLIN L-A INTRAMUSCULAR SYRINGE,200,000 UNIT/2 ML, 2,400,000 UNIT/4 ML, 600,000 UNIT/ML dicloxacillin oral capsule 250 mg, 500 mg nafcillin 2 gm vial sterile, latex-free 2 gram nafcillin injection recon soln gram, 0 gram nafcillin intravenous recon soln 2 gram (Augmentin XR) $0 (Amoxicillin/Potas sium Clav) (Ampicillin Sodium) (Ampicillin Trihydrate) (Ampicillin Trihydrate) (Ampicillin Sodium) (Ampicillin Sodium) $0 $0 $0 $0 $0 $0 (Unasyn) $0 (Dicloxacillin Sodium) $0 (Nafcillin Sodium) $0 (Nafcillin Sodium) $0 (Nafcillin Sodium) $0 25

40 oxacillin gm add-vantage vl addvantage, inner gram oxacillin in dextrose(iso-osm) intravenous piggyback gram/50 ml, 2 gram/50 ml oxacillin injection recon soln 0 gram oxacillin intravenous recon soln 2 gram penicillin g pot in dextrose intravenous piggyback million unit/50 ml, 2 million unit/50 ml, 3 million unit/50 ml penicillin g potassium injection recon soln 5 million unit penicillin g procaine intramuscular syringe.2 million unit/2 ml, 600,000 unit/ml penicillin gk 20 million unit 20 million unit penicillin v potassium oral recon soln 25 mg/5 ml, 250 mg/5 ml penicillin v potassium oral tablet 250 mg, 500 mg pfizerpen-g injection recon soln 20 million unit piperacillin-tazobactam intravenous recon soln 2.25 gram, gram, 4.5 gram piperacil-tazobact 40.5 gram p/f, latex-free 40.5 gram Quinolones ciprofloxacin hcl oral tablet 00 mg, 250 mg, 500 mg, 750 mg ciprofloxacin in 5 % dextrose intravenous piggyback 200 mg/00 ml (Oxacillin Sodium) $0 (Oxacillin Sodium/Dextrose, Iso) $0 (Oxacillin Sodium) $0 (Oxacillin Sodium) $0 (Pen G Pot/Dextrose- Water) (Penicillin G Potassium) (Penicillin G Procaine) (Penicillin G Potassium) (Penicillin V Potassium) (Penicillin V Potassium) (Penicillin G Potassium) $0 $0 $0 $0 $0 $0 $0 (Zosyn) $0 (Zosyn) $0 (Cipro) $0 (Cipro I.V.) $0 26

41 ciprofloxacin lactate intravenous (Ciprofloxacin solution 400 mg/40 ml Lactate) $0 ciprofloxacin oral suspension,microcapsule recon 250 (Cipro) $0 mg/5 ml, 500 mg/5 ml ciprofloxacn-d5w 400 mg/200 ml p/f,latex/f, in d5w 400 mg/200 ml (Cipro I.V.) $0 levofloxacin in d5w intravenous piggyback 500 mg/00 ml, 750 (Levaquin) $0 mg/50 ml levofloxacin intravenous solution 25 mg/ml (Levofloxacin) $0 levofloxacin oral solution 250 mg/0 ml (Levaquin) $0 levofloxacin oral tablet 250 mg, 500 mg, 750 mg (Levaquin) $0 moxifloxacin oral tablet 400 mg (Avelox) $0 ofloxacin oral tablet 400 mg (Ofloxacin) $0 Sulfonamides sulfadiazine oral tablet 500 mg (Sulfadiazine) $0 sulfamethoxazole-trimethoprim intravenous solution mg/5 ml sulfamethoxazole-trimethoprim oral suspension mg/5 ml sulfamethoxazole-trimethoprim oral tablet mg, mg (Sulfamethoxazole/ Trimethoprim) (Sulfamethoxazole/ Trimethoprim) $0 $0 (Bactrim) $0 sulfasalazine oral tablet 500 mg (Azulfidine) $0 sulfasalazine oral tablet,delayed release (dr/ec) 500 mg (Azulfidine) $0 sulfatrim oral suspension (Sulfamethoxazole/ mg/5 ml Trimethoprim) $0 Tetracyclines doxy-00 intravenous recon soln (Doxycycline 00 mg Hyclate) $0 doxycycline hyclate 00 mg cap 00 mg (Morgidox) $0 27

42 doxycycline hyclate 00 mg tab 00 mg doxycycline hyclate intravenous recon soln 00 mg doxycycline hyclate oral capsule 00 mg doxycycline hyclate oral capsule 50 mg doxycycline hyclate oral tablet 00 mg, 50 mg doxycycline hyclate oral tablet 20 mg doxycycline mono 00 mg cap 00 mg doxycycline mono 00 mg tablet f/c 00 mg doxycycline mono 50 mg tablet 50 mg doxycycline monohydrate oral capsule 50 mg, 50 mg, 75 mg doxycycline monohydrate oral suspension for reconstitution 25 mg/5 ml doxycycline monohydrate oral tablet 50 mg, 75 mg minocycline oral capsule 00 mg, 50 mg, 75 mg minocycline oral tablet 00 mg, 50 mg, 75 mg tetracycline oral capsule 250 mg, 500 mg TYGACIL INTRAVENOUS RECON SOLN 50 MG Anticancer Agents Anticancer Agents (Doryx) $0 (Doxycycline Hyclate) $0 (Adoxa) $0 (Morgidox) $0 (Avidoxy) $0 (Doryx) $0 (Adoxa) $0 (Avidoxy) $0 (Avidoxy) $0 (Adoxa) $0 (Vibramycin) $0 (Avidoxy) $0 (Minocin) $0 (Minocycline HCl) $0 (Tetracycline HCl) $0 28

43 ABRAXANE INTRAVENOUS SUSPENSION FOR RECONSTITUTION 00 MG ADCETRIS INTRAVENOUS RECON SOLN 50 MG adriamycin intravenous recon soln 0 mg, 20 mg, 50 mg (Doxorubicin HCl) $0 adriamycin intravenous solution 0 mg/5 ml (Doxorubicin HCl) $0 adrucil 2,500 mg/50 ml vial outer, latex-free 2.5 gram/50 ml (Fluorouracil) $0 adrucil intravenous solution 500 mg/0 ml (Fluorouracil) $0 AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION 2 MG, 3 MG, 5 MG AFINITOR ORAL TABLET 0 MG AFINITOR ORAL TABLET 2.5 MG, 5 MG, 7.5 MG ALECENSA ORAL CAPSULE 50 MG ALIMTA INTRAVENOUS RECON SOLN 500 MG anastrozole oral tablet mg (Arimidex) $0 AVASTIN INTRAVENOUS SOLUTION 25 MG/ML, 25 MG/ML (6 ML) azacitidine injection recon soln 00 mg (Vidaza) $0 BELEODAQ INTRAVENOUS RECON SOLN 500 MG BENDEKA INTRAVENOUS SOLUTION 25 MG/ML bexarotene oral capsule 75 mg (Targretin) $0 bicalutamide oral tablet 50 mg (Casodex) $0 PA NSO; QL (4 per 2 days) PA NSO; QL (2 per 28 days) PA NSO; QL (56 per 28 days) PA NSO; QL (28 per 28 days) PA NSO; QL (240 per 30 days) PA NSO PA NSO PA NSO PA NSO; QL (420 per 30 days) 29

44 bleomycin injection recon soln 30 unit bleomycin sulfate 5 unit vial latexfree 5 unit BLINCYTO INTRAVENOUS KIT 35 MCG BOSULIF ORAL TABLET 00 MG BOSULIF ORAL TABLET 500 MG CABOMETYX ORAL TABLET 20 MG, 60 MG CABOMETYX ORAL TABLET 40 MG CAPRELSA ORAL TABLET 00 MG CAPRELSA ORAL TABLET 300 MG COMETRIQ ORAL CAPSULE 00 MG/DAY(80 MG X-20 MG X), 40 MG/DAY(80 MG X-20 MG X3), 60 MG/DAY (20 MG X 3/DAY) COTELLIC ORAL TABLET 20 MG cyclophosphamide intravenous recon soln gram, 2 gram, 500 mg CYCLOPHOSPHAMIDE ORAL CAPSULE 25 MG, 50 MG cyclophosphamide oral tablet 25 mg, 50 mg CYRAMZA INTRAVENOUS SOLUTION 0 MG/ML, 0 MG/ML (50 ML) dactinomycin intravenous recon soln 0.5 mg (Bleomycin Sulfate) (Bleomycin Sulfate) (Cyclophosphamid e) (Cyclophosphamid e) $0 $0 $0 $0 (Dactinomycin) $0 PA NSO; QL (40 per 365 days) PA NSO; QL (20 per 30 days) PA NSO; QL (30 per 30 days) PA NSO; QL (30 per 30 days) PA NSO; QL (60 per 30 days) PA NSO; QL (60 per 30 days) PA NSO; QL (30 per 30 days) PA NSO; QL (2 per 28 days) PA NSO; LA; QL (63 per 28 days) ; ST ; ST PA NSO 30

45 DARZALEX INTRAVENOUS SOLUTION 20 MG/ML decitabine intravenous recon soln 50 mg (Dacogen) $0 doxorubicin, peg-liposomal intravenous suspension 2 mg/ml (Doxil) $0 DROXIA ORAL CAPSULE 200 MG, 300 MG, 400 MG ELIGARD (3 MONTH) SUBCUTANEOUS SYRINGE 22.5 MG ELIGARD (4 MONTH) SUBCUTANEOUS SYRINGE 30 MG ELIGARD (6 MONTH) SUBCUTANEOUS SYRINGE 45 MG ELIGARD SUBCUTANEOUS SYRINGE 7.5 MG ( MONTH) EMCYT ORAL CAPSULE 40 MG EMPLICITI INTRAVENOUS RECON SOLN 300 MG, 400 MG ERIVEDGE ORAL CAPSULE 50 MG ETOPOPHOS INTRAVENOUS RECON SOLN 00 MG etoposide intravenous solution 20 mg/ml (Etoposide) $0 exemestane oral tablet 25 mg (Aromasin) $0 FARESTON ORAL TABLET 60 MG FARYDAK ORAL CAPSULE 0 MG, 5 MG, 20 MG FASLODEX INTRAMUSCULAR SYRINGE 250 MG/5 ML PA NSO; LA QL ( per 84 days) QL ( per 2 days) QL ( per 68 days) PA NSO PA NSO; QL (30 per 30 days) PA NSO 3

46 floxuridine injection recon soln 0.5 gram (Floxuridine) $0 fluorouracil 5,000 mg/00 ml latexfree 5 gram/00 ml (Fluorouracil) $0 fluorouracil intravenous solution gram/20 ml, 2.5 gram/50 ml, 500 (Fluorouracil) $0 mg/0 ml flutamide oral capsule 25 mg (Flutamide) $0 GAZYVA INTRAVENOUS SOLUTION,000 MG/40 ML GILOTRIF ORAL TABLET 20 MG, 30 MG, 40 MG GLEOSTINE ORAL CAPSULE 0 MG, 00 MG, 40 MG HERCEPTIN INTRAVENOUS RECON SOLN 440 MG HEXALEN ORAL CAPSULE 50 MG hydroxyurea oral capsule 500 mg (Hydrea) $0 IBRANCE ORAL CAPSULE 00 MG, 25 MG, 75 MG ICLUSIG ORAL TABLET 5 MG ICLUSIG ORAL TABLET 45 MG ifosfamide gm/20 ml vial suv gram/20 ml ifosfamide intravenous recon soln gram ifosfamide-mesna intravenous kit - gram, 3,000-,000 mg (Ifex) $0 (Ifex) $0 (Ifosfamide/Mesna ) $0 imatinib oral tablet 00 mg (Gleevec) $0 imatinib oral tablet 400 mg (Gleevec) $0 IMBRUVICA ORAL CAPSULE 40 MG PA NSO PA NSO; QL (30 per 30 days) PA NSO PA NSO; QL (2 per 28 days) PA NSO; QL (60 per 30 days) PA NSO; QL (30 per 30 days) PA NSO; QL (90 per 30 days) PA NSO; QL (60 per 30 days) PA NSO 32

47 IMLYGIC INJECTION SUSPENSION 0EXP6 ( MILLION) PFU/ML IMLYGIC INJECTION SUSPENSION 0EXP8 (00 MILLION) PFU/ML INLYTA ORAL TABLET MG INLYTA ORAL TABLET 5 MG IRESSA ORAL TABLET 250 MG IXEMPRA 5 MG KIT WITH DILUENT 5 MG IXEMPRA INTRAVENOUS RECON SOLN 45 MG JAKAFI ORAL TABLET 0 MG, 5 MG, 20 MG, 25 MG, 5 MG KEYTRUDA INTRAVENOUS RECON SOLN 50 MG KEYTRUDA INTRAVENOUS SOLUTION 00 MG/4 ML (25 MG/ML) KYPROLIS INTRAVENOUS RECON SOLN 60 MG LENVIMA ORAL CAPSULE 0 MG/DAY (0 MG X /DAY), 4 MG/DAY(0 MG X -4 MG X ), 8 MG/DAY (0 MG X -4 MG X2), 20 MG/DAY (0 MG X 2), 24 MG/DAY(0 MG X 2-4 MG X ), 8 MG/DAY (4 MG X 2) letrozole oral tablet 2.5 mg (Femara) $0 LEUKERAN ORAL TABLET 2 MG leuprolide subcutaneous kit (Leuprolide mg/0.2 ml Acetate) $0 PA NSO; QL (4 per 365 days) PA NSO; QL (8 per 28 days) PA NSO; QL (80 per 30 days) PA NSO; QL (60 per 30 days) PA NSO; QL (60 per 30 days) PA NSO; QL (60 per 30 days) PA NSO PA NSO PA NSO; QL (6 per 28 days) PA NSO 33

48 lipodox 50 intravenous suspension 2 mg/ml lipodox intravenous suspension 2 mg/ml lomustine oral capsule 0 mg, 00 mg, 40 mg LONSURF ORAL TABLET MG LONSURF ORAL TABLET MG LUPRON DEPOT (3 MONTH) INTRAMUSCULAR SYRINGE KIT.25 MG, 22.5 MG LUPRON DEPOT (4 MONTH) INTRAMUSCULAR SYRINGE KIT 30 MG LUPRON DEPOT (6 MONTH) INTRAMUSCULAR SYRINGE KIT 45 MG LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 3.75 MG, 7.5 MG LYNPARZA ORAL CAPSULE 50 MG LYSODREN ORAL TABLET 500 MG MATULANE ORAL CAPSULE 50 MG megestrol oral tablet 20 mg, 40 mg MEKINIST ORAL TABLET 0.5 MG (Doxil) $0 (Doxil) $0 (Lomustine) $0 (Megestrol Acetate) $0 MEKINIST ORAL TABLET 2 MG mercaptopurine oral tablet 50 mg (Mercaptopurine) $0 methotrexate 50 mg/2 ml vial latexfree, 5's, mdv 25 mg/ml (Methotrexate $0 Sodium) PA NSO; QL (00 per 28 days) PA NSO; QL (80 per 28 days) QL ( per 84 days) QL ( per 84 days) QL ( per 68 days) PA NSO; QL (480 per 30 days) PA NSO; QL (90 per 30 days) PA NSO; QL (30 per 30 days) 34

49 methotrexate sodium (pf) injection (Methotrexate recon soln gram Sodium/PF) $0 methotrexate sodium (pf) injection (Methotrexate solution 25 mg/ml Sodium) $0 methotrexate sodium oral tablet 2.5 (Methotrexate mg Sodium) $0 mitoxantrone intravenous (Mitoxantrone concentrate 2 mg/ml HCl) $0 NEXAVAR ORAL TABLET 200 MG NILANDRON ORAL TABLET 50 MG nilutamide oral tablet 50 mg (Nilandron) $0 NINLARO ORAL CAPSULE 2.3 MG, 3 MG, 4 MG ODOMZO ORAL CAPSULE 200 MG ONCASPAR INJECTION SOLUTION 750 UNIT/ML OPDIVO INTRAVENOUS SOLUTION 40 MG/4 ML POMALYST ORAL CAPSULE MG, 2 MG, 3 MG, 4 MG PORTRAZZA INTRAVENOUS SOLUTION 800 MG/50 ML (6 MG/ML) PROLEUKIN INTRAVENOUS RECON SOLN 22 MILLION UNIT PURIXAN ORAL SUSPENSION 20 MG/ML REVLIMID ORAL CAPSULE 0 MG, 5 MG, 2.5 MG, 20 MG, 25 MG, 5 MG RITUXAN INTRAVENOUS CONCENTRATE 0 MG/ML SOLTAMOX ORAL SOLUTION 0 MG/5 ML ; ST PA NSO; QL (20 per 30 days) PA NSO; QL (3 per 28 days) PA NSO; LA PA NSO PA NSO PA NSO; QL (2 per 28 days) PA NSO; QL (00 per 2 days) PA NSO; LA PA NSO 35

50 SPRYCEL ORAL TABLET 00 MG, 40 MG, 50 MG, 70 MG, 80 MG SPRYCEL ORAL TABLET 20 MG STIVARGA ORAL TABLET 40 MG SUTENT ORAL CAPSULE 2.5 MG, 25 MG, 37.5 MG, 50 MG SYLVANT INTRAVENOUS RECON SOLN 00 MG, 400 MG SYNRIBO SUBCUTANEOUS RECON SOLN 3.5 MG TABLOID ORAL TABLET 40 MG TAFINLAR ORAL CAPSULE 50 MG, 75 MG TAGRISSO ORAL TABLET 40 MG, 80 MG tamoxifen oral tablet 0 mg, 20 mg (Tamoxifen Citrate) $0 TARCEVA ORAL TABLET 00 MG, 25 MG TARCEVA ORAL TABLET 50 MG TARGRETIN ORAL CAPSULE 75 MG TARGRETIN TOPICAL GEL % TASIGNA ORAL CAPSULE 50 MG, 200 MG TECENTRIQ INTRAVENOUS SOLUTION,200 MG/20 ML (60 MG/ML) TEMODAR INTRAVENOUS RECON SOLN 00 MG thiotepa injection recon soln 5 mg (Thiotepa) $0 PA NSO; QL (30 per 30 days) PA NSO; QL (60 per 30 days) PA NSO; QL (84 per 28 days) PA NSO; QL (30 per 30 days) PA NSO PA NSO; QL (28 per 28 days) PA NSO; QL (20 per 30 days) PA NSO; LA; QL (30 per 30 days) PA NSO; QL (60 per 30 days) PA NSO; QL (90 per 30 days) PA NSO; QL (420 per 30 days) PA NSO; QL (60 per 28 days) PA NSO; QL (2 per 28 days) PA NSO; QL (20 per 2 days) PA NSO; (vial only) 36

51 toposar intravenous solution 20 mg/ml (Etoposide) $0 TREANDA 25 MG VIAL 25 MG TREANDA INTRAVENOUS RECON SOLN 00 MG TREANDA INTRAVENOUS SOLUTION 80 MG/2 ML, 45 MG/0.5 ML TRELSTAR 22.5 MG SYRINGE OUTER 22.5 MG/2 ML TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 22.5 MG TRELSTAR INTRAMUSCULAR SYRINGE.25 MG/2 ML TRELSTAR INTRAMUSCULAR SYRINGE 3.75 MG/2 ML tretinoin (chemotherapy) oral capsule 0 mg (Tretinoin) $0 TREXALL ORAL TABLET 0 MG, 5 MG, 5 MG, 7.5 MG TYKERB ORAL TABLET 250 MG UNITUXIN INTRAVENOUS SOLUTION 3.5 MG/ML VALSTAR INTRAVESICAL SOLUTION 40 MG/ML VELCADE INJECTION RECON SOLN 3.5 MG VENCLEXTA ORAL TABLET 0 MG, 00 MG, 50 MG VENCLEXTA STARTING PACK ORAL TABLETS,DOSE PACK 0 MG-50 MG- 00 MG vinorelbine intravenous solution 50 mg/5 ml (Navelbine) $0 VOTRIENT ORAL TABLET 200 MG QL ( per 68 days) QL ( per 68 days) QL ( per 84 days) (capsule: 0mg) ; ST PA NSO PA NSO PA NSO; LA PA NSO; LA PA NSO; QL (20 per 30 days) 37

52 XALKORI ORAL CAPSULE 200 MG, 250 MG XTANDI ORAL CAPSULE 40 MG YERVOY INTRAVENOUS SOLUTION 50 MG/0 ML (5 MG/ML) YONDELIS INTRAVENOUS RECON SOLN MG ZELBORAF ORAL TABLET 240 MG ZOLADEX SUBCUTANEOUS IMPLANT 0.8 MG ZOLADEX SUBCUTANEOUS IMPLANT 3.6 MG ZOLINZA ORAL CAPSULE 00 MG ZYDELIG ORAL TABLET 00 MG, 50 MG ZYKADIA ORAL CAPSULE 50 MG ZYTIGA ORAL TABLET 250 MG Anticholinergic Agents Antimuscarinics/Antispasm odics atropine injection solution 0.4 mg/ml atropine injection syringe 0.05 mg/ml, 0. mg/ml propantheline oral tablet 5 mg STIOLTO RESPIMAT INHALATION MIST MCG/ACTUATION Anticonvulsants Anticonvulsants (Atropine Sulfate) $0 (Atropine Sulfate) $0 (Propantheline Bromide) $0 PA NSO; QL (60 per 30 days) PA NSO; QL (20 per 30 days) PA NSO PA NSO PA NSO; QL (240 per 30 days) QL ( per 84 days) QL ( per 28 days) PA NSO; QL (60 per 30 days) PA NSO; QL (40 per 28 days) PA NSO; QL (20 per 30 days) QL (4 per 28 days) 38

53 APTIOM ORAL TABLET 200 MG, 400 MG, 600 MG, 800 MG BANZEL ORAL SUSPENSION 40 MG/ML BANZEL ORAL TABLET 200 MG, 400 MG BRIVIACT INTRAVENOUS SOLUTION 50 MG/5 ML BRIVIACT ORAL SOLUTION 0 MG/ML BRIVIACT ORAL TABLET 0 MG, 00 MG, 25 MG, 50 MG, 75 MG carbamazepine oral capsule, er multiphase 2 hr 00 mg, 200 mg, (Carbatrol) $0 300 mg carbamazepine oral suspension 00 mg/5 ml (Tegretol) $0 carbamazepine oral tablet 200 mg (Tegretol) $0 carbamazepine oral tablet extended release 2 hr 00 mg, 200 mg, 400 (Tegretol XR) $0 mg carbamazepine oral tablet,chewable 00 mg (Carbamazepine) $0 CELONTIN ORAL CAPSULE 300 MG DILANTIN ORAL CAPSULE 30 MG $0 divalproex oral capsule, sprinkle (Depakote 25 mg Sprinkle) $0 divalproex oral tablet extended release 24 hr 250 mg, 500 mg (Depakote ER) $0 divalproex oral tablet,delayed release (dr/ec) 25 mg, 250 mg, 500 (Depakote) $0 mg epitol oral tablet 200 mg (Tegretol) $0 ethosuximide oral capsule 250 mg (Zarontin) $0 ST ST ST QL (80 per 30 days) QL (600 per 30 days) QL (60 per 30 days) 39

54 ethosuximide oral solution 250 mg/5 ml felbamate oral suspension 600 mg/5 ml felbamate oral tablet 400 mg, 600 mg fosphenytoin 500 mg pe/0 ml 0's,sdv,latex-free 500 mg pe/0 ml fosphenytoin injection solution 00 mg pe/2 ml FYCOMPA ORAL SUSPENSION 0.5 MG/ML FYCOMPA ORAL TABLET 0 MG, 2 MG, 2 MG, 4 MG, 6 MG, 8 MG gabapentin oral capsule 00 mg, 300 mg, 400 mg gabapentin oral solution 250 mg/5 ml gabapentin oral tablet 600 mg, 800 mg GABITRIL ORAL TABLET 2 MG, 6 MG LAMICTAL ORAL TABLET, CHEWABLE DISPERSIBLE 2 MG lamotrigine oral tablet 00 mg, 50 mg, 200 mg, 25 mg lamotrigine oral tablet extended release 24hr 00 mg, 200 mg, 25 mg, 250 mg, 300 mg, 50 mg lamotrigine oral tablet, chewable dispersible 25 mg, 5 mg lamotrigine oral tablets,dose pack 25 mg (35) levetiracetam intravenous solution 500 mg/5 ml (Zarontin) $0 (Felbatol) $0 (Felbatol) $0 (Cerebyx) $0 (Cerebyx) $0 (Neurontin) $0 (Neurontin) $0 (Neurontin) $0 (Lamictal) $0 (Lamictal XR) $0 (Lamictal) $0 (Lamictal (Blue)) $0 (Keppra) $0 ST ST 40

55 levetiracetam oral solution 00 mg/ml (Keppra) $0 levetiracetam oral tablet,000 mg, 250 mg, 500 mg, 750 mg (Roweepra) $0 levetiracetam oral tablet extended release 24 hr 500 mg, 750 mg (Keppra XR) $0 LYRICA ORAL CAPSULE 00 QL (90 per 30 days) MG, 50 MG, 200 MG, 225 MG, 25 MG, 300 MG, 50 MG, 75 MG LYRICA ORAL SOLUTION 20 QL (900 per 30 days) MG/ML oxcarbazepine oral suspension 300 mg/5 ml (Trileptal) $0 oxcarbazepine oral tablet 50 mg, 300 mg, 600 mg (Trileptal) $0 OXTELLAR XR ORAL TABLET ST EXTENDED RELEASE 24 HR 50 MG, 300 MG, 600 MG PEGANONE ORAL TABLET 250 MG phenobarbital oral elixir 20 mg/5 ml QL (500 per 30 days) (Phenobarbital) $0 (4 mg/ml) phenobarbital oral tablet 00 mg, QL (90 per 30 days) 5 mg, 6.2 mg, 32.4 mg, 60 mg, 64.8 mg, 97.2 mg (Phenobarbital) $0 phenobarbital oral tablet 30 mg (Phenobarbital) $0 QL (200 per 30 days) phenobarbital sodium injection (Phenobarbital QL (2 per 30 days) $0 solution 30 mg/ml, 65 mg/ml Sodium) phenytoin oral suspension 25 mg/5 ml (Dilantin-25) $0 phenytoin oral tablet,chewable 50 mg (Dilantin) $0 phenytoin sodium extended oral capsule 00 mg, 200 mg, 300 mg (Dilantin) $0 phenytoin sodium intravenous (Phenytoin solution 50 mg/ml Sodium) $0 4

56 phenytoin sodium intravenous (Phenytoin syringe 50 mg/ml Sodium) $0 POTIGA ORAL TABLET 200 MG, QL (90 per 30 days) 300 MG, 400 MG POTIGA ORAL TABLET 50 MG QL (270 per 30 days) primidone oral tablet 250 mg, 50 mg (Mysoline) $0 ROWEEPRA ORAL TABLET 500 MG $0 SABRIL ORAL POWDER IN PACKET 500 MG SABRIL ORAL TABLET 500 MG SPRITAM ORAL TABLET FOR ST; QL (60 per 30 SUSPENSION,000 MG days) SPRITAM ORAL TABLET FOR SUSPENSION 250 MG, 500 MG, 750 MG tiagabine oral tablet 2 mg, 4 mg (Gabitril) $0 topiragen oral tablet 00 mg, 200 mg, 25 mg, 50 mg (Topamax) $0 topiramate oral capsule, sprinkle 5 mg, 25 mg (Topamax) $0 topiramate oral capsule,sprinkle,er 24hr 00 mg, 50 mg, 200 mg, 25 (Qudexy XR) $0 mg, 50 mg topiramate oral tablet 00 mg, 200 mg, 25 mg, 50 mg (Topamax) $0 TROKENDI XR ORAL CAPSULE,EXTENDED RELEASE 24HR 00 MG, 200 MG, 25 MG, 50 MG valproate sodium intravenous solution 500 mg/5 ml (00 mg/ml) (Depacon) $0 valproic acid (as sodium salt) oral solution 250 mg/5 ml (Depakene) $0 valproic acid oral capsule 250 mg (Depakene) $0 VIMPAT INTRAVENOUS SOLUTION 200 MG/20 ML ST; QL (20 per 30 days) ST QL (200 per 5 days) 42

57 VIMPAT ORAL SOLUTION 0 MG/ML VIMPAT ORAL TABLET 00 MG, 50 MG, 200 MG, 50 MG zonisamide oral capsule 00 mg, 25 mg, 50 mg Antidementia Agents Antidementia Agents donepezil oral tablet 0 mg, 23 mg, (Zonegran) $0 QL (200 per 30 days) QL (60 per 30 days) QL (30 per 30 days) (Aricept) $0 5 mg donepezil oral tablet,disintegrating QL (30 per 30 days) (Donepezil HCl) $0 0 mg, 5 mg galantamine oral capsule,ext rel. QL (30 per 30 days) (Razadyne ER) $0 pellets 24 hr 6 mg, 24 mg, 8 mg galantamine oral solution 4 mg/ml (Galantamine Hbr) $0 QL (200 per 30 days) galantamine oral tablet 2 mg, 4 QL (60 per 30 days) (Razadyne) $0 mg, 8 mg memantine oral solution 2 mg/ml (Namenda) $0 QL (360 per 30 days) memantine oral tablet 0 mg, 5 mg (Namenda) $0 QL (60 per 30 days) memantine oral tablets,dose pack 5- QL (49 per 28 days) (Namenda) $0 0 mg NAMENDA XR ORAL QL (28 per 28 days) CAP,SPRINKLE,ER 24HR DOSE PACK MG NAMENDA XR ORAL QL (30 per 30 days) CAPSULE,SPRINKLE,ER 24HR 4 MG, 2 MG, 28 MG, 7 MG NAMZARIC ORAL CAPSULE,SPRINKLE,ER 24HR 4-0 MG, 28-0 MG rivastigmine tartrate oral capsule.5 mg, 3 mg, 4.5 mg, 6 mg rivastigmine transdermal patch 24 hour 3.3 mg/24 hour, 4.6 mg/24 hr, 9.5 mg/24 hr Antidepressants Antidepressants (Exelon) $0 (Exelon) $0 QL (60 per 30 days) QL (30 per 30 days) 43

58 amitriptyline oral tablet 0 mg, 00 (Amitriptyline PA NSO-HRM $0 mg, 50 mg, 25 mg, 50 mg, 75 mg HCl) amoxapine oral tablet 00 mg, 50 mg, 25 mg, 50 mg (Amoxapine) $0 BRINTELLIX ORAL TABLET 0 ST MG, 20 MG, 5 MG buproban oral tablet extended release 50 mg (Wellbutrin SR) $0 bupropion hcl (smoking deter) oral tablet extended release 50 mg (Wellbutrin SR) $0 bupropion hcl oral tablet 00 mg, 75 mg (Wellbutrin) $0 bupropion hcl oral tablet extended release 00 mg, 50 mg, 200 mg (Wellbutrin SR) $0 bupropion hcl oral tablet extended release 24 hr 50 mg, 300 mg (Wellbutrin XL) $0 citalopram oral solution 0 mg/5 ml (Citalopram Hydrobromide) $0 citalopram oral tablet 0 mg, 20 QL (30 per 30 days) (Celexa) $0 mg, 40 mg clomipramine oral capsule 25 mg, PA NSO-HRM (Anafranil) $0 50 mg, 75 mg desipramine oral tablet 0 mg, 00 mg, 50 mg, 25 mg, 50 mg, 75 mg (Norpramin) $0 doxepin oral capsule 0 mg, 00 PA NSO-HRM (Doxepin HCl) $0 mg, 50 mg, 25 mg, 50 mg, 75 mg doxepin oral concentrate 0 mg/ml (Doxepin HCl) $0 PA NSO-HRM duloxetine oral capsule,delayed (Cymbalta); QL (60 (Duloxetine) $0 release(dr/ec) 20 mg, 60 mg per 30 days) duloxetine oral capsule,delayed (Cymbalta); QL (30 (Duloxetine) $0 release(dr/ec) 30 mg per 30 days) duloxetine oral capsule,delayed (Irenka); QL (30 per 30 (Duloxetine) $0 release(dr/ec) 40 mg days) EMSAM TRANSDERMAL QL (30 per 30 days) PATCH 24 HOUR 2 MG/24 HR, 6 MG/24 HR, 9 MG/24 HR 44

59 escitalopram oxalate oral solution 5 mg/5 ml (Lexapro) $0 escitalopram oxalate oral tablet 0 mg, 20 mg, 5 mg (Lexapro) $0 FETZIMA ORAL CAPSULE,EXT REL 24HR DOSE PACK 20 MG (2)- 40 MG (26) FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR 20 MG, 20 MG, 40 MG, 80 MG fluoxetine oral capsule 0 mg, 20 mg, 40 mg (Prozac) $0 fluoxetine oral capsule,delayed release(dr/ec) 90 mg (Prozac Weekly) $0 fluoxetine oral solution 20 mg/5 ml (4 mg/ml) (Fluoxetine HCl) $0 fluoxetine oral tablet 0 mg, 20 mg (Fluoxetine HCl) $0 fluvoxamine oral capsule,extended (Fluvoxamine release 24hr 00 mg, 50 mg Maleate) $0 fluvoxamine oral tablet 00 mg, 25 (Fluvoxamine mg, 50 mg Maleate) $0 imipramine hcl oral tablet 0 mg, 25 (Tofranil) mg, 50 mg $0 imipramine pamoate oral capsule 00 mg, 25 mg, 50 mg, 75 mg (Tofranil-Pm) $0 maprotiline oral tablet 25 mg, 50 mg, 75 mg (Maprotiline HCl) $0 MARPLAN ORAL TABLET 0 MG mirtazapine oral tablet 5 mg, 30 mg, 45 mg, 7.5 mg (Remeron) $0 mirtazapine oral tablet,disintegrating 5 mg, 30 mg, (Remeron) $0 45 mg nefazodone oral tablet 00 mg, 50 mg, 200 mg, 250 mg, 50 mg (Nefazodone HCl) $0 ST ST PA NSO-HRM PA NSO-HRM 45

60 nortriptyline oral capsule 0 mg, 25 mg, 50 mg, 75 mg (Pamelor) $0 nortriptyline oral solution 0 mg/5 ml (Nortriptyline HCl) $0 olanzapine-fluoxetine oral capsule 2-25 mg, 2-50 mg, 3-25 mg, 6-25 (Symbyax) $0 mg, 6-50 mg paroxetine hcl oral tablet 0 mg, 20 mg, 30 mg, 40 mg (Paxil) $0 paroxetine hcl oral tablet extended release 24 hr 2.5 mg, 25 mg, 37.5 (Paxil CR) $0 mg PAXIL ORAL SUSPENSION 0 MG/5 ML perphenazine-amitriptyline oral (Perphenazine/Ami tablet 2-0 mg, 2-25 mg, 4-0 mg, triptyline HCl) 4-25 mg, 4-50 mg $0 phenelzine oral tablet 5 mg (Nardil) $0 PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR 00 MG, 25 MG, 50 MG protriptyline oral tablet 0 mg, 5 mg (Protriptyline HCl) $0 sertraline oral concentrate 20 mg/ml (Zoloft) $0 sertraline oral tablet 00 mg, 25 mg, 50 mg (Zoloft) $0 SILENOR ORAL TABLET 3 MG, 6 MG SURMONTIL ORAL CAPSULE 00 MG, 25 MG, 50 MG tranylcypromine oral tablet 0 mg (Parnate) $0 trazodone oral tablet 00 mg, 50 mg, 300 mg, 50 mg (Trazodone HCl) $0 trimipramine oral capsule 00 mg, (Trimipramine 25 mg, 50 mg Maleate) $0 TRINTELLIX ORAL TABLET 0 MG, 20 MG, 5 MG PA NSO-HRM ST; QL (30 per 30 days) QL (30 per 30 days) PA NSO-HRM PA NSO-HRM ST 46

61 venlafaxine oral capsule,extended release 24hr 50 mg, 37.5 mg, 75 mg venlafaxine oral tablet 00 mg, 25 mg, 37.5 mg, 50 mg, 75 mg venlafaxine oral tablet extended release 24hr 50 mg, 37.5 mg, 75 mg VIIBRYD ORAL TABLET 0 MG, 20 MG, 40 MG VIIBRYD ORAL TABLETS,DOSE PACK 0 MG (7)- 20 MG (23), 0 MG (7)-20 MG (7)-40 MG (6) Antidiabetic Agents Antidiabetic Agents, Miscellaneous acarbose oral tablet 00 mg, 25 mg, 50 mg CYCLOSET ORAL TABLET 0.8 MG GLYXAMBI ORAL TABLET 0-5 MG, 25-5 MG INVOKAMET ORAL TABLET 50-,000 MG, MG, 50-,000 MG, MG INVOKANA ORAL TABLET 00 MG, 300 MG JANUMET ORAL TABLET 50-,000 MG, MG JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 00-,000 MG, 50-,000 MG, MG JANUVIA ORAL TABLET 00 MG, 25 MG, 50 MG JARDIANCE ORAL TABLET 0 MG, 25 MG (Effexor XR) $0 (Venlafaxine HCl) $0 (Venlafaxine HCl) $0 (Precose) $0 QL (90 per 30 days) QL (80 per 30 days) ST ST ST ST 47

62 JENTADUETO ORAL TABLET 2.5-,000 MG, MG, MG JENTADUETO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 2.5-,000 MG, 5-,000 MG KORLYM ORAL TABLET 300 PA; QL (2 per 28 days) MG metformin oral tablet,000 mg (Glucophage) $0 QL (75 per 30 days) metformin oral tablet 500 mg (Glucophage) $0 QL (50 per 30 days) metformin oral tablet 850 mg (Glucophage) $0 QL (90 per 30 days) metformin oral tablet extended release 24 hr 500 mg metformin oral tablet extended release 24 hr 750 mg metformin oral tablet extended release 24hr,000 mg metformin oral tablet extended release 24hr 500 mg miglitol oral tablet 00 mg, 25 mg, 50 mg nateglinide oral tablet 20 mg, 60 mg pioglitazone oral tablet 5 mg, 30 mg, 45 mg pioglitazone-glimepiride oral tablet 30-2 mg, 30-4 mg pioglitazone-metformin oral tablet mg, mg repaglinide oral tablet 0.5 mg, mg, 2 mg repaglinide-metformin oral tablet mg, mg SYMLINPEN 20 SUBCUTANEOUS PEN INJECTOR 2,700 MCG/2.7 ML (Glucophage XR) $0 (Glucophage XR) $0 (Fortamet) $0 (Fortamet) $0 (Glyset) $0 (Starlix) $0 (Actos) $0 (Duetact) $0 (Actoplus Met) $0 (Prandin) $0 (Prandimet) $0 QL (20 per 30 days) QL (90 per 30 days) QL (60 per 30 days) QL (50 per 30 days) QL (90 per 30 days) QL (90 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (90 per 30 days) QL (240 per 30 days) QL (50 per 30 days) PA; QL (0.8 per 28 days) 48

63 SYMLINPEN 60 SUBCUTANEOUS PEN INJECTOR,500 MCG/.5 ML SYNJARDY ORAL TABLET 2.5-,000 MG, MG, 5-,000 MG, MG TRADJENTA ORAL TABLET 5 MG TRULICITY SUBCUTANEOUS PEN INJECTOR 0.75 MG/0.5 ML,.5 MG/0.5 ML VICTOZA 3-PAK SUBCUTANEOUS PEN INJECTOR 0.6 MG/0. ML (8 MG/3 ML) Insulins HUMULIN R U-500 (CONC) KWIKPEN SUBCUTANEOUS INSULIN PEN 500 UNIT/ML (3 ML) HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS SOLUTION 500 UNIT/ML LANTUS SOLOSTAR SUBCUTANEOUS INSULIN PEN 00 UNIT/ML (3 ML) LANTUS SUBCUTANEOUS SOLUTION 00 UNIT/ML NOVOLIN 70/30 SUBCUTANEOUS SUSPENSION 00 UNIT/ML (70-30) NOVOLIN N SUBCUTANEOUS SUSPENSION 00 UNIT/ML NOVOLIN R INJECTION SOLUTION 00 UNIT/ML PA; QL (6 per 28 days) ST QL (24 per 28 days) QL (40 per 28 days) QL (40 per 28 days) QL (40 per 28 days) QL (40 per 28 days) 49

64 NOVOLOG FLEXPEN QL (30 per 28 days) SUBCUTANEOUS INSULIN PEN 00 UNIT/ML NOVOLOG MIX FLEXPEN QL (30 per 28 days) SUBCUTANEOUS INSULIN PEN 00 UNIT/ML (70-30) NOVOLOG MIX QL (40 per 28 days) SUBCUTANEOUS SOLUTION 00 UNIT/ML (70-30) NOVOLOG PENFILL QL (30 per 28 days) SUBCUTANEOUS CARTRIDGE 00 UNIT/ML NOVOLOG SUBCUTANEOUS QL (40 per 28 days) SOLUTION 00 UNIT/ML TOUJEO SOLOSTAR SUBCUTANEOUS INSULIN PEN 300 UNIT/ML (.5 ML) Sulfonylureas glimepiride oral tablet mg, 2 mg (Amaryl) $0 QL (30 per 30 days) glimepiride oral tablet 4 mg (Amaryl) $0 QL (60 per 30 days) glipizide oral tablet 0 mg (Glucotrol) $0 QL (20 per 30 days) glipizide oral tablet 5 mg (Glucotrol) $0 QL (60 per 30 days) glipizide oral tablet extended QL (60 per 30 days) (Glucotrol XL) $0 release 24hr 0 mg glipizide oral tablet extended QL (30 per 30 days) (Glucotrol XL) $0 release 24hr 2.5 mg, 5 mg glipizide-metformin oral tablet 2.5- (Glipizide/Metform QL (240 per 30 days) $0 250 mg in HCl) glipizide-metformin oral tablet 2.5- (Glipizide/Metform QL (20 per 30 days) $0 500 mg, mg in HCl) glyburide micronized oral tablet.5 PA-HRM; AGE (Max (Glynase) $0 mg, 3 mg, 6 mg 64 Years) glyburide oral tablet.25 mg, 2.5 PA-HRM; AGE (Max (Glyburide) $0 mg, 5 mg 64 Years) glyburide-metformin oral tablet PA-HRM; AGE (Max (Glucovance) $ mg, mg, mg 64 Years) tolazamide oral tablet 250 mg (Tolazamide) $0 QL (20 per 30 days) 50

65 tolazamide oral tablet 500 mg (Tolazamide) $0 QL (60 per 30 days) tolbutamide oral tablet 500 mg (Tolbutamide) $0 QL (80 per 30 days) Antifungals Antifungals ABELCET INTRAVENOUS SUSPENSION 5 MG/ML aloe vesta 2% antifungal oint 2 % * (Miconazole Nitrate) AMBISOME INTRAVENOUS SUSPENSION FOR RECONSTITUTION 50 MG amphotericin b injection recon soln (Amphotericin B) $0 50 mg anti-fungal % powder % * (Tolnaftate) baza antifungal 2% cream 2's 2 % (Nuzole) * blis-to-sol % liquid % * (Tolnaftate) CANCIDAS INTRAVENOUS RECON SOLN 50 MG, 70 MG ciclopirox topical cream 0.77 % (Loprox) $0 ciclopirox topical gel 0.77 % (Loprox) $0 ciclopirox topical shampoo % (Loprox) $0 ciclopirox topical solution 8 % (Penlac) $0 ciclopirox topical suspension 0.77 (Ciclopirox $0 % Olamine) ciclopirox-ure-camph-menth-euc (Ciclodan) $0 topical solution 8 % clotrim % vaginal cream % * (Gyne-Lotrimin) clotrimazole % cream (otc) % * (Lotrimin AF) clotrimazole % solution (otc) % (Clotrimazole) * clotrimazole insert 00 mg * (Clotrimazole) clotrimazole mucous membrane (Clotrimazole) $0 troche 0 mg clotrimazole topical cream % (Clotrimazole) $0 clotrimazole topical solution % (Clotrimazole) $0 5

66 clotrimazole-7 cream % * (Gyne-Lotrimin) clotrimazole-betamethasone topical cream % (Lotrisone) $0 clotrimazole-betamethasone topical (Clotrimazole/Beta lotion % methasone Dip) $0 critic-aid clear af 2% oint 2's, w/ (Miconazole antifungal 2 % * Nitrate) cvs 3-day vaginal cream 2 % * (Gyne-Lotrimin) cvs af % spray powder % * (Tinactin) cvs miconazole 3 combo pack 3pref (Miconazole applic w/cream 4 % (200 mg)- 2 % Nitrate) (9 gram) * dermafungal 2% ointment 2 % * (Miconazole Nitrate) econazole topical cream % (Econazole Nitrate) $0 elon dual defense 25% solution 25 % * (Undecylenic Acid) fluconazole in dextrose(iso-o) intravenous piggyback 400 mg/200 ml fluconazole in nacl (iso-osm) intravenous piggyback 00 mg/50 ml, 200 mg/00 ml fluconazole oral suspension for reconstitution 0 mg/ml, 40 mg/ml fluconazole oral tablet 00 mg, 50 mg, 200 mg, 50 mg fluconazole-nacl 400 mg/200 ml 0's,latex-free, p/f 400 mg/200 ml flucytosine oral capsule 250 mg, 500 mg (Fluconazole In Nacl,Iso-Osm) (Fluconazole In Nacl,Iso-Osm) $0 $0 (Diflucan) $0 (Diflucan) $0 (Fluconazole In Nacl,Iso-Osm) $0 (Ancobon) $0 fungi cure intensive % spray % * (Clotrimazole) FUNGI-NAIL TINCTURE * fungoid-d % cream % * (Tinactin) gnp miconazole 3 combo pack 4 % (200 mg)- 2 % (9 gram) * (Miconazole Nitrate) 52

67 griseofulvin microsize oral tablet (Grifulvin V) $0 500 mg inzo antifungal 2% cream 2 % * (Nuzole) itraconazole oral capsule 00 mg (Sporanox) $0 ketoconazole oral tablet 200 mg (Ketoconazole) $0 ketoconazole topical cream 2 % (Ketoconazole) $0 ketoconazole topical shampoo 2 % (Nizoral) $0 lamisil af defens % spray pwd % (Tinactin) * lamisil af defense % powder % * (Tolnaftate) LAMISIL ANTIFUNGAL % SPRAY FOR ATHLETES FOOT % * LAMISIL AT % GEL % * micatin 2% antifungal cream 2 % * (Nuzole) miconazole 3 combo pack 3 sup,9gm (Monistat 3) crm w/app 200 mg- 2 % (9 gram) * miconazole 7 00 mg vag supp 00 (Miconazole mg * Nitrate) miconazole nitrate 2% cream 2 % * (Nuzole) (Miconazole miconazole nitrate 2% cream 2 % * Nitrate) miconazole-3 vaginal suppository (Miconazole $0 200 mg Nitrate) MONISTAT 3 COMBO PACK 3 SUPP, 9 GM CREAM 200 MG- 2 % (9 GRAM) * MONISTAT 3 COMBO PACK 4 % (200 MG)- 2 % (9 GRAM) * monistat 7 cream 7 applicators 2 % (Miconazole * Nitrate) myco nail a 25% solution 25 % * (Undecylenic Acid) NOXAFIL ORAL SUSPENSION 200 MG/5 ML (40 MG/ML) NOXAFIL ORAL TABLET,DELAYED RELEASE (DR/EC) 00 MG 53

68 nyamyc topical powder 00,000 (Nystatin) $0 unit/gram nystatin oral suspension 00,000 (Nystatin) $0 unit/ml nystatin oral tablet 500,000 unit (Nystatin) $0 nystatin topical cream 00,000 (Nystatin) $0 unit/gram nystatin topical ointment 00,000 (Nystatin) $0 unit/gram nystatin topical powder 00,000 (Nystatin) $0 unit/gram nystatin-triamcinolone topical (Nystatin/Triamcin $0 cream 00, unit/g-% ) nystatin-triamcinolone topical (Nystatin/Triamcin $0 ointment 00, unit/gram-% ) nystop topical powder 00,000 (Nystatin) $0 unit/gram pv foot odor control % powder % (Tinactin) * qc 3 day vaginal 4% cream 200 (Miconazole mg/5 gram (4 %) * Nitrate) ra antifungal % liquid spray liquid (Tolnaftate) spray % * remedy phytplx antifungal oint 2 % (Miconazole * Nitrate) terbinafine % cream % * (Lamisil At) terbinafine hcl oral tablet 250 mg (Lamisil) $0 tolnaftate % cream % * (Tinactin) tolnaftate % solution % * (Tolnaftate) (Miconazole triple paste af 2% ointment 2 % * Nitrate) voriconazole intravenous solution (Vfend IV) $0 200 mg voriconazole oral suspension for reconstitution 200 mg/5 ml (40 (Vfend) $0 mg/ml) 54

69 voriconazole oral tablet 200 mg, 50 mg Antihistamines Antihistamines alavert 0 mg odt non-drowsy, mint 0 mg * alavert d-2 allergy-sinus tab 5-20 mg * ALLEGRA ALLERGY 80 MG TABLET 80 MG * ALLEGRA ALLERGY 60 MG TABLET 60 MG * aller-chlor 2 mg/5 ml syrup 2 mg/5 ml * (Vfend) $0 (Claritin) (Claritin-D 2 Hour) (Chlorpheniramine Maleate) aller-chlor 4 mg tablet 4 mg * (Chlor-Trimeton) allerclear d-2hr tablet 5-20 mg * (Claritin-D 2 Hour) allerclear d-24hr er tablet nondrowsy mg * Hour) (Claritin-D 24 allergy 4 mg tablet 4 mg * (Chlor-Trimeton) allerhist-.34 mg tablet.34 mg * (Clemastine Fumarate) aller-tec d 5-20 mg tablet 5-20 mg * (Zyrtec-D) ambi 60pse-4cpm tablet 4-60 mg * (Chlorpheniramine/ Pseudoephed) aprodine tablet mg * (Triprolidine/Pseud oephedrine) banophen 25 mg capsule 25 mg * (Zzzquil) banophen 25 mg tablet 25 mg * (Diphenhydramine HCl) banophen allergy 2.5 mg/5 ml a/f 2.5 mg/5 ml * (Zzzquil) benadryl allergy 25 mg ultratb (Diphenhydramine ultratab 25 mg * HCl) cetirizine hcl mg/ ml soln children, s/f, grape (otc) mg/ml * (Children'S Zyrtec) 55

70 cetirizine hcl 0 mg tablet indoor & outdoor 0 mg * cetirizine hcl 5 mg chew tab children's,outer,u-d 5 mg * cetirizine-pse er 5-20 mg tab 5-20 mg * child allegra allergy 30 mg/5 ml suspension 30 mg/5 ml * CHILD CLARITIN 5 MG/5 ML SOLN A/F,D/F,S/F,GRAPE 5 MG/5 ML * child triaminic cold & allergy -2.5 mg/5 ml * child wal-tap cold-allergy elx -2.5 mg/5 ml * CHILD ZYRTEC MG/ML SOLUTION D/F,S/F,GRAPE MG/ML * children's allegra allergy oral tablet 30 mg * CHILDREN'S ZYRTEC 0 MG ODT 0 MG * child's aller-tec mg/ml soln mg/ml * CHILD'S CLARITIN 5 MG TAB CHEW 5 MG * child's wal-dryl 2.5 mg/5 ml a/f,s/f,d/f,bubb gum 2.5 mg/5 ml * child's wal-zyr 0 mg chew tab 0 mg * CLARITIN 0 MG LIQUI-GEL CAP 0 MG * CLARITIN 0 MG REDITABS 0 MG * CLARITIN 0 MG TABLET (OTC) 0 MG * (Zyrtec) (Zyrtec) (Zyrtec-D) (Fexofenadine HCl) (Dimetapp) (Dimetapp) (Allegra Allergy) (Children'S Zyrtec) (Zzzquil) (Zyrtec) 56

71 CLARITIN 5 MG REDITABS 5 MG * cold-allergy-sinus oral tablet mg * compoz 25 mg gelcap 25 mg * cvs allergy 25 mg tablet 25 mg * cvs allergy relief 0 mg sftgl 0 mg * cvs child allergy 0 mg chw tb 24 hr,indoor/outdoor 0 mg * cvs cold & cough nighttime liq mg/5 ml * cyproheptadine oral syrup 2 mg/5 ml cyproheptadine oral tablet 4 mg dailyhist-.34 mg tablet.34 mg * dayhist allergy.34 mg tablet 2 hr relief.34 mg * dimaphen elixir a/f, grape, gluten-f -2.5 mg/5 ml * dimetapp cold & congest liquid mg/5 ml * (Triprolidine/Pseud oephedrine) (Diphenhydramine HCl) (Diphenhydramine HCl) (Zyrtec) (Zyrtec) (Triaminic Nighttime Cold- Cough) (Cyproheptadine HCl) (Cyproheptadine HCl) (Clemastine Fumarate) (Clemastine Fumarate) $0 $0 (Dimetapp) (Triaminic Nighttime Cold- Cough) diphenhist 2.5 mg/5 ml soln 2.5 mg/5 ml * (Zzzquil) diphenhist 25 mg capsule 25 mg * (Zzzquil) diphenhist 25 mg captab captab 25 (Diphenhydramine mg * HCl) diphenhydramine 25 mg capsule (otc) 25 mg * (Zzzquil) diphenhydramine 50 mg capsule (otc) 50 mg * (Zzzquil) 57

72 diphenhydramine 50 mg tablet 50 (Diphenhydramine mg * HCl) diphenhydramine hcl injection (Diphenhydramine $0 solution 50 mg/ml HCl) (Chlorpheniramine ed chlorped jr syrup 2 mg/5 ml * Maleate) ed-a-hist 4 mg-0 mg tablet 4-0 mg (Chlorpheniramine/ * Phenylephrine) fexofenadine hcl 80 mg tablet (Allegra Allergy) 24hr,original str (otc) 80 mg * fexofenadine hcl 30 mg/5 ml 30 (Fexofenadine mg/5 ml * HCl) fexofenadine hcl 60 mg tablet (Allegra Allergy) indoor/outdoor (otc) 60 mg * hm z-sleep 25 mg softgel 25 mg * (Zzzquil) levocetirizine oral solution 2.5 mg/5 (Xyzal) $0 ml levocetirizine oral tablet 5 mg (Xyzal) $0 loratadine 0 mg tablet 0 mg * (Claritin) loratadine allergy 5 mg/5 ml d/f, a/f, (Children'S s/f 5 mg/5 ml * Claritin) loratadine-d 2 hour tablet nondrowsy 5-20 mg * Hour) (Claritin-D 2 loratadine-d 24hr tablet mg (Claritin-D 24 * Hour) $0 q-dryl 2.5 mg/5 ml liquid a/f 2.5 (Zzzquil) mg/5 ml * ra sleep aid 50 mg/30 ml liq 50 (Zzzquil) mg/30 ml * siladryl 2.5 mg/5 ml liquid 2.5 (Zzzquil) mg/5 ml * promethazine oral syrup 6.25 mg/5 pv nyt-time sleep 25 mg caplet 25 simply sleep 25 mg caplet caplet 25 (Promethazine (Diphenhydramine (Diphenhydramine ml mg * mg * HCl) HCl) HCl) PA-HRM; AGE (Max 64 Years) 58

73 (Doxylamine sleep aid 25 mg tablet 25 mg * Succinate) sm allergy relief.34 mg tab.34 (Clemastine mg * Fumarate) sm sinus and allergy tablet (Chlorpheniramine/ maximum strength 4-60 mg * Pseudoephed) sm z-sleep 50 mg/30 ml liquid (Zzzquil) berry,gluten-free 50 mg/30 ml * sudogest sinus & allergy tab 4-60 (Chlorpheniramine/ mg * Pseudoephed) TRIAMINIC NIGHTTIME COLD- COUGH CHILDREN'S, GRAPE MG/5 ML * unisom 50 mg sleepgels softgel 50 (Zzzquil) mg * wal-act d cold & allergy tab (Triprolidine/Pseud mg * oephedrine) wal-dryl allergy 25 mg capsule 25 (Zzzquil) mg * wal-dryl allergy 25 mg minitab (Diphenhydramine minitab, coated 25 mg * HCl) wal-fex allergy 80 mg tablet 80 (Allegra Allergy) mg * wal-fex allergy 60 mg tablet 60 mg * (Allegra Allergy) wal-finate 4 mg tablet 4 mg * (Chlor-Trimeton) (Chlorpheniramine/ wal-finate-d tablet 4-60 mg * Pseudoephed) wal-itin 0 mg odt non-drowsy 0 (Claritin) mg * wal-itin 0 mg tablet non-drowsy 0 (Claritin) mg * wal-itin 5 mg/5 ml syrup children's, (Children'S grape 5 mg/5 ml * Claritin) (Claritin-D 2 wal-itin d 2 hour tablet 5-20 mg * Hour) wal-itin d 24 hour tablet mg (Claritin-D 24 * Hour) 59

74 wal-phed pe sinus-allergy tab 4-0 (Chlorpheniramine/ mg * Phenylephrine) wal-phed sinus and allergy tab 4-60 (Chlorpheniramine/ mg * Pseudoephed) wal-sleep z 25 mg odt 25 mg * (Unisom Sleepmelts) wal-sleep z 25 mg softgel 25 mg * (Zzzquil) wal-sleep z 50 mg/30 ml liquid berry, a/f, d/f, s/f 50 mg/30 ml * (Zzzquil) wal-som 25 mg tablet 25 mg * (Doxylamine Succinate) wal-som 50 mg softgel softgel 50 mg * (Zzzquil) wal-tap elixir -2.5 mg/5 ml * (Dimetapp) wal-zyr 0 mg tablet 0 mg * (Zyrtec) wal-zyr d tablet 2 hr 5-20 mg * (Zyrtec-D) wal-zyr solution children's, a/f mg/ml * (Children'S Zyrtec) ZYRTEC 0 MG LIQUID GELS 0 MG * ZYRTEC 0 MG ODT 0 MG * ZYRTEC 0 MG TABLET INDOOR/OUTDOOR 24 HR (OTC) 0 MG * Anti-Infectives (Skin And Mucous Membrane) Anti-Infectives (Skin And Mucous Membrane) ABREVA 0% CREAM 0 % * AVC VAGINAL VAGINAL CREAM 5 % clindamycin phosphate vaginal cream 2 % (Cleocin) $0 metronidazole vaginal gel 0.75 % (Metrogel-Vaginal) $0 terconazole vaginal cream 0.4 %, 0.8 % (Terazol 7) $0 60

75 terconazole vaginal suppository 80 mg Antimigraine Agents Antimigraine Agents dihydroergotamine injection (Terconazole) $0 QL (30 per 28 days) (D.H.E.45) $0 solution mg/ml dihydroergotamine nasal spray,nonaerosol 0.5 mg/pump act. (4 mg/ml) QL (8 per 28 days) (Migranal) $0 ERGOMAR SUBLINGUAL QL (40 per 28 days) TABLET 2 MG naratriptan oral tablet mg, 2.5 mg (Amerge) $0 QL (8 per 28 days) rizatriptan oral tablet 0 mg, 5 mg (Maxalt) $0 QL (8 per 28 days) rizatriptan oral tablet,disintegrating QL (8 per 28 days) (Maxalt Mlt) $0 0 mg, 5 mg sumatriptan 6 mg/0.5 ml syrng (Sumatriptan QL (4 per 28 days) $0 p/f,dehp/f,pvc/f 6 mg/0.5 ml Succinate) sumatriptan nasal spray,nonaerosol 20 mg/actuation, 5 (Imitrex) $0 QL (2 per 28 days) mg/actuation sumatriptan succinate oral tablet QL (8 per 28 days) (Imitrex) $0 00 mg, 25 mg, 50 mg sumatriptan succinate subcutaneous (Sumatriptan QL (4 per 28 days) $0 cartridge 4 mg/0.5 ml Succinate) sumatriptan succinate subcutaneous QL (4 per 28 days) (Imitrex) $0 cartridge 6 mg/0.5 ml sumatriptan succinate subcutaneous (Sumatriptan QL (4 per 28 days) $0 pen injector 4 mg/0.5 ml Succinate) sumatriptan succinate subcutaneous QL (4 per 28 days) (Sumatriptan pen injector 6 mg/0.5 ml, 6 mg/0.5 $0 Succinate) ml (auto-injector) sumatriptan succinate subcutaneous QL (4 per 28 days) (Imitrex) $0 solution 6 mg/0.5 ml zolmitriptan oral tablet 2.5 mg, 5 QL (2 per 28 days) (Zomig) $0 mg zolmitriptan oral QL (2 per 28 days) (Zomig Zmt) $0 tablet,disintegrating 2.5 mg, 5 mg Antimycobacterials 6

76 Antimycobacterials CAPASTAT INJECTION RECON SOLN GRAM dapsone oral tablet 00 mg, 25 mg (Dapsone) $0 ethambutol oral tablet 00 mg, 400 mg (Myambutol) $0 isoniazid oral solution 50 mg/5 ml (Isoniazid) $0 isoniazid oral tablet 00 mg, 300 mg (Isoniazid) $0 PASER ORAL GRANULES DR FOR SUSP IN PACKET 4 GRAM PRIFTIN ORAL TABLET 50 MG pyrazinamide oral tablet 500 mg (Pyrazinamide) $0 rifabutin oral capsule 50 mg (Mycobutin) $0 rifampin intravenous recon soln 600 mg (Rifadin) $0 rifampin oral capsule 50 mg, 300 mg (Rifadin) $0 RIFATER ORAL TABLET MG SIRTURO ORAL TABLET 00 MG TRECATOR ORAL TABLET 250 MG Antinausea Agents Antinausea Agents AKYNZEO ORAL CAPSULE 300- PA; QL (88 per 68 days) 0.5 MG compro rectal suppository 25 mg (Compazine) $0 cvs motion sickness 50 mg tab 50 mg * (Dimenhydrinate) dimenhydrinate injection solution 50 (Dimenhydrinate) mg/ml $0 dramamine 50 mg tablet 50 mg * (Dimenhydrinate) dramamine less drowsy 25 mg tb 25 mg * (Meclizine HCl) driminate 50 mg tablet 50 mg * (Dimenhydrinate) 62

77 dronabinol oral capsule 0 mg, 2.5 mg, 5 mg (Marinol) $0 EMEND INTRAVENOUS RECON QL (2 per 28 days) SOLN 50 MG EMEND ORAL CAPSULE 25 MG, 80 MG EMEND ORAL CAPSULE 40 MG EMEND ORAL CAPSULE,DOSE PACK 25 MG ()- 80 MG (2) EMEND ORAL SUSPENSION FOR RECONSTITUTION 25 MG (25 MG/ ML FINAL CONC.) granisetron (pf) intravenous (Granisetron solution 00 mcg/ml HCl/PF) $0 granisetron hcl intravenous solution mg/ml ( ml) (Granisetron HCl) $0 granisetron hcl oral tablet mg (Granisetron HCl) $0 meclizine 2.5 mg caplet caplet (otc) 2.5 mg * (Meclizine HCl) meclizine 25 mg tablet (otc) 25 mg * (Meclizine HCl) meclizine oral tablet 2.5 mg, 25 mg (Meclizine HCl) $0 motion sickness 25 mg tablet 25 mg * (Meclizine HCl) ondansetron hcl (pf) injection (Ondansetron solution 4 mg/2 ml HCl/PF) $0 ondansetron hcl (pf) injection (Ondansetron syringe 4 mg/2 ml HCl/PF) $0 ondansetron hcl oral solution 4 (Zofran) $0 mg/5 ml ondansetron hcl oral tablet 24 mg, 4 (Zofran) $0 mg, 8 mg ondansetron oral (Zofran Odt) $0 tablet,disintegrating 4 mg, 8 mg phenadoz rectal suppository 2.5 PA-HRM; AGE (Max (Phenergan) $0 mg, 25 mg 64 Years) prochlorperazine edisylate injection (Prochlorperazine solution 0 mg/2 ml (5 mg/ml) Edisylate) $0 63

78 prochlorperazine maleate oral tablet 0 mg, 5 mg prochlorperazine rectal suppository 25 mg promethazine oral tablet 2.5 mg, 25 mg, 50 mg promethazine rectal suppository 2.5 mg, 25 mg, 50 mg promethegan rectal suppository 2.5 mg, 25 mg, 50 mg TRANSDERM-SCOP TRANSDERMAL PATCH 3 DAY.5 MG ( MG OVER 3 DAYS) travel sickness 25 mg tab chew 25 mg * (Compazine) $0 (Compazine) $0 (Promethazine HCl) $0 (Phenergan) $0 (Phenergan) $0 (Bonine) wal-dram 50 mg tablet 50 mg * (Dimenhydrinate) Antiparasite Agents Antiparasite Agents ALBENZA ORAL TABLET 200 MG ALINIA ORAL SUSPENSION FOR RECONSTITUTION 00 MG/5 ML ALINIA ORAL TABLET 500 MG atovaquone oral suspension 750 mg/5 ml (Mepron) $0 atovaquone-proguanil oral tablet mg, mg (Malarone) $0 chloroquine phosphate oral tablet (Chloroquine 250 mg, 500 mg Phosphate) $0 COARTEM ORAL TABLET MG DARAPRIM ORAL TABLET 25 MG EMVERM ORAL TABLET,CHEWABLE 00 MG $0 PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) QL (0 per 30 days) QL (6 per 2 days) 64

79 hydroxychloroquine oral tablet 200 mg (Plaquenil) $0 ivermectin oral tablet 3 mg (Stromectol) $0 mefloquine oral tablet 250 mg (Mefloquine HCl) $0 NEBUPENT INHALATION RECON SOLN 300 MG paromomycin oral capsule 250 mg (Paromomycin Sulfate) $0 PENTAM INJECTION RECON SOLN 300 MG PRIMAQUINE ORAL TABLET 26.3 MG QL (90 per 30 days) quinine sulfate oral capsule 324 mg (Qualaquin) $0 PA; QL (42 per 7 days) Antiparkinsonian Agents Antiparkinsonian Agents amantadine hcl oral capsule 00 mg (Amantadine HCl) $0 amantadine hcl oral solution 50 mg/5 ml (Amantadine HCl) $0 amantadine hcl oral tablet 00 mg (Amantadine HCl) $0 APOKYN SUBCUTANEOUS CARTRIDGE 0 MG/ML AZILECT ORAL TABLET 0.5 MG, MG benztropine oral tablet 0.5 mg, (Benztropine mg, 2 mg Mesylate) $0 bromocriptine oral capsule 5 mg (Parlodel) $0 bromocriptine oral tablet 2.5 mg (Parlodel) $0 cabergoline oral tablet 0.5 mg (Cabergoline) $0 carbidopa oral tablet 25 mg (Lodosyn) $0 carbidopa-levodopa oral tablet 0-00 mg, mg, mg carbidopa-levodopa oral tablet extended release mg, mg (Sinemet CR) $0 (Sinemet CR) $0 QL (60 per 30 days) PA-HRM; AGE (Max 64 Years) 65

80 carbidopa-levodopa-entacapone oral tablet mg, mg, mg, mg, mg, mg (Stalevo 50) $0 entacapone oral tablet 200 mg (Comtan) $0 NEUPRO TRANSDERMAL PATCH 24 HOUR MG/24 HOUR, 2 MG/24 HOUR, 3 MG/24 HOUR, 4 MG/24 HOUR, 6 MG/24 HOUR, 8 MG/24 HOUR pramipexole oral tablet 0.25 mg, 0.25 mg, 0.5 mg, 0.75 mg, mg,.5 mg (Mirapex) $0 ropinirole oral tablet 0.25 mg, 0.5 mg, mg, 2 mg, 3 mg, 4 mg, 5 mg (Requip) $0 ropinirole oral tablet extended release 24 hr 2 mg, 2 mg, 4 mg, 6 (Requip XL) $0 mg, 8 mg selegiline hcl oral capsule 5 mg (Eldepryl) $0 selegiline hcl oral tablet 5 mg (Selegiline HCl) $0 trihexyphenidyl oral elixir 0.4 mg/ml (Trihexyphenidyl HCl) $0 trihexyphenidyl oral tablet 2 mg, 5 (Trihexyphenidyl mg HCl) $0 Antipsychotic Agents Antipsychotic Agents ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 300 MG ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 400 MG PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) QL ( per 28 days) 66

81 ABILIFY MAINTENA QL ( per 28 days) INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 300 MG, 400 MG aripiprazole oral solution mg/ml (Abilify) $0 QL (900 per 30 days) aripiprazole oral tablet 0 mg, 5 QL (30 per 30 days) (Abilify) $0 mg, 20 mg, 30 mg, 5 mg aripiprazole oral tablet 2 mg (Abilify) $0 QL (60 per 30 days) aripiprazole oral QL (90 per 30 days) (Abilify Discmelt) $0 tablet,disintegrating 0 mg aripiprazole oral QL (60 per 30 days) (Abilify Discmelt) $0 tablet,disintegrating 5 mg ARISTADA INTRAMUSCULAR QL (.6 per 28 days) SUSPENSION,EXTENDED REL SYRING 44 MG/.6 ML ARISTADA INTRAMUSCULAR QL (2.4 per 28 days) SUSPENSION,EXTENDED REL SYRING 662 MG/2.4 ML ARISTADA INTRAMUSCULAR QL (3.2 per 28 days) SUSPENSION,EXTENDED REL SYRING 882 MG/3.2 ML chlorpromazine injection solution (Chlorpromazine 25 mg/ml HCl) $0 chlorpromazine oral tablet 0 mg, (Chlorpromazine 00 mg, 200 mg, 25 mg, 50 mg HCl) $0 clozapine oral tablet 00 mg (Clozaril) $0 QL (270 per 30 days) clozapine oral tablet 200 mg (Clozaril) $0 QL (35 per 30 days) clozapine oral tablet 25 mg, 50 mg (Clozaril) $0 QL (90 per 30 days) clozapine oral tablet,disintegrating 00 mg, 2.5 mg, 50 mg, 200 mg, (Fazaclo) $0 ST 25 mg FANAPT ORAL TABLET MG, 0 MG, 2 MG, 2 MG, 4 MG, 6 MG, 8 MG FANAPT ORAL TABLETS,DOSE PACK MG(2)-2MG(2)- 4MG(2)- 6MG(2) ST; QL (60 per 30 days) ST; QL (8 per 28 days) 67

82 fluphenazine decanoate injection solution 25 mg/ml fluphenazine hcl injection solution 2.5 mg/ml fluphenazine hcl oral concentrate 5 mg/ml fluphenazine hcl oral elixir 2.5 mg/5 ml fluphenazine hcl oral tablet mg, 0 mg, 2.5 mg, 5 mg GEODON INTRAMUSCULAR RECON SOLN 20 MG/ML (FINAL CONC.) haloperidol decanoate intramuscular solution 00 mg/ml haloperidol decanoate intramuscular solution 50 mg/ml haloperidol lactate injection solution 5 mg/ml haloperidol lactate oral concentrate 2 mg/ml haloperidol oral tablet 0.5 mg, mg, 0 mg, 2 mg, 20 mg, 5 mg INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 7 MG/0.75 ML, 56 MG/ML, 234 MG/.5 ML, 39 MG/0.25 ML, 78 MG/0.5 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 273 MG/0.875 ML, 40 MG/.35 ML, 546 MG/.75 ML, 89 MG/2.625 ML LATUDA ORAL TABLET 20 MG, 20 MG, 40 MG, 60 MG, 80 MG (Fluphenazine Decanoate) (Fluphenazine HCl) (Fluphenazine HCl) (Fluphenazine HCl) (Fluphenazine HCl) (Haloperidol Decanoate) (Haldol Decanoate 50) (Haloperidol Lactate) (Haloperidol Lactate) $0 $0 $0 $0 $0 $0 $0 $0 $0 (Haloperidol) $0 QL (6 per 28 days) loxapine succinate oral capsule 0 (Loxapine $0 mg, 25 mg, 5 mg, 50 mg Succinate) 68

83 molindone oral tablet 0 mg (Molindone HCl) $0 QL (240 per 30 days) molindone oral tablet 25 mg (Molindone HCl) $0 QL (270 per 30 days) molindone oral tablet 5 mg (Molindone HCl) $0 QL (20 per 30 days) NUPLAZID ORAL TABLET 7 PA NSO; QL (60 per MG 30 days) olanzapine intramuscular recon soln QL (30 per 30 days) (Zyprexa) $0 0 mg olanzapine oral tablet 0 mg, 5 QL (30 per 30 days) (Zyprexa) $0 mg, 2.5 mg, 20 mg, 5 mg, 7.5 mg olanzapine oral tablet,disintegrating QL (30 per 30 days) (Zyprexa Zydis) $0 0 mg, 5 mg, 5 mg olanzapine oral tablet,disintegrating QL (3 per 30 days) (Zyprexa Zydis) $0 20 mg paliperidone oral tablet extended QL (30 per 30 days) (Invega) $0 release 24hr.5 mg, 3 mg, 9 mg paliperidone oral tablet extended QL (60 per 30 days) (Invega) $0 release 24hr 6 mg perphenazine oral tablet 6 mg, 2 mg, 4 mg, 8 mg (Perphenazine) $0 pimozide oral tablet mg, 2 mg (Orap) $0 quetiapine oral tablet 00 mg, 200 QL (90 per 30 days) (Seroquel) $0 mg, 25 mg, 300 mg, 400 mg, 50 mg REXULTI ORAL TABLET 0.25 QL (20 per 30 days) MG REXULTI ORAL TABLET 0.5 MG QL (60 per 30 days) REXULTI ORAL TABLET MG, QL (30 per 30 days) 2 MG, 3 MG, 4 MG RISPERDAL CONSTA QL (4 per 28 days) INTRAMUSCULAR SYRINGE 2.5 MG/2 ML, 25 MG/2 ML, 37.5 MG/2 ML, 50 MG/2 ML risperidone oral solution mg/ml (Risperdal) $0 QL (480 per 30 days) risperidone oral tablet 0.25 mg, 0.5 QL (60 per 30 days) (Risperdal) $0 mg, mg, 2 mg, 3 mg, 4 mg risperidone oral QL (60 per 30 days) tablet,disintegrating 0.25 mg, 0.5 mg, mg, 2 mg (Risperdal M-Tab) $0 69

84 risperidone oral tablet,disintegrating 3 mg, 4 mg SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 0 MG, 2.5 MG, 5 MG thioridazine oral tablet 0 mg, 00 mg, 25 mg, 50 mg thiothixene oral capsule mg, 0 mg, 2 mg, 5 mg trifluoperazine oral tablet mg, 0 mg, 2 mg, 5 mg VERSACLOZ ORAL SUSPENSION 50 MG/ML VRAYLAR ORAL CAPSULE.5 MG, 3 MG, 4.5 MG, 6 MG VRAYLAR ORAL CAPSULE,DOSE PACK.5 MG ()- 3 MG (6) ziprasidone hcl oral capsule 20 mg, 40 mg, 60 mg, 80 mg ZYPREXA RELPREVV 405 MG VL KIT W/ DILUENT, OUTER 405 MG ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 20 MG (Risperdal M-Tab) $0 (Thioridazine HCl) $0 (Thiothixene) $0 (Trifluoperazine HCl) $0 (Geodon) $0 Antivirals (Systemic) Antiretrovirals abacavir oral tablet 300 mg (Ziagen) $0 abacavir-lamivudine-zidovudine oral tablet mg APTIVUS ORAL CAPSULE 250 MG APTIVUS ORAL SOLUTION 00 MG/ML (Trizivir) $0 QL (20 per 30 days) ST; QL (60 per 30 days) PA NSO-HRM ST; QL (540 per 30 days) QL (30 per 30 days) QL (7 per 30 days) QL (60 per 30 days) 70

85 ATRIPLA ORAL TABLET MG COMPLERA ORAL TABLET MG CRIXIVAN ORAL CAPSULE 200 MG, 400 MG DESCOVY ORAL TABLET MG didanosine oral capsule,delayed release(dr/ec) 25 mg, 200 mg, 250 mg, 400 mg EDURANT ORAL TABLET 25 MG EMTRIVA ORAL CAPSULE 200 MG EMTRIVA ORAL SOLUTION 0 MG/ML EPIVIR HBV ORAL SOLUTION 25 MG/5 ML (5 MG/ML) EPZICOM ORAL TABLET MG EVOTAZ ORAL TABLET MG FUZEON SUBCUTANEOUS RECON SOLN 90 MG GENVOYA ORAL TABLET MG INTELENCE ORAL TABLET 00 MG, 200 MG, 25 MG INVIRASE ORAL CAPSULE 200 MG INVIRASE ORAL TABLET 500 MG ISENTRESS ORAL POWDER IN PACKET 00 MG ISENTRESS ORAL TABLET 400 MG (Videx EC) $0 7

86 ISENTRESS ORAL TABLET,CHEWABLE 00 MG, 25 MG KALETRA ORAL SOLUTION MG/5 ML KALETRA ORAL TABLET MG, MG lamivudine oral solution 0 mg/ml (Epivir) $0 lamivudine oral tablet 00 mg, 50 mg, 300 mg (Epivir) $0 lamivudine-zidovudine oral tablet mg (Combivir) $0 LEXIVA ORAL SUSPENSION 50 MG/ML LEXIVA ORAL TABLET 700 MG nevirapine oral suspension 50 mg/5 ml (Viramune) $0 nevirapine oral tablet 200 mg (Viramune) $0 nevirapine oral tablet extended release 24 hr 00 mg, 400 mg (Viramune XR) $0 NORVIR ORAL CAPSULE 00 MG NORVIR ORAL SOLUTION 80 MG/ML NORVIR ORAL TABLET 00 MG ODEFSEY ORAL TABLET MG PREZCOBIX ORAL TABLET MG-MG PREZISTA ORAL SUSPENSION 00 MG/ML PREZISTA ORAL TABLET 50 MG, 400 MG, 600 MG, 75 MG, 800 MG RESCRIPTOR ORAL TABLET 200 MG 72

87 RESCRIPTOR ORAL TABLET, DISPERSIBLE 00 MG RETROVIR INTRAVENOUS SOLUTION 0 MG/ML REYATAZ ORAL CAPSULE 50 MG, 200 MG, 300 MG REYATAZ ORAL POWDER IN PACKET 50 MG SELZENTRY ORAL TABLET 50 MG, 300 MG stavudine oral capsule 5 mg, 20 mg, 30 mg, 40 mg (Zerit) $0 stavudine oral recon soln mg/ml (Zerit) $0 STRIBILD ORAL TABLET MG SUSTIVA ORAL CAPSULE 200 MG, 50 MG SUSTIVA ORAL TABLET 600 MG TIVICAY ORAL TABLET 0 MG, 25 MG, 50 MG TRIUMEQ ORAL TABLET MG TRUVADA ORAL TABLET MG, MG, MG, MG VIDEX 2 GRAM PEDIATRIC ORAL RECON SOLN 0 MG/ML (FINAL) VIDEX 4 GM PEDIATRIC SOLN 0 MG/ML (FINAL) VIRACEPT ORAL TABLET 250 MG, 625 MG VIRAMUNE XR ORAL TABLET EXTENDED RELEASE 24 HR 00 MG 73

88 VIREAD ORAL POWDER 40 MG/SCOOP (40 MG/GRAM) VIREAD ORAL TABLET 50 MG, 200 MG, 250 MG, 300 MG VITEKTA ORAL TABLET 50 MG, 85 MG ZIAGEN ORAL SOLUTION 20 MG/ML zidovudine oral capsule 00 mg (Retrovir) $0 zidovudine oral syrup 0 mg/ml (Retrovir) $0 zidovudine oral tablet 300 mg (Zidovudine) $0 Antivirals, Miscellaneous foscarnet intravenous solution 24 mg/ml (Foscavir) $0 RELENZA DISKHALER INHALATION BLISTER WITH DEVICE 5 MG/ACTUATION rimantadine oral tablet 00 mg (Flumadine) $0 SYNAGIS 00 MG/ ML VIAL 00 MG/ML SYNAGIS INTRAMUSCULAR SOLUTION 50 MG/0.5 ML TAMIFLU ORAL CAPSULE 30 MG TAMIFLU ORAL CAPSULE 45 MG TAMIFLU ORAL CAPSULE 75 MG TAMIFLU ORAL SUSPENSION FOR RECONSTITUTION 6 MG/ML Hcv Antivirals DAKLINZA ORAL TABLET 30 MG, 60 MG, 90 MG EPCLUSA ORAL TABLET MG QL (84 per 80 days) QL (48 per 80 days) QL (42 per 80 days) QL (540 per 80 days) PA; QL (28 per 28 days) PA; QL (28 per 28 days) 74

89 HARVONI ORAL TABLET MG OLYSIO ORAL CAPSULE 50 MG SOVALDI ORAL TABLET 400 MG TECHNIVIE ORAL TABLET MG VIEKIRA PAK ORAL TABLETS,DOSE PACK 2.5 MG- 75 MG -50 MG/250 MG VIEKIRA XR ORAL TABLET, IR - ER, BIPHASIC 24HR 8.33 MG- 50 MG MG-200 MG ZEPATIER ORAL TABLET MG Interferons INTRON A 25 MILLION UNIT/2.5 ML 0 MILLION UNIT/ML INTRON A INJECTION RECON SOLN 0 MILLION UNIT ( ML) INTRON A INJECTION RECON SOLN 8 MILLION UNIT ( ML), 50 MILLION UNIT ( ML) INTRON A INJECTION SOLUTION 6 MILLION UNIT/ML PEGASYS PROCLICK SUBCUTANEOUS PEN INJECTOR 35 MCG/0.5 ML, 80 MCG/0.5 ML PEGASYS SUBCUTANEOUS SOLUTION 80 MCG/ML PEGASYS SUBCUTANEOUS SYRINGE 80 MCG/0.5 ML PEGINTRON SUBCUTANEOUS KIT 20 MCG/0.5 ML, 50 MCG/0.5 ML, 50 MCG/0.5 ML, 80 MCG/0.5 ML PA; QL (30 per 30 days) PA; QL (28 per 28 days) PA; QL (28 per 28 days) PA; QL (56 per 28 days) PA; QL (2 per 28 days) PA; QL (84 per 28 days) PA; QL (30 per 30 days) PA NSO PA NSO PA NSO PA NSO PA PA PA PA 75

90 SYLATRON SUBCUTANEOUS KIT 200 MCG, 300 MCG, 600 MCG Nucleosides And Nucleotides acyclovir oral capsule 200 mg (Zovirax) $0 acyclovir oral suspension 200 mg/5 ml (Zovirax) $0 acyclovir oral tablet 400 mg, 800 mg (Zovirax) $0 acyclovir sodium intravenous (Acyclovir solution 50 mg/ml Sodium) $0 adefovir oral tablet 0 mg (Hepsera) $0 entecavir oral tablet 0.5 mg, mg (Baraclude) $0 famciclovir oral tablet 25 mg, 250 mg, 500 mg (Famvir) $0 ganciclovir sodium intravenous recon soln 500 mg (Cytovene) $0 ribasphere oral capsule 200 mg (Rebetol) $0 ribasphere oral tablet 200 mg, 400 mg, 600 mg (Copegus) $0 TYZEKA ORAL TABLET 600 MG valacyclovir oral tablet gram, 500 mg (Valtrex) $0 valganciclovir oral tablet 450 mg (Valcyte) $0 VIRAZOLE INHALATION RECON SOLN 6 GRAM Blood Products/Modifiers/Volume Expanders Anticoagulants CEPROTIN (BLUE BAR) INTRAVENOUS RECON SOLN 500 UNIT ELIQUIS ORAL TABLET 2.5 MG, 5 MG PA NSO; QL (4 per 28 days) 76

91 enoxaparin subcutaneous solution 300 mg/3 ml enoxaparin subcutaneous syringe 00 mg/ml, 20 mg/0.8 ml, 50 mg/ml, 30 mg/0.3 ml, 40 mg/0.4 ml, 60 mg/0.6 ml, 80 mg/0.8 ml fondaparinux subcutaneous syringe 0 mg/0.8 ml fondaparinux subcutaneous syringe 2.5 mg/0.5 ml fondaparinux subcutaneous syringe 5 mg/0.4 ml fondaparinux subcutaneous syringe 7.5 mg/0.6 ml heparin (porcine) in 5 % dex intravenous parenteral solution 2,500 unit/250 ml, 20,000 unit/500 ml (40 unit/ml), 25,000 unit/500 ml (50 unit/ml) heparin (porcine) in 5 % dex intravenous parenteral solution 25,000 unit/250 ml(00 unit/ml) heparin (porcine) in nacl (pf) intravenous parenteral solution,000 unit/500 ml heparin (porcine) injection solution,000 unit/ml, 0,000 unit/ml, 20,000 unit/ml, 5,000 unit/ml heparin, porcine (pf) injection solution 5,000 unit/0.5 ml heparin, porcine (pf) injection syringe 5,000 unit/0.5 ml heparin-0.45% nacl 25,000 units/250 ml (00 units/ml) bag latex-free, inner 25,000 unit/250 ml (Lovenox) $0 (Lovenox) $0 (Arixtra) $0 (Arixtra) $0 (Arixtra) $0 (Arixtra) $0 (Heparin Sodium,Porcine/D5 W) (Heparin Sod,Pork In 0.45% NaCl) (Heparin Sodium,Porcine/Ns /PF) (Heparin Sodium,Porcine) (Heparin Sodium,Porcine/PF ) (Heparin Sodium,Porcine/PF ) (Heparin Sod,Pork In 0.45% NaCl) $0 $0 $0 $0 $0 $0 $0 QL (24 per 30 days) QL (5 per 30 days) QL (2 per 30 days) QL (8 per 30 days) 77

92 heparin-d5w 25,000 units/250 ml (00 units/ml) bag excel container 25,000 unit/250 ml(00 unit/ml) IPRIVASK SUBCUTANEOUS RECON SOLN 5 MG jantoven oral tablet mg, 0 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg PRADAXA ORAL CAPSULE 0 MG, 50 MG, 75 MG warfarin oral tablet mg, 0 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg XARELTO ORAL TABLET 0 MG, 5 MG, 20 MG XARELTO ORAL TABLETS,DOSE PACK 5 MG (42)- 20 MG (9) Blood Formation Modifiers CINRYZE INTRAVENOUS RECON SOLN 500 UNIT (5 ML) EPOGEN 0,000 UNITS/ML VIAL SDV, P/F, OUTER 0,000 UNIT/ML EPOGEN INJECTION SOLUTION 2,000 UNIT/ML, 20,000 UNIT/2 ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML GRANIX SUBCUTANEOUS SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML LEUKINE INJECTION RECON SOLN 250 MCG MIRCERA INJECTION SYRINGE 00 MCG/0.3 ML, 200 MCG/0.3 ML, 50 MCG/0.3 ML, 75 MCG/0.3 ML (Heparin Sodium,Porcine/D5 W) $0 (Coumadin) $0 (Coumadin) $0 PA; QL (24 per 28 days) ST; QL (60 per 30 days) PA PA; QL (2 per 28 days) PA; QL (2 per 28 days) PA; QL (0.6 per 28 days) 78

93 MOZOBIL SUBCUTANEOUS SOLUTION 24 MG/.2 ML (20 MG/ML) NEULASTA SUBCUTANEOUS SYRINGE 6 MG/0.6ML NEULASTA SUBCUTANEOUS SYRINGE, W/ WEARABLE INJECTOR 6 MG/0.6 ML NEUMEGA SUBCUTANEOUS RECON SOLN 5 MG NEUPOGEN INJECTION SOLUTION 300 MCG/ML, 480 MCG/.6 ML NEUPOGEN INJECTION SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML PROCRIT 0,000 UNITS/ML VIAL 4'S, MDV, OUTER 20,000 UNIT/2 ML PROCRIT INJECTION SOLUTION 0,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML PROCRIT INJECTION SOLUTION 40,000 UNIT/ML PROMACTA ORAL TABLET 2.5 MG, 25 MG, 50 MG, 75 MG ZARXIO INJECTION SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML Hematologic Agents, Miscellaneous aminocaproic acid oral solution 250 mg/ml (25 %) aminocaproic acid oral tablet,000 mg, 500 mg anagrelide oral capsule 0.5 mg, mg (Aminocaproic Acid) (Aminocaproic Acid) $0 $0 (Agrylin) $0 PA; QL (2 per 28 days) PA; QL (2 per 28 days) PA; QL (6 per 28 days) PA; QL (30 per 30 days) 79

94 protamine intravenous solution 0 mg/ml (Protamine Sulfate) $0 tranexamic acid intravenous solution,000 mg/0 ml (00 (Tranexamic Acid) $0 mg/ml) tranexamic acid oral tablet 650 mg (Lysteda) $0 QL (30 per 30 days) Platelet-Aggregation Inhibitors aspirin-dipyridamole oral capsule, er multiphase 2 hr mg (Aggrenox) $0 BRILINTA ORAL TABLET 60 MG, 90 MG cilostazol oral tablet 00 mg, 50 mg (Pletal) $0 clopidogrel oral tablet 300 mg, 75 mg (Plavix) $0 dipyridamole oral tablet 25 mg, 50 mg, 75 mg (Persantine) $0 EFFIENT ORAL TABLET 0 MG, QL (30 per 30 days) 5 MG pentoxifylline oral tablet extended release 400 mg (Pentoxifylline) $0 Caloric Agents Caloric Agents AMINO ACIDS 5 % INTRAVENOUS PARENTERAL SOLUTION 5 % AMINOSYN 0 % INTRAVENOUS PARENTERAL SOLUTION 0 % AMINOSYN 3.5 % INTRAVENOUS PARENTERAL SOLUTION 3.5 % AMINOSYN 7 % INTRAVENOUS PARENTERAL SOLUTION 7 % 80

95 AMINOSYN 7 % WITH ELECTROLYTES INTRAVENOUS PARENTERAL SOLUTION 7 % AMINOSYN 8.5 % INTRAVENOUS PARENTERAL SOLUTION 8.5 % AMINOSYN 8.5 %- ELECTROLYTES INTRAVENOUS PARENTERAL SOLUTION 8.5 % AMINOSYN II 0 % INTRAVENOUS PARENTERAL SOLUTION 0 % AMINOSYN II 5 % INTRAVENOUS PARENTERAL SOLUTION 5 % AMINOSYN II 7 % INTRAVENOUS PARENTERAL SOLUTION 7 % AMINOSYN II 8.5 % INTRAVENOUS PARENTERAL SOLUTION 8.5 % AMINOSYN II 8.5 %- ELECTROLYTES INTRAVENOUS PARENTERAL SOLUTION 8.5 % AMINOSYN M 3.5 % INTRAVENOUS PARENTERAL SOLUTION 3.5 % AMINOSYN-HBC 7% INTRAVENOUS PARENTERAL SOLUTION 7 % AMINOSYN-PF 0 % INTRAVENOUS PARENTERAL SOLUTION 0 % 8

96 AMINOSYN-PF 7 % (SULFITE- FREE) INTRAVENOUS PARENTERAL SOLUTION 7 % AMINOSYN-RF 5.2 % INTRAVENOUS PARENTERAL SOLUTION 5.2 % CLINIMIX 5%/D5W SULFITE FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX 5%/D25W SULFITE- FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX 2.75%/D5W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 2.75 % CLINIMIX 4.25%/D0W SULF FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX 4.25%/D5W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX 4.25%-D20W SULF- FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX 4.25%-D25W SULF- FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX 5%-D20W(SULFITE- FREE) INTRAVENOUS PARENTERAL SOLUTION 5 % 82

97 CLINIMIX E 2.75%/D0W SUL FREE INTRAVENOUS PARENTERAL SOLUTION 2.75 % CLINIMIX E 2.75%/D5W SULF FREE INTRAVENOUS PARENTERAL SOLUTION 2.75 % CLINIMIX E 4.25%/D0W SUL FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX E 4.25%/D25W SUL FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX E 4.25%/D5W SULF FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX E 5%/D5W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX E 5%/D20W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX E 5%/D25W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINISOL SF 5 % INTRAVENOUS PARENTERAL SOLUTION 5 % cysteine (l-cysteine) intravenous solution 50 mg/ml dex4 glucose 4 gm tablet chew grape flavor 4 gram * (Cysteine HCl) $0 (Dextrose) 83

98 dextrose 0 % in water (d0w) intravenous parenteral solution 0 % dextrose 0 % in water (d0w) intravenous solution dextrose 20 % in water (d20w) intravenous parenteral solution 20 % dextrose 25 % in water (d25w) intravenous syringe dextrose 40 % in water (d40w) intravenous parenteral solution 40 % dextrose 5 % in ringers intravenous parenteral solution 5 % dextrose 5 % in water (d5w) intravenous parenteral solution dextrose 50 % in water (d50w) intravenous parenteral solution dextrose 50 % in water (d50w) intravenous syringe dextrose 70 % in water (d70w) intravenous parenteral solution FREAMINE HBC 6.9 % INTRAVENOUS PARENTERAL SOLUTION 6.9 % FREAMINE III 0 % INTRAVENOUS PARENTERAL SOLUTION 0 % (Dextrose 0 % in Water) (Dextrose 0 % in Water) (Dextrose 20 % in Water) (Dextrose 25 % in Water) (Dextrose 40 % in Water) (Dextrose 5 % In Ringers) (Dextrose 5 % in Water) (Dextrose 50 % in Water) (Dextrose 50 % in Water) (Dextrose 70 % in Water) $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 gluco burst 40% gel 40 % * (Dextrose) glucose 4 gram tablet chew na/f, caffeine free 4 gram * (Dextrose) glucose 40% gel tropical fruit 40 % * (Dextrose) glutose 5 gel 3 pak, outer, u-d 40 % * (Dextrose) 84

99 HEPATAMINE 8% INTRAVENOUS PARENTERAL SOLUTION 8 % HEPATASOL 8 % INTRAVENOUS PARENTERAL SOLUTION 8 % insta-glucose gel 24 gram/3 gram * INTRALIPID INTRAVENOUS EMULSION 20 %, 30 % KABIVEN INTRAVENOUS EMULSION % NEPHRAMINE 5.4 % INTRAVENOUS PARENTERAL SOLUTION 5.4 % NUTRILIPID INTRAVENOUS EMULSION 20 % PERIKABIVEN INTRAVENOUS EMULSION % PREMASOL 0 % INTRAVENOUS PARENTERAL SOLUTION 0 % PREMASOL 6 % INTRAVENOUS PARENTERAL SOLUTION 6 % PROCALAMINE 3% INTRAVENOUS PARENTERAL SOLUTION 3 % PROSOL 20 % INTRAVENOUS PARENTERAL SOLUTION smoflipid intravenous emulsion 20 % TRAVASOL 0 % INTRAVENOUS PARENTERAL SOLUTION 0 % TROPHAMINE 0 % INTRAVENOUS PARENTERAL SOLUTION 0 % (Dextrose/Dextrin/ Maltose) (Fat Emul/Soy/Mct/Oli v/fish Oil) 85

100 TROPHAMINE 6% INTRAVENOUS PARENTERAL SOLUTION 6 % Cardiovascular Agents Alpha-Adrenergic Agents clonidine hcl oral tablet 0. mg, 0.2 mg, 0.3 mg clonidine transdermal patch weekly 0. mg/24 hr, 0.2 mg/24 hr clonidine transdermal patch weekly 0.3 mg/24 hr clorpres oral tablet 0.-5 mg, mg, mg doxazosin oral tablet mg, 2 mg, 4 mg, 8 mg (Catapres) $0 (Catapres-Tts ) $0 (Catapres-Tts ) $0 (Clonidine HCl/Chlorthalidon e) $0 (Cardura) $0 guanfacine oral tablet mg, 2 mg (Tenex) $0 midodrine oral tablet 0 mg, 2.5 mg, (Midodrine HCl) 5 mg $0 NORTHERA ORAL CAPSULE 00 MG, 200 MG, 300 MG phenylephrine hcl injection solution 0 mg/ml (Vazculep) $0 prazosin oral capsule mg, 2 mg, 5 mg (Minipress) $0 Angiotensin Ii Receptor Antagonists BENICAR HCT ORAL TABLET MG, MG, MG BENICAR ORAL TABLET 20 MG, 40 MG, 5 MG candesartan oral tablet 6 mg, 32 mg, 4 mg, 8 mg (Atacand) $0 QL (4 per 28 days) QL (8 per 28 days) PA-HRM; AGE (Max 64 Years) PA; QL (80 per 30 days) 86

101 candesartan-hydrochlorothiazid oral tablet mg, mg, mg ENTRESTO ORAL TABLET MG, 49-5 MG, MG irbesartan oral tablet 50 mg, 300 mg, 75 mg irbesartan-hydrochlorothiazide oral tablet mg, mg losartan oral tablet 00 mg, 25 mg, 50 mg losartan-hydrochlorothiazide oral tablet mg, mg, mg telmisartan oral tablet 20 mg, 40 mg, 80 mg telmisartan-hydrochlorothiazid oral tablet mg, mg, mg TRIBENZOR ORAL TABLET MG, MG, MG, MG, MG valsartan oral tablet 60 mg, 320 mg, 40 mg, 80 mg valsartan-hydrochlorothiazide oral tablet mg, mg, mg, mg, mg Angiotensin-Converting Enzyme Inhibitors benazepril oral tablet 0 mg, 20 mg, 40 mg, 5 mg benazepril-hydrochlorothiazide oral tablet mg, mg, mg, mg captopril oral tablet 00 mg, 2.5 mg, 25 mg, 50 mg (Atacand HCT) $0 (Avapro) $0 (Avalide) $0 (Cozaar) $0 (Hyzaar) $0 (Micardis) $0 (Micardis HCT) $0 (Diovan) $0 (Diovan HCT) $0 (Lotensin) $0 (Lotensin HCT) $0 (Captopril) $0 PA; QL (60 per 30 days) ST 87

102 captopril-hydrochlorothiazide oral tablet 25-5 mg, mg, 50-5 mg, mg enalapril maleate oral tablet 0 mg, 2.5 mg, 20 mg, 5 mg enalaprilat intravenous solution.25 mg/ml enalapril-hydrochlorothiazide oral tablet 0-25 mg, mg fosinopril oral tablet 0 mg, 20 mg, 40 mg fosinopril-hydrochlorothiazide oral tablet mg, mg lisinopril oral tablet 0 mg, 2.5 mg, 20 mg, 30 mg, 40 mg, 5 mg lisinopril-hydrochlorothiazide oral tablet mg, mg, mg (Captopril/Hydroch lorothiazide) $0 (Vasotec) $0 (Enalaprilat Dihydrate) $0 (Vaseretic) $0 (Fosinopril Sodium) (Fosinopril/Hydroc hlorothiazide) $0 $0 (Zestril) $0 (Zestoretic) $0 moexipril oral tablet 5 mg, 7.5 mg (Moexipril HCl) $0 moexipril-hydrochlorothiazide oral (Moexipril/Hydroc tablet mg, 5-25 mg, 7.5- hlorothiazide) 2.5 mg $0 perindopril erbumine oral tablet 2 mg, 4 mg, 8 mg (Aceon) $0 quinapril oral tablet 0 mg, 20 mg, 40 mg, 5 mg (Accupril) $0 quinapril-hydrochlorothiazide oral tablet mg, mg, 20- (Accuretic) $0 25 mg ramipril oral capsule.25 mg, 0 mg, 2.5 mg, 5 mg (Altace) $0 trandolapril oral tablet mg, 2 mg, 4 mg (Mavik) $0 Antiarrhythmic Agents amiodarone oral tablet 00 mg, 200 mg, 400 mg (Cordarone) $0 88

103 disopyramide phosphate oral capsule 00 mg, 50 mg dofetilide oral capsule 25 mcg, 250 mcg, 500 mcg flecainide oral tablet 00 mg, 50 mg, 50 mg lidocaine (pf) intravenous syringe 50 mg/5 ml ( %) lidocaine in 5 % dextrose (pf) intravenous parenteral solution 8 mg/ml (0.8 %) mexiletine oral capsule 50 mg, 200 mg, 250 mg MULTAQ ORAL TABLET 400 MG pacerone oral tablet 00 mg, 200 mg, 400 mg procainamide injection solution 00 mg/ml, 500 mg/ml propafenone oral capsule,extended release 2 hr 225 mg, 325 mg, 425 mg propafenone oral tablet 50 mg, 225 mg, 300 mg quinidine gluconate oral tablet extended release 324 mg quinidine sulfate oral tablet 200 mg, 300 mg quinidine sulfate oral tablet extended release 300 mg Beta-Adrenergic Blocking Agents acebutolol oral capsule 200 mg, 400 mg atenolol oral tablet 00 mg, 25 mg, 50 mg (Norpace) $0 (Tikosyn) $0 (Tambocor) $0 (Lidocaine HCl/PF) (Lidocaine HCl/D5w/PF) $0 $0 (Mexiletine HCl) $0 (Cordarone) $0 (Procainamide HCl) $0 (Rythmol SR) $0 (Rythmol) $0 (Quinidine Gluconate) $0 (Quinidine Sulfate) $0 (Quinidine Sulfate) $0 (Sectral) $0 (Tenormin) $0 89

104 atenolol-chlorthalidone oral tablet mg, mg (Tenoretic 50) $0 betaxolol oral tablet 0 mg, 20 mg (Betaxolol HCl) $0 bisoprolol fumarate oral tablet 0 mg, 5 mg (Zebeta) $0 bisoprolol-hydrochlorothiazide oral tablet mg, mg, 5- (Ziac) $ mg BYSTOLIC ORAL TABLET 0 MG, 2.5 MG, 20 MG, 5 MG carvedilol oral tablet 2.5 mg, 25 mg, 3.25 mg, 6.25 mg (Coreg) $0 esmolol intravenous solution 00 mg/0 ml (0 mg/ml) (Brevibloc) $0 labetalol intravenous solution 5 mg/ml (Labetalol HCl) $0 labetalol oral tablet 00 mg, 200 mg, 300 mg (Trandate) $0 metoprolol succinate oral tablet extended release 24 hr 00 mg, 200 (Toprol XL) $0 mg, 25 mg, 50 mg metoprolol ta-hydrochlorothiaz oral tablet mg, mg, (Lopressor HCT) $0 mg metoprolol tartrate intravenous (Metoprolol solution 5 mg/5 ml Tartrate) $0 metoprolol tartrate intravenous (Metoprolol syringe 5 mg/5 ml Tartrate) $0 metoprolol tartrate oral tablet 00 mg, 25 mg, 37.5 mg, 50 mg, 75 mg (Lopressor) $0 nadolol oral tablet 20 mg, 40 mg, 80 (Corgard) mg $0 pindolol oral tablet 0 mg, 5 mg (Pindolol) $0 propranolol intravenous solution mg/ml (Propranolol HCl) $0 90

105 propranolol oral capsule,extended release 24 hr 20 mg, 60 mg, 60 mg, 80 mg propranolol oral solution 20 mg/5 ml (4 mg/ml), 40 mg/5 ml (8 mg/ml) propranolol oral tablet 0 mg, 20 mg, 40 mg, 60 mg, 80 mg propranolol-hydrochlorothiazid oral tablet mg, mg sorine oral tablet 20 mg, 60 mg, (Inderal LA) $0 (Propranolol HCl) $0 (Propranolol HCl) $0 (Propranolol/Hydro chlorothiazid) $0 (Betapace) $0 240 mg, 80 mg sotalol 20 mg tablet 20 mg (Betapace) $0 sotalol af oral tablet 20 mg (Betapace) $0 sotalol oral tablet 60 mg, 240 mg, 80 mg timolol maleate oral tablet 0 mg, 20 mg, 5 mg Calcium-Channel Blocking Agents cartia xt oral capsule,extended release 24hr 20 mg, 80 mg, 240 mg, 300 mg diltiazem 24hr er 80 mg cap 80 mg diltiazem 24hr er 360 mg cap 360 mg diltiazem hcl intravenous recon soln 00 mg diltiazem hcl intravenous solution 5 mg/ml diltiazem hcl oral capsule, extended release 80 mg, 360 mg, 420 mg diltiazem hcl oral capsule,extended release 2 hr 20 mg, 60 mg, 90 mg diltiazem hcl oral capsule,extended release 24hr 20 mg, 240 mg, 300 mg (Betapace) $0 (Timolol Maleate) $0 (Cardizem CD) $0 (Cardizem CD) $0 (Cardizem CD) $0 (Cardizem CD) $0 (Cardizem CD) $0 (Cardizem CD) $0 (Cardizem CD) $0 (Cardizem CD) $0 9

106 diltiazem hcl oral tablet 20 mg, 30 mg, 60 mg, 90 mg diltiazem hcl oral tablet extended release 24 hr 80 mg, 240 mg, 300 mg, 360 mg, 420 mg dilt-xr oral capsule,ext release degradable 20 mg, 80 mg, 240 mg matzim la oral tablet extended release 24 hr 80 mg, 240 mg, 300 mg, 360 mg, 420 mg taztia xt oral capsule, extended release 20 mg, 80 mg, 240 mg, 300 mg, 360 mg verapamil intravenous syringe 2.5 mg/ml verapamil oral capsule, 24 hr er pellet ct 00 mg, 200 mg, 300 mg verapamil oral capsule,ext rel. pellets 24 hr 20 mg, 80 mg, 240 mg, 360 mg verapamil oral tablet 20 mg, 40 mg, 80 mg verapamil oral tablet extended release 20 mg, 80 mg, 240 mg Cardiovascular Agents, Miscellaneous CORLANOR ORAL TABLET 5 MG, 7.5 MG DEMSER ORAL CAPSULE 250 MG (Cardizem CD) $0 (Cardizem LA) $0 (Cardizem CD) $0 (Cardizem CD) $0 (Cardizem CD) $0 (Verapamil HCl) $0 (Verelan Pm) $0 (Verelan) $0 (Calan) $0 (Calan SR) $0 digitek oral tablet 25 mcg (Lanoxin) $0 ST (High Risk Med for Ages 65 and Older and Dose is Greater Than 25mcg Per Day); QL (30 per 30 days) 92

107 digitek oral tablet 250 mcg (Lanoxin) $0 digox 25 mcg tablet 25 mcg (Lanoxin) $0 digox 250 mcg tablet 250 mcg (Lanoxin) $0 digoxin 0.25 mg/ml syringe 250 mcg/ml digoxin injection solution 250 mcg/ml DIGOXIN ORAL SOLUTION 50 MCG/ML (Digoxin) $0 (Digoxin) $0 digoxin oral tablet 25 mcg (Lanoxin) $0 digoxin oral tablet 250 mcg (Lanoxin) $0 PA-HRM; (High Risk Med for Ages 65 and Older and Dose is Greater Than 25mcg Per Day); QL (30 per 30 days); AGE (Max 64 Years) (High Risk Med for Ages 65 and Older and Dose is Greater Than 25mcg Per Day); QL (30 per 30 days) PA-HRM; (High Risk Med for Ages 65 and Older and Dose is Greater Than 25mcg Per Day); QL (30 per 30 days); AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA-HRM; QL (300 per 30 days); AGE (Max 64 Years) (High Risk Med for Ages 65 and Older and Dose is Greater Than 25mcg Per Day); QL (30 per 30 days) PA-HRM; (High Risk Med for Ages 65 and Older and Dose is Greater Than 25mcg Per Day); QL (30 per 30 days); AGE (Max 64 Years) 93

108 dobutamine in d5w intravenous parenteral solution,000 mg/250 ml (4,000 mcg/ml), 250 mg/250 ml ( mg/ml), 500 mg/250 ml (2,000 mcg/ml) dobutamine intravenous solution 250 mg/20 ml (2.5 mg/ml) dopamine in 5 % dextrose intravenous solution 200 mg/250 ml (800 mcg/ml), 400 mg/250 ml (,600 mcg/ml), 800 mg/250 ml (3,200 mcg/ml) dopamine intravenous solution 200 mg/5 ml (40 mg/ml), 400 mg/5 ml (80 mg/ml), 800 mg/0 ml (80 mg/ml), 800 mg/5 ml (60 mg/ml) ephedrine sulfate injection solution 50 mg/ml epinephrine hcl (pf) intravenous solution mg/ml ( ml) epinephrine injection auto-injector 0.5 mg/0.5 ml, 0.3 mg/0.3 ml epinephrine injection solution mg/ml ( ml) epinephrine injection syringe 0. mg/ml EPIPEN 2-PAK INJECTION AUTO-INJECTOR 0.3 MG/0.3 ML EPIPEN JR 2-PAK INJECTION AUTO-INJECTOR 0.5 MG/0.3 ML ethamolin intravenous solution 5 % FIRAZYR SUBCUTANEOUS SYRINGE 30 MG/3 ML hydralazine injection solution 20 mg/ml (Dobutamine HCl/D5W) $0 (Dobutamine HCl) $0 (Dopamine HCl/D5W) $0 (Dopamine HCl) $0 (Ephedrine Sulfate) $0 (Epinephrine HCl/PF) $0 (Adrenaclick) $0 (Epinephrine) $0 (Epinephrine) $0 (Ethanolamine Oleate) $0 (Hydralazine HCl) $0 94

109 hydralazine oral tablet 0 mg, 00 mg, 25 mg, 50 mg LANOXIN ORAL TABLET 87.5 MCG LANOXIN ORAL TABLET 62.5 MCG milrinone in 5 % dextrose intravenous piggyback 20 mg/00 ml (200 mcg/ml), 40 mg/200 ml (200 mcg/ml) milrinone intravenous solution mg/ml norepinephrine bitartrate intravenous solution mg/ml papaverine injection solution 30 mg/ml papaverine oral capsule, extended release 50 mg RANEXA ORAL TABLET EXTENDED RELEASE 2 HR,000 MG, 500 MG Dihydropyridines afeditab cr oral tablet extended release 30 mg, 60 mg amlodipine oral tablet 0 mg, 2.5 mg, 5 mg amlodipine-benazepril oral capsule 0-20 mg, 0-40 mg, mg, 5-0 mg, 5-20 mg, 5-40 mg (Hydralazine HCl) $0 (Milrinone Lactate/D5W) $0 (Milrinone Lactate) $0 (Levophed Bitartrate) $0 (Papaverine HCl) $0 (Papaverine HCl) $0 (Adalat CC) $0 (Norvasc) $0 (Lotrel) $0 PA-HRM; (High Risk Med for Ages 65 and Older and Dose is Greater Than 25mcg Per Day); QL (30 per 30 days); AGE (Max 64 Years) (High Risk Med for Ages 65 and Older and Dose is Greater Than 25mcg Per Day); QL (30 per 30 days) PA PA 95

110 amlodipine-valsartan oral tablet 0-60 mg, mg, 5-60 mg, 5- (Exforge) $0 320 mg amlodipine-valsartan-hcthiazid oral tablet mg, mg, mg, mg, (Exforge HCT) $ mg AZOR ORAL TABLET 0-20 MG, 0-40 MG, 5-20 MG, 5-40 MG CLEVIPREX INTRAVENOUS EMULSION 50 MG/00 ML felodipine oral tablet extended release 24 hr 0 mg, 2.5 mg, 5 mg (Felodipine) $0 isradipine oral capsule 2.5 mg, 5 mg (Isradipine) $0 nicardipine oral capsule 20 mg, 30 mg (Nicardipine HCl) $0 nifedical xl oral tablet extended release 24hr 30 mg, 60 mg (Procardia XL) $0 nifedipine er 30 mg tablet f/c 30 mg (Adalat CC) $0 nifedipine oral tablet extended release 24hr 30 mg (Adalat CC) $0 nifedipine oral tablet extended release 24hr 60 mg, 90 mg (Procardia XL) $0 Diuretics amiloride oral tablet 5 mg (Amiloride HCl) $0 amiloride-hydrochlorothiazide oral (Amiloride/Hydroc tablet 5-50 mg hlorothiazide) $0 bumetanide injection solution 0.25 mg/ml (Bumetanide) $0 bumetanide oral tablet 0.5 mg, mg, 2 mg (Bumetanide) $0 chlorothiazide oral tablet 250 mg, 500 mg (Chlorothiazide) $0 chlorothiazide sodium intravenous recon soln 500 mg (Sodium Diuril) $0 chlorthalidone oral tablet 25 mg, 50 mg (Chlorthalidone) $0 ST 96

111 DYRENIUM ORAL CAPSULE 00 MG, 50 MG furosemide injection solution 0 mg/ml (Furosemide) $0 furosemide injection syringe 0 mg/ml (Furosemide) $0 furosemide oral solution 0 mg/ml, 40 mg/5 ml (8 mg/ml) (Furosemide) $0 furosemide oral tablet 20 mg, 40 mg, 80 mg (Lasix) $0 hydrochlorothiazide oral capsule 2.5 mg (Microzide) $0 hydrochlorothiazide oral tablet 2.5 (Hydrochlorothiazi mg, 25 mg, 50 mg de) $0 indapamide oral tablet.25 mg, 2.5 mg (Indapamide) $0 methyclothiazide oral tablet 5 mg (Methyclothiazide) $0 metolazone oral tablet 0 mg, 2.5 mg, 5 mg (Zaroxolyn) $0 torsemide oral tablet 0 mg, 00 mg, 20 mg, 5 mg (Demadex) $0 triamterene-hydrochlorothiazid oral capsule mg, mg (Dyazide) $0 triamterene-hydrochlorothiazid oral tablet mg, mg (Maxzide) $0 Dyslipidemics amlodipine-atorvastatin oral tablet 0-0 mg, 0-20 mg, 0-40 mg, 0-80 mg, mg, mg, (Caduet) $0 mg, 5-0 mg, 5-20 mg, 5-40 mg, 5-80 mg atorvastatin oral tablet 0 mg, 20 mg, 40 mg, 80 mg (Lipitor) $0 cholestyramine light oral powder 4 (Cholestyramine/A gram spartame) $0 cholestyramine light oral powder in packet 4 gram (Questran) $0 97

112 cholestyramine packet 4 gram (Questran) $0 colestipol hcl granules packet 5 gram (Colestid) $0 colestipol oral granules 5 gram (Colestid) $0 colestipol oral tablet gram (Colestid) $0 endur-acin sr 500 mg tablet 500 mg * (Slo-Niacin) fenofibrate micronized oral capsule 30 mg, 34 mg, 200 mg, 43 mg, 67 (Lofibra) $0 mg fenofibrate nanocrystallized oral tablet 45 mg, 48 mg (Tricor) $0 fenofibrate oral tablet 20 mg, 60 mg, 40 mg, 54 mg (Lofibra) $0 fenofibric acid (choline) oral capsule,delayed release(dr/ec) 35 (Trilipix) $0 mg, 45 mg fenofibric acid oral tablet 05 mg, 35 mg (Fibricor) $0 gemfibrozil oral tablet 600 mg (Lopid) $0 JUXTAPID ORAL CAPSULE 0 MG, 20 MG, 30 MG, 40 MG, 5 MG, 60 MG KYNAMRO SUBCUTANEOUS SYRINGE 200 MG/ML LIVALO ORAL TABLET MG, 2 MG, 4 MG lovastatin oral tablet 0 mg, 20 mg, 40 mg (Mevacor) $0 niacin 50 mg tablet 50 mg * (Slo-Niacin) niacin 500 mg capsule sa 500 mg * (Niacin) niacin 500 mg tablet 500 mg * (Slo-Niacin) niacin oral tablet extended release 24 hr,000 mg, 500 mg, 750 mg (Niaspan) $0 niacin tr 500 mg caplet caplet 500 mg * (Slo-Niacin) niacinamide 500 mg tablet 500 mg * (Niacinamide) PA PA; QL (4 per 28 days) QL (30 per 30 days) 98

113 niacor oral tablet 500 mg (Niacin) $0 omega-3 acid ethyl esters oral capsule gram (Lovaza) $0 PRALUENT PEN SUBCUTANEOUS PEN INJECTOR 50 MG/ML, 75 MG/ML PRALUENT SYRINGE SUBCUTANEOUS SYRINGE 50 MG/ML, 75 MG/ML pravastatin oral tablet 0 mg, 20 mg, 40 mg, 80 mg (Pravachol) $0 prevalite oral powder 4 gram (Cholestyramine/A spartame) $0 prevalite packet outer 4 gram (Cholestyramine/A spartame) $0 REPATHA PUSHTRONEX SUBCUTANEOUS WEARABLE INJECTOR 420 MG/3.5 ML REPATHA SURECLICK SUBCUTANEOUS PEN INJECTOR 40 MG/ML REPATHA SYRINGE SUBCUTANEOUS SYRINGE 40 MG/ML rosuvastatin oral tablet 0 mg, 20 mg, 40 mg, 5 mg (Crestor) $0 simvastatin oral tablet 0 mg, 20 mg, 40 mg, 5 mg (Zocor) $0 PA; QL (2 per 28 days) PA; QL (2 per 28 days) PA; QL (3.5 per 28 days) PA; QL (3 per 28 days) PA; QL (3 per 28 days) simvastatin oral tablet 80 mg (Zocor) $0 QL (30 per 30 days) VASCEPA ORAL CAPSULE GRAM WELCHOL ORAL POWDER IN PACKET 3.75 GRAM WELCHOL ORAL TABLET 625 MG ZETIA ORAL TABLET 0 MG 99

114 Renin-Angiotensin- Aldosterone System Inhibitors eplerenone oral tablet 25 mg, 50 mg (Inspra) $0 spironolactone oral tablet 00 mg, 25 mg, 50 mg (Aldactone) $0 spironolacton-hydrochlorothiaz oral (Aldactazide) tablet mg $0 Vasodilators BIDIL ORAL TABLET MG isosorbide dinitrate oral tablet 0 mg, 20 mg, 30 mg, 5 mg (Isochron) $0 isosorbide dinitrate oral tablet extended release 40 mg (Isochron) $0 isosorbide dinitrate sublingual (Isosorbide tablet 2.5 mg, 5 mg Dinitrate) $0 isosorbide mononitrate oral tablet (Isosorbide 0 mg, 20 mg Mononitrate) $0 isosorbide mononitrate oral tablet extended release 24 hr 20 mg, 30 (Imdur) $0 mg, 60 mg minitran transdermal patch 24 hour 0. mg/hr, 0.2 mg/hr, 0.6 mg/hr (Nitro-Dur) $0 minitran transdermal patch 24 hour 0.4 mg/hr (Nitro-Dur) $0 minoxidil oral tablet 0 mg, 2.5 mg (Minoxidil) $0 NITRO-BID TRANSDERMAL $0 OINTMENT 2 % nitroglycerin in 5 % dextrose intravenous solution 00 mg/250 ml (400 mcg/ml), 25 mg/250 ml (00 mcg/ml), 50 mg/250 ml (200 mcg/ml) nitroglycerin intravenous solution 50 mg/0 ml (5 mg/ml) (Nitroglycerin/D5 W) $0 (Nitroglycerin) $0 QL (30 per 30 days) QL (60 per 30 days) 00

115 nitroglycerin transdermal patch 24 hour 0. mg/hr, 0.2 mg/hr, 0.6 mg/hr nitroglycerin transdermal patch 24 hour 0.4 mg/hr NITROSTAT SUBLINGUAL TABLET 0.3 MG, 0.4 MG, 0.6 MG PROGLYCEM ORAL SUSPENSION 50 MG/ML Central Nervous System Agents Central Nervous System Agents AMPYRA ORAL TABLET EXTENDED RELEASE 2 HR 0 MG caffeine citrated intravenous solution 60 mg/3 ml (20 mg/ml) caffeine citrated oral solution 60 mg/3 ml (20 mg/ml) caffeine-sodium benzoate injection solution 250 mg/ml (25 mg/ml caffeine) clonidine hcl oral tablet extended release 2 hr 0. mg dexmethylphenidate oral tablet 0 mg, 2.5 mg, 5 mg dextroamphetamine oral capsule, extended release 0 mg, 5 mg, 5 mg dextroamphetamine oral tablet 0 mg, 5 mg dextroamphetamine-amphetamine oral capsule,extended release 24hr 0 mg, 5 mg, 5 mg (Nitro-Dur) $0 (Nitro-Dur) $0 (Cafcit) $0 (Cafcit) $0 (Caffeine/Sodium Benzoate) $0 (Kapvay) $0 (Focalin) $0 (Dexedrine) $0 (Dexedrine) $0 (Adderall XR) $0 QL (30 per 30 days) QL (60 per 30 days) PA; QL (60 per 30 days) QL (60 per 30 days) QL (20 per 30 days) QL (80 per 30 days) QL (30 per 30 days) 0

116 dextroamphetamine-amphetamine oral capsule,extended release 24hr 20 mg, 25 mg, 30 mg dextroamphetamine-amphetamine oral tablet 0 mg, 2.5 mg, 5 mg, 20 mg, 30 mg, 5 mg, 7.5 mg flumazenil intravenous solution 0. mg/ml guanfacine oral tablet extended release 24 hr mg, 2 mg, 3 mg, 4 mg lithium carbonate oral capsule 50 mg, 300 mg, 600 mg lithium carbonate oral tablet 300 mg lithium carbonate oral tablet extended release 300 mg, 450 mg lithium citrate oral solution 8 meq/5 ml methylphenidate cd 20 mg cap 20 mg methylphenidate cd 40 mg cap 40 mg methylphenidate oral capsule, er biphasic mg, 50 mg, 60 mg methylphenidate oral capsule, er biphasic mg methylphenidate oral capsule,er biphasic mg, 40 mg methylphenidate oral solution 0 mg/5 ml, 5 mg/5 ml methylphenidate oral tablet 0 mg, 20 mg, 5 mg methylphenidate oral tablet extended release 0 mg, 20 mg (Adderall XR) $0 (Adderall) $0 (Romazicon) $0 (Intuniv) $0 (Lithium Carbonate) $0 (Lithobid) $0 (Lithobid) $0 (Lithium Citrate) $0 (Metadate Cd) $0 (Metadate Cd) $0 (Metadate Cd) $0 (Metadate Cd) $0 (Metadate Cd) $0 (Methylin) $0 (Ritalin) $0 (Methylphenidate HCl) $0 QL (60 per 30 days) QL (60 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (60 per 30 days) QL (30 per 30 days) QL (900 per 30 days) QL (90 per 30 days) QL (90 per 30 days) 02

117 methylphenidate oral tablet extended release 24hr 8 mg, 27 mg, 54 mg (Concerta) $0 methylphenidate oral tablet extended release 24hr 36 mg (Concerta) $0 NUEDEXTA ORAL CAPSULE 20-0 MG QUILLIVANT XR ORAL SUSPENSION,EXT REL 24HR,RECON 5 MG/ML (25 MG/5 ML) riluzole oral tablet 50 mg (Rilutek) $0 SAVELLA ORAL TABLET 00 MG, 2.5 MG, 25 MG, 50 MG SAVELLA ORAL TABLETS,DOSE PACK 2.5 MG (5)-25 MG(8)-50 MG(42) STRATTERA ORAL CAPSULE 0 MG, 00 MG, 8 MG, 25 MG, 40 MG, 60 MG, 80 MG tetrabenazine oral tablet 2.5 mg, 25 mg (Xenazine) $0 Contraceptives Contraceptives AFTERA.5 MG TABLET.5 MG * 3 $0 altavera (28) oral tablet mg (Amethyst) $0 alyacen /35 (28) oral tablet -35 mg-mcg (Modicon) $0 alyacen 7/7/7 (28) oral tablet 0.5/0.75/ mg- 35 mcg (Modicon) $0 amethia lo oral tablets,dose pack,3 month 0.0 mg-20 mcg (84)/0 mcg (Seasonique) $0 (7) QL (30 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (60 per 30 days) PA; QL (2 per 28 days) QL (6 per 365 days) QL (9 per 84 days) 03

118 amethia oral tablets,dose pack,3 month 0.5 mg-30 mcg (84)/0 mcg (7) (Seasonique) $0 apri oral tablet mg (Desogen) $0 aranelle (28) oral tablet 0.5// mg-mcg (Modicon) $0 ashlyna oral tablets,dose pack,3 month 0.5 mg-30 mcg (84)/0 mcg (Seasonique) $0 (7) aubra oral tablet mg-mcg (Amethyst) $0 aviane oral tablet mg-mcg (Amethyst) $0 azurette (28) oral tablet mgx2 /0.0 mg x 5 (Mircette) $0 balziva (28) oral tablet mgmcg (Modicon) $0 bekyree (28) oral tablet mgx2 /0.0 mg x 5 (Mircette) $0 blisovi 24 fe oral tablet mg-20 mcg (24)/75 mg (4) (Loestrin Fe) $0 blisovi fe.5/30 (28) oral tablet.5 mg-30 mcg (2)/75 mg (7) (Loestrin Fe) $0 blisovi fe /20 (28) oral tablet mg- 20 mcg (2)/75 mg (7) (Loestrin Fe) $0 briellyn oral tablet mg-mcg (Modicon) $0 camila oral tablet 0.35 mg (Nor-Q-D) $0 camrese lo oral tablets,dose pack,3 month 0.0 mg-20 mcg (84)/0 mcg (Seasonique) $0 (7) camrese oral tablets,dose pack,3 month 0.5 mg-30 mcg (84)/0 mcg (Seasonique) $0 (7) caziant (28) oral tablet 0./.25/.5- (Desogen) $0 25 mg-mcg cryselle (28) oral tablet mgmcg cyclafem /35 (28) oral tablet -35 mg-mcg (Norgestrel-Ethinyl Estradiol) $0 (Modicon) $0 QL (9 per 84 days) QL (9 per 84 days) QL (9 per 84 days) 04

119 cyclafem 7/7/7 (28) oral tablet 0.5/0.75/ mg- 35 mcg (Modicon) $0 cyred oral tablet mg (Desogen) $0 dasetta /35 (28) oral tablet -35 mg-mcg (Modicon) $0 dasetta 7/7/7 (28) oral tablet 0.5/0.75/ mg- 35 mcg (Modicon) $0 daysee oral tablets,dose pack,3 QL (9 per 84 days) month 0.5 mg-30 mcg (84)/0 mcg (7) (Seasonique) $0 deblitane oral tablet 0.35 mg (Nor-Q-D) $0 delyla (28) oral tablet mgmcg (Amethyst) $0 desog-e.estradiol/e.estradiol oral tablet mgx2 /0.0 mg x 5 (Mircette) $0 desogestrel-ethinyl estradiol oral tablet mg (Desogen) $0 drospirenone-ethinyl estradiol oral tablet mg, mg (Yaz) $0 econtra ez.5 mg tablet inner.5 QL (6 per 365 days) (Aftera) mg * elinest oral tablet mg-mcg (Norgestrel-Ethinyl Estradiol) $0 ELLA ORAL TABLET 30 MG QL (6 per 365 days) emoquette oral tablet mg (Desogen) $0 enpresse oral tablet (6)/75-40 (5)/25-30(0) (Amethyst) $0 enskyce oral tablet mg (Desogen) $0 errin oral tablet 0.35 mg (Nor-Q-D) $0 estarylla oral tablet mg-mcg (Ortho-Cyclen) $0 falmina (28) oral tablet mgmcg (Amethyst) $0 gianvi (28) oral tablet mg (Yaz) $0 gildagia oral tablet mg-mcg (Modicon) $0 gildess.5/30 (2) oral tablet.5-30 (Loestrin) mg-mcg $0 05

120 gildess /20 (2) oral tablet -20 mg-mcg (Loestrin) $0 gildess 24 fe oral tablet mg-20 mcg (24)/75 mg (4) (Loestrin Fe) $0 gildess fe.5/30 (28) oral tablet.5 mg-30 mcg (2)/75 mg (7) (Loestrin Fe) $0 gildess fe /20 (28) oral tablet mg- 20 mcg (2)/75 mg (7) (Loestrin Fe) $0 heather oral tablet 0.35 mg (Nor-Q-D) $0 introvale oral tablets,dose pack,3 (Levonorgestrelmonth 0.5 mg-30 mcg Ethin Estradiol) $0 jencycla oral tablet 0.35 mg (Nor-Q-D) $0 jolessa oral tablets,dose pack,3 (Levonorgestrelmonth 0.5 mg-30 mcg Ethin Estradiol) $0 jolivette oral tablet 0.35 mg (Nor-Q-D) $0 juleber oral tablet mg (Desogen) $0 junel.5/30 (2) oral tablet.5-30 mg-mcg (Loestrin) $0 junel /20 (2) oral tablet -20 mgmcg (Loestrin) $0 junel fe.5/30 (28) oral tablet.5 mg-30 mcg (2)/75 mg (7) (Loestrin Fe) $0 junel fe /20 (28) oral tablet mg- 20 mcg (2)/75 mg (7) (Loestrin Fe) $0 junel fe 24 oral tablet mg-20 mcg (24)/75 mg (4) (Loestrin Fe) $0 kariva (28) oral tablet mgx2 /0.0 mg x 5 (Mircette) $0 kelnor /35 (28) oral tablet -35 mg-mcg (Demulen -50-2) $0 kimidess (28) oral tablet mgx2 /0.0 mg x 5 (Mircette) $0 kurvelo oral tablet mg (Amethyst) $0 l norgest/e.estradiol-e.estrad oral tablets,dose pack,3 month 0.0 mg- 20 mcg (84)/0 mcg (7), 0.5 mg-30 (Seasonique) $0 mcg (84)/0 mcg (7) QL (9 per 84 days) QL (9 per 84 days) QL (9 per 84 days) 06

121 larin.5/30 (2) oral tablet.5-30 mg-mcg (Loestrin) $0 larin /20 (2) oral tablet -20 mgmcg (Loestrin) $0 larin 24 fe oral tablet mg-20 mcg (24)/75 mg (4) (Loestrin Fe) $0 larin fe.5/30 (28) oral tablet.5 mg-30 mcg (2)/75 mg (7) (Loestrin Fe) $0 larin fe /20 (28) oral tablet mg- 20 mcg (2)/75 mg (7) (Loestrin Fe) $0 larissia oral tablet mg-mcg (Amethyst) $0 leena 28 oral tablet 0.5// mg-mcg (Modicon) $0 lessina oral tablet mg-mcg (Amethyst) $0 levonest (28) oral tablet (6)/75-40 (5)/25-30(0) (Amethyst) $0 levonor-eth estrad outer QL (9 per 84 days) (Amethyst) $ mg levonorgestrel.5 mg tablet (otc) QL (6 per 365 days) (Aftera).5 mg * levonorgestrel oral tablet 0.75 mg (Plan B One-Step) $0 QL (2 per 365 days) levonorgestrel oral tablet.5 mg (Plan B One-Step) $0 QL (6 per 365 days) levonorgestrel-ethinyl estrad oral tablet mg-mcg (Amethyst) $0 levonorgestrel-ethinyl estrad oral QL (9 per 84 days) tablets,dose pack,3 month 0.5 mg- 30 mcg (Amethyst) $0 levonorg-eth estrad triphasic oral QL (9 per 84 days) tablet (6)/75-40 (5)/25-30(0) (Amethyst) $0 levora-28 oral tablet mg (Amethyst) $0 lomedia 24 fe oral tablet mg-20 mcg (24)/75 mg (4) (Loestrin Fe) $0 loryna (28) oral tablet mg (Yaz) $0 low-ogestrel (28) oral tablet (Norgestrel-Ethinyl mg-mcg Estradiol) $0 07

122 lutera (28) oral tablet mgmcg (Amethyst) $0 lyza oral tablet 0.35 mg (Nor-Q-D) $0 marlissa oral tablet mg (Amethyst) $0 microgestin.5/30 (2) oral tablet.5-30 mg-mcg (Loestrin) $0 microgestin /20 (2) oral tablet - 20 mg-mcg (Loestrin) $0 microgestin fe.5/30 (28) oral tablet.5 mg-30 mcg (2)/75 mg (7) (Loestrin Fe) $0 microgestin fe /20 (28) oral tablet mg-20 mcg (2)/75 mg (7) (Loestrin Fe) $0 mono-linyah oral tablet mgmcg (Ortho-Cyclen) $0 mononessa (28) oral tablet mg-mcg (Ortho-Cyclen) $0 my way.5 mg tablet (otc).5 mg * (Aftera) QL (6 per 365 days) myzilra oral tablet (6)/75-40 (5)/25-30(0) (Amethyst) $0 necon 0.5/35 (28) oral tablet mg-mcg (Modicon) $0 necon /35 (28) oral tablet -35 mgmcg (Modicon) $0 necon /50 (28) oral tablet -50 mgmcg (Norinyl +50) $0 necon 0/ (28) oral tablet /-35 mg-mcg/mg-mcg (Modicon) $0 necon 7/7/7 (28) oral tablet 0.5/0.75/ mg- 35 mcg (Modicon) $0 next choice one dose.5 mg tb (otc) QL (6 per 365 days) (Aftera).5 mg * next choice one dose oral tablet.5 QL (6 per 365 days) (Plan B One-Step) $0 mg nikki (28) oral tablet mg (Yaz) $0 nora-be oral tablet 0.35 mg (Nor-Q-D) $0 norethindrone (contraceptive) oral tablet 0.35 mg (Nor-Q-D) $0 08

123 norethindrone ac-eth estradiol oral tablet -20 mg-mcg (Loestrin) $0 norethindrone-e.estradiol-iron oral tablet mg-20 mcg (24)/75 mg (4) (Loestrin Fe) $0 norg-ee / x28 day regimen 0.8/0.25/0.25 mg-35 (Ortho-Cyclen) $0 mcg (28) norgestimate-ethinyl estradiol oral tablet 0.8/0.25/0.25 mg-25 mcg, (Ortho-Cyclen) $ mg-mcg norlyroc oral tablet 0.35 mg (Nor-Q-D) $0 nortrel 0.5/35 (28) oral tablet (Modicon) mg-mcg $0 nortrel /35 (2) oral tablet -35 mg-mcg (Modicon) $0 nortrel /35 (28) oral tablet -35 mg-mcg (Modicon) $0 nortrel 7/7/7 (28) oral tablet 0.5/0.75/ mg- 35 mcg (Modicon) $0 NUVARING VAGINAL RING MG/24 HR ocella oral tablet mg (Yaz) $0 ogestrel (28) oral tablet mgmcg Estradiol) (Norgestrel-Ethinyl $0 opcicon one-step.5 mg tablet.5 mg * (Aftera) orsythia oral tablet mg-mcg (Amethyst) $0 philith oral tablet mg-mcg (Modicon) $0 pimtrea (28) oral tablet mgx2 /0.0 mg x 5 (Mircette) $0 pirmella oral tablet 0.5/0.75/ mg- 35 mcg, -35 mg-mcg (Modicon) $0 PLAN B ONE-STEP.5 MG TABLET (OTC).5 MG * 3 $0 portia oral tablet mg (Amethyst) $0 previfem oral tablet mg-mcg (Ortho-Cyclen) $0 ST; QL ( per 28 days) QL (6 per 365 days) QL (6 per 365 days) 09

124 quasense oral tablets,dose pack,3 (Levonorgestrel- QL (9 per 84 days) $0 month 0.5 mg-30 mcg Ethin Estradiol) react.5 mg tablet.5 mg * (Aftera) QL (6 per 365 days) reclipsen (28) oral tablet mg (Desogen) $0 setlakin oral tablets,dose pack,3 (Levonorgestrel- QL (9 per 84 days) $0 month 0.5 mg-30 mcg Ethin Estradiol) sharobel oral tablet 0.35 mg (Nor-Q-D) $0 sprintec (28) oral tablet mgmcg (Ortho-Cyclen) $0 sronyx oral tablet mg-mcg (Amethyst) $0 syeda oral tablet mg (Yaz) $0 tarina fe /20 (28) oral tablet mg- 20 mcg (2)/75 mg (7) (Loestrin Fe) $0 tilia fe oral tablet -20(5)/-30(7) /mg-35mcg (9) (Loestrin Fe) $0 tri-estarylla oral tablet 0.8/0.25/0.25 mg-35 mcg (28) (Ortho-Cyclen) $0 tri-legest fe oral tablet -20(5)/- 30(7) /mg-35mcg (9) (Loestrin Fe) $0 tri-linyah oral tablet 0.8/0.25/0.25 mg-35 mcg (28) (Ortho-Cyclen) $0 tri-lo-estarylla oral tablet 0.8/0.25/0.25 mg-25 mcg (Ortho-Cyclen) $0 tri-lo-marzia oral tablet 0.8/0.25/0.25 mg-25 mcg (Ortho-Cyclen) $0 tri-lo-sprintec oral tablet 0.8/0.25/0.25 mg-25 mcg (Ortho-Cyclen) $0 trinessa (28) oral tablet 0.8/0.25/0.25 mg-35 mcg (28) (Ortho-Cyclen) $0 tri-previfem (28) oral tablet 0.8/0.25/0.25 mg-35 mcg (28) (Ortho-Cyclen) $0 tri-sprintec (28) oral tablet 0.8/0.25/0.25 mg-35 mcg (28) (Ortho-Cyclen) $0 trivora (28) oral tablet (6)/75-40 (5)/25-30(0) (Amethyst) $0 0

125 velivet triphasic regimen (28) oral tablet 0./.25/.5-25 mg-mcg (Desogen) $0 vestura (28) oral tablet mg (Yaz) $0 vienva oral tablet mg-mcg (Amethyst) $0 viorele (28) oral tablet mgx2 /0.0 mg x 5 (Mircette) $0 vyfemla (28) oral tablet mgmcg (Modicon) $0 wera (28) oral tablet mg-mcg (Modicon) $0 xulane transdermal patch weekly mcg/24 hr (Ortho Evra) $0 zarah oral tablet mg (Yaz) $0 zenchent (28) oral tablet mgmcg (Modicon) $0 zovia /35e (28) oral tablet -35 mg-mcg (Demulen -50-2) $0 zovia /50e (28) oral tablet -50 mg-mcg (Demulen -50-2) $0 Cough And Cold Products Cough And Cold Products 5dm-5peh-2cpm liquid strawberry mg/5 ml * 25cpd-200gfn liquid mg/5 ml * 30pse-50gfn-5dm liquid mg/5 ml * 3brm-5dm-30pse liquid mg/5 ml * 3brm-30dm-50pse liquid (otc) mg/5 ml * actinel pediatric liquid mg/5 ml * adt robitussin linger cold syr 5 mg/5 ml * adt robitussin peak cld dm max mg/5 ml * (Chlorpheniramine/ Phenyleph/Dm) (Chlophedianol HCl/Guaifenesin) (Trispec Pse) (Brompheniramine/ Pseudoephed/Dm) (Brompheniramine/ Pseudoephed/Dm) (Trispec Pse) (Dextromethorphan Hbr) (G-Zyncof) QL (3 per 28 days)

126 adult robitussin peak cold liq nondrowsy 0-00 mg/5 ml * (G-Zyncof) adult wal-tussin dm max liq (G-Zyncof) a/f,cherry menthol mg/5 ml * adult wal-tussin dm syrup (Cough Formula a/f,cherry,adult 0-00 mg/5 ml * Dm) (Robitussin adult wal-tussin liquid 00 mg/5 ml Mucus-Chest * Congest) alka-seltzer plus mucus-conges 0- (Guaifenesin/Dextr 200 mg * omethorphan) ambi 0peh-4cpm-20dm tablet 4-0- (Chlorpheniramine/ 20 mg * Phenyleph/Dm) ambi 20dm-4cpm tablet 4-20 mg * (Coricidin Hbp) ambi 40pse-400gfn-20dm tablet mg * (Poly-Vent Dm) ambi 60pse-4cpm-20dm tablet (Chlorpheniramin/ 20 mg * Pseudoephed/Dm) benzonatate 00 mg capsule 00 mg * (Zonatuss) 3 $0 benzonatate 50 mg capsule 50 mg * (Zonatuss) 3 $0 benzonatate 200 mg capsule 200 mg * (Zonatuss) 3 $0 bio-dtuss dmx liquid mg/5 (Brompheniramine/ ml * Pseudoephed/Dm) bionel pediatric liquid mg/5 ml * (Trispec Pse) biospec dmx liquid 5-25 mg/5 ml * (G-Zyncof) bp 8 cough oral suspension a/f, (Guaifenesin/Dm/P grape (otc) mg/5 ml * seudoephedrine) bpm-pse-dm liquid a/f, cotton candy (Brompheniramine/ (otc) mg/5 ml * Pseudoephed/Dm) bromfed dm cough syrup (Brompheniramine/ mg/5 ml * Pseudoephed/Dm) 3 $0 bromphenex dm syrup (otc) mg/5 ml * 2

127 bromphenir-pseudoephed-dm syr (rx) mg/5 ml * brom-pse-dm cough syrup butter scotch (otc) mg/5 ml * centergy dm pediatric drops -2-3 mg/ml * cheracol d cough formula 0-00 mg/5 ml * cheratussin dac syrup mg/5 ml * child sudafed pe cough-cold lq mg/5 ml * child triaminic cgh-congst syr 5-00 mg/5 ml * child wal-tussin 7.5 mg odt 7.5 mg * children's mucinex cough liq a/f 5-00 mg/5 ml * children's silfedrine liq 5 mg/5 ml * childs sudafed 5 mg/5 ml liq nondrowsy,a/f,s/f 5 mg/5 ml * chl mucinex chest congest liq a/f 00 mg/5 ml * chld triaminic cgh-sor thr sus 60-5 mg/5 ml * codituss dm syrup mg/5 ml * cold multi-symptom day-night pseudoephedrine-free mg * cold relief multi-symp caplet cplt,2 day,2 night mg * cold-flu relief d/n softgel mg(d)/ mg * (Brompheniramine/ Pseudoephed/Dm) (Brompheniramine/ Pseudoephed/Dm) (Chlorpheniramine/ Phenyleph/Dm) (G-Zyncof) (Tusnel C) (Dextromethorphan /Phenylephrine) (Cough Formula Dm) (Dextromethorphan Hbr) (G-Zyncof) (Pseudoephedrine HCl) (Pseudoephedrine HCl) (Robitussin Mucus-Chest Congest) (Acetaminophen/D extromethorphan) (Pyrilamine/Pe/De xtromethorphan) (Dm Hb/Pe/Acetaminop hen/chlorph) (Dm Hb/Pe/Acetaminop hen/chlorph) (Vicks Dayquil- Nyquil) 3

128 cold-flu relief liquid ,000 mg/30 ml * (D- Methorphan/Aceta min/doxylamn) congestac tablet mg * (Poly-Vent Ir) congest-eze mg caplet mg * (Poly-Vent Ir) coricidin hbp cold-multi sympt mg/5 ml * (D- Methorphan/Aceta min/doxylamn) coricidin hbp softgel mg * (Guaifenesin/Dextr omethorphan) cough & cold tablet 4-30 mg * (Coricidin Hbp) cvs chest cong relief pe tab mg * (Maxiphen) cvs chest congest relief dm tb mg * (Allfen Dm) cvs child cold-cough day liq (Dextromethorphan mg/5 ml * /Phenylephrine) (Robitussin cvs child's chest congest liq 00 Mucus-Chest mg/5 ml * Congest) cvs cough & sore throat susp 60-5 mg/5 ml * cvs daytime-nighttime cold-flu multi-symp,twin pack mg/5 ml * cvs tussin cgh 5 mg liq gels nondrowsy, liq gels 5 mg * cvs tussin dm cough-chest liq mg/5 ml * cvs tussin max-str syrup 5 mg/5 ml * daytime cold & cough liquid, mg/30 ml * daytime cold-flu liquid a/f, glutenfree mg/5 ml * (Acetaminophen/D extromethorphan) (Dm/Pe/Acetamino phen/doxylamine) (Robitussin) (G-Zyncof) (Dextromethorphan Hbr) (Triaminic) (D- Methorphan/Pe/Ac etaminophen) 4

129 daytime cough liquid a/f, gluten-free (Dextromethorphan 5 mg/5 ml * Hbr) daytime-nighttime cough liquid (Dextromethorphan 5mg/5ml(d)/ mg/30ml * Hb/Doxylamine) delsym cough+chest cngst dm lq 5-00 mg/5 ml * (G-Zyncof) despec-dm tablet mg * (Poly-Vent Dm) dextromethorphan er 30 mg/5 ml 30 mg/5 ml * (Delsym) diabetic tussin dm liquid 0-00 mg/5 ml * (G-Zyncof) diabetic tussin dm max-str liq mg/5 ml * (G-Zyncof) ed bron gp liquid 5-00 mg/5 ml * (Despec) entre-cough liquid mg/5 ml * (Trispec Pse) expectorant 00 mg/5 ml syrup 00 mg/5 ml * expectorant dm cough liquid mg/5 ml * expectorant max cough-cold 30-5 mg/5 ml * geri-tussin dm syrup 0-00 mg/5 ml * guaifenesin 200 mg tablet (otc) 200 mg * guaifenesin dac oral solution mg/5 ml * guaifenesin er 600 mg tablet 600 mg * head congestion day-night pack mg * hydrocodone-chlorphen er susp 0-8 mg/5 ml * (Robitussin Mucus-Chest Congest) (G-Zyncof) (Dextromethorphan /Pseudoephed) (Cough Formula Dm) (Allfen) (Tusnel C) (Mucinex) (Dm Hb/Pe/Acetaminop hen/chlorph) (Tussionex) 3 $0 5

130 hydrocodone-homatropine 5-.5 mg tablet 5-.5 mg * hydromet syrup 5-.5 mg/5 ml * (Tussigon) 3 $0 (Hydrocodone Bit/Homatrop Me- Br) 3 $0 liquibid d-r tablet mg * (Maxiphen) lohist-dm syrup mg/5 ml * (Ala-Hist Dm) 3 $0 lortuss ex liquid mg/5 ml (Tusnel C) * mar-cof bp liquid mg/5 ml (Bromphenira/Pseu 3 $0 * doephed/codein) mar-cof cg liquid mg/5 ml * (M-Clear Wc) 3 $0 mucus dm mg tablet (Mucinex Dm) mg * mucus dm max tablet 60-,200 mg * (Mucinex Dm) mucus relief 400 mg tablet d/f 400 (Allfen) mg * nasal-sinus decongest tab 30 mg * (Sudafed 2-Hour) neo-tuss liquid mg/5 ml * (G-Zyncof) NEXAFED 30 MG TABLET 30 MG * NIGHT TIME COLD-FLU RLF SFTGL SFTGL, MULTI- SYMPTOM MG * (Dnight time cough & sore throat 2.5- Methorphan/Aceta 30-,000 mg/30 ml * min/doxylamn) mesehist dm oral syrup nasohist dm pediatric drops -2-3 nighttime cough liquid gluten-free, (Chlorpheniramin/ (Chlorpheniramine/ (Dextromethorphan mg/5 ml * mg/ml * cherry mg/5 ml * Pseudoephed/Dm) Phenyleph/Dm) Hb/Doxylamine) nighttime d cold-flu rlf liq multisymptom,cherry mg/5 ml * (Dm/P- Ephed/Acetaminop h/doxylam) 6

131 nohist-dm liquid mg/5 ml * pecgen dmx 25-5 mg/5 ml liq 5-25 mg/5 ml * pedia relief cough-cold liquid a/f, cherry -5-5 mg/5 ml * pediacare multi-symt cold liq non drowsy, grape mg/5 ml * phenylhistine dh liquid (otc) mg/5 ml * poly-tussin liquid mg/5 ml * promethazine vc-codeine syrup mg/5 ml * promethazine-codeine syrup mg/5 ml * promethazine-dm syrup mg/5 ml * pseudoephed 30 mg/5 ml soln 30 mg/5 ml * pseudoephedrine 30 mg tablet 30 mg * pseudoephedrine 60 mg tablet exstr, non drowsy (otc) 60 mg * pv flu relief therapy liquid daytime mg/5 ml * pv night-time softgel multisympt.,softgel mg * (Chlorpheniramine/ Phenyleph/Dm) (G-Zyncof) (Chlorpheniramin/ Pseudoephed/Dm) (Dextromethorphan /Phenylephrine) (P-Ephed HCl/Cod/Chlorphe nir) (Chlorcyclizine/Co deine) (Promethazine/Phe nyleph/codeine) (Promethazine HCl/Codeine) (Promethazine/Dex tromethorphan) (Pseudoephedrine HCl) 3 $0 3 $0 3 $0 (Sudafed 2-Hour) (Sudafed 2-Hour) (D- Methorphan/Pe/Ac etaminophen) (Dm/P- Ephed/Acetaminop h/doxylam) pv tussin pe liquid 5-00 mg/5 ml * (Despec) q-tapp dm elixir -5-5 mg/5 ml * (Brompheniramine/ Pseudoephed/Dm) (Robitussin q-tussin 00 mg/5 ml solution a/f, Mucus-Chest non-drowsy 00 mg/5 ml * Congest) 7

132 q-tussin dm syrup 0-00 mg/5 ml * ra child plus cough-runny nose pseudoephedrine free mg/5 ml * ra daytime-nighttime softgel cold-flu relief mg(d)/ mg * ra flu formula gelcap mg * ra maximum strength flu tablet mg * ra mucus relief 400 mg tablet 400 mg * ra multi-symptom cold caplet nighttime,cplt mg * (Cough Formula Dm) (Dextromethorphn/ Acetaminoph/Cp) (Vicks Dayquil- Nyquil) (Dm/Pe/Acetamino ph/diphenhydram) (Coricidin Hbp) (Allfen) (Dm Hb/Pe/Acetaminop hen/chlorph) (Cough Formula Dm) ra tussin dm syrup a/f 0-00 mg/5 ml * refenesen 200 mg tablet 200 mg * (Allfen) refenesen pe caplet mg * (Maxiphen) relcof c liquid mg/5 ml * (M-Clear Wc) 3 $0 REZIRA SOLUTION 60-5 MG/5 ML * robafen 00 mg/5 ml syrup 00 mg/5 ml * robafen cough 5 mg liquidgel nondrowsy,liquidgel 5 mg * robafen-dm syrup 0-00 mg/5 ml * robitussin cough-chest-cong dm mg * ROBITUSSIN LONG-ACTING LIQ -7.5 MG/5 ML * robitussin pediatric cough syp a/f,long-acting 7.5 mg/5 ml * (Robitussin Mucus-Chest Congest) 3 $0 (Robitussin) (Cough Formula Dm) (Guaifenesin/Dextr omethorphan) (Dextromethorphan Hbr) 8

133 rydex liquid mg/5 ml * rynex dm liquid a/f, prof use only mg/5 ml * safetussin dm liquid 0-00 mg/5 ml * scot-tussin 00 mg/5 ml liq 00 mg/5 ml * scot-tussin dm s-f liquid 2-5 mg/5 ml * siltussin dm cough syrup 0-00 mg/5 ml * siltussin sa 00 mg/5 ml syr 00 mg/5 ml * sm adult nasal decongestant lq 5 mg/5 ml * sm childrens plus cold susp grape,multi-symptom mg/5 ml * sm cold-cough child elixir -5-5 mg/5 ml * sm cough & runny nose liquid -5 mg/5 ml * sm cough-head congestion lq mg/5 ml * sm flu severe cold-congestion maximum strength ,000 mg * sm mucus relief cough liquid childrens, a/f 5-00 mg/5 ml * sm nite time cold-flu liquid ,000 mg/30 ml * (Bromphenira/Pseu doephed/codein) (Brompheniram/Ph enylephrine/dm) (G-Zyncof) (Robitussin Mucus-Chest Congest) (Vicks Children'S Nyquil) (Cough Formula Dm) (Robitussin Mucus-Chest Congest) (Pseudoephedrine HCl) (Dm Hb/Pe/Acetaminop hen/chlorph) (Brompheniramine/ Pseudoephed/Dm) (Vicks Children'S Nyquil) (Trispec Pse) (Dm Hb/Pseudoephed/A cetamin/cp) (G-Zyncof) (Dm/P- Ephed/Acetaminop h/doxylam) 9

134 sm nite time cold-flu rel sfgl softgel mg * sm pain reliever cold caplet mg * (Dm/P- Ephed/Acetaminop h/doxylam) (Dm Hb/Pseudoephed/A cetamin/cp) (Chlorpheniramin/ Pseudoephed/Dm) (Dm/Pseudoephed/ Acetaminophen) (Guaifenesin/Dm/P seudoephedrine) sm pedia relief liquid -5-5 mg/5 ml * sm severe cold m-s caplet mg * sm tussin cf syrup mg/5 ml * sudafed 30 mg tablet nondrowsy,max-str 30 mg * (Sudafed 2-Hour) sudogest 30 mg tablet boxed 30 mg * (Sudafed 2-Hour) sudogest 60 mg tablet 60 mg * (Sudafed 2-Hour) suphedrin liquid 5 mg/5 ml * (Pseudoephedrine HCl) suphedrine pe combo pack cplt 5- (Diphenhydram/Pe/ mg * Dm/Acetamin/Gg) THERAFLU COLD AND COUGH POWDER MG * THERAFLU MULTI-SYMP COLD CPLT MG * TRIAMINIC COUGH-SORE THROAT LQ A/F,CHILDREN'S 60-5 MG/5 ML * triaminic daytime cold-cough (Dextromethorphan children's, cherry mg/5 ml * /Phenylephrine) tri-dex pe oral syrup mg/5 (Chlorpheniramine/ ml * Phenyleph/Dm) trymine cg liquid mg/5 ml * (M-Clear Wc) tusnel diabetic liquid (otc) 0-00 mg/5 ml * (G-Zyncof) TUSNEL LIQUID A/F,A/F,D/F MG/5 ML * 20

135 TUSNEL PEDIATRIC LIQUID (RX) MG/5 ML * TUSSI PRES-B LIQUID MG/5 ML * tussin cf cough-cold syrup a/f mg/5 ml * (Maxiphen Dmx) tussin cold-congestion gelcap liquid (Guaifenesin/Dm/P gelcap mg * seudoephedrine) tussin dm syrup 5-00 mg/5 ml * (Cough Formula Dm) VANACOF LIQUID MG/5 ML * vicks dayquil cough liquid a/f,8 hr (Dextromethorphan rlf 5 mg/5 ml * Hbr) (Dvicks dayquil liquicaps cold & flu 5- Methorphan/Pe/Ac mg * etaminophen) vicks nature fusion cough liq 5 mg/5 (Dextromethorphan ml * Hbr) vicks nyquil severe cold-flu (Dm/Pe/Acetamino mg/5 ml * phen/doxylamine) virdec dm drops mg/ml * (Chlorpheniramine/ Phenyleph/Dm) virtussin ac liquid 0-00 mg/5 ml * (M-Clear Wc) v-r infant non-asa cold drp (Dm/Pseudoephed/ mg/.6 ml * Acetaminophen) v-r non-aspirin flu gelcap gelatin (Dm/Pseudoephed/ caplet mg * Acetaminophen) v-r pedia relief inf drops (Dextromethorphan decongestant mg/0.8 ml * /Pseudoephed) vr triacting cold-cough liq -5-5 (Chlorpheniramin/ mg/5 ml * Pseudoephed/Dm) v-r tussin cf syrup mg/5 (Guaifenesin/Dm/P ml * seudoephedrine) wal-phed 30 mg tablet non-drowsy 30 mg * (Sudafed 2-Hour) 2

136 wal-phed pe day-night combo pk (Diphenhydram/Pe/ gluten-free mg * Dm/Acetamin/Gg) wal-tussin cough 5 mg softgel 5 mg * (Robitussin) wal-tussin cough 5 mg/5 ml 5 (Dextromethorphan mg/5 ml * Hbr) wal-tussin cough-cold cf liq pseudoephedrine free (Maxiphen Dmx) mg/5 ml * zephrex-d 30 mg tablet 30 mg * (Sudafed 2-Hour) ZONATUSS 50 MG CAPSULE 50 MG * 3 $0 zyncof mg/5 ml liquid mg/5 ml * (G-Zyncof) Dental And Oral Agents Dental And Oral Agents cevimeline oral capsule 30 mg (Evoxac) $0 chlorhexidine gluconate mucous membrane mouthwash 0.2 % oralone dental paste 0. % periogard mucous membrane mouthwash 0.2 % pilocarpine hcl oral tablet 5 mg, 7.5 mg PREVIDENT 5000 SENSITIVE DENTAL PASTE.-5 % triamcinolone acetonide dental paste 0. % (Peridex) $0 (Triamcinolone Acetonide) $0 (Peridex) $0 (Salagen) $0 (Triamcinolone Acetonide) $0 $0 Dermatological Agents Dermatological Agents, Other 8-MOP ORAL CAPSULE 0 MG acitretin oral capsule 0 mg, 7.5 mg, 25 mg (Soriatane) $0 acne medication 0% lotion 0 % * (Benzoyl Peroxide) 22

137 ACNE MEDICATION 5% LOTION 5 % * acneclear gel 0 % * (Benzoyl Peroxide) acyclovir topical ointment 5 % (Zovirax) $0 QL (30 per 30 days) ALCOHOL PADS TOPICAL PADS, MEDICATED $0 ALCOHOL PREP PADS $0 amlactin 2% lotion 2 % * (Ammonium Lactate) ammonium lactate 2% cream (Ammonium fragrance free (otc) 2 % * Lactate) ammonium lactate 2% lotion (otc) (Ammonium 2 % * Lactate) ammonium lactate topical cream 2 % (Lac-Hydrin) $0 ammonium lactate topical lotion 2 % (Lac-Hydrin) $0 ANACAINE TOPICAL OINTMENT 0 % benzoyl peroxide 0% gel aqueous (otc) 0 % * (Benzoyl Peroxide) benzoyl peroxide 5% gel aqueous (otc) 5 % * (Benzoyl Peroxide) BETADINE 5% SPRAY 5 % * calcipotriene scalp solution % (Calcipotriene) $0 calcipotriene topical cream % (Dovonex) $0 calcipotriene topical ointment % (Calcipotriene) $0 calcitrene topical ointment % (Calcipotriene) $0 calcitriol topical ointment 3 mcg/gram (Vectical) $0 CASTELLANI PAINT MODIFIED.5 % * CONDYLOX TOPICAL GEL 0.5 % COSENTYX (50 MG/ML) 300 PA MG DOSE-2 PENS 50 MG/ML 23

138 COSENTYX (50 MG/ML) 300 MG DOSE-2 SYRINGES 50 MG/ML COSENTYX PEN SUBCUTANEOUS PEN INJECTOR 50 MG/ML COSENTYX SUBCUTANEOUS SYRINGE 50 MG/ML cvs skin treatment body lotion 2 % * fluorouracil topical cream 0.5 %, 5 % fluorouracil topical solution 2 %, 5 % (Ammonium Lactate) (Carac) $0 (Fluorouracil) $0 geri-hydrolac 2% lotion 2 % * (Ammonium Lactate) geri-hydrolac 5% lotion 5 % * (Ammonium Lactate) imiquimod topical cream in packet 5 PA NSO; QL (24 per (Aldara) $0 % 30 days) LACTINOL HX CREAM * lobana bath oil * (Mineral Oil) methoxsalen rapid oral capsule 0 mg (Oxsoralen-Ultra) $0 PANRETIN TOPICAL GEL 0. % persa-gel 0% 2's,max-strength 0 % * (Benzoyl Peroxide) PICATO TOPICAL GEL 0.05 % QL (3 per 56 days) PICATO TOPICAL GEL 0.05 % QL (2 per 56 days) podocon topical liquid 25 % (Podophyllum Resin) $0 podofilox topical solution 0.5 % (Condylox) $0 potassium hydroxide topical (Potassium solution 5 % Hydroxide) $0 pv acne pimple 0% gel 0 % * (Benzoyl Peroxide) SANTYL TOPICAL OINTMENT 250 UNIT/GRAM PA PA PA 24

139 TALTZ AUTOINJECTOR PA SUBCUTANEOUS AUTO- INJECTOR 80 MG/ML TALTZ SYRINGE PA SUBCUTANEOUS SYRINGE 80 MG/ML TOLAK TOPICAL CREAM 4 % VALCHLOR TOPICAL GEL 0.06 % zenatane oral capsule 0 mg, 20 mg, (Isotretinoin) 30 mg, 40 mg $0 zinc oxide 20% ointment 20 % * (Boudreauxs) ZOVIRAX TOPICAL CREAM 5 % QL (5 per 30 days) Dermatological Antibacterials bacitracin 500 unit/gm ointmnt 500 unit/gram * (Bacitracin) bacitraycin plus 500 unit/gm 500 unit/gram * (Bacitracin) clindamycin phosphate topical gel % (Cleocin T) $0 clindamycin phosphate topical lotion % (Cleocin T) $0 clindamycin phosphate topical solution % (Cleocin T) $0 clindamycin phosphate topical swab % cvs triple antibiotic ointment 3.5mg- 400 unit- 5,000 unit/gram * ery pads topical swab 2 % erythromycin with ethanol topical gel 2 % erythromycin with ethanol topical solution 2 % (Cleocin T) $0 (Neomycin Su/Bacitrac Zn/Poly) (Erythromycin Base/Ethanol) $0 (Erygel) $0 (Erythromycin Base/Ethanol) $0 25

140 erythromycin with ethanol topical (Erythromycin swab 2 % Base/Ethanol) $0 gentamicin topical cream 0. % (Gentamicin Sulfate) $0 gentamicin topical ointment 0. % (Gentamicin Sulfate) $0 metronidazole topical cream 0.75 % (Metrocream) $0 metronidazole topical gel 0.75 %, % (Rosadan) $0 metronidazole topical lotion 0.75 % (Metrolotion) $0 mupirocin calcium topical cream 2 % (Bactroban) $0 mupirocin topical ointment 2 % (Centany) $0 neomycin-polymyxin b gu irrigation (Neosporin G.U. solution 40 mg-200,000 unit/ml Irrigant) $0 (Neomycin neosporin ointment 3.5mg-400 unit- Su/Bacitrac 5,000 unit/gram * Zn/Poly) rosadan topical cream 0.75 % (Metrocream) $0 selenium sulfide topical lotion 2.5 % (Selenium Sulfide) $0 selenium sulfide topical shampoo 2.25 % (Selenium Sulfide) $0 silver nitrate topical ointment 0 % (Silver Nitrate) $0 silver nitrate topical solution 0.5 %, 0 %, 25 %, 50 % (Silver Nitrate) $0 silver sulfadiazine topical cream % (Silvadene) $0 ssd topical cream % (Silvadene) $0 sulfacetamide sodium (acne) topical suspension 0 % (Klaron) $0 (Neomycin triple antibiotic ointment carton Su/Bacitrac 3.5mg-400 unit- 5,000 unit/gram * Zn/Poly) Dermatological Anti- Inflammatory Agents ala-cort topical cream % (Anusol-HC) $0 ala-scalp topical lotion 2 % (Scalacort) $0 26

141 (Alclometasone alclometasone topical cream 0.05 % $0 Dipropionate) alclometasone topical ointment 0.05 (Alclometasone $0 % Dipropionate) aquanil hc % lotion % * (Cortizone-0) beta hc % lotion % * (Cortizone-0) $0 $0 $0 $0 betamethasone valerate topical (Luxiq) $0 foam 0.2 % $0 $0 betamethasone, augmented topical (Diprolene AF) $0 cream 0.05 % $0 betamethasone, augmented topical (Diprolene) $0 lotion 0.05 % betamethasone, augmented topical (Diprolene) $0 ointment 0.05 % clobetasol 0.05% cream 0.05 % (Temovate) $0 (Clobetasol clobetasol scalp solution 0.05 % $0 Propionate) clobetasol topical foam 0.05 % (Olux) $0 (Clobetasol clobetasol topical gel 0.05 % $0 Propionate) clobetasol topical lotion 0.05 % (Clobex) $0 clobetasol topical ointment 0.05 % (Temovate) $0 clobetasol topical shampoo 0.05 % (Clobex) $0 betamethasone dipropionate topical betamethasone dipropionate topical betamethasone dipropionate topical betamethasone valerate topical betamethasone valerate topical betamethasone valerate topical betamethasone, augmented topical (Betamethasone (Betamethasone (Betamethasone (Betamethasone (Betamethasone (Betamethasone (Betamethasone cream 0.05 % lotion 0.05 % ointment 0.05 % cream 0. % lotion 0. % ointment 0. % gel 0.05 % Dipropionate) Dipropionate) Dipropionate) Valerate) Valerate) Valerate) Dipropionate) 27

142 clobetasol-emollient topical cream 0.05 % (Temovate) $0 clocortolone pivalate topical cream 0. % (Cloderm) $0 colocort rectal enema 00 mg/60 ml (Cortenema) $0 cormax scalp solution 0.05 % (Clobetasol Propionate) $0 cortizone-0 % creme maximum strength % * (Hydrocortisone) CORTIZONE-0 % LOTION % * cortizone-0 % ointment % * (Hydrocortisone) dermarest eczema % lotion % * (Cortizone-0) desonide topical cream 0.05 % (Desowen) $0 desonide topical ointment 0.05 % (Desonide) $0 desoximetasone topical cream 0.05 %, 0.25 % (Topicort) $0 desoximetasone topical gel 0.05 % (Topicort) $0 desoximetasone topical ointment 0.05 %, 0.25 % (Topicort) $0 ELIDEL TOPICAL CREAM % fluocinonide topical cream 0.05 % (Vanos) $0 fluocinonide topical gel 0.05 % (Fluocinonide) $0 fluocinonide topical ointment 0.05 % (Fluocinonide) $0 fluocinonide topical solution 0.05 % (Fluocinonide) $0 fluticasone topical cream 0.05 % (Cutivate) $0 fluticasone topical ointment % (Fluticasone Propionate) $0 halobetasol propionate topical cream 0.05 % (Ultravate) $0 halobetasol propionate topical ointment 0.05 % (Ultravate) $0 hydro skin % lotion % * (Cortizone-0) hydrocortisone 0.5% cream (otc) 0.5 % * (Hydrocortisone) 28

143 hydrocortisone 0.5% ointment 0.5 % (Hydrocortisone) * hydrocortisone % cream maximum (Hydrocortisone) strength (otc) % * hydrocortisone % cream maximum (Hydrocortisone strength % * Acetate) hydrocortisone % lotion (otc) % (Cortizone-0) 3 $0 * hydrocortisone % ointment carton (Hydrocortisone) (otc) % * hydrocortisone acet-aloe vera (Hydrocortisone $0 topical gel 2 % Acetate/Aloe V) hydrocortisone buty 0.% cream 0. (Hydrocortisone $0 % Butyrate) hydrocortisone butyrate topical (Locoid) $0 ointment 0. % hydrocortisone butyrate topical (Locoid) $0 solution 0. % $0 hydrocortisone rectal enema 00 (Cortenema) $0 mg/60 ml hydrocortisone topical cream %, (Anusol-HC) $0 2.5 % hydrocortisone topical lotion 2.5 % (Scalacort) $0 hydrocortisone topical ointment (Hydrocortisone) $0 %, 2.5 % $0 hydrocortisone valerate topical (Westcort) $0 ointment 0.2 % mometasone topical cream 0. % (Elocon) $0 mometasone topical ointment 0. % (Elocon) $0 mometasone topical solution 0. % (Elocon) $0 neosporin % anti-itch cream % * (Hydrocortisone) ONFI ORAL TABLET 0 MG, 20 MG hydrocortisone butyr-emollient hydrocortisone valerate topical (Hydrocortisone (Hydrocortisone topical cream 0. % cream 0.2 % Butyrate) Valerate) PA NSO; QL (60 per 30 days) 29

144 prednicarbate topical cream 0. % (Dermatop) $0 prednicarbate topical ointment 0. % (Dermatop) $0 preparation h hc % cream % * (Hydrocortisone) procto-med hc rectal cream 2.5 % (Hydrocortisone) $0 procto-pak rectal cream % (Anusol-HC) $0 proctosol hc rectal cream 2.5 % (Hydrocortisone) $0 proctozone-hc rectal cream 2.5 % (Hydrocortisone) $0 recort plus % cream % * (Hydrocortisone) tacrolimus topical ointment 0.03 %, 0. % (Protopic) $0 triamcinolone acetonide topical (Triamcinolone cream %, 0. %, 0.5 % Acetonide) $0 triamcinolone acetonide topical (Triamcinolone lotion %, 0. % Acetonide) $0 triamcinolone acetonide topical (Triamcinolone ointment %, 0. %, 0.5 % Acetonide) $0 trianex topical ointment 0.05 % (Triamcinolone Acetonide) $0 u-cort topical cream -0 % (Hydrocortisone Acetate/Urea) $0 Dermatological Retinoids adapalene topical cream 0. % (Differin) $0 adapalene topical gel 0. % (Differin) $0 TAZORAC TOPICAL CREAM 0.05 %, 0. % tretinoin gel micro 0.04% tube 0.04 PA (Retin-A Micro) $0 % tretinoin gel micro 0.% tube 0. % (Retin-A Micro) $0 PA tretinoin microspheres topical gel PA (Retin-A Micro) $0 with pump 0.04 %, 0. % tretinoin topical cream %, PA (Retin-A) $ %, 0. % tretinoin topical gel 0.0 %, (Retin-A) $0 PA %, 0.05 % Scabicides And Pediculicides 30

145 cvs lice killing shampoo maximum strength % * (Piperonyl Butoxide/Pyrethrin s) cvs permethrin % lotion % * (Nix) malathion topical lotion 0.5 % (Ovide) $0 NIX % CREME RINSE LIQUID W/ NIT COMB % * permethrin topical cream 5 % (Elimite) $0 ra lice treatment % crm rinse 2x59ml, 2 combs % * (Nix) sm lice treatment permethrin 2's % * (Nix) v-r lice cream rinse % * (Nix) Devices Devices ASSURE ID INSULIN SAFETY SYRINGE ML 29 GAUGE X /2" BD INSULIN SYR 0.3 ML 3GX5/6 0.3 ML 3 GAUGE X 5/6 $0 $0 BD INSULIN SYR 0.5 ML 3GX5/6" 0.5 ML 3 GAUGE X $0 5/6 BD INSULIN SYR ML 3GX5/6" ML 3 GAUGE X $0 5/6 BD ULTRA-FINE PEN NDL 8MMX3G SHORT 3 GAUGE X $0 5/6" INSULIN SYRINGE-NEEDLE U- 00 SYRINGE 0.3 ML 29 GAUGE, ML 29 GAUGE X /2", /2 ML $0 28 GAUGE PEN NEEDLE, DIABETIC NEEDLE 29 GAUGE X /2" $0 VGO 40 DISPOSABLE DEVICE $0 3

146 Disinfectants (For Non- Dermatologic Use) Disinfectants (For Non- Dermatologic Use) sm iodine tincture * (Iodine) Enzyme Replacement/Modifiers Enzyme Replacement/Modifiers ADAGEN INTRAMUSCULAR SOLUTION 250 UNIT/ML ALDURAZYME INTRAVENOUS SOLUTION 2.9 MG/5 ML CEREZYME INTRAVENOUS RECON SOLN 400 UNIT CREON ORAL CAPSULE,DELAYED RELEASE(DR/EC) 2,000-38,000-60,000 UNIT, 24,000-76,000-20,000 UNIT, 3,000-9,500-5,000 UNIT, 36,000-4,000-80,000 UNIT, 6,000-9,000-30,000 UNIT ELAPRASE INTRAVENOUS SOLUTION 6 MG/3 ML ELITEK INTRAVENOUS RECON SOLN.5 MG, 7.5 MG FABRAZYME INTRAVENOUS RECON SOLN 35 MG KANUMA INTRAVENOUS SOLUTION 2 MG/ML KRYSTEXXA INTRAVENOUS SOLUTION 8 MG/ML KUVAN ORAL TABLET,SOLUBLE 00 MG MYOZYME INTRAVENOUS RECON SOLN 50 MG PA 32

147 NAGLAZYME INTRAVENOUS SOLUTION 5 MG/5 ML ORFADIN ORAL CAPSULE 0 MG, 2 MG, 20 MG, 5 MG pancrelipase 5000 oral capsule,delayed release(dr/ec) 5,000-7,000-27,000 unit PULMOZYME INHALATION SOLUTION MG/ML STRENSIQ SUBCUTANEOUS SOLUTION 00 MG/ML, 40 MG/ML VIMIZIM INTRAVENOUS SOLUTION 5 MG/5 ML ( MG/ML) VPRIV INTRAVENOUS RECON SOLN 400 UNIT ZAVESCA ORAL CAPSULE 00 MG ZENPEP ORAL CAPSULE,DELAYED RELEASE(DR/EC) 0,000-34,000-55,000 UNIT, 5,000-5,000-82,000 UNIT, 20,000-68,000-09,000 UNIT, 25,000-85,000-36,000 UNIT, 3,000-0,000-6,000 UNIT, 40,000-36,000-28,000 UNIT, 5,000-7,000-27,000 UNIT Eye, Ear, Nose, Throat Agents Eye, Ear, Nose, Throat Agents, Miscellaneous AKTEN (PF) OPHTHALMIC GEL (Zenpep) $0 3.5 % alcaine ophthalmic drops 0.5 % (Proparacaine HCl) $0 altacaine ophthalmic drops 0.5 % (Tetravisc) $0 altamist 0.65% nose spray 0.65 % * (Little Remedies) PA; LA PA QL (90 per 30 days) 33

148 apraclonidine ophthalmic drops 0.5 % artificial tears.4 % drops.4 % * artificial tears drops p/f, sterile % * (Iopidine) $0 (Polyvinyl Alcohol) (Dextran 70/Hypromellose/P F) artificial tears eye drops strl % * (Tears Naturale) artificial tears eye ointment 83-5 % (Genteal Pm) * atropine ophthalmic drops % (Isopto Atropine) $0 atropine ophthalmic ointment % (Atropine Sulfate) $0 atropine-care ophthalmic drops % (Isopto Atropine) $0 ayr saline 0.65% nose drops 0.65 % * (Sodium Chloride) ayr saline 0.65% nose spray 0.65 % * (Little Remedies) azelastine nasal aerosol,spray 37 mcg (0. %) (Astepro) $0 azelastine ophthalmic drops 0.05 % (Azelastine HCl) $0 (Dextran bion tears eye drops % * 70/Hypromellose/P F) carteolol ophthalmic drops % (Carteolol HCl) $0 cromolyn ophthalmic drops 4 % (Cromolyn Sodium) $0 cvs artificial tears drops sterile - (Glycerin/Propylen 0.3 % * e Glycol) cvs lubricant 0.5% eye drops sterile 0.5 % * (Refresh Tears) cvs lubricant dry eye rlf % % * cvs lubricant eye ointment p/f % * cvs lubricant gel eye drops % * (Carboxymethylcel lulose Sodium) (Genteal Pm) (Carboxymethylcel l/hypromellose) QL (30 per 25 days) 34

149 cvs lubricating eye drops dry eye soln % * cvs natural tears drops % * (Refresh Optive) (Dextran 70/Hypromellose/P F) cyclopentolate ophthalmic drops 0.5 (Cyclogyl) $0 %, %, 2 % CYSTARAN OPHTHALMIC DROPS 0.44 % deep sea 0.65% nose spray 0.65 % * (Little Remedies) (Oxymetazoline dristan long lasting mist 0.05 % * HCl) epinastine ophthalmic drops 0.05 % (Elestat) $0 (Genteal Mild To eq gentle 0.3% eye drops 0.3 % * Moderate) eq revive plus 0.5% eye drops 0.5 % (Carboxymethylcel * lulose Sodium) flucaine ophthalmic drops (Proparacaine/Fluo $0 % rescein Sod) GENTEAL GEL DROPS % * GENTEAL MILD 0.2% EYE DROPS 0.2 % * GENTEAL MILD-MODERATE EYE DROP P/F, DRY EYE RELIEF 0.3 % * GENTEAL SEVERE 0.3% EYE GEL P/F, STRL, INNER 0.3 % * genteal tears 0.%-0.3% drop 0.- (Tears Naturale) 0.3 % * (Isopto homatropaire ophthalmic drops 5 % $0 Homatropine) $0 ipratropium bromide nasal (Atrovent) $0 spray,non-aerosol 0.03 % homatropine hbr ophthalmic drops (Isopto 5 % Homatropine) QL (30 per 28 days) 35

150 ipratropium bromide nasal spray,non-aerosol 0.06 % isopto tears 0.5% eye drops 0.5 % * (Atrovent) $0 (Genteal Mild To Moderate) LACRISERT OPHTHALMIC INSERT 5 MG lubricant % eye drops 0.5- (Carboxymethylcel 0.9 % * l/glycerin/pf) lubricant % eye drops % * (Refresh Optive) lubricant 0.6% eye drops 0.6 % * (Propylene Glycol) lubrifresh pm eye ointment 83-5 % * (Genteal Pm) muro-28 2% eye drops 2 % * (Sodium Chloride) muro-28 5% eye drops 5 % * (Sodium Chloride) muro-28 5% eye ointment 5 % * (Sodium Chloride) naphazoline ophthalmic drops 0. % (Naphazoline HCl) $0 nasal decongestant 0.05% spray 0.05 % * (Afrin) natural balance tears drops 0.4 % * (Genteal Mild To Moderate) nature's tears drops 0.4 % * (Genteal Mild To Moderate) neo-synephrine 2 hour spray 0.05 (Oxymetazoline % * HCl) ocean 0.65% nasal spray 0.65 % * (Little Remedies) olopatadine ophthalmic drops 0. % (Patanol) $0 PATADAY OPHTHALMIC DROPS 0.2 % phenylephrine hcl ophthalmic drops 0 %, 2.5 % (Mydfrin) $0 proparacaine ophthalmic drops 0.5 % (Proparacaine HCl) $0 pure & gentle eye drops lubricant 0.3 % * pv artificial tears 0.4 % * (Genteal Mild To Moderate) (Genteal Mild To Moderate) QL (5 per 0 days) ST 36

151 pv lubricant.4 % eye drops.4 % (Polyvinyl * Alcohol) REFRESH CELLUVISC % EYE DROPS % * REFRESH CLASSIC EYE DROPS U-D,P/F,30X.4ML % * REFRESH LACRI-LUBE OINTMENT % * REFRESH OPTIVE EYE DROPS % * (Carboxymethylcel retaine cmc 0.5% eye drops 0.5 % * lulose Sodium) saline mist 0.65% nose spry 0.65 % (Little Remedies) * sea soft 0.65% nasal mist 0.65 % * (Little Remedies) sm lubricant eye drops strl (Systane) % * sodium chloride 5% eye drop 5 % * (Sodium Chloride) sodium chloride 5% eye oint 5 % * (Sodium Chloride) SYSTANE % EYE DROPS % * SYSTANE GEL EYE DROPS % * (Polyvinyl tears again.4 % drops.4 % * Alcohol) tears again eye ointment % * (Genteal Pm) (Dextran tears naturale free drops u- 70/Hypromellose/P d,36x.9ml,p/f % * F) $0 (Lanolin/Mineral ultra fresh pm ointment * Oil/Petrolatum) (Oxymetazoline vicks qlearquil 0.05% mist 0.05 % * HCl) pv pure-gentle eye drops sterile 0.3 tetracaine hcl (pf) ophthalmic drops (Genteal Mild To (Tetracaine % * 0.5 % Moderate) HCl/PF) 37

152 vicks sinex 2 hour spray 0.05 % * (Afrin) Eye, Ear, Nose, Throat Anti-Infectives Agents acetic acid otic solution 2 % (Acetic Acid) $0 bacitracin ophthalmic ointment 500 unit/gram (Bacitracin) $0 bacitracin-polymyxin b ophthalmic (Bacitracin/Polymy ointment 500-0,000 unit/gram xin B Sulfate) $0 bleph-0 ophthalmic drops 0 % (Sulfacetamide Sodium) $0 CIPRODEX OTIC DROPS,SUSPENSION % ciprofloxacin hcl ophthalmic drops 0.3 % (Ciloxan) $0 ciprofloxacin hcl otic dropperette 0.2 % (Cetraxal) $0 COLY-MYCIN S OTIC DROPS,SUSPENSION MG/ML erythromycin ophthalmic ointment 5 mg/gram (0.5 %) (Ilotycin) $0 gatifloxacin ophthalmic drops 0.5 % (Zymaxid) $0 gentak ophthalmic ointment 0.3 % (3 mg/gram) (Garamycin) $0 gentamicin ophthalmic drops 0.3 % (Garamycin) $0 gentamicin ophthalmic ointment 0.3 % (3 mg/gram) (Garamycin) $0 levofloxacin ophthalmic drops 0.5 % (Levofloxacin) $0 MOXEZA OPHTHALMIC DROPS, VISCOUS 0.5 % NATACYN OPHTHALMIC DROPS,SUSPENSION 5 % neomycin-bacitracin-poly-hc ophthalmic ointment ,000 mg-unit/g-% (Neomycin Su/Baci Zn/Poly/HC) $0 38

153 neomycin-bacitracin-polymyxin ophthalmic ointment ,000 mg-unit-unit/g neomycin-polymyxin b-dexameth ophthalmic drops,suspension 3.5mg/ml-0,000 unit/ml-0. % neomycin-polymyxin b-dexameth ophthalmic ointment 3.5 mg/g- 0,000 unit/g-0. % neomycin-polymyxin-gramicidin ophthalmic drops.75 mg-0,000 unit-0.025mg/ml neomycin-polymyxin-hc ophthalmic drops,suspension 3.5-0,000-0 mgunit-mg/ml neomycin-polymyxin-hc otic drops,suspension 3.5-0,000- mg/ml-unit/ml-% neomycin-polymyxin-hc otic solution 3.5-0,000- mg/mlunit/ml-% neo-polycin hc ophthalmic ointment ,000 mg-unit/g-% (Neomycin Su/Bacitra/Polymy xin) $0 (Maxitrol) $0 (Maxitrol) $0 (Neosporin) $0 (Neomycin/Polymy xin B Sulf/HC) (Neomycin/Polymy xin B Sulf/HC) $0 $0 (Cortisporin) $0 (Neomycin Su/Baci Zn/Poly/HC) $0 (Neomycin neo-polycin ophthalmic ointment Su/Bacitra/Polymy ,000 mg-unit-unit/g xin) $0 ofloxacin ophthalmic drops 0.3 % (Floxin) $0 ofloxacin otic drops 0.3 % (Floxin) $0 polymyxin b sulf-trimethoprim ophthalmic drops 0,000 unit- mg/ml REFRESH OPTIVE ADVANCED DROPS % * sulfacetamide sodium ophthalmic drops 0 % sulfacetamide sodium ophthalmic ointment 0 % (Polytrim) $0 (Sulfacetamide Sodium) (Sulfacetamide Sodium) $0 $0 39

154 sulfacetamide-prednisolone ophthalmic drops 0 %-0.23 % (0.25 %) TOBRADEX OPHTHALMIC OINTMENT % TOBRADEX ST OPHTHALMIC DROPS,SUSPENSION % (Sulfacetamide/Pre dnisolone Sp) $0 tobramycin ophthalmic drops 0.3 % (Tobrex) $0 tobramycin-dexamethasone ophthalmic drops,suspension (Tobradex) $0 % trifluridine ophthalmic drops % (Viroptic) $0 VIGAMOX OPHTHALMIC DROPS 0.5 % ZIRGAN OPHTHALMIC GEL 0.5 % ZYLET OPHTHALMIC DROPS,SUSPENSION % Eye, Ear, Nose, Throat Anti-Inflammatory Agents ALREX OPHTHALMIC DROPS,SUSPENSION 0.2 % bromfenac ophthalmic drops 0.09 % dexamethasone sodium phosphate ophthalmic drops 0. % diclofenac sodium ophthalmic drops 0. % DUREZOL OPHTHALMIC DROPS 0.05 % flunisolide nasal spray,non-aerosol 25 mcg (0.025 %) fluorometholone ophthalmic drops,suspension 0. % flurbiprofen sodium ophthalmic drops 0.03 % (Bromfenac Sodium) $0 (Dexasol) $0 (Diclofenac Sodium) $0 (Flunisolide) $0 (FML) $0 (Ocufen) $0 ST QL (50 per 25 days) 40

155 fluticasone nasal spray,suspension 50 mcg/actuation ILEVRO OPHTHALMIC DROPS,SUSPENSION 0.3 % ketorolac ophthalmic drops 0.4 %, 0.5 % LOTEMAX OPHTHALMIC DROPS,GEL 0.5 % LOTEMAX OPHTHALMIC DROPS,SUSPENSION 0.5 % LOTEMAX OPHTHALMIC OINTMENT 0.5 % NEVANAC OPHTHALMIC DROPS,SUSPENSION 0. % prednisolone acetate ophthalmic drops,suspension % prednisolone sodium phosphate ophthalmic drops % PROLENSA OPHTHALMIC DROPS 0.07 % RESTASIS OPHTHALMIC DROPPERETTE 0.05 % XIIDRA OPHTHALMIC DROPPERETTE 5 % Gastrointestinal Agents Antiflatulents bicarsim forte 25 mg tablet 25 mg * cvs gas relief 25 mg chew tab extra strength 25 mg * cvs gas relief 25 mg softgel softgel 25 mg * cvs gas relief 80 mg tab chew 80 mg * gas relief 25 mg chew tablet max str,lactose-free 25 mg * (Fluticasone Propionate) $0 (Acular) $0 (Omnipred) $0 (Prednisolone Sod Phosphate) $0 (Simethicone) (Gas-X) (Phazyme) (Gas-X) (Gas-X) QL (60 per 30 days) PA; QL (60 per 30 days) 4

156 gas relief 80 mg tablet chew lactosefree 80 mg * (Gas-X) gas-x ultra strength softgel 80 mg * (Phazyme) mi-acid gas 80 mg tab chew 80 mg * (Gas-X) mytab gas 80 mg tablet chew 80 mg * (Gas-X) mytab gas max str 25 mg tab 25 mg * (Gas-X) simethicone 80 mg softgel 80 mg * (Phazyme) simethicone 40 mg/0.6 ml drop 40 mg/0.6 ml * (Simethicone) v-r anti-gas 66 mg softgel 66 mg * (Phazyme) Antiulcer Agents And Acid Suppressants acid reducer 20 mg tablet maximum strength 20 mg * (Pepcid Ac) amoxicil-clarithromy-lansopraz oral (Prevpac) combo pack mg $0 CARAFATE ORAL SUSPENSION 00 MG/ML cimetidine hcl oral solution 300 mg/5 ml (Cimetidine HCl) $0 cimetidine oral tablet 200 mg, 300 mg, 400 mg, 800 mg (Cimetidine) $0 cvs cimetidine 200 mg tablet (otc) 200 mg * (Tagamet Hb) esomeprazole sodium intravenous recon soln 20 mg, 40 mg (Nexium I.V.) $0 famotidine (pf) intravenous solution 20 mg/2 ml (Famotidine) $0 famotidine (pf)-nacl (iso-os) (Famotidine In intravenous piggyback 20 mg/50 ml Nacl,Iso-Osm/PF) $0 famotidine 40 mg/4 ml vial 25's,outer 0 mg/ml (Famotidine) $0 (Rx Product Only) 42

157 famotidine oral tablet 20 mg, 40 mg (Pepcid) $0 (Rx Product Only) gnp acid reducer 0 mg tablet 0 mg * (Pepcid Ac) lansoprazole dr 5 mg capsule na/f (otc) 5 mg * (Prevacid 24hr) lansoprazole oral capsule,delayed (Rx Product Only) (Prevacid) $0 release(dr/ec) 5 mg, 30 mg misoprostol oral tablet 00 mcg, 200 mcg (Cytotec) $0 omeprazole dr 20 mg tablet 20 mg * (Omeprazole) omeprazole mag dr 20.6 mg cap two (Omeprazole 4-days course 20 mg * Magnesium) omeprazole oral capsule,delayed release(dr/ec) 0 mg, 20 mg, 40 mg (Prilosec) $0 omeprazole-sodium bicarbonate (Rx Product Only) (Zegerid) $0 oral capsule 20-. mg-gram pantoprazole intravenous recon soln (Protonix IV) 40 mg $0 pantoprazole oral tablet,delayed release (dr/ec) 20 mg, 40 mg (Protonix) $0 PRILOSEC OTC 20.6 MG TABLET OTC 20 MG * pub famotidine 20 mg tablet max strength (otc) 20 mg * (Pepcid Ac) pv acid relief 200 mg tablet 200 mg * (Tagamet Hb) ra omeprazole-bicarb 20-,00 3x4 day course (otc) 20-. mggram (Zegerid Otc) * ranitidine 50 mg tablet maximum strength (otc) 50 mg * (Zantac) ranitidine 75 mg tablet s/f, sodiumfree 75 mg * (Zantac) ranitidine hcl 50 mg/2 ml vial sdv 50 (Rx Product Only) (Ranitidine HCl) $0 mg/2 ml (25 mg/ml) ranitidine hcl injection solution 25 (Rx Product Only) (Ranitidine HCl) $0 mg/ml 43

158 ranitidine hcl oral capsule 50 mg, (Rx Product Only) (Ranitidine HCl) $0 300 mg ranitidine hcl oral syrup 5 mg/ml (Ranitidine HCl) $0 (Rx Product Only) ranitidine hcl oral tablet 50 mg, (Rx Product Only) (Zantac) $0 300 mg sucralfate oral suspension 00 mg/ml (Sucralfate) $0 sucralfate oral tablet gram (Carafate) $0 wal-zan 75 mg tablet 75 mg * (Zantac) ZANTAC 50 MG TABLET TWIN PACK(2X45TABS) (OTC) 50 MG * ZANTAC 50 MG TABLET TWIN PK, MAX STRGTH (OTC) 50 MG * ZANTAC 75 MG TABLET 75 MG * Gastrointestinal Agents, Other acid gone antacid liquid mg/5 ml * (Gaviscon) almacone liquid mg/5 (Maalox Maximum ml * Strength) almacone-2 liquid mg/5 (Maalox Maximum ml * Strength) aluminum hydroxide gel sugar-free (Aluminum 320 mg/5 ml * Hydroxide) AMITIZA ORAL CAPSULE 24 QL (60 per 30 days) MCG, 8 MCG antacid plus x-stren susp (Maalox Maximum 40 mg/5 ml * Strength) antacid ultra tablet chew 400 mg (,000 mg) * (Tums) antacid xtra strength chew tab extra-strength 300 mg (750 mg) * (Tums) antacid-antigas liquid (Maalox Maximum mg/5 ml * Strength) 44

159 anti-diarrheal 2 mg caplet caplet 2 mg * bismatrol suspension 262 mg/5 ml * BUPHENYL ORAL TABLET 500 MG calci-chew tablet 500 mg calcium (,250 mg) * calcium 500 mg chewable tablet tab chew,p/f 500 mg calcium (,250 mg) * calcium antacid 500 mg chw tab assorted fruit 200 mg calcium (500 mg) * CALCIUM-500 MG TABLET CHEWABLE SOY FREE, YEAST FREE MG-UNIT * cal-gest 500 mg tablet chew 200 mg calcium (500 mg) * CARBAGLU ORAL TABLET, DISPERSIBLE 200 MG child soothe 400 mg tab chew 400 mg * children pepto 400 mg tab chew bubble gum, na/f 400 mg * comfort gel max str susp max-str mg/5 ml * comfort gel suspension regular str, cherry mg/5 ml * constulose oral solution 0 gram/5 ml cromolyn oral concentrate 00 mg/5 ml cvs antacid-antigas tab chew, mg * (Imodium A-D) (Pepto-Bismol) (Tums) (Tums) (Tums) (Tums) (Tums) (Tums) (Maalox Maximum Strength) (Maalox Maximum Strength) (Lactulose) $0 (Gastrocrom) $0 (Calcium Carbonate/Simethi cone) 45

160 cvs anti-diarrheal 2 mg sftgel softgel (Loperamide HCl) 2 mg * cvs anti-diarrheal suspension 262 mg/5 ml * (Pepto-Bismol) cvs loperamide mg/7.5 ml liq mint mg/7.5 ml * (Loperamide HCl) diamode 2 mg tablet outer, f/c 2 mg * (Imodium A-D) dicyclomine oral capsule 0 mg (Bentyl) $0 dicyclomine oral solution 0 mg/5 ml (Dicyclomine HCl) $0 dicyclomine oral tablet 20 mg (Bentyl) $0 diphenoxylate-atropine oral liquid (Diphenoxylate mg/5 ml HCl/Atropine) $0 diphenoxylate-atropine oral tablet mg (Lomotil) $0 enulose oral solution 0 gram/5 ml (Lactulose) $0 flanax antacid liquid (Maalox Maximum mg/5 ml * Strength) foaming antacid liquid mg/5 ml * (Gaviscon) GATTEX 5 MG 30-VIAL KIT 5 MG GATTEX ONE-VIAL SUBCUTANEOUS KIT 5 MG gelusil antacid & antigas liq 400- (Maalox Maximum mg/5 ml * Strength) gelusil tablet chewable cool mint mg * (Almacone) generlac oral solution 0 gram/5 ml (Lactulose) $0 glycopyrrolate injection solution 0.2 mg/ml (Robinul) $0 glycopyrrolate oral tablet mg, 2 mg (Robinul) $0 imodium a-d mg/7.5 ml liquid mint (Loperamide HCl) mg/7.5 ml * PA PA 46

161 IMODIUM A-D 2 MG CAPLET CAPLET 2 MG * kaopectate 262 mg/5 ml susp vanilla flavor 262 mg/5 ml * kionex 5 gm/60 ml suspension gram/60 ml kionex oral powder (Pepto-Bismol) (Sodium Polystyrene Sulfonate) (Sodium Polystyrene Sulfonate) $0 $0 lactulose oral solution 0 gram/5 (Lactulose) $0 ml LINZESS ORAL CAPSULE 45 MCG, 290 MCG loperamide mg/5 ml liquid mg/5 (Loperamide HCl) ml * loperamide oral capsule 2 mg (Loperamide HCl) $0 LOTRONEX ORAL TABLET 0.5 MG, MG maalox advanced suspension (Maalox Maximum regular strength mg/5 Strength) ml * MAGNEBIND 300 TABLET MG * magnesium 500 mg capsule s/f,na/f (Uromag) 500 mg * magnesium oxide 250 mg tablet 250 (Magox 400) mg * magnesium oxide 400 mg tablet (Magox 400) s/f,p/f,gluten-free 400 mg * magnesium oxide 500 mg tablet (Magox 400) p/f,s/f,lactose-free 500 mg * masanti liquid mg/5 ml (Maalox Maximum * Strength) medi-first pep-t-med tab chew 262 mg * (Pepto-Bismol To- Go) QL (30 per 30 days) 47

162 methscopolamine oral tablet 2.5 mg, (Methscopolamine 5 mg Bromide) $0 metoclopramide hcl injection (Metoclopramide solution 5 mg/ml HCl) $0 metoclopramide hcl oral solution 5 (Metoclopramide mg/5 ml HCl) $0 metoclopramide hcl oral tablet 0 mg, 5 mg (Reglan) $0 mgo 400 mg tablet 400 mg * (Magox 400) mi acid suspension (Maalox Maximum mg/5 ml, mg/5 ml * Strength) mi-acid ds tablet mg * (Rolaids) mintox maximum strength susp max (Maalox Maximum str, lemon creme mg/5 Strength) ml * mintox plus tablet chewable mg * (Almacone) mintox suspension mint creme 200- (Maalox Maximum mg/5 ml * Strength) MOVANTIK ORAL TABLET 2.5 MG, 25 MG NUTRESTORE ORAL POWDER IN PACKET 5 GRAM OCALIVA ORAL TABLET 0 MG, 5 MG phillips 500 mg caplet 500 mg * (Magox 400) pink bismuth tablet chew 262 mg * (Pepto-Bismol To- Go) ra loperamide mg/7.5 ml susp mint (Loperamide HCl) mg/7.5 ml * ra magnesium 500 mg capsule 500 mg * (Uromag) RAVICTI ORAL LIQUID. GRAM/ML RELISTOR ORAL TABLET 50 MG QL (30 per 30 days) PA; QL (30 per 30 days) PA PA; QL (90 per 30 days) 48

163 RELISTOR SUBCUTANEOUS SOLUTION 2 MG/0.6 ML RELISTOR SUBCUTANEOUS SYRINGE 2 MG/0.6 ML, 8 MG/0.4 ML ri-gel ii suspension mg/5 ml * ri-mox suspension mg/5 ml * sm foaming antacid tablet chew mg * sm stomach relief caplet 262 mg * sodium bicarb 650 mg tablet 0 gr 650 mg * sodium polystyrene (sorb free) oral suspension 5 gram/60 ml sodium polystyrene sulfonate rectal enema 30 gram/20 ml soothe 262 mg caplet caplet 262 mg * soothe 262 mg/5 ml suspension s/f,cherry 262 mg/5 ml * sps (with sorbitol) oral suspension 5-20 gram/60 ml (Maalox Maximum Strength) (Maalox Maximum Strength) (Gaviscon) (Bismuth Subsalicylate) (Sodium Bicarbonate) (Sodium Polystyrene Sulfonate) (Sodium Polystyrene Sulfonate) (Bismuth Subsalicylate) $0 $0 (Pepto-Bismol) (Sodium Polystyrene Sulfonate) $0 ursodiol oral capsule 300 mg (Actigall) $0 ursodiol oral tablet 250 mg, 500 mg (Urso) $0 VIBERZI ORAL TABLET 00 MG, 75 MG Laxatives alophen pills 5 mg * (Dulcolax) bisac-evac 0 mg suppository 0 mg * (Dulcolax) PA; QL (28 per 28 days) PA; QL (28 per 28 days) ST; QL (60 per 30 days) 49

164 bisacodyl 0 mg suppository 0 mg * (Dulcolax) bisacodyl ec 5 mg tablet 5 mg * (Dulcolax) biscolax 0 mg suppository 0 mg * (Dulcolax) BLADDER CONTROL PAD X- LONG 9'S,X-LONG * COLACE 00 MG CAPSULE 00 MG * cvs enema disposable 9-7 gram/8 ml * (Enema) cvs fiber therapy 500 mg caplt soluble, caplet 500 mg * (Citrucel) cvs kids 00 mg mini enema 00 mg/5 ml * (Docusate Sodium) cvs purelax powder 4 once-daily doses 7 gram/dose * (Gavilax) cvs purelax powder packet s/f, 0 daily doses 7 gram * (Miralax) cvs senna laxative 8.6 mg tab 8.6 mg (Senokot) * cvs stool softener softgel softgel 240 mg * (Surfak) doc-q-lace 00 mg softgel 00 mg * (Colace) docu liquid 50 mg/5 ml 50 mg/5 ml * (Docusate Sodium) docusate sodium 00 mg tablet crushable 00 mg * (Docusate Sodium) docusate sodium-senna tablet (Sennosides/Docus mg * ate Sodium) docusol mini-enema outer 283 mg * (Docusate Sodium) dok 00 mg softgel softgel 00 mg * (Colace) dok 00 mg tablet 00 mg * (Docusate Sodium) dulcolax ss 00 mg softgel 00 mg * (Colace) enema disposable 9-7 gram/8 ml * (Enema) enema ready to use latex-free 9-7 gram/8 ml * (Enema) 50

165 enemeez mini enema 5cc tubes, (Docusate Sodium) outer 283 mg/5 ml * enemeez plus mini enema outer 283- (Docusol Plus) 20 mg/5 ml * (Psyllium Seed eq fiber therapy powder * (With Sugar)) equalactin 500 mg tab chew 500 mg (Calcium * Polycarbophil) fiber tablet unboxed 625 mg * (Fibercon) fiber therapy (psyllium) oral powder (Psyllium Seed) * fiber therapy powder 2 gram/9 (Citrucel) gram * fiber-lax captabs 500mg (Fibercon) polycarbophil 625 mg * fibertab oral tablet 625 mg * (Fibercon) FLEET BISACODYL 0 MG ENEMA 0 MG/30 ML * gavilyte-c oral recon soln 240- (Golytely) $ gram gavilyte-g oral recon soln 236- (Golytely) $ gram (Nulytely with gavilyte-n oral recon soln 420 gram $0 Flavor Packs) gentlelax powder 30 once-daily (Gavilax) doses 7 gram/dose * glycolax powder 7 doses (otc) 7 (Gavilax) 3 $0 gram/dose * healthylax powder packet 4x7gm, (Miralax) outer 7 gram * hydrocil instant packet * (Psyllium Seed) KONSYL 6 GM PACKET S/F, GLUTEN-F, OUTER 6 GRAM * konsyl fiber 625 mg caplet caplet, s/f (Fibercon) 625 mg * konsyl psyllium fiber packet orange, (Psyllium Husk gluten free 3.4 gram * (With Sugar)) 5

166 magic bullet 0 mg suppos 0 mg * (Dulcolax) milk of magnesia suspension 400 (Milk Of mg/5 ml * Magnesia) mineral oil laxative * (Mineral Oil) MOVIPREP ORAL POWDER IN PACKET GRAM natural fiber lax powder * (Psyllium Seed (With Sugar)) oral saline laxative liquid s/f, ginger (Na Phos,M-B/Na lemon gram/5 ml * Phos,Di-Ba) peg 3350-electrolytes oral recon soln gram, gram (Golytely) $0 peg-electrolyte soln oral recon soln (Nulytely with 420 gram Flavor Packs) $0 peri-colace tablet mg * (Sennosides/Docus ate Sodium) phillips' lax liqui-gels 00 mg * (Colace) phosphate oral saline laxative s/f, (Na Phos,M-B/Na ginger lemon gram/5 ml * Phos,Di-Ba) polyethylene glycol 3350 oral (Polyethylene powder 7 gram/dose Glycol 3350) $0 polyethylene glycol 3350 oral (Polyethylene powder in packet 7 gram Glycol 3350) $0 polyethylene glycol 3350 powd 4 once-daily doses (otc) 7 gram/dose (Gavilax) * polyethylene glycol 3350 powd 7 grams pkts,outer (otc) 7 gram * (Miralax) polyethylene glycol 3350 powd outer,s/f (otc) 7 gram * (Miralax) promolaxin 00 mg tablet 00 mg * (Docusate Sodium) pv senna 8.6 mg softgel 8.6 mg * (Sennosides) ra enema twin pack 2 x 4.5oz, rtu 9-7 gram/8 ml * (Enema) ra laxative peg 3350 powder 4 once-daily doses 7 gram/dose * (Gavilax) 52

167 reguloid powder orange * (Psyllium Seed (With Sugar)) senexon 8.8 mg/5 ml liquid 8.8 mg/5 ml * (Sennosides) senexon tablet 8.6 mg * (Senokot) senna 8.8 mg/5 ml syrup a/f, chocolate 8.8 mg/5 ml * (Sennosides) senna-lax 8.6 mg tablet 8.6 mg * (Senokot) senokot-s tablet mg * (Sennosides/Docus ate Sodium) silace 50 mg/5 ml liquid 50 mg/5 ml * (Docusate Sodium) silace 60 mg/5 ml syrup 60 mg/5 ml * (Docusate Sodium) sm clearlax powder 4 once-daily doses 7 gram/dose * (Gavilax) sm fiber laxative 500 mg cplt 500 mg * (Citrucel) sm fiber smooth powder * (Psyllium Seed) smoothlax powder packet 0 oncedaily doses 7 gram * (Miralax) trilyte with flavor packets oral recon (Nulytely with soln 420 gram Flavor Packs) $0 Phosphate Binders calcium acetate oral capsule 667 mg (Phoslo) $0 calcium acetate oral tablet 667 mg (Calcium Acetate) $0 calphron 667 mg tablet 667 mg * (Calcium Acetate) eliphos oral tablet 667 mg (Calcium Acetate) $0 (Calcium magnebind 400 oral tablet Carbonate/Mag mg Carb/Fa) $0 PHOSLYRA ORAL SOLUTION 667 MG (69 MG CALCIUM)/5 ML RENAGEL ORAL TABLET 400 MG, 800 MG 53

168 RENVELA ORAL POWDER IN PACKET 0.8 GRAM, 2.4 GRAM RENVELA ORAL TABLET 800 MG Genitourinary Agents Antispasmodics, Urinary MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HR 25 MG, 50 MG oxybutynin chloride oral syrup 5 mg/5 ml oxybutynin chloride oral tablet 5 mg oxybutynin chloride oral tablet extended release 24hr 0 mg, 5 mg, 5 mg tolterodine oral capsule,extended release 24hr 2 mg, 4 mg (Oxybutynin Chloride) (Oxybutynin Chloride) $0 $0 (Ditropan XL) $0 (Detrol LA) $0 tolterodine oral tablet mg, 2 mg (Detrol) $0 TOVIAZ ORAL TABLET EXTENDED RELEASE 24 HR 4 MG, 8 MG trospium oral capsule,extended release 24hr 60 mg trospium oral tablet 20 mg Genitourinary Agents, Miscellaneous alfuzosin oral tablet extended release 24 hr 0 mg tamsulosin oral capsule,extended release 24hr 0.4 mg terazosin oral capsule mg, 0 mg, 2 mg, 5 mg Heavy Metal Antagonists Heavy Metal Antagonists (Trospium Chloride) (Trospium Chloride) $0 $0 (Uroxatral) $0 (Flomax) $0 (Terazosin HCl) $0 54

169 deferoxamine injection recon soln 2 gram, 500 mg DEPEN TITRATABS ORAL TABLET 250 MG EXJADE ORAL TABLET, DISPERSIBLE 25 MG, 250 MG, 500 MG FERRIPROX ORAL SOLUTION 00 MG/ML FERRIPROX ORAL TABLET 500 MG sodium thiosulfate intravenous solution gram/0 ml (00 mg/ml), 2.5 gram/50 ml (250 mg/ml) SYPRINE ORAL CAPSULE 250 MG Hormonal Agents, Stimulant/Replacement/Modif ying Androgens ANDRODERM TRANSDERMAL PATCH 24 HOUR 2 MG/24 HOUR, 4 MG/24 HR ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP MG/.25 GRAM (.62 %) (Desferal) $0 (Sodium Thiosulfate) $0 ANDROGEL TRANSDERMAL GEL IN PACKET.62 % (20.25 MG/.25 GRAM),.62 % (40.5 MG/2.5 GRAM) androxy oral tablet 0 mg (Fluoxymesterone) $0 danazol oral capsule 00 mg, 200 mg, 50 mg (Danazol) $0 oxandrolone oral tablet 0 mg, 2.5 mg (Oxandrin) $0 PA; QL (30 per 30 days) PA; QL (50 per 30 days) PA; QL (50 per 30 days) 55

170 testosterone cypionate intramuscular oil 00 mg/ml, 200 mg/ml testosterone enanthate intramuscular oil 200 mg/ml testosterone transdermal gel 50 mg/5 gram ( %) testosterone transdermal gel in metered-dose pump.25 gram/ actuation ( %) testosterone transdermal gel in packet % (25 mg/2.5gram) testosterone transdermal gel in packet % (50 mg/5 gram) Estrogens And Antiestrogens COMBIPATCH TRANSDERMAL PATCH SEMIWEEKLY MG/24 HR, MG/24 HR DUAVEE ORAL TABLET MG ESTRACE VAGINAL CREAM 0.0 % (0. MG/GRAM) estradiol oral tablet 0.5 mg, mg, 2 mg estradiol transdermal patch semiweekly mg/24 hr, mg/24 hr, 0.05 mg/24 hr, mg/24 hr, 0. mg/24 hr estradiol transdermal patch weekly mg/24 hr, mg/24 hr, 0.05 mg/24 hr, 0.06 mg/24 hr, mg/24 hr, 0. mg/24 hr estradiol valerate intramuscular oil 0 mg/ml, 20 mg/ml, 40 mg/ml estradiol-norethindrone acet oral tablet mg, -0.5 mg (Depo- Testosterone) (Testosterone Enanthate) $0 $0 (Testim) $0 (Vogelxo) $0 (Androgel) $0 (Testim) $0 (Estrace) $0 (Vivelle-Dot) $0 (Climara) $0 (Delestrogen) $0 (Activella) $0 PA PA; QL (5 per 28 days) PA; QL (300 per 30 days) PA; QL (300 per 30 days) PA; QL (300 per 30 days) PA; QL (300 per 30 days) PA-HRM; QL (8 per 28 days); AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA-HRM; QL (8 per 28 days); AGE (Max 64 Years) PA-HRM; QL (4 per 28 days); AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) 56

171 estropipate oral tablet 0.75 mg,.5 mg, 3 mg FEMRING VAGINAL RING 0.05 MG/24 HR, 0. MG/24 HR MENEST ORAL TABLET 0.3 MG, MG,.25 MG, 2.5 MG (Estropipate) $0 mimvey lo oral tablet mg (Activella) $0 mimvey oral tablet -0.5 mg (Activella) $0 PREMARIN INJECTION RECON SOLN 25 MG PREMARIN ORAL TABLET 0.3 MG, 0.45 MG, MG, 0.9 MG,.25 MG PREMARIN VAGINAL CREAM MG/GRAM PREMPHASE ORAL TABLET MG (4)/ 0.625MG-5MG(4) PREMPRO ORAL TABLET MG, MG, MG, MG raloxifene oral tablet 60 mg (Evista) $0 VAGIFEM VAGINAL TABLET 0 MCG Glucocorticoids/Mineraloco rticoids a-hydrocort injection recon soln 00 (Hydrocortisone mg Sod Succinate) $0 betamethasone acet,sod phos injection suspension 6 mg/ml (Celestone) $0 cortisone oral tablet 25 mg (Cortisone Acetate) $0 dexamethasone oral elixir 0.5 mg/5 (Dexamethasone) $0 ml dexamethasone oral tablet 0.5 mg, 0.75 mg, mg,.5 mg, 2 mg, 4 mg, 6 mg (Dexamethasone) $0 PA-HRM; AGE (Max 64 Years) QL ( per 84 days) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) QL (8 per 28 days) 57

172 dexamethasone sodium phosphate (Dexamethasone injection solution 0 mg/ml, 4 mg/ml Sod Phosphate) $0 fludrocortisone oral tablet 0. mg (Fludrocortisone Acetate) $0 hydrocortisone oral tablet 0 mg, 20 (Cortef) $0 mg, 5 mg methylprednisolone acetate injection suspension 40 mg/ml, 80 mg/ml (Depo-Medrol) $0 methylprednisolone oral tablet 6 (Medrol) $0 mg, 32 mg, 4 mg, 8 mg methylprednisolone oral (Medrol) $0 tablets,dose pack 4 mg methylprednisolone sodium succ injection recon soln 25 mg, 40 mg (Solu-Medrol) $0 methylprednisolone ss gm vl mdv,latex-free,000 mg (Solu-Medrol) $0 prednisolone sodium phosphate oral solution 5 mg/5 ml (3 mg/ml), 25 mg/5 ml (5 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml) (Pediapred) $0 prednisone oral solution 5 mg/5 ml (Prednisone) $0 prednisone oral tablet mg, 2.5 mg, (Prednisone) $0 20 mg, 5 mg, 50 mg prednisone oral tablet 0 mg (Prednisone) $0 prednisone oral tablets,dose pack 0 mg, 0 mg (48 pack), 5 mg, 5 mg (48 pack) (Prednisone) $0 SOLU-CORTEF (PF) INJECTION RECON SOLN 00 MG/2 ML triamcinolone acetonide injection (Triamcinolone suspension 0 mg/ml, 40 mg/ml Acetonide) $0 Pituitary desmopressin injection solution 4 (Desmopressin mcg/ml Acetate) $0 desmopressin nasal solution 0. QL (5 per 30 days) (DDAVP) $0 mg/ml (refrigerate) 58

173 desmopressin nasal spray,nonaerosol 0 mcg/spray (0. ml) desmopressin oral tablet 0. mg, 0.2 mg GENOTROPIN MINIQUICK SUBCUTANEOUS SYRINGE 0.2 MG/0.25 ML, 0.4 MG/0.25 ML, 0.6 MG/0.25 ML, 0.8 MG/0.25 ML, MG/0.25 ML,.2 MG/0.25 ML,.4 MG/0.25 ML,.6 MG/0.25 ML,.8 MG/0.25 ML, 2 MG/0.25 ML GENOTROPIN SUBCUTANEOUS CARTRIDGE 2 MG/ML (36 UNIT/ML), 5 MG/ML (5 UNIT/ML) INCRELEX SUBCUTANEOUS SOLUTION 0 MG/ML LUPRON DEPOT-PED (3 MONTH) INTRAMUSCULAR SYRINGE KIT 30 MG LUPRON DEPOT-PED INTRAMUSCULAR KIT.25 MG, 5 MG, 7.5 MG (PED) NORDITROPIN FLEXPRO SUBCUTANEOUS PEN INJECTOR 0 MG/.5 ML (6.7 MG/ML), 5 MG/.5 ML (0 MG/ML), 30 MG/3 ML (0 MG/ML), 5 MG/.5 ML (3.3 MG/ML) octreotide acet 50 mcg/ml syr outer,single-dose,0 50 mcg/ml ( ml) octreotide acetate injection solution,000 mcg/ml, 00 mcg/ml, 200 mcg/ml, 500 mcg/ml octreotide acetate injection solution 50 mcg/ml (Desmopressin Acetate) $0 (DDAVP) $0 (Octreotide Acetate) $0 (Sandostatin) $0 (Octreotide Acetate) $0 QL (5 per 30 days) PA PA QL ( per 84 days) PA 59

174 SAIZEN CLICK.EASY SUBCUTANEOUS CARTRIDGE 8.8 MG/.5 ML (FNL) SAIZEN SUBCUTANEOUS RECON SOLN 5 MG, 8.8 MG SANDOSTATIN LAR 0 MG KIT 0 MG SANDOSTATIN LAR 20 MG KIT 20 MG SANDOSTATIN LAR 30 MG KIT 30 MG SANDOSTATIN LAR DEPOT INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 0 MG, 20 MG, 30 MG SEROSTIM SUBCUTANEOUS RECON SOLN 4 MG, 5 MG, 6 MG SOMATULINE DEPOT SUBCUTANEOUS SYRINGE 20 MG/0.5 ML, 60 MG/0.2 ML, 90 MG/0.3 ML SOMAVERT SUBCUTANEOUS RECON SOLN 0 MG, 5 MG, 20 MG, 25 MG, 30 MG SUPPRELIN LA IMPLANT KIT 50 MG (65 MCG/DAY) Progestins DEPO-PROVERA INTRAMUSCULAR SOLUTION 400 MG/ML hydroxyprogesterone caproate intramuscular oil 250 mg/ml medroxyprogesterone intramuscular suspension 50 mg/ml medroxyprogesterone intramuscular syringe 50 mg/ml medroxyprogesterone oral tablet 0 mg, 2.5 mg, 5 mg (Hydroxyprogester one Caproate) $0 (Depo-Provera) $0 $0 (Provera) $0 PA PA PA QL ( per 28 days) QL ( per 360 days) QL (0 per 28 days) PA NSO QL ( per 84 days) QL ( per 84 days) 60

175 MEGACE ES ORAL SUSPENSION 625 MG/5 ML megestrol oral suspension 400 mg/0 ml (40 mg/ml), 625 mg/5 ml norethindrone acetate oral tablet 5 mg progesterone in oil intramuscular oil 50 mg/ml progesterone micronized oral capsule 00 mg, 200 mg Thyroid And Antithyroid Agents levothyroxine intravenous recon soln 00 mcg, 200 mcg, 500 mcg levothyroxine oral tablet 00 mcg, 2 mcg, 25 mcg, 37 mcg, 50 mcg, 75 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg liothyronine oral tablet 25 mcg, 5 mcg, 50 mcg (Megace Es) $0 (Aygestin) $0 (Progesterone) $0 (Prometrium) $0 (Levothyroxine Sodium) $0 (Levoxyl) $0 (Cytomel) $0 methimazole oral tablet 0 mg, 5 mg (Tapazole) $0 propylthiouracil oral tablet 50 mg (Propylthiouracil) $0 Immunological Agents Immunological Agents ARCALYST SUBCUTANEOUS RECON SOLN 220 MG ASTAGRAF XL ORAL CAPSULE,EXTENDED RELEASE 24HR 0.5 MG, MG, 5 MG AUBAGIO ORAL TABLET 4 PA; QL (28 per 28 MG, 7 MG days) azathioprine oral tablet 50 mg (Imuran) $0 azathioprine sodium injection recon (Azathioprine $0 soln 00 mg Sodium) CARIMUNE NF NANOFILTERED INTRAVENOUS RECON SOLN 6 GRAM 6

176 CELLCEPT INTRAVENOUS INTRAVENOUS RECON SOLN 500 MG CIMZIA POWDER FOR PA RECONST SUBCUTANEOUS KIT 400 MG (200 MG X 2 VIALS) CIMZIA SUBCUTANEOUS PA SYRINGE KIT 400 MG/2 ML (200 MG/ML X 2) cyclosporine intravenous solution (Sandimmune) $0 250 mg/5 ml cyclosporine modified oral capsule (Neoral) $0 00 mg, 25 mg, 50 mg cyclosporine modified oral solution (Neoral) $0 00 mg/ml cyclosporine oral capsule 00 mg, (Sandimmune) $0 25 mg ENBREL SUBCUTANEOUS PA RECON SOLN 25 MG ( ML) ENBREL SUBCUTANEOUS PA SYRINGE 25 MG/0.5ML (0.5), 50 MG/ML (0.98 ML) ENBREL SURECLICK PA SUBCUTANEOUS PEN INJECTOR 50 MG/ML (0.98 ML) ENVARSUS XR ORAL TABLET EXTENDED RELEASE 24 HR 0.75 MG, MG, 4 MG FLEBOGAMMA DIF INTRAVENOUS SOLUTION 0 %, 5 % GAMASTAN S/D INTRAMUSCULAR SOLUTION 5-8 % RANGE GAMMAGARD LIQUID INJECTION SOLUTION 0 % GAMMAPLEX INTRAVENOUS SOLUTION 5 % 62

177 gengraf oral capsule 00 mg, 25 (Neoral) $0 mg, 50 mg gengraf oral solution 00 mg/ml (Neoral) $0 HUMIRA PEDIATRIC CROHN'S PA START SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML, 40 MG/0.8 ML (6 PACK) HUMIRA PEN CROHN'S-UC-HS PA START SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML HUMIRA PEN PSORIASIS- PA UVEITIS SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML HUMIRA PEN SUBCUTANEOUS PA PEN INJECTOR KIT 40 MG/0.8 ML HUMIRA SUBCUTANEOUS PA SYRINGE KIT 0 MG/0.2 ML, 20 MG/0.4 ML, 40 MG/0.8 ML HYPERRAB S/D (PF) INTRAMUSCULAR SOLUTION 50 UNIT/ML, 50 UNIT/ML (0 ML) HYQVIA IG COMPONENT SUBCUTANEOUS SOLUTION 2.5 GRAM/25 ML (0 %) HYQVIA SUBCUTANEOUS SOLUTION 0 GRAM /00 ML (0 %), 2.5 GRAM /25 ML (0 %), 20 GRAM /200 ML (0 %), 30 GRAM /300 ML (0 %), 5 GRAM /50 ML (0 %) ILARIS (PF) SUBCUTANEOUS PA RECON SOLN 80 MG/.2 ML (50 MG/ML) IMOGAM RABIES-HT (PF) INTRAMUSCULAR SOLUTION 50 UNIT/ML 63

178 KINERET SUBCUTANEOUS SYRINGE 00 MG/0.67 ML leflunomide oral tablet 0 mg, 20 mg mycophenolate mofetil oral capsule 250 mg mycophenolate mofetil oral suspension for reconstitution 200 mg/ml mycophenolate mofetil oral tablet 500 mg mycophenolate sodium oral tablet,delayed release (dr/ec) 80 mg, 360 mg NULOJIX INTRAVENOUS RECON SOLN 250 MG OCTAGAM INTRAVENOUS SOLUTION 0 %, 5 % ORENCIA (WITH MALTOSE) INTRAVENOUS RECON SOLN 250 MG ORENCIA SUBCUTANEOUS SYRINGE 25 MG/ML PRIVIGEN INTRAVENOUS SOLUTION 0 % PROGRAF INTRAVENOUS SOLUTION 5 MG/ML RAPAMUNE ORAL SOLUTION MG/ML RIDAURA ORAL CAPSULE 3 MG sirolimus oral tablet 0.5 mg, mg, 2 mg tacrolimus oral capsule 0.5 mg, mg, 5 mg TYSABRI INTRAVENOUS SOLUTION 300 MG/5 ML (Arava) $0 (Cellcept) $0 (Cellcept) $0 (Cellcept) $0 (Myfortic) $0 (Rapamune) $0 (Hecoria) $0 PA; QL (8.76 per 28 days) PA PA PA; LA; QL (5 per 28 days) 64

179 ZORTRESS ORAL TABLET 0.25 MG, 0.5 MG, 0.75 MG Vaccines ACTHIB (PF) INTRAMUSCULAR RECON SOLN 0 MCG/0.5 ML ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SUSPENSION 2 LF-( MCG)-5LF/0.5 ML ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SYRINGE 2 LF-( MCG)-5LF/0.5 ML BCG (TICE STRAIN) VIAL LATEX-FREE, OUTER 50 MG BCG VACCINE, LIVE (PF) PERCUTANEOUS SUSPENSION FOR RECONSTITUTION 50 MG BEXSERO (PF) INTRAMUSCULAR SYRINGE MCG/0.5 ML BOOSTRIX TDAP INTRAMUSCULAR SUSPENSION LF-MCG- LF/0.5ML BOOSTRIX TDAP INTRAMUSCULAR SYRINGE LF-MCG-LF/0.5ML CERVARIX VACCINE (PF) INTRAMUSCULAR SYRINGE MCG/0.5 ML COMVAX (PF) INTRAMUSCULAR SUSPENSION MCG/0.5 ML ; QL (20 per 30 days) 65

180 DAPTACEL (DTAP PEDIATRIC) (PF) INTRAMUSCULAR SUSPENSION LF-MCG- LF/0.5ML ENGERIX-B (PF) INTRAMUSCULAR SYRINGE 20 MCG/ML ENGERIX-B 20 MCG/ML VIAL 0'S,ADULT,P/F,OUTER 20 MCG/ML ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SUSPENSION 0 MCG/0.5 ML ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SYRINGE 0 MCG/0.5 ML GARDASIL (PF) INTRAMUSCULAR SUSPENSION MCG/0.5 ML GARDASIL (PF) INTRAMUSCULAR SYRINGE MCG/0.5 ML GARDASIL 9 (PF) INTRAMUSCULAR SUSPENSION 0.5 ML GARDASIL 9 (PF) INTRAMUSCULAR SYRINGE 0.5 ML HAVRIX (PF) INTRAMUSCULAR SUSPENSION,440 ELISA UNIT/ML HAVRIX (PF) INTRAMUSCULAR SYRINGE,440 ELISA UNIT/ML, 720 ELISA UNIT/0.5 ML ; QL (3 per 365 days) ; QL (3 per 365 days) ; QL (3 per 365 days) ; QL (3 per 365 days) QL (.5 per 365 days) QL (.5 per 365 days) QL (.5 per 365 days) QL (.5 per 365 days) 66

181 HIBERIX (PF) INTRAMUSCULAR RECON SOLN 0 MCG/0.5 ML IMOVAX RABIES VACCINE (PF) INTRAMUSCULAR RECON SOLN 2.5 UNIT INFANRIX (DTAP) (PF) INTRAMUSCULAR SUSPENSION LF-MCG- LF/0.5ML IPOL INJECTION SUSPENSION UNIT/0.5 ML IPOL INJECTION SYRINGE UNIT/0.5 ML IXIARO (PF) INTRAMUSCULAR SYRINGE 6 MCG/0.5 ML KINRIX (PF) INTRAMUSCULAR SUSPENSION 25 LF-58 MCG-0 LF/0.5 ML KINRIX (PF) INTRAMUSCULAR SYRINGE 25 LF-58 MCG-0 LF/0.5 ML MENACTRA (PF) INTRAMUSCULAR SOLUTION 4 MCG/0.5 ML MENHIBRIX (PF) INTRAMUSCULAR RECON SOLN MCG/0.5 ML MENOMUNE - A/C/Y/W-35 (PF) SUBCUTANEOUS RECON SOLN 50 MCG MENVEO A-C-Y-W-35-DIP (PF) INTRAMUSCULAR KIT 0-5 MCG/0.5 ML MENVEO MENA COMPONENT (PF) INTRAMUSCULAR RECON SOLN 0 MCG /0.5 ML (FINAL) 67

182 MENVEO MENCYW-35 COMPNT (PF) INTRAMUSCULAR RECON SOLN 5 MCG X 3/ 0.5 ML (FINAL) M-M-R II (PF) SUBCUTANEOUS RECON SOLN,000-2,500 TCID50/0.5 ML PEDIARIX (PF) INTRAMUSCULAR SYRINGE 0 MCG-25LF-25 MCG-0LF/0.5 ML PEDVAX HIB (PF) INTRAMUSCULAR SOLUTION 7.5 MCG/0.5 ML PENTACEL (PF) INTRAMUSCULAR KIT 5 LF UNIT-20 MCG-5 LF/0.5 ML PENTACEL ACTHIB COMPONENT (PF) INTRAMUSCULAR RECON SOLN 0 MCG/0.5 ML PROQUAD (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 0EXP TCID50/0.5 QUADRACEL (PF) INTRAMUSCULAR SUSPENSION 5 LF-48 MCG- 5 LF UNIT/0.5ML RABAVERT (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 2.5 UNIT RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION 0 MCG/ML, 40 MCG/ML QL (2 per 365 days) QL (2 per 365 days) ; QL (3 per 365 days) 68

183 RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 0 MCG/ML, 5 MCG/0.5 ML ROTARIX ORAL SUSPENSION FOR RECONSTITUTION 0EXP6 CCID50/ML ROTATEQ VACCINE ORAL SUSPENSION 2 ML TENIVAC (PF) INTRAMUSCULAR SYRINGE 5-2 LF UNIT/0.5 ML TETANUS TOXOID,ADSORBED (PF) INTRAMUSCULAR SUSPENSION 5 LF UNIT/0.5 ML TETANUS,DIPHTHERIA TOX PED(PF) INTRAMUSCULAR SUSPENSION 5-25 LF UNIT/0.5 ML tetanus-diphtheria toxoids-td intramuscular suspension 2-2 lf unit/0.5 ml TRUMENBA INTRAMUSCULAR SYRINGE 20 MCG/0.5 ML TWINRIX (PF) INTRAMUSCULAR SUSPENSION 720 ELISA UNIT - 20 MCG/ML TWINRIX (PF) INTRAMUSCULAR SYRINGE 720 ELISA UNIT -20 MCG/ML TYPHIM VI INTRAMUSCULAR SOLUTION 25 MCG/0.5 ML TYPHIM VI INTRAMUSCULAR SYRINGE 25 MCG/0.5 ML VAQTA (PF) INTRAMUSCULAR SUSPENSION 50 UNIT/ML (Tetanus, Diphtheria Tox,Adult) ; QL (3 per 365 days) 69

184 VAQTA (PF) INTRAMUSCULAR SYRINGE 25 UNIT/0.5 ML, 50 UNIT/ML VAQTA 25 UNITS/0.5 ML VIAL SDV, OUTER 25 UNIT/0.5 ML VARIVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION,350 UNIT/0.5 ML YF-VAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 0 EXP4.74 UNIT/0.5 ML ZOSTAVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 9,400 UNIT/0.65 ML Inflammatory Bowel Disease Agents Inflammatory Bowel Disease Agents alosetron oral tablet 0.5 mg, mg (Alosetron HCl) $0 APRISO ORAL CAPSULE,EXTENDED RELEASE 24HR GRAM ASACOL HD ORAL TABLET,DELAYED RELEASE (DR/EC) 800 MG balsalazide oral capsule 750 mg (Colazal) $0 budesonide oral capsule,delayed,extend.release 3 mg (Entocort EC) $0 DELZICOL ORAL CAPSULE (WITH DEL REL TABLETS) 400 MG DIPENTUM ORAL CAPSULE 250 MG QL (2 per 365 days) QL ( per 365 days) ST 70

185 mesalamine oral tablet,delayed release (dr/ec) 800 mg Irrigating Solutions Irrigating Solutions acetic acid irrigation solution 0.25 (Asacol Hd) $0 % (Acetic Acid) $0 LACTATED RINGERS IRRIGATION SOLUTION ringers irrigation solution (Ringers Solution) $0 sodium chloride irrigation solution (Sodium Chloride 0.9 % Irrig Solution) $0 sorbitol irrigation solution 3 %, 3.3 % (Sorbitol Solution) $0 sorbitol-mannitol urethral solution (Mannitol/Sorbitol g/00 ml Solution) $0 water for irrigation, sterile (Water For irrigation solution Irrigation,Sterile) $0 Metabolic Bone Disease Agents Metabolic Bone Disease Agents alendronate oral solution 70 mg/75 ml alendronate oral tablet 0 mg, 40 mg, 5 mg alendronate oral tablet 35 mg, 70 mg calcitonin (salmon) nasal spray,non-aerosol 200 unit/actuation (Alendronate Sodium) $0 (Fosamax) $0 (Fosamax) $0 (Miacalcin) $0 calcitriol intravenous solution mcg/ml (Calcitriol) $0 calcitriol oral capsule 0.25 mcg, 0.5 mcg (Rocaltrol) $0 calcitriol oral solution mcg/ml (Rocaltrol) $0 doxercalciferol intravenous solution 4 mcg/2 ml (Doxercalciferol) $0 QL (300 per 28 days) QL (4 per 28 days) QL (3.7 per 28 days) 7

186 doxercalciferol oral capsule 0.5 mcg, mcg, 2.5 mcg (Hectorol) $0 FORTEO SUBCUTANEOUS PEN INJECTOR 20 MCG/DOSE PA; QL (2.4 per 28 days) MCG/2.4 ML FORTICAL NASAL SPRAY,NON- AEROSOL 200 UNIT/ACTUATION QL (3.7 per 28 days) ibandronate intravenous solution 3 (Ibandronate QL (3 per 84 days) $0 mg/3 ml Sodium) ibandronate intravenous syringe 3 QL (3 per 84 days) (Boniva) $0 mg/3 ml ibandronate oral tablet 50 mg (Boniva) $0 QL ( per 28 days) MIACALCIN INJECTION SOLUTION 200 UNIT/ML NATPARA SUBCUTANEOUS PA; QL (2 per 28 days) CARTRIDGE 00 MCG/DOSE, 25 MCG/DOSE, 50 MCG/DOSE, 75 MCG/DOSE paricalcitol oral capsule mcg, 2 mcg, 4 mcg (Zemplar) $0 PROLIA SUBCUTANEOUS QL ( per 80 days) SYRINGE 60 MG/ML risedronate oral tablet 50 mg (Actonel) $0 QL ( per 28 days) risedronate oral tablet 30 mg, 5 mg (Actonel) $0 QL (30 per 28 days) ZEMPLAR INTRAVENOUS SOLUTION 2 MCG/ML, 5 MCG/ML zoledronic acid intravenous solution 4 mg/5 ml (Zometa) $0 (Zoledronic zoledronic acid-mannitol-water Acid/Mannitol and intravenous piggyback 4 mg/00 ml Water) $0 zoledronic acid-mannitol-water QL (00 per 300 days) (Reclast) $0 intravenous solution 5 mg/00 ml ZOMETA INTRAVENOUS SOLUTION 4 MG/00 ML 72

187 Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents ACTEMRA INTRAVENOUS SOLUTION 200 MG/0 ML (20 MG/ML), 400 MG/20 ML (20 MG/ML), 80 MG/4 ML (20 MG/ML) ACTEMRA SUBCUTANEOUS SYRINGE 62 MG/0.9 ML ACTIMMUNE SUBCUTANEOUS SOLUTION 00 MCG/0.5 ML allopurinol oral tablet 00 mg, 300 mg amifostine crystalline intravenous recon soln 500 mg anticoag citrate phos dextrose solution gram-mg/00ml AVONEX (WITH ALBUMIN) INTRAMUSCULAR KIT 30 MCG AVONEX INTRAMUSCULAR PEN INJECTOR KIT 30 MCG/0.5 ML AVONEX INTRAMUSCULAR SYRINGE KIT 30 MCG/0.5 ML BENLYSTA INTRAVENOUS RECON SOLN 20 MG, 400 MG BETASERON SUBCUTANEOUS KIT 0.3 MG bethanechol chloride oral tablet 0 mg, 25 mg, 5 mg, 50 mg buspirone oral tablet 0 mg, 5 mg, 30 mg, 5 mg, 7.5 mg CERDELGA ORAL CAPSULE 84 MG (Zyloprim) $0 (Ethyol) $0 (Citrate Phosphate Dextros Soln) $0 (Urecholine) $0 (Buspirone HCl) $0 PA PA ST ST ST PA ST PA 73

188 CETYLEV ORAL TABLET, EFFERVESCENT 2.5 GRAM, 500 MG colchicine oral tablet 0.6 mg (Colcrys) $0 colchicine-probenecid oral tablet (Colchicine/Proben mg ecid) $0 COPAXONE SUBCUTANEOUS SYRINGE 20 MG/ML, 40 MG/ML CYSTADANE ORAL POWDER GRAM/.7 ML droperidol injection solution 2.5 mg/ml (Droperidol) $0 dutasteride oral capsule 0.5 mg (Avodart) $0 dutasteride-tamsulosin oral capsule, er multiphase 24 hr mg (Jalyn) $0 ELMIRON ORAL CAPSULE 00 MG ergoloid oral tablet mg (Ergoloid Mesylates) $0 EXTAVIA SUBCUTANEOUS KIT 0.3 MG finasteride oral tablet 5 mg (Proscar) $0 fomepizole intravenous solution gram/ml (Fomepizole) $0 FUSILEV INTRAVENOUS RECON SOLN 50 MG GAUZE PAD TOPICAL BANDAGE 2 X 2 " $0 GILENYA ORAL CAPSULE 0.5 MG GLUCAGEN HYPOKIT INJECTION RECON SOLN MG GLUCAGON EMERGENCY KIT (HUMAN) INJECTION KIT MG guanidine oral tablet 25 mg (Guanidine HCl) $0 hydroxyzine hcl intramuscular solution 25 mg/ml, 50 mg/ml (Hydroxyzine HCl) $0 QL (30 per 30 days) ST QL (28 per 28 days) PA-HRM; AGE (Max 64 Years) 74

189 hydroxyzine hcl oral solution 0 mg/5 ml hydroxyzine hcl oral tablet 0 mg, 25 mg, 50 mg hydroxyzine pamoate oral capsule 00 mg, 25 mg, 50 mg (Hydroxyzine HCl) $0 (Hydroxyzine HCl) $0 (Vistaril) $0 KEVEYIS ORAL TABLET 50 MG LEMTRADA INTRAVENOUS SOLUTION 2 MG/.2 ML leucovorin calcium 200 mg vial sdv, (Leucovorin p/f, latex-free 200 mg Calcium) $0 leucovorin calcium injection recon (Leucovorin soln 00 mg, 350 mg Calcium) $0 leucovorin calcium oral tablet 0 (Leucovorin mg, 5 mg, 25 mg, 5 mg Calcium) $0 levocarnitine (with sugar) oral (Levocarnitine solution 00 mg/ml (With Sugar)) $0 levocarnitine oral tablet 330 mg (Carnitor) $0 levoleucovorin calcium intravenous recon soln 50 mg (Fusilev) $0 mesna intravenous solution 00 mg/ml (Mesnex) $0 MESNEX ORAL TABLET 400 MG MESTINON ORAL SYRUP 60 MG/5 ML MESTINON TIMESPAN ORAL TABLET EXTENDED RELEASE 80 MG MINERAL OIL HEAVY * morrhuate sodium intravenous (Sodium solution 5 % Morrhuate) $0 ORENCIA CLICKJECT SUBCUTANEOUS AUTO- INJECTOR 25 MG/ML PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA NSO; QL (20 per 30 days) PA PA 75

190 ORFADIN ORAL SUSPENSION 4 MG/ML OTEZLA ORAL TABLET 30 MG OTEZLA STARTER ORAL TABLETS,DOSE PACK 0 MG (4)-20 MG (4)-30 MG (47), 0 MG (4)-20 MG (4)-30 MG(9) OTREXUP (PF) SUBCUTANEOUS AUTO- INJECTOR 0 MG/0.4 ML, 2.5 MG/0.4 ML, 5 MG/0.4 ML, 7.5 MG/0.4 ML, 20 MG/0.4 ML, 22.5 MG/0.4 ML, 25 MG/0.4 ML, 7.5 MG/0.4 ML PANTILINERS PAD * PLEGRIDY SUBCUTANEOUS PEN INJECTOR 25 MCG/0.5 ML, 63 MCG/0.5 ML- 94 MCG/0.5 ML PLEGRIDY SUBCUTANEOUS SYRINGE 25 MCG/0.5 ML, 63 MCG/0.5 ML- 94 MCG/0.5 ML probenecid oral tablet 500 mg (Probenecid) $0 PROCYSBI ORAL CAPSULE, DELAYED REL SPRINKLE 25 MG, 75 MG pv extra cleansing douche * (Acetic Acid) pyridostigmine bromide oral tablet 60 mg (Mestinon) $0 pyridostigmine bromide oral tablet extended release 80 mg (Mestinon) $0 qc mineral oil heavy * (Mineral Oil) ra feminine care douche * (Acetic Acid) PA; QL (60 per 30 days) PA; QL (60 per 30 days) ST ST 76

191 RASUVO (PF) SUBCUTANEOUS AUTO-INJECTOR 0 MG/0.2 ML, 2.5 MG/0.25 ML, 5 MG/0.3 ML, 7.5 MG/0.35 ML, 20 MG/0.4 ML, 22.5 MG/0.45 ML, 25 MG/0.5 ML, 27.5 MG/0.55 ML, 30 MG/0.6 ML, 7.5 MG/0.5 ML REBIF (WITH ALBUMIN) SUBCUTANEOUS SYRINGE 22 MCG/0.5 ML, 44 MCG/0.5 ML REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 22 MCG/0.5 ML, 44 MCG/0.5 ML, 8.8MCG/0.2ML-22 MCG/0.5ML (6) REBIF TITRATION PACK SUBCUTANEOUS SYRINGE 8.8MCG/0.2ML-22 MCG/0.5ML (6) REMICADE INTRAVENOUS RECON SOLN 00 MG sb disp douche extra clns v&w * (Acetic Acid) SENSIPAR ORAL TABLET 30 MG, 60 MG, 90 MG SIGNIFOR SUBCUTANEOUS SOLUTION 0.3 MG/ML ( ML), 0.6 MG/ML ( ML), 0.9 MG/ML ( ML) SIMPONI ARIA INTRAVENOUS SOLUTION 2.5 MG/ML SIMPONI SUBCUTANEOUS PEN INJECTOR 00 MG/ML, 50 MG/0.5 ML SIMPONI SUBCUTANEOUS SYRINGE 00 MG/ML, 50 MG/0.5 ML PA QL (60 per 30 days) PA PA PA 77

192 STELARA SUBCUTANEOUS SYRINGE 45 MG/0.5 ML, 90 MG/ML STERILE PADS 2" X 2" 2 X 2 " $0 summer's eve dche-xtra clns 2's,extra-cleansing * (Acetic Acid) summer's eve douche-ultra clns 2's,2pk,ultra clns * (Acetic Acid) SYNAREL NASAL SPRAY,NON- AEROSOL 2 MG/ML TECFIDERA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 20 MG TECFIDERA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 20 MG (4)- 240 MG (46), 240 MG THALOMID ORAL CAPSULE 00 MG, 50 MG, 200 MG, 50 MG topical light mineral oil * (Mineral Oil) PA QL (4 per 30 days) QL (60 per 30 days) PA NSO; QL (60 per 30 days) TYBOST ORAL TABLET 50 MG QL (30 per 30 days) ULORIC ORAL TABLET 40 MG, QL (30 per 30 days) 80 MG XELJANZ ORAL TABLET 5 MG XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HR MG ZINBRYTA SUBCUTANEOUS SYRINGE 50 MG/ML Ophthalmic Agents Antiglaucoma Agents acetazolamide oral capsule, extended release 500 mg acetazolamide oral tablet 25 mg, 250 mg (Diamox Sequels) $0 (Acetazolamide) $0 PA; QL (60 per 30 days) PA; QL (30 per 30 days) ST 78

193 acetazolamide sodium injection (Acetazolamide recon soln 500 mg Sodium) $0 ALPHAGAN P OPHTHALMIC DROPS 0. % AZOPT OPHTHALMIC DROPS,SUSPENSION % betaxolol ophthalmic drops 0.5 % (Betaxolol HCl) $0 bimatoprost ophthalmic drops 0.03 % (Bimatoprost) $0 brimonidine ophthalmic drops 0.5 %, 0.2 % (Alphagan P) $0 COMBIGAN OPHTHALMIC DROPS % dorzolamide ophthalmic drops 2 % (Trusopt) $0 dorzolamide-timolol ophthalmic drops mg/ml (Cosopt) $0 latanoprost ophthalmic drops % (Xalatan) $0 levobunolol ophthalmic drops 0.25 %, 0.5 % (Betagan) $0 LUMIGAN OPHTHALMIC DROPS 0.0 % methazolamide oral tablet 25 mg, 50 (Neptazane) mg $0 metipranolol ophthalmic drops 0.3 % (Metipranolol) $0 PHOSPHOLINE IODIDE OPHTHALMIC DROPS 0.25 % pilocarpine hcl ophthalmic drops %, 2 %, 4 % (Isopto Carpine) $0 SIMBRINZA OPHTHALMIC DROPS,SUSPENSION -0.2 % timolol maleate ophthalmic drops 0.25 %, 0.5 % (Timoptic) $0 timolol maleate ophthalmic gel forming solution 0.25 %, 0.5 % (Timoptic-Xe) $0 (drops: 0.5%, 0.20%) QL (2.5 per 25 days) 79

194 TRAVATAN Z OPHTHALMIC DROPS % travoprost (benzalkonium) ophthalmic drops % Replacement Preparations Replacement Preparations calcitrate + vit d caplet mg-unit * calcitrate 200 mg (950 mg) tab 200 mg (950 mg) * calcium,000 + d3 caplet,000 mg(2,500 mg)-800 unit * calcium 500+d tablet chew 500 mg(,250mg) -400 unit * calcium 500-vit d3 400 tablet p/f,na/f,no lactose 500 mg(,250mg) -400 unit * calcium vit d 400 caplet s/f, p/f, caplet 600 mg(,500mg) -400 unit * calcium vit d 400 softgl 600 mg(,500mg) -400 unit * calcium vit d tablet mg-unit * calcium vitamin d sftgl rapid release, sftgl 600 mg(,500mg) -500 unit * calcium 600 mg tablet 600 mg (,500 mg) * calcium 600+d softgel 600 mg calcium- 200 unit * calcium 600-vit d3 200 tablet 600 mg(,500mg) -200 unit * calcium 600-vit d3 400 tablet 600 mg(,500mg) -400 unit * (Travoprost (Benzalkonium)) (Citracal-Vitamin D) $0 (Calcium Citrate) (Caltrate 600 Plus D3) (Calcium Vit D) (Calcium Carbonate/Vitamin D3) (Caltrate 600 Plus D3) (Calcium Carbonate/Vitamin D3) (Calcium Carbonate) (Calcium Carbonate/Vitamin D3) (Caltrate 600 Plus D3) (Caltrate 600 Plus D3) QL (2.5 per 25 days) QL (2.5 per 25 days) 80

195 calcium carb,250 mg/5 ml sus 500 mg/5 ml (,250 mg/5 ml) * calcium carbonate 648 mg tab 260 mg calcium (648 mg) * calcium chloride intravenous solution 00 mg/ml (0 %) calcium chloride intravenous syringe 00 mg/ml (0 %) calcium citrate - vit d caplet caplet, coated mg-unit * calcium citrate-vit d3 caplet s/f, p/f mg-unit * calcium gluconate 500 mg tab 45 mg (500 mg) * calcium gluconate intravenous solution 00 mg/ml (0%) calcium with vit d tablet mg-unit * CALTRATE D SOFT CHEW TAB VANILLA CREME 600 MG (,500 MG)-800 UNIT * CALTRATE 600 PLUS D3 TABLET 600 MG(,500MG) -800 UNIT * citracal + d maximum caplet mg-unit * citrus calcium + d tablet mg-unit * cvs calcium + vitamin d3 sftgl absorbable 600 mg(,500mg) -500 unit * cvs calcium vit d 200 tb 500 mg(,250mg) -200 unit * cvs calcium vit d tablet oyster shell 500 mg(,250mg) -25 unit * (Calcium Carbonate) (Calcium Carbonate) (Calcium Chloride) $0 (Calcium Chloride) $0 (Citracal-Vitamin D) (Citracal-Vitamin D) (Calcium Gluconate) (Calcium Gluconate) (Calcium Carbonate/Vitamin D2) (Citracal-Vitamin D) (Citracal-Vitamin D) (Calcium Carbonate/Vitamin D3) (Caltrate 600 Plus D3) (Caltrate 600 Plus D3) $0 8

196 cvs calcium 600-vit d3 800 tab p/f, s/f,gluten-free 600 mg(,500mg) unit * cvs magnesium 250 mg tablet 250 mg * (Caltrate 600 Plus D3) (Magnesium) cvs pediatric electrolyte soln * (Pedialyte) cvs pediatric electrolyte soln a/f, p/f * (Pedialyte) d0 %-0.45 % sodium chloride (Dextrose 0 % intravenous parenteral solution and 0.45 % NaCl) $0 d2.5 %-0.45 % sodium chloride (Dextrose 2.5 % intravenous parenteral solution and 0.45 % NaCl) $0 d5 % and 0.9 % sodium chloride (Dextrose 5 % and intravenous parenteral solution 0.9 % NaCl) $0 d5 %-0.45 % sodium chloride (Dextrose 5 %-0.45 intravenous parenteral solution % NaCl) $0 dextrose 0 % and 0.2 % nacl (Dextrose 0 % intravenous parenteral solution and 0.2 % NaCl) $0 dextrose 5 %-lactated ringers (Dextrose 5%- intravenous parenteral solution Lactated Ringers) $0 dextrose 5%-0.2 % sod chloride (Dextrose 5 %-0.2 intravenous parenteral solution % NaCl) $0 dextrose 5%-0.3 % sod.chloride (Dextrose 5 % and intravenous parenteral solution 0.3 % NaCl) $0 dextrose with sodium chloride (Dextrose 5 %-0.2 intravenous parenteral solution 5- % NaCl) 0.2 % $0 dextrose-kcl-nacl intravenous solution % effer-k oral tablet, effervescent 25 meq electrolyte-48 in d5w intravenous parenteral solution eql calcium 600 mg + d softgel 600 mg(,500mg) -00 unit * (Potassium Chloride/D5-0.2%NaCl) $0 (Klor-Con-Ef) $0 (Electrolyte-48 Solution/D5W) (Calcium Carbonate/Vitamin D3) $0 82

197 gnp calcium 500-vit d3 600 tab 500mg (,250mg) -600 unit * gnp calcium 600+d3+min chew tb p/f,gluten/f,yeast/f 600 mg calcium- 800 unit-40 mg * hm calcium 600+d plus tab chew gluten-free 600 mg calcium- 800 unit-40 mg * hm calcium citrate-vit d cplt caplet, gluten-free mg-unit * HYPERLYTE CR INTRAVENOUS SOLUTION MEQ/20 ML IONOSOL-B IN D5W INTRAVENOUS PARENTERAL SOLUTION 5 % IONOSOL-MB IN D5W INTRAVENOUS PARENTERAL SOLUTION 5 % ISOLYTE M IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION ISOLYTE-H IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION 5 % ISOLYTE-P IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION 5 % ISOLYTE-S INTRAVENOUS PARENTERAL SOLUTION k-effervescent oral tablet, effervescent 25 meq KELP 50 MCG TABLET 50 MCG * KLOR-CON 0 ORAL TABLET EXTENDED RELEASE 0 MEQ klor-con m0 oral tablet,er particles/crystals 0 meq (Caltrate 600 Plus D3) (Ca/D3/Mag Ox/Zinc/Cop/Mang /Bor) (Ca/D3/Mag Ox/Zinc/Cop/Mang /Bor) (Citracal-Vitamin D) (Klor-Con-Ef) $0 $0 (Potassium $0 Chloride) 83

198 klor-con m5 oral tablet,er (Potassium particles/crystals 5 meq Chloride) $0 klor-con m20 oral tablet,er (Potassium particles/crystals 20 meq Chloride) $0 klor-con sprinkle oral capsule, (Potassium extended release 0 meq, 8 meq Chloride) $0 (Calcium liquid calcium 600-vit d3 sfgl 600 Carbonate/Vitamin mg(,500mg) -400 unit * D3) liquid calcium 600-vit d3 sfgl (Calcium softgel,p/f,gluten-f 600 mg(,500mg) Carbonate/Vitamin -500 unit * D3) liquid calcium with vitamin d softgel, s/f, p/f 600 mg calcium- 200 (Calcium Carbonate/Vitamin unit * D3) mag delay dr 64 mg tablet 64 mg * (Slow-Mag) mag64 dr 64 mg tablet 64 mg * (Slow-Mag) mag-g 500 mg tablet 27 mg (500 mg) * (Magonate) magnesium 250 mg tablet 250 mg * (Magnesium) magnesium 300 mg capsule 300 mg * magnesium chloride injection solution 200 mg/ml (20 %) magnesium gluc 500 mg tablet 27 mg (500 mg) * magnesium sulf in 0.45% nacl intravenous solution 20 gram/500 ml (40 mg/ml) magnesium sulfate in d5w intravenous piggyback gram/00 ml, 4 gram/00 ml magnesium sulfate in water intravenous parenteral solution 20 gram/500 ml (4 %), 40 gram/,000 ml (4 %) (Magnesium Oxide/Mag Aa Chelate) (Magnesium Chloride) $0 (Magonate) (Magnesium Sulf In 0.45% NaCl) (Magnesium Sulfate/D5W) (Magnesium Sulfate in Water) $0 $0 $0 84

199 magnesium sulfate in water intravenous piggyback 2 gram/50 ml (4 %), 4 gram/00 ml (4 %), 4 gram/50 ml (8 %) magnesium sulfate injection solution 4 meq/ml (50 %) magnesium sulfate injection syringe 4 meq/ml natural calcium 500 mg tablet 500 mg calcium (,250 mg) * NORMOSOL-M IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION NORMOSOL-R PH 7.4 INTRAVENOUS PARENTERAL SOLUTION (Magnesium Sulfate in Water) (Magnesium Sulfate) (Magnesium Sulfate) (Calcium Carbonate) $0 $0 $0 nu-mag 7.5 mg tablet 7.5 mg * (Slow-Mag) NUTRILYTE II INTRAVENOUS SOLUTION MEQ/20 ML NUTRILYTE INTRAVENOUS SOLUTION MEQ/20 ML oysco 500-vit d3 200 tablet 500 (Caltrate 600 Plus mg(,250mg) -200 unit * D3) oysco d tablet mg-unit * (Caltrate 600 Plus D3) oysco-500 tablet 500 mg calcium (Calcium (,250 mg) * Carbonate) oyster shell 250 mg + vit d tb 250- (Caltrate 600 Plus 25 mg-unit * D3) oyster shell 500-vit d3 200 tb 500 (Caltrate 600 Plus mg(,250mg) -200 unit * D3) oyster shell calcium 500 mg tb (Calcium 500mg elemental ca 500 mg calcium Carbonate) (,250 mg) * oyster shell calcium tablet 500 mg(,250mg) -400 unit * (Caltrate 600 Plus D3) 85

200 oyster shell calcium-vit d tab p/f,s/f,gluten-free 500 mg(,250mg) -400 unit * oystercal-d 500 mg-400 unit tb 500 mg(,250mg) -400 unit * (Caltrate 600 Plus D3) (Caltrate 600 Plus D3) pediatric electrolyte solution * (Pedialyte) PHOS-NAK PACKET MG * phospha 250 neutral oral tablet 250 mg (K-Phos Neutral) $0 PLASMA-LYTE 48 INTRAVENOUS PARENTERAL SOLUTION PLASMA-LYTE A INTRAVENOUS PARENTERAL SOLUTION PLASMA-LYTE-56 IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION 5 % potassium acetate intravenous solution 2 meq/ml, 4 meq/ml potassium bicarb and chloride oral tablet, effervescent 25 meq potassium bicarb-citric acid oral tablet, effervescent 25 meq potassium chlorid-d5-0.45%nacl intravenous parenteral solution 0 meq/l, 20 meq/l, 30 meq/l, 40 meq/l potassium chloride in 0.9%nacl intravenous parenteral solution 20 meq/l, 40 meq/l potassium chloride in 5 % dex intravenous parenteral solution 20 meq/l, 30 meq/l, 40 meq/l potassium chloride in lr-d5 intravenous parenteral solution 20 meq/l (Potassium Acetate) (Pot Chloride/Pot Bicarb/Cit Ac) $0 $0 (Klor-Con-Ef) $0 (Potassium Chloride/D5-0.45nacl) (Potassium Chloride In 0.9%NaCl) (Potassium Chloride In D5w) (Potassium Chloride In Lr-D5) $0 $0 $0 $0 86

201 potassium chloride intravenous piggyback 0 meq/00 ml, 20 meq/00 ml, 30 meq/00 ml, 40 meq/00 ml potassium chloride intravenous solution 2 meq/ml potassium chloride oral capsule, extended release 0 meq, 8 meq potassium chloride oral liquid 20 meq/5 ml, 40 meq/5 ml potassium chloride oral packet 20 meq potassium chloride oral tablet extended release 8 meq potassium chloride oral tablet,er particles/crystals 0 meq potassium chloride oral tablet,er particles/crystals 20 meq potassium chloride-0.45 % nacl intravenous parenteral solution 20 meq/l potassium chloride-d5-0.2%nacl intravenous parenteral solution 0 meq/l, 20 meq/l, 30 meq/l, 40 meq/l potassium chloride-d5-0.3%nacl intravenous parenteral solution 20 meq/l potassium chloride-d5-0.9%nacl intravenous parenteral solution 20 meq/l, 40 meq/l potassium citrate oral tablet extended release 0 meq (,080 mg), 5 meq, 5 meq (540 mg) potassium citrate-citric acid oral packet 3,300-,002 mg potassium cl 0 meq/50 ml sol 0 meq/50 ml (Potassium Chloride) (Potassium Chloride) (Potassium Chloride) (Potassium Chloride) $0 $0 $0 $0 (Klor-Con) $0 (Klor-Con 0) $0 (Klor-Con 0) $0 (Potassium Chloride) (Potassium Chloride-0.45% NaCl) (Potassium Chloride/D5-0.2%NaCl) (Potassium Chloride/D5-0.3%NaCl) (Potassium Chloride/D5-0.9%NaCl) $0 $0 $0 $0 $0 (Urocit-K) $0 (Potassium Citrate/Citric Acid) (Potassium Chloride) $0 $0 87

202 potassium cl 20 meq/50 ml sol 20 meq/50 ml potassium cl er 0 meq tablet 0 meq potassium cl er 0 meq tablet f/c 0 meq potassium cl er 20 meq tablet 20 meq (Potassium Chloride) (Potassium Chloride) $0 $0 (Klor-Con 0) $0 (Potassium Chloride) $0 (Potassium potassium phosphate m-/d-basic Phos,M-Basic-Dintravenous solution 3 mmol/ml Basic) $0 (Ca/D3/Mag ra cal 600-vit d3-min chew tab 600 Ox/Zinc/Cop/Mang mg calcium- 400 unit-40 mg * /Bor) ra hi-cal plus vitamin d tab 500 (Caltrate 600 Plus mg(,250mg) -200 unit * D3) (Calcium ra oyster shell-vitamin d tab s/f, p/f Carbonate/Vitamin 250 (625)-25 mg-unit * D2) ra pediatric electrolyte soln a/f * (Pedialyte) ra pediatric freezer pops * (Pedialyte) ringers intravenous parenteral solution (Ringers Solution) $0 sm calcium 600-vit d3 800 tab 600 (Caltrate 600 Plus mg(,500mg) -800 unit * D3) sm pediatric electrolyte soln * (Pedialyte) sodium acetate intravenous solution 2 meq/ml, 4 meq/ml (Sodium Acetate) $0 sodium bicarbonate intravenous (Sodium solution meq/ml (8.4 %) Bicarbonate) $0 sodium bicarbonate intravenous syringe 0 meq/0 ml (8.4 %), 4.2 % (Sodium (0.5 meq/ml), 7.5 % (0.9 meq/ml), Bicarbonate) $0 8.4 % ( meq/ml) sodium chloride 0.45 % intravenous parenteral solution 0.45 % (Sodium Chloride 0.45 %) $0 88

203 sodium chloride 0.9 % intravenous parenteral solution 0.9 % sodium chloride 3 % intravenous parenteral solution 3 % sodium chloride 5 % intravenous parenteral solution 5 % sodium chloride intravenous parenteral solution 2.5 meq/ml, 4 meq/ml sodium lactate intravenous parenteral solution 67 meq/l sodium lactate intravenous solution 5 meq/ml sodium phosphate intravenous solution 3 mmol/ml TPN ELECTROLYTES II IV SOLN 25'S,20ML/50ML FTV MEQ/20 ML TPN ELECTROLYTES INTRAVENOUS SOLUTION MEQ/20 ML virt-phos 250 neutral oral tablet 250 mg v-r calcium d 33 caplet mg-unit * Respiratory Tract Agents Anti-Inflammatories, Inhaled Corticosteroids ADVAIR DISKUS INHALATION BLISTER WITH DEVICE MCG/DOSE, MCG/DOSE, MCG/DOSE ADVAIR HFA INHALATION HFA AEROSOL INHALER 5-2 MCG/ACTUATION, MCG/ACTUATION, 45-2 MCG/ACTUATION (0.9 % Sodium Chloride) (Sodium Chloride 3 %) (Sodium Chloride 5 %) $0 $0 $0 (Sodium Chloride) $0 (Sodium Lactate) $0 (Sodium Lactate) $0 (Sodium Phos,M- Basic-D-Basic) $0 (K-Phos Neutral) $0 (Caltrate 600 Plus D3) QL (60 per 30 days) QL (2 per 28 days) 89

204 BREO ELLIPTA INHALATION BLISTER WITH DEVICE MCG/DOSE, MCG/DOSE DULERA INHALATION HFA AEROSOL INHALER 00-5 MCG/ACTUATION, MCG/ACTUATION FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 00 MCG/ACTUATION, 50 MCG/ACTUATION FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 250 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 0 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 220 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 44 MCG/ACTUATION QVAR INHALATION AEROSOL 40 MCG/ACTUATION, 80 MCG/ACTUATION Antileukotrienes montelukast oral granules in packet 4 mg (Singulair) $0 montelukast oral tablet 0 mg (Singulair) $0 montelukast oral tablet,chewable 4 (Singulair) $0 mg, 5 mg zafirlukast oral tablet 0 mg, 20 mg (Accolate) $0 Bronchodilators albuterol sulfate inhalation solution for nebulization 0.63 mg/3 ml,.25 mg/3 ml, 2.5 mg /3 ml (0.083 %), 5 mg/ml (Albuterol Sulfate) $0 QL (60 per 30 days) QL (3 per 28 days) QL (60 per 30 days) QL (20 per 30 days) QL (2 per 28 days) QL (24 per 28 days) QL (2.2 per 28 days) QL (7.4 per 25 days) 90

205 albuterol sulfate oral syrup 2 mg/5 ml albuterol sulfate oral tablet 2 mg, 4 mg albuterol sulfate oral tablet extended release 2 hr 4 mg, 8 mg ATROVENT HFA INHALATION HFA AEROSOL INHALER 7 MCG/ACTUATION COMBIVENT RESPIMAT INHALATION MIST MCG/ACTUATION ipratropium bromide inhalation solution 0.02 % ipratropium-albuterol inhalation solution for nebulization 0.5 mg-3 mg(2.5 mg base)/3 ml metaproterenol oral syrup 0 mg/5 ml metaproterenol oral tablet 0 mg, 20 mg PROAIR HFA INHALATION HFA AEROSOL INHALER 90 MCG/ACTUATION PROAIR RESPICLICK INHALATION AEROSOL POWDR BREATH ACTIVATED 90 MCG/ACTUATION SEREVENT DISKUS INHALATION BLISTER WITH DEVICE 50 MCG/DOSE SPIRIVA RESPIMAT INHALATION MIST.25 MCG/ACTUATION, 2.5 MCG/ACTUATION (Albuterol Sulfate) $0 (Albuterol Sulfate) $0 (Vospire ER) $0 (Ipratropium Bromide) (Ipratropium/Albut erol Sulfate) (Metaproterenol Sulfate) (Metaproterenol Sulfate) $0 $0 $0 $0 QL (25.8 per 28 days) QL (8 per 30 days) 9

206 SPIRIVA WITH HANDIHALER INHALATION CAPSULE, W/INHALATION DEVICE 8 MCG STRIVERDI RESPIMAT INHALATION MIST 2.5 MCG/ACTUATION terbutaline oral tablet 2.5 mg, 5 mg terbutaline subcutaneous solution mg/ml theochron oral tablet extended release 2 hr 00 mg, 200 mg, 300 mg theophylline in dextrose 5 % intravenous parenteral solution 200 mg/00 ml, 200 mg/50 ml, 400 mg/250 ml, 400 mg/500 ml, 800 mg/250 ml theophylline oral solution 80 mg/5 ml theophylline oral tablet extended release 2 hr 00 mg, 200 mg, 300 mg, 450 mg theophylline oral tablet extended release 24 hr 400 mg, 600 mg TUDORZA PRESSAIR INHALATION AEROSOL POWDR BREATH ACTIVATED 400 MCG/ACTUATION, 400 MCG/ACTUATION (30 ACTUAT) VENTOLIN HFA INHALATION HFA AEROSOL INHALER 90 MCG/ACTUATION Respiratory Tract Agents, Other acetylcysteine intravenous solution 200 mg/ml (20 %) (Terbutaline Sulfate) (Terbutaline Sulfate) (Theophylline Anhydrous) (Theophylline/D5 W) (Theophylline Anhydrous) (Theophylline Anhydrous) (Theophylline Anhydrous) $0 $0 $0 $0 $0 $0 $0 (Acetadote) $0 QL (2 per 28 days) 92

207 acetylcysteine solution 00 mg/ml (0 %), 200 mg/ml (20 %) CINQAIR INTRAVENOUS SOLUTION 0 MG/ML cromolyn inhalation solution for nebulization 20 mg/2 ml cromolyn sodium nasal spray 5.2 mg/spray (4 %) * DALIRESP ORAL TABLET 500 MCG ESBRIET ORAL CAPSULE 267 MG KALYDECO ORAL GRANULES IN PACKET 50 MG, 75 MG KALYDECO ORAL TABLET 50 MG NUCALA SUBCUTANEOUS RECON SOLN 00 MG OFEV ORAL CAPSULE 00 MG, 50 MG ORKAMBI ORAL TABLET MG PROLASTIN-C INTRAVENOUS RECON SOLN,000 MG sodium chloride 0.9% inhal vl u-d, suv, p/f (rx) 0.9 % * XOLAIR SUBCUTANEOUS RECON SOLN 50 MG (Acetadote) $0 (Cromolyn Sodium) $0 (Nasalcrom) (Pulmosal) 3 $0 Skeletal Muscle Relaxants Skeletal Muscle Relaxants baclofen oral tablet 0 mg, 20 mg (Baclofen) $0 carisoprodol oral tablet 250 mg, 350 mg chlorzoxazone oral tablet 500 mg (Soma) $0 (Parafon Forte DSC) $0 PA QL (30 per 30 days) PA; QL (270 per 30 days) PA; QL (60 per 30 days) PA; QL (60 per 30 days) PA; LA; QL ( per 28 days) PA PA; QL (20 per 30 days) PA PA-HRM; QL (20 per 30 days); AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) 93

208 cyclobenzaprine oral tablet 0 mg, 5 mg dantrolene oral capsule 00 mg, 25 mg, 50 mg (Fexmid) $0 (Dantrium) $0 metaxall oral tablet 800 mg (Skelaxin) $0 metaxalone oral tablet 400 mg, 800 mg methocarbamol oral tablet 500 mg, 750 mg revonto intravenous recon soln 20 mg tizanidine oral capsule 2 mg, 4 mg, 6 mg (Skelaxin) $0 (Robaxin) $0 (Dantrium) $0 (Zanaflex) $0 tizanidine oral tablet 2 mg, 4 mg (Zanaflex) $0 Sleep Disorder Agents Sleep Disorder Agents armodafinil oral tablet 50 mg, 200 mg, 250 mg, 50 mg BELSOMRA ORAL TABLET 0 MG, 5 MG, 20 MG, 5 MG eszopiclone oral tablet mg, 2 mg, 3 mg (Nuvigil) $0 (Lunesta) $0 HETLIOZ ORAL CAPSULE 20 MG ROZEREM ORAL TABLET 8 MG XYREM ORAL SOLUTION 500 MG/ML PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA QL (30 per 30 days) PA-HRM; QL (30 per 30 days); AGE (Max 64 Years) PA LA 94

209 zaleplon oral capsule 0 mg, 5 mg (Sonata) $0 zolpidem oral tablet 0 mg, 5 mg (Ambien) $0 zolpidem oral tablet,ext release multiphase 2.5 mg, 6.25 mg Vasodilating Agents Vasodilating Agents (Ambien CR) $0 ADCIRCA ORAL TABLET 20 MG PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any nonbenzodiazepine hypnotic drug); QL (60 per 30 days); AGE (Max 64 Years) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any nonbenzodiazepine hypnotic drug); QL (30 per 30 days); AGE (Max 64 Years) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any nonbenzodiazepine hypnotic drug); QL (30 per 30 days); AGE (Max 64 Years) PA; QL (60 per 30 days) 95

210 ADEMPAS ORAL TABLET 0.5 MG, MG,.5 MG, 2 MG, 2.5 MG epoprostenol (glycine) intravenous recon soln 0.5 mg,.5 mg LETAIRIS ORAL TABLET 0 MG, 5 MG (Flolan) $0 OPSUMIT ORAL TABLET 0 MG ORENITRAM ORAL TABLET EXTENDED RELEASE 0.25 MG, 0.25 MG, MG, 2.5 MG REMODULIN INJECTION SOLUTION MG/ML, 0 MG/ML, 2.5 MG/ML, 5 MG/ML sildenafil intravenous solution 0 mg/2.5 ml (Revatio) $0 sildenafil oral tablet 20 mg (Revatio) $0 TRACLEER ORAL TABLET 25 MG, 62.5 MG TYVASO INHALATION SOLUTION FOR NEBULIZATION.74 MG/2.9 ML (0.6 MG/ML) TYVASO REFILL KIT INHALATION SOLUTION FOR NEBULIZATION.74 MG/2.9 ML (0.6 MG/ML) TYVASO STARTER KIT INHALATION SOLUTION FOR NEBULIZATION.74 MG/2.9 ML UPTRAVI ORAL TABLET,000 MCG,,200 MCG,,400 MCG,,600 MCG, 400 MCG, 600 MCG, 800 MCG UPTRAVI ORAL TABLET 200 MCG PA; QL (90 per 30 days) PA; QL (30 per 30 days) PA; QL (30 per 30 days) PA PA; QL (37.5 per day) PA; QL (90 per 30 days) PA; LA; QL (60 per 30 days) PA; QL (60 per 30 days) PA; QL (240 per 30 days) 96

211 UPTRAVI ORAL TABLETS,DOSE PACK 200 MCG (40)- 800 MCG (60) Vitamins And Minerals Vitamins And Minerals a thru z advanced formula tab gluten-free mg-mcg * a thru z advanced formula tab new formula * a thru z select 50+ formula tb advanced formula mgmcg-mcg * a thru z select men 50+ tablet mcg * a thru z select multivit tab mcg * a thru z select tablet adults 50+,iron-free mg-mcgmcg * a thru z select tablet new formulation * a thru z select women's tablet * abc plus tablet mgmcg-mcg * (Multivitamin/Iron/ Folic Acid) (Multivitamin with Minerals/Lut) (Biocel) (Biocel) (Biocel) (Biocel) (Multivitamin with Minerals/Lut) (Mv,Fe,Min/Lutein ) (Biocel) adult multi gummies 200 mcg * (One-A-Day Vitacraves) adult one daily gummies 200 mcg * (One-A-Day Vitacraves) adults' 50+ daily formula tab mg-mcg-mcg * (Biocel) adults 50+ multivitamin tablet mg-mcg-mcg * (Biocel) adults' daily formula tablet (Multivitamin/Iron/ mg-mcg * Folic Acid) animal chews tablet * (Multivitamin) PA; QL (200 per 365 days) 97

212 antioxidant softgel softgel * (Beta-Carotene(A) W-C and E/Min) apatate forte liquid * (Multivitamin with Minerals) b complete tablet * (Vitamin B Complex) b complex capsule * (Vitamin B Complex) b complex formula # tablet * (Vitamin B Complex) b complex tablet * (Vitamin B Complex) b mcg tablet 500 mcg * (B-2) b-2 dots 500 mcg tablet 500 mcg * (B-2) balance b-00 tablet * (Vitamin B Complex) balance b-50 tablet * (Vitamin B Complex) balance b-50 tablet inner,p/f,gluten/f (Vitamin B * Complex) balanced b-00 tablet * (Vitamin B Complex) balanced b-00 tablet 00 mg * (Vit B Complex 00 No.3/Herbal) balanced b-50 tablet * (Vitamin B Complex) balanced b-50 tablet * (Vitamin B Complex) balanced b-complex caplet p/f,nolactose 400 mcg * (Dialyvite 800) b-complex plus vitamin c cplt caplet * (Vita-Bee with C) b-complex with b2 tablet * (Vitamin B Complex) b-complex with c tablet * (Vita-Bee with C) b-complex with vit c caplet s/f,p/f,gluten-free 400 mcg * (Dialyvite 800) 98

213 biosupp liquid * (Multivitamin with Minerals) biotin 300 mcg tablet 300 mcg * (Biotin) biovol syrup * (Multivitamin with Minerals) c complex 500 mg tablet sa 500 mg * (Ascorbic Acid) calcidol drops 8,000 unit/ml * (Drisdol) centamin liquid 9 mg iron/5 ml * (Multivit- Minerals/Ferrous Gluc) central-vite seniors tablet * (Multivit with Iron- Minerals) (Multivitcentram-care multivit-min liq 9 mg Minerals/Ferrous iron/5 ml * Gluc) centravites 50 plus tablet * (Multivit with Iron- centrum complete multivit tab mg-mcg * centrum multivit-mineral liq 9 mg iron/5 ml * centrum silver tablet adults mg-mcg-mcg * century adults 50+ tablet gluten free mg-mcg-mcg * century mature tablet * cerovite liquid 9 mg iron/5 ml * Minerals) (Multivitamin/Iron/ Folic Acid) (Multivit- Minerals/Ferrous Gluc) (Biocel) (Biocel) century ultimate women's tab mg-mcg * cerovite advanced form tab mg-mcg * (Multivitamin with Minerals/Lut) (Multivitamin/Iron/ Folic Acid) (Multivitamin/Iron/ Folic Acid) (Multivit- Minerals/Ferrous Gluc) 99

214 certavite sr-antioxidant tab mg-mcg-mcg * certavite-antioxidant liquid 9 mg iron/5 ml * certavite-antioxidant tablet mg-mcg * child chew + iron tab chew * (Biocel) (Multivit- Minerals/Ferrous Gluc) (Multivitamin/Iron/ Folic Acid) (Multivitamin with Iron) child chew vitamin tablet * (Multivitamin) child ferrous sulfate 5 mg/ml 5 mg iron (75 mg)/ml * (Fer-In-Sol) children's chewable vitamin * (Multivitamin) childrens multivit tab chew * (Multivitamin) complete multi 50+ tablet mcg * (Biocel) complete multivitamin tab * (Multivit,Th Iron,Other Min) complete senior tablet * (Multivit with Iron- Minerals) cvs bal b-00 tablet * (Vitamin B Complex) cvs bal b-50 tablet * (Vitamin B Complex) cvs balanced b-50 tablet * (Vitamin B Complex) cvs b-complex-vit c caplet caplet * (Vita-Bee with C) cvs child vit-mineral tab * (Multivit with Iron- Minerals) cvs children's chewable vit * (Multivitamin) cvs childs vit with c tab chew * (Multivitamin) cvs child's vitamin-iron tb * (Multivitamin with Iron) cvs daily gummies complete adult vit (One-A-Day 200 mcg * Vitacraves) cvs daily multiple tablet * (Multivitamin) 200

215 cvs daily multiple tablet for women * (Multivitamin) cvs daily teen multi-vitamin (Multivitamin/Iron/ mg-mcg * Folic Acid) cvs gummy swirls chewable * (Multivitamin) cvs iron 27 mg tablet 240 mg (27 mg (Fergon) iron) * cvs men's daily gummies p/f, glutenfree 200 mcg * Vitacraves) (One-A-Day cvs men's multi-vit tablet * (Multivitamin) cvs prenatal vitamin tablet * (Prenatal Vit Calc,Iron,Folic) cvs spectravite adult 50+ tabs mg-mcg-mcg * (Biocel) cvs spectravite advanced tab (Multivitamin/Iron/ mg-mcg * Folic Acid) cvs spectravite liquid * (Pediavit) cvs spectravite senior * (Multivitamin with Minerals/Lut) cvs spectravite senior tab * (Multivit with Iron- Minerals) cvs spectravite senior tablet mcg * (Biocel) cvs spectravite tablet chew * (Multivitamin with Iron) cvs spectravite ultra women tb 8- (Multivitamin/Iron/ 400 mg-mcg * Folic Acid) cvs super b complx & c cplt caplet, p/f * (Vita-Bee with C) cvs vision formula tablet,000 unit- (Vit A,C and 200 mg-60 unit-2 mg * E/Lutein/Minerals) cvs vitamin b-00 complx tb * (Vitamin B Complex) cvs vitamin c,000 mg tb chw,000 mg * (Ascorbic Acid) cvs vitamin d3,000 unit sfgl softgel (D3-50),000 unit * 20

216 cvs women's daily gummies p/f, (One-A-Day gluten-free 200 mcg * Vitacraves) cyanocobalamin,000 mcg/ml 25's (Cyanocobalamin 3 $0,000 mcg/ml * (Vitamin B-2)) d3 dots 2,000 unit tablet p/f 2,000 (Vitamin D3) unit * (Multivitamin with daily multi vitamin-iron tab * Iron) daily multiple tablet mg-mcg (Multivitamin/Iron/ * Folic Acid) daily multiple vitamin tab sugar (Multivitamin) coated * daily value multivitamin tab s/f * (Multivitamin) (Multivitamin with daily vitamin + iron tablet * Iron) daily vitamin formula tablet * (Multivitamin) (Multivitamin with daily vitamin formula tablet * Minerals) daily vitamin tablet p/f,na/f * (Multivitamin) daily vite tablet s/f, p/f * (Multivitamin) daily vite tablet s/f,p/f * (Multivitamin) (Multivitamin with daily vite with iron tablet * Iron) dino-life extra c tab chew * (Multivitamin) (Multivit with Irondino-life iron-zinc tb chew * Minerals) dino-life tablet chewable * (Multivitamin) (B,B2,B3,B6,B2 eldertonic elixir mg * /Dexpan/Zn/Mang) (Multivitamin with ellis tonic * Minerals) daily multivitamin-iron tablet 8- daily vit formula + iron tab (Multivitamin/Iron/ (Multivitamin/Iron/ 400 mg-mcg * mg-mcg * Folic Acid) Folic Acid) 202

217 eq child complete chew tablet 8 mg iron * (Pedi Mv No.58/Ferrous Fumarate) eq complete multivitamin tab mg-mcg-mcg * (Biocel) eq complete multivitamin tab glutenfree mg-mcg * Folic Acid) (Multivitamin/Iron/ eql central-vite select tablet * (Multivitamin with Minerals/Lut) eql century mature tablet mcg * (Biocel) eql chewable multi vitamin tab * (Multivitamin) eql child's multivit tab chew with vitamin c * (Multivitamin) eql childs multivit-mineral tb * (Multivit with Iron- Minerals) eql eye health plus lutein tab,000 (Vit A,C and unit-200 mg-60 unit-2 mg * E/Lutein/Minerals) eql one daily 50 plus tablet * (Multivitamin with Minerals) eql one daily essential tablet * (Multivitamin) eql one daily maximum tablet mg * (Tab A Vite) eql one daily men's tablet * ergocalciferol 8,000 units/ml 8,000 unit/ml * essentia tablet mg-mcg * essential balance tablet * essential daily tablet w/iron & calcium mg * ferocon capsule mg * ferretts 325 mg tablet 325 mg (06 mg iron) * (Multivitamin with Minerals) (Drisdol) (Multivitamin/Iron/ Folic Acid) (Mv,Fe,Min/Lutein ) (Tab A Vite) (Fe Fumarate/Vit C/B2-If/Fa) 3 $0 (Ferrous Fumarate) 203

218 ferrex 50 capsule outer, u-d 50 mg iron * ferrex 50 plus capsule mg * (Iron Polysaccharide Complex) (Iron Aspgly,Ps/C/Succi nic Acid) ferrocite tablet 324 mg (06 mg iron) * (Ferrous Fumarate) ferrous fumarate 324 mg tab 324 mg (Ferrous Fumarate) (06 mg iron) * ferrous gluconate 240 mg tab 240mg=27mg elemental 240 mg (27 (Fergon) mg iron) * ferrous gluconate 324 mg tab 324 mg (36 mg iron), 324 mg (37.5 mg iron), 324 mg (38 mg iron) * (Fergon) ferrous sulf 220 mg/5 ml elix 220 mg (Ferrous Sulfate) (44 mg iron)/5 ml * ferrous sulf 300 mg/5 ml liq 300 mg (60 mg iron)/5 ml * (Ferrous Sulfate) ferrous sulf ec 324 mg tablet 324 mg (Ferrous Sulfate) (65 mg iron) * ferrous sulfate 325 mg tablet red 325 mg (65 mg iron) * (Slow Fe) flintstones complete tablet * (Multivit with Iron- Minerals) flintstones extra c tab chew * (Multivitamin) flintstones tablet chewable * (Multivitamin) (Pedi Mv flintstones with iron tab chew 8 mg No.79/Ferrous iron * Fumarate) folic acid mg tablet (rx) mg * (Folic Acid) 3 $0 folic acid,000 mcg tablet p/f,s/f (otc) mg * (Folic Acid) FOLIC ACID 20 MG CAPSULE 20 MG * 204

219 folic acid 400 mcg tablet s/f,p/f,lactose-free 400 mcg * (Folic Acid) fosfree tablet mg * (Calcium/Multivita min with Iron) geravim liquid * (Pediavit) geriaton liquid * (Pediavit) gnp century mature tablet glutenfree mg-mcg-mcg * (Biocel) gnp century tablet gluten-free 8- (Multivitamin/Iron/ 400 mg-mcg * Folic Acid) gnp one daily essential tablet * (Multivitamin) gs prenatal vitamins tablet (Pnv33/Ferrous mg-mcg * Fumarate/Fa) gummi bear multivit tab chew multivit & minerals * (Multivitamin) hair vitamins * (Multivitamin with Iron) healthy eyes caplet caplet,000 (Vit A,C and unit-200 mg-60 unit-2 mg * E/Lutein/Minerals) hemocyte tablet u-u,blister pk 324 mg (06 mg iron) * (Ferrous Fumarate) hi-b complex tablet * (Vitamin B Complex) hm complete 50+ tablet (Biocel) mg-mcg-mcg * hm one daily with iron tablet glutenfree mg-mcg * Folic Acid) (Multivitamin/Iron/ hm super vitamin b complex glutenfree 400 mcg * (Dialyvite 800) honey bears chew tab * (Multivitamin) honey bears-iron-zinc tab chew * (Multivit with Iron- Minerals) icaps plus tablet lactose free * (Multivitamin with Minerals) iferex 50 capsule 50 mg iron * (Iron Polysaccharide Complex) 205

220 iron 27 mg tablet 236 mg (27 mg iron) * (Fergon) iron 28 mg tablet 256 mg (28 mg iron) * (Fergon) kenwood therapeutic liquid * (Multivitamin,Ther apeutic) life-pack women's p/f,s/f 0.8 mg * (Multivit with Iron- Minerals) LIQUI-E LIQUID 400 UNIT/5 ML * little animals child tb chw * (Multivitamin) little animals-iron tab chew * (Multivitamin with Iron) lysiplex plus liquid * (Pediavit) MACUVITE EYE CARE TABLET 7,60 UNIT-3 MG-00 UNIT * MACUVITE TABLET 5, UNIT-MG-UNIT * mega multivitamin-mineral tab * (Multivitamin with Minerals) mega multivit-chelated min tab * (Multivitamin with Minerals) MEPHYTON 5 MG TABLET 5 MG * 3 $0 milltrium senior multivit tab * (Multivitamin with Minerals/Lut) multi complete-iron tablet (Multivitamin/Iron/ mg-mcg * Folic Acid) multi-day plus iron tablet (Multivitamin/Iron/ mg-mcg * Folic Acid) multi-delyn with iron liquid 0 mg (Multivitamin/Ferr iron/5 ml * ous Gluconate) multiple vitamin with iron tab * (Multivitamin with Iron) multiple vitamin w-minerals tb * (Multivitamin with Minerals) multiple vitamins tablet one daily * (Multivitamin) 206

221 multivitamin child tab chew * (Multivitamin) multi-vitamin daily tablet * (Multivitamin) (Multivitmultivitamin-mineral liquid 9 mg Minerals/Ferrous iron/5 ml * Gluc) multivit-fluor 0.5 mg tab chew (Pedi M.Vit No.7 chewable, d/f, s/f 0.5 mg with Fluoride) $0 multivit-iron child tab chew (Multivitamin with children's * Iron) multivit-mineral hp cap * (Multivitamin,Ther and Minerals) multivit-minerals tablet s/f,p/f * (Multivitamin with Minerals) my favorite multiple liquid * (Multivitamin) myvitalife soft-gel capsule * NASCOBAL 500 MCG NASAL SPRAY 500 MCG/SPRAY * nephplex rx tablet mg-mg-mcg-mg * nephron fa tablet mg * nephro-vite rx tablet mgmg-mcg * niacinamide er 500 mg tablet 500 mg * nu-iron 50 capsule 50 mg iron * ocutabs tablet s/f, w/lutein * oncovite tablet * one daily complete tablet * (Multivitamin with Minerals) (Vit B Cmplx No3/Fa/C/Biot/Zin c) (Fe Fumarate/Doss/Fa/ Bcomp,C) (Vit B Cmplx 3/Fa/Vit C/Biotin) 3 $0 3 $0 3 $0 3 $0 (Niacinamide) (Iron Polysaccharide Complex) (Beta-Carotene(A) W-C and E/Min) (Multivitamin,Ther apeutic) (Multivitamin with Minerals) 207

222 one daily essential tablet * (Multivitamin) one daily multivitamin tab * (Multivitamin) one daily multivitamin tablet * (Multivitamin with Iron) one daily multivitamin tablet 400 mcg * (Quintabs) one daily multivitamin-iron tb 8- (Multivitamin/Iron/ 400 mg-mcg * Folic Acid) one daily plus iron tablet (Multivitamin/Iron/ mg-mcg * Folic Acid) one daily tablet * (Multivitamin) one daily tablet * (Multivitamin with Iron) one daily tablet men's formula * (Multivitamin) one daily with minerals tablet * (Multivitamin with Minerals) one-a-day essential tablet * (Multivitamin) one-a-day max formula tab * (Multivitamin with Minerals) one-a-day teen advantage tab 8- (Multivitamin/Iron/ 400 mg-mcg * Folic Acid) one-a-day teen advantage tab 9 mg (Multivits,Ca,Mine iron-400 mcg * rals/iron/fa) pharmacist multi-vite tab * (Multivitamin) pnv prenatal plus multivit tab s/f, (Pnv with gluten-free 27 mg iron- mg Ca,No.72/Iron/Fa) (Iron poly-iron 50 mg capsule 50 mg Polysaccharide iron * Complex) poly-vita drops, unitmg-unit/ml * poly-vita with iron drops,500 unit- 400 unit-0 mg/ml * poly-vitamin drops, unit-mg-unit/ml * (Pediatric Multivitamin No.20) (Ped Multivit #46/Iron Sulfate) (Pediatric Multivitamin No.20) (All Rx Prenatal Vitamins Covered) 208

223 poly-vitamin tab chew * (Multivitamin) polyvitamin w-iron drops,500 (Ped Multivit unit-400 unit-0 mg/ml * #46/Iron Sulfate) (Prenatal Vit prenatal tablet (otc) mg * No.30/Iron/Fa) (Prenatal prenatal tablet 27 mg iron- 800 mcg Vit#96/Ferrous * Fum/Fa) prenatal tablet 28 mg iron- 800 mcg (Prenatal Vit/Iron * Fumarate/Fa) prenatal vitamins tablet phosphorus (Prenatal) free 28 mg iron- 800 mcg * (Multivitamin with pub multivitamin 50 plus tab * Minerals/Lut) (Vitamin B pv b-00 complex * Complex) (Vitamin B pv b-50 complex * Complex) pv kid's gummy bear tab chew (Multivitamin) chewable * pv kid's vit + extra c chew tb * (Multivitamin) (Multivitamin with pv kid's vit + iron tab chew * Iron) pv kid's vit complete tab chew * (Multivitamin) pv kid's vitamins chew tab * (Multivitamin) (Multivitamin with pv multivital platinum tablet * Minerals/Lut) prenatal vitamin plus low iron oral prenatal vitamin tablet 28 mg ironprosight tablet 5, unit-mgunit * pv kids vitamins+iron tab chew 5 (Pnv with (Prenatal Vit/Iron (A/C/E/Zinc/Sod (Ped Multivit tablet 27 mg iron- mg 800 mcg * mg iron * Ca,No.72/Iron/Fa) Fumarate/Fa) Selenate/Copper) #7/Iron Fumarate) (All Rx Prenatal Vitamins Covered) 209

224 pv multivital platinum tablet w/lutein & lycopene mcg * pv prenatal formula tablet 28 mg iron- 800 mcg * pv prenatal formula tablet 28 mg iron- 800 mcg * pv stress 500 plus zinc tab * pyridoxine 00 mg/ml vial 25's 00 mg/ml * qc child complete vit chew tab 8 mg iron * (Biocel) (Prenatal Vit No.3/Iron/Fa) (Prenatal Vit/Iron Fumarate/Fa) (Multivitamin,Stres s Formula/Zn) (Pyridoxine HCl) 3 $0 (Pedi Mv No.67/Ferrous Fumarate) qc children's chewable tablet * (Multivitamin) qc maximum daily multivit tab 8- (Tab A Vite) 0.4 mg * qc multi-vite 50 & over tablet (Multivitamin with w/lycopene * Minerals/Lut) qc multi-vite tablet mg-mcg (Multivitamin/Iron/ * Folic Acid) qc women's daily multivit tab (Tab A Vite) mg * (Vitamin B ra balanced b-00 tablet 0.4 mg * Complex/Folic Acid) (Vitamin B ra b-complex tablet p/f * Complex) (Vitamin B ra b-complex tablet p/f * Complex) (Multivitamin with ra central vite select tab p/f * Minerals/Lut) (Multivit with Ironra central-vite select tab p/f * Minerals) ra central-vite senior tablet (Biocel) 250 mg-mcg-mcg * 20

225 ra central-vite tablet mg-mcg-mcg * (Biocel) ra central-vite tablet mgmcg * Folic Acid) (Multivitamin/Iron/ ra one daily energy tablet * (Multivitamin with Minerals) ra one daily plus iron tablet * (Multivitamin with Iron) ra one daily tablet p/f * (Multivitamin) ra prenatal tablet 28 mg iron- 800 (Prenatal Vit/Iron mcg * Fumarate/Fa) ra therapeutic m multivit tab mg * (Tab A Vite) ra vit b-2,000 mcg/ml liq,000 (Cyanocobalamin mcg/ml * (Vitamin B-2)) ra vitamin b-2,000 mcg tab timed-release,000 mcg * (B-2) ra vitamin c,000 mg tab sa w/bioflavonoids,000 mg * (Ascorbic Acid) ra vitamin c 500 mg tab chew p/f 500 mg * (Ascorbic Acid) ra vitamin c tr 500 mg caplet caplet,p/f,s/f 500 mg * (Ascorbic Acid) rena-vite rx tablet mg-mgmcg * 3/Fa/Vit C/Biotin) (Vit B Cmplx 3 $0 scooby-doo one a day tablet * (Multivit with Iron- Minerals) senior tabs mg-mcgmcg * (Biocel) sentry senior multivitamin tab sodium/f,yeast/f mcg * (Biocel) sentry senior tablet mgmcg-mcg * (Biocel) sentry tablet mg-mcg * (Multivitamin/Iron/ Folic Acid) 2

226 sm airshield effervescent tab 5, unit-mg-unit * (Vit A,C, and E/Dietary Supp No.2) sm animal shapes tab chew * (Multivitamin) sm animal shapes tab chew toddlers * (Multivitamin) sm animal shapes w-iron tab (Multivitamin with children's * Iron) sm antioxidant vitamins tablet,000 (Vit A,C and unit-200 mg-60 unit-2 mg * E/Lutein/Minerals) sm b complex with vit c tablet gluten-free * (Vita-Bee with C) sm complete multi-vit-mineral (Multivitamin/Iron/ advanced formula mg-mcg * Folic Acid) sm complete senior formula tab * (Multivit with Iron- Minerals) sm complete senior formula tab mg-mcg-mcg * sm hair, skin and nails caplet caplet, gluten-free * sm multivitamin w-iron tab * sm natural balanced b-00 tab 00 mg * sm opti-vitamin tablet,000 unit- 200 mg-60 unit-2 mg * sm prenatal vitamins tablet 28 mg iron- 800 mcg * sm super b complex-c caplet caplet * sm therapeutic m tablet mg * sm vitamin b complex tablet glutenfree 0.4 mg * (Biocel) (Multivitamin with Minerals) (Multivitamin with Iron) (Vit B Complex 00 Cmb #2/Herbs) (Vit A,C and E/Lutein/Minerals) (Prenatal) (Vita-Bee with C) (Multivit,Tx,Iron/C alcm/fa/mins) (Vitamin B Complex/Folic Acid) 22

227 sm vitamin b-00 complex tab gluten-free 0.4 mg * (Vitamin B Complex/Folic Acid) sm vitamin d3 4,000 unit sftgl softgel, gluten-free 4,000 unit * (D3-50) sodium fluoride oral tablet mg (Pedi M.Vit No.7 fluoride (2.2 mg) with Fluoride) $0 stress b tablet * (Vitamin B Complex) stress b with zinc tablet * (Multivitamin,Stres s Formula/Zn) stress formula tablet * (Multivitamin,Stres s Formula) stress formula with iron tab * (Iron/Mv,Stress Form) (Vit B stress formula with iron tab 500 mg- Comp/C/Fa/Iron/Vi 400 mcg- 8 mg iron * t E) stress formula with zinc tab * (Multivitamin,Stres s Formula/Zn) (Vit B stress-c with iron tablet 500 mg-400 Comp/C/Fa/Iron/Vi mcg- 8 mg iron * t E) (Mv-Min/Iron sunvite tablet 8 mg iron-400 mcg- Fum/Fa/K/Lyco/Lu 25 mcg * tn) super b complex-c caplet caplet * (Vita-Bee with C) (Vitamin B super b maxi complex caplet 0.4 mg Complex/Folic * Acid) super b with vit c capsule * super b-50 complex capsule * super b-50 complex plus tab * (B Complex with Vitamin C) (Vitamin B Complex) (Vitamin B Complex) 23

228 super b-complex folic-vit c tb p/f 400 mcg * (Dialyvite 800) super multiple vit-mineral tab * (Multivit with Iron- Minerals) super multivitamin tablet * (Multivitamin) super quints b-50 tablet 0.4 mg * (Vitamin B Complex/Folic Acid) super quints b-50 tablets * (Vitamin B Complex) super thera vite m tablet * (Multivitamin,Ther and Minerals) superior 35 vit-mineral tab sa * (Multivit with Iron- Minerals) superplex-t tablet * (Vita-Bee with C) support liquid * (Multivitamin with Minerals) support-500 softgel * (B Complex with Vitamin C) 3 $0 sv hair, skin and nails caplet mg (Mv,Ca,Min/Iron iron-66.7 mcg-,000 mcg * Gluc/Fa/Biotin) tab-a-vite tablet * (Multivitamin) tab-a-vite with iron tablet * (Multivitamin with Iron) tab-a-vite-minerals tablet * (Multivitamin with Minerals) thera m plus tablet 9 mg iron-400 (Multivits,Ca,Mine mcg * rals/iron/fa) thera tablet * (Multivitamin,Ther apeutic) thera-d 2000 tablet 2,000 unit * (Vitamin D3) theradex m tablet mg * (Multivit,Tx,Iron/C alcm/fa/mins) thera-m caplet caplet mg * (Multivit,Tx,Iron/C thera-m tablet w/beta carotene 9 mg iron-400 mcg * alcm/fa/mins) (Multivits,Ca,Mine rals/iron/fa) 24

229 therapeutic-m caplet p/f, s/f, caplet 9 (Multivits,Ca,Mine mg iron-400 mcg * rals/iron/fa) thera-tabs tablet * (Multivitamin,Ther apeutic) theratrum compl 50 plus tab * (Multivitamin with Minerals/Lut) theratrum complete 50 plus (Multivit with Ironp/f,caplet * Minerals) thiamine 200 mg/2 ml vial 25's,mdv,outer 00 mg/ml * (Thiamine HCl) 3 $0 thiamine 500 mg tablet 500 mg * (Thiamine HCl) total b with vit c caplet * (Vita-Bee with C) totalday multiple tablet sa * (Multivitamin with Minerals) (Vit A tri-vi-sol drops 750 unit-35 mg -400 Palmitate/Vit C/Vit unit/ml * D3) tri-vita drops, unit-mgunit/ml * tri-vitamin drops, unitmg-unit/ml * ultra b-00 complex tablet * v-c forte capsule mg * vic-forte capsule mg * vision plus lutein vitamin tab * vision vitamins * vision vitamins tablet w/lutein,p/f,000 unit-200 mg-60 unit-2 mg * vit d2.25 mg (50,000 unit) 50,000 unit * (Pedi Multivits A,C, and D3 No.2) (Pedi Multivits A,C, and D3 No.2) (Vitamin B Complex) (Multivitamin- Minerals No.7/Fa) (Multivitamin- Minerals No.7/Fa) (Multivitamin with Minerals/Lut) (Beta-Carotene(A) W-C and E/Min) (Vit A,C and E/Lutein/Minerals) 3 $0 3 $0 (Drisdol) 3 $0 25

230 VITAFOL FE+ (WITH DOCUSATE) ORAL CAPSULE 90 MG IRON- MG -50 MG-200 MG vitalets tablet chewable child, orange,s/f * vitamin a 0,000 units capsule soluble 0,000 unit * vitamin a 25,000 units capsule softgel 25,000 unit * (Multivitamin with Iron) (Vitamin A) (Vitamin A) vitamin and minerals tablet * (Multivitamin,Ther and Minerals) (Vit B vitamin b complex tablet 500 mg- Comp/C/Fa/Iron/Vi 400 mcg- 8 mg iron * t E) vitamin b complex-vit c cap * (B Complex with Vitamin C) vitamin b complex-vit c tablet * (Vita-Bee with C) vitamin b-2,000 mcg tablet,000 mcg * (B-2) vitamin b-2 00 mcg tablet 00 mcg * (B-2) vitamin b mcg tablet 250 mcg * (B-2) vitamin b2 500 mcg tablet 500 mcg * (B-2) vitamin b-2 tr,000 mcg tab (Cyanocobalamin lactose free,000 mcg * (Vitamin B-2)) vitamin b2-folic acid tablet 500- (Cyanocobalamin/ 400 mcg * Folic Acid) vitamin b mg tablet p/f 250 mg * (Pyridoxine HCl) vitamin b-6 50 mg tablet 50 mg * (Pyridoxine HCl) vitamin b-complex & c caplet p/f,no (Fa/Vit B Complex lactose,cplt mcg-mg * and C/Rice Bran) vitamin c,000 mg tablet,000 mg * (Ascorbic Acid) 26

231 vitamin c,500 mg tablet sa na/f,s/f,starch/free,500 mg * (Ascorbic Acid) vitamin c 250 mg tablet 250 mg * (Ascorbic Acid) vitamin c 250 mg tablet chew 250 mg * (Ascorbic Acid) vitamin c 500 mg/5 ml liquid 500 mg/5 ml * (Ascorbic Acid) vitamin d,000 unit tablet,000 unit * (Vitamin D3) vitamin d3,000 unit tablet s/f,p/f,000 unit * (Vitamin D3) vitamin d3,000 units softgel softgel, p/f, s/f,000 unit * (D3-50) vitamin d3 0,000 unit softgel softgel 0,000 unit * (D3-50) vitamin d3 2,000 unit tablet s/f,p/f 2,000 unit * (Vitamin D3) vitamin d3 400 unit tab chew orange, p/f 400 unit * (Vitamin D3) vitamin d3 400 unit tablet s/f,p/f 400 unit * (Vitamin D3) vitamin d3 400 unit/5 ml liq 400 (Cholecalciferol unit/5 ml * (Vitamin D3)) vitamin d3 5,000 unit capsule s/f, p/f 5,000 unit * (D3-50) vitamin d3 5,000 unit/ml drops a/f, p/f,gluten-free 5,000 unit/ml * (Just D) vitamin k 00 mcg tablet p/f, glutenfree 00 mcg * (Phytonadione) vitamins for hair tablet * (Multivitamin) vitrum 50+ senior tablet mcg * (Biocel) vitrum senior tablet f/f,p/f * (Multivitamin with Minerals/Lut) v-r natural b-00 tablet * (Vitamin B Complex) 27

232 yelets tablet mg-mcg * (Multivitamin/Iron/ Folic Acid) zoo chews gummie tablet * (Multivitamin) 28

233 INDEX 3 3 day vaginal pse-50gfn-5dm... 3-day vaginal MOP A a thru z advanced formula a thru z high potency a thru z select a thru z select 50+ formula a thru z select women's abacavir abacavir-lamivudine-zidovudine abc plus ABELCET... 5 ABILIFY MAINTENA... 66, 67 ABRAXANE... 28, 29 ABREVA acamprosate... 5 acarbose acebutolol acephen... 3 acetaminophen... 3 acetaminophen-codeine... 3 acetazolamide acetazolamide sodium acetic acid... 38, 7 acetylcysteine... 92, 93 acid gone antacid acid reducer (famotidine)... 42, 43 acid relief (cimetidine) acitretin acne medication... 22, 24 ACNE MEDICATION acne-clear ACTEMRA ACTHIB (PF) ACTIMMUNE actinel pediatric... acyclovir... 76, 23 acyclovir sodium ADACEL(TDAP ADOLESN/ADULT)(PF) 65 ADAGEN adapalene ADCETRIS ADCIRCA adefovir ADEMPAS adriamycin adrucil adt robitussin peak cld dm max... adult multivitamin gummies 97 adult nasal decongestant... 9 adult one daily gummies adult robitussin lingering cld adult robitussin peak cold dm... 2 adult wal-tussin... 2 adult wal-tussin dm max... 2 adults 50 plus adults 50+ daily formula adults' daily formula ADVAIR DISKUS ADVAIR HFA ADVIL... af 52 afeditab cr AFINITOR AFINITOR DISPERZ AFTERA a-hydrocort airshield AKTEN (PF) AKYNZEO ala-cort ala-scalp alavert alavert d-2 allergy-sinus ALBENZA albuterol sulfate... 90, 9 alcaine alclometasone ALCOHOL PADS ALCOHOL PREP PADS ALDURAZYME ALECENSA alendronate... 7 alfuzosin ALIMTA ALINIA alka-seltzer plus mucus-conges... 2 ALLEGRA ALLERGY aller-chlor allerclear d-2hr allerclear d-24hr allergy (chlorpheniramine) allergy (diphenhydramine) allergy relief (cetirizine) allergy relief (clemastine) allerhist aller-tec d allopurinol ALLZITAL... 3 almacone almacone aloe vesta antifungal (micon). 5 alophen alosetron I- VillageCareMAX Full Advantage FIDA Plan 206 Formulary Formulary ID: Version: 8 Effective: October 0, 206

234 ALPHAGAN P alprazolam... 6 ALREX altacaine altamist altavera (28) aluminum hydroxide gel alyacen /35 (28) alyacen 7/7/7 (28) amantadine hcl ambi 0peh-4cpm-20dm... 2 ambi 20dm-4cpm... 2 ambi 40pse-400gfn-20dm... 2 ambi 60pse-4cpm ambi 60pse-4cpm-20dm... 2 AMBISOME... 5 amethia amethia lo amifostine crystalline amiloride amiloride-hydrochlorothiazide96 AMINO ACIDS 5 % aminocaproic acid AMINOSYN 0 % AMINOSYN 3.5 % AMINOSYN 7 % AMINOSYN 7 % WITH ELECTROLYTES... 8 AMINOSYN 8.5 %... 8 AMINOSYN 8.5 %- ELECTROLYTES... 8 AMINOSYN II 0 %... 8 AMINOSYN II 5 %... 8 AMINOSYN II 7 %... 8 AMINOSYN II 8.5 %... 8 AMINOSYN II 8.5 %- ELECTROLYTES... 8 AMINOSYN M 3.5 %... 8 AMINOSYN-HBC 7%... 8 AMINOSYN-PF 0 %... 8 AMINOSYN-PF 7 % (SULFITE-FREE) AMINOSYN-RF 5.2 % amiodarone AMITIZA amitriptyline... 43, 44 amlactin amlodipine amlodipine-atorvastatin amlodipine-benazepril amlodipine-valsartan amlodipine-valsartan-hcthiazid ammonium lactate amoxapine amoxicil-clarithromy-lansopraz amoxicillin amoxicillin-pot clavulanate... 24, 25 amphotericin b... 5 ampicillin ampicillin sodium ampicillin-sulbactam AMPYRA... 0 ANACAINE anagrelide anastrozole ANDRODERM ANDROGEL androxy animal chews animal shape vitamins animal shapes plus iron antacid anti-gas antacid anti-gas (ca carb-sim) antacid extra-strength antacid plus extra strength anticoag citrate phos dextrose anti-diarrheal anti-diarrheal (loperamide). 45, 46 antifungal (tolnaftate)... 5, 54 anti-gas maximum strength.. 42 antioxidant antioxidant vitamins apatate forte APOKYN apraclonidine apri APRISO aprodine APTIOM... 38, 39 APTIVUS aquanil hc aranelle (28) ARCALYST... 6 aripiprazole ARISTADA armodafinil arthritis pain relief (acetam)... 0 artificial tears (petro/min) artificial tears (pf) artificial tears (polyvin alc).. 34 artificial tears(dext70-hypro) 34 artificial tears(glycerin-peg). 34 artificial tears(hypromellose) 36 ASACOL HD ascomp with codeine... 3 ascorbic acid (vitamin c)... 20, 27 ashlyna aspirin..., 2 aspirin, buffered... aspirin-dipyridamole aspir-low... 2 ASSURE ID INSULIN SAFETY... 3 ASTAGRAF XL... 6 atenolol atenolol-chlorthalidone atorvastatin atovaquone atovaquone-proguanil I-2 VillageCareMAX Full Advantage FIDA Plan 206 Formulary Formulary ID: Version: 8 Effective: October 0, 206

235 ATRIPLA... 7 atropine... 38, 34 atropine-care ATROVENT HFA... 9 AUBAGIO... 6 aubra AVASTIN AVC VAGINAL aviane AVONEX AVONEX (WITH ALBUMIN) ayr saline azacitidine azathioprine... 6 azathioprine sodium... 6 azelastine AZILECT azithromycin AZOPT AZOR aztreonam azurette (28) B b complete b complex b complex b complex-vitamin b b complex-vitamin c-folic acid... 98, 205, 24 b-00 complex b-2 dots b-50 complex bacitracin... 8, 25, 38 bacitracin-polymyxin b bacitraycin plus baclofen bal b bal b balance b balance b balanced b , 20 balanced b balanced b balanced b-50 complex balsalazide balziva (28) banophen banophen allergy BANZEL baza antifungal... 5 BCG VACCINE, LIVE (PF) 65 b-complex b-complex with vitamin c... 98, 200, 22, 26 BD INSULIN PEN NEEDLE UF SHORT... 3 BD INSULIN SYRINGE ULTRA-FINE... 3 bekyree (28) BELBUCA... 4 BELEODAQ BELSOMRA benadryl allergy benazepril benazepril-hydrochlorothiazide BENDEKA BENICAR BENICAR HCT BENLYSTA benzonatate... 2 benzoyl peroxide benztropine BETADINE beta-hc betamethasone acet,sod phos 57 betamethasone dipropionate. 27 betamethasone valerate betamethasone, augmented.. 27 BETASERON betaxolol... 90, 79 bethanechol chloride BETHKIS... 7 bexarotene BEXSERO (PF) bicalutamide bicarsim forte... 4 BICILLIN C-R BICILLIN L-A BIDIL bimatoprost bio-dtuss dmx... 2 bion tears (pf) bionel pediatric... 2 biospec dmx... 2 biosupp biotin biovol bisac-evac bisacodyl biscolax bismatrol bisoprolol fumarate bisoprolol-hydrochlorothiazide bleomycin bleph BLINCYTO blisovi 24 fe blisovi fe.5/30 (28) blisovi fe /20 (28) blis-to-sol (tolnaftate)... 5 BOOSTRIX TDAP BOSULIF bp 8 cough... 2 BREO ELLIPTA briellyn BRILINTA brimonidine BRINTELLIX BRIVIACT bromfed dm... 2 bromfenac bromocriptine bromphenex dm... 2 I-3 VillageCareMAX Full Advantage FIDA Plan 206 Formulary Formulary ID: Version: 8 Effective: October 0, 206

236 brompheniramine-pseudoephdm..., 2, 3 budesonide bufferin... 2 bumetanide BUPHENYL buprenorphine hcl... 4, 5 buprenorphine-naloxone... 5 buproban bupropion hcl bupropion hcl (smoking deter)... 5, 44 buspirone butalbital compound w/codeine 4 butalbital-acetaminop-caf-cod. 4 butalbital-acetaminophen... 4 butalbital-acetaminophen-caff. 4 butalbital-aspirin-caffeine... 4 BUTRANS... 4 BYSTOLIC C c complex cabergoline CABOMETYX ca-d3-mag ox-zinc-cop-mangbor... 83, 88 caffeine citrated... 0 caffeine-sodium benzoate... 0 calci-chew calcidol calcipotriene calcitonin (salmon)... 7 calcitrate calcitrate-vitamin d calcitrene calcitriol... 23, 7 calcium d... 80, 8 calcium d (d3)... 8 calcium calcium d(3) calcium 600 with vitamin d3 84 calcium acetate calcium antacid calcium carbonate... 45, 8 calcium carbonate-vitamin d calcium carbonate-vitamin d , 8, 82, 83, 88 CALCIUM CARBONATE- VITAMIN D calcium chloride... 8 calcium citrate-vitamin d3.. 8, 83 calcium gluconate... 8 calcium+d CALDOLOR... 2 cal-gest antacid calphron CALTRATE D... 8 CALTRATE WITH VITAMIN D camila camrese camrese lo CANCIDAS... 5 candesartan candesartan-hydrochlorothiazid capacet... 4 CAPASTAT... 6, 62 CAPRELSA captopril captopril-hydrochlorothiazide 88 CARAFATE CARBAGLU carbamazepine carbidopa carbidopa-levodopa carbidopa-levodopa-entacapone CARIMUNE NF NANOFILTERED... 6 carisoprodol carteolol cartia xt... 9 carvedilol CASTELLANI PAINT MODIFIED CAYSTON caziant (28) cefaclor cefadroxil... 20, 2 cefazolin... 2 cefazolin in dextrose (iso-os). 2 cefdinir... 2 cefditoren pivoxil... 2 cefepime... 2 CEFEPIME IN DEXTROSE 5 %... 2 CEFEPIME IN DEXTROSE,ISO-OSM... 2 cefotaxime... 2 cefoxitin... 2 cefoxitin in dextrose, iso-osm 2 cefpodoxime... 2 cefprozil... 2, 22 ceftazidime ceftibuten ceftriaxone ceftriaxone in dextrose,iso-os. 22 cefuroxime axetil cefuroxime sodium celecoxib... 2 CELLCEPT INTRAVENOUS CELONTIN centamin centergy dm... 3 central vite with lutein... 2 central-vite... 2 central-vite for seniors central-vite select , 20 central-vite senior centram-care centravites 50 plus centrum I-4 VillageCareMAX Full Advantage FIDA Plan 206 Formulary Formulary ID: Version: 8 Effective: October 0, 206

237 centrum complete centrum silver century century adults century mature... 99, 203, 205 century ultimate women's cephalexin CEPROTIN (BLUE BAR) CERDELGA CEREZYME cerovite cerovite advanced formula certavite senior-antioxidant certavite-antioxid (iron gluc) 200 certavite-antioxidant CERVARIX VACCINE (PF) cetirizine... 55, 56 cetirizine-pseudoephedrine CETYLEV cevimeline CHANTIX... 5 CHANTIX CONTINUING MONTH BOX... 5 CHANTIX STARTING MONTH BOX... 5 cheracol d... 3 cheratussin dac... 3 chest congestion relief + dm 4 chest congestion relief pe... 4 chewable multi vitamin child allergy relf(cetirizine) child complete multivitamin 203 child cough and sore throat.. 4 child mucinex chest congestion... 3 child plus cough and runnynose... 8 child triaminic cold-allergy child triaminic cough-congest... 3 child triaminic cough-sore thr... 3 child vitamin with minerals child wal-tap cold-allergy child wal-tussin cough relief 3 CHILDREN'S ADVIL... 2 children's allegra allergy children's aller-tec children's chest congestion... 4 children's chewable children's chewable complete children's chewable vitamin. 200 children's chewable w/minerals CHILDREN'S CLARITIN children's cold-cough daytime... 4 children's complete vitamin. 20 children's mapap... 5 children's mucinex cough... 3 children's multivit w/extra c. 203 children's non-aspirin... 4, 5 children's pain reliever... 0 children's pain-fever relief... 4 children's pepto childrens plus multi-symp cold... 9 children's silapap... 5 children's silfedrine... 3 children's soothe children's sudafed... 3 children's sudafed pe cough. 3 children's tactinal... 4 children's wal-dryl allergy children's wal-zyr CHILDREN'S ZYRTEC ALLERGY childs chew vite child's vitamin with iron child's vitamin with vitamin c childs/iron chlophedianol-guaifenesin... chloramphenicol sod succinate... 8 chlordiazepoxide hcl... 7 chlorhexidine gluconate chloroquine phosphate chlorothiazide chlorothiazide sodium chlorpheniramine-phenyleph-dm... chlorpromazine chlorthalidone chlorzoxazone cholecalciferol (vitamin d3) 20, 27 cholestyramine (with sugar) cholestyramine light choline,magnesium salicylate 2 ciclopirox... 5 ciclopirox-ure-camph-menth-euc... 5 cilostazol cimetidine cimetidine hcl CIMZIA CIMZIA POWDER FOR RECONST CINQAIR CINRYZE CIPRODEX ciprofloxacin ciprofloxacin hcl... 26, 38 ciprofloxacin in 5 % dextrose 26, 27 ciprofloxacin lactate citalopram citracal + d maximum... 8 citrus calcium... 8 clarithromycin CLARITIN CLARITIN LIQUI-GEL I-5 VillageCareMAX Full Advantage FIDA Plan 206 Formulary Formulary ID: Version: 8 Effective: October 0, 206

238 CLARITIN REDITABS.. 56, 57 clearlax CLEVIPREX clindamycin hcl... 8 clindamycin in 5 % dextrose.. 8 clindamycin palmitate hcl... 8 clindamycin pediatric... 8 clindamycin phosphate... 8, 9, 60, 25 CLINIMIX 5%/D5W SULFITE FREE CLINIMIX 5%/D25W SULFITE-FREE CLINIMIX 2.75%/D5W SULFIT FREE CLINIMIX 4.25%/D0W SULF FREE CLINIMIX 4.25%/D5W SULFIT FREE CLINIMIX 4.25%-D20W SULF-FREE CLINIMIX 4.25%-D25W SULF-FREE CLINIMIX 5%- D20W(SULFITE-FREE) CLINIMIX E 2.75%/D0W SUL FREE CLINIMIX E 2.75%/D5W SULF FREE CLINIMIX E 4.25%/D0W SUL FREE CLINIMIX E 4.25%/D25W SUL FREE CLINIMIX E 4.25%/D5W SULF FREE CLINIMIX E 5%/D5W SULFIT FREE CLINIMIX E 5%/D20W SULFIT FREE CLINIMIX E 5%/D25W SULFIT FREE CLINISOL SF 5 % clobetasol clobetasol-emollient clocortolone pivalate clomipramine clonazepam... 7 clonidine clonidine hcl... 86, 0 clopidogrel clorazepate dipotassium... 7 clorpres clotrimazole... 5 clotrimazole clotrimazole-betamethasone clozapine COARTEM codeine sulfate... 5 codituss dm... 3 COLACE colchicine colchicine-probenecid cold and cough (diphenhydr-pe) cold multi-symptom day/night... 3 cold relief m/s day/night... 3 cold-allergy-sinus cold-flu relief... 4 cold-flu relief, day/night... 3 colestipol colistin (colistimethate na)... 9 colocort COLY-MYCIN S COMBIGAN COMBIPATCH COMBIVENT RESPIMAT. 9 COMETRIQ comfort gel comfort gel extra strength COMPLERA... 7 complete complete multi complete multivitamin. 200, 203 complete multivitamin-mineral , 22 complete senior , 22 compoz compro COMVAX (PF) CONDYLOX congestac... 4 congest-eze... 4 constulose COPAXONE coricidin hbp... 4 coricidin hbp cold-multi sympt... 4 CORLANOR cormax cortisone cortizone CORTIZONE COSENTYX COSENTYX (2 SYRINGES) COSENTYX PEN COSENTYX PEN (2 PENS) 23 COTELLIC cough and cold... 4 cough and runny nose... 9 CREON critic-aid clear af CRIXIVAN... 7 cromolyn... 34, 45, 93 cryselle (28) CUBICIN... 9 cyanocobalamin (vitamin b-2)... 98, 202, 2, 26 cyclafem /35 (28) cyclafem 7/7/7 (28) cyclobenzaprine cyclopentolate cyclophosphamide CYCLOPHOSPHAMIDE CYCLOSET I-6 VillageCareMAX Full Advantage FIDA Plan 206 Formulary Formulary ID: Version: 8 Effective: October 0, 206

239 cyclosporine cyclosporine modified cyproheptadine CYRAMZA cyred CYSTADANE CYSTARAN cysteine (l-cysteine) D d0 %-0.45 % sodium chloride d2.5 %-0.45 % sodium chloride d3 dots d5 % and 0.9 % sodium chloride d5 %-0.45 % sodium chloride dactinomycin daily gummies daily multiple , 20, 202 daily multi-vitamin daily multivitamin with iron 202 daily multi-vitamins/iron daily teen multi-vitamin daily value daily vitamin daily vitamin formula daily vitamin formula + iron 202 daily vitamin formula-minerals daily vitamin with iron daily vites/iron dailyhist daily-vite DAKLINZA DALIRESP danazol dantrolene dapsone DAPTACEL (DTAP PEDIATRIC) (PF) DARAPRIM DARZALEX... 3 dasetta /35 (28) dasetta 7/7/7 (28) dayhist allergy daysee daytime cold and cough... 4 daytime cold-flu... 4 day-time cough... 5 daytime-nighttime... 8 daytime-nighttime cold-flu.. 4 daytime-nighttime cough... 5 deblitane decitabine... 3 decongestant cough... 9 deep sea nasal deferoxamine... 54, 55 delsym cough-chest congest dm... 5 delyla (28) DELZICOL DEMSER DEPEN TITRATABS DEPO-PROVERA dermafungal dermarest eczema (hydrocort) DESCOVY... 7 desipramine desmopressin... 58, 59 desog-e.estradiol/e.estradiol. 05 desogestrel-ethinyl estradiol 05 desonide desoximetasone despec-dm (pseudoeph-dmguaif)... 5 dex4 glucose dexamethasone dexamethasone sodium phosphate... 40, 58 dexmethylphenidate... 0 dextroamphetamine... 0 dextroamphetamineamphetamine... 0, 02 dextromethorphan polistirex 5 dextrose 0 % and 0.2 % nacl dextrose 0 % in water (d0w) dextrose 20 % in water (d20w) dextrose 25 % in water (d25w) dextrose 40 % in water (d40w) dextrose 5 % in ringers dextrose 5 % in water (d5w).. 84 dextrose 5 %-lactated ringers82 dextrose 5%-0.2 % sod chloride dextrose 5%-0.3 % sod.chloride dextrose 50 % in water (d50w) dextrose 70 % in water (d70w) dextrose with sodium chloride dextrose-kcl-nacl diabetic tussin dm... 5 diamode diazepam... 7 diazepam intensol... 7 diclofenac potassium... 2 diclofenac sodium... 2, 40 diclofenac-misoprostol... 2 dicloxacillin dicyclomine didanosine... 7 DIFICID diflunisal... 2 digitek... 92, 93 digox digoxin I-7 VillageCareMAX Full Advantage FIDA Plan 206 Formulary Formulary ID: Version: 8 Effective: October 0, 206

240 DIGOXIN dihydroergotamine... 6 DILANTIN diltiazem hcl... 9, 92 dilt-xr dimaphen (pe) dimenhydrinate dimetapp cold-congestion dino-life dino-life with extra c dino-life with iron-zinc DIPENTUM diphenhist diphenhydramine hcl... 57, 58 diphenoxylate-atropine dipyridamole disopyramide phosphate disulfiram... 5 divalproex dobutamine dobutamine in d5w doc-q-lace docu docusate sodium docusol dofetilide dok donepezil dopamine dopamine in 5 % dextrose dorzolamide dorzolamide-timolol douche vinegar and water extra doxazosin doxepin doxercalciferol... 7, 72 doxorubicin, peg-liposomal... 3 doxy doxycycline hyclate... 27, 28 doxycycline monohydrate dramamine dramamine less drowsy driminate dristan long lasting dronabinol droperidol drospirenone-ethinyl estradiol DROXIA... 3 DUAVEE dulcolax stool softener (dss) 50 DULERA duloxetine DUREZOL dutasteride dutasteride-tamsulosin DYRENIUM E e.c. prin... 2 e.e.s e.e.s. granules econazole econtra ez ed a-hist ed bron gp... 5 ed chlorped jr EDURANT... 7 effer-k EFFIENT ELAPRASE eldertonic electrolyte-48 in d5w ELIDEL ELIGARD... 3 ELIGARD (3 MONTH)... 3 ELIGARD (4 MONTH)... 3 ELIGARD (6 MONTH)... 3 elinest eliphos ELIQUIS ELITEK ELLA ellis tonic ELMIRON elon dual defense EMCYT... 3 EMEND emoquette EMPLICITI... 3 EMSAM EMTRIVA... 7 EMVERM enalapril maleate enalaprilat enalapril-hydrochlorothiazide 88 ENBREL ENBREL SURECLICK endocet... 5 endodan... 5 endur-acin enema... 50, 52 enema disposable enemeez... 5 enemeez plus... 5 ENGERIX-B (PF) ENGERIX-B PEDIATRIC (PF) enoxaparin enpresse enskyce entacapone entecavir entre-cough... 5 ENTRESTO enulose ENVARSUS XR EPCLUSA ephedrine sulfate epinastine epinephrine epinephrine hcl (pf) EPIPEN 2-PAK EPIPEN JR 2-PAK epitol EPIVIR HBV... 7 I-8 VillageCareMAX Full Advantage FIDA Plan 206 Formulary Formulary ID: Version: 8 Effective: October 0, 206

241 eplerenone EPOGEN epoprostenol (glycine) EPZICOM... 7 eq gentle equalactin... 5 ergocalciferol (vitamin d2). 203, 25 ergoloid ERGOMAR... 6 ERIVEDGE... 3 errin ery pads ery-tab ERY-TAB ERYTHROCIN erythrocin (as stearate) erythromycin... 24, 38 erythromycin ethylsuccinate.. 23 erythromycin with ethanol.. 25, 26 ESBRIET escitalopram oxalate esmolol esomeprazole sodium essentia essential balance with lutein 203 essential daily estarylla ESTRACE estradiol estradiol valerate estradiol-norethindrone acet. 56 estropipate eszopiclone ethambutol ethamolin ethosuximide... 39, 40 etodolac... 2 ETOPOPHOS... 3 etoposide... 3 EVOTAZ... 7 exemestane... 3 EXJADE expectorant... 5 expectorant dm... 5 expectorant max strength... 5 EXTAVIA extra cleansing douche eye health plus lutein F FABRAZYME falmina (28) famciclovir famotidine... 42, 43 famotidine (pf) famotidine (pf)-nacl (iso-os) 42 FANAPT FARESTON... 3 FARYDAK... 3 FASLODEX... 3 felbamate felodipine feminine care douche FEMRING fenofibrate fenofibrate micronized fenofibrate nanocrystallized fenofibric acid fenofibric acid (choline) fenoprofen... 2, 3 fentanyl... 5 fentanyl citrate... 5 ferocon ferretts ferrex ferrex 50 plus FERRIPROX ferrocite ferrous fumarate ferrous gluconate , 206 ferrous sulfate , 204 FETZIMA feverall... 5 fexofenadine fiber (calcium polycarbophil)... 5 fiber laxative (methylcellulo)53 fiber smooth fiber therapy (m-cell/sugar).. 5 fiber therapy (m-cellulose) fiber therapy (psyllium)... 5 fiber therapy (psyllium/sugar)... 5 fiber-lax... 5 fibertab... 5 finasteride FIRAZYR flanax antacid FLEBOGAMMA DIF flecainide FLECTOR... 3 FLEET BISACODYL... 5 flintstones complete (iron) flintstones multivitamin flintstones with iron flintstones/extra c FLOVENT DISKUS FLOVENT HFA floxuridine flu formula daytime-nighttime... 8 flu relief therapy daytime... 7 flu severe cold-congestion... 9 flucaine fluconazole fluconazole in dextrose(iso-o) 52 fluconazole in nacl (iso-osm). 52 flucytosine fludrocortisone flumazenil flunisolide fluocinonide fluorometholone fluorouracil... 32, 24 fluoxetine I-9 VillageCareMAX Full Advantage FIDA Plan 206 Formulary Formulary ID: Version: 8 Effective: October 0, 206

242 fluphenazine decanoate fluphenazine hcl flurbiprofen... 3 flurbiprofen sodium flutamide fluticasone... 28, 4 fluvoxamine foaming antacid... 46, 49 folic acid , 205 FOLIC ACID fomepizole fondaparinux foot odor control FORTEO FORTICAL foscarnet fosfree fosinopril fosinopril-hydrochlorothiazide fosphenytoin FREAMINE HBC 6.9 % FREAMINE III 0 % fungi cure FUNGI-NAIL fungoid-d furosemide FUSILEV FUZEON... 7 FYCOMPA G gabapentin GABITRIL galantamine GAMASTAN S/D GAMMAGARD LIQUID GAMMAPLEX ganciclovir sodium GARDASIL (PF) GARDASIL 9 (PF) gas relief... 4, 42 gas relief extra strength... 4 gas-x ultra-strength gatifloxacin GATTEX 30-VIAL GATTEX ONE-VIAL GAUZE PAD gavilyte-c... 5 gavilyte-g... 5 gavilyte-n... 5 GAZYVA gelusil antacid and anti-gas.. 46 gemfibrozil generlac gengraf GENOTROPIN GENOTROPIN MINIQUICK gentak gentamicin... 8, 26, 38 gentamicin in nacl (iso-osm).. 7 gentamicin sulfate (ped) (pf).. 8 gentamicin sulfate (pf)... 8 GENTEAL MILD TO MODERATE GENTEAL GEL GENTEAL MILD GENTEAL SEVERE genteal tears gentlelax... 5 GENVOYA... 7 GEODON geravim geriaton geri-hydrolac geri-tussin dm... 5 gianvi (28) gildagia gildess.5/30 (2) gildess /20 (2) gildess 24 fe gildess fe.5/30 (28) gildess fe /20 (28) GILENYA GILOTRIF GLEOSTINE glimepiride glipizide glipizide-metformin GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT (HUMAN) gluco burst glucose glucose gel glutose glyburide glyburide micronized glyburide-metformin glycolax... 5 glycopyrrolate glydo... 4 GLYXAMBI granisetron (pf) granisetron hcl GRANIX griseofulvin microsize guaifenesin... 5 guaifenesin dac... 5 guanfacine... 86, 02 guanidine gummi bear multivitamin , 209 gummy swirls H hair vitamins hair,skin and nails... 22, 24 halobetasol propionate haloperidol haloperidol decanoate haloperidol lactate HARVONI HAVRIX (PF) head congestion day-night... 5 healthy eyes healthylax... 5 I-0 VillageCareMAX Full Advantage FIDA Plan 206 Formulary Formulary ID: Version: 8 Effective: October 0, 206

243 heather hemocyte heparin (porcine) heparin (porcine) in 5 % dex. 77, 78 heparin (porcine) in nacl (pf). 77 heparin(porcine) in 0.45% nacl heparin, porcine (pf) HEPATAMINE 8% HEPATASOL 8 % HERCEPTIN HETLIOZ HEXALEN hi-b complex HIBERIX (PF) hi-cal plus vit d homatropaire homatropine hbr honey bears honey bears with iron-zinc HUMIRA HUMIRA PEDIATRIC CROHN'S START HUMIRA PEN HUMIRA PEN CROHN'S-UC- HS START HUMIRA PEN PSORIASIS- UVEITIS HUMULIN R U-500 (CONC) KWIKPEN HUMULIN R U-500 (CONCENTRATED) hydralazine... 94, 95 hydrochlorothiazide hydrocil instant... 5 hydrocodone-acetaminophen 5, 6 hydrocodone-chlorpheniramine... 5 hydrocodone-homatropine... 6 hydrocodone-ibuprofen... 6 hydrocortisone... 28, 29, 58 hydrocortisone acet-aloe vera hydrocortisone acetate hydrocortisone butyrate hydrocortisone butyr-emollient hydrocortisone valerate hydromet... 6 hydromorphone... 6 hydromorphone (pf)... 6 hydroskin hydroxychloroquine hydroxyprogesterone caproate hydroxyurea hydroxyzine hcl... 74, 75 hydroxyzine pamoate HYPERLYTE CR HYPERRAB S/D (PF) HYQVIA HYQVIA IG COMPONENT HYSINGLA ER... 6 I ibandronate IBRANCE ibuprofen... 2, 3, 4 ibuprofen jr strength... 3 icaps plus ICLUSIG iferex ifosfamide ifosfamide-mesna ILARIS (PF) ILEVRO... 4 imatinib IMBRUVICA imipenem-cilastatin imipramine hcl imipramine pamoate imiquimod IMLYGIC imodium a-d IMODIUM A-D IMOGAM RABIES-HT (PF) IMOVAX RABIES VACCINE (PF) INCRELEX indapamide indomethacin... 3 indomethacin sodium... 3 INFANRIX (DTAP) (PF) infant's ibuprofen... 3 INFANT'S MOTRIN... 3 infants' non-aspirin cold... 2 INLYTA insta-glucose INSULIN SYRINGE-NEEDLE U INTELENCE... 7 INTRALIPID INTRON A introvale INVANZ INVEGA SUSTENNA INVEGA TRINZA INVIRASE... 7 INVOKAMET INVOKANA inzo antifungal iodine IONOSOL-B IN D5W IONOSOL-MB IN D5W IPOL ipratropium bromide... 35, 36, 9 ipratropium-albuterol... 9 IPRIVASK irbesartan irbesartan-hydrochlorothiazide IRESSA iron high potency I- VillageCareMAX Full Advantage FIDA Plan 206 Formulary Formulary ID: Version: 8 Effective: October 0, 206

244 ISENTRESS... 7, 72 ISOLYTE M IN 5 % DEXTROSE ISOLYTE-H IN 5 % DEXTROSE ISOLYTE-P IN 5 % DEXTROSE ISOLYTE-S isoniazid isopto tears isosorbide dinitrate isosorbide mononitrate isradipine itraconazole ivermectin IXEMPRA IXIARO (PF) J JAKAFI jantoven JANUMET JANUMET XR JANUVIA JARDIANCE jencycla JENTADUETO JENTADUETO XR jolessa jolivette jr. acetaminophen... 0 juleber junel.5/30 (2) junel /20 (2) junel fe.5/30 (28) junel fe /20 (28) junel fe junior mapap... 6 JUXTAPID K KABIVEN KALETRA KALYDECO KANUMA kaopectate (bismuth subsalicy) kariva (28) k-effervescent kelnor /35 (28) KELP (IODINE) ketoconazole ketoprofen... 3 ketorolac... 3, 4 KEVEYIS KEYTRUDA kids mini enema kid's vitamins kid's vitamins + extra c kids vitamins + iron kid's vitamins + iron kimidess (28) KINERET KINRIX (PF) kionex kionex (with sorbitol) KLOR-CON klor-con m klor-con m klor-con m klor-con sprinkle konsyl (sugar)... 5 konsyl fiber... 5 KONSYL SUGAR-FREE... 5 KORLYM KRYSTEXXA kurvelo KUVAN KYNAMRO KYPROLIS L l norgest/e.estradiol-e.estrad 06 labetalol LACRISERT LACTATED RINGERS... 7 LACTINOL HX lactulose LAMICTAL LAMISIL (AEROSOL) lamisil af LAMISIL AT lamivudine lamivudine-zidovudine lamotrigine LANOXIN lansoprazole LANTUS LANTUS SOLOSTAR larin.5/30 (2) larin /20 (2) larin 24 fe larin fe.5/30 (28) larin fe /20 (28) larissia latanoprost LATUDA laxative peg LAZANDA... 6 leena leflunomide LEMTRADA LENVIMA lessina LETAIRIS letrozole leucovorin calcium LEUKERAN LEUKINE leuprolide levetiracetam... 40, 4 levobunolol levocarnitine levocarnitine (with sugar) levocetirizine levofloxacin... 27, 38 levofloxacin in d5w levoleucovorin calcium levonest (28) I-2 VillageCareMAX Full Advantage FIDA Plan 206 Formulary Formulary ID: Version: 8 Effective: October 0, 206

245 levonorgestrel levonorgestrel-ethinyl estrad 07 levonorg-eth estrad triphasic 07 levora levothyroxine... 6 LEXIVA lice cream rinse... 3 lice killing... 30, 3 lice treatment... 3 lice treatment (permethrin).. 3 lidocaine... 5 lidocaine (pf)... 4, 89 lidocaine hcl... 4, 5 lidocaine in 5 % dextrose (pf) 89 lidocaine viscous... 4 lidocaine-prilocaine... 5 life-pack women's linezolid... 9 LINZESS liothyronine... 6 lipodox lipodox liquibid d-r... 6 liquid calcium with vitamin d LIQUI-E lisinopril lisinopril-hydrochlorothiazide 88 lithium carbonate lithium citrate little animals little animals-iron LIVALO lobana bath lohist-dm... 6 lomedia 24 fe lomustine LONSURF loperamide... 46, 47, 48 loratadine loratadine-d lorazepam... 7 lorcet (hydrocodone)... 6 lorcet hd... 6 lorcet plus... 6 lortuss ex... 6 loryna (28) losartan losartan-hydrochlorothiazide. 87 LOTEMAX... 4 LOTRONEX lovastatin low-ogestrel (28) loxapine succinate lubricant dry eye relief lubricant eye lubricant eye (cmc-glycer)(pf) lubricant eye (cmc-glycerin) 36 lubricant eye (pg-peg 400) lubricant eye (polyv alcohol) 37 lubricant eye (propyl glycol) 36 lubricant eye drops lubricant gel lubricating drops lubrifresh pm LUMIGAN LUPRON DEPOT LUPRON DEPOT (3 MONTH) LUPRON DEPOT (4 MONTH) LUPRON DEPOT (6 MONTH) LUPRON DEPOT-PED LUPRON DEPOT-PED (3 MONTH) lutera (28) LYNPARZA LYRICA... 4 lysiplex plus LYSODREN lyza M maalox advanced MACUVITE MACUVITE EYE CARE mag mag-delay mag-g MAGNEBIND magnebind magnesium... 82, 84 magnesium (oxide/aa chelate) magnesium chloride magnesium gluconate magnesium oxide... 47, 48 magnesium sulf in 0.45% nacl magnesium sulfate magnesium sulfate in d5w magnesium sulfate in water. 84, 85 malathion... 3 mapap (acetaminophen)... 6, 7 mapap arthritis pain... 7 mapap extra strength... 7 maprotiline mar-cof bp... 6 mar-cof cg... 6 margesic... 7 marlissa MARPLAN masanti double strength MATULANE matzim la maximum daily multivitamin maximum strength flu... 8 meclizine medroxyprogesterone mefenamic acid... 3 mefloquine I-3 VillageCareMAX Full Advantage FIDA Plan 206 Formulary Formulary ID: Version: 8 Effective: October 0, 206

246 MEFOXIN IN DEXTROSE (ISO-OSM) mega multiple/chelated mineral mega multivitamin with mineral MEGACE ES... 6 megestrol... 34, 6 MEKINIST meloxicam... 3 memantine MENACTRA (PF) MENEST MENHIBRIX (PF) MENOMUNE - A/C/Y/W-35 (PF) men's daily gummies men's multi-vitamin men's one daily MENVEO A-C-Y-W-35-DIP (PF) MENVEO MENA COMPONENT (PF) MENVEO MENCYW-35 COMPNT (PF) MEPHYTON mercaptopurine meropenem mesalamine... 7 mesehist dm... 6 mesna MESNEX MESTINON MESTINON TIMESPAN metaproterenol... 9 metaxall metaxalone metformin methadone... 7 methadose... 7 methazolamide methenamine hippurate... 9 methimazole... 6 methocarbamol methotrexate sodium... 34, 35 methotrexate sodium (pf) methoxsalen rapid methscopolamine methyclothiazide methylphenidate... 02, 03 methylprednisolone methylprednisolone acetate.. 58 methylprednisolone sodium succ metipranolol metoclopramide hcl metolazone metoprolol succinate metoprolol ta-hydrochlorothiaz metoprolol tartrate metronidazole... 9, 60, 26 metronidazole in nacl (iso-os) 9 mexiletine mgo MIACALCIN mi-acid mi-acid gas relief micatin miconazole miconazole nitrate... 52, 53 miconazole microgestin.5/30 (2) microgestin /20 (2) microgestin fe.5/30 (28) microgestin fe /20 (28) midodrine miglitol milk of magnesia milltrium senior milrinone milrinone in 5 % dextrose mimvey mimvey lo mineral oil... 76, 78 MINERAL OIL mineral oil laxative minitran minocycline minoxidil mintox mintox maximum strength mintox plus MIRCERA mirtazapine misoprostol mitoxantrone M-M-R II (PF) moexipril moexipril-hydrochlorothiazide molindone mometasone MONISTAT monistat mono-linyah mononessa (28) montelukast morphine... 7, 8 MORPHINE... 8 morphine (pf) in 0.9 % nacl... 7 morphine concentrate... 7 morphine in dextrose 5 %... 7 morrhuate sodium motion sickness motion sickness (meclizine) MOVANTIK MOVIPREP MOXEZA moxifloxacin MOZOBIL mucus dm... 6 mucus dm max... 6 mucus relief... 6, 8 mucus relief cough... 9 MULTAQ I-4 VillageCareMAX Full Advantage FIDA Plan 206 Formulary Formulary ID: Version: 8 Effective: October 0, 206

247 multi complete with iron multi-day with iron multi-delyn with iron multiple vitamin-minerals multiple vitamins multiple vitamins with iron multi-symptom cold night time... 8 multivital platinum , 20 multivitamin 50 plus multi-vitamin hp/minerals multivitamin with fluoride multivitamin with iron. 206, 22 multivitamin with minerals multi-vite multi-vite 50 and over mupirocin mupirocin calcium muro my favorite multiple my way myco nail a mycophenolate mofetil mycophenolate sodium MYOZYME MYRBETRIQ mytab gas mytab gas maximum strength my-vitalife myzilra N nabumetone... 4 nadolol nafcillin NAGLAZYME naloxone... 5 naltrexone... 5 NAMENDA XR NAMZARIC naphazoline naproxen... 4 naproxen sodium... 4 naratriptan... 6 NARCAN... 6 nasal and sinus decongestant 6 nasal decongestant (oxymetazl) NASCOBAL nasohist dm... 6 NATACYN nateglinide NATPARA natural b natural b-00 complex natural balance natural calcium natural fiber laxative therapy 52 natural tears (pf) nature's tears (hypromellose) 36 NEBUPENT necon 0.5/35 (28) necon /35 (28) necon /50 (28) necon 0/ (28) necon 7/7/7 (28) nefazodone neomycin... 8 neomycin-bacitracin-poly-hc 38 neomycin-bacitracin-polymyxin neomycin-polymyxin b gu neomycin-polymyxin b- dexameth neomycin-polymyxingramicidin neomycin-polymyxin-hc neo-polycin neo-polycin hc neosporin (neo-bac-polym).. 26 neosporin anti-itch neo-synephrine 2 h spr (oxym) neo-tuss... 6 nephplex rx NEPHRAMINE 5.4 % nephron fa nephro-vite rx NEULASTA NEUMEGA NEUPOGEN NEUPRO NEVANAC... 4 nevirapine NEXAFED... 6 NEXAVAR next choice one dose niacin niacinamide... 98, 207 niacor nicardipine NICODERM CQ... 6 nicorelief... 6 nicorette... 6 nicotine... 6 nicotine (polacrilex)... 6 NICOTROL... 6 nifedical xl nifedipine night time... 7 night time cold-flu night time cold-flu relief... 9 night time cough-sore throat 6 nighttime cough... 6 nikki (28) NILANDRON nilutamide NINLARO NITE TIME COLD-FLU RELIEF... 6 nite time-d cold-flu relief... 6 NITRO-BID nitrofurantoin macrocrystal... 9 nitrofurantoin monohyd/m-cryst... 9, 20 nitroglycerin... 00, 0 I-5 VillageCareMAX Full Advantage FIDA Plan 206 Formulary Formulary ID: Version: 8 Effective: October 0, 206

248 nitroglycerin in 5 % dextrose 00 NITROSTAT... 0 NIX CREME RINSE... 3 nohist-dm... 7 non-aspirin cold non-aspirin extra strength.. 8, 0 non-aspirin flu... 2 non-aspirin jr strength... 5 nora-be NORDITROPIN FLEXPRO 59 norepinephrine bitartrate norethindrone (contraceptive) norethindrone acetate... 6 norethindrone ac-eth estradiol norethindrone-e.estradiol-iron norgestimate-ethinyl estradiol norlyroc NORMOSOL-M IN 5 % DEXTROSE NORMOSOL-R PH nortemp... 8 NORTHERA nortrel 0.5/35 (28) nortrel /35 (2) nortrel /35 (28) nortrel 7/7/7 (28) nortriptyline NORVIR NOVOLIN 70/ NOVOLIN N NOVOLIN R NOVOLOG NOVOLOG FLEXPEN NOVOLOG MIX NOVOLOG MIX FLEXPEN NOVOLOG PENFILL NOXAFIL NUCALA NUCYNTA... 8 NUCYNTA ER... 8 NUEDEXTA nu-iron NULOJIX nu-mag NUPLAZID NUTRESTORE NUTRILIPID NUTRILYTE NUTRILYTE II NUVARING nyamyc nystatin nystatin-triamcinolone nystop nyt-time sleep O OCALIVA ocean nasal ocella OCTAGAM octreotide acetate ocutabs ODEFSEY ODOMZO OFEV ofloxacin... 27, 39 ogestrel (28) olanzapine olanzapine-fluoxetine olopatadine OLYSIO omega-3 acid ethyl esters omeprazole omeprazole magnesium omeprazole-sodium bicarbonate ONCASPAR oncovite ondansetron ondansetron hcl ondansetron hcl (pf) one daily , 2 one daily 50 plus one daily complete one daily energy... 2 one daily essential 203, 205, 208 one daily maximum (with ca) one daily multi-vit w-mineral one daily multivitamin one daily multivit-iron(folic) 208 one daily plus iron 205, 208, 2 one daily plus minerals one daily with iron one-a-day essential one-a-day maximum formula208 one-a-day teen advantage ONFI... 7, 29 opcicon one-step OPDIVO OPSUMIT opti-vitamins oral saline laxative oralone ORENCIA ORENCIA (WITH MALTOSE) ORENCIA CLICKJECT ORENITRAM ORFADIN... 33, 76 ORKAMBI orsythia OTEZLA OTEZLA STARTER OTREXUP (PF) oxacillin oxacillin in dextrose(iso-osm) 26 oxandrolone oxcarbazepine... 4 OXTELLAR XR... 4 I-6 VillageCareMAX Full Advantage FIDA Plan 206 Formulary Formulary ID: Version: 8 Effective: October 0, 206

249 oxybutynin chloride oxycodone... 8, 9 oxycodone-acetaminophen... 9 oxycodone-aspirin... 9 OXYCONTIN... 9 oxymorphone... 9 oysco 500/d oysco d oysco oyster shell calcium oyster shell calcium-vit d oyster shell calcium-vit d3.. 85, 86 oystercal-d P pacerone pain relief... 9 pain relief adult... 5 pain reliever jr strength... 0 paliperidone pancrelipase PANRETIN PANTILINERS pantoprazole papaverine paricalcitol paromomycin paroxetine hcl PASER PATADAY PAXIL pecgen dmx... 7 pedia relief pedia relief cough-cold... 7 pedia relief infant... 2 pediacare multi-symptom cold... 7 PEDIARIX (PF) pediatric electrolyte... 82, 86, 88 pediatric freezer pops pediatric multivitamin.. 207, 22 PEDVAX HIB (PF) peg 3350-electrolytes PEGANONE... 4 PEGASYS PEGASYS PROCLICK peg-electrolyte soln PEGINTRON PEN NEEDLE, DIABETIC. 3 penicillin g pot in dextrose penicillin g potassium penicillin g procaine penicillin v potassium PENTACEL (PF) PENTACEL ACTHIB COMPONENT (PF) PENTAM pentoxifylline pep-t-med peri-colace PERIKABIVEN perindopril erbumine periogard permethrin... 3 perphenazine perphenazine-amitriptyline persa-gel pfizerpen-g pharbetol... 9, 0 pharmacist favorite multi-vit 208 phenadoz phenelzine phenobarbital... 4 phenobarbital sodium... 4 phenylephrine hcl... 86, 36 phenylhistine dh... 7 phenytoin... 4 phenytoin sodium... 4, 42 phenytoin sodium extended... 4 philith phillips phillips liqui-gels PHOSLYRA PHOS-NAK phospha 250 neutral phosphate laxative PHOSPHOLINE IODIDE phytonadione (vitamin k) PICATO pilocarpine hcl... 22, 79 pimozide pimtrea (28) pindolol pink bismuth pioglitazone pioglitazone-glimepiride pioglitazone-metformin piperacillin-tazobactam pirmella piroxicam... 4 PLAN B ONE-STEP PLASMA-LYTE PLASMA-LYTE A PLASMA-LYTE-56 IN 5 % DEXTROSE PLEGRIDY podocon podofilox polyethylene glycol poly-iron polymyxin b sulfate polymyxin b sulf-trimethoprim poly-tussin... 7 poly-vita poly-vita (iron) poly-vitamin poly-vitamin with iron poly-vitamins POMALYST portia PORTRAZZA potassium acetate potassium bicarb and chloride I-7 VillageCareMAX Full Advantage FIDA Plan 206 Formulary Formulary ID: Version: 8 Effective: October 0, 206

250 potassium bicarb-citric acid. 86 potassium chlorid-d5-0.45%nacl potassium chloride... 87, 88 potassium chloride in 0.9%nacl potassium chloride in 5 % dex potassium chloride in lr-d potassium chloride-0.45 % nacl potassium chloride-d5-0.2%nacl potassium chloride-d5-0.3%nacl potassium chloride-d5-0.9%nacl potassium citrate potassium citrate-citric acid. 87 potassium hydroxide potassium phosphate m-/d-basic POTIGA PRADAXA PRALUENT PEN PRALUENT SYRINGE pramipexole pravastatin prazosin prednicarbate prednisolone acetate... 4 prednisolone sodium phosphate... 4, 58 prednisone PREMARIN PREMASOL 0 % PREMASOL 6 % PREMPHASE PREMPRO prenatal , 209, 22 prenatal formula prenatal plus (calcium carb). 208 prenatal tablet... 2 prenatal vit#96-ferrous fum-fa prenatal vitamin... 20, 209 prenatal vitamin plus low iron prenatal vitamin with minerals prenatal vit-iron fumarate-fa 209 preparation h hydrocortisone 30 PREVAIL BLADDER CONTROL PAD prevalite PREVIDENT 5000 SENSITIVE previfem PREZCOBIX PREZISTA PRIFTIN PRILOSEC OTC PRIMAQUINE primidone PRISTIQ PRIVIGEN PROAIR HFA... 9 PROAIR RESPICLICK... 9 probenecid procainamide PROCALAMINE 3% prochlorperazine prochlorperazine edisylate prochlorperazine maleate PROCRIT procto-med hc procto-pak proctosol hc proctozone-hc PROCYSBI progesterone in oil... 6 progesterone micronized... 6 PROGLYCEM... 0 PROGRAF PROLASTIN-C PROLENSA... 4 PROLEUKIN PROLIA PROMACTA promethazine... 58, 64 promethazine vc-codeine... 7 promethazine-codeine... 7 promethazine-dm... 7 promethegan promolaxin propafenone propantheline proparacaine propranolol... 90, 9 propranolol-hydrochlorothiazid... 9 propylthiouracil... 6 PROQUAD (PF) prosight PROSOL 20 % protamine protriptyline pseudoephedrine hcl... 7 PULMOZYME pure and gentle eye... 36, 37 purelax PURIXAN pyrazinamide pyridostigmine bromide pyridoxine (vitamin b6) Q q-dryl q-pap... 0 q-pap extra strength... 0 q-tapp dm... 7 q-tussin... 7 q-tussin dm... 8 QUADRACEL (PF) quasense... 0 quetiapine QUILLIVANT XR I-8 VillageCareMAX Full Advantage FIDA Plan 206 Formulary Formulary ID: Version: 8 Effective: October 0, 206

251 quinapril quinapril-hydrochlorothiazide 88 quinidine gluconate quinidine sulfate quinine sulfate QVAR R RABAVERT (PF) raloxifene ramipril RANEXA ranitidine hcl... 43, 44 RAPAMUNE RASUVO (PF) RAVICTI react... 0 REBIF (WITH ALBUMIN) 77 REBIF REBIDOSE REBIF TITRATION PACK 77 reclipsen (28)... 0 RECOMBIVAX HB (PF)... 68, 69 recort plus refenesen... 8 refenesen pe... 8 REFRESH CELLUVISC REFRESH CLASSIC (PF).. 37 REFRESH LACRI-LUBE REFRESH OPTIVE REFRESH OPTIVE ADVANCED reguloid relcof c... 8 RELENZA DISKHALER RELISTOR... 48, 49 remedy phytoplex antifungal. 54 REMICADE REMODULIN RENAGEL rena-vite rx... 2 RENVELA repaglinide repaglinide-metformin REPATHA PUSHTRONEX.. 99 REPATHA SURECLICK REPATHA SYRINGE reprexain... 0 RESCRIPTOR... 72, 73 RESTASIS... 4 retaine cmc RETROVIR revive plus REVLIMID revonto REXULTI REYATAZ REZIRA... 8 ribasphere RIDAURA rifabutin rifampin RIFATER ri-gel ii riluzole rimantadine ri-mox ringers... 7, 88 risedronate RISPERDAL CONSTA risperidone... 69, 70 RITUXAN rivastigmine rivastigmine tartrate rizatriptan... 6 robafen... 8 robafen cough... 8 robafen dm... 8 robitussin cough-chest cong dm... 8 ROBITUSSIN LONG-ACTING... 8 robitussin pediatric... 8 ropinirole rosadan rosuvastatin ROTARIX ROTATEQ VACCINE ROWEEPRA roxicet... 0 ROZEREM rydex... 9 rynex dm... 9 S SABRIL safe tussin dm... 9 SAIZEN SAIZEN CLICK.EASY saline mist SANDOSTATIN LAR DEPOT SANTYL SAPHRIS (BLACK CHERRY) SAVELLA scooby-doo one a day... 2 scot-tussin dm... 9 scot-tussin expectorant... 9 sea soft nasal mist selegiline hcl selenium sulfide SELZENTRY senexon senior tabs... 2 senna... 52, 53 senna lax senna laxative senna with docusate sodium. 50 senokot-s SENSIPAR sentry... 2 sentry senior... 2 SEREVENT DISKUS... 9 SEROSTIM sertraline setlakin... 0 sharobel... 0 I-9 VillageCareMAX Full Advantage FIDA Plan 206 Formulary Formulary ID: Version: 8 Effective: October 0, 206

252 SIGNIFOR silace siladryl sa silapap... 0 sildenafil SILENOR siltussin sa... 9 siltussin-dm... 9 silver nitrate silver sulfadiazine SIMBRINZA simethicone simply sleep SIMPONI SIMPONI ARIA simvastatin sinus and allergy(pseudoephed) sirolimus SIRTURO skin treatment sleep aid (diphenhydramine).. 58 sleep aid (doxylamine) smoflipid smoothlax sodium acetate sodium bicarbonate... 49, 88 sodium chloride... 37, 7, 89, 93 sodium chloride 0.45 % sodium chloride 0.9 % sodium chloride 3 % sodium chloride 5 % sodium fluoride sodium lactate sodium phosphate sodium polystyrene (sorb free) sodium polystyrene sulfonate sodium thiosulfate SOLTAMOX SOLU-CORTEF (PF) SOMATULINE DEPOT SOMAVERT soothe (bismuth subsalicylate) soothe regular strength sorbitol... 7 sorbitol-mannitol... 7 sorine... 9 sotalol... 9 sotalol af... 9 SOVALDI spectravite spectravite adult spectravite advanced formula spectravite senior spectravite senior w-lycopene spectravite ultra women SPIRIVA RESPIMAT... 9 SPIRIVA WITH HANDIHALER spironolactone spironolacton-hydrochlorothiaz sprintec (28)... 0 SPRITAM SPRYCEL sps (with sorbitol) sronyx... 0 ssd st joseph aspirin... 4 st. joseph aspirin... 4 stavudine STELARA STERILE PADS STIOLTO RESPIMAT STIVARGA stomach relief stool softener STRATTERA STRENSIQ streptomycin... 8 stress 500 plus zinc stress b with zinc stress b-biotin stress formula stress formula plus iron stress formula with iron stress formula with zinc STRIBILD STRIVERDI RESPIMAT sucralfate sudafed sudogest sudogest sinus and allergy sulfacetamide sodium sulfacetamide sodium (acne) 26 sulfacetamide-prednisolone.. 40 sulfadiazine sulfamethoxazole-trimethoprim sulfasalazine sulfatrim sulindac... 4 sumatriptan... 6 sumatriptan succinate... 6 summer's eve disposable douche summers eve extra cleansing 78 sunvite super b complex-vitamin c.. 20, 22, 23 super b maxi complex super b/c super b-50 complex super b-50 complex plus super multiple super multivitamin super quints super quints b super thera vite m superior I-20 VillageCareMAX Full Advantage FIDA Plan 206 Formulary Formulary ID: Version: 8 Effective: October 0, 206

253 superplex-t suphedrin suphedrine pe day-night suphedrine severe cold max str support support SUPPRELIN LA SUPRAX SURMONTIL SUSTIVA SUTENT syeda... 0 SYLATRON SYLVANT SYMLINPEN SYMLINPEN SYNAGIS SYNAREL SYNERCID SYNJARDY SYNRIBO SYPRINE SYSTANE (PROPYLENE GLYCOL) SYSTANE GEL T tab-a-vite tab-a-vite/iron tab-a-vite-minerals TABLOID tacrolimus... 30, 64 tactinal... 0 tactinal extra strength... 0 TAFINLAR TAGRISSO TALTZ AUTOINJECTOR.. 25 TALTZ SYRINGE TAMIFLU tamoxifen tamsulosin TARCEVA TARGRETIN tarina fe /20 (28)... 0 TASIGNA tazicef TAZORAC taztia xt tears again tears again (pva) tears naturale free (pf) TECENTRIQ TECFIDERA TECHNIVIE TEFLARO telmisartan telmisartan-hydrochlorothiazid TEMODAR tencon... 0 TENIVAC (PF) terazosin terbinafine hcl terbutaline terconazole... 60, 6 testosterone testosterone cypionate testosterone enanthate TETANUS TOXOID,ADSORBED (PF) TETANUS,DIPHTHERIA TOX PED(PF) tetanus-diphtheria toxoids-td 69 tetrabenazine tetracaine hcl (pf) tetracycline THALOMID the magic bullet theochron theophylline theophylline in dextrose 5 % 92 thera m plus (ferrous fumarat) thera vitamin thera-d theradex m THERAFLU DAYTIME COLD-COUGH THERAFLU MULTI- SYMPTOM COLD thera-m therapeutic liquid therapeutic m + beta-carotene... 2 therapeutic-m therapeutic-m vitamin/minerals thera-tabs theratrum complete 50 plus.. 25 theratrum complete 50 plus/lut thiamine hcl (vitamin b) thioridazine thiotepa thiothixene tiagabine TICE BCG tilia fe... 0 timolol maleate... 9, 79 TIVICAY tizanidine TOBI PODHALER... 8 TOBRADEX TOBRADEX ST tobramycin tobramycin in % nacl... 8 tobramycin in 0.9 % nacl... 8 tobramycin sulfate... 8 tobramycin-dexamethasone.. 40 TOLAK tolazamide... 50, 5 tolbutamide... 5 tolmetin... 4 tolnaftate tolterodine I-2 VillageCareMAX Full Advantage FIDA Plan 206 Formulary Formulary ID: Version: 8 Effective: October 0, 206

254 topiragen topiramate toposar torsemide total b/c totalday multiple TOUJEO SOLOSTAR TOVIAZ TPN ELECTROLYTES TPN ELECTROLYTES II TRACLEER TRADJENTA tramadol... 0 tramadol-acetaminophen... 0 trandolapril tranexamic acid TRANSDERM-SCOP tranylcypromine TRAVASOL 0 % TRAVATAN Z travel sickness (meclizine) travoprost (benzalkonium) trazodone TREANDA TRECATOR TRELSTAR tretinoin tretinoin (chemotherapy) tretinoin microspheres TREXALL triacting m-sym cold/cough. 2 triamcinolone acetonide... 22, 30, 58 triaminic cold and cough (pe) TRIAMINIC COLD AND COUGHNT(PE) TRIAMINIC COUGH-SORE THROAT triamterene-hydrochlorothiazid trianex TRIBENZOR tri-buffered aspirin... 4 tri-dex pe tri-estarylla... 0 trifluoperazine trifluridine trihexyphenidyl tri-legest fe... 0 tri-linyah... 0 tri-lo-estarylla... 0 tri-lo-marzia... 0 tri-lo-sprintec... 0 trilyte with flavor packets trimethoprim trimipramine trinessa (28)... 0 TRINTELLIX triple antibiotic... 25, 26 triple paste af tri-previfem (28)... 0 tri-sprintec (28)... 0 TRIUMEQ tri-vi-sol tri-vita tri-vitamin trivora (28)... 0 TROKENDI XR TROPHAMINE 0 % TROPHAMINE 6% trospium TRULICITY TRUMENBA TRUVADA trymine cg TUDORZA PRESSAIR tusnel diabetic TUSNEL NEW FORMULA 20 TUSNEL PEDIATRIC... 2 TUSSI PRES-B... 2 tussin cf... 20, 2 tussin cf cough-cold... 2 tussin cold-congestion... 2 tussin cough (dm only)... 4 tussin dm... 8, 2 tussin dm cough and chest... 4 tussin maximum strength... 4 tussin pe... 7 TWINRIX (PF) TYBOST TYGACIL TYKERB TYPHIM VI TYSABRI TYVASO TYVASO REFILL KIT TYVASO STARTER KIT TYZEKA U u-cort ULORIC ultra b-00 complex ultra fresh pm ultra strength antacid unisom sleepgels UNITUXIN UPTRAVI... 96, 97 ursodiol V VAGIFEM valacyclovir VALCHLOR valganciclovir valproate sodium valproic acid valproic acid (as sodium salt). 42 valsartan valsartan-hydrochlorothiazide 87 VALSTAR valu-tapp dm... 9 VANACOF... 2 vancomycin vancomycin in dextrose 5 %.. 20 VAQTA (PF)... 69, 70 VARIVAX (PF) I-22 VillageCareMAX Full Advantage FIDA Plan 206 Formulary Formulary ID: Version: 8 Effective: October 0, 206

255 VASCEPA v-c forte VELCADE velivet triphasic regimen (28)... VENCLEXTA VENCLEXTA STARTING PACK venlafaxine VENTOLIN HFA verapamil VERSACLOZ vestura (28)... VGO VIBERZI vic-forte vicks dayquil cold-flu relief. 2 vicks dayquil cough... 2 vicks nature fusion cough... 2 vicks nyquil severe cold-flu. 2 vicks qlearquil(oxymetazoline) vicks sinex 2-hour vicodin... vicodin es... vicodin hp... VICTOZA VIDEX 2 GRAM PEDIATRIC VIDEX 4 GRAM PEDIATRIC VIEKIRA PAK VIEKIRA XR vienva... VIGAMOX VIIBRYD VIMIZIM VIMPAT... 42, 43 vinorelbine viorele (28)... VIRACEPT VIRAMUNE XR VIRAZOLE virdec dm... 2 VIREAD virt-phos 250 neutral virtussin ac... 2 vision vision formula (with lutein) 20, 25 vision plus lutein vit b complex-folic acid VITAFOL FE+ (WITH DOCUSATE) vitalets vitamin a vitamin b complex... 98, 20 vitamin b-00 complex vitamin b2-folic acid vitamin b vitamin c... 2, 26, 27 vitamin d , 27 vitamins and minerals vitamins b complex... 98, 26 vitamins for hair VITEKTA vitrum senior VOLTAREN... 4 voriconazole... 54, 55 VOTRIENT VPRIV VRAYLAR vyfemla (28)... W wal-act d cold and allergy wal-dram wal-dryl allergy wal-fex allergy wal-finate wal-finate-d wal-itin wal-itin d wal-itin d 2 hour wal-phed... 60, 2 wal-phed pe day-night wal-phed pe sinus and allergy 60 wal-profen... 4 wal-sleep z wal-som (diphenhydramine).. 60 wal-som (doxylamine) wal-tap wal-tussin cough wal-tussin cough and cold cf 22 wal-tussin dm... 2 wal-zan wal-zyr (cetirizine) wal-zyr d warfarin water for irrigation, sterile... 7 WELCHOL wera (28)... womens daily gummies women's daily multivitamin. 20 X XALKORI XARELTO XELJANZ XELJANZ XR XIFAXAN XIIDRA... 4 XOLAIR XTANDI xulane... xylon 0... XYREM Y yelets YERVOY YF-VAX (PF) YONDELIS Z zafirlukast zaleplon ZANTAC ZANTAC zarah... I-23 VillageCareMAX Full Advantage FIDA Plan 206 Formulary Formulary ID: Version: 8 Effective: October 0, 206

256 ZARXIO ZAVESCA zebutal... ZELBORAF ZEMPLAR zenatane zenchent (28)... ZENPEP ZEPATIER zephrex-d ZETIA ZIAGEN zidovudine ZINBRYTA zinc oxide ziprasidone hcl ZIRGAN ZOLADEX zoledronic acid zoledronic acid-mannitol-water ZOLINZA zolmitriptan... 6 zolpidem ZOMETA ZONATUSS zonisamide zoo chews ZORTRESS ZOSTAVAX (PF) zovia /35e (28)... zovia /50e (28)... ZOVIRAX z-sleep... 58, 59 ZUBSOLV... 6 ZYDELIG ZYKADIA ZYLET zyncof ZYPREXA RELPREVV ZYRTEC ZYTIGA ZYVOX I-24 VillageCareMAX Full Advantage FIDA Plan 206 Formulary Formulary ID: Version: 8 Effective: October 0, 206

257 Formulary ID: , Version 8