Empire FIDA Plan 2015 年 承 保 藥 物 清 單 ( 處 方 集 ) 此 為 Empire BlueCross BlueShield HealthPlus Fully Integrated Duals Advantage (FIDA) Plan 參 與 者 可 獲 取 的 藥

給 付 藥 物 ( 處 方 藥 物 ) 清 單 Empire BlueCross BlueShield HealthPlus Fully Integrated Duals Advantage (FIDA) Plan (Medicare-Medicaid Plan) 2015 年 參 與 者 服 務 部..1-855-817-5789 (TTY 711) 當 地 時 間 週 一 至 週 五 上 午 8 點 至 下 午 8 點 ENYDMKT-0035-15 11.15 Formulary CH 處 方 藥 物 ID..00015333 版 本..14 發 佈 時 間 11/01/2015

Empire FIDA Plan 2015 年 承 保 藥 物 清 單 ( 處 方 集 ) 此 為 Empire BlueCross BlueShield HealthPlus Fully Integrated Duals Advantage (FIDA) Plan 參 與 者 可 獲 取 的 藥 物 清 單 Empire BlueCross BlueShield HealthPlus FIDA Plan 為 一 個 與 Medicare 及 紐 約 州 衛 生 署 (Medicaid) 訂 立 的 託 管 保 健 計 劃, 以 透 過 Fully Integrated Duals Advantage (FIDA) Demonstration 向 參 與 者 提 供 該 兩 項 計 劃 的 福 利 Empire BlueCross BlueShield HealthPlus 是 HealthPlus, LLC 的 商 標 名 稱, 該 公 司 屬 Blue Cross and Blue Shield Association 的 獨 立 持 照 組 織 福 利 承 保 藥 物 清 單 及 藥 房 以 及 服 務 提 供 者 網 絡 可 能 於 年 內 及 各 年 1 月 1 日 不 時 變 更 您 可 以 透 過 登 錄 www.empireblue.com/fida 或 於 週 一 至 週 五 上 午 8 時 至 下 午 8 致 電 Empire FIDA Plan 參 與 者 服 務 部, 電 話 號 碼 為 1-855-817-5789( 聽 語 障 用 戶 請 致 電 1-800-855-2880)(TTY 711) 查 看 Empire FIDA Plan 的 最 新 承 保 藥 物 清 單 可 能 存 在 限 制 或 局 限 如 需 更 多 資 訊, 請 致 電 Empire FIDA Plan 參 與 者 服 務 部 或 查 閱 Empire FIDA Plan 參 與 者 手 冊 無 需 為 任 何 承 保 藥 物 支 付 共 付 費 您 可 以 免 費 獲 取 此 資 訊 的 其 他 版 本, 如 盲 文 或 大 字 版 本 請 於 週 一 至 週 五 上 午 8 點 至 晚 上 8 點 致 電 1-855-817-5789( 聽 語 障 用 戶 請 致 電 1-800-855-2880)(TTY 711) 此 為 免 付 費 電 話 您 可 以 免 費 獲 得 此 資 訊 的 其 他 語 言 版 本 請 於 週 一 至 週 五 上 午 8 點 至 晚 上 8 點 致 電 1-855-817-5789 ( 聽 語 障 用 戶 請 致 電 1-800-855-2880)(TTY 711) 此 為 免 付 費 電 話 Usted puede obtener esta información gratuitamente en otros idiomas.llame al 1-855-817-5789 (TTY 1-800-855-2884) (TTY 711) de lunes a viernes de 8 a.m. a 8 p.m. hora local.la llamada es gratuita. 您 可 以 免 費 獲 得 此 資 訊 的 其 他 語 言 版 本 請 致 電 1-855-817-5789 (TTY 711) 當 地 時 間 週 一 至 週 五 上 午 8 點 至 晚 上 8 點 此 為 免 付 費 電 話 Ou ka jwenn enfòmasyon sa gratis nan lòt lang.rele 1-855-817-5789 (TTY 711) lendi rive vandredi depi 8 è a.m. pou 8 è p.m. nan lè lokal.apèl sa gratis. È possibile ottenere queste informazioni gratuitamente in altre lingue.chiamare 1-855-817-5789 (TTY 711) dal lunedì al venerdì, dalle 8:00 alle 20:00 ora locale.la chiamata è gratuita. 이 정보는 다른 언어로 무료로 얻을 수 있습니다.현지 시간으로 월요일부터 금요일까지, 오전 8시에서 오후 8시 사이에1-855-817-5789 (TTY 711)번으로문의하십시오.통화는 무료입니다.? 如 果 您 有 疑 問, 請 於 當 地 時 間 週 一 至 週 五 上 午 8 點 至 晚 上 8 點 致 電 Empire FIDA Plan, 電 話 號 碼 為 1-855-817-5789( 聽 語 障 用 戶 請 致 電 1-800-855-2880)(TTY 711) 此 為 免 付 費 電 話 如 需 更 多 資 訊, 請 訪 問 www.empireblue.com/fida ENYDMEM-0035-15 1

Вы можете получить данную информацию бесплатно на любом языке.звоните по номеру 1-855-817-5789 (TTY 711) с понедельника по пятницу с 8:00 до 20:00 по местному времени.звонок бесплатный. 紐 約 州 已 建 立 一 個 名 為 Independent Consumer Advocacy Network (ICAN) 的 參 與 者 調 查 官 計 劃, 以 就 Empire FIDA Plan 所 提 供 的 任 何 服 務 向 參 與 者 提 供 免 費 私 密 的 幫 助 您 可 以 致 電 免 費 電 話 1-844-614-8800 或 登 錄 icannys.org 瞭 解 ICAN? 如 果 您 有 疑 問, 請 於 當 地 時 間 週 一 至 週 五 上 午 8 點 至 晚 上 8 點 致 電 Empire FIDA Plan, 電 話 號 碼 為 1-855-817-5789( 聽 語 障 用 戶 請 致 電 1-800-855-2880)(TTY 711) 此 為 免 付 費 電 話 如 需 更 多 資 訊, 請 訪 問 www.empireblue.com/fida ENYDMEM-0035-15 2

常 見 問 題 ( 常 見 問 題 ) 如 果 您 對 承 保 藥 物 清 單 存 在 疑 問, 請 在 此 處 尋 找 相 關 答 案 您 可 以 閱 覽 所 有 常 見 問 題 瞭 解 更 多 資 訊, 或 直 接 找 到 想 瞭 解 的 問 題 及 相 關 答 案 1. 承 保 藥 物 清 單 上 包 括 哪 些 處 方 藥 物?( 我 們 將 承 保 藥 物 清 單 簡 稱 為 藥 物 清 單 ) 承 保 藥 物 清 單 ( 從 9 頁 開 始 ) 上 的 藥 物 為 Empire FIDA Plan 承 保 的 藥 物 此 等 藥 物 可 從 我 們 的 網 絡 內 藥 房 獲 取 倘 我 們 與 一 間 藥 房 達 成 協 議 合 作 並 向 您 提 供 服 務, 則 該 藥 房 為 我 們 的 網 絡 內 藥 房 我 們 將 此 等 藥 房 稱 為 網 絡 藥 房 倘 出 現 以 下 情 況,Empire FIDA Plan 將 承 保 藥 物 清 單 上 的 所 有 藥 物 : 您 的 醫 生 或 其 他 網 絡 處 方 醫 生 說 明 您 需 要 該 等 藥 物, 以 達 到 康 復 或 保 持 健 康, 該 藥 物 為 您 的 身 體 狀 況 醫 療 所 需, 及 您 於 Empire FIDA Plan 的 網 絡 藥 房 配 藥 Empire FIDA Plan 可 能 存 在 評 估 若 干 藥 物 的 其 他 步 驟 ( 見 下 文 問 題 5) 在 某 些 情 況 下, 在 獲 得 指 定 藥 物 之 前, 您 可 能 需 要 做 些 事, 如 先 嘗 試 其 他 藥 物 您 可 以 訪 問 我 們 的 網 站 www.empireblue.com/fida 或 於 週 一 至 週 五 上 午 8 點 至 晚 上 8 點 致 電 參 與 者 服 務 部, 電 話 號 碼 為 1-855-817-5789( 聽 語 障 用 戶 請 致 電 1-800-855-2880)(TTY 711), 以 查 閱 最 新 的 承 保 藥 物 清 單 2. 藥 物 清 單 是 否 會 變 更? 是 Empire FIDA Plan 可 能 於 年 內 在 藥 物 清 單 上 添 加 或 刪 除 藥 物 通 常 情 況 下, 藥 物 清 單 僅 在 發 生 以 下 情 況 時 才 會 變 更 : 一 種 功 效 可 等 同 於 藥 物 清 單 上 現 有 藥 物 的 新 藥 物 出 現, 或 我 們 得 知 某 種 藥 物 不 安 全 我 們 亦 可 能 變 更 有 關 藥 物 的 規 則 例 如, 我 們 可 能 : 決 定 就 某 種 藥 物 要 求 或 不 要 求 事 先 批 准 ( 事 先 批 准 指 您 在 獲 得 某 種 藥 物 前 由 Empire FIDA Plan 或 您 的 Interdisciplinary Team (IDT) 作 出 的 批 准 ) 增 加 或 變 更 您 可 獲 取 藥 物 的 劑 量 ( 稱 為 劑 量 限 制 ) 就 某 項 藥 物 添 加 或 變 更 漸 進 式 治 療 限 制 ( 漸 進 式 治 療 指 在 我 們 承 保 另 一 種 藥 物 前, 您 必 須 嘗 試 一 種 藥 物 ) ( 有 關 此 等 藥 物 規 則 的 更 多 資 訊, 請 參 閱 第 9 頁 )? 如 果 您 有 疑 問, 請 於 當 地 時 間 週 一 至 週 五 上 午 8 點 至 晚 上 8 點 致 電 Empire FIDA Plan, 電 話 號 碼 為 1-855-817-5789( 聽 語 障 用 戶 請 致 電 1-800-855-2880)(TTY 711) 此 為 免 付 費 電 話 如 需 更 多 資 訊, 請 訪 問 www.empireblue.com/fida ENYDMEM-0035-15 3

當 您 使 用 的 某 種 藥 物 從 藥 物 清 單 上 刪 除 時, 我 們 會 通 知 您 當 我 們 變 更 承 保 某 種 藥 物 的 規 則 時, 我 們 亦 會 通 知 您 下 文 問 題 3 4 及 7 提 供 有 關 藥 物 清 單 變 更 時 的 更 多 資 訊 您 可 以 隨 時 登 錄 www.empireblue.com/fida 在 綫 查 看 Empire FIDA Plan 的 最 新 藥 物 清 單 您 亦 可 於 週 一 至 週 五 上 午 8 點 至 晚 上 8 點 致 電 參 與 者 服 務 部, 電 話 號 碼 為 1-855-817-5789 ( 聽 語 障 用 戶 請 致 電 1-800-855-2880)(TTY 711), 以 查 核 當 前 藥 物 清 單 3. 當 一 種 功 效 可 等 同 於 藥 物 清 單 上 現 有 藥 物 的 較 便 宜 藥 物 出 現 時 會 如 何? 當 一 種 功 效 可 等 同 於 藥 物 清 單 上 現 有 藥 物 的 較 便 宜 藥 物 出 現 時 : 當 您 下 次 配 藥 時, 您 的 藥 劑 師 可 能 會 給 您 開 這 種 較 便 宜 的 藥 物 倘 您 及 您 的 服 務 提 供 者 認 為 這 種 較 便 宜 的 藥 物 不 適 合 您 使 用, 您 的 服 務 提 供 者 可 告 知 藥 劑 師 繼 續 提 供 您 目 前 使 用 的 藥 物 Empire FIDA Plan 可 能 決 定 將 較 貴 的 藥 物 從 藥 物 清 單 上 刪 除 倘 您 正 在 服 用 某 種 因 同 等 功 效 的 較 便 宜 藥 物 出 現 而 將 從 藥 物 清 單 上 刪 除 的 藥 物, 在 將 該 藥 物 自 藥 物 清 單 上 刪 除 之 前, 我 們 將 提 前 至 少 60 日 通 知 您, 或 在 您 再 次 配 藥 時 通 知 您 如 此, 您 可 在 藥 物 清 單 變 更 前 獲 得 60 天 的 藥 物 供 應 倘 您 收 到 此 類 通 知, 您 應 與 您 的 服 務 提 供 者 商 討 開 始 使 用 清 單 上 的 藥 物, 或 請 求 特 例 4. 當 我 們 發 現 某 種 藥 物 不 安 全 時 會 如 何? 倘 食 物 和 藥 品 管 理 局 (FDA) 認 為 您 正 在 使 用 的 某 種 藥 物 不 安 全, 我 們 會 立 即 將 其 從 藥 物 清 單 上 刪 除 我 們 會 向 您 寄 送 函 件 或 電 話 告 知 您 這 種 不 安 全 的 藥 物 已 從 藥 物 清 單 上 刪 除 如 果 您 收 到 關 於 不 安 全 藥 物 的 通 知, 請 立 即 聯 絡 您 的 醫 生 您 的 醫 生 會 幫 助 您 找 到 另 一 種 適 合 您 的 藥 物 5. 藥 物 承 保 是 否 存 在 任 何 局 限 或 限 制? 或 者 是 否 需 採 取 任 何 規 定 的 行 動, 以 獲 得 特 定 藥 物? 是 的, 某 些 藥 物 有 承 保 規 則 或 對 您 可 獲 取 的 劑 量 有 所 限 制 在 某 些 情 況 下, 在 獲 得 藥 物 之 前, 您 可 能 需 要 做 些 事 例 如 : 事 先 批 准 ( 或 事 先 核 准 ): 就 某 些 藥 物 而 言, 在 您 配 藥 之 前, 您 或 您 的 醫 生 或 其 他 處 方 醫 生 必 須 獲 得 來 自 Empire FIDA Plan 或 您 的 Interdisciplinary Team (IDT) 的 批 准 倘 您 未 獲 批 准, Empire FIDA Plan 可 能 不 會 承 保 該 藥 物 劑 量 限 制 : 有 時,Empire FIDA Plan 會 限 制 您 可 獲 取 的 藥 物 劑 量 漸 進 式 治 療 : 有 時,Empire FIDA Plan 會 要 求 您 進 行 漸 進 式 治 療 這 意 味 著 您 須 根 據 您 的 身 體 狀 況 按 特 定 順 序 使 用 藥 物 在 我 們 承 保 另 一 種 藥 物 之 前, 您 可 能 須 先 使 用 某 種 藥 物 倘 您 的 醫 生 認 為 第 一 種 藥 物 並 不 適 合 您 使 用, 則 我 們 會 承 保 第 二 種 藥 物 您 可 以 透 過 查 看 從 第 9 頁 開 始 的 表 格 瞭 解 您 的 藥 物 是 否 存 在 任 何 其 他 要 求 您 亦 可 以 透 過 訪 問 我 們 的 網 站 www.empireblue.com/fida 獲 取 更 多 資 訊 我 們 已 公 佈 說 明 事 先 核 准 限 制 及 漸 進 式 治 療 限 制 相 關 事 項 的 在 綫 文 件 您 亦 可 以 要 求 我 們 給 您 寄 送 一 份 副 本 您 可 以 就 此 等 限 制 請 求 特 例 有 關 特 例 的 更 多 資 訊, 請 參 閱 問 題 9? 如 果 您 有 疑 問, 請 於 當 地 時 間 週 一 至 週 五 上 午 8 點 至 晚 上 8 點 致 電 Empire FIDA Plan, 電 話 號 碼 為 1-855-817-5789( 聽 語 障 用 戶 請 致 電 1-800-855-2880)(TTY 711) 此 為 免 付 費 電 話 如 需 更 多 資 訊, 請 訪 問 www.empireblue.com/fida ENYDMEM-0035-15 4

如 果 您 目 前 居 於 一 家 療 養 院 或 其 他 長 期 護 理 機 構, 並 需 要 某 種 藥 物 清 單 上 沒 有 的 藥 物, 或 您 無 法 輕 易 獲 取 該 種 藥 物, 我 們 可 以 幫 助 您 無 論 您 是 否 為 Empire FIDA Plan 的 新 參 與 者, 我 們 就 該 種 藥 物 承 保 31 日 的 緊 急 供 應 ( 除 非 您 的 處 方 未 達 31 日 ) 這 使 您 有 充 分 時 間 與 您 的 醫 生 或 其 他 處 方 醫 生 商 討 他 / 她 可 以 幫 助 您 決 定 是 否 使 用 藥 物 清 單 上 存 在 的 某 種 類 似 藥 物 替 代, 或 是 否 請 求 特 例 有 關 特 例 的 更 多 資 訊, 請 參 閱 問 題 18 6. 您 將 如 何 知 曉 您 想 要 的 某 種 藥 物 是 否 存 在 限 制 或 在 獲 取 該 藥 物 前 是 否 需 要 採 取 規 定 行 動? 位 於 第 9 頁 的 承 保 藥 物 清 單 上 印 有 標 籤 名 為 的 一 欄 7. 如 果 我 們 承 保 某 些 藥 物 的 規 則 發 生 變 更 會 如 何? 例 如, 倘 我 們 就 某 種 藥 物 添 加 事 先 核 准 ( 批 准 ) 劑 量 限 制 及 / 或 漸 進 式 治 療 限 制 倘 我 們 就 某 種 藥 物 添 加 事 先 核 准 ( 批 准 ) 劑 量 限 制 及 / 或 漸 進 式 治 療 限 制, 我 們 會 告 知 您 我 們 會 在 添 加 該 項 限 制 前 至 少 60 日 或 在 您 下 次 配 藥 時 告 知 您 如 此, 您 可 在 藥 物 清 單 變 更 前 獲 得 60 日 的 藥 物 供 應 這 使 您 有 充 分 時 間 與 您 的 醫 生 或 其 他 處 方 醫 生 商 討 對 策 8. 如 何 在 藥 物 清 單 上 找 到 某 種 藥 物? 有 兩 種 方 式 可 供 您 選 擇 : 您 可 以 按 字 母 搜 索 ( 如 果 您 知 道 如 何 拼 寫 該 藥 物 的 名 稱 ), 或 您 可 按 身 體 狀 況 搜 索 要 按 字 母 搜 索, 您 可 找 到 位 於 頁 碼 頁 面 的 字 母 清 單 一 節 然 後 在 清 單 上 尋 找 您 的 藥 物 的 名 稱 要 按 身 體 狀 況 搜 索, 您 可 找 到 位 於 頁 碼 頁 面 的 標 題 為 按 身 體 狀 況 分 類 的 藥 物 清 單 一 節 然 後 找 到 與 您 的 身 體 狀 況 相 符 的 一 節 例 如, 如 果 您 有 心 臟 問 題, 則 應 在 該 類 中 尋 找 在 該 處, 您 將 可 以 找 到 治 療 心 臟 病 的 藥 物 9. 倘 您 想 要 的 某 種 藥 物 不 在 藥 物 清 單 上 時 怎 麼 辦? 倘 您 發 現 您 的 藥 物 不 在 藥 物 清 單 上, 請 於 週 一 至 週 五 上 午 9 點 至 晚 上 9 點 致 電 參 與 者 服 務 部, 電 話 號 碼 為 1-855-817-5789( 聽 語 障 用 戶 請 致 電 1-800-855-2880)(TTY 711) 如 果 您 得 知 Empire FIDA Plan 未 承 保 該 種 藥 物, 您 可 採 取 以 下 行 動 : 請 求 參 與 者 服 務 部 提 供 與 您 想 要 的 藥 物 類 似 的 藥 物 清 單 然 後 將 該 清 單 出 示 予 您 的 醫 生 或 其 他 處 方 醫 生 他 / 她 可 開 具 藥 物 清 單 上 一 種 與 您 想 要 的 藥 物 類 似 的 藥 物 或 您 可 向 此 計 劃 或 您 的 Interdisciplinary Team (IDT) 請 求 特 例, 以 承 保 您 的 藥 物 有 關 特 例 的 更 多 資 訊, 請 參 閱 問 題 9 10. 如 果 您 為 Empire FIDA Plan 的 新 參 與 者, 且 未 能 在 藥 物 清 單 上 找 到 您 的 藥 物 或 無 法 獲 得 藥 物 時 怎 麼 辦?? 如 果 您 有 疑 問, 請 於 當 地 時 間 週 一 至 週 五 上 午 8 點 至 晚 上 8 點 致 電 Empire FIDA Plan, 電 話 號 碼 為 1-855-817-5789( 聽 語 障 用 戶 請 致 電 1-800-855-2880)(TTY 711) 此 為 免 付 費 電 話 如 需 更 多 資 訊, 請 訪 問 www.empireblue.com/fida ENYDMEM-0035-15 5

我 們 可 以 幫 助 您 如 有 需 要, 在 您 成 為 Empire FIDA Plan 參 與 者 的 首 90 日 內, 我 們 須 承 保 長 達 90 日 的 藥 物 臨 時 供 應 這 使 您 有 充 分 時 間 與 您 的 醫 生 或 其 他 處 方 醫 生 商 討 他 / 她 可 以 幫 助 您 決 定 是 否 使 用 藥 物 清 單 上 存 在 的 某 種 類 似 藥 物 替 代, 或 是 否 請 求 特 例 倘 以 下 情 況 發 生, 我 們 將 承 保 長 達 90 日 的 臨 時 供 應 : 您 在 使 用 藥 物 清 單 上 並 不 存 在 的 藥 物, 或 保 健 計 劃 規 則 使 您 未 獲 得 您 的 處 方 醫 生 規 定 的 劑 量, 或 該 種 藥 物 需 獲 得 Empire FIDA Plan 或 您 的 Interdisciplinary Team (IDT) 的 事 先 批 准, 或 您 在 使 用 一 種 用 於 漸 進 式 治 療 的 藥 物 如 果 您 居 於 一 家 療 養 院 或 其 他 長 期 護 理 機 構, 您 可 在 長 達 98 日 內 按 您 的 處 方 重 新 配 藥 在 此 98 日 內, 您 可 多 次 配 藥 這 使 您 的 處 方 醫 生 有 時 間 將 您 的 藥 物 改 成 藥 物 清 單 上 已 有 的 藥 物, 或 請 求 特 例 如 果 您 的 護 理 級 別 變 更, 要 求 您 從 一 家 機 構 或 治 療 中 心 轉 移 至 另 一 家, 您 可 有 資 格 按 您 的 現 有 處 方 進 行 一 次 臨 時 配 藥 例 如, 如 果 您 從 醫 院 出 院, 且 根 據 醫 院 的 處 方, 您 需 再 使 用 某 些 藥 物, 您 還 可 以 進 行 一 次 配 藥 不 論 是 否 在 加 入 計 劃 的 首 90 日 內, 您 可 以 獲 得 一 次 臨 時 配 藥 特 例 欲 瞭 解 詳 情, 請 讓 您 的 處 方 醫 生 致 電 我 們 11. 您 是 否 可 以 請 求 特 例 承 保 藥 物? 是 的 您 可 以 請 求 Empire FIDA Plan 或 您 的 Interdisciplinary Team (IDT) 破 例 承 保 藥 物 清 單 上 沒 有 的 藥 物 您 亦 可 以 請 求 Empire FIDA Plan 或 您 的 IDT 變 更 您 所 用 藥 物 的 相 關 規 則 例 如,Empire FIDA Plan 可 能 會 限 制 我 們 承 保 的 藥 物 劑 量 如 果 您 的 藥 物 存 在 劑 量 限 制, 您 可 以 要 求 我 們 或 您 的 IDT 變 更 該 限 制, 並 承 保 更 多 劑 量 其 他 示 例 : 您 可 以 要 求 我 們 或 您 的 IDT 取 消 漸 進 式 治 療 限 制 或 事 先 批 准 規 定 12. 獲 取 特 例 需 要 多 長 時 間? 首 先,Empire FIDA Plan 或 您 的 Interdisciplinary Team (IDT) 須 收 到 一 份 來 自 您 的 處 方 醫 生 表 明 支 持 您 的 特 例 請 求 的 聲 明 收 到 聲 明 之 後, 我 們 將 在 72 小 時 內 決 定 是 否 批 准 您 的 特 例 請 求 如 果 您 的 處 方 醫 生 認 為 72 小 時 的 等 待 時 間 會 讓 您 的 健 康 受 損, 您 可 請 求 緊 急 特 例 我 們 會 快 速 作 出 決 定 如 果 您 的 處 方 醫 生 支 持 您 的 請 求, 您 將 在 收 到 其 支 持 聲 明 後 24 小 時 內 得 到 我 們 的 答 復 13. 如 何 請 求 特 例? 要 請 求 特 例, 請 致 電 您 的 醫 療 經 理 人 您 的 醫 療 經 理 人 將 與 您 和 您 的 服 務 提 供 者 協 作, 幫 助 您 請 求 特 例? 如 果 您 有 疑 問, 請 於 當 地 時 間 週 一 至 週 五 上 午 8 點 至 晚 上 8 點 致 電 Empire FIDA Plan, 電 話 號 碼 為 1-855-817-5789( 聽 語 障 用 戶 請 致 電 1-800-855-2880)(TTY 711) 此 為 免 付 費 電 話 如 需 更 多 資 訊, 請 訪 問 www.empireblue.com/fida ENYDMEM-0035-15 6

14. 什 麼 是 仿 製 藥 物? 仿 製 藥 物 為 由 與 品 牌 藥 物 相 同 的 成 份 製 成 的 藥 物 這 些 藥 物 通 常 較 品 牌 藥 物 便 宜, 且 知 名 度 不 高 仿 製 藥 物 已 獲 食 物 和 藥 品 管 理 局 (FDA) 批 准 Empire FIDA Plan 既 承 保 品 牌 藥 物, 亦 承 保 仿 製 藥 物 15. 什 麼 是 非 處 方 藥 物? OTC 指 非 處 方 當 您 的 服 務 提 供 者 將 若 干 非 處 方 藥 物 作 為 處 方 書 面 寫 明 時,Empire FIDA Plan 會 承 保 該 等 非 處 方 藥 物 您 可 以 閱 覽 Empire FIDA Plan 藥 物 清 單, 瞭 解 獲 承 保 的 非 處 方 藥 物 16. Empire FIDA Plan 是 否 承 保 非 處 方 非 藥 物 產 品? 當 您 的 服 務 提 供 者 將 若 干 非 處 方 非 藥 物 產 品 作 為 處 方 書 面 寫 明 時,Empire FIDA Plan 會 承 保 該 等 非 處 方 非 藥 物 產 品 Empire FIDA Plan 承 保 維 他 命 及 礦 物 質 等 非 藥 物 項 目 您 可 以 閱 覽 Empire FIDA Plan 藥 物 清 單, 瞭 解 獲 承 保 的 非 處 方 非 藥 物 產 品 有 哪 些 17. 什 麼 是 共 付 費? 您 無 需 為 藥 物 清 單 上 已 有 的 藥 物 支 付 共 付 費 18. 什 麼 是 藥 物 分 級? 分 級 即 為 具 有 不 同 規 則 及 規 章 的 各 種 不 同 類 型 藥 物 的 組 別 所 有 Empire FIDA Plan 分 級 都 無 需 共 付 費 第 1 級 藥 物 為 首 選 D 部 分 仿 製 及 品 牌 藥 物 第 2 級 藥 物 為 無 需 事 先 核 准 的 D 部 分 非 首 選 品 牌 及 仿 製 藥 物 第 3 級 包 括 非 D 部 分 藥 物 ( 品 牌 藥 物 與 仿 製 藥 物 ) 某 些 藥 物 可 能 需 要 事 先 核 准 第 4 級 包 括 處 方 內 的 非 處 方 藥 物 承 保 藥 物 清 單 從 下 頁 開 始 的 承 保 藥 物 清 單 提 供 Empire FIDA Plan 承 保 藥 物 的 相 關 資 訊 如 果 您 未 能 在 清 單 內 找 到 您 需 要 的 藥 物, 請 閱 覽 始 於 索 引 頁 碼 頁 面 的 索 引? 如 果 您 有 疑 問, 請 於 當 地 時 間 週 一 至 週 五 上 午 8 點 至 晚 上 8 點 致 電 Empire FIDA Plan, 電 話 號 碼 為 1-855-817-5789( 聽 語 障 用 戶 請 致 電 1-800-855-2880)(TTY 711) 此 為 免 付 費 電 話 如 需 更 多 資 訊, 請 訪 問 www.empireblue.com/fida ENYDMEM-0035-15 7

圖 表 的 第 一 欄 列 明 藥 物 的 名 稱 品 牌 藥 物 為 大 寫 ( 如 ABELCET), 仿 製 藥 物 為 小 寫 斜 體 ( 如 fluconazole) 一 欄 內 的 資 訊 將 告 訴 您 Empire FIDA Plan 對 承 保 您 的 藥 物 是 否 存 在 任 何 規 則 下 文 為 一 欄 內 所 用 代 碼 的 含 義 ; B/D: 此 種 處 方 藥 物 可 能 根 據 Medicare B 部 分 ( 例 如, 意 味 著 您 應 從 服 務 提 供 者 處 獲 取 該 種 藥 物 ) 或 D 部 分 ( 意 味 著 您 應 從 您 的 藥 房 獲 取 該 種 藥 物 ) 承 保 視 乎 情 況 而 定 您 可 能 需 要 提 交 說 明 該 種 藥 物 的 使 用 事 項 的 資 料, 以 決 定 按 何 種 方 式 承 保 無 論 按 何 種 方 式, 您 無 需 為 此 種 藥 物 支 付 任 何 費 用 HI: 家 庭 注 射 此 種 處 方 藥 物 可 能 根 據 我 們 的 醫 療 福 利 承 保 如 需 更 多 資 訊, 請 致 電 會 員 服 務 部 LA: 供 應 有 限 此 種 處 方 藥 物 可 能 僅 可 從 若 干 藥 房 獲 取 如 需 更 多 資 訊, 請 致 電 會 員 服 務 部 MO: 郵 購 藥 物 此 種 處 方 藥 物 可 透 過 我 們 的 郵 購 服 務 及 零 售 網 絡 藥 房 獲 取 考 慮 就 您 的 長 期 ( 保 養 ) 藥 物 ( 如 高 血 壓 藥 物 ) 使 用 郵 寄 訂 購 零 售 網 絡 藥 房 可 能 更 適 合 於 短 期 處 方 藥 物 ( 如 抗 生 素 ) PAR: 需 要 事 先 核 准 就 若 干 藥 物 而 言, 此 計 劃 可 能 要 求 您 或 您 的 醫 師 獲 得 事 先 核 准 這 意 味 著 您 在 配 藥 前 需 獲 得 批 准 如 果 您 未 獲 得 批 准, 我 們 可 能 不 會 承 保 該 種 藥 物 QLL: 劑 量 限 制 就 若 干 藥 物 而 言, 此 計 劃 會 限 制 我 們 承 保 的 藥 物 劑 量 ST: 漸 進 式 治 療 在 某 些 情 況 下, 在 我 們 承 保 另 一 種 藥 物 之 前, 此 計 劃 可 能 要 求 您 先 嘗 試 若 干 藥 物 來 治 療 您 的 病 症 例 如, 倘 藥 物 A 及 藥 物 B 均 適 合 治 療 您 的 病 症, 我 們 可 能 不 會 承 保 藥 物 B, 除 非 您 已 先 嘗 試 使 用 藥 物 A 如 果 藥 物 A 對 您 而 言 沒 有 療 效, 則 我 們 會 承 保 藥 物 B 附 註 : 藥 物 後 的 星 標 (*) 指 該 種 藥 物 為 非 D 部 分 藥 物 此 等 藥 物 對 申 訴 亦 有 不 同 規 則 申 訴 即 為 請 求 我 們 審 閱 一 項 承 保 決 定 及 變 更 決 定 ( 倘 您 認 為 我 們 有 誤 ) 的 一 種 正 式 方 式 例 如,Empire FIDA Plan 或 您 的 Interdisciplinary Team (IDT) 可 能 決 定 您 想 要 的 某 種 藥 物 不 獲 或 不 再 獲 Medicare 或 Medicaid 承 保 倘 您 或 您 的 醫 生 或 您 的 處 方 醫 生 不 同 意 該 項 決 定, 您 可 以 申 訴 如 欲 瞭 解 如 何 申 訴 的 相 關 說 明, 請 致 電 參 與 者 服 務 部, 電 話 號 碼 為 1-855-817-5789( 聽 語 障 用 戶 請 致 電 1-800-855-2880)(TTY 711) 或 FIDA 參 與 者 申 訴 部 1-844-614-8800 您 亦 可 以 閱 覽 參 與 者 手 冊, 瞭 解 申 訴 方 法? 如 果 您 有 疑 問, 請 於 當 地 時 間 週 一 至 週 五 上 午 8 點 至 晚 上 8 點 致 電 Empire FIDA Plan, 電 話 號 碼 為 1-855-817-5789( 聽 語 障 用 戶 請 致 電 1-800-855-2880)(TTY 711) 此 為 免 付 費 電 話 如 需 更 多 資 訊, 請 訪 問 www.empireblue.com/fida ENYDMEM-0035-15 8

ANTI - INFECTIVES ANTIFUNGAL AGENTS ABELCET 2 $0 B/D PAR; MO AMBISOME 2 $0 B/D PAR; MO amphotericin b 2 $0 B/D PAR; MO CANCIDAS 2 $0 B/D PAR; MO clotrimazole mucous membrane 2 $0 MO ERAXIS(WATER DILUENT) 2 $0 PAR; MO fluconazole 2 $0 MO fluconazole in dextrose(iso-o) 2 $0 fluconazole in nacl (iso-osm) intravenous piggyback 200 mg/100 ml fluconazole in nacl (iso-osm) intravenous piggyback 400 mg/200 ml 2 $0 MO 2 $0 flucytosine 2 $0 MO griseofulvin microsize oral suspension 2 $0 MO griseofulvin ultramicrosize 2 $0 MO itraconazole 2 $0 PAR; MO ketoconazole oral 2 $0 MO NOXAFIL ORAL SUSPENSION 2 $0 PAR; MO; QLL (630 per 30 days) nystatin oral suspension 2 $0 MO nystatin oral tablet 2 $0 MO terbinafine hcl oral 2 $0 MO; QLL (30 per 30 days) voriconazole intravenous 2 $0 MO voriconazole oral suspension for reconstitution 2 $0 PAR; MO; QLL (300 per 30 days) voriconazole oral tablet 200 mg 2 $0 PAR; MO; QLL (60 per 30 days) voriconazole oral tablet 50 mg 2 $0 PAR; MO; QLL (120 per 30 days) ANTIVIRALS abacavir 2 $0 MO abacavir-lamivudine-zidovudine 2 $0 MO acyclovir oral capsule 2 $0 MO ENYDMEM-0035-15 9

acyclovir oral suspension 200 mg/5 ml 2 $0 MO acyclovir oral tablet 2 $0 MO acyclovir sodium intravenous recon soln 500 mg 2 $0 B/D PAR acyclovir sodium intravenous solution 2 $0 B/D PAR; MO adefovir 2 $0 MO amantadine hcl oral capsule 2 $0 MO amantadine hcl oral tablet 2 $0 MO APTIVUS ORAL CAPSULE 2 $0 MO APTIVUS ORAL SOLUTION 2 $0 ATRIPLA 2 $0 MO BARACLUDE 2 $0 PAR; MO cidofovir 2 $0 B/D PAR; MO COMPLERA 2 $0 MO CRIXIVAN ORAL CAPSULE 200 MG, 400 MG 2 $0 MO DAKLINZA 2 $0 PAR; MO; QLL (30 per 30 days) didanosine 2 $0 MO EDURANT 2 $0 MO EMTRIVA 2 $0 MO entecavir 2 $0 PAR; MO EPIVIR HBV ORAL SOLUTION 2 $0 MO EPIVIR ORAL SOLUTION 2 $0 MO EPZICOM 2 $0 MO EVOTAZ 2 $0 MO famciclovir oral tablet 125 mg, 250 mg 2 $0 MO; QLL (60 per 30 days) famciclovir oral tablet 500 mg 2 $0 MO; QLL (21 per 7 days) foscarnet 2 $0 B/D PAR; MO FUZEON SUBCUTANEOUS RECON SOLN 2 $0 MO; QLL (60 per 30 days) ganciclovir sodium 2 $0 MO HARVONI 2 $0 PAR; MO; QLL (28 per 28 days) INTELENCE ORAL TABLET 100 MG, 200 MG 2 $0 MO ENYDMEM-0035-15 10

INTELENCE ORAL TABLET 25 MG 2 $0 INVIRASE 2 $0 MO ISENTRESS 2 $0 MO KALETRA 2 $0 MO lamivudine 2 $0 MO lamivudine-zidovudine 2 $0 MO LEXIVA 2 $0 MO nevirapine 2 $0 MO NORVIR 2 $0 MO OLYSIO 2 $0 PAR; MO PREZCOBIX 2 $0 MO PREZISTA ORAL SUSPENSION 2 $0 MO PREZISTA ORAL TABLET 150 MG, 600 MG, 75 MG, 800 MG 2 $0 MO RELENZA DISKHALER 2 $0 MO; QLL (60 per 180 days) RESCRIPTOR 2 $0 MO RETROVIR INTRAVENOUS 2 $0 MO REYATAZ ORAL CAPSULE 150 MG, 200 MG, 300 MG 2 $0 MO REYATAZ ORAL POWDER IN PACKET 2 $0 MO ribasphere oral capsule 2 $0 PAR; MO ribasphere oral tablet 200 mg 2 $0 PAR; MO ribavirin oral capsule 2 $0 PAR; MO ribavirin oral tablet 200 mg 2 $0 PAR; MO rimantadine 2 $0 MO SELZENTRY 2 $0 MO SOVALDI 2 $0 PAR; MO stavudine 2 $0 MO STRIBILD 2 $0 MO SUSTIVA 2 $0 MO SYNAGIS 2 $0 PAR; MO; LA ENYDMEM-0035-15 11

TAMIFLU ORAL CAPSULE 30 MG 2 $0 MO; QLL (84 per 1 day) TAMIFLU ORAL CAPSULE 45 MG 2 $0 MO; QLL (42 per 1 day) TAMIFLU ORAL CAPSULE 75 MG 2 $0 MO; QLL (56 per 365 days) TAMIFLU ORAL SUSPENSION FOR RECONSTITUTION TIVICAY 2 $0 MO TRIUMEQ 2 $0 MO TRIZIVIR 2 $0 MO TRUVADA 2 $0 MO TYBOST 2 $0 MO 2 $0 MO; QLL (360 per 180 days) TYZEKA 2 $0 PAR; MO valacyclovir 2 $0 MO; QLL (30 per 1 day) VALCYTE ORAL TABLET 2 $0 MO valganciclovir 2 $0 MO VIDEX 2 GRAM PEDIATRIC 2 $0 MO VIDEX 4 GRAM PEDIATRIC 2 $0 MO VIEKIRA PAK 2 $0 PAR; MO VIRACEPT ORAL TABLET 2 $0 MO VIRAMUNE XR 2 $0 MO VIRAZOLE 2 $0 PAR; MO VIREAD ORAL POWDER 2 $0 MO; QLL (240 per 30 days) VIREAD ORAL TABLET 2 $0 MO VITEKTA 2 $0 MO ZIAGEN ORAL SOLUTION 2 $0 MO zidovudine 2 $0 MO CEPHALOSPORINS cefaclor oral capsule 2 $0 MO cefaclor oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml 2 $0 MO cefaclor oral tablet extended release 12 hr 2 $0 MO cefadroxil oral capsule 2 $0 MO ENYDMEM-0035-15 12

cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml 2 $0 MO cefadroxil oral tablet 2 $0 MO cefazolin in dextrose (iso-os) intravenous piggyback 1 gram/50 ml, 2 gram/50 ml 2 $0 MO cefazolin injection recon soln 1 gram, 500 mg 2 $0 MO cefazolin injection recon soln 10 gram, 100 gram, 20 gram, 300 g 2 $0 cefazolin intravenous 2 $0 cefdinir 2 $0 MO cefepime 2 $0 MO cefoxitin in dextrose, iso-osm 2 $0 cefoxitin intravenous recon soln 1 gram 2 $0 MO cefoxitin intravenous recon soln 10 gram, 2 gram 2 $0 cefpodoxime 2 $0 MO cefprozil 2 $0 MO ceftazidime injection recon soln 1 gram, 2 gram 2 $0 MO ceftazidime injection recon soln 6 gram 2 $0 ceftriaxone in dextrose,iso-os 2 $0 MO ceftriaxone injection recon soln 1 gram, 2 gram, 250 mg, 500 mg 2 $0 MO ceftriaxone injection recon soln 10 gram 2 $0 ceftriaxone intravenous recon soln 2 $0 MO cefuroxime axetil oral tablet 2 $0 MO cefuroxime sodium injection recon soln 1.5 gram, 750 mg 2 $0 MO cefuroxime sodium intravenous 2 $0 cephalexin oral capsule 250 mg, 500 mg 1 $0 MO cephalexin oral suspension for reconstitution 1 $0 MO cephalexin oral tablet 1 $0 MO TEFLARO 2 $0 MO ERYTHROMYCINS / OTHER MACROLIDES ENYDMEM-0035-15 13

azithromycin intravenous 2 $0 MO azithromycin oral suspension for reconstitution 2 $0 MO azithromycin oral tablet 250 mg (6 pack) 2 $0 azithromycin oral tablet 250 mg, 500 mg, 600 mg 2 $0 MO clarithromycin oral suspension for reconstitution 2 $0 MO clarithromycin oral tablet 2 $0 MO clarithromycin oral tablet extended release 24 hr 2 $0 MO; QLL (28 per 1 day) ery-tab 2 $0 MO erythrocin (as stearate) oral tablet 250 mg 2 $0 MO ERYTHROCIN INTRAVENOUS RECON SOLN 500 MG 2 $0 erythromycin ethylsuccinate oral tablet 2 $0 MO erythromycin oral tablet 2 $0 MO MISCELLANEOUS ANTIINFECTIVES ALBENZA 2 $0 MO ALINIA ORAL SUSPENSION FOR RECONSTITUTION 2 $0 MO; QLL (180 per 3 days) ALINIA ORAL TABLET 2 $0 MO amikacin injection solution 1,000 mg/4 ml, 500 mg/2 ml 2 $0 MO atovaquone 2 $0 PAR; MO atovaquone-proguanil 2 $0 MO AZACTAM IN DEXTROSE (ISO-OSM) 2 $0 aztreonam 2 $0 MO baciim 2 $0 BILTRICIDE 2 $0 MO CAPASTAT 2 $0 CAYSTON 2 $0 PAR; MO; LA chloramphenicol sod succinate 2 $0 chloroquine phosphate oral 2 $0 MO clindamycin hcl 2 $0 MO ENYDMEM-0035-15 14

clindamycin phosphate injection 2 $0 MO clindamycin phosphate intravenous solution 300 mg/2 ml, 900 mg/6 ml clindamycin phosphate intravenous solution 600 mg/4 ml 2 $0 2 $0 MO colistin (colistimethate na) 2 $0 MO DAPSONE 2 $0 MO DARAPRIM 2 $0 MO ethambutol 2 $0 MO gentamicin injection 2 $0 MO gentamicin sulfate (ped) (pf) 2 $0 MO gentamicin sulfate (pf) intravenous solution 100 mg/10 ml GENTAMICIN SULFATE (PF) INTRAVENOUS SOLUTION 60 MG/6 ML gentamicin sulfate (pf) intravenous solution 80 mg/8 ml 2 $0 MO 2 $0 2 $0 hydroxychloroquine oral 1 $0 MO imipenem-cilastatin 2 $0 MO INVANZ INJECTION 2 $0 MO isoniazid oral 1 $0 MO ivermectin oral 2 $0 MO linezolid intravenous 2 $0 linezolid oral 2 $0 PAR; MO; QLL (28 per 1 day) linezolid-0.9% sodium chloride 2 $0 mefloquine 2 $0 MO MEPRON 2 $0 PAR; MO meropenem 2 $0 MO metro i.v. 2 $0 MO metronidazole in nacl (iso-os) 2 $0 MO metronidazole oral 2 $0 MO MYCOBUTIN 2 $0 MO ENYDMEM-0035-15 15

NEBUPENT 2 $0 B/D PAR; MO neomycin 2 $0 MO paromomycin 2 $0 MO PASER 2 $0 MO PENTAM 2 $0 MO pin-x oral suspension 4 $0 [*] PIN-X ORAL TABLET,CHEWABLE 4 $0 MO; [*] PRIFTIN 2 $0 MO PRIMAQUINE 2 $0 MO pyrazinamide 2 $0 MO reese's pinworm medicine 4 $0 [*] rifabutin 2 $0 MO rifampin intravenous 2 $0 MO rifampin oral 2 $0 MO RIFATER 2 $0 MO STREPTOMYCIN INTRAMUSCULAR 2 $0 MO STROMECTOL 2 $0 MO SYNERCID 2 $0 tobramycin in 0.225 % nacl 2 $0 B/D PAR; MO; QLL (280 per 28 days) tobramycin sulfate injection recon soln 2 $0 tobramycin sulfate injection solution 2 $0 MO TRECATOR 2 $0 MO TYGACIL 2 $0 MO XIFAXAN ORAL TABLET 550 MG 2 $0 MO ZYVOX INTRAVENOUS PARENTERAL SOLUTION 200 MG/100 ML ZYVOX INTRAVENOUS PARENTERAL SOLUTION 600 MG/300 ML ZYVOX ORAL SUSPENSION FOR RECONSTITUTION 2 $0 2 $0 MO 2 $0 PAR; MO; QLL (1800 per 1 day) ZYVOX ORAL TABLET 2 $0 PAR; MO; QLL (28 per 1 day) ENYDMEM-0035-15 16

PENICILLINS amoxicillin oral capsule 1 $0 MO amoxicillin oral suspension for reconstitution 1 $0 MO amoxicillin oral tablet 1 $0 MO amoxicillin oral tablet,chewable 125 mg, 250 mg 1 $0 MO amoxicillin-pot clavulanate 2 $0 MO ampicillin 2 $0 MO ampicillin sodium injection 2 $0 MO ampicillin sodium intravenous 2 $0 ampicillin-sulbactam injection recon soln 1.5 gram, 3 gram 2 $0 MO ampicillin-sulbactam injection recon soln 15 gram 2 $0 ampicillin-sulbactam intravenous recon soln 1.5 gram ampicillin-sulbactam intravenous recon soln 3 gram 2 $0 2 $0 MO BICILLIN C-R 2 $0 MO BICILLIN L-A 2 $0 MO dicloxacillin 2 $0 MO nafcillin injection 2 $0 MO nafcillin intravenous recon soln 2 gram 2 $0 MO oxacillin injection 2 $0 MO oxacillin intravenous 2 $0 PENICILLIN G POT IN DEXTROSE 2 $0 penicillin g potassium 2 $0 MO penicillin g procaine intramuscular syringe 1.2 million unit/2 ml penicillin g procaine intramuscular syringe 600,000 unit/ml 2 $0 MO 2 $0 penicillin g sodium 2 $0 MO penicillin v potassium 2 $0 MO piperacillin-tazobactam 2 $0 MO ENYDMEM-0035-15 17

QUINOLONES ciprofloxacin (mixture) oral tablet, er multiphase 24 hr 1,000 mg ciprofloxacin (mixture) oral tablet, er multiphase 24 hr 500 mg 1 $0 MO; QLL (14 per 1 day) 1 $0 MO; QLL (3 per 1 day) ciprofloxacin hcl oral tablet 1 $0 MO ciprofloxacin lactate intravenous solution 200 mg/20 ml ciprofloxacin lactate intravenous solution 400 mg/40 ml 1 $0 MO 1 $0 levofloxacin intravenous 2 $0 MO levofloxacin oral tablet 2 $0 MO; QLL (14 per 1 day) moxifloxacin 2 $0 MO; QLL (21 per 1 day) ofloxacin oral tablet 400 mg 2 $0 SULFA'S / RELATED AGENTS sulfadiazine oral 2 $0 MO sulfamethoxazole-trimethoprim 1 $0 MO TETRACYCLINES demeclocycline oral 2 $0 MO DOXY-100 2 $0 MO doxycycline hyclate intravenous 2 $0 doxycycline hyclate oral capsule 2 $0 MO doxycycline hyclate oral tablet 100 mg, 20 mg 2 $0 MO doxycycline hyclate oral tablet 50 mg 2 $0 doxycycline hyclate oral tablet,delayed release (dr/ec) doxycycline monohydrate oral capsule 100 mg, 150 mg, 50 mg 2 $0 MO 2 $0 MO doxycycline monohydrate oral capsule 75 mg 2 $0 MO; QLL (60 per 1 day) doxycycline monohydrate oral tablet 2 $0 MO minocycline oral capsule 2 $0 MO minocycline oral tablet 2 $0 MO ENYDMEM-0035-15 18

tetracycline 2 $0 MO URINARY TRACT AGENTS MACRODANTIN ORAL CAPSULE 50 MG 2 $0 PAR; MO methenamine hippurate 2 $0 MO nitrofurantoin macrocrystal oral capsule 50 mg 2 $0 PAR; MO trimethoprim 2 $0 MO VANCOMYCIN VANCOMYCIN IN D5W INTRAVENOUS PIGGYBACK 1 GRAM/200 ML VANCOMYCIN IN D5W INTRAVENOUS PIGGYBACK 500 MG/100 ML 2 $0 B/D PAR; MO 2 $0 B/D PAR VANCOMYCIN IN DEXTROSE ISO-OSM 2 $0 B/D PAR vancomycin intravenous 2 $0 B/D PAR; MO vancomycin oral capsule 125 mg 2 $0 PAR; MO; QLL (40 per 1 day) vancomycin oral capsule 250 mg 2 $0 PAR; MO; QLL (80 per 1 day) ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS ADJUNCTIVE AGENTS amifostine crystalline 2 $0 PAR; MO dexrazoxane hcl intravenous recon soln 250 mg 2 $0 B/D PAR dexrazoxane hcl intravenous recon soln 500 mg 2 $0 B/D PAR; MO ELITEK 2 $0 PAR; MO FUSILEV 2 $0 B/D PAR; MO KEPIVANCE 2 $0 leucovorin calcium injection recon soln 100 mg, 200 mg, 350 mg, 50 mg 2 $0 B/D PAR; MO leucovorin calcium injection recon soln 500 mg 2 $0 B/D PAR leucovorin calcium oral 2 $0 MO mesna 2 $0 B/D PAR; MO MESNEX ORAL 2 $0 MO XGEVA 2 $0 PAR; MO; QLL (1.7 per 28 days) ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS ENYDMEM-0035-15 19

ABRAXANE 2 $0 B/D PAR; MO AFINITOR 2 $0 PAR; MO AFINITOR DISPERZ 2 $0 PAR; MO ALIMTA 2 $0 PAR; MO anastrozole 2 $0 MO ARRANON 2 $0 B/D PAR ARZERRA 2 $0 B/D PAR; MO ASTAGRAF XL 2 $0 B/D PAR; MO AVASTIN INTRAVENOUS SOLUTION 25 MG/ML AVASTIN INTRAVENOUS SOLUTION 25 MG/ML (16 ML) 2 $0 PAR; MO 2 $0 PAR azacitidine 2 $0 PAR; MO azathioprine 2 $0 B/D PAR; MO BELEODAQ 2 $0 PAR; MO bexarotene 2 $0 PAR; MO bicalutamide 2 $0 MO BICNU 2 $0 B/D PAR; MO bleomycin 2 $0 B/D PAR; MO BLINCYTO 2 $0 PAR; MO BOSULIF 2 $0 PAR; MO BUSULFEX 2 $0 B/D PAR CAPRELSA 2 $0 PAR; MO; LA carboplatin intravenous solution 2 $0 B/D PAR; MO CELLCEPT INTRAVENOUS 2 $0 B/D PAR; MO CELLCEPT ORAL SUSPENSION FOR RECONSTITUTION 2 $0 B/D PAR; MO cisplatin 2 $0 B/D PAR; MO cladribine 2 $0 B/D PAR; MO CLOLAR 2 $0 B/D PAR; MO COMETRIQ 2 $0 PAR; MO ENYDMEM-0035-15 20

COSMEGEN 2 $0 B/D PAR; MO cyclophosphamide oral capsule 2 $0 B/D PAR; MO cyclosporine intravenous 2 $0 B/D PAR cyclosporine modified 2 $0 B/D PAR; MO cyclosporine oral capsule 2 $0 B/D PAR; MO CYRAMZA INTRAVENOUS SOLUTION 10 MG/ML CYRAMZA INTRAVENOUS SOLUTION 10 MG/ML (50 ML) 2 $0 PAR; MO 2 $0 PAR cytarabine 2 $0 B/D PAR; MO cytarabine (pf) injection solution 100 mg/5 ml (20 mg/ml), 2 gram/20 ml (100 mg/ml) 2 $0 B/D PAR; MO cytarabine (pf) injection solution 20 mg/ml 2 $0 B/D PAR dacarbazine 2 $0 B/D PAR; MO daunorubicin intravenous solution 2 $0 B/D PAR DAUNOXOME 2 $0 B/D PAR; MO decitabine 2 $0 B/D PAR; MO DOCEFREZ INTRAVENOUS RECON SOLN 20 MG docetaxel intravenous solution 10 mg/ml, 140 mg/7 ml (20 mg/ml), 160 mg/16 ml (10 mg/ml), 20 mg/2 ml (10 mg/ml) docetaxel intravenous solution 20 mg/ml (1 ml), 80 mg/4 ml (20 mg/ml), 80 mg/8 ml (10 mg/ml) 2 $0 B/D PAR 2 $0 B/D PAR 2 $0 B/D PAR; MO DOXIL 2 $0 B/D PAR; MO doxorubicin intravenous recon soln 2 $0 B/D PAR doxorubicin intravenous solution 2 $0 B/D PAR; MO DROXIA 2 $0 MO EMCYT 2 $0 MO epirubicin intravenous solution 200 mg/100 ml 2 $0 B/D PAR epirubicin intravenous solution 50 mg/25 ml 2 $0 B/D PAR; MO ERBITUX 2 $0 PAR; MO ERIVEDGE 2 $0 PAR; MO ENYDMEM-0035-15 21

ERWINAZE 2 $0 B/D PAR; MO ETOPOPHOS 2 $0 B/D PAR; MO etoposide intravenous 2 $0 B/D PAR; MO exemestane 2 $0 MO FARESTON 2 $0 MO FARYDAK ORAL CAPSULE 10 MG 2 $0 PAR; MO; QLL (60 per 30 days) FARYDAK ORAL CAPSULE 15 MG, 20 MG 2 $0 PAR; MO; QLL (30 per 30 days) FASLODEX 2 $0 PAR; MO FIRMAGON KIT W DILUENT SYRINGE 2 $0 B/D PAR; MO fludarabine intravenous recon soln 2 $0 B/D PAR; MO fludarabine intravenous solution 2 $0 B/D PAR fluorouracil intravenous 2 $0 B/D PAR; MO flutamide 2 $0 MO FOLOTYN 2 $0 B/D PAR; MO GAZYVA 2 $0 PAR; MO gemcitabine intravenous recon soln 1 gram, 200 mg 2 $0 B/D PAR; MO gemcitabine intravenous recon soln 2 gram 2 $0 B/D PAR gemcitabine intravenous solution 2 $0 B/D PAR gengraf 2 $0 B/D PAR; MO GILOTRIF 2 $0 PAR; MO GLEEVEC 2 $0 PAR; MO GLEOSTINE 2 $0 MO HALAVEN 2 $0 PAR; MO HERCEPTIN 2 $0 PAR; MO HEXALEN 2 $0 MO hydroxyurea 2 $0 MO IBRANCE 2 $0 PAR; MO; QLL (30 per 30 days) ICLUSIG 2 $0 PAR; MO idarubicin 2 $0 B/D PAR IFEX 2 $0 B/D PAR; MO ENYDMEM-0035-15 22

ifosfamide intravenous recon soln 1 gram 2 $0 B/D PAR; MO ifosfamide intravenous recon soln 3 gram 2 $0 B/D PAR ifosfamide intravenous solution 2 $0 B/D PAR IMBRUVICA 2 $0 PAR; MO INLYTA 2 $0 PAR; MO irinotecan intravenous solution 100 mg/5 ml, 40 mg/2 ml 2 $0 B/D PAR; MO irinotecan intravenous solution 500 mg/25 ml 2 $0 B/D PAR ISTODAX 2 $0 PAR; MO IXEMPRA 2 $0 B/D PAR; MO JAKAFI 2 $0 PAR; MO JEVTANA 2 $0 B/D PAR; MO KADCYLA 2 $0 PAR; MO KEYTRUDA 2 $0 PAR; MO LENVIMA ORAL CAPSULE 10 MG/DAY (10 MG [1]/DAY) LENVIMA ORAL CAPSULE 14 MG (10 MG[1] -4 MG[1])/DAY, 20 MG/DAY (10 MG [2]/DAY) LENVIMA ORAL CAPSULE 24 MG (10 MG[2] -4 MG[1])/DAY letrozole 2 $0 MO LEUKERAN 2 $0 MO 2 $0 PAR; MO; QLL (30 per 30 days) 2 $0 PAR; MO; QLL (60 per 30 days) 2 $0 PAR; MO; QLL (90 per 30 days) leuprolide 2 $0 PAR; MO LOMUSTINE 2 $0 MO LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 3.75 MG, 7.5 MG LUPRON DEPOT-PED INTRAMUSCULAR KIT 7.5 MG (PED) 2 $0 PAR; MO 2 $0 PAR; MO LYNPARZA 2 $0 PAR; MO; QLL (480 per 30 days) LYSODREN 2 $0 MO MATULANE 2 $0 MO megestrol oral suspension 400 mg/10 ml (10 ml) 2 $0 PAR ENYDMEM-0035-15 23

megestrol oral suspension 400 mg/10 ml (40 mg/ml) 2 $0 PAR; MO megestrol oral tablet 2 $0 PAR; MO MEKINIST 2 $0 PAR; MO melphalan hcl 2 $0 B/D PAR mercaptopurine 2 $0 MO methotrexate sodium 2 $0 MO methotrexate sodium (pf) injection recon soln 2 $0 methotrexate sodium (pf) injection solution 2 $0 MO mitomycin 2 $0 B/D PAR; MO mitoxantrone 2 $0 MO MUSTARGEN 2 $0 B/D PAR; MO mycophenolate mofetil 2 $0 B/D PAR; MO mycophenolate sodium 2 $0 B/D PAR; MO NEXAVAR 2 $0 PAR; MO; LA; QLL (120 per 30 days) NILANDRON 2 $0 MO NIPENT 2 $0 B/D PAR; MO NULOJIX 2 $0 B/D PAR; MO octreotide acetate 2 $0 PAR; MO ONCASPAR 2 $0 B/D PAR; MO OPDIVO 2 $0 PAR; MO oxaliplatin intravenous recon soln 100 mg 2 $0 B/D PAR; MO oxaliplatin intravenous recon soln 50 mg 2 $0 B/D PAR oxaliplatin intravenous solution 2 $0 B/D PAR; MO paclitaxel 2 $0 B/D PAR; MO PERJETA 2 $0 PAR; MO POMALYST 2 $0 PAR; MO PROGRAF INTRAVENOUS 2 $0 B/D PAR; MO PURIXAN 2 $0 PAR; MO RAPAMUNE 2 $0 B/D PAR; MO ENYDMEM-0035-15 24

REVLIMID ORAL CAPSULE 10 MG 2 $0 PAR; MO; LA; QLL (60 per 30 days) REVLIMID ORAL CAPSULE 15 MG, 2.5 MG, 20 MG, 25 MG 2 $0 PAR; MO; LA; QLL (30 per 30 days) REVLIMID ORAL CAPSULE 5 MG 2 $0 PAR; MO; LA; QLL (150 per 30 days) RITUXAN 2 $0 PAR; MO SIMULECT INTRAVENOUS RECON SOLN 10 MG SIMULECT INTRAVENOUS RECON SOLN 20 MG 2 $0 B/D PAR 2 $0 B/D PAR; MO sirolimus 2 $0 B/D PAR; MO SOLTAMOX 2 $0 MO SOMATULINE DEPOT 2 $0 MO SPRYCEL 2 $0 PAR; MO STIVARGA 2 $0 PAR; MO; QLL (120 per 30 days) SUTENT 2 $0 PAR; MO SYNRIBO 2 $0 PAR; MO TABLOID 2 $0 MO tacrolimus oral 2 $0 B/D PAR; MO TAFINLAR 2 $0 PAR; MO tamoxifen 2 $0 MO TARCEVA 2 $0 PAR; MO TARGRETIN 2 $0 PAR; MO TASIGNA 2 $0 PAR; MO THALOMID ORAL CAPSULE 100 MG, 50 MG 2 $0 PAR; MO; QLL (30 per 30 days) THALOMID ORAL CAPSULE 150 MG, 200 MG 2 $0 PAR; MO; QLL (60 per 30 days) thiotepa 2 $0 B/D PAR; MO toposar 2 $0 B/D PAR; MO topotecan 2 $0 B/D PAR; MO TORISEL 2 $0 B/D PAR; MO TREANDA 2 $0 B/D PAR; MO ENYDMEM-0035-15 25

TRELSTAR 2 $0 MO TRELSTAR DEPOT 2 $0 TRELSTAR LA 2 $0 tretinoin (chemotherapy) 2 $0 MO TREXALL 2 $0 MO TRISENOX 2 $0 B/D PAR; MO TYKERB 2 $0 PAR; MO; LA UNITUXIN 2 $0 MO VECTIBIX 2 $0 PAR; MO VELCADE 2 $0 PAR; MO vinblastine intravenous solution 2 $0 B/D PAR; MO vincasar pfs intravenous solution 1 mg/ml 2 $0 B/D PAR vincasar pfs intravenous solution 2 mg/2 ml 2 $0 B/D PAR; MO vincristine 2 $0 B/D PAR; MO vinorelbine 2 $0 B/D PAR; MO VOTRIENT 2 $0 PAR; MO XALKORI 2 $0 PAR; MO XTANDI 2 $0 PAR; MO YERVOY 2 $0 PAR; MO ZALTRAP 2 $0 PAR; MO ZANOSAR 2 $0 B/D PAR; MO ZELBORAF 2 $0 PAR; MO ZOLINZA 2 $0 PAR; MO ZORTRESS 2 $0 B/D PAR; MO ZYDELIG 2 $0 PAR; MO; QLL (60 per 30 days) ZYKADIA 2 $0 PAR; MO ZYTIGA 2 $0 PAR; MO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH ANTICONVULSANTS APTIOM 2 $0 ST; MO ENYDMEM-0035-15 26

BANZEL ORAL SUSPENSION 2 $0 PAR; MO; QLL (2400 per 30 days) BANZEL ORAL TABLET 200 MG 2 $0 PAR; MO; QLL (480 per 30 days) BANZEL ORAL TABLET 400 MG 2 $0 PAR; MO; QLL (240 per 30 days) carbamazepine oral capsule, er multiphase 12 hr 2 $0 MO carbamazepine oral suspension 100 mg/5 ml 2 $0 MO carbamazepine oral tablet 2 $0 MO carbamazepine oral tablet extended release 12 hr 2 $0 MO carbamazepine oral tablet,chewable 2 $0 MO CELONTIN ORAL CAPSULE 300 MG 2 $0 MO clonazepam oral tablet 0.5 mg 2 $0 PAR; MO; QLL (1200 per 30 days) clonazepam oral tablet 1 mg 2 $0 PAR; MO; QLL (600 per 30 days) clonazepam oral tablet 2 mg 2 $0 PAR; MO; QLL (300 per 30 days) clonazepam oral tablet,disintegrating 0.125 mg 2 $0 PAR; MO; QLL (4800 per 30 days) clonazepam oral tablet,disintegrating 0.25 mg 2 $0 PAR; MO; QLL (2400 per 30 days) clonazepam oral tablet,disintegrating 0.5 mg 2 $0 PAR; MO; QLL (1200 per 30 days) clonazepam oral tablet,disintegrating 1 mg 2 $0 PAR; MO; QLL (600 per 30 days) clonazepam oral tablet,disintegrating 2 mg 2 $0 PAR; MO; QLL (300 per 30 days) diazepam rectal 2 $0 MO; QLL (2 per 1 day) DILANTIN CAPSULES 2 $0 MO DILANTIN EXTENDED CAPSULES 2 $0 MO DILANTIN INFATABS 2 $0 MO divalproex 2 $0 MO epitol 2 $0 MO EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 100 MG EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 200 MG EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 300 MG ethosuximide 2 $0 MO 2 $0 MO; QLL (480 per 30 days) 2 $0 MO; QLL (240 per 30 days) 2 $0 MO; QLL (180 per 30 days) felbamate 2 $0 MO ENYDMEM-0035-15 27

fosphenytoin 2 $0 B/D PAR; MO FYCOMPA ORAL TABLET 10 MG, 12 MG 2 $0 MO; QLL (30 per 30 days) FYCOMPA ORAL TABLET 2 MG 2 $0 MO; QLL (180 per 30 days) FYCOMPA ORAL TABLET 4 MG 2 $0 MO; QLL (90 per 30 days) FYCOMPA ORAL TABLET 6 MG 2 $0 MO; QLL (60 per 30 days) FYCOMPA ORAL TABLET 8 MG 2 $0 MO; QLL (45 per 30 days) gabapentin oral capsule 100 mg 2 $0 MO; QLL (1080 per 30 days) gabapentin oral capsule 300 mg 2 $0 MO; QLL (360 per 30 days) gabapentin oral capsule 400 mg 2 $0 MO; QLL (270 per 30 days) gabapentin oral solution 250 mg/5 ml 2 $0 MO; QLL (2160 per 30 days) gabapentin oral solution 250 mg/5 ml (5 ml), 300 mg/6 ml (6 ml) 2 $0 QLL (2160 per 30 days) gabapentin oral tablet 600 mg 2 $0 MO; QLL (180 per 30 days) gabapentin oral tablet 800 mg 2 $0 MO; QLL (135 per 30 days) GABITRIL 2 $0 MO lamotrigine oral tablet 2 $0 MO lamotrigine oral tablet, chewable dispersible 2 $0 MO levetiracetam in nacl (iso-os) intravenous piggyback 1,000 mg/100 ml, 1,500 mg/100 ml levetiracetam in nacl (iso-os) intravenous piggyback 500 mg/100 ml 2 $0 B/D PAR 2 $0 B/D PAR; MO levetiracetam intravenous 2 $0 B/D PAR; MO levetiracetam oral solution 100 mg/ml 2 $0 MO levetiracetam oral solution 500 mg/5 ml (5 ml) 2 $0 levetiracetam oral tablet 2 $0 MO levetiracetam oral tablet extended release 24 hr 500 mg levetiracetam oral tablet extended release 24 hr 750 mg 2 $0 MO; QLL (180 per 30 days) 2 $0 MO; QLL (120 per 30 days) LYRICA ORAL CAPSULE 100 MG 2 $0 PAR; MO; QLL (180 per 30 days) LYRICA ORAL CAPSULE 150 MG 2 $0 PAR; MO; QLL (120 per 30 days) LYRICA ORAL CAPSULE 200 MG 2 $0 PAR; MO; QLL (90 per 30 days) ENYDMEM-0035-15 28

LYRICA ORAL CAPSULE 225 MG, 300 MG 2 $0 PAR; MO; QLL (60 per 30 days) LYRICA ORAL CAPSULE 25 MG 2 $0 PAR; MO; QLL (720 per 30 days) LYRICA ORAL CAPSULE 50 MG 2 $0 PAR; MO; QLL (360 per 30 days) LYRICA ORAL CAPSULE 75 MG 2 $0 PAR; MO; QLL (240 per 30 days) LYRICA ORAL SOLUTION 2 $0 PAR; MO; QLL (900 per 30 days) ONFI ORAL SUSPENSION 2 $0 PAR; MO; QLL (480 per 30 days) ONFI ORAL TABLET 10 MG 2 $0 PAR; MO; QLL (120 per 30 days) ONFI ORAL TABLET 20 MG 2 $0 PAR; MO; QLL (60 per 30 days) oxcarbazepine 2 $0 MO OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR 150 MG OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR 300 MG OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR 600 MG PEGANONE 2 $0 MO 2 $0 MO; QLL (480 per 30 days) 2 $0 MO; QLL (240 per 30 days) 2 $0 MO; QLL (120 per 30 days) phenobarbital oral elixir 2 $0 PAR; MO; QLL (3000 per 30 days) phenobarbital oral tablet 100 mg 2 $0 PAR; QLL (120 per 30 days) phenobarbital oral tablet 15 mg 2 $0 PAR; MO; QLL (800 per 30 days) phenobarbital oral tablet 16.2 mg 2 $0 PAR; MO; QLL (741 per 30 days) phenobarbital oral tablet 30 mg 2 $0 PAR; MO; QLL (400 per 30 days) phenobarbital oral tablet 32.4 mg 2 $0 PAR; MO; QLL (370 per 30 days) phenobarbital oral tablet 60 mg 2 $0 PAR; MO; QLL (200 per 30 days) phenobarbital oral tablet 64.8 mg 2 $0 PAR; MO; QLL (185 per 30 days) phenobarbital oral tablet 97.2 mg 2 $0 PAR; MO; QLL (123 per 30 days) phenytoin oral suspension 100 mg/4 ml 2 $0 phenytoin oral suspension 125 mg/5 ml 2 $0 MO phenytoin oral tablet,chewable 2 $0 MO phenytoin sodium extended 2 $0 MO phenytoin sodium intravenous solution 2 $0 B/D PAR; MO phenytoin sodium intravenous syringe 2 $0 B/D PAR ENYDMEM-0035-15 29

POTIGA ORAL TABLET 200 MG, 300 MG, 400 MG 2 $0 MO; QLL (90 per 30 days) POTIGA ORAL TABLET 50 MG 2 $0 MO; QLL (270 per 30 days) primidone 2 $0 MO SABRIL 2 $0 PAR; MO; LA; QLL (180 per 30 days) tiagabine 2 $0 MO topiramate oral capsule, sprinkle 2 $0 PAR; MO topiramate oral tablet 2 $0 PAR; MO valproate sodium 2 $0 B/D PAR; MO valproic acid 2 $0 MO valproic acid (as sodium salt) oral solution 250 mg/5 ml valproic acid (as sodium salt) oral solution 250 mg/5 ml (5 ml), 500 mg/10 ml (10 ml) 2 $0 MO 2 $0 VIMPAT INTRAVENOUS 2 $0 B/D PAR; QLL (1200 per 30 days) VIMPAT ORAL SOLUTION 2 $0 MO; QLL (1200 per 30 days) VIMPAT ORAL TABLET 100 MG 2 $0 MO; QLL (120 per 30 days) VIMPAT ORAL TABLET 150 MG 2 $0 MO; QLL (80 per 30 days) VIMPAT ORAL TABLET 200 MG 2 $0 MO; QLL (60 per 30 days) VIMPAT ORAL TABLET 50 MG 2 $0 MO; QLL (240 per 30 days) zonisamide 2 $0 MO ANTIPARKINSONISM AGENTS APOKYN 2 $0 PAR; MO; LA AZILECT 2 $0 MO benztropine oral 2 $0 PAR; MO bromocriptine 2 $0 MO carbidopa-levodopa 2 $0 MO entacapone 2 $0 MO NEUPRO 2 $0 PAR; MO; QLL (30 per 30 days) pramipexole oral tablet 2 $0 MO ropinirole oral tablet 2 $0 MO ENYDMEM-0035-15 30

selegiline hcl 2 $0 MO TASMAR ORAL TABLET 100 MG 2 $0 MO tolcapone 2 $0 MO MIGRAINE / CLUSTER HEADACHE THERAPY ERGOMAR 2 $0 MO MIGRANAL 2 $0 MO; QLL (8 per 28 days) rizatriptan 2 $0 MO; QLL (12 per 30 days) sumatriptan succinate oral 2 $0 MO; QLL (9 per 30 days) sumatriptan succinate subcutaneous cartridge 2 $0 MO; QLL (4 per 30 days) sumatriptan succinate subcutaneous pen injector 4 mg/0.5 ml, 6 mg/0.5 ml sumatriptan succinate subcutaneous pen injector 6 mg/0.5 ml (auto-injector) 2 $0 MO; QLL (4 per 30 days) 2 $0 QLL (4 per 30 days) sumatriptan succinate subcutaneous solution 2 $0 MO; QLL (4 per 30 days) sumatriptan succinate subcutaneous syringe 6 mg/0.5 ml 2 $0 QLL (4 per 30 days) zolmitriptan 2 $0 MO; QLL (9 per 30 days) ZOMIG NASAL 2 $0 MO; QLL (6 per 30 days) MISCELLANEOUS NEUROLOGICAL THERAPY AMPYRA 2 $0 PAR; MO; LA; QLL (60 per 30 days) COPAXONE SUBCUTANEOUS SYRINGE 20 MG/ML COPAXONE SUBCUTANEOUS SYRINGE 40 MG/ML 2 $0 PAR; MO; QLL (30 per 30 days) 2 $0 PAR; MO; QLL (12 per 28 days) donepezil oral tablet 10 mg, 5 mg 2 $0 MO; QLL (30 per 30 days) donepezil oral tablet,disintegrating 2 $0 MO; QLL (30 per 30 days) EXELON TRANSDERMAL 2 $0 MO; QLL (30 per 30 days) galantamine oral capsule,ext rel. pellets 24 hr 2 $0 MO; QLL (30 per 30 days) galantamine oral solution 2 $0 MO; QLL (180 per 30 days) galantamine oral tablet 2 $0 MO; QLL (60 per 30 days) GILENYA 2 $0 PAR; MO; QLL (30 per 30 days) ENYDMEM-0035-15 31

GLATOPA 2 $0 PAR; MO; QLL (30 per 30 days) NAMENDA ORAL SOLUTION 2 $0 PAR; MO; QLL (300 per 30 days) NAMENDA ORAL TABLET 10 MG 2 $0 MO; QLL (60 per 30 days) NAMENDA ORAL TABLET 5 MG 2 $0 MO; QLL (90 per 30 days) NAMENDA TITRATION PAK 2 $0 MO; QLL (60 per 30 days) NAMENDA XR ORAL CAP,SPRINKLE,ER 24HR DOSE PACK NAMENDA XR ORAL CAPSULE,SPRINKLE,ER 24HR NAMZARIC 2 $0 MO 2 $0 PAR; MO; QLL (28 per 365 days) 2 $0 PAR; MO; QLL (30 per 30 days) NUEDEXTA 2 $0 MO; QLL (60 per 30 days) rivastigmine tartrate oral capsule 2 $0 MO; QLL (60 per 30 days) rivastigmine transdermal patch 2 $0 MO; QLL (30 per 30 days) TECFIDERA 2 $0 PAR; MO tetrabenazine oral tablet 12.5 mg 2 $0 PAR; MO; QLL (240 per 30 days) tetrabenazine oral tablet 25 mg 2 $0 PAR; MO; QLL (120 per 30 days) TYSABRI 2 $0 MO; LA XENAZINE ORAL TABLET 12.5 MG 2 $0 PAR; MO; LA; QLL (240 per 30 days) XENAZINE ORAL TABLET 25 MG 2 $0 PAR; MO; LA; QLL (120 per 30 days) MUSCLE RELAXANTS / ANTISPASMODIC THERAPY baclofen 2 $0 MO cyclobenzaprine oral tablet 2 $0 PAR; MO dantrolene 2 $0 MO MESTINON ORAL SYRUP 2 $0 MO MESTINON TIMESPAN 2 $0 MO pyridostigmine bromide 2 $0 MO tizanidine oral tablet 2 $0 MO NARCOTIC ANALGESICS ABSTRAL 2 $0 PAR; MO; QLL (120 per 30 days) ENYDMEM-0035-15 32

acetaminophen-codeine oral solution 120 mg-12 mg /5 ml (5 ml), 240 mg-24 mg /10 ml (10 ml), 300 mg-30 mg /12.5 ml acetaminophen-codeine oral solution 120-12 mg/5 ml 2 $0 QLL (4500 per 30 days) 2 $0 MO; QLL (4500 per 30 days) acetaminophen-codeine oral tablet 300-15 mg 2 $0 MO; QLL (390 per 30 days) acetaminophen-codeine oral tablet 300-30 mg 2 $0 MO; QLL (360 per 30 days) acetaminophen-codeine oral tablet 300-60 mg 2 $0 MO; QLL (180 per 30 days) ACTIQ 2 $0 PAR; MO; QLL (120 per 30 days) buprenorphine hcl injection solution 2 $0 MO buprenorphine hcl injection syringe 2 $0 buprenorphine hcl sublingual tablet 2 mg 2 $0 PAR; MO; QLL (240 per 30 days) buprenorphine hcl sublingual tablet 8 mg 2 $0 PAR; MO; QLL (60 per 30 days) butalbital compound w/codeine 2 $0 PAR; MO duramorph (pf) injection solution 0.5 mg/ml 2 $0 B/D PAR; MO duramorph (pf) injection solution 1 mg/ml 2 $0 B/D PAR endocet oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg 2 $0 MO; QLL (360 per 30 days) fentanyl citrate 2 $0 PAR; MO; QLL (120 per 30 days) fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr 2 $0 ST; MO; QLL (15 per 30 days) FENTORA 2 $0 PAR; MO; QLL (120 per 30 days) hydrocodone-acetaminophen oral solution 2.5-167 mg/5 ml hydrocodone-acetaminophen oral solution 7.5-325 mg/15 ml hydrocodone-acetaminophen oral tablet 10-300 mg, 5-300 mg, 7.5-300 mg hydrocodone-acetaminophen oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg 2 $0 QLL (2700 per 30 days) 2 $0 MO; QLL (2700 per 30 days) 2 $0 MO; QLL (390 per 30 days) 2 $0 MO; QLL (360 per 30 days) hydrocodone-ibuprofen 2 $0 MO; QLL (480 per 30 days) hydromorphone oral tablet 2 mg, 4 mg 2 $0 MO; QLL (360 per 30 days) hydromorphone oral tablet 8 mg 2 $0 MO; QLL (180 per 30 days) ENYDMEM-0035-15 33

LAZANDA 2 $0 PAR; MO; QLL (30 per 30 days) levorphanol tartrate 2 $0 MO; QLL (180 per 30 days) methadone injection 2 $0 methadone intensol 2 $0 MO; QLL (180 per 30 days) methadone oral concentrate 2 $0 MO; QLL (180 per 30 days) methadone oral solution 10 mg/5 ml 2 $0 MO; QLL (900 per 30 days) methadone oral solution 5 mg/5 ml 2 $0 MO; QLL (1800 per 30 days) methadone oral tablet 10 mg 2 $0 MO; QLL (180 per 30 days) methadone oral tablet 5 mg 2 $0 MO; QLL (360 per 30 days) methadose oral concentrate 2 $0 MO; QLL (180 per 30 days) morphine (pf) injection solution 0.5 mg/ml 2 $0 B/D PAR morphine (pf) injection solution 1 mg/ml 2 $0 B/D PAR; MO morphine (pf) intravenous patient control.analgesia soln 150 mg/30 ml morphine (pf) intravenous patient control.analgesia soln 30 mg/30 ml 2 $0 MO 2 $0 morphine concentrate oral solution 2 $0 MO; QLL (270 per 30 days) morphine intravenous cartridge 2 $0 MORPHINE INTRAVENOUS CARTRIDGE 2 $0 morphine intravenous solution 100 mg/4 ml, 25 mg/ml, 250 mg/10 ml 2 $0 morphine intravenous solution 50 mg/ml 2 $0 MO morphine intravenous syringe 2 mg/ml, 4 mg/ml 2 $0 morphine oral capsule, er multiphase 24 hr 120 mg, 75 mg, 90 mg morphine oral capsule, er multiphase 24 hr 30 mg, 45 mg, 60 mg morphine oral capsule,extend.release pellets 100 mg, 20 mg, 30 mg, 50 mg, 60 mg, 80 mg 2 $0 MO; QLL (60 per 30 days) 2 $0 MO; QLL (30 per 30 days) 2 $0 MO; QLL (60 per 30 days) morphine oral solution 20 mg/5 ml 2 $0 MO; QLL (1350 per 30 days) morphine oral tablet 15 mg 2 $0 MO; QLL (360 per 30 days) morphine oral tablet 30 mg 2 $0 MO; QLL (180 per 30 days) ENYDMEM-0035-15 34

morphine oral tablet extended release 100 mg, 15 mg, 30 mg, 60 mg 2 $0 MO; QLL (90 per 30 days) morphine oral tablet extended release 200 mg 2 $0 MO; QLL (60 per 30 days) oxycodone oral capsule 2 $0 MO; QLL (360 per 30 days) oxycodone oral concentrate 2 $0 MO; QLL (360 per 30 days) oxycodone oral tablet 10 mg, 5 mg 2 $0 MO; QLL (360 per 30 days) oxycodone oral tablet 15 mg 2 $0 MO; QLL (540 per 30 days) oxycodone oral tablet 20 mg, 30 mg 2 $0 MO; QLL (180 per 30 days) oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg 2 $0 MO; QLL (360 per 30 days) oxycodone-aspirin 2 $0 MO; QLL (360 per 30 days) SUBSYS 2 $0 PAR; MO; LA; QLL (120 per 30 days) NON-NARCOTIC ANALGESICS acephen rectal suppository 120 mg, 650 mg 4 $0 MO; [*] acephen rectal suppository 325 mg 4 $0 [*] acetadryl 4 $0 [*] aceta-gesic 4 $0 [*] ACETAMINOPHEN EXTRA STRENGTH 4 $0 [*] acetaminophen oral drops,suspension 4 $0 [*] acetaminophen oral elixir 4 $0 [*] acetaminophen oral liquid 500 mg/5 ml 4 $0 [*] acetaminophen oral solution 160 mg/5 ml (5 ml) 4 $0 MO; [*] acetaminophen oral solution 325 mg/10.15 ml, 650 mg/20.3 ml 4 $0 [*] acetaminophen oral suspension 160 mg/5 ml 4 $0 [*] acetaminophen oral tablet 4 $0 MO; [*] acetaminophen oral tablet extended release 4 $0 [*] acetaminophen oral tablet,disintegrating 4 $0 [*] acetaminophen pain relief 4 $0 [*] acetaminophen pm 4 $0 [*] acetaminophen pm extra str 4 $0 [*] ENYDMEM-0035-15 35

acetaminophen rectal suppository 120 mg, 650 mg 4 $0 [*] ADDED STRENGTH PAIN RELIEVER 4 $0 [*] adult low dose aspirin 4 $0 MO; [*] arthritis pain relief (acetam) 4 $0 [*] aspir-81 4 $0 [*] aspirin childrens 4 $0 [*] aspirin low dose 4 $0 MO; [*] aspirin low-strength 4 $0 [*] aspirin oral tablet 325 mg 4 $0 MO; [*] aspirin oral tablet,chewable 4 $0 MO; [*] aspirin oral tablet,delayed release (dr/ec) 325 mg, 81 mg 4 $0 MO; [*] aspirin, buffered 4 $0 [*] aspir-low 4 $0 MO; [*] aspir-trin 4 $0 MO; [*] athenol 4 $0 [*] bayer plus extra strength 4 $0 MO; [*] betatemp 4 $0 [*] buprenorphine-naloxone sublingual tablet 2-0.5 mg 2 $0 PAR; MO; QLL (360 per 30 days) buprenorphine-naloxone sublingual tablet 8-2 mg 2 $0 PAR; MO; QLL (90 per 30 days) butorphanol tartrate injection 2 $0 MO butorphanol tartrate nasal 2 $0 MO; QLL (5 per 28 days) child aspirin 4 $0 [*] child ibuprofen 4 $0 [*] children's acetaminophen oral suspension 160 mg/5 ml, 160 mg/5 ml (5 ml) CHILDREN'S ACETAMINOPHEN ORAL SUSPENSION 325 MG/10.15 ML 4 $0 [*] 4 $0 [*] children's aspirin 4 $0 MO; [*] children's ibuprofen 4 $0 MO; [*] children's mapap 4 $0 [*] ENYDMEM-0035-15 36

children's medi-profen 4 $0 [*] children's medi-tabs 4 $0 [*] children's non-aspirin oral elixir 4 $0 [*] children's non-aspirin oral suspension 4 $0 [*] children's non-aspirin oral tablet,chewable 4 $0 [*] children's non-aspirin pain 4 $0 [*] children's pain & fever relief oral elixir 4 $0 MO; [*] children's pain & fever relief oral suspension 4 $0 MO; [*] children's pain & fever relief oral tablet,chewable 4 $0 MO; [*] children's profen ib 4 $0 [*] children's q-pap 4 $0 MO; [*] children's silapap 4 $0 [*] diclofenac potassium 2 $0 MO diclofenac sodium oral 2 $0 MO diflunisal 2 $0 MO diphenhydramine-acetaminophen 4 $0 [*] ENTERIC COATED ASPIRIN 4 $0 [*] etodolac oral capsule 200 mg 2 $0 MO etodolac oral tablet 2 $0 MO etodolac oral tablet extended release 24 hr 2 $0 MO fenoprofen oral tablet 2 $0 MO fever reducer 4 $0 [*] fever reducer & pain reliever oral suspension 4 $0 [*] feverall rectal suppository 120 mg, 325 mg, 650 mg 4 $0 [*] flanax (naproxen) 4 $0 [*] flurbiprofen 2 $0 MO ibu-drops 4 $0 [*] IBUPROFEN IB 4 $0 [*] ibuprofen jr strength 4 $0 [*] ibuprofen oral capsule 4 $0 [*] ENYDMEM-0035-15 37

ibuprofen oral drops,suspension 4 $0 [*] ibuprofen oral suspension 2 $0 MO ibuprofen oral tablet 100 mg 4 $0 [*] ibuprofen oral tablet 200 mg 4 $0 MO; [*] ibuprofen oral tablet 400 mg, 600 mg, 800 mg 2 $0 MO ibuprofen pm oral tablet 4 $0 [*] ibuprofen-diphenhydramine cit 4 $0 [*] ibuprofen-diphenhydramine hcl 4 $0 [*] infant fever reducer-pain relf 4 $0 [*] infants ibu-drops 4 $0 [*] infant's ibuprofen 4 $0 [*] infant's medi-profen 4 $0 [*] infant's non-aspirin 4 $0 [*] infants profenib 4 $0 [*] i-prin 4 $0 [*] jr. acetaminophen 4 $0 [*] junior mapap 4 $0 MO; [*] lite coat aspirin 4 $0 [*] little remedies fever & pain 4 $0 [*] LO-DOSE ASPIRIN 4 $0 [*] mapap (acetaminophen) oral capsule 4 $0 MO; [*] mapap (acetaminophen) oral drops,suspension 4 $0 [*] mapap (acetaminophen) oral elixir 4 $0 MO; [*] mapap (acetaminophen) oral liquid 4 $0 MO; [*] mapap (acetaminophen) oral suspension 4 $0 [*] mapap (acetaminophen) oral tablet 4 $0 MO; [*] mapap (acetaminophen) oral tablet,chewable 4 $0 MO; [*] mapap arthritis pain 4 $0 MO; [*] mapap extra strength 4 $0 MO; [*] mapap pm 4 $0 MO; [*] ENYDMEM-0035-15 38

meclofenamate oral 2 $0 MO meloxicam oral suspension 2 $0 MO; QLL (300 per 30 days) meloxicam oral tablet 1 $0 MO; QLL (30 per 30 days) MENSTRUAL COMPLETE 4 $0 [*] menstrual relief 4 $0 [*] nabumetone 2 $0 MO nalbuphine injection 2 $0 MO naloxone injection solution 2 $0 MO naloxone injection syringe 0.4 mg/ml 2 $0 naloxone injection syringe 1 mg/ml 2 $0 MO naltrexone oral 2 $0 MO naproxen 2 $0 MO naproxen sodium oral capsule 4 $0 [*] naproxen sodium oral tablet 220 mg 4 $0 MO; [*] naproxen sodium oral tablet 275 mg, 550 mg 2 $0 MO NORTEMP 4 $0 [*] oxaprozin 2 $0 MO pain-off 4 $0 [*] pamprin max 4 $0 [*] pediacare fever reducer 4 $0 [*] percogesic 4 $0 [*] percogesic extra strength 4 $0 MO; [*] pharbetol 4 $0 [*] piroxicam 2 $0 MO provil 4 $0 [*] q-pap extra strength 4 $0 MO; [*] q-pap oral drops 4 $0 MO; [*] q-pap oral liquid 4 $0 MO; [*] q-pap oral tablet 325 mg 4 $0 [*] q-pap oral tablet 500 mg 4 $0 MO; [*] ENYDMEM-0035-15 39

silapap 4 $0 [*] SUBOXONE SUBLINGUAL FILM 12-3 MG 2 $0 PAR; MO; QLL (60 per 30 days) SUBOXONE SUBLINGUAL FILM 2-0.5 MG 2 $0 PAR; MO; QLL (360 per 30 days) SUBOXONE SUBLINGUAL FILM 4-1 MG 2 $0 PAR; MO; QLL (180 per 30 days) SUBOXONE SUBLINGUAL FILM 8-2 MG 2 $0 PAR; MO; QLL (90 per 30 days) sulindac oral 2 $0 MO tolmetin 2 $0 MO tramadol oral tablet 2 $0 MO; QLL (240 per 30 days) tramadol-acetaminophen 2 $0 MO; QLL (240 per 30 days) tri-buffered aspirin 4 $0 MO; [*] VOLTAREN GEL TOPICAL GEL 1 % 2 $0 MO; QLL (1000 per 30 days) PSYCHOTHERAPEUTIC DRUGS ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 2 $0 MO; QLL (1 per 28 days) 2 $0 QLL (1 per 28 days) ABILIFY ORAL TABLET 10 MG 2 $0 MO; QLL (90 per 30 days) ABILIFY ORAL TABLET 15 MG, 20 MG 2 $0 MO; QLL (60 per 30 days) ABILIFY ORAL TABLET 2 MG 2 $0 MO; QLL (450 per 30 days) ABILIFY ORAL TABLET 30 MG 2 $0 MO; QLL (30 per 30 days) ABILIFY ORAL TABLET 5 MG 2 $0 MO; QLL (180 per 30 days) ADASUVE 2 $0 alprazolam oral tablet 2 $0 MO; QLL (90 per 30 days) amitriptyline 2 $0 PAR; MO amoxapine 2 $0 MO amphetamine salt combo oral tablet 10 mg, 12.5 mg, 15 mg, 20 mg, 5 mg, 7.5 mg 2 $0 PAR; MO; QLL (90 per 30 days) amphetamine salt combo oral tablet 30 mg 2 $0 PAR; MO; QLL (60 per 30 days) aripiprazole oral solution 2 $0 MO; QLL (900 per 30 days) aripiprazole oral tablet 10 mg 2 $0 MO; QLL (90 per 30 days) aripiprazole oral tablet 15 mg, 20 mg 2 $0 MO; QLL (60 per 30 days) ENYDMEM-0035-15 40

aripiprazole oral tablet 2 mg 2 $0 MO; QLL (450 per 30 days) aripiprazole oral tablet 30 mg 2 $0 MO; QLL (30 per 30 days) aripiprazole oral tablet 5 mg 2 $0 MO; QLL (180 per 30 days) BRINTELLIX ORAL TABLET 10 MG 2 $0 ST; MO; QLL (60 per 30 days) BRINTELLIX ORAL TABLET 20 MG 2 $0 ST; MO; QLL (30 per 30 days) BRINTELLIX ORAL TABLET 5 MG 2 $0 ST; MO; QLL (120 per 30 days) bupropion hcl oral tablet 100 mg 2 $0 MO; QLL (135 per 30 days) bupropion hcl oral tablet 75 mg 2 $0 MO; QLL (180 per 30 days) bupropion hcl oral tablet extended release 100 mg 2 $0 MO; QLL (120 per 30 days) bupropion hcl oral tablet extended release 150 mg, 200 mg bupropion hcl oral tablet extended release 24 hr 150 mg bupropion hcl oral tablet extended release 24 hr 300 mg 2 $0 MO; QLL (60 per 30 days) 2 $0 MO; QLL (90 per 30 days) 2 $0 MO; QLL (45 per 30 days) buspirone 2 $0 MO chlorpromazine 2 $0 PAR; MO citalopram oral solution 1 $0 MO; QLL (600 per 30 days) citalopram oral tablet 10 mg 1 $0 MO; QLL (120 per 30 days) citalopram oral tablet 20 mg 1 $0 MO; QLL (60 per 30 days) citalopram oral tablet 40 mg 1 $0 MO; QLL (30 per 30 days) clomipramine 2 $0 PAR; MO clorazepate dipotassium 2 $0 MO; QLL (120 per 30 days) clozapine oral tablet 100 mg 2 $0 MO; QLL (270 per 30 days) clozapine oral tablet 200 mg 2 $0 MO; QLL (135 per 30 days) clozapine oral tablet 25 mg 2 $0 MO; QLL (1080 per 30 days) clozapine oral tablet 50 mg 2 $0 MO; QLL (540 per 30 days) clozapine oral tablet,disintegrating 100 mg 2 $0 QLL (270 per 30 days) clozapine oral tablet,disintegrating 12.5 mg 2 $0 QLL (2160 per 30 days) clozapine oral tablet,disintegrating 150 mg 2 $0 QLL (180 per 30 days) clozapine oral tablet,disintegrating 200 mg 2 $0 QLL (135 per 30 days) ENYDMEM-0035-15 41

clozapine oral tablet,disintegrating 25 mg 2 $0 QLL (1080 per 30 days) desipramine oral 2 $0 MO DESVENLAFAXINE FUMARATE ORAL TABLET EXTENDED RELEASE 24HR 100 MG DESVENLAFAXINE FUMARATE ORAL TABLET EXTENDED RELEASE 24HR 50 MG DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE 24 HR 100 MG DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE 24 HR 50 MG DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE 24HR 100 MG DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE 24HR 50 MG dextroamphetamine oral capsule, extended release 10 mg, 5 mg dextroamphetamine oral capsule, extended release 15 mg 2 $0 MO; QLL (120 per 30 days) 2 $0 MO; QLL (240 per 30 days) 2 $0 MO; QLL (120 per 30 days) 2 $0 MO; QLL (240 per 30 days) 2 $0 QLL (120 per 30 days) 2 $0 QLL (240 per 30 days) 2 $0 MO; QLL (60 per 30 days) 2 $0 MO; QLL (120 per 30 days) dextroamphetamine oral tablet 10 mg 2 $0 PAR; MO; QLL (180 per 30 days) dextroamphetamine oral tablet 5 mg 2 $0 PAR; MO; QLL (90 per 30 days) diazepam injection solution 2 $0 diazepam injection syringe 2 $0 MO diazepam intensol 2 $0 PAR; MO; QLL (240 per 30 days) diazepam oral concentrate 2 $0 PAR; QLL (240 per 30 days) diazepam oral solution 5 mg/5 ml 2 $0 MO; QLL (1200 per 30 days) diazepam oral tablet 10 mg 2 $0 PAR; MO; QLL (120 per 30 days) diazepam oral tablet 2 mg 2 $0 PAR; MO; QLL (600 per 30 days) diazepam oral tablet 5 mg 2 $0 PAR; MO; QLL (240 per 30 days) doxepin oral 2 $0 PAR; MO duloxetine oral capsule,delayed release(dr/ec) 20 mg duloxetine oral capsule,delayed release(dr/ec) 30 mg 2 $0 MO; QLL (180 per 30 days) 2 $0 MO; QLL (120 per 30 days) ENYDMEM-0035-15 42

duloxetine oral capsule,delayed release(dr/ec) 40 mg duloxetine oral capsule,delayed release(dr/ec) 60 mg 2 $0 MO; QLL (90 per 30 days) 2 $0 MO; QLL (60 per 30 days) EMSAM 2 $0 PAR; MO; QLL (30 per 30 days) ergoloid 2 $0 PAR; MO escitalopram oxalate oral solution 1 $0 MO; QLL (600 per 30 days) escitalopram oxalate oral tablet 10 mg 1 $0 MO; QLL (60 per 30 days) escitalopram oxalate oral tablet 20 mg 1 $0 MO; QLL (30 per 30 days) escitalopram oxalate oral tablet 5 mg 1 $0 MO; QLL (120 per 30 days) FANAPT ORAL TABLET 1 MG 2 $0 MO; QLL (720 per 30 days) FANAPT ORAL TABLET 10 MG 2 $0 MO; QLL (72 per 30 days) FANAPT ORAL TABLET 12 MG 2 $0 MO; QLL (60 per 30 days) FANAPT ORAL TABLET 2 MG 2 $0 MO; QLL (360 per 30 days) FANAPT ORAL TABLET 4 MG 2 $0 MO; QLL (180 per 30 days) FANAPT ORAL TABLET 6 MG 2 $0 MO; QLL (120 per 30 days) FANAPT ORAL TABLET 8 MG 2 $0 MO; QLL (90 per 30 days) FANAPT ORAL TABLETS,DOSE PACK 2 $0 MO; QLL (8 per 30 days) FAZACLO ORAL TABLET,DISINTEGRATING 100 MG FAZACLO ORAL TABLET,DISINTEGRATING 12.5 MG FAZACLO ORAL TABLET,DISINTEGRATING 150 MG FAZACLO ORAL TABLET,DISINTEGRATING 200 MG FAZACLO ORAL TABLET,DISINTEGRATING 25 MG FETZIMA ORAL CAPSULE,EXT REL 24HR DOSE PACK FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR 120 MG, 80 MG FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR 20 MG 2 $0 QLL (270 per 30 days) 2 $0 QLL (2160 per 30 days) 2 $0 QLL (180 per 30 days) 2 $0 QLL (135 per 30 days) 2 $0 QLL (1080 per 30 days) 2 $0 PAR; MO; QLL (28 per 365 days) 2 $0 PAR; MO; QLL (30 per 30 days) 2 $0 PAR; MO; QLL (180 per 30 days) ENYDMEM-0035-15 43

FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR 40 MG 2 $0 PAR; MO; QLL (90 per 30 days) fluoxetine oral capsule 10 mg 1 $0 MO; QLL (240 per 30 days) fluoxetine oral capsule 20 mg 1 $0 MO; QLL (120 per 30 days) fluoxetine oral capsule 40 mg 1 $0 MO; QLL (60 per 30 days) fluoxetine oral solution 1 $0 MO; QLL (600 per 30 days) fluoxetine oral tablet 10 mg 1 $0 MO; QLL (240 per 30 days) fluoxetine oral tablet 20 mg 1 $0 MO; QLL (120 per 30 days) fluphenazine decanoate 2 $0 MO fluphenazine hcl 2 $0 MO fluvoxamine oral tablet 100 mg 2 $0 MO; QLL (90 per 30 days) fluvoxamine oral tablet 25 mg 2 $0 MO; QLL (360 per 30 days) fluvoxamine oral tablet 50 mg 2 $0 MO; QLL (180 per 30 days) GEODON INTRAMUSCULAR 2 $0 MO guanfacine oral tablet extended release 24 hr 2 $0 PAR; MO; QLL (30 per 30 days) guanidine 2 $0 MO haloperidol 2 $0 MO haloperidol decanoate 2 $0 MO haloperidol lactate 2 $0 MO imipramine hcl 2 $0 PAR; MO INTUNIV ER 2 $0 PAR; MO; QLL (30 per 30 days) INVEGA ORAL TABLET EXTENDED RELEASE 24HR 1.5 MG INVEGA ORAL TABLET EXTENDED RELEASE 24HR 3 MG INVEGA ORAL TABLET EXTENDED RELEASE 24HR 6 MG INVEGA ORAL TABLET EXTENDED RELEASE 24HR 9 MG 2 $0 MO; QLL (240 per 30 days) 2 $0 MO; QLL (120 per 30 days) 2 $0 MO; QLL (60 per 30 days) 2 $0 MO; QLL (40 per 30 days) INVEGA SUSTENNA 2 $0 MO; QLL (2 per 28 days) INVEGA TRINZA INTRAMUSCULAR SYRINGE 273 MG/0.875 ML 2 $0 MO; QLL (0.875 per 90 days) ENYDMEM-0035-15 44

INVEGA TRINZA INTRAMUSCULAR SYRINGE 410 MG/1.315 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 546 MG/1.75 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 819 MG/2.625 ML KHEDEZLA ORAL TABLET EXTENDED RELEASE 24HR 100 MG KHEDEZLA ORAL TABLET EXTENDED RELEASE 24HR 50 MG 2 $0 MO; QLL (1.315 per 90 days) 2 $0 MO; QLL (1.75 per 90 days) 2 $0 MO; QLL (2.625 per 90 days) 2 $0 MO; QLL (120 per 30 days) 2 $0 MO; QLL (240 per 30 days) LATUDA ORAL TABLET 120 MG 2 $0 MO; QLL (30 per 30 days) LATUDA ORAL TABLET 20 MG 2 $0 MO; QLL (240 per 30 days) LATUDA ORAL TABLET 40 MG 2 $0 MO; QLL (120 per 30 days) LATUDA ORAL TABLET 60 MG 2 $0 MO; QLL (75 per 30 days) LATUDA ORAL TABLET 80 MG 2 $0 MO; QLL (60 per 30 days) lithium carbonate 2 $0 MO lithium citrate oral solution 8 meq/5 ml 2 $0 MO lorazepam oral tablet 2 $0 MO; QLL (90 per 30 days) loxapine succinate 2 $0 MO maprotiline oral tablet 25 mg 2 $0 MO; QLL (270 per 30 days) maprotiline oral tablet 50 mg 2 $0 MO; QLL (135 per 30 days) maprotiline oral tablet 75 mg 2 $0 MO MARPLAN 2 $0 MO methylphenidate oral tablet 2 $0 PAR; MO; QLL (90 per 30 days) mirtazapine oral tablet 15 mg 2 $0 MO; QLL (90 per 30 days) mirtazapine oral tablet 30 mg 2 $0 MO; QLL (45 per 30 days) mirtazapine oral tablet 45 mg 2 $0 MO; QLL (30 per 30 days) mirtazapine oral tablet 7.5 mg 2 $0 MO; QLL (180 per 30 days) mirtazapine oral tablet,disintegrating 15 mg 2 $0 MO; QLL (90 per 30 days) mirtazapine oral tablet,disintegrating 30 mg 2 $0 MO; QLL (45 per 30 days) mirtazapine oral tablet,disintegrating 45 mg 2 $0 MO; QLL (30 per 30 days) modafinil oral tablet 100 mg 2 $0 PAR; MO; QLL (30 per 30 days) ENYDMEM-0035-15 45

modafinil oral tablet 200 mg 2 $0 PAR; MO; QLL (60 per 30 days) nefazodone oral tablet 100 mg 2 $0 MO; QLL (180 per 30 days) nefazodone oral tablet 150 mg 2 $0 MO; QLL (120 per 30 days) nefazodone oral tablet 200 mg 2 $0 MO; QLL (90 per 30 days) nefazodone oral tablet 250 mg 2 $0 MO; QLL (72 per 30 days) nefazodone oral tablet 50 mg 2 $0 MO; QLL (360 per 30 days) nortriptyline 2 $0 MO olanzapine intramuscular 2 $0 MO; QLL (60 per 30 days) olanzapine oral tablet 10 mg 2 $0 MO; QLL (60 per 30 days) olanzapine oral tablet 15 mg 2 $0 MO; QLL (40 per 30 days) olanzapine oral tablet 2.5 mg 2 $0 MO; QLL (240 per 30 days) olanzapine oral tablet 20 mg 2 $0 MO; QLL (30 per 30 days) olanzapine oral tablet 5 mg 2 $0 MO; QLL (120 per 30 days) olanzapine oral tablet 7.5 mg 2 $0 MO; QLL (80 per 30 days) olanzapine oral tablet,disintegrating 10 mg 2 $0 MO; QLL (60 per 30 days) olanzapine oral tablet,disintegrating 15 mg 2 $0 MO; QLL (40 per 30 days) olanzapine oral tablet,disintegrating 20 mg 2 $0 MO; QLL (30 per 30 days) olanzapine oral tablet,disintegrating 5 mg 2 $0 MO; QLL (120 per 30 days) ORAP 2 $0 MO paroxetine hcl oral tablet 10 mg 1 $0 MO; QLL (180 per 30 days) paroxetine hcl oral tablet 20 mg 1 $0 MO; QLL (90 per 30 days) paroxetine hcl oral tablet 30 mg 1 $0 MO; QLL (60 per 30 days) paroxetine hcl oral tablet 40 mg 1 $0 MO; QLL (45 per 30 days) paroxetine hcl oral tablet extended release 24 hr 12.5 mg paroxetine hcl oral tablet extended release 24 hr 25 mg paroxetine hcl oral tablet extended release 24 hr 37.5 mg 1 $0 MO; QLL (180 per 30 days) 1 $0 MO; QLL (90 per 30 days) 1 $0 MO; QLL (60 per 30 days) PAXIL ORAL SUSPENSION 2 $0 MO; QLL (900 per 30 days) perphenazine 2 $0 MO ENYDMEM-0035-15 46

phenelzine 2 $0 MO PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR 100 MG PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR 25 MG PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR 50 MG protriptyline 2 $0 MO 2 $0 PAR; MO; QLL (120 per 30 days) 2 $0 PAR; MO; QLL (480 per 30 days) 2 $0 PAR; MO; QLL (240 per 30 days) quetiapine oral tablet 100 mg 1 $0 MO; QLL (240 per 30 days) quetiapine oral tablet 200 mg 1 $0 MO; QLL (120 per 30 days) quetiapine oral tablet 25 mg 1 $0 MO; QLL (960 per 30 days) quetiapine oral tablet 300 mg 1 $0 MO; QLL (80 per 30 days) quetiapine oral tablet 400 mg 1 $0 MO; QLL (60 per 30 days) quetiapine oral tablet 50 mg 1 $0 MO; QLL (480 per 30 days) REXULTI ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG 2 $0 PAR; MO; QLL (60 per 30 days) REXULTI ORAL TABLET 3 MG, 4 MG 2 $0 PAR; MO; QLL (30 per 30 days) RISPERDAL CONSTA INTRAMUSCULAR SYRINGE 12.5 MG/2 ML, 25 MG/2 ML, 37.5 MG/2 ML RISPERDAL CONSTA INTRAMUSCULAR SYRINGE 50 MG/2 ML 2 $0 MO; QLL (2 per 28 days) 2 $0 MO risperidone oral solution 1 $0 MO; QLL (480 per 30 days) risperidone oral tablet 0.25 mg 1 $0 MO; QLL (1920 per 30 days) risperidone oral tablet 0.5 mg 1 $0 MO; QLL (960 per 30 days) risperidone oral tablet 1 mg 1 $0 MO; QLL (480 per 30 days) risperidone oral tablet 2 mg 1 $0 MO; QLL (240 per 30 days) risperidone oral tablet 3 mg 1 $0 MO; QLL (160 per 30 days) risperidone oral tablet 4 mg 1 $0 MO; QLL (120 per 30 days) risperidone oral tablet,disintegrating 0.25 mg 1 $0 MO; QLL (1920 per 30 days) risperidone oral tablet,disintegrating 0.5 mg 1 $0 MO; QLL (960 per 30 days) risperidone oral tablet,disintegrating 1 mg 1 $0 MO; QLL (480 per 30 days) risperidone oral tablet,disintegrating 2 mg 1 $0 MO; QLL (240 per 30 days) ENYDMEM-0035-15 47

risperidone oral tablet,disintegrating 3 mg 1 $0 MO; QLL (160 per 30 days) risperidone oral tablet,disintegrating 4 mg 1 $0 MO; QLL (120 per 30 days) ROZEREM 2 $0 MO; QLL (30 per 30 days) SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 10 MG SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 2.5 MG SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 5 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 150 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 200 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 300 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 400 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 50 MG 2 $0 MO; QLL (60 per 30 days) 2 $0 MO; QLL (240 per 30 days) 2 $0 MO; QLL (120 per 30 days) 2 $0 MO; QLL (160 per 30 days) 2 $0 MO; QLL (120 per 30 days) 2 $0 MO; QLL (80 per 30 days) 2 $0 MO; QLL (60 per 30 days) 2 $0 MO; QLL (480 per 30 days) sertraline oral concentrate 1 $0 MO; QLL (300 per 30 days) sertraline oral tablet 100 mg 1 $0 MO; QLL (60 per 30 days) sertraline oral tablet 25 mg 1 $0 MO; QLL (240 per 30 days) sertraline oral tablet 50 mg 1 $0 MO; QLL (120 per 30 days) sleep aid (doxylamine) 4 $0 [*] STRATTERA ORAL CAPSULE 10 MG, 18 MG, 25 MG, 40 MG STRATTERA ORAL CAPSULE 100 MG, 60 MG, 80 MG 2 $0 PAR; MO; QLL (60 per 30 days) 2 $0 PAR; MO; QLL (30 per 30 days) SURMONTIL 2 $0 PAR; MO temazepam oral capsule 15 mg, 22.5 mg, 30 mg 2 $0 MO; QLL (30 per 30 days) thioridazine 2 $0 PAR; MO thiothixene 2 $0 MO tranylcypromine 2 $0 MO trazodone 2 $0 MO ENYDMEM-0035-15 48

trifluoperazine 2 $0 MO ultra sleep (doxylamine succ) 4 $0 [*] venlafaxine oral capsule,extended release 24hr 150 mg venlafaxine oral capsule,extended release 24hr 37.5 mg venlafaxine oral capsule,extended release 24hr 75 mg 2 $0 MO; QLL (60 per 30 days) 2 $0 MO; QLL (180 per 30 days) 2 $0 MO; QLL (90 per 30 days) venlafaxine oral tablet 100 mg 2 $0 MO; QLL (113 per 30 days) venlafaxine oral tablet 25 mg 2 $0 MO; QLL (450 per 30 days) venlafaxine oral tablet 37.5 mg 2 $0 MO; QLL (300 per 30 days) venlafaxine oral tablet 50 mg 2 $0 MO; QLL (225 per 30 days) venlafaxine oral tablet 75 mg 2 $0 MO; QLL (150 per 30 days) venlafaxine oral tablet extended release 24hr 150 mg VENLAFAXINE ORAL TABLET EXTENDED RELEASE 24HR 225 MG venlafaxine oral tablet extended release 24hr 37.5 mg venlafaxine oral tablet extended release 24hr 75 mg 2 $0 MO; QLL (60 per 30 days) 2 $0 MO; QLL (30 per 30 days) 2 $0 MO; QLL (180 per 30 days) 2 $0 MO; QLL (90 per 30 days) VERSACLOZ 2 $0 LA; QLL (600 per 30 days) VIIBRYD ORAL TABLET 10 MG 2 $0 ST; MO; QLL (120 per 30 days) VIIBRYD ORAL TABLET 20 MG 2 $0 ST; MO; QLL (60 per 30 days) VIIBRYD ORAL TABLET 40 MG 2 $0 ST; MO; QLL (30 per 30 days) VIIBRYD ORAL TABLETS,DOSE PACK 10 MG (7)- 20 MG (23) VIIBRYD ORAL TABLETS,DOSE PACK 10 MG (7)-20 MG (7)-40 MG (16) 2 $0 ST; QLL (30 per 30 days) 2 $0 ST; MO; QLL (30 per 30 days) XYREM 2 $0 PAR; MO; LA; QLL (540 per 30 days) zaleplon oral capsule 10 mg 2 $0 PAR; MO; QLL (60 per 30 days) zaleplon oral capsule 5 mg 2 $0 PAR; MO; QLL (30 per 30 days) zenzedi oral tablet 10 mg 2 $0 PAR; MO; QLL (180 per 30 days) ENYDMEM-0035-15 49

zenzedi oral tablet 5 mg 2 $0 PAR; MO; QLL (90 per 30 days) ziprasidone hcl oral capsule 20 mg 2 $0 MO; QLL (240 per 30 days) ziprasidone hcl oral capsule 40 mg 2 $0 MO; QLL (120 per 30 days) ziprasidone hcl oral capsule 60 mg, 80 mg 2 $0 MO; QLL (60 per 30 days) zolpidem oral tablet 2 $0 PAR; MO; QLL (30 per 30 days) ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 210 MG, 405 MG ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 300 MG 2 $0 LA CARDIOVASCULAR, HYPERTENSION / LIPIDS ANTIARRHYTHMIC AGENTS 2 $0 MO; LA amiodarone intravenous solution 2 $0 B/D PAR; MO amiodarone intravenous syringe 2 $0 B/D PAR amiodarone oral 2 $0 MO flecainide 2 $0 MO lidocaine (pf) intravenous solution 2 $0 MO lidocaine (pf) intravenous syringe 100 mg/5 ml (2 %), 50 mg/5 ml (1 %) 2 $0 mexiletine 2 $0 MO MULTAQ 2 $0 MO; QLL (60 per 30 days) pacerone oral tablet 100 mg, 200 mg, 400 mg 2 $0 MO procainamide injection solution 100 mg/ml 2 $0 MO procainamide injection solution 500 mg/ml 2 $0 propafenone oral tablet 2 $0 MO quinidine sulfate tablets oral tablet 200 mg, 300 mg 2 $0 MO sorine oral tablet 120 mg, 160 mg, 80 mg 2 $0 MO sorine oral tablet 240 mg 2 $0 sotalol af 2 $0 MO sotalol oral 2 $0 MO ENYDMEM-0035-15 50

TIKOSYN 2 $0 MO ANTIHYPERTENSIVE THERAPY acebutolol 1 $0 MO afeditab cr 2 $0 MO amiloride oral 2 $0 MO amiloride-hydrochlorothiazide 2 $0 MO amlodipine oral tablet 10 mg, 2.5 mg 1 $0 MO; QLL (30 per 30 days) amlodipine oral tablet 5 mg 1 $0 MO; QLL (45 per 30 days) amlodipine-benazepril 1 $0 MO amlodipine-valsartan 2 $0 MO; QLL (30 per 30 days) amlodipine-valsartan-hcthiazid 2 $0 MO; QLL (30 per 30 days) atenolol 1 $0 MO atenolol-chlorthalidone 1 $0 MO AZOR 2 $0 MO; QLL (30 per 30 days) benazepril 1 $0 MO benazepril-hydrochlorothiazide 1 $0 MO betaxolol oral 2 $0 MO bisoprolol fumarate 2 $0 MO bisoprolol-hydrochlorothiazide 2 $0 MO bumetanide 2 $0 MO BYSTOLIC 2 $0 MO candesartan oral tablet 16 mg, 4 mg, 8 mg 1 $0 MO; QLL (60 per 30 days) candesartan oral tablet 32 mg 1 $0 MO; QLL (30 per 30 days) candesartan-hydrochlorothiazid oral tablet 16-12.5 mg candesartan-hydrochlorothiazid oral tablet 32-12.5 mg, 32-25 mg 1 $0 MO; QLL (60 per 30 days) 1 $0 MO; QLL (30 per 30 days) captopril 1 $0 MO captopril-hydrochlorothiazide 1 $0 MO cartia xt 2 $0 MO carvedilol 1 $0 MO ENYDMEM-0035-15 51

chlorothiazide 2 $0 MO chlorothiazide sodium 2 $0 MO chlorthalidone oral tablet 25 mg, 50 mg 2 $0 MO clonidine hcl oral tablet 1 $0 MO clonidine patches 2 $0 MO; QLL (4 per 28 days) COREG CR 2 $0 ST; MO DEMSER 2 $0 MO diltiazem hcl intravenous 2 $0 diltiazem hcl oral capsule, extended release 2 $0 MO diltiazem hcl oral capsule,ext release degradable 2 $0 MO diltiazem hcl oral capsule,extended release 12 hr 2 $0 MO diltiazem hcl oral capsule,extended release 24hr 2 $0 MO diltiazem hcl oral tablet 2 $0 MO diltiazem hcl oral tablet extended release 24 hr 180 mg, 300 mg, 420 mg diltiazem hcl oral tablet extended release 24 hr 240 mg, 360 mg 2 $0 2 $0 MO dilt-xr 2 $0 MO doxazosin 2 $0 MO enalapril maleate 1 $0 MO enalapril-hydrochlorothiazide 1 $0 MO eplerenone 2 $0 MO eprosartan 1 $0 MO; QLL (30 per 30 days) felodipine 2 $0 MO fosinopril 1 $0 MO fosinopril-hydrochlorothiazide 1 $0 MO furosemide injection 2 $0 MO furosemide oral solution 10 mg/ml, 40 mg/5 ml 1 $0 MO furosemide oral tablet 1 $0 MO hydralazine 2 $0 MO hydrochlorothiazide 1 $0 MO ENYDMEM-0035-15 52

indapamide 1 $0 MO irbesartan 1 $0 MO; QLL (30 per 30 days) irbesartan-hydrochlorothiazide oral tablet 150-12.5 mg irbesartan-hydrochlorothiazide oral tablet 300-12.5 mg 1 $0 MO; QLL (60 per 30 days) 1 $0 MO; QLL (30 per 30 days) isradipine 2 $0 MO labetalol intravenous solution 2 $0 MO labetalol oral 2 $0 MO lisinopril 1 $0 MO lisinopril-hydrochlorothiazide 1 $0 MO losartan oral tablet 100 mg 1 $0 MO; QLL (30 per 30 days) losartan oral tablet 25 mg, 50 mg 1 $0 MO; QLL (60 per 30 days) losartan-hydrochlorothiazide 1 $0 MO; QLL (30 per 30 days) methyclothiazide 2 $0 MO metolazone 1 $0 MO metoprolol succinate 2 $0 MO metoprolol ta-hydrochlorothiaz 2 $0 MO metoprolol tartrate intravenous solution 2 $0 MO metoprolol tartrate intravenous syringe 2 $0 metoprolol tartrate oral 1 $0 MO minoxidil oral 2 $0 MO moexipril 1 $0 MO moexipril-hydrochlorothiazide 1 $0 MO nadolol 1 $0 MO nadolol-bendroflumethiazide 2 $0 MO nicardipine 2 $0 MO nifedical xl 2 $0 MO nifedipine oral tablet extended release 2 $0 MO nifedipine oral tablet extended release 24hr 2 $0 MO nimodipine 2 $0 MO ENYDMEM-0035-15 53

perindopril erbumine 1 $0 MO pindolol 2 $0 MO prazosin oral 2 $0 MO propranolol intravenous 2 $0 propranolol oral 2 $0 MO propranolol-hydrochlorothiazid 2 $0 MO quinapril 1 $0 MO quinapril-hydrochlorothiazide 1 $0 MO ramipril 1 $0 MO spironolactone 1 $0 MO spironolacton-hydrochlorothiaz 1 $0 MO taztia xt 2 $0 MO TEKTURNA 2 $0 MO; QLL (30 per 30 days) TEKTURNA HCT 2 $0 MO; QLL (30 per 30 days) telmisartan oral tablet 20 mg, 40 mg 1 $0 MO; QLL (30 per 30 days) telmisartan oral tablet 80 mg 1 $0 MO; QLL (60 per 30 days) telmisartan-amlodipine 1 $0 MO; QLL (30 per 30 days) telmisartan-hydrochlorothiazid oral tablet 40-12.5 mg, 80-25 mg telmisartan-hydrochlorothiazid oral tablet 80-12.5 mg 1 $0 MO; QLL (30 per 30 days) 1 $0 MO; QLL (60 per 30 days) terazosin 1 $0 MO timolol maleate oral 2 $0 MO torsemide oral 1 $0 MO trandolapril 1 $0 MO triamterene-hydrochlorothiazid oral capsule 37.5-25 mg 1 $0 MO triamterene-hydrochlorothiazid oral tablet 1 $0 MO TRIBENZOR 2 $0 MO; QLL (30 per 30 days) valsartan oral tablet 160 mg 2 $0 MO; QLL (60 per 30 days) valsartan oral tablet 320 mg 2 $0 MO; QLL (30 per 30 days) ENYDMEM-0035-15 54

valsartan oral tablet 40 mg, 80 mg 2 $0 MO; QLL (90 per 30 days) valsartan-hydrochlorothiazide 1 $0 MO; QLL (30 per 30 days) verapamil intravenous solution 2 $0 MO verapamil intravenous syringe 2 $0 verapamil oral 2 $0 MO CARDIAC GLYCOSIDES DIGITEK ORAL TABLET 125 MCG 1 $0 MO; QLL (30 per 30 days) digox oral tablet 125 mcg 1 $0 MO; QLL (30 per 30 days) digoxin oral solution 50 mcg/ml 2 $0 MO digoxin oral tablet 125 mcg 1 $0 MO; QLL (30 per 30 days) LANOXIN ORAL TABLET 125 MCG 2 $0 MO; QLL (30 per 30 days) LANOXIN ORAL TABLET 62.5 MCG 2 $0 MO COAGULATION THERAPY AGGRENOX 2 $0 MO; QLL (60 per 30 days) aspirin-dipyridamole 2 $0 MO; QLL (60 per 30 days) BRILINTA ORAL TABLET 90 MG 2 $0 MO; QLL (60 per 30 days) cilostazol 2 $0 MO clopidogrel oral tablet 300 mg 2 $0 MO; QLL (1 per 30 days) clopidogrel oral tablet 75 mg 2 $0 MO; QLL (30 per 30 days) COUMADIN ORAL 2 $0 MO EFFIENT 2 $0 MO; QLL (30 per 30 days) ELIQUIS ORAL TABLET 2.5 MG 2 $0 MO; QLL (60 per 30 days) ELIQUIS ORAL TABLET 5 MG 2 $0 MO; QLL (74 per 30 days) enoxaparin subcutaneous solution 2 $0 MO; QLL (84 per 30 days) enoxaparin subcutaneous syringe 100 mg/ml, 150 mg/ml enoxaparin subcutaneous syringe 120 mg/0.8 ml, 80 mg/0.8 ml 2 $0 MO; QLL (28 per 30 days) 2 $0 MO; QLL (22.4 per 30 days) enoxaparin subcutaneous syringe 30 mg/0.3 ml 2 $0 MO; QLL (8.4 per 30 days) enoxaparin subcutaneous syringe 40 mg/0.4 ml 2 $0 MO; QLL (11.2 per 30 days) enoxaparin subcutaneous syringe 60 mg/0.6 ml 2 $0 MO; QLL (16.8 per 30 days) ENYDMEM-0035-15 55

fondaparinux subcutaneous syringe 10 mg/0.8 ml 2 $0 MO; QLL (24 per 30 days) fondaparinux subcutaneous syringe 2.5 mg/0.5 ml 2 $0 MO; QLL (15 per 30 days) fondaparinux subcutaneous syringe 5 mg/0.4 ml 2 $0 MO; QLL (12 per 30 days) fondaparinux subcutaneous syringe 7.5 mg/0.6 ml 2 $0 MO; QLL (18 per 30 days) FRAGMIN SUBCUTANEOUS SOLUTION 2 $0 MO FRAGMIN SUBCUTANEOUS SYRINGE 2 $0 MO heparin (porcine) in 5 % dex intravenous parenteral solution 12,500 unit/250 ml heparin (porcine) in 5 % dex intravenous parenteral solution 25,000 unit/250 ml(100 unit/ml), 25,000 unit/500 ml (50 unit/ml) heparin (porcine) in nacl (pf) intravenous parenteral solution 1,000 unit/500 ml, 2,000 unit/1,000 ml 2 $0 B/D PAR 2 $0 B/D PAR; MO 2 $0 B/D PAR heparin (porcine) injection cartridge 2 $0 B/D PAR; MO heparin (porcine) injection solution 2 $0 B/D PAR; MO HEPARIN(PORCINE) IN 0.45% NACL INTRAVENOUS PARENTERAL SOLUTION 12,500 UNIT/250 ML heparin(porcine) in 0.45% nacl intravenous parenteral solution 25,000 unit/250 ml, 25,000 unit/500 ml 2 $0 B/D PAR 2 $0 B/D PAR heparin, porcine (pf) injection 2 $0 B/D PAR; MO jantoven 1 $0 MO MEPHYTON 3 $0 MO; [*] pentoxifylline 2 $0 MO PRADAXA 2 $0 MO; QLL (60 per 30 days) PROMACTA ORAL TABLET 12.5 MG, 25 MG, 75 MG 2 $0 PAR; MO; LA; QLL (30 per 30 days) PROMACTA ORAL TABLET 50 MG 2 $0 PAR; MO; LA; QLL (60 per 30 days) tranexamic acid intravenous 2 $0 MO vitamin k injection 3 $0 MO; [*] VITAMIN K ORAL 4 $0 MO; [*] ENYDMEM-0035-15 56

VITAMIN K1 3 $0 [*] vitamin k1 injection 3 $0 MO; [*] warfarin 1 $0 MO XARELTO ORAL TABLET 10 MG, 20 MG 2 $0 MO; QLL (30 per 30 days) XARELTO ORAL TABLET 15 MG 2 $0 MO; QLL (42 per 30 days) XARELTO ORAL TABLETS,DOSE PACK 2 $0 MO; QLL (51 per 365 days) LIPID/CHOLESTEROL LOWERING AGENTS amlodipine-atorvastatin 1 $0 MO; QLL (30 per 30 days) atorvastatin 1 $0 MO; QLL (30 per 30 days) cholestyramine (with sugar) 2 $0 MO cholestyramine light 2 $0 MO colestipol 2 $0 MO CRESTOR 2 $0 MO; QLL (30 per 30 days) fenofibrate micronized oral capsule 134 mg, 200 mg, 67 mg 2 $0 MO; QLL (30 per 30 days) fenofibrate nanocrystallized 2 $0 MO fenofibrate oral tablet 160 mg, 54 mg 2 $0 MO; QLL (30 per 30 days) gemfibrozil oral 2 $0 MO lovastatin oral tablet 10 mg, 20 mg 1 $0 MO; QLL (30 per 30 days) lovastatin oral tablet 40 mg 1 $0 MO; QLL (60 per 30 days) NIACIN (INOSITOL NIACINATE) ORAL TABLET 4 $0 [*] niacin oral tablet 500 mg 4 $0 MO; [*] niacin oral tablet extended release 24 hr 1,000 mg, 750 mg 2 $0 MO; QLL (60 per 30 days) niacin oral tablet extended release 24 hr 500 mg 2 $0 MO; QLL (30 per 30 days) NIACOR 1 $0 MO omega-3 acid ethyl esters 2 $0 PAR; MO pravastatin 1 $0 MO; QLL (30 per 30 days) prevalite 2 $0 MO simvastatin 1 $0 MO; QLL (30 per 30 days) ENYDMEM-0035-15 57

WELCHOL 2 $0 MO ZETIA 2 $0 MO; QLL (30 per 30 days) MISCELLANEOUS CARDIOVASCULAR AGENTS RANEXA 2 $0 MO VECAMYL 2 $0 NITRATES isosorbide dinitrate oral 2 $0 MO isosorbide mononitrate 2 $0 MO nitro-bid 2 $0 MO nitroglycerin intravenous 2 $0 B/D PAR nitroglycerin transdermal patch 24 hour 2 $0 MO NITROSTAT 1 $0 MO DERMATOLOGICALS/TOPICAL THERAPY ANTIPSORIATIC / ANTISEBORRHEIC acitretin 2 $0 MO calcipotriene topical cream 2 $0 MO; QLL (120 per 30 days) calcipotriene topical ointment 2 $0 MO; QLL (120 per 30 days) calcipotriene topical solution 2 $0 MO; QLL (60 per 30 days) selenium sulfide topical suspension 2 $0 MO BURN THERAPY silver sulfadiazine 2 $0 MO ssd 2 $0 MO MISCELLANEOUS DERMATOLOGICALS A & D ZINC OXIDE CREAM 4 $0 MO; [*] A + D (LAN, PET) 4 $0 MO; [*] allergy cream (diphenhyd, zn) 4 $0 [*] ammonium lactate topical 2 $0 MO anti-itch (diphenhydramine) topical gel 4 $0 [*] anti-itch(diphenhyd) with zinc topical cream 4 $0 [*] ENYDMEM-0035-15 58

ANTI-ITCH(DIPHENHYD) WITH ZINC TOPICAL CREAM 4 $0 [*] banophen anti-itch 4 $0 [*] calohist 4 $0 [*] carb-o-philic topical cream 20 % 4 $0 [*] diclofenac sodium topical gel 2 $0 PAR; MO; QLL (100 per 30 days) diphenhydramine hcl topical 4 $0 [*] ELIDEL 2 $0 PAR; MO; QLL (60 per 1 day) fluorouracil topical cream 5 % 2 $0 MO fluorouracil topical solution 2 $0 MO gormel 4 $0 MO; [*] imiquimod 2 $0 MO itch relief (diphenhydramine) topical gel 4 $0 [*] itch relief (pramoxine-zinc) 4 $0 [*] methoxsalen rapid 2 $0 PAR; MO OXSORALEN 2 $0 MO PANRETIN 2 $0 MO podofilox 2 $0 MO PROTOPIC 2 $0 PAR; MO; QLL (60 per 1 day) RUBBING ALCOHOL (ETHANOL) 4 $0 MO; [*] tacrolimus topical 2 $0 PAR; MO; QLL (60 per 1 day) U-CORT 2 $0 MO urea topical cream 20 % 4 $0 MO; [*] ureacin-20 4 $0 MO; [*] UVADEX 2 $0 VALCHLOR 2 $0 MO vitamin a & d diaper rash 4 $0 [*] vitamin a and d 4 $0 [*] vits a and d-white pet-lanolin topical ointment 4 $0 MO; [*] vits a and d-white pet-lanolin topical ointment in packet 4 $0 [*] ENYDMEM-0035-15 59

ZINC OXIDE DIAPER CREAM 4 $0 [*] zinc oxide topical ointment, 40 % 4 $0 [*] zinc oxide topical ointment 20 % 4 $0 MO; [*] THERAPY FOR ACNE acne treatment (benzoyl perox) topical gel 4 $0 [*] adapalene topical gel 0.3 % 2 $0 MO adapalene topical gel with pump 2 $0 MO amnesteem 2 $0 MO benzoyl peroxide topical gel 10 %, 5 % 4 $0 MO; [*] clindamycin phosphate topical 2 $0 MO DIFFERIN TOPICAL GEL 0.3 % 2 $0 MO DIFFERIN TOPICAL GEL WITH PUMP 2 $0 MO ery pads 2 $0 MO erythromycin with ethanol 2 $0 MO erythromycin-benzoyl peroxide 2 $0 MO metronidazole topical cream 2 $0 MO metronidazole topical gel 0.75 % 2 $0 MO metronidazole topical lotion 2 $0 MO persa-gel 4 $0 [*] rosadan topical cream 2 $0 MO TAZORAC 2 $0 PAR; MO tretinoin topical cream 2 $0 MO; QLL (45 per 30 days) tretinoin topical gel 0.01 %, 0.025 % 2 $0 MO; QLL (45 per 30 days) TRETIN-X CREAM KIT TOPICAL COMBO PACK 0.05 %, 0.1 % TOPICAL ANESTHETICS 2 $0 MO anti-itch (benz-resor) 4 $0 [*] calagesic 4 $0 [*] CALDYPHEN TOPICAL LOTION 1-8 % 4 $0 [*] lidocaine (pf) injection solution 10 mg/ml (1 %), 20 mg/ml (2 %), 40 mg/ml (4 %), 5 mg/ml (0.5 %) 2 $0 MO ENYDMEM-0035-15 60

lidocaine (pf) injection solution 15 mg/ml (1.5 %) 2 $0 lidocaine hcl injection solution 10 mg/ml (1 %), 20 mg/ml (2 %) 2 $0 MO lidocaine hcl laryngotracheal 2 $0 MO lidocaine hcl mucous membrane gel 2 $0 MO lidocaine hcl mucous membrane jelly in applicator 2 $0 MO lidocaine hcl mucous membrane solution 2 % 2 $0 lidocaine hcl mucous membrane solution 4 % (40 mg/ml) 2 $0 MO lidocaine hcl urethral 2 $0 lidocaine topical adhesive patch,medicated 2 $0 PAR; MO; QLL (90 per 30 days) lidocaine topical ointment 2 $0 MO lidocaine viscous 2 $0 MO lidocaine-prilocaine 2 $0 MO vagicaine topical cream 5-2 % 4 $0 [*] vagicream topical cream 5-2 % 4 $0 [*] TOPICAL ANTIBACTERIALS ANTIBIOTIC (BACITRACIN ZINC) 4 $0 [*] antibiotic (neomy-bacit-polym) 4 $0 [*] ANTIBIOTIC + PAIN RELIEF 4 $0 [*] ANTIBIOTIC PLUS (PRAMOXINE) 4 $0 [*] antiseptic solution 4 $0 [*] bacitracin topical ointment 4 $0 MO; [*] bacitracin topical packet 4 $0 [*] bacitracin zinc topical ointment 4 $0 MO; [*] bacitracin zinc topical packet 4 $0 [*] bacitracin-polymyxin b topical ointment 4 $0 MO; [*] bacitracin-polymyxin b topical packet 4 $0 [*] bacitraycin plus topical ointment 500 unit/gram 4 $0 [*] DOUBLE ANTIBIOTIC 4 $0 [*] first aid abx pain relief 4 $0 [*] ENYDMEM-0035-15 61

first aid antiseptic topical solution 4 $0 [*] gentamicin topical 2 $0 MO grx dyne topical solution 10 % 4 $0 [*] multi antibiotic plus 4 $0 [*] mupirocin ointment 2 $0 MO poly bacitracin 4 $0 [*] povidone-iodine topical liquid in packet 4 $0 [*] povidone-iodine topical ointment 4 $0 MO; [*] povidone-iodine topical solution 10 % 4 $0 [*] povidone-iodine topical spray,non-aerosol 4 $0 [*] sulfacetamide sodium (acne) 2 $0 MO SULFAMYLON TOPICAL CREAM 2 $0 MO tri-biozene 4 $0 [*] triple antibiotic (pram) extra 4 $0 [*] triple antibiotic plus 4 $0 [*] triple antibiotic topical ointment 4 $0 MO; [*] triple antibiotic topical ointment in packet 4 $0 MO; [*] TOPICAL ANTIFUNGALS af 4 $0 [*] aloe vesta topical ointment 2 % 4 $0 [*] ANTIFUNGAL (CLOTRIMAZOLE) 4 $0 [*] antifungal (tolnaftate) topical aerosol,spray 4 $0 [*] ANTIFUNGAL (TOLNAFTATE) TOPICAL CREAM 4 $0 [*] antifungal (tolnaftate) topical powder 4 $0 MO; [*] antifungal spray 4 $0 [*] athlete's foot (terbinafine) 4 $0 [*] athlete's foot (tolnaftate) 4 $0 [*] baza antifungal 4 $0 MO; [*] ciclodan topical solution 2 $0 PAR; MO ciclopirox topical cream 2 $0 MO ENYDMEM-0035-15 62

ciclopirox topical gel 2 $0 MO ciclopirox topical shampoo 2 $0 MO ciclopirox topical solution 2 $0 PAR; MO ciclopirox topical suspension 2 $0 MO clotrim antifungal 4 $0 [*] clotrimazole af 4 $0 [*] clotrimazole foot 4 $0 [*] clotrimazole topical 2 $0 MO clotrimazole-betamethasone 2 $0 MO critic-aid clear af 4 $0 MO; [*] econazole topical 2 $0 MO ELON DUAL DEFENSE 4 $0 [*] FUNGI-NAIL TOPICAL SOLUTION 4 $0 [*] fungoid-d 4 $0 [*] inzo antifungal 4 $0 [*] jock itch (terbinafine) 4 $0 [*] ketoconazole topical 2 $0 MO lotrimin af jock itch powder 4 $0 [*] lotrimin af powder 4 $0 MO; [*] micatin 4 $0 [*] miconazole nitrate topical aerosol powder 4 $0 [*] miconazole nitrate topical cream 4 $0 MO; [*] miconazorb af 4 $0 [*] micro-guard 4 $0 MO; [*] MYCO NAIL A 4 $0 [*] nuzole 4 $0 [*] nystatin topical 2 $0 MO nystatin-triamcinolone 2 $0 MO nystop 2 $0 MO podactin 4 $0 [*] ENYDMEM-0035-15 63

REMEDY ANTIFUNGAL TOPICAL POWDER 4 $0 [*] terbinafine hcl topical 4 $0 MO; [*] tinactin topical powder 4 $0 MO; [*] tolnaftate topical aerosol powder 4 $0 [*] tolnaftate topical cream 4 $0 [*] tolnaftate topical powder 4 $0 [*] tolnaftate topical solution 4 $0 MO; [*] triple paste af 4 $0 MO; [*] zeasorb (miconazole) 4 $0 MO; [*] TOPICAL ANTIVIRALS ABREVA 4 $0 MO; [*] acyclovir topical 2 $0 MO; QLL (30 per 30 days) DENAVIR 2 $0 MO; QLL (5 per 1 day) TOPICAL CORTICOSTEROIDS ala-cort topical cream 2 $0 MO alclometasone 2 $0 MO amcinonide 2 $0 MO anti-itch (hc) topical cream 4 $0 [*] anti-itch (hc) topical ointment 4 $0 [*] betamethasone dipropionate 2 $0 MO betamethasone valerate topical cream 2 $0 MO betamethasone valerate topical lotion 2 $0 MO betamethasone valerate topical ointment 2 $0 MO betamethasone, augmented 2 $0 MO CAPEX 2 $0 MO clobetasol topical cream 2 $0 MO clobetasol topical foam 2 $0 MO clobetasol topical gel 2 $0 MO clobetasol topical ointment 2 $0 MO clobetasol topical solution 2 $0 MO ENYDMEM-0035-15 64

clobetasol-emollient topical cream 2 $0 MO cormax topical solution 2 $0 MO cortaid topical cream 4 $0 MO; [*] cortisone (hydrocortisone) 4 $0 [*] cortizone-10 plus 4 $0 [*] cortizone-10 topical cream 4 $0 [*] cortizone-10 topical ointment 4 $0 [*] desonide 2 $0 MO desoximetasone 2 $0 MO diflorasone 2 $0 MO fluocinolone 2 $0 MO fluocinolone-shower cap 2 $0 MO fluocinonide topical cream 0.05 % 2 $0 MO fluocinonide topical gel 2 $0 MO fluocinonide topical ointment 2 $0 MO fluocinonide topical solution 2 $0 MO fluocinonide-e 2 $0 MO fluticasone topical 2 $0 MO halobetasol propionate 2 $0 MO HALOG 2 $0 MO hydrocortisone acetate topical 4 $0 [*] hydrocortisone plus 4 $0 [*] hydrocortisone topical cream 0.5 % 4 $0 MO; [*] hydrocortisone topical cream 1 %, 2.5 % 2 $0 MO hydrocortisone topical lotion 1 % 4 $0 MO; [*] hydrocortisone topical lotion 2.5 % 2 $0 MO hydrocortisone topical ointment 0.5 % 4 $0 MO; [*] hydrocortisone topical ointment 1 %, 2.5 % 2 $0 MO hydrocortisone valerate 2 $0 MO hydrocortisone-aloe vera topical cream 1 % 4 $0 MO; [*] ENYDMEM-0035-15 65

hydrocortisone-min oil-wht pet 2 $0 MO mometasone 2 $0 MO noble formula hc topical cream 4 $0 [*] recort plus 4 $0 [*] scalpicin anti-itch 4 $0 MO; [*] soothing care (hydrocortisone) 4 $0 [*] triamcinolone acetonide topical cream 2 $0 MO triamcinolone acetonide topical lotion 2 $0 MO triamcinolone acetonide topical ointment 0.025 %, 0.1 %, 0.5 % 2 $0 MO trianex 2 $0 MO triderm topical cream 2 $0 MO TOPICAL ENZYMES SANTYL 2 $0 MO; QLL (30 per 30 days) TOPICAL SCABICIDES / PEDICULICIDES lice complete kit 1-2-3 4 $0 [*] LICE CREAM RINSE 4 $0 [*] lice killing 4 $0 [*] LICE KILLING (PERMETHRIN) 4 $0 [*] lice pyrinyl shampoo 4 $0 [*] LICE SOLUTION 4 $0 [*] LICE TREATMENT (PERMETHRIN) 4 $0 [*] lice treatment topical liquid 1 % 4 $0 [*] lice treatment topical shampoo 4 $0 [*] lindane 2 $0 MO permethrin topical cream 2 $0 MO permethrin topical liquid 4 $0 MO; [*] pyrethrin lice treatment m 4 $0 [*] RID COMPLETE LICE ELIM KIT TOPICAL 4 $0 [*] RID LICE KILLING 4 $0 [*] ENYDMEM-0035-15 66

DIAGNOSTICS / MISCELLANEOUS AGENTS ANTIDOTES acetylcysteine intravenous 2 $0 B/D PAR; MO IRRIGATING SOLUTIONS lactated ringers irrigation 2 $0 B/D PAR; MO neomycin-polymyxin b gu 2 $0 MO ringers irrigation 2 $0 B/D PAR; MO MISCELLANEOUS AGENTS ADAGEN 2 $0 MO alendronate oral tablet 40 mg 1 $0 MO; QLL (30 per 30 days) anagrelide 2 $0 MO ARALAST NP 2 $0 PAR; MO; LA BUPHENYL ORAL TABLET 2 $0 PAR; MO cevimeline 2 $0 MO CLINIMIX 4.25%/D5W SULFIT FREE 2 $0 B/D PAR CLINIMIX E 2.75%/D10W SUL FREE 2 $0 B/D PAR CLINIMIX E 2.75%/D5W SULF FREE 2 $0 B/D PAR d10 % & 0.45 % sodium chloride 2 $0 B/D PAR d2.5 %-0.45 % sodium chloride 2 $0 B/D PAR d5 % and 0.9 % sodium chloride 2 $0 B/D PAR; MO d5 %-0.45 % sodium chloride 2 $0 B/D PAR; MO dex4 glucose bits 4 $0 [*] dex4 glucose oral tablet,chewable 4 $0 MO; [*] dex4 glucose pouch pack 4 $0 [*] dex4 glucose quick dissolve 4 $0 [*] dextrose 10 % and 0.2 % nacl 2 $0 B/D PAR dextrose 10 % in water (d10w) intravenous parenteral solution 2 $0 B/D PAR; MO dextrose 25 % in water (d25w) 2 $0 B/D PAR dextrose 30 % in water (d30w) 2 $0 B/D PAR ENYDMEM-0035-15 67

dextrose 40 % in water (d40w) 2 $0 B/D PAR dextrose 5 % in water (d5w) 2 $0 B/D PAR; MO dextrose 5 %-lactated ringers 2 $0 B/D PAR; MO dextrose 5%-0.2 % sod chloride 2 $0 B/D PAR dextrose 5%-0.3 % sod.chloride 2 $0 B/D PAR dextrose 50 % in water (d50w) intravenous parenteral solution dextrose 50 % in water (d50w) intravenous syringe 2 $0 B/D PAR; MO 2 $0 B/D PAR dextrose 70 % in water (d70w) 2 $0 B/D PAR; MO dextrose oral gel 4 $0 [*] dextrose with sodium chloride 2 $0 B/D PAR disulfiram 2 $0 MO EXJADE 2 $0 PAR; MO; LA gerber good start glucose 4 $0 [*] GLUCO BURST 4 $0 [*] glucose bits 4 $0 [*] glucose gel 4 $0 [*] glucose oral tablet,chewable 4 $0 [*] glucose oral tablet,chewable 4 gram 4 $0 MO; [*] INCRELEX 2 $0 PAR; MO; LA insta-glucose 4 $0 MO; [*] levocarnitine (with sugar) 2 $0 B/D PAR; MO levocarnitine oral tablet 2 $0 B/D PAR; MO midodrine 2 $0 MO ORFADIN 2 $0 LA pilocarpine hcl oral 2 $0 MO POLYETHYLENE GLYCOL 3350 4 $0 MO; [*] RENAGEL 2 $0 ST; MO RENVELA ORAL POWDER IN PACKET 0.8 GRAM 2 $0 MO; QLL (180 per 30 days) ENYDMEM-0035-15 68

RENVELA ORAL POWDER IN PACKET 2.4 GRAM 2 $0 MO; QLL (90 per 30 days) RENVELA ORAL TABLET 2 $0 MO; QLL (270 per 30 days) riluzole 2 $0 MO sodium chloride 0.9 % intravenous 2 $0 MO sodium chloride irrigation 2 $0 MO sodium polystyrene (sorb free) 2 $0 sodium polystyrene sulfonate oral powder 2 $0 MO sodium polystyrene sulfonate oral suspension 2 $0 sodium polystyrene sulfonate rectal 2 $0 SODIUM POLYSTYRENE SULFONATE RECTAL 2 $0 sps oral 2 $0 MO sps rectal 2 $0 SYPRINE 2 $0 MO water for irrigation, sterile 2 $0 B/D PAR; MO ZEMAIRA 2 $0 PAR; MO; LA MISCELLANEOUS DEVICES ALCOHOL, RUBBING 4 $0 [*] isopropyl alcohol solution 70 % 4 $0 MO; [*] isopropyl alcohol, rubbing 4 $0 MO; [*] SMOKING DETERRENTS buproban 2 $0 MO; QLL (60 per 30 days) CHANTIX 2 $0 PAR; MO; QLL (60 per 30 days) CHANTIX CONTINUING MONTH BOX 2 $0 PAR; MO; QLL (56 per 28 days) CHANTIX STARTING MONTH BOX 2 $0 PAR; MO; QLL (53 per 365 days) nicorelief buccal gum 4 $0 MO; [*] nicotine (polacrilex) buccal gum 4 $0 MO; [*] nicotine (polacrilex) buccal lozenge 4 $0 MO; [*]; QLL (20 per 1 day) nicotine transdermal patch 24 hour 14 mg/24 hr, 21 mg/24 hr, 7 mg/24 hr 4 $0 MO; [*]; QLL (30 per 30 days) ENYDMEM-0035-15 69

nicotine transdermal patch, td daily, sequential 4 $0 MO; [*] NICOTROL NS 2 $0 MO; QLL (120 per 30 days) nts step 1 4 $0 [*]; QLL (30 per 30 days) quit 2 buccal gum 4 $0 [*] quit 4 buccal gum 4 $0 [*] stop smoking aid buccal lozenge 4 $0 [*]; QLL (20 per 1 day) EAR, NOSE / THROAT MEDICATIONS MISCELLANEOUS AGENTS anefrin 4 $0 [*] ayr saline nasal drops 4 $0 MO; [*] azelastine nasal 2 $0 MO; QLL (30 per 25 days) baby ayr saline 4 $0 [*] chlorhexidine gluconate mucous membrane 2 $0 MO cough drops mucous membrane lozenge 10 mg 4 $0 [*] COUGH DROPS MUCOUS MEMBRANE LOZENGE 2.7 MG, 5 MG, 5.8 MG, 6.1 MG, 8 MG, 9.1 MG 4 $0 [*] dristan long lasting 4 $0 [*] ipratropium bromide nasal 2 $0 MO; QLL (30 per 30 days) MENTHOL COUGH MUCOUS MEMBRANE LOZENGE 6.1 MG 4 $0 [*] nasal decongestant (oxymetazl) 4 $0 [*] NASAL RELIEF 4 $0 [*] nasal spray (oxymetazoline) 4 $0 [*] nrs nasal relief 4 $0 [*] original nasal spray 4 $0 [*] oxymetazoline 4 $0 [*] paroex oral rinse 2 $0 MO periogard 2 $0 MO sinus nasal spray 4 $0 [*] sinus relief (oxymetazoline) 4 $0 [*] ENYDMEM-0035-15 70

SORE THROAT (MENTHOL) 4 $0 [*] triamcinolone acetonide dental 2 $0 MO TYZINE NASAL DROPS 0.05 % 2 $0 MO MISCELLANEOUS OTIC PREPARATIONS acetic acid otic 2 $0 MO acetic acid-aluminum acetate 2 $0 MO fluocinolone acetonide oil 2 $0 MO hydrocortisone-acetic acid 2 $0 MO ofloxacin otic 2 $0 MO OTIC STEROID / ANTIBIOTIC CIPRODEX 2 $0 MO COLY-MYCIN S 2 $0 MO neomycin-polymyxin-hc otic 2 $0 MO ENDOCRINE/DIABETES ADRENAL HORMONES ACTHAR H.P. 2 $0 PAR; MO cortisone 2 $0 MO dexamethasone 2 $0 MO dexamethasone sodium phos (pf) 2 $0 MO dexamethasone sodium phosphate injection 2 $0 MO fludrocortisone 2 $0 MO hydrocortisone oral 2 $0 MO methylprednisolone acetate 2 $0 MO methylprednisolone sodium succ injection recon soln 125 mg, 40 mg 2 $0 MO methylprednisolone sodium succ intravenous 2 $0 MO methylprednisolone tablets 2 $0 MO prednisolone oral solution 15 mg/5 ml 2 $0 MO prednisolone sodium phosphate oral solution 15 mg/5 ml, 5 mg base/5 ml (6.7 mg/5 ml) 2 $0 MO ENYDMEM-0035-15 71

prednisolone sodium phosphate oral tablet,disintegrating 2 $0 MO prednisone intensol 2 $0 MO prednisone oral solution 2 $0 MO prednisone oral tablet 1 $0 MO prednisone oral tablets,dose pack 1 $0 MO triamcinolone acetonide injection suspension 10 mg/ml triamcinolone acetonide injection suspension 40 mg/ml ANTITHYROID AGENTS 2 $0 MO 2 $0 methimazole oral tablet 10 mg, 5 mg 2 $0 MO propylthiouracil 2 $0 MO DIABETES THERAPY acarbose oral tablet 100 mg 2 $0 MO; QLL (90 per 30 days) acarbose oral tablet 25 mg 2 $0 MO; QLL (360 per 30 days) acarbose oral tablet 50 mg 2 $0 MO; QLL (180 per 30 days) alcohol pads 1 $0 MO BYDUREON 2 $0 MO; QLL (4 per 28 days) BYETTA SUBCUTANEOUS PEN INJECTOR 10 MCG/DOSE(250 MCG/ML) 2.4 ML BYETTA SUBCUTANEOUS PEN INJECTOR 5 MCG/DOSE (250 MCG/ML) 1.2 ML 2 $0 MO; QLL (2.4 per 30 days) 2 $0 MO; QLL (1.2 per 30 days) CYCLOSET 2 $0 ST; MO; QLL (180 per 30 days) GAUZE PADS 2 X 2 1 $0 MO; QLL (200 per 30 days) glimepiride oral tablet 1 mg 1 $0 MO; QLL (240 per 30 days) glimepiride oral tablet 2 mg 1 $0 MO; QLL (120 per 30 days) glimepiride oral tablet 4 mg 1 $0 MO; QLL (60 per 30 days) glipizide oral tablet 10 mg 1 $0 MO; QLL (120 per 30 days) glipizide oral tablet 5 mg 1 $0 MO; QLL (240 per 30 days) glipizide oral tablet extended release 24hr 10 mg 1 $0 MO; QLL (60 per 30 days) glipizide oral tablet extended release 24hr 2.5 mg 1 $0 MO; QLL (240 per 30 days) ENYDMEM-0035-15 72

glipizide oral tablet extended release 24hr 5 mg 1 $0 MO; QLL (120 per 30 days) glipizide-metformin oral tablet 2.5-250 mg 1 $0 MO; QLL (240 per 30 days) glipizide-metformin oral tablet 2.5-500 mg, 5-500 mg GLUCAGEN HYPOKIT 2 $0 MO GLUCAGON EMERGENCY KIT (HUMAN) 2 $0 MO HUMALOG KWIKPEN 2 $0 MO HUMALOG MIX 50-50 2 $0 MO HUMALOG MIX 50-50 KWIKPEN 2 $0 MO HUMALOG MIX 75-25 2 $0 MO HUMALOG MIX 75-25 KWIKPEN 2 $0 MO HUMALOG SUBCUTANEOUS CARTRIDGE 2 $0 MO HUMALOG SUBCUTANEOUS SOLUTION 100 UNIT/ML HUMALOG SUBCUTANEOUS SOLUTION 100 UNIT/ML (PREFILLED SYRINGE) 1 $0 MO; QLL (120 per 30 days) 2 $0 MO 2 $0 HUMULIN 70/30 2 $0 MO HUMULIN 70/30 KWIKPEN 2 $0 MO HUMULIN N 2 $0 MO HUMULIN N KWIKPEN 2 $0 MO HUMULIN R 2 $0 MO HUMULIN R U-500 (CONCENTRATED) 2 $0 MO INSULIN PEN NEEDLE 1 $0 MO; QLL (200 per 30 days) INSULIN SYRINGE (DISP) U-100 0.3 ML 1 $0 MO; QLL (200 per 30 days) INSULIN SYRINGE (DISP) U-100 1 ML 1 $0 MO; QLL (200 per 30 days) INSULIN SYRINGE (DISP) U-100 1/2 ML 1 $0 MO; QLL (200 per 30 days) JANUMET 2 $0 MO; QLL (60 per 30 days) JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 100-1,000 MG JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 50-1,000 MG, 50-500 MG 2 $0 MO; QLL (30 per 30 days) 2 $0 MO; QLL (60 per 30 days) JANUVIA ORAL TABLET 100 MG 2 $0 MO; QLL (30 per 30 days) ENYDMEM-0035-15 73

JANUVIA ORAL TABLET 25 MG 2 $0 MO; QLL (120 per 30 days) JANUVIA ORAL TABLET 50 MG 2 $0 MO; QLL (60 per 30 days) JARDIANCE 2 $0 PAR; MO; QLL (30 per 30 days) JENTADUETO 2 $0 MO; QLL (60 per 30 days) KOMBIGLYZE XR ORAL TABLET, ER MULTIPHASE 24 HR 2.5-1,000 MG KOMBIGLYZE XR ORAL TABLET, ER MULTIPHASE 24 HR 5-1,000 MG, 5-500 MG 2 $0 MO; QLL (60 per 30 days) 2 $0 MO; QLL (30 per 30 days) LANTUS 2 $0 MO LANTUS SOLOSTAR 2 $0 MO LEVEMIR 2 $0 MO LEVEMIR FLEXTOUCH 2 $0 MO metformin oral tablet 1,000 mg 1 $0 MO; QLL (76 per 30 days) metformin oral tablet 500 mg 1 $0 MO; QLL (153 per 30 days) metformin oral tablet 850 mg 1 $0 MO; QLL (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 1,000 mg metformin oral tablet extended release 24hr 500 mg 1 $0 MO; QLL (120 per 30 days) 1 $0 MO; QLL (80 per 30 days) 1 $0 MO; QLL (75 per 30 days) 1 $0 MO; QLL (150 per 30 days) nateglinide oral tablet 120 mg 2 $0 MO; QLL (90 per 30 days) nateglinide oral tablet 60 mg 2 $0 MO; QLL (180 per 30 days) NEEDLES, INSULIN DISP.,SAFETY 1 $0 MO; QLL (200 per 30 days) ONGLYZA ORAL TABLET 2.5 MG 2 $0 MO; QLL (60 per 30 days) ONGLYZA ORAL TABLET 5 MG 2 $0 MO; QLL (30 per 30 days) pioglitazone oral tablet 15 mg 1 $0 MO; QLL (90 per 30 days) pioglitazone oral tablet 30 mg 1 $0 MO; QLL (45 per 30 days) pioglitazone oral tablet 45 mg 1 $0 MO; QLL (30 per 30 days) pioglitazone-glimepiride 2 $0 MO; QLL (30 per 30 days) ENYDMEM-0035-15 74

pioglitazone-metformin 2 $0 MO; QLL (90 per 30 days) PRANDIMET 2 $0 MO; QLL (150 per 30 days) PROGLYCEM 2 $0 MO SYMLINPEN 120 2 $0 PAR; MO; QLL (11 per 30 days) SYMLINPEN 60 2 $0 PAR; MO; QLL (6 per 30 days) TANZEUM 2 $0 MO; QLL (4 per 28 days) tolazamide oral tablet 250 mg 1 $0 MO; QLL (120 per 30 days) tolazamide oral tablet 500 mg 1 $0 MO; QLL (60 per 30 days) tolbutamide 1 $0 MO; QLL (180 per 30 days) TOUJEO SOLOSTAR 2 $0 MO TRADJENTA 2 $0 MO; QLL (30 per 30 days) TRULICITY 2 $0 MO; QLL (2 per 28 days) VICTOZA 2-PAK 2 $0 MO; QLL (9 per 30 days) VICTOZA 3-PAK 2 $0 MO; QLL (9 per 30 days) MISCELLANEOUS HORMONES ALDURAZYME 2 $0 PAR; MO ANDRODERM 2 $0 PAR; MO; QLL (30 per 30 days) ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP 1.25 GRAM/ ACTUATION (1 %) ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP 20.25 MG/1.25 GRAM (1.62 %) ANDROGEL TRANSDERMAL GEL IN PACKET 1 % (25 MG/2.5GRAM), 1 % (50 MG/5 GRAM) ANDROGEL TRANSDERMAL GEL IN PACKET 1.62 % (20.25 MG/1.25 GRAM) ANDROGEL TRANSDERMAL GEL IN PACKET 1.62 % (40.5 MG/2.5 GRAM) 2 $0 PAR; MO; QLL (300 per 30 days) 2 $0 PAR; MO; QLL (150 per 30 days) 2 $0 PAR; MO; QLL (300 per 30 days) 2 $0 PAR; MO; QLL (30 per 30 days) 2 $0 PAR; MO; QLL (60 per 30 days) androxy 2 $0 PAR; MO cabergoline 2 $0 MO calcitonin (salmon) 2 $0 MO; QLL (4 per 30 days) ENYDMEM-0035-15 75

calcitriol intravenous solution 1 mcg/ml 2 $0 B/D PAR; MO calcitriol oral 2 $0 B/D PAR; MO CEREZYME INTRAVENOUS RECON SOLN 400 UNIT 2 $0 PAR; MO danazol oral 2 $0 MO desmopressin injection 2 $0 MO desmopressin nasal 2 $0 MO desmopressin oral 2 $0 MO doxercalciferol intravenous 2 $0 B/D PAR doxercalciferol oral 2 $0 B/D PAR; MO ELAPRASE 2 $0 PAR; MO FABRAZYME 2 $0 PAR; MO HECTOROL INTRAVENOUS SOLUTION 2 MCG/ML (1 ML) HECTOROL INTRAVENOUS SOLUTION 4 MCG/2 ML 2 $0 PAR 2 $0 PAR; MO HECTOROL ORAL 2 $0 PAR; MO KUVAN ORAL TABLET,SOLUBLE 2 $0 PAR; MO MYOZYME 2 $0 PAR; MO NAGLAZYME 2 $0 PAR; MO; LA oxandrolone oral tablet 10 mg 2 $0 PAR; MO; QLL (60 per 30 days) oxandrolone oral tablet 2.5 mg 2 $0 PAR; MO; QLL (120 per 30 days) pamidronate 2 $0 B/D PAR; MO paricalcitol oral 2 $0 B/D PAR; MO SENSIPAR ORAL TABLET 30 MG, 60 MG 2 $0 MO; QLL (60 per 30 days) SENSIPAR ORAL TABLET 90 MG 2 $0 MO; QLL (120 per 30 days) SOMAVERT 2 $0 PAR; MO; LA STIMATE 2 $0 MO SYNAREL 2 $0 PAR; MO TESTIM 2 $0 PAR; MO; QLL (300 per 30 days) testosterone cypionate 2 $0 MO ENYDMEM-0035-15 76

testosterone enanthate 2 $0 MO testosterone transdermal gel in packet 2 $0 PAR; MO; QLL (300 per 30 days) ZAVESCA 2 $0 PAR; MO; LA ZEMPLAR INTRAVENOUS 2 $0 B/D PAR; MO zoledronic acid intravenous recon soln 2 $0 PAR zoledronic acid intravenous solution 2 $0 PAR; MO ZOMETA INTRAVENOUS SOLUTION 4 MG/100 ML THYROID HORMONES 2 $0 PAR; MO levothyroxine oral 2 $0 MO levoxyl oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg 2 $0 MO liothyronine oral 2 $0 MO SYNTHROID 2 $0 MO unithroid oral tablet 100 mcg, 112 mcg, 125 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg GASTROENTEROLOGY ANTIDIARRHEALS / ANTISPASMODICS 2 $0 MO anti-diarrheal (loperamide) oral capsule 4 $0 [*] ANTI-DIARRHEAL (LOPERAMIDE) ORAL LIQUID 4 $0 [*] anti-diarrheal (loperamide) oral tablet 4 $0 MO; [*] atropine injection syringe 0.05 mg/ml, 0.1 mg/ml 2 $0 bismatrol oral suspension 262 mg/15 ml 4 $0 MO; [*] bismatrol oral suspension 525 mg/15 ml 4 $0 [*] bismatrol oral tablet,chewable 4 $0 [*] bismuth 4 $0 [*] bismuth maximum strength 4 $0 [*] diamode 4 $0 [*] diarrhea relief (bismuth subs) 4 $0 [*] ENYDMEM-0035-15 77

dicyclomine oral capsule 2 $0 MO dicyclomine oral solution 2 $0 MO dicyclomine oral tablet 2 $0 MO diotame 4 $0 [*] diphenoxylate-atropine 2 $0 MO glycopyrrolate oral 2 $0 MO kaopectate (bismuth subsalicy) 4 $0 MO; [*] KAOPECTATE CHILD(BIS SSALICYL) 4 $0 [*] kaopectate ex str (bismuth ss) 4 $0 [*] kao-tin (bismuth subsalicylat) 4 $0 [*] k-pec antidiarrheal (bism sub) 4 $0 [*] loperamide oral capsule 2 $0 MO loperamide oral liquid 1 mg/5 ml 4 $0 MO; [*] loperamide oral liquid 1 mg/7.5 ml 4 $0 [*] loperamide oral tablet 4 $0 [*] medi-bismuth 4 $0 [*] opium tincture oral tincture 2 $0 MO peptic relief 4 $0 [*] pepto-bismol oral tablet,chewable 4 $0 MO; [*] pepto-bismol to-go 4 $0 [*] pink bismuth maximum strength 4 $0 [*] pink bismuth oral suspension 4 $0 [*] pink bismuth oral tablet 4 $0 [*] pink bismuth oral tablet,chewable 4 $0 MO; [*] soothe (bismuth subsalicylate) 4 $0 [*] MISCELLANEOUS GASTROINTESTINAL AGENTS ADVANCED ANTACID-ANTIGAS 4 $0 [*] almacone oral suspension 4 $0 [*] almacone-2 4 $0 [*] alophen 4 $0 [*] ENYDMEM-0035-15 78

alosetron 2 $0 PAR; MO; QLL (60 per 30 days) aluminum hydroxide gel oral suspension 320 mg/5 ml aluminum hydroxide gel oral suspension 600 mg/5 ml 4 $0 MO; [*] 4 $0 [*] AMITIZA 2 $0 MO antacid anti-gas double str 4 $0 [*] ANTACID ANTI-GAS ORAL SUSPENSION 4 $0 [*] antacid liquid 4 $0 [*] antacid plus anti-gas 4 $0 [*] ANTACID WITH SIMETHICONE ORAL SUSPENSION 4 $0 [*] ANTACID-ANTIGAS 4 $0 [*] antacid-simethicone 4 $0 [*] antacid-simethicone ds 4 $0 [*] anti-gas ultra strength 4 $0 [*] anti-nausea 4 $0 [*] APRISO 2 $0 MO ASACOL HD 2 $0 MO balsalazide 2 $0 MO bisac-evac 4 $0 MO; [*] bisacodyl oral 4 $0 MO; [*] bisacodyl rectal 4 $0 MO; [*] bisa-lax 4 $0 [*] biscolax 4 $0 MO; [*] budesonide oral 2 $0 MO CANASA 2 $0 MO child suppository 4 $0 [*] children's pepto 4 $0 [*] CIMZIA 2 $0 PAR; MO; QLL (6 per 28 days) CIMZIA POWDER FOR RECONST 2 $0 PAR; MO; QLL (6 per 28 days) ENYDMEM-0035-15 79

CIMZIA STARTER KIT 2 $0 PAR; MO; QLL (6 per 28 days) CITRATE OF MAGNESIA 4 $0 [*] citroma 4 $0 [*] CLEARLAX ORAL POWDER 4 $0 MO; [*] colocort 2 $0 MO col-rite 4 $0 [*] comfort gel 4 $0 [*] comfort gel extra strength 4 $0 [*] compro 2 $0 PAR; MO constulose 2 $0 MO CREON 2 $0 MO CYSTADANE 2 $0 MO DELZICOL 2 $0 MO dimenhydrinate oral 4 $0 MO; [*] diocto oral liquid 4 $0 [*] diocto oral syrup 4 $0 MO; [*] dioctyl 4 $0 [*] DIPENTUM 2 $0 MO disposable enema 4 $0 [*] doc-q-lace 4 $0 MO; [*] doc-q-lax 4 $0 MO; [*] docu 4 $0 MO; [*] docuprene 4 $0 [*] docusate calcium 4 $0 MO; [*] docusate sodium oral capsule 4 $0 MO; [*] docusate sodium oral liquid 4 $0 MO; [*] docusate sodium oral tablet 4 $0 [*] docusil 4 $0 [*] dok oral capsule 100 mg 4 $0 MO; [*] dok oral capsule 250 mg 4 $0 [*] ENYDMEM-0035-15 80

dok oral tablet 4 $0 MO; [*] dok plus 4 $0 [*] dramamine oral tablet 4 $0 MO; [*] driminate 4 $0 [*] dronabinol 2 $0 B/D PAR; MO; QLL (120 per 30 days) ducodyl 4 $0 [*] dulcolax stool softener (dss) 4 $0 MO; [*] EMEND ORAL CAPSULE 125 MG 2 $0 B/D PAR; MO; QLL (4 per 30 days) EMEND ORAL CAPSULE 40 MG 2 $0 B/D PAR; MO; QLL (1 per 1 day) EMEND ORAL CAPSULE 80 MG 2 $0 B/D PAR; MO; QLL (8 per 30 days) EMEND ORAL CAPSULE,DOSE PACK 2 $0 B/D PAR; MO; QLL (12 per 30 days) enema disposable 4 $0 [*] enema rectal 4 $0 [*] ENEMA RECTAL 4 $0 [*] enulose 2 $0 MO EPSOM SALT 4 $0 [*] fiber (calcium polycarbophil) 4 $0 MO; [*] fiber (psyllium husk) 4 $0 [*] FIBER (PSYLLIUM HUSK/SUGAR) 4 $0 [*] FIBER (WITH ASPARTAME) 4 $0 [*] fiber laxative (ca polycarbo) 4 $0 [*] fiber laxative (husk/sugar) 4 $0 [*] fiber laxative (methylcellulo) 4 $0 [*] fiber laxative (psyllium husk) 4 $0 [*] fiber laxative (psyllium) s/f 4 $0 [*] FIBER ORAL POWDER 4 $0 [*] fiber smooth 4 $0 [*] FIBER SMOOTH (SUCROSE) 4 $0 [*] fiber therapy 4 $0 [*] ENYDMEM-0035-15 81

fiber therapy (ca polycarboph) 4 $0 [*] fiber therapy (psyllium seed) 4 $0 [*] fiber therapy (psyllium) 4 $0 [*] fiber therapy laxative (husk) 4 $0 [*] fiber therapy sugar free 4 $0 [*] FIBER-CAPS 4 $0 [*] fiber-lax 4 $0 MO; [*] fiber-tabs 4 $0 [*] flanax antacid 4 $0 [*] foaming antacid extra strength 4 $0 [*] foaming antacid oral suspension 4 $0 [*] formula em 4 $0 [*] gas relief extra strength oral capsule 4 $0 [*] gas relief oral capsule 4 $0 [*] gas relief ultra strength 4 $0 [*] gavilax oral powder 4 $0 MO; [*] gavilyte-c 2 $0 MO gavilyte-g 2 $0 MO gavilyte-n 2 $0 MO generlac 2 $0 MO gentle laxative 4 $0 [*] gentlelax 4 $0 [*] geri-kot 4 $0 [*] geri-lanta 4 $0 [*] geri-mox antacid-antigas 4 $0 [*] GERI-MUCIL 4 $0 [*] glycerin (adult) 4 $0 [*] glycerin (child) 4 $0 [*] glycolax oral powder 4 $0 [*] healthylax 4 $0 [*] ENYDMEM-0035-15 82

heartburn relief (magnesium carbonate/aluminum hydroxide) tab chews 4 $0 [*] HEMORRHOID RECTAL OINTMENT 4 $0 [*] hemorrhoidal cream 4 $0 [*] hemorrhoidal rectal cream 0.25-3-12 % 4 $0 [*] hemorrhoidal rectal ointment 4 $0 MO; [*] HEMORRHOIDAL RECTAL OINTMENT 0.25-14-71.9 %, 0.25-14-74.9 % 4 $0 [*] hydrocortisone acetate rectal suppository 4 $0 MO; [*] hydrocortisone rectal enema 2 $0 MO kao-tin (docusate calcium) 4 $0 [*] konsyl (sugar) oral powder 3.4 gram/11 gram 4 $0 [*] konsyl (sugar) oral powder 3.4 gram/12 gram 4 $0 MO; [*] konsyl easy mix 4 $0 [*] konsyl fiber 4 $0 [*] konsyl formula-d 4 $0 MO; [*] konsyl sugar-free (aspartame) oral powder 4 $0 [*] konsyl sugar-free oral capsule 4 $0 MO; [*] konsyl sugar-free oral powder 4 $0 MO; [*] lactulose 2 $0 MO laxa clear 4 $0 [*] laxacin 4 $0 [*] laxative (glycerin-pediatric) 4 $0 [*] laxative peg 3350 oral powder 4 $0 [*] laxative-senna 4 $0 [*] LIALDA 2 $0 MO LINZESS 2 $0 MO liquid antacid 4 $0 [*] LOTRONEX 2 $0 PAR; MO; QLL (60 per 30 days) mag-al plus 4 $0 [*] mag-al plus extra strength 4 $0 [*] ENYDMEM-0035-15 83

magnesium citrate oral solution 4 $0 MO; [*] meclizine oral tablet 12.5 mg, 25 mg 2 $0 MO meclizine oral tablet,chewable 4 $0 [*] mesalamine rectal 2 $0 MO mesalamine with cleansing wipe 2 $0 MO metoclopramide hcl injection solution 2 $0 MO metoclopramide hcl injection syringe 2 $0 metoclopramide hcl oral solution 2 $0 MO metoclopramide hcl oral tablet 2 $0 MO mi-acid oral suspension 4 $0 MO; [*] mi-acid oral tablet,chewable 4 $0 [*] milk of magnesia 4 $0 MO; [*] milk of magnesia concentrated 4 $0 MO; [*] mineral oil extra heavy oral 4 $0 [*] mineral oil heavy oral 4 $0 MO; [*] mineral oil laxative 4 $0 MO; [*] mineral oil oral 4 $0 MO; [*] mineral oil rectal 4 $0 [*] mintox 4 $0 MO; [*] mintox maximum strength 4 $0 MO; [*] mintox plus 4 $0 MO; [*] motion relief (meclizine) 4 $0 [*] MOTION SICKNESS (MECLIZINE) 4 $0 [*] motion sickness relief(mecliz) 4 $0 [*] natural fiber laxative 4 $0 [*] natural fiber laxative (sugar) 4 $0 [*] natural fiber laxative s/f 4 $0 [*] natural fiber laxative smooth 4 $0 [*] natural fiber laxative therapy 4 $0 [*] natural fiber laxative(aspart) 4 $0 [*] ENYDMEM-0035-15 84

natural fiber supplement oral powder in packet 4 $0 [*] natural laxative 4 $0 [*] NATURAL PSYLLIUM FIBER 4 $0 [*] NATURAL VEGETABLE 4 $0 [*] NATURAL VEGETABLE (PSYLLIUM) 4 $0 [*] natural vegetable powder 4 $0 [*] nausea control 4 $0 [*] nausea relief 4 $0 [*] ondansetron hcl (pf) injection solution 2 $0 MO ondansetron hcl (pf) injection syringe 2 $0 ondansetron hcl intravenous solution 2 $0 MO ondansetron hcl oral solution 2 $0 B/D PAR; MO; QLL (450 per 30 days) ondansetron hcl oral tablet 24 mg 2 $0 B/D PAR; QLL (30 per 30 days) ondansetron hcl oral tablet 4 mg, 8 mg 2 $0 B/D PAR; MO; QLL (90 per 30 days) ondansetron odt 2 $0 B/D PAR; MO; QLL (90 per 30 days) oral saline laxative oral liquid 4 $0 [*] p-col rite 4 $0 [*] peg 3350-electrolytes oral recon soln 236-22.74-6.74-5.86 gram peg 3350-electrolytes oral recon soln 240-22.72-6.72-5.84 gram 2 $0 MO 2 $0 peg-3350 with flavor packs 2 $0 peg-electrolyte soln 2 $0 PENTASA 2 $0 MO perdiem overnight relief 4 $0 MO; [*] peri-colace 4 $0 MO; [*] PHOSPHATE LAXATIVE 4 $0 [*] polyethylene glycol 3350 oral 2 $0 MO ENYDMEM-0035-15 85

prochlorperazine edisylate injection solution 10 mg/2 ml (5 mg/ml) 2 $0 PAR; MO prochlorperazine maleate oral 2 $0 PAR; MO prochlorperazine maleate rectal 2 $0 PAR; MO procto-pak 2 $0 MO proctosol hc 2 $0 MO proctozone-hc 2 $0 MO promolaxin 4 $0 [*] psyllium husk oral capsule 4 $0 [*] purelax 4 $0 [*] ready-to-use enema 4 $0 [*] ready-to-use enema (min oil) 4 $0 [*] reguloid oral capsule 4 $0 [*] reguloid oral powder 4 $0 MO; [*] reguloid, sugar free 4 $0 [*] RELISTOR SUBCUTANEOUS SOLUTION 2 $0 PAR; MO RELISTOR SUBCUTANEOUS SYRINGE 2 $0 PAR; MO REMICADE 2 $0 PAR; MO ri-gel 4 $0 [*] ri-gel ii 4 $0 [*] ri-mox 4 $0 [*] ri-mox plus 4 $0 [*] SANI-SUPP (ADULT) 4 $0 MO; [*] sani-supp (infant) 4 $0 MO; [*] senexon 4 $0 MO; [*] senexon-s 4 $0 MO; [*] senna lax 4 $0 MO; [*] senna laxative 4 $0 [*] senna oral syrup 8.8 mg/5 ml 4 $0 MO; [*] SENNA ORAL TABLET 4 $0 [*] senna plus 4 $0 MO; [*] ENYDMEM-0035-15 86

SENNA PROMPT 4 $0 [*] senna with docusate sodium 4 $0 [*] senna-extra 4 $0 [*] senna-gen 4 $0 MO; [*] senna-s 4 $0 MO; [*] senno 4 $0 [*] sennosides-docusate sodium 4 $0 [*] SENOKOTXTRA 4 $0 MO; [*] sen-o-tab 4 $0 [*] silace oral liquid 4 $0 MO; [*] silace oral syrup 4 $0 [*] simethicone oral capsule 180 mg 4 $0 [*] sodium bicarbonate oral 4 $0 MO; [*] sof-lax 4 $0 [*] soluble fiber 4 $0 [*] STIMULANT LAXATIVE PLUS 4 $0 [*] stool softener oral capsule 100 mg, 240 mg 4 $0 MO; [*] STOOL SOFTENER ORAL CAPSULE 250 MG 4 $0 MO; [*] stool softener oral capsule 50 mg 4 $0 [*] stool softener oral liquid 4 $0 [*] stool softener oral syrup 4 $0 [*] stool softener oral tablet 4 $0 [*] stool softener-laxative 4 $0 [*] stool softener-stimulant laxat 4 $0 [*] sulfasalazine 2 $0 MO sulfazine 2 $0 MO sulfazine ec 2 $0 MO suppository adult 4 $0 [*] surfak 4 $0 MO; [*] travel sickness (meclizine) 4 $0 MO; [*] ENYDMEM-0035-15 87

ursodiol 2 $0 MO vegetable laxative 4 $0 [*] WOMEN'S GENTLE LAXATIVE(BISAC) 4 $0 [*] women's laxative (bisacodyl) 4 $0 [*] ULCER THERAPY acid control (ranitidine) oral tablet 150 mg 4 $0 [*] ACID REDUCER (CIMETIDINE) 4 $0 [*] acid reducer (famotidine) 4 $0 [*] ACID REDUCER (RANITIDINE) 4 $0 [*] acid reducer complete (famot) 4 $0 [*] acid relief (cimetidine) 4 $0 [*] cimetidine oral tablet 200 mg 4 $0 MO; [*] DEXILANT 2 $0 ST; MO; QLL (30 per 30 days) DUAL ACTION COMPLETE 4 $0 [*] famotidine (pf) 2 $0 MO famotidine (pf)-nacl (iso-os) 2 $0 famotidine intravenous 2 $0 MO famotidine oral suspension 2 $0 MO famotidine oral tablet 10 mg 4 $0 MO; [*] famotidine oral tablet 20 mg, 40 mg 2 $0 MO heartburn relief (famotidine) 4 $0 [*] HEARTBURN RELIEF (LANSOPRAZOLE) ORAL CAPSULE,DELAYED RELEASE(DR/EC) 15 MG heartburn relief (ranitidine) 4 $0 [*] 4 $0 [*]; QLL (30 per 30 days) lansoprazole oral capsule,delayed release(dr/ec) 2 $0 MO; QLL (30 per 30 days) misoprostol 2 $0 MO omeprazole magnesium 4 $0 [*] omeprazole oral capsule,delayed release(dr/ec) 2 $0 MO; QLL (30 per 30 days) omeprazole oral tablet,delayed release (dr/ec) 4 $0 MO; [*] pantoprazole oral 2 $0 MO; QLL (30 per 30 days) ENYDMEM-0035-15 88

pepcid ac oral tablet 20 mg 4 $0 MO; [*] PRILOSEC OTC 4 $0 MO; [*] ranitidine hcl injection 2 $0 MO ranitidine hcl oral syrup 2 $0 MO ranitidine hcl oral tablet 150 mg, 300 mg 2 $0 MO ranitidine hcl oral tablet 75 mg 4 $0 MO; [*] sucralfate oral tablet 2 $0 MO tagamet hb 4 $0 MO; [*] IMMUNOLOGY, VACCINES / BIOTECHNOLOGY BIOTECHNOLOGY DRUGS ACTIMMUNE 2 $0 PAR; MO ARANESP (IN POLYSORBATE) 2 $0 PAR; MO ARCALYST 2 $0 PAR; MO AVONEX (WITH ALBUMIN) 2 $0 PAR; MO; QLL (4 per 28 days) AVONEX INTRAMUSCULAR PEN INJECTOR KIT 2 $0 PAR; MO; QLL (4 per 28 days) AVONEX INTRAMUSCULAR SYRINGE 2 $0 PAR; MO; QLL (4 per 28 days) AVONEX INTRAMUSCULAR SYRINGE KIT 2 $0 PAR; MO; QLL (4 per 28 days) EXTAVIA SUBCUTANEOUS KIT 2 $0 PAR; MO EXTAVIA SUBCUTANEOUS RECON SOLN 2 $0 PAR GENOTROPIN 2 $0 PAR; MO GENOTROPIN MINIQUICK 2 $0 PAR; MO HUMATROPE INJECTION CARTRIDGE 12 MG (36 UNIT), 24 MG (72 UNIT) 2 $0 PAR; MO ILARIS (PF) 2 $0 PAR; MO; LA INTRON A INJECTION 2 $0 PAR; MO LEUKINE INJECTION RECON SOLN 2 $0 PAR; MO MOZOBIL 2 $0 PAR; MO NEULASTA SUBCUTANEOUS SYRINGE 2 $0 PAR; MO; QLL (2 per 28 days) NEUMEGA 2 $0 PAR; MO; QLL (21 per 21 days) NEUPOGEN 2 $0 PAR; MO ENYDMEM-0035-15 89

NORDITROPIN FLEXPRO 2 $0 PAR; MO PEGASYS 2 $0 PAR; MO PEGASYS PROCLICK SUBCUTANEOUS PEN INJECTOR 180 MCG/0.5 ML 2 $0 PAR; MO PEGINTRON 2 $0 PAR; MO PEGINTRON REDIPEN 2 $0 PAR; MO PROCRIT 2 $0 PAR; MO; QLL (12 per 28 days) PROLEUKIN 2 $0 B/D PAR; MO REBIF (WITH ALBUMIN) 2 $0 PAR; MO REBIF REBIDOSE 2 $0 PAR; MO REBIF TITRATION PACK 2 $0 PAR; MO SYLATRON 2 $0 PAR; MO VACCINES / MISCELLANEOUS IMMUNOLOGICALS ACTHIB (PF) 1 $0 MO ADACEL(TDAP ADOLESN/ADULT)(PF) 1 $0 MO ATGAM 2 $0 B/D PAR BCG VACCINE, LIVE (PF) 2 $0 MO BEXSERO (PF) 2 $0 MO BOOSTRIX TDAP 1 $0 MO CARIMUNE NF NANOFILTERED INTRAVENOUS RECON SOLN 12 GRAM, 6 GRAM 2 $0 PAR; MO CERVARIX VACCINE (PF) 1 $0 MO COMVAX (PF) 1 $0 MO DAPTACEL (DTAP PEDIATRIC) (PF) 1 $0 MO ENGERIX-B (PF) 1 $0 B/D PAR; MO ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SUSPENSION ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SYRINGE 1 $0 B/D PAR; MO 1 $0 B/D PAR GAMASTAN S/D 2 $0 PAR; MO GAMMAGARD LIQUID 2 $0 PAR; MO ENYDMEM-0035-15 90

GAMMAGARD S-D (IGA < 1 MCG/ML) 2 $0 PAR; MO GAMMAPLEX 2 $0 PAR; MO GAMUNEX-C 2 $0 PAR; MO GARDASIL (PF) 2 $0 MO GARDASIL 9 (PF) 2 $0 MO HAVRIX (PF) INTRAMUSCULAR SUSPENSION HAVRIX (PF) INTRAMUSCULAR SYRINGE 1,440 ELISA UNIT/ML HAVRIX (PF) INTRAMUSCULAR SYRINGE 720 ELISA UNIT/0.5 ML 1 $0 MO 1 $0 MO 1 $0 IMOVAX RABIES VACCINE (PF) 2 $0 MO INFANRIX (DTAP) (PF) 2 $0 MO IPOL INJECTION SUSPENSION 1 $0 MO IPOL INJECTION SYRINGE 1 $0 IXIARO (PF) 2 $0 MO MENACTRA (PF) INTRAMUSCULAR SOLUTION 2 $0 MO MENOMUNE - A/C/Y/W-135 2 $0 MENOMUNE - A/C/Y/W-135 (PF) 2 $0 MO MENVEO A-C-Y-W-135-DIP (PF) 2 $0 MO M-M-R II (PF) 1 $0 MO PEDVAX HIB (PF) 1 $0 MO PROQUAD (PF) 2 $0 QUADRACEL (PF) 2 $0 RABAVERT (PF) 2 $0 MO RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 10 MCG/ML RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 5 MCG/0.5 ML ROTARIX 2 $0 1 $0 B/D PAR; MO 1 $0 B/D PAR; MO 1 $0 B/D PAR ENYDMEM-0035-15 91

ROTATEQ VACCINE 1 $0 MO TETANUS,DIPHTHERIA TOX PED(PF) 2 $0 MO TETANUS-DIPHTHERIA TOXOIDS-TD 1 $0 MO THYMOGLOBULIN 2 $0 B/D PAR TICE BCG 2 $0 MO TRUMENBA 2 $0 TWINRIX (PF) 1 $0 MO TYPHIM VI INTRAMUSCULAR SOLUTION 2 $0 TYPHIM VI INTRAMUSCULAR SYRINGE 2 $0 MO VAQTA (PF) INTRAMUSCULAR SUSPENSION 2 $0 MO VAQTA (PF) INTRAMUSCULAR SYRINGE 2 $0 VARIVAX (PF) 2 $0 MO VARIZIG INTRAMUSCULAR RECON SOLN 2 $0 MO VARIZIG INTRAMUSCULAR SOLUTION 2 $0 YF-VAX (PF) 2 $0 MO ZOSTAVAX (PF) 2 $0 MO MUSCULOSKELETAL / RHEUMATOLOGY GOUT THERAPY allopurinol 1 $0 MO colchicine-probenecid 2 $0 MO COLCRYS 2 $0 MO probenecid 2 $0 MO ULORIC 2 $0 ST; MO OSTEOPOROSIS THERAPY alendronate oral solution 2 $0 MO; QLL (300 per 28 days) alendronate oral tablet 10 mg, 5 mg 1 $0 MO; QLL (30 per 30 days) alendronate oral tablet 35 mg, 70 mg 1 $0 MO; QLL (4 per 28 days) BONIVA INTRAVENOUS 2 $0 B/D PAR; MO EVISTA 2 $0 MO; QLL (30 per 30 days) ENYDMEM-0035-15 92

FORTEO 2 $0 PAR; MO; QLL (3 per 28 days) ibandronate intravenous solution 2 $0 B/D PAR; MO ibandronate intravenous syringe 2 $0 MO ibandronate oral 2 $0 MO; QLL (1 per 28 days) PROLIA 2 $0 PAR; MO; QLL (2 per 365 days) raloxifene 2 $0 MO; QLL (30 per 30 days) OTHER RHEUMATOLOGICALS ACTEMRA INTRAVENOUS 2 $0 PAR; MO DEPEN TITRATABS 2 $0 MO ENBREL SUBCUTANEOUS RECON SOLN 2 $0 PAR; MO; QLL (8 per 28 days) ENBREL SUBCUTANEOUS SYRINGE 25 MG/0.5ML (0.51) ENBREL SUBCUTANEOUS SYRINGE 50 MG/ML (0.98 ML) 2 $0 PAR; MO; QLL (4.08 per 28 days) 2 $0 PAR; MO; QLL (8 per 28 days) ENBREL SURECLICK 2 $0 PAR; MO; QLL (8 per 28 days) HUMIRA PEDIATRIC CROHN'S START 2 $0 PAR; MO; QLL (4.8 per 365 days) HUMIRA PEN 2 $0 PAR; MO; QLL (3.2 per 28 days) HUMIRA PEN CROHN'S-UC-HS START 2 $0 PAR; MO; QLL (4.8 per 365 days) HUMIRA PEN PSORIASIS STARTER 2 $0 PAR; MO; QLL (3.2 per 28 days) HUMIRA SUBCUTANEOUS SYRINGE KIT 10 MG/0.2 ML, 20 MG/0.4 ML HUMIRA SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML 2 $0 PAR; MO; QLL (2 per 28 days) 2 $0 PAR; MO; QLL (3.2 per 28 days) KINERET 2 $0 PAR; MO; QLL (28 per 28 days) leflunomide 2 $0 MO RIDAURA 2 $0 MO SAVELLA ORAL TABLET 100 MG 2 $0 MO; QLL (60 per 30 days) SAVELLA ORAL TABLET 12.5 MG 2 $0 MO; QLL (480 per 30 days) SAVELLA ORAL TABLET 25 MG 2 $0 MO; QLL (240 per 30 days) SAVELLA ORAL TABLET 50 MG 2 $0 MO; QLL (120 per 30 days) SAVELLA ORAL TABLETS,DOSE PACK 2 $0 MO; QLL (1 per 365 days) SIMPONI 2 $0 PAR; MO; QLL (1 per 28 days) ENYDMEM-0035-15 93

OBSTETRICS / GYNECOLOGY ESTROGENS / PROGESTINS camila 2 $0 MO DEPO-PROVERA INTRAMUSCULAR SOLUTION 400 MG/ML 2 $0 MO errin 2 $0 MO ESTRACE VAGINAL 2 $0 MO estradiol oral 2 $0 PAR; MO estradiol transdermal patch weekly 2 $0 PAR; MO; QLL (4 per 28 days) ESTRING 2 $0 MO; QLL (1 per 90 days) lyza 2 $0 MO medroxyprogesterone 2 $0 MO MENEST 2 $0 PAR; MO nora-be 2 $0 MO norethindrone (contraceptive) 2 $0 MO norethindrone acetate 2 $0 MO PREMARIN ORAL 2 $0 MO PREMARIN VAGINAL 2 $0 MO progesterone micronized 2 $0 ST; MO VAGIFEM 2 $0 MO MISCELLANEOUS OB/GYN clindamycin phosphate vaginal 2 $0 MO clotrimazole 3 day 4 $0 MO; [*] clotrimazole vaginal cream 4 $0 MO; [*] clotrimazole-3 4 $0 [*] clotrimazole-7 4 $0 [*] metronidazole vaginal 2 $0 MO miconazole 7 4 $0 MO; [*] miconazole nitrate vaginal comb pack,prefill appl & cream 4 $0 [*] miconazole nitrate vaginal cream 4 $0 MO; [*] ENYDMEM-0035-15 94

MICONAZOLE NITRATE VAGINAL KIT 1,200-2 MG-% 4 $0 [*] miconazole nitrate vaginal suppository 4 $0 [*] miconazole-3 vaginal kit 4 $0 [*] miconazole-3 vaginal suppository 2 $0 MO; QLL (6 per 30 days) NUVARING 2 $0 MO terconazole 2 $0 MO tioconazole 4 $0 [*] tioconazole-1 4 $0 [*] tranexamic acid oral 2 $0 MO vagistat-3 4 $0 [*] XULANE 2 $0 MO zazole vaginal cream 0.4 % 2 $0 ORAL CONTRACEPTIVES / RELATED AGENTS altavera (28) 2 $0 MO alyacen 1/35 (28) 2 $0 MO alyacen 7/7/7 (28) 2 $0 MO apri 2 $0 MO aranelle (28) 2 $0 MO aviane 2 $0 MO azurette (28) 2 $0 MO caziant (28) 2 $0 MO cryselle (28) 2 $0 MO drospirenone-ethinyl estradiol oral tablet 3-0.03 mg 2 $0 MO elinest 2 $0 MO ELLA 2 $0 MO enpresse 2 $0 MO falmina (28) 2 $0 MO gildagia 2 $0 MO gildess fe 2 $0 MO ENYDMEM-0035-15 95

junel 1.5/30 (21) 2 $0 MO junel 1/20 (21) 2 $0 MO junel fe 1.5/30 (28) 2 $0 MO junel fe 1/20 (28) 2 $0 MO kariva (28) 2 $0 MO kelnor 1/35 (28) 2 $0 MO lessina 2 $0 MO levonest (28) 2 $0 MO levonorgestrel oral tablet 1.5 mg 4 $0 [*] levonorgestrel-ethinyl estrad oral tablet 0.15-0.03 mg levonorgestrel-ethinyl estrad oral tablets,dose pack,3 month 2 $0 MO 2 $0 MO low-ogestrel (28) 2 $0 MO lutera (28) 2 $0 MO marlissa 2 $0 MO microgestin 1.5/30 (21) 2 $0 MO microgestin 1/20 (21) 2 $0 MO microgestin fe 1.5/30 (28) 2 $0 MO microgestin fe 1/20 (28) 2 $0 MO mono-linyah 2 $0 MO mononessa (28) 2 $0 MO my way 4 $0 [*] myzilra 2 $0 MO necon 0.5/35 (28) 2 $0 MO necon 1/35 (28) 2 $0 MO necon 1/50 (28) 2 $0 MO necon 10/11 (28) 2 $0 MO necon 7/7/7 (28) 2 $0 MO next choice one dose 4 $0 [*] norgestimate-ethinyl estradiol 2 $0 MO ENYDMEM-0035-15 96

nortrel 0.5/35 (28) 2 $0 MO nortrel 1/35 (21) 2 $0 MO nortrel 1/35 (28) 2 $0 MO nortrel 7/7/7 (28) 2 $0 MO ocella 2 $0 MO ogestrel (28) 2 $0 MO PLAN B ONE-STEP 4 $0 MO; [*] portia 2 $0 MO previfem 2 $0 MO reclipsen (28) 2 $0 MO sprintec (28) 2 $0 MO syeda 2 $0 MO tri-previfem (28) 2 $0 MO tri-sprintec (28) 2 $0 MO trivora (28) 2 $0 MO velivet triphasic regimen (28) 2 $0 MO viorele (28) 2 $0 MO zarah 2 $0 MO zenchent (28) 2 $0 MO zovia 1/35e (28) 2 $0 MO zovia 1/50e (28) 2 $0 MO OPHTHALMOLOGY ANTIBIOTICS ak-poly-bac 2 $0 MO bacitracin ophthalmic 2 $0 MO bacitracin-polymyxin b ophthalmic 2 $0 MO ciprofloxacin hcl ophthalmic 1 $0 MO erythromycin ophthalmic 2 $0 MO gentak ophthalmic ointment 2 $0 MO gentamicin ophthalmic 2 $0 MO ENYDMEM-0035-15 97

NATACYN 2 $0 MO neomycin-bacitracin-polymyxin 2 $0 MO neomycin-polymyxin-gramicidin 2 $0 MO neo-polycin 2 $0 MO ofloxacin ophthalmic 2 $0 MO polycin 2 $0 polymyxin b sulf-trimethoprim 2 $0 MO tobramycin 2 $0 MO VIGAMOX 2 $0 MO ANTIVIRALS trifluridine 2 $0 MO ZIRGAN 2 $0 MO BETA-BLOCKERS betaxolol ophthalmic 2 $0 MO carteolol 2 $0 MO levobunolol ophthalmic drops 0.5 % 2 $0 MO metipranolol 2 $0 MO timolol maleate ophthalmic 2 $0 MO TIMOPTIC OCUDOSE (PF) 2 $0 MO CHOLINESTERASE INHIBITOR MIOTICS PHOSPHOLINE IODIDE 2 $0 MO CYCLOPLEGIC MYDRIATICS tropicamide ophthalmic 2 $0 MO MISCELLANEOUS OPHTHALMOLOGICS alaway 4 $0 MO; [*] allergy eye (ketotifen) 4 $0 [*] altachlore 4 $0 [*] artificial tears 4 $0 [*] artificial tears (petro/min) 4 $0 MO; [*] artificial tears (pf) 4 $0 [*] ENYDMEM-0035-15 98

artificial tears (polyvin alc) 4 $0 MO; [*] artificial tears(glycerin-peg) 4 $0 [*] artificial tears(hypromellose) 4 $0 [*] azelastine ophthalmic 2 $0 MO CHILDREN'S ALAWAY 4 $0 [*] cromolyn ophthalmic 2 $0 MO dry eye relief 4 $0 [*] ketotifen fumarate 4 $0 MO; [*] moisture drops 4 $0 [*] MURO 128 4 $0 MO; [*] natural tears (pf) 4 $0 [*] nature's tears 4 $0 [*] PATADAY 2 $0 MO PATANOL 2 $0 MO PAZEO 2 $0 MO RESTASIS 2 $0 MO sodium chloride ophthalmic 4 $0 MO; [*] tears pure 4 $0 [*] VISINE TEARS 4 $0 MO; [*] NON-STEROIDAL ANTI-INFLAMMATORY AGENTS flurbiprofen sodium 2 $0 MO ILEVRO 2 $0 MO ketorolac ophthalmic 2 $0 MO NEVANAC 2 $0 MO ORAL DRUGS FOR GLAUCOMA acetazolamide oral 2 $0 MO acetazolamide sodium 2 $0 MO methazolamide oral 2 $0 MO OTHER GLAUCOMA DRUGS AZOPT 2 $0 MO ENYDMEM-0035-15 99

bimatoprost 2 $0 MO COMBIGAN 2 $0 MO dorzolamide 2 $0 MO dorzolamide-timolol 2 $0 MO latanoprost 2 $0 MO LUMIGAN OPHTHALMIC DROPS 0.01 % 2 $0 MO TRAVATAN Z 2 $0 MO; QLL (5 per 30 days) travoprost (benzalkonium) 2 $0 MO STEROID-ANTIBIOTIC COMBINATIONS neomycin-bacitracin-poly-hc 2 $0 MO neomycin-polymyxin b-dexameth 2 $0 MO neomycin-polymyxin-hc ophthalmic 2 $0 MO neo-polycin hc 2 $0 tobramycin-dexamethasone 2 $0 MO STEROIDS dexamethasone sodium phosphate ophthalmic 2 $0 MO fluorometholone 2 $0 MO prednisolone acetate 2 $0 MO prednisolone sodium phosphate ophthalmic 2 $0 MO STEROID-SULFONAMIDE COMBINATIONS BLEPHAMIDE S.O.P. 2 $0 MO sulfacetamide-prednisolone 2 $0 MO SULFONAMIDES sulfacetamide sodium ophthalmic drops 2 $0 MO SYMPATHOMIMETICS ALPHAGAN P OPHTHALMIC DROPS 0.1 % 2 $0 MO apraclonidine 2 $0 MO brimonidine 2 $0 MO VASOCONSTRICTOR DECONGESTANTS ALLERGY EYE (NAPHAZOLINE-PHEN) 4 $0 [*] ENYDMEM-0035-15 100

altazine 4 $0 [*] eye drops (with povidone) 4 $0 [*] naphazoline 2 $0 MO opti-clear 4 $0 [*] sterile eye drops ophthalmic drops 0.05 % 4 $0 [*] tetrahydrozoline ophthalmic 4 $0 [*] VISINE 4 $0 [*] visine-a 4 $0 MO; [*] RESPIRATORY AND ALLERGY ANTIHISTAMINE / ANTIALLERGENIC AGENTS acta-tabs pe 4 $0 [*] adult cough formula dm max 4 $0 [*] adult tussin chest congestion 4 $0 [*] ADULT TUSSIN COUGH CONGEST DM 4 $0 [*] ADULT TUSSIN DM 4 $0 [*] ala-hist ir 4 $0 MO; [*] ALL DAY ALLERGY (CETIRIZINE) ORAL CAPSULE 4 $0 [*] all day allergy (cetirizine) oral solution 4 $0 [*]; QLL (300 per 30 days) all day allergy (cetirizine) oral tablet 4 $0 MO; [*]; QLL (30 per 30 days) all day allergy (cetirizine) oral tablet,chewable 10 mg 4 $0 MO; [*] all day allergy relief(cetir) 4 $0 [*]; QLL (30 per 30 days) all day allergy-d 4 $0 MO; [*] allergy (chlorpheniramine) 4 $0 MO; [*] allergy (diphenhydramine) 4 $0 [*] ALLERGY COMPLETE-D 4 $0 [*] allergy multi-symptom 4 $0 [*] allergy plus severe sinus ha 4 $0 [*] allergy relief (cetirizine) oral capsule 4 $0 [*] allergy relief (cetirizine) oral tablet 4 $0 [*]; QLL (30 per 30 days) ENYDMEM-0035-15 101

ALLERGY RELIEF (CLEMASTINE) 4 $0 MO; [*] allergy relief (fexofenadine) 4 $0 [*] allergy relief (loratadine) oral solution 4 $0 [*] allergy relief (loratadine) oral tablet 4 $0 MO; [*]; QLL (30 per 30 days) ALLERGY RELIEF (LORATADINE) ORAL TABLET,DISINTEGRATING allergy relief multi-symptom 4 $0 [*] allergy relief(chlorpheniramn) 4 $0 [*] allergy relief(diphenhydramin) 4 $0 [*] allergy relief-d (cetirizine) 4 $0 [*] ALLERGY RELIEF-D (LORATADINE) 4 $0 [*] ALLERGY RELIEF-SINUS HEADACHE 4 $0 [*] ALLERGY SINUS HEADACHE (PE) ORAL TABLET 12.5-5-325 MG 4 $0 [*]; QLL (30 per 30 days) 4 $0 [*] allergy sinus pe 4 $0 [*] aller-tec 4 $0 [*]; QLL (30 per 30 days) aller-tec d 4 $0 [*] allfen 4 $0 [*] allfen dm 4 $0 MO; [*] ALL-NITE COLD-FLU ORAL LIQUID 6.25-15- 325 MG/15 ML 4 $0 [*] ambi 10peh-4cpm 4 $0 [*] ambi 60pse-4cpm 4 $0 [*] antitussive dm 4 $0 [*] ap-hist dm 4 $0 [*] aprodine 4 $0 MO; [*] arbinoxa 2 $0 PAR; MO banophen allergy 4 $0 MO; [*] banophen oral capsule 25 mg 4 $0 MO; [*] banophen oral capsule 50 mg 4 $0 [*] banophen oral liquid 4 $0 MO; [*] ENYDMEM-0035-15 102

banophen oral tablet 4 $0 [*] benzonatate oral capsule 100 mg, 200 mg 3 $0 MO; [*] biocotron 4 $0 [*] BIOSPEC DMX 4 $0 [*] brohist d 4 $0 [*] brompheniramine-pseudoeph-dm oral syrup 4 $0 MO; [*] brotapp 4 $0 MO; [*] cetiri-d 4 $0 [*] cetirizine oral solution 1 mg/ml 4 $0 MO; [*]; QLL (300 per 30 days) cetirizine oral solution 5 mg/5 ml 4 $0 [*] cetirizine oral tablet 4 $0 MO; [*]; QLL (30 per 30 days) CETIRIZINE ORAL TABLET 4 $0 MO; [*]; QLL (30 per 30 days) cetirizine oral tablet,chewable 4 $0 MO; [*] cetirizine-pseudoephedrine 4 $0 MO; [*] CHEST CONGESTION RELIEF + DM 4 $0 [*] CHEST CONGESTION RELIEF ORAL TABLET 4 $0 [*] CHEST CONGESTION RELIEF PE 4 $0 [*] chest congestion-cough relief 4 $0 [*] chest-sinus congestion relief 4 $0 [*] child allergy relf(cetirizine) oral solution 4 $0 [*]; QLL (300 per 30 days) CHILD ALLERGY RELF(CETIRIZINE) ORAL TABLET,CHEWABLE 4 $0 [*] child chest congestion + cough 4 $0 [*] child mucinex chest congestion 4 $0 [*] child mucus relief cough 4 $0 [*] child mucus relief expectorant 4 $0 [*] children night time cold-cough 4 $0 [*] children's allergy (diphenhyd) oral elixir 4 $0 [*] children's allergy (diphenhyd) oral liquid 4 $0 [*] children's allergy relief(lor) 4 $0 [*] children's allergy(cetirizine) 4 $0 [*]; QLL (300 per 30 days) ENYDMEM-0035-15 103

children's aller-tec 4 $0 [*]; QLL (300 per 30 days) children's cetirizine oral solution 4 $0 [*]; QLL (300 per 30 days) children's cetirizine oral tablet,chewable 4 $0 MO; [*] children's chest congestion 4 $0 [*] children's cold & cough dm 4 $0 [*] children's cold-allergy (pe) 4 $0 [*] children's dibromm cold & alle 4 $0 [*] children's dibromm dm cold & c 4 $0 [*] children's mucinex cough 4 $0 [*] children's silfedrine 4 $0 [*] child's all day allergy(cetir) 4 $0 [*]; QLL (300 per 30 days) childs triacting cold & cough 4 $0 [*] chlorpheniramine maleate oral tablet 4 $0 [*] chlorpheniramine maleate oral tablet extended release 4 $0 MO; [*] chlortabs 4 $0 [*] clemastine oral tablet 1.34 mg 4 $0 MO; [*] clemastine oral tablet 2.68 mg 2 $0 PAR; MO COLD & ALLERGY PE 4 $0 [*] COLD & COUGH DM 4 $0 [*] cold & cough elixir 4 $0 [*] COLD & FLU SEVERE 4 $0 [*] cold & sinus pain relief 4 $0 [*] COLD HEAD CONGESTION DAY/NITE 4 $0 [*] COLD HEAD CONGESTION DAYTIME 4 $0 [*] cold head congestion nighttime 4 $0 [*] cold head congestion sever day 4 $0 [*] cold multi-symptom 4 $0 [*] COLD MULTI-SYMPTOM (CHLORPHEN) 4 $0 [*] COLD MULTI-SYMPTOM DAY/NIGHT 4 $0 [*] COLD MULTI-SYMPTOM NIGHTTIME 4 $0 [*] ENYDMEM-0035-15 104

cold relief m/s day/night 4 $0 [*] COLD-COUGH SINUS RELIEF PE 4 $0 [*] cold-flu relief, day/night 4 $0 [*] cold-sinus relief 4 $0 [*] CORICIDIN HBP COLD-MULTI SYMPT 4 $0 [*] cough control (guaifenesin) 4 $0 [*] cough control dm 4 $0 [*] COUGH CONTROL DM MAX 4 $0 [*] cough dm er 4 $0 [*] COUGH DROPS (WITH EUCALYPTUS) MUCOUS MEMBRANE LOZENGE, 3.1 MG, 7.6 MG cough drops (with eucalyptus) mucous membrane lozenge 7 mg, 8 mg 4 $0 [*] 4 $0 [*] cough drops mucous membrane lozenge 5.4 mg 4 $0 [*] cough formula dm 4 $0 [*] cough suppressant-expectorant 4 $0 [*] cough syrup 4 $0 [*] cough syrup dm 4 $0 [*] cough-sore throat night 4 $0 [*] DAY TIME PE 4 $0 [*] DAYTIME & NIGHTTIME COLD 4 $0 [*] DAYTIME COLD & FLU RELIEF (PE) 4 $0 [*] DAYTIME COLD-FLU 4 $0 [*] day-time cough 4 $0 [*] DAYTIME SINUS 4 $0 [*] daytime-nighttime 4 $0 [*] dextromethorphan polistirex 4 $0 [*] dextromethorphan-guaifenesin 4 $0 [*] diabetic siltussin das-na 4 $0 [*] diabetic siltussin-dm 4 $0 [*] ENYDMEM-0035-15 105

diabetic siltussin-dm max str 4 $0 [*] DIABETIC TUSSIN DM ORAL LIQUID 10-100 MG/5 ML 4 $0 MO; [*] diabetic tussin dm oral liquid 10-200 mg/5 ml 4 $0 [*] DIABETIC TUSSIN EX ORAL LIQUID 4 $0 MO; [*] diabetic tussin max st 4 $0 MO; [*] dimaphen (pe) 4 $0 [*] dimaphen dm 4 $0 MO; [*] dimetapp cold-congestion 4 $0 [*] dimetapp dm cold-cough (pe) 4 $0 [*] diphenhydramine hcl injection solution 50 mg/ml 2 $0 PAR; MO diphenhydramine hcl injection syringe 2 $0 PAR; MO diphenhydramine hcl oral capsule 4 $0 MO; [*] diphenhydramine hcl oral elixir 4 $0 [*] diphenhydramine hcl oral liquid 4 $0 [*] diphenhydramine hcl oral syrup 4 $0 [*] diphenhydramine hcl oral tablet 25 mg 4 $0 [*] dm max 4 $0 [*] dristan cold 4 $0 [*] endacof - dm 4 $0 [*] entre-hist pse 4 $0 [*] epinephrine injection solution 1 mg/ml (1:1,000) 2 $0 MO epinephrine injection syringe 0.1 mg/ml (1:10,000) 2 $0 MO EPIPEN 2-PAK 2 $0 MO; QLL (2 per 1 day) EPIPEN JR 2-PAK 2 $0 MO; QLL (2 per 1 day) expectorant cough syrup 4 $0 [*] EXPECTORANT ORAL LIQUID 4 $0 [*] fenesin ir 4 $0 [*] fenesin pe ir 4 $0 [*] fexofenadine oral tablet 180 mg, 60 mg 4 $0 MO; [*] FLU & SEVERE COLD-DAYTIME 4 $0 [*] ENYDMEM-0035-15 106

flu & severe cold-nighttime 4 $0 [*] FLU & SORE THROAT RELIEF 4 $0 [*] flu relief therapy daytime 4 $0 [*] flu relief therapy nighttime 4 $0 [*] geri-tussin 4 $0 [*] g-tron 4 $0 [*] guaifenesin oral liquid 4 $0 [*] guaifenesin oral tablet 200 mg 4 $0 MO; [*] guaifenesin oral tablet extended release 12hr 4 $0 MO; [*] GUAIFENESIN-DM 4 $0 [*] HEAD CONGESTION COLD RELIEF 4 $0 [*] hist-pse 4 $0 [*] hot steam liquid 4 $0 [*] hydrocodone compound syrup 3 $0 [*] hydrocodone-chlorpheniramine 3 $0 MO; [*] hydrocodone-homatropine oral syrup 5-1.5 mg/5 ml HYDROCODONE-HOMATROPINE ORAL SYRUP 5-1.5 MG/5 ML (5 ML) 3 $0 MO; [*] 3 $0 [*] hydrocodone-homatropine oral tablet 3 $0 MO; [*] hydromet 3 $0 MO; [*] IBUPROFEN COLD 4 $0 [*] IBUPROFEN COLD-SINUS(WITH PSE) 4 $0 [*] iophen dm-nr 4 $0 MO; [*] iophen-nr 4 $0 MO; [*] kidkare cough/cold 4 $0 [*] levocetirizine oral tablet 2 $0 MO; QLL (30 per 30 days) liquibid d-r 4 $0 [*] lohist - d 4 $0 MO; [*] lohist peb dm 4 $0 [*] lohist-peb 4 $0 [*] ENYDMEM-0035-15 107

loradamed 4 $0 MO; [*]; QLL (30 per 30 days) lorata-d 4 $0 [*] lorata-dine d 4 $0 [*] loratadine oral solution 4 $0 MO; [*] loratadine oral tablet 4 $0 MO; [*]; QLL (30 per 30 days) loratadine oral tablet,disintegrating 4 $0 MO; [*]; QLL (30 per 30 days) loratadine-d 4 $0 MO; [*] mapap cold formula 4 $0 [*] mapap sinus max strength (pe) 4 $0 [*] medicidin-d 4 $0 [*] medikoff drops 4 $0 [*] menthol cough drops 4 $0 [*] menthol cough mucous membrane lozenge 6.5 mg 4 $0 [*] menthol drops 4 $0 [*] mucaphed 4 $0 [*] MUCINEX COUGH MINI-MELTS 4 $0 MO; [*] mucinex dm 4 $0 MO; [*] mucinex fast-max cold-flu-thrt oral tablet 4 $0 [*] mucinex fast-max dm max 4 $0 [*] mucinex fast-max severe cold oral tablet 4 $0 [*] mucinex oral tablet extended release 12hr 600 mg 4 $0 MO; [*] mucosa 4 $0 [*] mucosa dm 4 $0 [*] mucus dm 4 $0 [*] mucus relief chest 4 $0 [*] MUCUS RELIEF COLD-FLU-SORE THR ORAL TABLET 4 $0 [*] MUCUS RELIEF COUGH 4 $0 [*] mucus relief d (phenylephrine) 4 $0 [*] mucus relief dm 4 $0 MO; [*] mucus relief dm max 4 $0 [*] ENYDMEM-0035-15 108

mucus relief er oral tablet extended release 12hr 4 $0 [*] mucus relief oral tablet 400 mg 4 $0 MO; [*] mucus relief pe 4 $0 [*] mucus relief plus 4 $0 [*] MUCUS RELIEF SEV CONGEST-COLD 4 $0 [*] mucus relief sinus 4 $0 [*] multi-symptom cold (pe & cpm) 4 $0 [*] multi-symptom cold (pe) 4 $0 [*] multi-symptom cold daytime 4 $0 [*] multi-symptom cold night time 4 $0 [*] nasal decongestant (pe) oral tablet 10 mg 4 $0 [*] nasal decongestant (pseudoeph) 4 $0 [*] NIGHT TIME COLD & FLU RELIEF 4 $0 [*] night time cold oral tablet 4 $0 [*] NIGHT TIME COLD-FLU ORAL LIQUID 4 $0 [*] NIGHT TIME COLD-FLU RELIEF ORAL LIQUID 12.5-30-1,000 MG/30 ML 4 $0 [*] night time cough & sore throat 4 $0 [*] nightime sleep 4 $0 [*] nighttime cold-flu 4 $0 [*] NIGHTTIME COLD-FLU RELIEF 4 $0 [*] nighttime cough 4 $0 [*] nighttime cough-cold 4 $0 [*] nighttime sinus 4 $0 [*] nighttime sleep aid (diphen) 4 $0 [*] NITE TIME COLD-FLU 4 $0 [*] nite time cold-flu formula 4 $0 [*] NITE TIME COLD-FLU RELIEF 4 $0 [*] NITE TIME COUGH 4 $0 [*] NITE TIME-D COLD-FLU RELIEF 4 $0 [*] NITE-TIME COLD-FLU 4 $0 [*] ENYDMEM-0035-15 109

nitetime multi-symptom 4 $0 [*] nohist-dm 4 $0 MO; [*] nohist-lq 4 $0 [*] non-pseudo sinus pain-pressure 4 $0 [*] nyquil d 4 $0 [*] organ-i nr 4 $0 MO; [*] ormir 4 $0 [*] pedia relief cough-cold 4 $0 [*] pediacare multi-symptom cold 4 $0 [*] pediatric cough & cold oral liquid 1-15-5 mg/5 ml 4 $0 [*] pharbechlor 4 $0 [*] pharbedryl 4 $0 [*] POLY HIST FORTE (DOXYLAMINE) 4 $0 MO; [*] promethazine injection solution 2 $0 PAR; MO promethazine vc-codeine 3 $0 MO; [*] promethazine-codeine 3 $0 MO; [*] promethazine-dm 3 $0 MO; [*] promethazine-phenyleph-codeine 3 $0 [*] promethegan rectal suppository 12.5 mg 2 $0 PAR; MO pseudoephedrine hcl oral liquid 4 $0 MO; [*] pseudoephedrine hcl oral tablet 30 mg 4 $0 MO; [*] pseudoephedrine hcl oral tablet 60 mg 4 $0 [*] pseudoephedrine hcl oral tablet extended release 4 $0 MO; [*] pyrilamine-phenylephrine 4 $0 [*] q-dryl oral capsule 4 $0 [*] q-dryl oral liquid 4 $0 MO; [*] q-tapp 4 $0 MO; [*] q-tussin 4 $0 [*] q-tussin dm 4 $0 [*] quenalin 4 $0 [*] ENYDMEM-0035-15 110

refenesen 4 $0 [*] refenesen dm 4 $0 [*] refenesen pe 4 $0 [*] ri-tussin 4 $0 [*] ri-tussin dm 4 $0 [*] robafen 4 $0 MO; [*] robafen dm 4 $0 MO; [*] robafen dm cough 4 $0 [*] RU-HIST D 4 $0 MO; [*] rydex 4 $0 [*] rynex dm 4 $0 [*] rynex pe 4 $0 [*] rynex pse 4 $0 [*] SEVERE ALLERGY-SINUS HEADACHE 4 $0 [*] SEVERE COLD (DIPHEN-PE-ACETAM) 4 $0 [*] SEVERE COLD MULTI-SYMPTOM 4 $0 [*] SEVERE COLD PE 4 $0 [*] siladryl sa 4 $0 [*] silphen cough 4 $0 [*] siltussin dm das 4 $0 [*] siltussin sa 4 $0 MO; [*] siltussin-dm 4 $0 [*] sinus & allergy non-drowsy 4 $0 [*] SINUS & ALLERGY PE 4 $0 [*] SINUS & ALLERGY(PHENYLEPHRINE) 4 $0 [*] sinus cong & pain day-night 4 $0 [*] SINUS CONGESTION&PAIN(CHLORPH) 4 $0 [*] sinus decongestant (pe) 4 $0 [*] SINUS HEADACHE PE 4 $0 [*] SLEEP AID (DIPHENHYDRAMINE) ORAL CAPSULE 50 MG 4 $0 [*] ENYDMEM-0035-15 111

sleep aid (diphenhydramine) oral tablet 4 $0 [*] SLEEP AID MAX STR (DIPHENHYDR) 4 $0 [*] sleep tablet (diphenhydramine) 4 $0 [*] SUDAFED 24 HOUR 4 $0 MO; [*] sudogest 4 $0 MO; [*] sudogest 12-hour 4 $0 MO; [*] sudogest cold & allergy 4 $0 [*] sudogest pe 4 $0 MO; [*] sudogest sinus & allergy 4 $0 [*] suphedrin 4 $0 [*] suphedrin 12 hour 4 $0 [*] SUPHEDRINE 4 $0 [*] SUPHEDRINE 12 HOUR 4 $0 [*] SUPHEDRINE PE 4 $0 [*] suphedrine pe cold & allergy 4 $0 [*] suphedrine pe sinus & allergy 4 $0 [*] suphedrine pe sinus headache 4 $0 [*] tl-hist dm 4 $0 [*] tusnel diabetic 4 $0 [*] tussi pres-b oral liquid 4-10-20 mg/5 ml 4 $0 [*] tussigon 3 $0 MO; [*] TUSSIN 4 $0 [*] tussin chest congestion 4 $0 [*] tussin cough &chest congestion 4 $0 [*] tussin cough dm 4 $0 [*] TUSSIN DM CLEAR 4 $0 [*] tussin dm cough 4 $0 [*] tussin dm cough & chest oral liquid 10-200 mg/5 ml 4 $0 [*] tussin dm cough & chest oral syrup 4 $0 [*] ENYDMEM-0035-15 112

TUSSIN DM MAX ORAL LIQUID 10-200 MG/5 ML 4 $0 [*] tussin dm oral liquid 4 $0 [*] tussin dm oral syrup 10-100 mg/5 ml 4 $0 [*] tussin dm oral tablet 4 $0 [*] tussin expectorant 4 $0 [*] tussin honey 4 $0 [*] tussin maximum strength 4 $0 [*] tussin maximum strength cough 4 $0 [*] vaporizing steam 4 $0 [*] VAZOTAB (PYRILAMINE) 4 $0 [*] PULMONARY AGENTS acetylcysteine 2 $0 B/D PAR; MO ADVAIR DISKUS 2 $0 MO; QLL (60 per 30 days) ADVAIR HFA 2 $0 MO; QLL (12 per 30 days) AEROSPAN 2 $0 MO; QLL (18 per 30 days) albuterol sulfate inhalation solution for nebulization 0.63 mg/3 ml, 1.25 mg/3 ml, 2.5 mg /3 ml (0.083 %) albuterol sulfate inhalation solution for nebulization 2.5 mg/0.5 ml, 5 mg/ml albuterol sulfate oral syrup 1 $0 MO albuterol sulfate oral tablet 2 $0 MO albuterol sulfate oral tablet extended release 12 hr 2 $0 MO 1 $0 B/D PAR; MO; QLL (360 per 30 days) 1 $0 B/D PAR; MO; QLL (60 per 30 days) ANORO ELLIPTA 2 $0 MO; QLL (60 per 30 days) ARNUITY ELLIPTA 2 $0 MO; QLL (30 per 30 days) ASMANEX HFA 2 $0 MO; QLL (13 per 30 days) ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 110 MCG (30 DOSES) ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 110 MCG (7 DOSES), 220 MCG (14 DOSES) 2 $0 MO; QLL (0.14 per 30 days) 2 $0 ENYDMEM-0035-15 113

ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 220 MCG (120 DOSES), 220 MCG (30 DOSES), 220 MCG (60 DOSES) 2 $0 MO; QLL (0.24 per 30 days) ATROVENT HFA 2 $0 MO; QLL (26 per 30 days) BREO ELLIPTA 2 $0 MO; QLL (60 per 30 days) COMBIVENT RESPIMAT 2 $0 MO; QLL (8 per 30 days) cromolyn inhalation 2 $0 B/D PAR; MO; QLL (240 per 30 days) cromolyn nasal 4 $0 MO; [*] DALIRESP 2 $0 PAR; MO; QLL (30 per 30 days) DULERA 2 $0 MO; QLL (13 per 30 days) FIRAZYR 2 $0 PAR; MO FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 250 MCG/ACTUATION, 50 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 110 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 220 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 44 MCG/ACTUATION flunisolide nasal spray,non-aerosol 25 mcg (0.025 %) 2 $0 MO; QLL (60 per 30 days) 2 $0 MO; QLL (240 per 30 days) 2 $0 MO; QLL (12 per 30 days) 2 $0 MO; QLL (24 per 30 days) 2 $0 MO; QLL (11 per 30 days) 2 $0 MO; QLL (75 per 30 days) fluticasone nasal 2 $0 MO; QLL (16 per 30 days) FORADIL AEROLIZER 2 $0 MO; QLL (60 per 30 days) ipratropium bromide inhalation 2 $0 B/D PAR; MO ipratropium-albuterol 2 $0 B/D PAR; MO; QLL (540 per 30 days) KALYDECO ORAL TABLET 2 $0 PAR; MO; QLL (60 per 30 days) LETAIRIS 2 $0 PAR; MO; LA; QLL (30 per 30 days) ENYDMEM-0035-15 114

levalbuterol hcl inhalation solution for nebulization 0.31 mg/3 ml, 1.25 mg/0.5 ml, 1.25 mg/3 ml levalbuterol hcl inhalation solution for nebulization 0.63 mg/3 ml metaproterenol oral 2 $0 MO 2 $0 B/D PAR; MO; QLL (270 per 30 days) 2 $0 B/D PAR; MO; QLL (540 per 30 days) montelukast 2 $0 MO; QLL (30 per 30 days) NASONEX 2 $0 MO; QLL (17 per 30 days) PERFOROMIST 2 $0 B/D PAR; MO; QLL (120 per 30 days) PROAIR HFA 2 $0 MO; QLL (18 per 30 days) PROAIR RESPICLICK 2 $0 MO; QLL (2 per 30 days) PULMOZYME 2 $0 B/D PAR; MO QVAR INHALATION AEROSOL 40 MCG/ACTUATION QVAR INHALATION AEROSOL 80 MCG/ACTUATION 2 $0 MO; QLL (9 per 30 days) 2 $0 MO; QLL (18 per 30 days) SEREVENT DISKUS 2 $0 MO; QLL (60 per 30 days) sildenafil oral 2 $0 PAR; MO; QLL (90 per 30 days) SPIRIVA RESPIMAT INHALATION MIST 2.5 MCG/ACTUATION 2 $0 MO; QLL (4 per 30 days) SPIRIVA WITH HANDIHALER 2 $0 MO; QLL (30 per 30 days) STIOLTO RESPIMAT 2 $0 MO; QLL (4 per 30 days) terbutaline oral 2 $0 MO terbutaline subcutaneous 2 $0 MO theophylline oral tablet extended release 2 $0 MO theophylline oral tablet extended release 12 hr 2 $0 MO TRACLEER 2 $0 PAR; MO; LA; QLL (60 per 30 days) VENTAVIS 2 $0 PAR; MO XOLAIR 2 $0 PAR; MO; LA; QLL (6 per 28 days) zafirlukast 2 $0 MO; QLL (60 per 30 days) UROLOGICALS ENYDMEM-0035-15 115

ANTICHOLINERGICS / ANTISPASMODICS MYRBETRIQ 2 $0 MO; QLL (30 per 30 days) oxybutynin chloride oral syrup 2 $0 MO; QLL (600 per 30 days) oxybutynin chloride oral tablet 2 $0 MO; QLL (120 per 30 days) oxybutynin chloride oral tablet extended release 24hr 10 mg, 15 mg oxybutynin chloride oral tablet extended release 24hr 5 mg 2 $0 MO; QLL (60 per 30 days) 2 $0 MO; QLL (30 per 30 days) tolterodine oral capsule,extended release 24hr 2 $0 MO; QLL (30 per 30 days) tolterodine oral tablet 2 $0 MO; QLL (60 per 30 days) TOVIAZ 2 $0 MO; QLL (30 per 30 days) trospium oral tablet 2 $0 MO; QLL (60 per 30 days) VESICARE 2 $0 MO; QLL (30 per 30 days) BENIGN PROSTATIC HYPERPLASIA(BPH) THERAPY alfuzosin 2 $0 MO finasteride oral tablet 5 mg 2 $0 MO tamsulosin 2 $0 MO CHOLINERGIC STIMULANTS bethanechol chloride 2 $0 MO MISCELLANEOUS UROLOGICALS CIALIS ORAL TABLET 2.5 MG, 5 MG 2 $0 PAR; MO; QLL (30 per 30 days) CYSTAGON 2 $0 MO; LA potassium citrate oral tablet extended release 10 meq (1,080 mg), 5 meq (540 mg) URINARY ANESTHETICS 2 $0 MO azo 4 $0 [*] AZO URINARY PAIN RELIEF ORAL TABLET 95 MG 4 $0 [*] azo-dine oral tablet 95 mg 4 $0 [*] azo-tabs 4 $0 [*] urinary pain relief oral tablet 95 mg 4 $0 [*] ENYDMEM-0035-15 116

VITAMINS, HEMATINICS / ELECTROLYTES ELECTROLYTES alcalak 4 $0 [*] ANTACID CALCIUM ORAL TABLET,CHEWABLE 215 MG CALCIUM (500 MG) 4 $0 [*] calcium 500 + d (d3) 4 $0 [*] calcium 500 + d oral tablet 500 mg(1,250mg) -200 unit calcium 500 + d oral tablet 500 mg(1,250mg) -400 unit 4 $0 MO; [*] 4 $0 [*] CALCIUM 500 ORAL TABLET 4 $0 [*] calcium 500 with d 4 $0 MO; [*] calcium 600 4 $0 [*] calcium 600 + d(3) oral tablet 600 mg(1,500mg) - 200 unit, 600 mg(1,500mg) -400 unit CALCIUM 600 + D(3) ORAL TABLET 600-125 MG-UNIT 4 $0 MO; [*] 4 $0 [*] calcium 600 with vitamin d3 oral tablet 4 $0 [*] calcium acetate oral capsule 1 $0 MO calcium antacid oral tablet,chewable 200 mg calcium (500 mg) calcium antacid oral tablet,chewable 300 mg (750 mg), 320 mg (750 mg) CALCIUM ANTACID ORAL TABLET,CHEWABLE 400 MG (1,000 MG) 4 $0 MO; [*] 4 $0 [*] 4 $0 [*] calcium antacid tropical 4 $0 [*] calcium antacid ultra max st 4 $0 [*] calcium carbonate oral suspension 4 $0 MO; [*] calcium carbonate oral tablet 260 mg calcium (648 mg), 500 mg calcium (1,250 mg), 600 mg (1,500 mg) calcium carbonate oral tablet,chewable 200 mg calcium (500 mg), 400 mg (1,000 mg) 4 $0 MO; [*] 4 $0 [*] ENYDMEM-0035-15 117

calcium carbonate-vitamin d3 oral tablet 500 mg(1,250mg) -125 unit, 500 mg(1,250mg) -200 unit, 500 mg(1,250mg) -400 unit, 500mg (1,250mg) -600 unit calcium carbonate-vitamin d3 oral tablet 600 mg(1,500mg) -200 unit, 600 mg(1,500mg) -400 unit, 600 mg(1,500mg) -800 unit 4 $0 [*] 4 $0 MO; [*] calcium citrate + 4 $0 [*] calcium citrate + d 4 $0 [*] calcium citrate + d with mag 4 $0 [*] calcium citrate-vitamin d2 4 $0 [*] calcium citrate-vitamin d3 oral tablet 200 mg calcium -250 unit, 250 mg calcium- 200 unit calcium citrate-vitamin d3 oral tablet 315-200 mgunit CALCIUM CITRATE-VITAMIN D3 ORAL TABLET 315-250 MG-UNIT 4 $0 [*] 4 $0 MO; [*] 4 $0 MO; [*] calcium+d oral tablet 500 mg(1,250mg) -200 unit 4 $0 [*] CITRACAL REGULAR 4 $0 MO; [*] citrus calcium oral tablet 200 mg calcium -250 unit 4 $0 [*] citrus calcium oral tablet 315-250 mg-unit 4 $0 MO; [*] copper chloride 3 $0 MO; [*] dextrose-kcl-nacl 2 $0 B/D PAR hi-cal plus vit d 4 $0 [*] high potency calcium 4 $0 [*] klor-con 10 2 $0 MO klor-con 8 2 $0 MO klor-con m10 2 $0 MO klor-con m15 2 $0 MO klor-con m20 2 $0 MO K-TAB ORAL TABLET EXTENDED RELEASE 8 MEQ 2 $0 lactated ringers intravenous 2 $0 B/D PAR; MO ENYDMEM-0035-15 118

mag 64 4 $0 MO; [*] mag-delay 4 $0 MO; [*] mag-g 4 $0 MO; [*] magnesium gluconate oral tablet 27 mg (500 mg) 4 $0 MO; [*] magnesium gluconate oral tablet 27.5 mg (500 mg) 4 $0 [*] magnesium oxide oral tablet 400 mg, 420 mg 4 $0 MO; [*] magnesium sulfate in water intravenous parenteral solution magnesium sulfate in water intravenous piggyback 2 gram/50 ml (4 %), 4 gram/50 ml (8 %) magnesium sulfate in water intravenous piggyback 4 gram/100 ml (4 %) 2 $0 2 $0 2 $0 MO magnesium sulfate injection solution 2 $0 MO magnesium sulfate injection syringe 2 $0 manganese chloride 3 $0 [*] NORMOSOL-R 2 $0 B/D PAR NORMOSOL-R IN 5 % DEXTROSE 2 $0 B/D PAR oral electrolytes 4 $0 [*] oralyte 4 $0 [*] oysco 500/d oral tablet 4 $0 MO; [*] oysco d 4 $0 MO; [*] oysco-500 4 $0 MO; [*] oyst-cal-500 4 $0 MO; [*] oyster shell + d3 4 $0 [*] oyster shell calcium 4 $0 MO; [*] oyster shell calcium 500 4 $0 MO; [*] oyster shell calcium-vit d3 4 $0 MO; [*] oystercal-d 4 $0 [*] pedialyte freezer pops 4 $0 [*] PEDIALYTE ORAL POWDER IN PACKET 10.6-4.7 MEQ/8.5 GRAM 4 $0 MO; [*] ENYDMEM-0035-15 119

pedialyte oral solution 4 $0 MO; [*] pedialyte singles 4 $0 [*] pediatric electrolyte 4 $0 [*] pediatric freezer pops 4 $0 [*] potassium chlorid-d5-0.45%nacl intravenous parenteral solution 10 meq/l, 30 meq/l, 40 meq/l potassium chlorid-d5-0.45%nacl intravenous parenteral solution 20 meq/l potassium chloride in 0.9%nacl intravenous parenteral solution 20 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 chloride in lr-d5 intravenous parenteral solution 40 meq/l potassium chloride intravenous piggyback 10 meq/100 ml, 20 meq/100 ml, 20 meq/50 ml, 30 meq/100 ml, 40 meq/100 ml potassium chloride intravenous piggyback 10 meq/50 ml 2 $0 B/D PAR 2 $0 B/D PAR; MO 2 $0 B/D PAR 2 $0 B/D PAR 2 $0 B/D PAR; MO 2 $0 B/D PAR 2 $0 B/D PAR 2 $0 B/D PAR; MO potassium chloride intravenous solution 2 $0 B/D PAR; MO potassium chloride oral capsule, extended release 2 $0 MO potassium chloride oral tablet extended release 2 $0 MO potassium chloride oral tablet,er particles/crystals 2 $0 MO potassium chloride-0.45 % nacl 2 $0 B/D PAR potassium chloride-d5-0.2%nacl intravenous parenteral solution 20 meq/l potassium chloride-d5-0.2%nacl intravenous parenteral solution 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 2 $0 B/D PAR; MO 2 $0 B/D PAR 2 $0 B/D PAR 2 $0 B/D PAR; MO ENYDMEM-0035-15 120

potassium chloride-d5-0.9%nacl intravenous parenteral solution 40 meq/l 2 $0 B/D PAR ringers intravenous 2 $0 B/D PAR sodium chloride 0.45 % intravenous parenteral solution 2 $0 MO sodium chloride 0.45 % intravenous piggyback 2 $0 sodium chloride 3 % 2 $0 MO sodium chloride 5 % 2 $0 sodium chloride intravenous 2 $0 B/D PAR; MO TPN ELECTROLYTES 2 $0 B/D PAR ULTRA STRENGTH ANTACID 4 $0 [*] ultra strength calcium antacid 4 $0 [*] zinc chloride intraveneous solution 3 $0 MO; [*] MISCELLANEOUS NUTRITION PRODUCTS AMINOSYN 8.5 % 2 $0 B/D PAR AMINOSYN 8.5 %-ELECTROLYTES 2 $0 B/D PAR AMINOSYN II 10 % 2 $0 B/D PAR AMINOSYN II 7 % 2 $0 B/D PAR AMINOSYN II 8.5 % 2 $0 B/D PAR AMINOSYN II 8.5 %-ELECTROLYTES 2 $0 B/D PAR AMINOSYN M 3.5 % 2 $0 B/D PAR AMINOSYN-HBC 7% 2 $0 B/D PAR AMINOSYN-PF 10 % 2 $0 B/D PAR AMINOSYN-PF 7 % (SULFITE-FREE) 2 $0 B/D PAR CLINIMIX 5%/D15W SULFITE FREE 2 $0 B/D PAR CLINIMIX 5%/D25W SULFITE-FREE 2 $0 B/D PAR CLINIMIX 2.75%/D5W SULFIT FREE 2 $0 B/D PAR CLINIMIX 4.25%/D10W SULF FREE 2 $0 B/D PAR CLINIMIX 4.25%-D20W SULF-FREE 2 $0 B/D PAR CLINIMIX 4.25%-D25W SULF-FREE 2 $0 B/D PAR CLINIMIX 5%-D20W(SULFITE-FREE) 2 $0 B/D PAR ENYDMEM-0035-15 121

CLINIMIX E 4.25%/D10W SUL FREE 2 $0 CLINIMIX E 4.25%/D25W SUL FREE 2 $0 B/D PAR CLINIMIX E 4.25%/D5W SULF FREE 2 $0 B/D PAR CLINIMIX E 5%/D15W SULFIT FREE 2 $0 B/D PAR CLINIMIX E 5%/D20W SULFIT FREE 2 $0 B/D PAR CLINIMIX E 5%/D25W SULFIT FREE 2 $0 B/D PAR CLINISOL SF 15 % 2 $0 B/D PAR; MO freamine iii 10 % 2 $0 B/D PAR HEPATAMINE 8% 2 $0 B/D PAR intralipid intravenous emulsion 20 % 2 $0 B/D PAR; MO ISOLYTE-P IN 5 % DEXTROSE 2 $0 B/D PAR NORMOSOL-M IN 5 % DEXTROSE 2 $0 B/D PAR NORMOSOL-R PH 7.4 2 $0 B/D PAR PLASMA-LYTE 148 2 $0 B/D PAR PLASMA-LYTE-56 IN 5 % DEXTROSE 2 $0 B/D PAR travasol 10 % 2 $0 B/D PAR; MO TROPHAMINE 10 % 2 $0 B/D PAR; MO TROPHAMINE 6% 2 $0 B/D PAR VITAMINS / HEMATINICS a thru z 4 $0 [*] a thru z advanced formula 4 $0 [*] a thru z high potency oral tablet 4 $0 [*] adults' daily formula 4 $0 [*] animal chews 4 $0 [*] animal shape vitamins 4 $0 [*] ANIMAL SHAPES COMPLETE ORAL TABLET,CHEWABLE 4 $0 [*] AQUASOL A 3 $0 MO; [*] ascorbic acid oral tablet 4 $0 [*] ascorbic acid oral tablet extended release 1,000 mg 4 $0 MO; [*] ENYDMEM-0035-15 122

ascorbic acid oral tablet extended release 1,500 mg, 500 mg 4 $0 [*] ascorbic acid oral tablet,chewable 4 $0 [*] ascorbic acid with rose hips 4 $0 [*] b-12 dots 4 $0 MO; [*] bee-zee 4 $0 [*] biotin oral tablet 300 mcg 4 $0 MO; [*] c 500 timed released 4 $0 [*] c complex 4 $0 [*] c-1000 oral tablet 4 $0 [*] c-1000 oral tablet extended release 4 $0 MO; [*] c-1000 with rose hips 4 $0 [*] c-250 4 $0 [*] c-500 4 $0 [*] ca-d3-mag ox-zinc-cop-mang-bor oral tablet 4 $0 [*] calcidol 4 $0 [*] calciferol 4 $0 MO; [*] CALCIUM MAGNESIUM + D ORAL TABLET 500-250-200 MG-MG-UNIT 4 $0 [*] calvite p&d 4 $0 [*] central vite with lutein 4 $0 [*] central-vite oral tablet 18-400 mg-mcg 4 $0 [*] century 4 $0 [*] century adults 50+ 4 $0 [*] century ultimate women's oral tablet 18-400 mgmcg 4 $0 [*] cerovite advanced formula 4 $0 MO; [*] certavite-antioxid (iron gluc) oral liquid 9 mg iron/15 ml 4 $0 MO; [*] certavite-antioxidant 4 $0 MO; [*] chewable multi vitamin 4 $0 [*] chewable vitamin c 4 $0 [*] ENYDMEM-0035-15 123

chewable-vite 4 $0 MO; [*] children's chewable vitamin 4 $0 [*] children's multivit w/extra c 4 $0 [*] childs chew vite 4 $0 [*] child's vitamin with vitamin c 4 $0 [*] cholecalciferol (vitamin d3) oral capsule 1,000 unit, 5,000 unit cholecalciferol (vitamin d3) oral capsule 2,000 unit, 400 unit 4 $0 MO; [*] 4 $0 [*] cholecalciferol (vitamin d3) oral drops 400 unit/ml 4 $0 MO; [*] cholecalciferol (vitamin d3) oral tablet 1,000 unit, 2,000 unit, 5,000 unit 4 $0 MO; [*] cholecalciferol (vitamin d3) oral tablet 400 unit 4 $0 [*] classic prenatal 4 $0 MO; [*] cyanocobalamin (vitamin b-12) injection 3 $0 MO; [*] cyanocobalamin (vitamin b-12) oral tablet 1,000 mcg, 100 mcg, 250 mcg, 500 mcg cyanocobalamin (vitamin b-12) oral tablet extended release 2,000 mcg cyanocobalamin (vitamin b-12) sublingual tablet 1,000 mcg 4 $0 [*] 4 $0 [*] 4 $0 MO; [*] d-2000 4 $0 MO; [*] daily multiple for men 4 $0 [*] daily multiple for men 50+ 4 $0 [*] daily multiple for women 50+ 4 $0 [*] daily multiple oral tablet, 18-400 mg-mcg 4 $0 [*] daily multiple vitamins/iron 4 $0 [*] daily multi-vitamin 4 $0 [*] daily multivitamin with iron 4 $0 [*] daily multivitamin-minerals 4 $0 [*] daily multi-vitamins/iron 4 $0 [*] DAILY PRENATAL 4 $0 [*] ENYDMEM-0035-15 124

daily vitamin formula 4 $0 [*] daily vitamin formula-minerals 4 $0 [*] daily vitamin with iron 4 $0 [*] daily vites/iron 4 $0 MO; [*] daily-vite 4 $0 MO; [*] delta d3 4 $0 MO; [*] dialyvite 800 4 $0 MO; [*] dialyvite oral tablet 1-100-300-50 mg-mg-mcg-mg 3 $0 MO; [*] dialyvite vitamin d 4 $0 MO; [*] dino-life 4 $0 [*] dino-life with extra c 4 $0 [*] dino-life with iron-zinc 4 $0 [*] d-vi-sol 4 $0 MO; [*] d-vita 4 $0 [*] ergocalciferol (vitamin d2) oral capsule 3 $0 MO; [*] ergocalciferol (vitamin d2) oral drops 4 $0 MO; [*] ergocalciferol (vitamin d2) oral tablet 400 unit 4 $0 MO; [*] essentia 4 $0 [*] feosol oral tablet 325 mg (65 mg iron) 4 $0 MO; [*] FERAHEME 3 $0 MO; [*] ferocon 3 $0 MO; [*] ferosul oral tablet 4 $0 MO; [*] ferrex 150 4 $0 MO; [*] ferrocite plus 3 $0 MO; [*] ferro-time 4 $0 MO; [*] ferrous gluconate oral tablet 236 mg (27 mg iron), 256 mg (28 mg iron) 4 $0 [*] ferrous sulfate oral tablet 325 mg (65 mg iron) 4 $0 MO; [*] ferrousul 4 $0 [*] fluoritab oral tablet,chewable 1 mg fluoride (2.2 mg) 2 $0 MO ENYDMEM-0035-15 125

folbee plus oral tablet 5-1.5-25 mg 3 $0 MO; [*] folic acid injection 3 $0 MO; [*] folic acid oral tablet 1 mg 3 $0 MO; [*] folic acid oral tablet 400 mcg, 800 mcg 4 $0 MO; [*] full spectrum b-vitamin c 4 $0 [*] gummi bear multivitamin 4 $0 [*] gummy swirls 4 $0 [*] hematinic plus vit/minerals 3 $0 MO; [*] hydroxocobalamin 3 $0 MO; [*] icaps plus 4 $0 [*] iferex 150 4 $0 MO; [*] infed 3 $0 MO; [*] iron (dried) 4 $0 [*] iron (ferrous sulfate) 4 $0 [*] iron high potency 4 $0 [*] IRON ORAL TABLET 325 MG (65 MG IRON) 4 $0 [*] iron oral tablet extended release 159 mg (45 mg iron) 4 $0 [*] kid's vitamins + extra c 4 $0 [*] kid's vitamins oral tablet,chewable 4 $0 [*] little animals 4 $0 [*] m.v.i. adult 3 $0 [*] M.V.I. PEDIATRIC 3 $0 [*] M.V.I.-12 (WITHOUT VITAMIN K) 3 $0 [*] men's daily multivit-mineral 4 $0 [*] men's multi-vitamin 4 $0 [*] men's one daily oral tablet 4 $0 [*] multi complete with iron 4 $0 [*] multi-day with iron 4 $0 [*] multi-delyn 4 $0 MO; [*] multiple vitamin essential 4 $0 [*] ENYDMEM-0035-15 126

multiple vitamin-minerals 4 $0 [*] multiple vitamins 4 $0 [*] multivitamin 4 $0 MO; [*] multivitamin with iron 4 $0 [*] multivitamin with minerals oral tablet 4 $0 MO; [*] multi-vitamins with iron 4 $0 [*] myferon 150 4 $0 MO; [*] mynephrocaps 3 $0 [*] nephro-vite rx 3 $0 MO; [*] omnicap 4 $0 [*] once daily 4 $0 [*] one daily 50 plus 4 $0 [*] one daily complete 4 $0 [*] one daily energy oral tablet 4 $0 [*] one daily essential oral tablet, 0.4 mg 4 $0 [*] one daily for men 4 $0 [*] one daily for women 4 $0 [*] one daily maximum 4 $0 [*] one daily maximum (with ca) 4 $0 [*] one daily men's 50+ oral tablet 400-600-120 mcgmcg-mg 4 $0 [*] one daily multi-vit w-mineral 4 $0 [*] one daily multivitamin oral tablet 4 $0 [*] one daily oral tablet, 0.4-600 mg-mcg 4 $0 [*] ONE DAILY ORAL TABLET 300-18-400-50 MG-MG-MCG-MG 4 $0 [*] one daily plus iron 4 $0 [*] one daily plus minerals 4 $0 [*] one daily prenatal oral combo pack 28-800-440 mg-mcg-mg 4 $0 [*] one daily with iron 4 $0 [*] ENYDMEM-0035-15 127

one daily womens 50 plus 4 $0 [*] ONE DAILY WOMEN'S METABOLISM 4 $0 [*] one-a-day essential 4 $0 MO; [*] one-a-day maximum formula 4 $0 [*] one-a-day teen advantage 4 $0 [*] oyster shell calcium with d 4 $0 [*] pnv cmb#95-ferrous fumarate-fa 4 $0 [*] poly-iron 4 $0 MO; [*] poly-vita 4 $0 [*] poly-vitamin 4 $0 [*] poly-vitamins 4 $0 [*] prenatal 4 $0 [*] prenatal + dha oral combo pack 28 mg iron- 975 mcg-200 mg 4 $0 [*] prenatal complete 4 $0 [*] prenatal formula oral tablet, 28-0.8 mg 4 $0 [*] prenatal multivitamins 4 $0 [*] prenatal vit#96-ferrous fum-fa 4 $0 MO; [*] PRENATAL VITAMIN ORAL TABLET 2 $0 MO PRENATAL VITAMIN ORAL TABLET 27-0.8 MG 4 $0 [*] prenatal vitamin with minerals 4 $0 [*] prenatal vit-iron fumarate-fa 4 $0 [*] pyridoxine injection 3 $0 MO; [*] pyridoxine oral tablet 100 mg 4 $0 [*] quintabs-m iron free 4 $0 [*] renal caps 3 $0 MO; [*] rena-vite 4 $0 MO; [*] rena-vite rx 3 $0 MO; [*] reno caps 3 $0 MO; [*] risacal-d 4 $0 MO; [*] ENYDMEM-0035-15 128

slow release iron oral tablet extended release 142 mg (45 mg iron), 47.5 mg iron 4 $0 [*] sodium fluoride oral tablet 2 $0 MO sodium fluoride oral tablet,chewable 1 mg fluoride (2.2 mg) spectravite advanced formula oral tablet 18-400 mg-mcg 2 $0 MO 4 $0 [*] spectravite ultra women 4 $0 [*] stress formula advanced 4 $0 [*] tab-a-vite 4 $0 MO; [*] tab-a-vite/iron 4 $0 MO; [*] tab-a-vite-minerals 4 $0 [*] thera-d 4 $0 [*] theralogix companion 4 $0 [*] thiamine hcl injection 3 $0 MO; [*] thiamine hcl oral tablet 100 mg, 250 mg, 50 mg 4 $0 [*] thiamine mononitrate 4 $0 [*] tl icon 3 $0 MO; [*] tricon 3 $0 MO; [*] triphrocaps 3 $0 MO; [*] TRI-VI-SOL 4 $0 MO; [*] tri-vita 4 $0 [*] tri-vitamin 4 $0 MO; [*] VENOFER INTRAVENOUS SOLUTION 100 MG IRON/5 ML, 200 MG IRON/10 ML VENOFER INTRAVENOUS SOLUTION 50 MG IRON/2.5 ML 3 $0 MO; [*] 3 $0 [*] vitalee 4 $0 [*] vitamin a oral capsule 10,000 unit 4 $0 MO; [*] vitamin a oral capsule 25,000 unit, 8,000 unit 4 $0 [*] VITAMIN A PALMITATE ORAL CAPSULE 4 $0 [*] vitamin b-1 4 $0 MO; [*] ENYDMEM-0035-15 129

VITAMIN B-1 (MONONITRATE) 4 $0 [*] vitamin b-12 oral tablet 1,000 mcg, 100 mcg, 250 mcg, 500 mcg vitamin b-12 oral tablet extended release 2,000 mcg 4 $0 MO; [*] 4 $0 [*] vitamin b-12 sublingual tablet 1,000 mcg 4 $0 [*] vitamin b-6 oral tablet 100 mg 4 $0 MO; [*] vitamin c cough drops 4 $0 [*] VITAMIN C DROPS 4 $0 [*] vitamin c oral capsule, extended release 4 $0 MO; [*] VITAMIN C ORAL LOZENGE 4 $0 [*] vitamin c oral syrup 4 $0 MO; [*] vitamin c oral tablet 1,000 mg, 250 mg, 500 mg 4 $0 MO; [*] vitamin c oral tablet 100 mg 4 $0 [*] vitamin c oral tablet extended release 1,000 mg 4 $0 [*] VITAMIN C ORAL TABLET EXTENDED RELEASE 500 MG 4 $0 MO; [*] vitamin c oral tablet,chewable 250 mg, 500 mg 4 $0 MO; [*] VITAMIN C WITH ROSE HIPS ORAL TABLET 4 $0 MO; [*] vitamin c with rose hips oral tablet extended release 4 $0 [*] vitamin d2 3 $0 MO; [*] vitamin d3 oral capsule 1,000 unit, 2,000 unit, 400 unit 4 $0 MO; [*] vitamin d3 oral tablet 1,000 unit, 400 unit 4 $0 MO; [*] vitamin d3 oral tablet 2,000 unit 4 $0 [*] VITAMIN D3 ORAL TABLET 5,000 UNIT 4 $0 [*] vitamin e (dl, acetate) oral capsule 400 unit 4 $0 MO; [*] vitamin e mixed oral capsule 400 unit 4 $0 [*] vol-care rx 3 $0 MO; [*] yelets 4 $0 [*] zoo chews 4 $0 [*] ENYDMEM-0035-15 130

Index A A & D ZINC OXIDE CREAM... 58 A + D (LAN, PET)... 58 a thru z... 122 a thru z advanced formula.. 122 a thru z high potency... 122 abacavir... 9 abacavir-lamivudine-zidovudine... 9 ABELCET... 9 ABILIFY... 40 ABILIFY MAINTENA... 40 ABRAXANE... 20 ABREVA... 64 ABSTRAL... 32 acarbose... 72 acebutolol... 51 acephen... 35 acetadryl... 35 aceta-gesic... 35 acetaminophen... 35, 36 ACETAMINOPHEN EXTRA STRENGTH... 35 acetaminophen pain relief... 35 acetaminophen pm... 35 acetaminophen pm extra str.. 35 acetaminophen-codeine... 33 acetazolamide oral... 99 acetazolamide sodium... 99 acetic acid... 71 acetic acid-aluminum acetate 71 acetylcysteine... 67, 113 acid control (ranitidine)... 88 ACID REDUCER (CIMETIDINE)... 88 acid reducer (famotidine)... 88 ACID REDUCER (RANITIDINE)... 88 acid reducer complete (famot)88 acid relief (cimetidine)... 88 acitretin... 58 acne treatment (benzoyl perox)... 60 acta-tabs pe... 101 ACTEMRA... 93 ACTHAR H.P.... 71 ACTHIB (PF)... 90 ACTIMMUNE... 89 ACTIQ... 33 acyclovir... 9, 10, 64 acyclovir sodium... 10 ADACEL(TDAP ADOLESN/ADULT)(PF).. 90 ADAGEN... 67 adapalene... 60 ADASUVE... 40 ADDED STRENGTH PAIN RELIEVER... 36 adefovir... 10 adult cough formula dm max 101 adult low dose aspirin... 36 adult tussin chest congestion 101 ADULT TUSSIN COUGH CONGEST DM... 101 ADULT TUSSIN DM... 101 adults' daily formula... 122 ADVAIR DISKUS... 113 ADVAIR HFA... 113 ADVANCED ANTACID- ANTIGAS... 78 AEROSPAN... 113 af 62 afeditab cr... 51 AFINITOR... 20 AFINITOR DISPERZ... 20 AGGRENOX... 55 ak-poly-bac... 97 ala-cort... 64 ala-hist ir... 101 alaway... 98 ALBENZA... 14 albuterol sulfate... 113 alcalak... 117 alclometasone... 64 alcohol pads... 72 ALCOHOL, RUBBING... 69 ALDURAZYME... 75 alendronate... 67, 92 alfuzosin... 116 ALIMTA... 20 ALINIA... 14 all day allergy (cetirizine)... 101 ALL DAY ALLERGY (CETIRIZINE)... 101 all day allergy relief(cetir).. 101 all day allergy-d... 101 allergy (chlorpheniramine). 101 allergy (diphenhydramine).. 101 ALLERGY COMPLETE-D 101 allergy cream (diphenhyd, zn) 58 allergy eye (ketotifen)... 98 ALLERGY EYE (NAPHAZOLINE-PHEN)... 100 allergy multi-symptom... 101 allergy plus severe sinus ha. 101 allergy relief (cetirizine)... 101 ALLERGY RELIEF (CLEMASTINE)... 102 allergy relief (fexofenadine) 102 allergy relief (loratadine)... 102 ALLERGY RELIEF (LORATADINE)... 102 allergy relief multi-symptom 102 allergy relief(chlorpheniramn)... 102 allergy relief(diphenhydramin)... 102 allergy relief-d (cetirizine).. 102 ALLERGY RELIEF-D (LORATADINE)... 102 ALLERGY RELIEF-SINUS HEADACHE... 102 ALLERGY SINUS HEADACHE (PE)... 102? 如 果 您 有 疑 問, 請 於 當 地 時 間 週 一 至 週 五 上 午 8 點 至 晚 上 8 點 致 電 Empire FIDA Plan, 電 話 號 碼 為 1-855-817-5789( 聽 語 障 用 戶 請 致 電 1-800-855-2880) 此 為 免 付 費 電 話 如 需 更 多 資 訊, 請 訪 問 www.empireblue.com/fida H8417_15_20348_T CMS Approved 12/24/2014 ENYDMKT-0023-15 131

allergy sinus pe... 102 aller-tec... 102 aller-tec d... 102 allfen... 102 allfen dm... 102 ALL-NITE COLD-FLU... 102 allopurinol... 92 almacone... 78 almacone-2... 78 aloe vesta... 62 alophen... 78 alosetron... 79 ALPHAGAN P... 100 alprazolam... 40 altachlore... 98 altavera (28)... 95 altazine... 101 aluminum hydroxide gel... 79 alyacen 1/35 (28)... 95 alyacen 7/7/7 (28)... 95 amantadine hcl... 10 ambi 10peh-4cpm... 102 ambi 60pse-4cpm... 102 AMBISOME... 9 amcinonide... 64 amifostine crystalline... 19 amikacin... 14 amiloride... 51 amiloride-hydrochlorothiazide... 51 AMINOSYN 8.5 %... 121 AMINOSYN 8.5 %- ELECTROLYTES... 121 AMINOSYN II 10 %... 121 AMINOSYN II 7 %... 121 AMINOSYN II 8.5 %... 121 AMINOSYN II 8.5 %- ELECTROLYTES... 121 AMINOSYN M 3.5 %... 121 AMINOSYN-HBC 7%... 121 AMINOSYN-PF 10 %... 121 AMINOSYN-PF 7 % (SULFITE-FREE)... 121 amiodarone... 50 AMITIZA... 79 amitriptyline... 40 amlodipine... 51 amlodipine-atorvastatin... 57 amlodipine-benazepril... 51 amlodipine-valsartan... 51 amlodipine-valsartan-hcthiazid... 51 ammonium lactate... 58 amnesteem... 60 amoxapine... 40 amoxicillin... 17 amoxicillin-pot clavulanate... 17 amphetamine salt combo... 40 amphotericin b...9 ampicillin... 17 ampicillin sodium... 17 ampicillin-sulbactam... 17 AMPYRA... 31 anagrelide... 67 anastrozole... 20 ANDRODERM... 75 ANDROGEL... 75 androxy... 75 anefrin... 70 animal chews... 122 animal shape vitamins... 122 ANIMAL SHAPES COMPLETE... 122 ANORO ELLIPTA... 113 ANTACID ANTI-GAS... 79 antacid anti-gas double str... 79 ANTACID CALCIUM... 117 antacid liquid... 79 antacid plus anti-gas... 79 ANTACID WITH SIMETHICONE... 79 ANTACID-ANTIGAS... 79 antacid-simethicone... 79 antacid-simethicone ds... 79 ANTIBIOTIC (BACITRACIN ZINC)... 61 antibiotic (neomy-bacit-polym)... 61 ANTIBIOTIC + PAIN RELIEF... 61 ANTIBIOTIC PLUS (PRAMOXINE)... 61 anti-diarrheal (loperamide)... 77 ANTI-DIARRHEAL (LOPERAMIDE)... 77 ANTIFUNGAL (CLOTRIMAZOLE)... 62 antifungal (tolnaftate)... 62 ANTIFUNGAL (TOLNAFTATE)... 62 antifungal spray... 62 anti-gas ultra strength... 79 anti-itch (benz-resor)... 60 anti-itch (diphenhydramine).. 58 anti-itch (hc)... 64 anti-itch(diphenhyd) with zinc 58 ANTI-ITCH(DIPHENHYD) WITH ZINC... 59 anti-nausea... 79 antiseptic solution... 61 antitussive dm... 102 ap-hist dm... 102 APOKYN... 30 apraclonidine... 100 apri... 95 APRISO... 79 aprodine... 102 APTIOM... 26 APTIVUS... 10 AQUASOL A... 122 ARALAST NP... 67 aranelle (28)... 95 ARANESP (IN POLYSORBATE)... 89 arbinoxa... 102 ARCALYST... 89 aripiprazole... 40, 41 ARNUITY ELLIPTA... 113 ARRANON... 20 arthritis pain relief (acetam).. 36 artificial tears... 98 artificial tears (petro/min)... 98 artificial tears (pf)... 98 artificial tears (polyvin alc)... 99 artificial tears(glycerin-peg).. 99? 如 果 您 有 疑 問, 請 於 當 地 時 間 週 一 至 週 五 上 午 8 點 至 晚 上 8 點 致 電 Empire FIDA Plan, 電 話 號 碼 為 1-855-817-5789( 聽 語 障 用 戶 請 致 電 1-800-855-2880)(TTY 711) 此 為 免 付 費 電 話 如 需 更 多 資 訊, 請 訪 問 www.empireblue.com/fida ENYDMEM-0035-15 132

artificial tears(hypromellose) 99 ARZERRA... 20 ASACOL HD... 79 ascorbic acid... 122, 123 ascorbic acid with rose hips 123 ASMANEX HFA... 113 ASMANEX TWISTHALER... 113, 114 aspir-81... 36 aspirin... 36 aspirin childrens... 36 aspirin low dose... 36 aspirin low-strength... 36 aspirin, buffered... 36 aspirin-dipyridamole... 55 aspir-low... 36 aspir-trin... 36 ASTAGRAF XL... 20 atenolol... 51 atenolol-chlorthalidone... 51 ATGAM... 90 athenol... 36 athlete's foot (terbinafine)... 62 athlete's foot (tolnaftate)... 62 atorvastatin... 57 atovaquone... 14 atovaquone-proguanil... 14 ATRIPLA... 10 atropine... 77 ATROVENT HFA... 114 AVASTIN... 20 aviane... 95 AVONEX... 89 AVONEX (WITH ALBUMIN)... 89 ayr saline... 70 azacitidine... 20 AZACTAM IN DEXTROSE (ISO-OSM)... 14 azathioprine... 20 azelastine... 70, 99 AZILECT... 30 azithromycin... 14 azo... 116 AZO URINARY PAIN RELIEF... 116 azo-dine... 116 AZOPT... 99 AZOR... 51 azo-tabs... 116 aztreonam... 14 azurette (28)... 95 B b-12 dots... 123 baby ayr saline... 70 baciim... 14 bacitracin... 61, 97 bacitracin zinc... 61 bacitracin-polymyxin b... 61, 97 bacitraycin plus... 61 baclofen... 32 balsalazide... 79 banophen... 102, 103 banophen allergy... 102 banophen anti-itch... 59 BANZEL... 27 BARACLUDE... 10 bayer plus extra strength... 36 baza antifungal... 62 BCG VACCINE, LIVE (PF). 90 bee-zee... 123 BELEODAQ... 20 benazepril... 51 benazepril-hydrochlorothiazide... 51 benzonatate... 103 benzoyl peroxide... 60 benztropine... 30 betamethasone dipropionate.. 64 betamethasone valerate... 64 betamethasone, augmented... 64 betatemp... 36 betaxolol... 51, 98 bethanechol chloride... 116 bexarotene... 20 BEXSERO (PF)... 90 bicalutamide... 20 BICILLIN C-R... 17 BICILLIN L-A... 17 BICNU... 20 BILTRICIDE... 14 bimatoprost... 100 biocotron... 103 BIOSPEC DMX... 103 biotin... 123 bisac-evac... 79 bisacodyl... 79 bisa-lax... 79 biscolax... 79 bismatrol... 77 bismuth... 77 bismuth maximum strength... 77 bisoprolol fumarate... 51 bisoprolol-hydrochlorothiazide... 51 bleomycin... 20 BLEPHAMIDE S.O.P.... 100 BLINCYTO... 20 BONIVA... 92 BOOSTRIX TDAP... 90 BOSULIF... 20 BREO ELLIPTA... 114 BRILINTA... 55 brimonidine... 100 BRINTELLIX... 41 brohist d... 103 bromocriptine... 30 brompheniramine-pseudoephdm... 103 brotapp... 103 budesonide... 79 bumetanide... 51 BUPHENYL... 67 buprenorphine hcl... 33 buprenorphine-naloxone... 36 buproban... 69 bupropion hcl... 41 buspirone... 41 BUSULFEX... 20 butalbital compound w/codeine... 33 butorphanol tartrate... 36 BYDUREON... 72 BYETTA... 72? 如 果 您 有 疑 問, 請 於 當 地 時 間 週 一 至 週 五 上 午 8 點 至 晚 上 8 點 致 電 Empire FIDA Plan, 電 話 號 碼 為 1-855-817-5789( 聽 語 障 用 戶 請 致 電 1-800-855-2880)(TTY 711) 此 為 免 付 費 電 話 如 需 更 多 資 訊, 請 訪 問 www.empireblue.com/fida ENYDMEM-0035-15 133

BYSTOLIC... 51 C c 500 timed released... 123 c complex... 123 c-1000... 123 c-1000 with rose hips... 123 c-250... 123 c-500... 123 cabergoline... 75 ca-d3-mag ox-zinc-cop-mangbor... 123 calagesic... 60 calcidol... 123 calciferol... 123 calcipotriene... 58 calcitonin (salmon)... 75 calcitriol... 76 CALCIUM 500... 117 calcium 500 + d... 117 calcium 500 + d (d3)... 117 calcium 500 with d... 117 calcium 600... 117 calcium 600 + d(3)... 117 CALCIUM 600 + D(3)... 117 calcium 600 with vitamin d3 117 calcium acetate... 117 calcium antacid... 117 CALCIUM ANTACID... 117 calcium antacid tropical... 117 calcium antacid ultra max st 117 calcium carbonate... 117 calcium carbonate-vitamin d3... 118 calcium citrate +... 118 calcium citrate + d... 118 calcium citrate + d with mag... 118 calcium citrate-vitamin d2.. 118 calcium citrate-vitamin d3.. 118 CALCIUM CITRATE- VITAMIN D3... 118 CALCIUM MAGNESIUM + D... 123 calcium+d... 118 CALDYPHEN... 60 calohist... 59 calvite p&d... 123 camila... 94 CANASA... 79 CANCIDAS...9 candesartan... 51 candesartan-hydrochlorothiazid... 51 CAPASTAT... 14 CAPEX... 64 CAPRELSA... 20 captopril... 51 captopril-hydrochlorothiazide 51 carbamazepine... 27 carbidopa-levodopa... 30 carb-o-philic... 59 carboplatin... 20 CARIMUNE NF NANOFILTERED... 90 carteolol... 98 cartia xt... 51 carvedilol... 51 CAYSTON... 14 caziant (28)... 95 cefaclor... 12 cefadroxil... 12, 13 cefazolin... 13 cefazolin in dextrose (iso-os). 13 cefdinir... 13 cefepime... 13 cefoxitin... 13 cefoxitin in dextrose, iso-osm. 13 cefpodoxime... 13 cefprozil... 13 ceftazidime... 13 ceftriaxone... 13 ceftriaxone in dextrose,iso-os. 13 cefuroxime axetil... 13 cefuroxime sodium... 13 CELLCEPT... 20 CELLCEPT INTRAVENOUS... 20 CELONTIN... 27 central vite with lutein... 123 central-vite... 123 century... 123 century adults 50+... 123 century ultimate women's... 123 cephalexin... 13 CEREZYME... 76 cerovite advanced formula.. 123 certavite-antioxid (iron gluc)... 123 certavite-antioxidant... 123 CERVARIX VACCINE (PF) 90 cetiri-d... 103 cetirizine... 103 CETIRIZINE... 103 cetirizine-pseudoephedrine. 103 cevimeline... 67 CHANTIX... 69 CHANTIX CONTINUING MONTH BOX... 69 CHANTIX STARTING MONTH BOX... 69 CHEST CONGESTION RELIEF... 103 CHEST CONGESTION RELIEF + DM... 103 CHEST CONGESTION RELIEF PE... 103 chest congestion-cough relief... 103 chest-sinus congestion relief 103 chewable multi vitamin... 123 chewable vitamin c... 123 chewable-vite... 124 child allergy relf(cetirizine). 103 CHILD ALLERGY RELF(CETIRIZINE)... 103 child aspirin... 36 child chest congestion + cough... 103 child ibuprofen... 36 child mucinex chest congestion... 103 child mucus relief cough... 103 child mucus relief expectorant... 103 child suppository... 79? 如 果 您 有 疑 問, 請 於 當 地 時 間 週 一 至 週 五 上 午 8 點 至 晚 上 8 點 致 電 Empire FIDA Plan, 電 話 號 碼 為 1-855-817-5789( 聽 語 障 用 戶 請 致 電 1-800-855-2880)(TTY 711) 此 為 免 付 費 電 話 如 需 更 多 資 訊, 請 訪 問 www.empireblue.com/fida ENYDMEM-0035-15 134

children night time cold-cough... 103 children's acetaminophen... 36 CHILDREN'S ACETAMINOPHEN... 36 CHILDREN'S ALAWAY... 99 children's allergy (diphenhyd)... 103 children's allergy relief(lor) 103 children's allergy(cetirizine) 103 children's aller-tec... 104 children's aspirin... 36 children's cetirizine... 104 children's chest congestion. 104 children's chewable vitamin 124 children's cold & cough dm 104 children's cold-allergy (pe). 104 children's dibromm cold & alle... 104 children's dibromm dm cold & c... 104 children's ibuprofen... 36 children's mapap... 36 children's medi-profen... 37 children's medi-tabs... 37 children's mucinex cough... 104 children's multivit w/extra c 124 children's non-aspirin... 37 children's non-aspirin pain... 37 children's pain & fever relief. 37 children's pepto... 79 children's profen ib... 37 children's q-pap... 37 children's silapap... 37 children's silfedrine... 104 child's all day allergy(cetir) 104 childs chew vite... 124 childs triacting cold & cough... 104 child's vitamin with vitamin c... 124 chloramphenicol sod succinate... 14 chlorhexidine gluconate... 70 chloroquine phosphate... 14 chlorothiazide... 52 chlorothiazide sodium... 52 chlorpheniramine maleate... 104 chlorpromazine... 41 chlortabs... 104 chlorthalidone... 52 cholecalciferol (vitamin d3). 124 cholestyramine (with sugar).. 57 cholestyramine light... 57 CIALIS... 116 ciclodan... 62 ciclopirox... 62, 63 cidofovir... 10 cilostazol... 55 cimetidine... 88 CIMZIA... 79 CIMZIA POWDER FOR RECONST... 79 CIMZIA STARTER KIT... 80 CIPRODEX... 71 ciprofloxacin (mixture)... 18 ciprofloxacin hcl... 18, 97 ciprofloxacin lactate... 18 cisplatin... 20 citalopram... 41 CITRACAL REGULAR... 118 CITRATE OF MAGNESIA.. 80 citroma... 80 citrus calcium... 118 cladribine... 20 clarithromycin... 14 classic prenatal... 124 CLEARLAX... 80 clemastine... 104 clindamycin hcl... 14 clindamycin phosphate.. 15, 60, 94 CLINIMIX 5%/D15W SULFITE FREE... 121 CLINIMIX 5%/D25W SULFITE-FREE... 121 CLINIMIX 2.75%/D5W SULFIT FREE... 121 CLINIMIX 4.25%/D10W SULF FREE... 121 CLINIMIX 4.25%/D5W SULFIT FREE... 67 CLINIMIX 4.25%-D20W SULF-FREE... 121 CLINIMIX 4.25%-D25W SULF-FREE... 121 CLINIMIX 5%- D20W(SULFITE-FREE) 121 CLINIMIX E 2.75%/D10W SUL FREE... 67 CLINIMIX E 2.75%/D5W SULF FREE... 67 CLINIMIX E 4.25%/D10W SUL FREE... 122 CLINIMIX E 4.25%/D25W SUL FREE... 122 CLINIMIX E 4.25%/D5W SULF FREE... 122 CLINIMIX E 5%/D15W SULFIT FREE... 122 CLINIMIX E 5%/D20W SULFIT FREE... 122 CLINIMIX E 5%/D25W SULFIT FREE... 122 CLINISOL SF 15 %... 122 clobetasol... 64 clobetasol-emollient... 65 CLOLAR... 20 clomipramine... 41 clonazepam... 27 clonidine hcl... 52 clonidine patches... 52 clopidogrel... 55 clorazepate dipotassium... 41 clotrim antifungal... 63 clotrimazole... 9, 63, 94 clotrimazole 3 day... 94 clotrimazole af... 63 clotrimazole foot... 63 clotrimazole-3... 94 clotrimazole-7... 94 clotrimazole-betamethasone.. 63 clozapine... 41, 42 colchicine-probenecid... 92 COLCRYS... 92? 如 果 您 有 疑 問, 請 於 當 地 時 間 週 一 至 週 五 上 午 8 點 至 晚 上 8 點 致 電 Empire FIDA Plan, 電 話 號 碼 為 1-855-817-5789( 聽 語 障 用 戶 請 致 電 1-800-855-2880)(TTY 711) 此 為 免 付 費 電 話 如 需 更 多 資 訊, 請 訪 問 www.empireblue.com/fida ENYDMEM-0035-15 135

COLD & ALLERGY PE... 104 COLD & COUGH DM... 104 cold & cough elixir... 104 COLD & FLU SEVERE... 104 cold & sinus pain relief... 104 COLD HEAD CONGESTION DAY/NITE... 104 COLD HEAD CONGESTION DAYTIME... 104 cold head congestion nighttime... 104 cold head congestion sever day... 104 cold multi-symptom... 104 COLD MULTI-SYMPTOM (CHLORPHEN)... 104 COLD MULTI-SYMPTOM DAY/NIGHT... 104 COLD MULTI-SYMPTOM NIGHTTIME... 104 cold relief m/s day/night... 105 COLD-COUGH SINUS RELIEF PE... 105 cold-flu relief, day/night... 105 cold-sinus relief... 105 colestipol... 57 colistin (colistimethate na)... 15 colocort... 80 col-rite... 80 COLY-MYCIN S... 71 COMBIGAN... 100 COMBIVENT RESPIMAT 114 COMETRIQ... 20 comfort gel... 80 comfort gel extra strength... 80 COMPLERA... 10 compro... 80 COMVAX (PF)... 90 constulose... 80 COPAXONE 20 MG/ML... 31 copper chloride... 118 COREG CR... 52 CORICIDIN HBP COLD- MULTI SYMPT... 105 cormax... 65 cortaid... 65 cortisone... 71 cortisone (hydrocortisone)... 65 cortizone-10... 65 cortizone-10 plus... 65 COSMEGEN... 21 cough control (guaifenesin). 105 cough control dm... 105 COUGH CONTROL DM MAX... 105 cough dm er... 105 cough drops... 70, 105 COUGH DROPS... 70 cough drops (with eucalyptus)... 105 COUGH DROPS (WITH EUCALYPTUS)... 105 cough formula dm... 105 cough suppressant-expectorant... 105 cough syrup... 105 cough syrup dm... 105 cough-sore throat night... 105 COUMADIN... 55 CREON... 80 CRESTOR... 57 critic-aid clear af... 63 CRIXIVAN... 10 cromolyn... 99, 114 cryselle (28)... 95 cyanocobalamin (vitamin b-12)... 124 cyclobenzaprine... 32 cyclophosphamide... 21 CYCLOSET... 72 cyclosporine... 21 cyclosporine modified... 21 CYRAMZA... 21 CYSTADANE... 80 CYSTAGON... 116 cytarabine... 21 cytarabine (pf)... 21 D d10 % & 0.45 % sodium chloride... 67 d2.5 %-0.45 % sodium chloride... 67 d-2000... 124 d5 % and 0.9 % sodium chloride... 67 d5 %-0.45 % sodium chloride 67 dacarbazine... 21 daily multiple... 124 daily multiple for men... 124 daily multiple for men 50+.. 124 daily multiple for women 50+... 124 daily multiple vitamins/iron. 124 daily multi-vitamin... 124 daily multivitamin with iron 124 daily multivitamin-minerals. 124 daily multi-vitamins/iron... 124 DAILY PRENATAL... 124 daily vitamin formula... 125 daily vitamin formula-minerals... 125 daily vitamin with iron... 125 daily vites/iron... 125 daily-vite... 125 DAKLINZA... 10 DALIRESP... 114 danazol... 76 dantrolene... 32 DAPSONE... 15 DAPTACEL (DTAP PEDIATRIC) (PF)... 90 DARAPRIM... 15 daunorubicin... 21 DAUNOXOME... 21 DAY TIME PE... 105 DAYTIME & NIGHTTIME COLD... 105 DAYTIME COLD & FLU RELIEF (PE)... 105 DAYTIME COLD-FLU... 105 day-time cough... 105 DAYTIME SINUS... 105 daytime-nighttime... 105 decitabine... 21 delta d3... 125? 如 果 您 有 疑 問, 請 於 當 地 時 間 週 一 至 週 五 上 午 8 點 至 晚 上 8 點 致 電 Empire FIDA Plan, 電 話 號 碼 為 1-855-817-5789( 聽 語 障 用 戶 請 致 電 1-800-855-2880)(TTY 711) 此 為 免 付 費 電 話 如 需 更 多 資 訊, 請 訪 問 www.empireblue.com/fida ENYDMEM-0035-15 136

DELZICOL... 80 demeclocycline... 18 DEMSER... 52 DENAVIR... 64 DEPEN TITRATABS... 93 DEPO-PROVERA 400 MG/ML... 94 desipramine... 42 desmopressin... 76 desonide... 65 desoximetasone... 65 DESVENLAFAXINE... 42 DESVENLAFAXINE FUMARATE... 42 dex4 glucose... 67 dex4 glucose bits... 67 dex4 glucose pouch pack... 67 dex4 glucose quick dissolve.. 67 dexamethasone... 71 dexamethasone sodium phos (pf)... 71 dexamethasone sodium phosphate... 71, 100 DEXILANT... 88 dexrazoxane hcl... 19 dextroamphetamine... 42 dextromethorphan polistirex 105 dextromethorphan-guaifenesin... 105 dextrose... 68 dextrose 10 % and 0.2 % nacl 67 dextrose 10 % in water (d10w)... 67 dextrose 25 % in water (d25w)... 67 dextrose 30 % in water (d30w)... 67 dextrose 40 % in water (d40w)... 68 dextrose 5 % in water (d5w). 68 dextrose 5 %-lactated ringers 68 dextrose 5%-0.2 % sod chloride... 68 dextrose 5%-0.3 % sod.chloride... 68 dextrose 50 % in water (d50w)... 68 dextrose 70 % in water (d70w)... 68 dextrose with sodium chloride 68 dextrose-kcl-nacl... 118 diabetic siltussin das-na... 105 diabetic siltussin-dm... 105 diabetic siltussin-dm max str 106 diabetic tussin dm... 106 DIABETIC TUSSIN DM... 106 DIABETIC TUSSIN EX... 106 diabetic tussin max st... 106 dialyvite... 125 dialyvite 800... 125 dialyvite vitamin d... 125 diamode... 77 diarrhea relief (bismuth subs) 77 diazepam... 27, 42 diazepam intensol... 42 diclofenac potassium... 37 diclofenac sodium... 37, 59 dicloxacillin... 17 dicyclomine... 78 didanosine... 10 DIFFERIN... 60 diflorasone... 65 diflunisal... 37 DIGITEK... 55 digox... 55 digoxin... 55 DILANTIN CAPSULES... 27 DILANTIN EXTENDED CAPSULES... 27 DILANTIN INFATABS... 27 diltiazem hcl... 52 dilt-xr... 52 dimaphen (pe)... 106 dimaphen dm... 106 dimenhydrinate... 80 dimetapp cold-congestion... 106 dimetapp dm cold-cough (pe)... 106 dino-life... 125 dino-life with extra c... 125 dino-life with iron-zinc... 125 diocto... 80 dioctyl... 80 diotame... 78 DIPENTUM... 80 diphenhydramine hcl... 59, 106 diphenhydramineacetaminophen... 37 diphenoxylate-atropine... 78 disposable enema... 80 disulfiram... 68 divalproex... 27 dm max... 106 DOCEFREZ... 21 docetaxel... 21 doc-q-lace... 80 doc-q-lax... 80 docu... 80 docuprene... 80 docusate calcium... 80 docusate sodium... 80 docusil... 80 dok... 80, 81 dok plus... 81 donepezil... 31 dorzolamide... 100 dorzolamide-timolol... 100 DOUBLE ANTIBIOTIC... 61 doxazosin... 52 doxepin... 42 doxercalciferol... 76 DOXIL... 21 doxorubicin... 21 DOXY-100... 18 doxycycline hyclate... 18 doxycycline monohydrate... 18 dramamine... 81 driminate... 81 dristan cold... 106 dristan long lasting... 70 dronabinol... 81 drospirenone-ethinyl estradiol95 DROXIA... 21 dry eye relief... 99? 如 果 您 有 疑 問, 請 於 當 地 時 間 週 一 至 週 五 上 午 8 點 至 晚 上 8 點 致 電 Empire FIDA Plan, 電 話 號 碼 為 1-855-817-5789( 聽 語 障 用 戶 請 致 電 1-800-855-2880)(TTY 711) 此 為 免 付 費 電 話 如 需 更 多 資 訊, 請 訪 問 www.empireblue.com/fida ENYDMEM-0035-15 137

DUAL ACTION COMPLETE... 88 ducodyl... 81 dulcolax stool softener (dss).. 81 DULERA... 114 duloxetine... 42, 43 duramorph (pf)... 33 d-vi-sol... 125 d-vita... 125 E econazole... 63 EDURANT... 10 EFFIENT... 55 ELAPRASE... 76 ELIDEL... 59 elinest... 95 ELIQUIS... 55 ELITEK... 19 ELLA... 95 ELON DUAL DEFENSE... 63 EMCYT... 21 EMEND... 81 EMSAM... 43 EMTRIVA... 10 enalapril maleate... 52 enalapril-hydrochlorothiazide 52 ENBREL... 93 ENBREL SURECLICK... 93 endacof - dm... 106 endocet... 33 enema... 81 ENEMA... 81 enema disposable... 81 ENGERIX-B (PF)... 90 ENGERIX-B PEDIATRIC (PF)... 90 enoxaparin... 55 enpresse... 95 entacapone... 30 entecavir... 10 ENTERIC COATED ASPIRIN... 37 entre-hist pse... 106 enulose... 81 epinephrine... 106 EPIPEN 2-PAK... 106 EPIPEN JR 2-PAK... 106 epirubicin... 21 epitol... 27 EPIVIR... 10 EPIVIR HBV... 10 eplerenone... 52 eprosartan... 52 EPSOM SALT... 81 EPZICOM... 10 EQUETRO... 27 ERAXIS(WATER DILUENT).9 ERBITUX... 21 ergocalciferol (vitamin d2).. 125 ergoloid... 43 ERGOMAR... 31 ERIVEDGE... 21 errin... 94 ERWINAZE... 22 ery pads... 60 ery-tab... 14 ERYTHROCIN... 14 erythrocin (as stearate)... 14 erythromycin... 14, 97 erythromycin ethylsuccinate.. 14 erythromycin with ethanol... 60 erythromycin-benzoyl peroxide... 60 escitalopram oxalate... 43 essentia... 125 ESTRACE... 94 estradiol... 94 ESTRING... 94 ethambutol... 15 ethosuximide... 27 etodolac... 37 ETOPOPHOS... 22 etoposide... 22 EVISTA... 92 EVOTAZ... 10 EXELON... 31 exemestane... 22 EXJADE... 68 EXPECTORANT... 106 expectorant cough syrup... 106 EXTAVIA... 89 eye drops (with povidone)... 101 F FABRAZYME... 76 falmina (28)... 95 famciclovir... 10 famotidine... 88 famotidine (pf)... 88 famotidine (pf)-nacl (iso-os). 88 FANAPT... 43 FARESTON... 22 FARYDAK... 22 FASLODEX... 22 FAZACLO... 43 felbamate... 27 felodipine... 52 fenesin ir... 106 fenesin pe ir... 106 fenofibrate... 57 fenofibrate micronized... 57 fenofibrate nanocrystallized.. 57 fenoprofen... 37 fentanyl... 33 fentanyl citrate... 33 FENTORA... 33 feosol... 125 FERAHEME... 125 ferocon... 125 ferosul... 125 ferrex 150... 125 ferrocite plus... 125 ferro-time... 125 ferrous gluconate... 125 ferrous sulfate... 125 ferrousul... 125 FETZIMA... 43, 44 fever reducer... 37 fever reducer & pain reliever 37 feverall... 37 fexofenadine... 106 FIBER... 81 fiber (calcium polycarbophil) 81 fiber (psyllium husk)... 81 FIBER (PSYLLIUM HUSK/SUGAR)... 81? 如 果 您 有 疑 問, 請 於 當 地 時 間 週 一 至 週 五 上 午 8 點 至 晚 上 8 點 致 電 Empire FIDA Plan, 電 話 號 碼 為 1-855-817-5789( 聽 語 障 用 戶 請 致 電 1-800-855-2880)(TTY 711) 此 為 免 付 費 電 話 如 需 更 多 資 訊, 請 訪 問 www.empireblue.com/fida ENYDMEM-0035-15 138

FIBER (WITH ASPARTAME)... 81 fiber laxative (ca polycarbo). 81 fiber laxative (husk/sugar)... 81 fiber laxative (methylcellulo). 81 fiber laxative (psyllium husk) 81 fiber laxative (psyllium) s/f... 81 fiber smooth... 81 FIBER SMOOTH (SUCROSE)... 81 fiber therapy... 81 fiber therapy (ca polycarboph)... 82 fiber therapy (psyllium seed). 82 fiber therapy (psyllium)... 82 fiber therapy laxative (husk). 82 fiber therapy sugar free... 82 FIBER-CAPS... 82 fiber-lax... 82 fiber-tabs... 82 finasteride... 116 FIRAZYR... 114 FIRMAGON KIT W DILUENT SYRINGE... 22 first aid abx pain relief... 61 first aid antiseptic... 62 flanax (naproxen)... 37 flanax antacid... 82 flecainide... 50 FLOVENT DISKUS... 114 FLOVENT HFA... 114 FLU & SEVERE COLD- DAYTIME... 106 flu & severe cold-nighttime. 107 FLU & SORE THROAT RELIEF... 107 flu relief therapy daytime... 107 flu relief therapy nighttime.. 107 fluconazole... 9 fluconazole in dextrose(iso-o). 9 fluconazole in nacl (iso-osm).. 9 flucytosine... 9 fludarabine... 22 fludrocortisone... 71 flunisolide... 114 fluocinolone... 65 fluocinolone acetonide oil... 71 fluocinolone-shower cap... 65 fluocinonide... 65 fluocinonide-e... 65 fluoritab... 125 fluorometholone... 100 fluorouracil... 22, 59 fluoxetine... 44 fluphenazine decanoate... 44 fluphenazine hcl... 44 flurbiprofen... 37 flurbiprofen sodium... 99 flutamide... 22 fluticasone... 65, 114 fluvoxamine... 44 foaming antacid... 82 foaming antacid extra strength... 82 folbee plus... 126 folic acid... 126 FOLOTYN... 22 fondaparinux... 56 FORADIL AEROLIZER... 114 formula em... 82 FORTEO... 93 foscarnet... 10 fosinopril... 52 fosinopril-hydrochlorothiazide... 52 fosphenytoin... 28 FRAGMIN... 56 freamine iii 10 %... 122 full spectrum b-vitamin c... 126 FUNGI-NAIL... 63 fungoid-d... 63 furosemide... 52 FUSILEV... 19 FUZEON... 10 FYCOMPA... 28 G gabapentin... 28 GABITRIL... 28 galantamine... 31 GAMASTAN S/D... 90 GAMMAGARD LIQUID... 90 GAMMAGARD S-D (IGA < 1 MCG/ML)... 91 GAMMAPLEX... 91 GAMUNEX-C... 91 ganciclovir sodium... 10 GARDASIL (PF)... 91 GARDASIL 9 (PF)... 91 gas relief... 82 gas relief extra strength... 82 gas relief ultra strength... 82 GAUZE PADS 2 X 2... 72 gavilax... 82 gavilyte-c... 82 gavilyte-g... 82 gavilyte-n... 82 GAZYVA... 22 gemcitabine... 22 gemfibrozil... 57 generlac... 82 gengraf... 22 GENOTROPIN... 89 GENOTROPIN MINIQUICK 89 gentak... 97 gentamicin...15, 62, 97 gentamicin sulfate (ped) (pf).. 15 gentamicin sulfate (pf)... 15 GENTAMICIN SULFATE (PF)... 15 gentle laxative... 82 gentlelax... 82 GEODON... 44 gerber good start glucose... 68 geri-kot... 82 geri-lanta... 82 geri-mox antacid-antigas... 82 GERI-MUCIL... 82 geri-tussin... 107 gildagia... 95 gildess fe... 95 GILENYA... 31 GILOTRIF... 22 GLATOPA... 32 GLEEVEC... 22 GLEOSTINE... 22? 如 果 您 有 疑 問, 請 於 當 地 時 間 週 一 至 週 五 上 午 8 點 至 晚 上 8 點 致 電 Empire FIDA Plan, 電 話 號 碼 為 1-855-817-5789( 聽 語 障 用 戶 請 致 電 1-800-855-2880)(TTY 711) 此 為 免 付 費 電 話 如 需 更 多 資 訊, 請 訪 問 www.empireblue.com/fida ENYDMEM-0035-15 139

glimepiride... 72 glipizide... 72, 73 glipizide-metformin... 73 GLUCAGEN HYPOKIT... 73 GLUCAGON EMERGENCY KIT (HUMAN)... 73 GLUCO BURST... 68 glucose... 68 glucose bits... 68 glucose gel... 68 glycerin (adult)... 82 glycerin (child)... 82 glycolax... 82 glycopyrrolate... 78 gormel... 59 griseofulvin microsize... 9 griseofulvin ultramicrosize... 9 grx dyne... 62 g-tron... 107 guaifenesin... 107 GUAIFENESIN-DM... 107 guanfacine... 44 guanidine... 44 gummi bear multivitamin... 126 gummy swirls... 126 H HALAVEN... 22 halobetasol propionate... 65 HALOG... 65 haloperidol... 44 haloperidol decanoate... 44 haloperidol lactate... 44 HARVONI... 10 HAVRIX (PF)... 91 HEAD CONGESTION COLD RELIEF... 107 healthylax... 82 heartburn relief (famotidine). 88 HEARTBURN RELIEF (LANSOPRAZOLE)... 88 heartburn relief (magnesium carbonate/aluminum hydroxide) tab chews... 83 heartburn relief (ranitidine).. 88 HECTOROL... 76 hematinic plus vit/minerals.. 126 HEMORRHOID... 83 hemorrhoidal... 83 HEMORRHOIDAL... 83 hemorrhoidal cream... 83 heparin (porcine)... 56 heparin (porcine) in 5 % dex. 56 heparin (porcine) in nacl (pf). 56 heparin(porcine) in 0.45% nacl... 56 HEPARIN(PORCINE) IN 0.45% NACL... 56 heparin, porcine (pf)... 56 HEPATAMINE 8%... 122 HERCEPTIN... 22 HEXALEN... 22 hi-cal plus vit d... 118 high potency calcium... 118 hist-pse... 107 hot steam liquid... 107 HUMALOG... 73 HUMALOG KWIKPEN... 73 HUMALOG MIX 50-50... 73 HUMALOG MIX 50-50 KWIKPEN... 73 HUMALOG MIX 75-25... 73 HUMALOG MIX 75-25 KWIKPEN... 73 HUMATROPE... 89 HUMIRA... 93 HUMIRA PEDIATRIC CROHN'S START... 93 HUMIRA PEN... 93 HUMIRA PEN CROHN'S-UC- HS START... 93 HUMIRA PEN PSORIASIS STARTER... 93 HUMULIN 70/30... 73 HUMULIN 70/30 KWIKPEN 73 HUMULIN N... 73 HUMULIN N KWIKPEN... 73 HUMULIN R... 73 HUMULIN R U-500 (CONCENTRATED)... 73 hydralazine... 52 hydrochlorothiazide... 52 hydrocodone compound syrup... 107 hydrocodone-acetaminophen. 33 hydrocodone-chlorpheniramine... 107 hydrocodone-homatropine.. 107 HYDROCODONE- HOMATROPINE... 107 hydrocodone-ibuprofen... 33 hydrocortisone...65, 71, 83 hydrocortisone acetate... 65, 83 hydrocortisone plus... 65 hydrocortisone valerate... 65 hydrocortisone-acetic acid... 71 hydrocortisone-aloe vera... 65 hydrocortisone-min oil-wht pet... 66 hydromet... 107 hydromorphone... 33 hydroxocobalamin... 126 hydroxychloroquine... 15 hydroxyurea... 22 I ibandronate... 93 IBRANCE... 22 ibu-drops... 37 ibuprofen... 37, 38 IBUPROFEN COLD... 107 IBUPROFEN COLD- SINUS(WITH PSE)... 107 IBUPROFEN IB... 37 ibuprofen jr strength... 37 ibuprofen pm... 38 ibuprofen-diphenhydramine cit... 38 ibuprofen-diphenhydramine hcl... 38 icaps plus... 126 ICLUSIG... 22 idarubicin... 22 iferex 150... 126 IFEX... 22 ifosfamide... 23 ILARIS (PF)... 89? 如 果 您 有 疑 問, 請 於 當 地 時 間 週 一 至 週 五 上 午 8 點 至 晚 上 8 點 致 電 Empire FIDA Plan, 電 話 號 碼 為 1-855-817-5789( 聽 語 障 用 戶 請 致 電 1-800-855-2880)(TTY 711) 此 為 免 付 費 電 話 如 需 更 多 資 訊, 請 訪 問 www.empireblue.com/fida ENYDMEM-0035-15 140

ILEVRO... 99 IMBRUVICA... 23 imipenem-cilastatin... 15 imipramine hcl... 44 imiquimod... 59 IMOVAX RABIES VACCINE (PF)... 91 INCRELEX... 68 indapamide... 53 INFANRIX (DTAP) (PF)... 91 infant fever reducer-pain relf 38 infants ibu-drops... 38 infant's ibuprofen... 38 infant's medi-profen... 38 infant's non-aspirin... 38 infants profenib... 38 infed... 126 INLYTA... 23 insta-glucose... 68 INSULIN PEN NEEDLE... 73 INSULIN SYRINGE (DISP) U- 100 0.3 ML... 73 INSULIN SYRINGE (DISP) U- 100 1 ML... 73 INSULIN SYRINGE (DISP) U- 100 1/2 ML... 73 INTELENCE... 10, 11 intralipid... 122 INTRON A... 89 INTUNIV ER... 44 INVANZ... 15 INVEGA... 44 INVEGA SUSTENNA... 44 INVEGA TRINZA... 44, 45 INVIRASE... 11 inzo antifungal... 63 iophen dm-nr... 107 iophen-nr... 107 IPOL... 91 ipratropium bromide... 70, 114 ipratropium-albuterol... 114 i-prin... 38 irbesartan... 53 irbesartan-hydrochlorothiazide... 53 irinotecan... 23 iron... 126 IRON... 126 iron (dried)... 126 iron (ferrous sulfate)... 126 iron high potency... 126 ISENTRESS... 11 ISOLYTE-P IN 5 % DEXTROSE... 122 isoniazid... 15 isopropyl alcohol... 69 isopropyl alcohol, rubbing... 69 isosorbide dinitrate... 58 isosorbide mononitrate... 58 isradipine... 53 ISTODAX... 23 itch relief (diphenhydramine). 59 itch relief (pramoxine-zinc)... 59 itraconazole...9 ivermectin... 15 IXEMPRA... 23 IXIARO (PF)... 91 J JAKAFI... 23 jantoven... 56 JANUMET... 73 JANUMET XR... 73 JANUVIA... 73, 74 JARDIANCE... 74 JENTADUETO... 74 JEVTANA... 23 jock itch (terbinafine)... 63 jr. acetaminophen... 38 junel 1.5/30 (21)... 96 junel 1/20 (21)... 96 junel fe 1.5/30 (28)... 96 junel fe 1/20 (28)... 96 junior mapap... 38 K KADCYLA... 23 KALETRA... 11 KALYDECO... 114 kaopectate (bismuth subsalicy)... 78 KAOPECTATE CHILD(BIS SSALICYL)... 78 kaopectate ex str (bismuth ss) 78 kao-tin (bismuth subsalicylat) 78 kao-tin (docusate calcium)... 83 kariva (28)... 96 kelnor 1/35 (28)... 96 KEPIVANCE... 19 ketoconazole... 9, 63 ketorolac... 99 ketotifen fumarate... 99 KEYTRUDA... 23 KHEDEZLA... 45 kidkare cough/cold... 107 kid's vitamins... 126 kid's vitamins + extra c... 126 KINERET... 93 klor-con 10... 118 klor-con 8... 118 klor-con m10... 118 klor-con m15... 118 klor-con m20... 118 KOMBIGLYZE XR... 74 konsyl (sugar)... 83 konsyl easy mix... 83 konsyl fiber... 83 konsyl formula-d... 83 konsyl sugar-free... 83 konsyl sugar-free (aspartame) 83 k-pec antidiarrheal (bism sub)78 K-TAB... 118 KUVAN... 76 L labetalol... 53 lactated ringers... 67, 118 lactulose... 83 lamivudine... 11 lamivudine-zidovudine... 11 lamotrigine... 28 LANOXIN... 55 lansoprazole... 88 LANTUS... 74 LANTUS SOLOSTAR... 74 latanoprost... 100 LATUDA... 45? 如 果 您 有 疑 問, 請 於 當 地 時 間 週 一 至 週 五 上 午 8 點 至 晚 上 8 點 致 電 Empire FIDA Plan, 電 話 號 碼 為 1-855-817-5789( 聽 語 障 用 戶 請 致 電 1-800-855-2880)(TTY 711) 此 為 免 付 費 電 話 如 需 更 多 資 訊, 請 訪 問 www.empireblue.com/fida ENYDMEM-0035-15 141

laxa clear... 83 laxacin... 83 laxative (glycerin-pediatric).. 83 laxative peg 3350... 83 laxative-senna... 83 LAZANDA... 34 leflunomide... 93 LENVIMA... 23 lessina... 96 LETAIRIS... 114 letrozole... 23 leucovorin calcium... 19 LEUKERAN... 23 LEUKINE... 89 leuprolide... 23 levalbuterol hcl... 115 LEVEMIR... 74 LEVEMIR FLEXTOUCH... 74 levetiracetam... 28 levetiracetam in nacl (iso-os) 28 levobunolol... 98 levocarnitine... 68 levocarnitine (with sugar)... 68 levocetirizine... 107 levofloxacin... 18 levonest (28)... 96 levonorgestrel... 96 levonorgestrel-ethinyl estrad. 96 levorphanol tartrate... 34 levothyroxine... 77 levoxyl... 77 LEXIVA... 11 LIALDA... 83 lice complete kit 1-2-3... 66 LICE CREAM RINSE... 66 lice killing... 66 LICE KILLING (PERMETHRIN)... 66 lice pyrinyl shampoo... 66 LICE SOLUTION... 66 lice treatment... 66 LICE TREATMENT (PERMETHRIN)... 66 lidocaine... 61 lidocaine (pf)... 50, 60, 61 lidocaine hcl... 61 lidocaine viscous... 61 lidocaine-prilocaine... 61 lindane... 66 linezolid... 15 linezolid-0.9% sodium chloride... 15 LINZESS... 83 liothyronine... 77 liquibid d-r... 107 liquid antacid... 83 lisinopril... 53 lisinopril-hydrochlorothiazide 53 lite coat aspirin... 38 lithium carbonate... 45 lithium citrate... 45 little animals... 126 little remedies fever & pain... 38 LO-DOSE ASPIRIN... 38 lohist - d... 107 lohist peb dm... 107 lohist-peb... 107 LOMUSTINE... 23 loperamide... 78 loradamed... 108 lorata-d... 108 loratadine... 108 lorata-dine d... 108 loratadine-d... 108 lorazepam... 45 losartan... 53 losartan-hydrochlorothiazide. 53 lotrimin af jock itch powder... 63 lotrimin af powder... 63 LOTRONEX... 83 lovastatin... 57 low-ogestrel (28)... 96 loxapine succinate... 45 LUMIGAN... 100 LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 3.75 MG, 7.5 MG... 23 LUPRON DEPOT-PED... 23 lutera (28)... 96 LYNPARZA... 23 LYRICA... 28, 29 LYSODREN... 23 lyza... 94 M m.v.i. adult... 126 M.V.I. PEDIATRIC... 126 M.V.I.-12 (WITHOUT VITAMIN K)... 126 MACRODANTIN... 19 mag 64... 119 mag-al plus... 83 mag-al plus extra strength... 83 mag-delay... 119 mag-g... 119 magnesium citrate... 84 magnesium gluconate... 119 magnesium oxide... 119 magnesium sulfate... 119 magnesium sulfate in water. 119 manganese chloride... 119 mapap (acetaminophen)... 38 mapap arthritis pain... 38 mapap cold formula... 108 mapap extra strength... 38 mapap pm... 38 mapap sinus max strength (pe)... 108 maprotiline... 45 marlissa... 96 MARPLAN... 45 MATULANE... 23 meclizine... 84 meclofenamate... 39 medi-bismuth... 78 medicidin-d... 108 medikoff drops... 108 medroxyprogesterone... 94 mefloquine... 15 megestrol... 23, 24 MEKINIST... 24 meloxicam... 39 melphalan hcl... 24 MENACTRA (PF)... 91 MENEST... 94? 如 果 您 有 疑 問, 請 於 當 地 時 間 週 一 至 週 五 上 午 8 點 至 晚 上 8 點 致 電 Empire FIDA Plan, 電 話 號 碼 為 1-855-817-5789( 聽 語 障 用 戶 請 致 電 1-800-855-2880)(TTY 711) 此 為 免 付 費 電 話 如 需 更 多 資 訊, 請 訪 問 www.empireblue.com/fida ENYDMEM-0035-15 142

MENOMUNE - A/C/Y/W-135... 91 MENOMUNE - A/C/Y/W-135 (PF)... 91 men's daily multivit-mineral 126 men's multi-vitamin... 126 men's one daily... 126 MENSTRUAL COMPLETE 39 menstrual relief... 39 menthol cough... 108 MENTHOL COUGH... 70 menthol cough drops... 108 menthol drops... 108 MENVEO A-C-Y-W-135-DIP (PF)... 91 MEPHYTON... 56 MEPRON... 15 mercaptopurine... 24 meropenem... 15 mesalamine... 84 mesalamine with cleansing wipe... 84 mesna... 19 MESNEX... 19 MESTINON... 32 MESTINON TIMESPAN... 32 metaproterenol... 115 metformin... 74 methadone... 34 methadone intensol... 34 methadose... 34 methazolamide... 99 methenamine hippurate... 19 methimazole... 72 methotrexate sodium... 24 methotrexate sodium (pf)... 24 methoxsalen rapid... 59 methyclothiazide... 53 methylphenidate... 45 methylprednisolone acetate... 71 methylprednisolone sodium succ... 71 methylprednisolone tablets... 71 metipranolol... 98 metoclopramide hcl... 84 metolazone... 53 metoprolol succinate... 53 metoprolol ta-hydrochlorothiaz... 53 metoprolol tartrate... 53 metro i.v.... 15 metronidazole... 15, 60, 94 metronidazole in nacl (iso-os) 15 mexiletine... 50 mi-acid... 84 micatin... 63 miconazole 7... 94 miconazole nitrate... 63, 94, 95 MICONAZOLE NITRATE... 95 miconazole-3... 95 miconazorb af... 63 microgestin 1.5/30 (21)... 96 microgestin 1/20 (21)... 96 microgestin fe 1.5/30 (28)... 96 microgestin fe 1/20 (28)... 96 micro-guard... 63 midodrine... 68 MIGRANAL... 31 milk of magnesia... 84 milk of magnesia concentrated... 84 mineral oil... 84 mineral oil extra heavy... 84 mineral oil heavy... 84 mineral oil laxative... 84 minocycline... 18 minoxidil... 53 mintox... 84 mintox maximum strength... 84 mintox plus... 84 mirtazapine... 45 misoprostol... 88 mitomycin... 24 mitoxantrone... 24 M-M-R II (PF)... 91 modafinil... 45, 46 moexipril... 53 moexipril-hydrochlorothiazide... 53 moisture drops... 99 mometasone... 66 mono-linyah... 96 mononessa (28)... 96 montelukast... 115 morphine... 34, 35 MORPHINE... 34 morphine (pf)... 34 morphine concentrate... 34 motion relief (meclizine)... 84 MOTION SICKNESS (MECLIZINE)... 84 motion sickness relief(mecliz) 84 moxifloxacin... 18 MOZOBIL... 89 mucaphed... 108 mucinex... 108 MUCINEX COUGH MINI- MELTS... 108 mucinex dm... 108 mucinex fast-max cold-flu-thrt... 108 mucinex fast-max dm max... 108 mucinex fast-max severe cold... 108 mucosa... 108 mucosa dm... 108 mucus dm... 108 mucus relief... 109 mucus relief chest... 108 MUCUS RELIEF COLD-FLU- SORE THR... 108 MUCUS RELIEF COUGH. 108 mucus relief d (phenylephrine)... 108 mucus relief dm... 108 mucus relief dm max... 108 mucus relief er... 109 mucus relief pe... 109 mucus relief plus... 109 MUCUS RELIEF SEV CONGEST-COLD... 109 mucus relief sinus... 109 MULTAQ... 50 multi antibiotic plus... 62 multi complete with iron... 126? 如 果 您 有 疑 問, 請 於 當 地 時 間 週 一 至 週 五 上 午 8 點 至 晚 上 8 點 致 電 Empire FIDA Plan, 電 話 號 碼 為 1-855-817-5789( 聽 語 障 用 戶 請 致 電 1-800-855-2880)(TTY 711) 此 為 免 付 費 電 話 如 需 更 多 資 訊, 請 訪 問 www.empireblue.com/fida ENYDMEM-0035-15 143

multi-day with iron... 126 multi-delyn... 126 multiple vitamin essential... 126 multiple vitamin-minerals... 127 multiple vitamins... 127 multi-symptom cold (pe & cpm)... 109 multi-symptom cold (pe)... 109 multi-symptom cold daytime 109 multi-symptom cold night time... 109 multivitamin... 127 multivitamin with iron... 127 multivitamin with minerals. 127 multi-vitamins with iron... 127 mupirocin ointment... 62 MURO 128... 99 MUSTARGEN... 24 my way... 96 MYCO NAIL A... 63 MYCOBUTIN... 15 mycophenolate mofetil... 24 mycophenolate sodium... 24 myferon 150... 127 mynephrocaps... 127 MYOZYME... 76 MYRBETRIQ... 116 myzilra... 96 N nabumetone... 39 nadolol... 53 nadolol-bendroflumethiazide. 53 nafcillin... 17 NAGLAZYME... 76 nalbuphine... 39 naloxone... 39 naltrexone... 39 NAMENDA... 32 NAMENDA TITRATION PAK... 32 NAMENDA XR... 32 NAMZARIC... 32 naphazoline... 101 naproxen... 39 naproxen sodium... 39 nasal decongestant (oxymetazl)... 70 nasal decongestant (pe)... 109 nasal decongestant (pseudoeph)... 109 NASAL RELIEF... 70 nasal spray (oxymetazoline).. 70 NASONEX... 115 NATACYN... 98 nateglinide... 74 natural fiber laxative... 84 natural fiber laxative (sugar). 84 natural fiber laxative s/f... 84 natural fiber laxative smooth. 84 natural fiber laxative therapy. 84 natural fiber laxative(aspart). 84 natural fiber supplement... 85 natural laxative... 85 NATURAL PSYLLIUM FIBER... 85 natural tears (pf)... 99 NATURAL VEGETABLE... 85 NATURAL VEGETABLE (PSYLLIUM)... 85 natural vegetable powder... 85 nature's tears... 99 nausea control... 85 nausea relief... 85 NEBUPENT... 16 necon 0.5/35 (28)... 96 necon 1/35 (28)... 96 necon 1/50 (28)... 96 necon 10/11 (28)... 96 necon 7/7/7 (28)... 96 NEEDLES, INSULIN DISP.,SAFETY... 74 nefazodone... 46 neomycin... 16 neomycin-bacitracin-poly-hc100 neomycin-bacitracin-polymyxin... 98 neomycin-polymyxin b gu... 67 neomycin-polymyxin b-dexameth... 100 neomycin-polymyxin-gramicidin... 98 neomycin-polymyxin-hc 71, 100 neo-polycin... 98 neo-polycin hc... 100 nephro-vite rx... 127 NEULASTA... 89 NEUMEGA... 89 NEUPOGEN... 89 NEUPRO... 30 NEVANAC... 99 nevirapine... 11 NEXAVAR... 24 next choice one dose... 96 niacin... 57 NIACIN (INOSITOL NIACINATE)... 57 NIACOR... 57 nicardipine... 53 nicorelief... 69 nicotine... 69, 70 nicotine (polacrilex)... 69 NICOTROL NS... 70 nifedical xl... 53 nifedipine... 53 night time cold... 109 NIGHT TIME COLD & FLU RELIEF... 109 NIGHT TIME COLD-FLU. 109 NIGHT TIME COLD-FLU RELIEF... 109 night time cough & sore throat... 109 nightime sleep... 109 nighttime cold-flu... 109 NIGHTTIME COLD-FLU RELIEF... 109 nighttime cough... 109 nighttime cough-cold... 109 nighttime sinus... 109 nighttime sleep aid (diphen) 109 NILANDRON... 24 nimodipine... 53 NIPENT... 24 NITE TIME COLD-FLU... 109? 如 果 您 有 疑 問, 請 於 當 地 時 間 週 一 至 週 五 上 午 8 點 至 晚 上 8 點 致 電 Empire FIDA Plan, 電 話 號 碼 為 1-855-817-5789( 聽 語 障 用 戶 請 致 電 1-800-855-2880)(TTY 711) 此 為 免 付 費 電 話 如 需 更 多 資 訊, 請 訪 問 www.empireblue.com/fida ENYDMEM-0035-15 144

nite time cold-flu formula... 109 NITE TIME COLD-FLU RELIEF... 109 NITE TIME COUGH... 109 NITE TIME-D COLD-FLU RELIEF... 109 NITE-TIME COLD-FLU... 109 nitetime multi-symptom... 110 nitro-bid... 58 nitrofurantoin macrocrystal.. 19 nitroglycerin... 58 NITROSTAT... 58 noble formula hc... 66 nohist-dm... 110 nohist-lq... 110 non-pseudo sinus pain-pressure... 110 nora-be... 94 NORDITROPIN FLEXPRO. 90 norethindrone (contraceptive) 94 norethindrone acetate... 94 norgestimate-ethinyl estradiol 96 NORMOSOL-M IN 5 % DEXTROSE... 122 NORMOSOL-R... 119 NORMOSOL-R IN 5 % DEXTROSE... 119 NORMOSOL-R PH 7.4... 122 NORTEMP... 39 nortrel 0.5/35 (28)... 97 nortrel 1/35 (21)... 97 nortrel 1/35 (28)... 97 nortrel 7/7/7 (28)... 97 nortriptyline... 46 NORVIR... 11 NOXAFIL... 9 nrs nasal relief... 70 nts step 1... 70 NUEDEXTA... 32 NULOJIX... 24 NUVARING... 95 nuzole... 63 nyquil d... 110 nystatin...9, 63 nystatin-triamcinolone... 63 nystop... 63 O ocella... 97 octreotide acetate... 24 ofloxacin... 18, 71, 98 ogestrel (28)... 97 olanzapine... 46 OLYSIO... 11 omega-3 acid ethyl esters... 57 omeprazole... 88 omeprazole magnesium... 88 omnicap... 127 ONCASPAR... 24 once daily... 127 ondansetron hcl... 85 ondansetron hcl (pf)... 85 ondansetron odt... 85 one daily... 127 ONE DAILY... 127 one daily 50 plus... 127 one daily complete... 127 one daily energy... 127 one daily essential... 127 one daily for men... 127 one daily for women... 127 one daily maximum... 127 one daily maximum (with ca)... 127 one daily men's 50+... 127 one daily multi-vit w-mineral... 127 one daily multivitamin... 127 one daily plus iron... 127 one daily plus minerals... 127 one daily prenatal... 127 one daily with iron... 127 one daily womens 50 plus... 128 ONE DAILY WOMEN'S METABOLISM... 128 one-a-day essential... 128 one-a-day maximum formula128 one-a-day teen advantage... 128 ONFI... 29 ONGLYZA... 74 OPDIVO... 24 opium tincture... 78 opti-clear... 101 oral electrolytes... 119 oral saline laxative... 85 oralyte... 119 ORAP... 46 ORFADIN... 68 organ-i nr... 110 original nasal spray... 70 ormir... 110 oxacillin... 17 oxaliplatin... 24 oxandrolone... 76 oxaprozin... 39 oxcarbazepine... 29 OXSORALEN... 59 OXTELLAR XR... 29 oxybutynin chloride... 116 oxycodone... 35 oxycodone-acetaminophen... 35 oxycodone-aspirin... 35 oxymetazoline... 70 oysco 500/d... 119 oysco d... 119 oysco-500... 119 oyst-cal-500... 119 oyster shell + d3... 119 oyster shell calcium... 119 oyster shell calcium 500... 119 oyster shell calcium with d.. 128 oyster shell calcium-vit d3... 119 oystercal-d... 119 P pacerone... 50 paclitaxel... 24 pain-off... 39 pamidronate... 76 pamprin max... 39 PANRETIN... 59 pantoprazole... 88 paricalcitol... 76 paroex oral rinse... 70 paromomycin... 16 paroxetine hcl... 46 PASER... 16? 如 果 您 有 疑 問, 請 於 當 地 時 間 週 一 至 週 五 上 午 8 點 至 晚 上 8 點 致 電 Empire FIDA Plan, 電 話 號 碼 為 1-855-817-5789( 聽 語 障 用 戶 請 致 電 1-800-855-2880)(TTY 711) 此 為 免 付 費 電 話 如 需 更 多 資 訊, 請 訪 問 www.empireblue.com/fida ENYDMEM-0035-15 145

PATADAY... 99 PATANOL... 99 PAXIL... 46 PAZEO... 99 p-col rite... 85 pedia relief cough-cold... 110 pediacare fever reducer... 39 pediacare multi-symptom cold... 110 pedialyte... 120 PEDIALYTE... 119 pedialyte freezer pops... 119 pedialyte singles... 120 pediatric cough & cold... 110 pediatric electrolyte... 120 pediatric freezer pops... 120 PEDVAX HIB (PF)... 91 peg 3350-electrolytes... 85 peg-3350 with flavor packs... 85 PEGANONE... 29 PEGASYS... 90 PEGASYS PROCLICK... 90 peg-electrolyte soln... 85 PEGINTRON... 90 PEGINTRON REDIPEN... 90 PENICILLIN G POT IN DEXTROSE... 17 penicillin g potassium... 17 penicillin g procaine... 17 penicillin g sodium... 17 penicillin v potassium... 17 PENTAM... 16 PENTASA... 85 pentoxifylline... 56 pepcid ac... 89 peptic relief... 78 pepto-bismol... 78 pepto-bismol to-go... 78 percogesic... 39 percogesic extra strength... 39 perdiem overnight relief... 85 PERFOROMIST... 115 peri-colace... 85 perindopril erbumine... 54 periogard... 70 PERJETA... 24 permethrin... 66 perphenazine... 46 persa-gel... 60 pharbechlor... 110 pharbedryl... 110 pharbetol... 39 phenelzine... 47 phenobarbital... 29 phenytoin... 29 phenytoin sodium... 29 phenytoin sodium extended... 29 PHOSPHATE LAXATIVE... 85 PHOSPHOLINE IODIDE... 98 pilocarpine hcl... 68 pindolol... 54 pink bismuth... 78 pink bismuth maximum strength... 78 pin-x... 16 PIN-X... 16 pioglitazone... 74 pioglitazone-glimepiride... 74 pioglitazone-metformin... 75 piperacillin-tazobactam... 17 piroxicam... 39 PLAN B ONE-STEP... 97 PLASMA-LYTE 148... 122 PLASMA-LYTE-56 IN 5 % DEXTROSE... 122 pnv cmb#95-ferrous fumarate-fa... 128 podactin... 63 podofilox... 59 poly bacitracin... 62 POLY HIST FORTE (DOXYLAMINE)... 110 polycin... 98 polyethylene glycol 3350... 85 POLYETHYLENE GLYCOL 3350... 68 poly-iron... 128 polymyxin b sulf-trimethoprim98 poly-vita... 128 poly-vitamin... 128 poly-vitamins... 128 POMALYST... 24 portia... 97 potassium chlorid-d5-0.45%nacl... 120 potassium chloride... 120 potassium chloride in 0.9%nacl... 120 potassium chloride in 5 % dex... 120 potassium chloride in lr-d5. 120 potassium chloride-0.45 % nacl... 120 potassium chloride-d5-0.2%nacl... 120 potassium chloride-d5-0.3%nacl... 120 potassium chloride-d5-0.9%nacl... 120, 121 potassium citrate... 116 POTIGA... 30 povidone-iodine... 62 PRADAXA... 56 pramipexole... 30 PRANDIMET... 75 pravastatin... 57 prazosin... 54 prednisolone... 71 prednisolone acetate... 100 prednisolone sodium phosphate... 71, 72, 100 prednisone... 72 prednisone intensol... 72 PREMARIN... 94 prenatal... 128 prenatal + dha... 128 prenatal complete... 128 prenatal formula... 128 prenatal multivitamins... 128 prenatal vit#96-ferrous fum-fa... 128 PRENATAL VITAMIN... 128 PRENATAL VITAMIN ORAL TABLET... 128? 如 果 您 有 疑 問, 請 於 當 地 時 間 週 一 至 週 五 上 午 8 點 至 晚 上 8 點 致 電 Empire FIDA Plan, 電 話 號 碼 為 1-855-817-5789( 聽 語 障 用 戶 請 致 電 1-800-855-2880)(TTY 711) 此 為 免 付 費 電 話 如 需 更 多 資 訊, 請 訪 問 www.empireblue.com/fida ENYDMEM-0035-15 146

prenatal vitamin with minerals... 128 prenatal vit-iron fumarate-fa128 prevalite... 57 previfem... 97 PREZCOBIX... 11 PREZISTA... 11 PRIFTIN... 16 PRILOSEC OTC... 89 PRIMAQUINE... 16 primidone... 30 PRISTIQ... 47 PROAIR HFA... 115 PROAIR RESPICLICK... 115 probenecid... 92 procainamide... 50 prochlorperazine edisylate... 86 prochlorperazine maleate... 86 prochlorperazine maleate rectal... 86 PROCRIT... 90 procto-pak... 86 proctosol hc... 86 proctozone-hc... 86 progesterone micronized... 94 PROGLYCEM... 75 PROGRAF... 24 PROLEUKIN... 90 PROLIA... 93 PROMACTA... 56 promethazine... 110 promethazine vc-codeine... 110 promethazine-codeine... 110 promethazine-dm... 110 promethazine-phenylephcodeine... 110 promethegan... 110 promolaxin... 86 propafenone... 50 propranolol... 54 propranolol-hydrochlorothiazid... 54 propylthiouracil... 72 PROQUAD (PF)... 91 PROTOPIC... 59 protriptyline... 47 provil... 39 pseudoephedrine hcl... 110 psyllium husk... 86 PULMOZYME... 115 purelax... 86 PURIXAN... 24 pyrazinamide... 16 pyrethrin lice treatment m... 66 pyridostigmine bromide... 32 pyridoxine... 128 pyrilamine-phenylephrine... 110 Q q-dryl... 110 q-pap... 39 q-pap extra strength... 39 q-tapp... 110 q-tussin... 110 q-tussin dm... 110 QUADRACEL (PF)... 91 quenalin... 110 quetiapine... 47 quinapril... 54 quinapril-hydrochlorothiazide54 quinidine sulfate tablets... 50 quintabs-m iron free... 128 quit 2... 70 quit 4... 70 QVAR... 115 R RABAVERT (PF)... 91 raloxifene... 93 ramipril... 54 RANEXA... 58 ranitidine hcl... 89 RAPAMUNE... 24 ready-to-use enema... 86 ready-to-use enema (min oil). 86 REBIF (WITH ALBUMIN).. 90 REBIF REBIDOSE... 90 REBIF TITRATION PACK.. 90 reclipsen (28)... 97 RECOMBIVAX HB (PF)... 91 recort plus... 66 reese's pinworm medicine... 16 refenesen... 111 refenesen dm... 111 refenesen pe... 111 reguloid... 86 reguloid, sugar free... 86 RELENZA DISKHALER... 11 RELISTOR... 86 REMEDY ANTIFUNGAL... 64 REMICADE... 86 RENAGEL... 68 renal caps... 128 rena-vite... 128 rena-vite rx... 128 reno caps... 128 RENVELA... 68, 69 RESCRIPTOR... 11 RESTASIS... 99 RETROVIR... 11 REVLIMID... 25 REXULTI... 47 REYATAZ... 11 ribasphere... 11 ribavirin... 11 RID COMPLETE LICE ELIM KIT... 66 RID LICE KILLING... 66 RIDAURA... 93 rifabutin... 16 rifampin... 16 RIFATER... 16 ri-gel... 86 ri-gel ii... 86 riluzole... 69 rimantadine... 11 ri-mox... 86 ri-mox plus... 86 ringers... 67, 121 risacal-d... 128 RISPERDAL CONSTA... 47 risperidone... 47, 48 ri-tussin... 111 ri-tussin dm... 111 RITUXAN... 25? 如 果 您 有 疑 問, 請 於 當 地 時 間 週 一 至 週 五 上 午 8 點 至 晚 上 8 點 致 電 Empire FIDA Plan, 電 話 號 碼 為 1-855-817-5789( 聽 語 障 用 戶 請 致 電 1-800-855-2880)(TTY 711) 此 為 免 付 費 電 話 如 需 更 多 資 訊, 請 訪 問 www.empireblue.com/fida ENYDMEM-0035-15 147

rivastigmine tartrate oral capsule... 32 rivastigmine transdermal patch... 32 rizatriptan... 31 robafen... 111 robafen dm... 111 robafen dm cough... 111 ropinirole... 30 rosadan... 60 ROTARIX... 91 ROTATEQ VACCINE... 92 ROZEREM... 48 RUBBING ALCOHOL (ETHANOL)... 59 RU-HIST D... 111 rydex... 111 rynex dm... 111 rynex pe... 111 rynex pse... 111 S SABRIL... 30 SANI-SUPP (ADULT)... 86 sani-supp (infant)... 86 SANTYL... 66 SAPHRIS (BLACK CHERRY)... 48 SAVELLA... 93 scalpicin anti-itch... 66 selegiline hcl... 31 selenium sulfide... 58 SELZENTRY... 11 senexon... 86 senexon-s... 86 senna... 86 SENNA... 86 senna lax... 86 senna laxative... 86 senna plus... 86 SENNA PROMPT... 87 senna with docusate sodium.. 87 senna-extra... 87 senna-gen... 87 senna-s... 87 senno... 87 sennosides-docusate sodium.. 87 SENOKOTXTRA... 87 sen-o-tab... 87 SENSIPAR... 76 SEREVENT DISKUS... 115 SEROQUEL XR... 48 sertraline... 48 SEVERE ALLERGY-SINUS HEADACHE... 111 SEVERE COLD (DIPHEN-PE- ACETAM)... 111 SEVERE COLD MULTI- SYMPTOM... 111 SEVERE COLD PE... 111 silace... 87 siladryl sa... 111 silapap... 40 sildenafil... 115 silphen cough... 111 siltussin dm das... 111 siltussin sa... 111 siltussin-dm... 111 silver sulfadiazine... 58 simethicone... 87 SIMPONI... 93 SIMULECT... 25 simvastatin... 57 sinus & allergy non-drowsy. 111 SINUS & ALLERGY PE... 111 SINUS & ALLERGY(PHENYLEPHRI NE)... 111 sinus cong & pain day-night 111 SINUS CONGESTION&PAIN(CHL ORPH)... 111 sinus decongestant (pe)... 111 SINUS HEADACHE PE... 111 sinus nasal spray... 70 sinus relief (oxymetazoline)... 70 sirolimus... 25 sleep aid (diphenhydramine) 112 SLEEP AID (DIPHENHYDRAMINE) 111 sleep aid (doxylamine)... 48 SLEEP AID MAX STR (DIPHENHYDR)... 112 sleep tablet (diphenhydramine)... 112 slow release iron... 129 sodium bicarbonate... 87 sodium chloride... 69, 99, 121 sodium chloride 0.45 %... 121 sodium chloride 0.9 %... 69 sodium chloride 3 %... 121 sodium chloride 5 %... 121 sodium fluoride... 129 sodium polystyrene (sorb free)... 69 sodium polystyrene sulfonate. 69 SODIUM POLYSTYRENE SULFONATE... 69 sof-lax... 87 SOLTAMOX... 25 soluble fiber... 87 SOMATULINE DEPOT... 25 SOMAVERT... 76 soothe (bismuth subsalicylate)78 soothing care (hydrocortisone)... 66 SORE THROAT (MENTHOL)... 71 sorine... 50 sotalol... 50 sotalol af... 50 SOVALDI... 11 spectravite advanced formula... 129 spectravite ultra women... 129 SPIRIVA RESPIMAT... 115 SPIRIVA WITH HANDIHALER... 115 spironolactone... 54 spironolacton-hydrochlorothiaz... 54 sprintec (28)... 97 SPRYCEL... 25 sps... 69 ssd... 58 stavudine... 11? 如 果 您 有 疑 問, 請 於 當 地 時 間 週 一 至 週 五 上 午 8 點 至 晚 上 8 點 致 電 Empire FIDA Plan, 電 話 號 碼 為 1-855-817-5789( 聽 語 障 用 戶 請 致 電 1-800-855-2880)(TTY 711) 此 為 免 付 費 電 話 如 需 更 多 資 訊, 請 訪 問 www.empireblue.com/fida ENYDMEM-0035-15 148

sterile eye drops... 101 STIMATE... 76 STIMULANT LAXATIVE PLUS... 87 STIOLTO RESPIMAT... 115 STIVARGA... 25 stool softener... 87 STOOL SOFTENER... 87 stool softener-laxative... 87 stool softener-stimulant laxat 87 stop smoking aid... 70 STRATTERA... 48 STREPTOMYCIN... 16 stress formula advanced... 129 STRIBILD... 11 STROMECTOL... 16 SUBOXONE... 40 SUBSYS... 35 sucralfate... 89 SUDAFED 24 HOUR... 112 sudogest... 112 sudogest 12-hour... 112 sudogest cold & allergy... 112 sudogest pe... 112 sudogest sinus & allergy... 112 sulfacetamide sodium... 100 sulfacetamide sodium (acne). 62 sulfacetamide-prednisolone 100 sulfadiazine... 18 sulfamethoxazole-trimethoprim... 18 SULFAMYLON... 62 sulfasalazine... 87 sulfazine... 87 sulfazine ec... 87 sulindac... 40 sumatriptan succinate... 31 suphedrin... 112 suphedrin 12 hour... 112 SUPHEDRINE... 112 SUPHEDRINE 12 HOUR.. 112 SUPHEDRINE PE... 112 suphedrine pe cold & allergy... 112 suphedrine pe sinus & allergy... 112 suphedrine pe sinus headache... 112 suppository adult... 87 surfak... 87 SURMONTIL... 48 SUSTIVA... 11 SUTENT... 25 syeda... 97 SYLATRON... 90 SYMLINPEN 120... 75 SYMLINPEN 60... 75 SYNAGIS... 11 SYNAREL... 76 SYNERCID... 16 SYNRIBO... 25 SYNTHROID... 77 SYPRINE... 69 T tab-a-vite... 129 tab-a-vite/iron... 129 tab-a-vite-minerals... 129 TABLOID... 25 tacrolimus... 25, 59 TAFINLAR... 25 tagamet hb... 89 TAMIFLU... 12 tamoxifen... 25 tamsulosin... 116 TANZEUM... 75 TARCEVA... 25 TARGRETIN... 25 TASIGNA... 25 TASMAR... 31 TAZORAC... 60 taztia xt... 54 tears pure... 99 TECFIDERA... 32 TEFLARO... 13 TEKTURNA... 54 TEKTURNA HCT... 54 telmisartan... 54 telmisartan-amlodipine... 54 telmisartan-hydrochlorothiazid... 54 temazepam... 48 terazosin... 54 terbinafine hcl... 9, 64 terbutaline... 115 terconazole... 95 TESTIM... 76 testosterone... 77 testosterone cypionate... 76 testosterone enanthate... 77 TETANUS,DIPHTHERIA TOX PED(PF)... 92 TETANUS-DIPHTHERIA TOXOIDS-TD... 92 tetrabenazine... 32 tetracycline... 19 tetrahydrozoline... 101 THALOMID... 25 theophylline... 115 thera-d... 129 theralogix companion... 129 thiamine hcl... 129 thiamine mononitrate... 129 thioridazine... 48 thiotepa... 25 thiothixene... 48 THYMOGLOBULIN... 92 tiagabine... 30 TICE BCG... 92 TIKOSYN... 51 timolol maleate... 54, 98 TIMOPTIC OCUDOSE (PF). 98 tinactin... 64 tioconazole... 95 tioconazole-1... 95 TIVICAY... 12 tizanidine... 32 tl icon... 129 tl-hist dm... 112 tobramycin... 98 tobramycin in 0.225 % nacl... 16 tobramycin sulfate... 16 tobramycin-dexamethasone. 100 tolazamide... 75? 如 果 您 有 疑 問, 請 於 當 地 時 間 週 一 至 週 五 上 午 8 點 至 晚 上 8 點 致 電 Empire FIDA Plan, 電 話 號 碼 為 1-855-817-5789( 聽 語 障 用 戶 請 致 電 1-800-855-2880)(TTY 711) 此 為 免 付 費 電 話 如 需 更 多 資 訊, 請 訪 問 www.empireblue.com/fida ENYDMEM-0035-15 149

tolbutamide... 75 tolcapone... 31 tolmetin... 40 tolnaftate... 64 tolterodine... 116 topiramate... 30 toposar... 25 topotecan... 25 TORISEL... 25 torsemide... 54 TOUJEO SOLOSTAR... 75 TOVIAZ... 116 TPN ELECTROLYTES... 121 TRACLEER... 115 TRADJENTA... 75 tramadol... 40 tramadol-acetaminophen... 40 trandolapril... 54 tranexamic acid... 56, 95 tranylcypromine... 48 travasol 10 %... 122 TRAVATAN Z... 100 travel sickness (meclizine)... 87 travoprost (benzalkonium).. 100 trazodone... 48 TREANDA... 25 TRECATOR... 16 TRELSTAR... 26 TRELSTAR DEPOT... 26 TRELSTAR LA... 26 tretinoin... 60 tretinoin (chemotherapy)... 26 TRETIN-X CREAM KIT... 60 TREXALL... 26 triamcinolone acetonide. 66, 71, 72 triamterene-hydrochlorothiazid... 54 trianex... 66 TRIBENZOR... 54 tri-biozene... 62 tri-buffered aspirin... 40 tricon... 129 triderm... 66 trifluoperazine... 49 trifluridine... 98 trimethoprim... 19 triphrocaps... 129 triple antibiotic... 62 triple antibiotic (pram) extra. 62 triple antibiotic plus... 62 triple paste af... 64 tri-previfem (28)... 97 TRISENOX... 26 tri-sprintec (28)... 97 TRIUMEQ... 12 TRI-VI-SOL... 129 tri-vita... 129 tri-vitamin... 129 trivora (28)... 97 TRIZIVIR... 12 TROPHAMINE 10 %... 122 TROPHAMINE 6%... 122 tropicamide... 98 trospium... 116 TRULICITY... 75 TRUMENBA... 92 TRUVADA... 12 tusnel diabetic... 112 tussi pres-b... 112 tussigon... 112 TUSSIN... 112 tussin chest congestion... 112 tussin cough &chest congestion... 112 tussin cough dm... 112 tussin dm... 113 TUSSIN DM CLEAR... 112 tussin dm cough... 112 tussin dm cough & chest... 112 TUSSIN DM MAX... 113 tussin expectorant... 113 tussin honey... 113 tussin maximum strength... 113 tussin maximum strength cough... 113 TWINRIX (PF)... 92 TYBOST... 12 TYGACIL... 16 TYKERB... 26 TYPHIM VI... 92 TYSABRI... 32 TYZEKA... 12 TYZINE... 71 U U-CORT... 59 ULORIC... 92 ultra sleep (doxylamine succ) 49 ULTRA STRENGTH ANTACID... 121 ultra strength calcium antacid... 121 unithroid... 77 UNITUXIN... 26 urea... 59 ureacin-20... 59 urinary pain relief... 116 ursodiol... 88 UVADEX... 59 V vagicaine... 61 vagicream... 61 VAGIFEM... 94 vagistat-3... 95 valacyclovir... 12 VALCHLOR... 59 VALCYTE... 12 valganciclovir... 12 valproate sodium... 30 valproic acid... 30 valproic acid (as sodium salt) 30 valsartan... 54, 55 valsartan-hydrochlorothiazide... 55 vancomycin... 19 VANCOMYCIN IN D5W... 19 VANCOMYCIN IN DEXTROSE ISO-OSM... 19 vaporizing steam... 113 VAQTA (PF)... 92 VARIVAX (PF)... 92 VARIZIG... 92 VAZOTAB (PYRILAMINE)... 113 VECAMYL... 58? 如 果 您 有 疑 問, 請 於 當 地 時 間 週 一 至 週 五 上 午 8 點 至 晚 上 8 點 致 電 Empire FIDA Plan, 電 話 號 碼 為 1-855-817-5789( 聽 語 障 用 戶 請 致 電 1-800-855-2880)(TTY 711) 此 為 免 付 費 電 話 如 需 更 多 資 訊, 請 訪 問 www.empireblue.com/fida ENYDMEM-0035-15 150

VECTIBIX... 26 vegetable laxative... 88 VELCADE... 26 velivet triphasic regimen (28) 97 venlafaxine... 49 VENLAFAXINE... 49 VENOFER... 129 VENTAVIS... 115 verapamil... 55 VERSACLOZ... 49 VESICARE... 116 VICTOZA 2-PAK... 75 VICTOZA 3-PAK... 75 VIDEX 2 GRAM PEDIATRIC... 12 VIDEX 4 GRAM PEDIATRIC... 12 VIEKIRA PAK... 12 VIGAMOX... 98 VIIBRYD... 49 VIMPAT... 30 vinblastine... 26 vincasar pfs... 26 vincristine... 26 vinorelbine... 26 viorele (28)... 97 VIRACEPT... 12 VIRAMUNE XR... 12 VIRAZOLE... 12 VIREAD... 12 VISINE... 101 VISINE TEARS... 99 visine-a... 101 vitalee... 129 vitamin a... 129 vitamin a & d diaper rash... 59 vitamin a and d... 59 VITAMIN A PALMITATE 129 vitamin b-1... 129 VITAMIN B-1 (MONONITRATE)... 130 vitamin b-12... 130 vitamin b-6... 130 vitamin c... 130 VITAMIN C... 130 vitamin c cough drops... 130 VITAMIN C DROPS... 130 vitamin c with rose hips... 130 VITAMIN C WITH ROSE HIPS... 130 vitamin d2... 130 vitamin d3... 130 VITAMIN D3... 130 vitamin e (dl, acetate)... 130 vitamin e mixed... 130 vitamin k... 56 VITAMIN K... 56 vitamin k1... 57 VITAMIN K1... 57 VITEKTA... 12 vits a and d-white pet-lanolin. 59 vol-care rx... 130 VOLTAREN GEL... 40 voriconazole...9 VOTRIENT... 26 W warfarin... 57 water for irrigation, sterile... 69 WELCHOL... 58 WOMEN'S GENTLE LAXATIVE(BISAC)... 88 women's laxative (bisacodyl). 88 X XALKORI... 26 XARELTO... 57 XENAZINE... 32 XGEVA... 19 XIFAXAN... 16 XOLAIR... 115 XTANDI... 26 XULANE... 95 XYREM... 49 Y yelets... 130 YERVOY... 26 YF-VAX (PF)... 92 Z zafirlukast... 115 zaleplon... 49 ZALTRAP... 26 ZANOSAR... 26 zarah... 97 ZAVESCA... 77 zazole... 95 zeasorb (miconazole)... 64 ZELBORAF... 26 ZEMAIRA... 69 ZEMPLAR... 77 zenchent (28)... 97 zenzedi... 49, 50 ZETIA... 58 ZIAGEN... 12 zidovudine... 12 zinc chloride intraveneous solution... 121 zinc oxide... 60 ZINC OXIDE DIAPER CREAM... 60 ziprasidone hcl... 50 ZIRGAN... 98 zoledronic acid... 77 ZOLINZA... 26 zolmitriptan... 31 zolpidem... 50 ZOMETA... 77 ZOMIG... 31 zonisamide... 30 zoo chews... 130 ZORTRESS... 26 ZOSTAVAX (PF)... 92 zovia 1/35e (28)... 97 zovia 1/50e (28)... 97 ZYDELIG... 26 ZYKADIA... 26 ZYPREXA RELPREVV... 50 ZYTIGA... 26 ZYVOX... 16? 如 果 您 有 疑 問, 請 於 當 地 時 間 週 一 至 週 五 上 午 8 點 至 晚 上 8 點 致 電 Empire FIDA Plan, 電 話 號 碼 為 1-855-817-5789( 聽 語 障 用 戶 請 致 電 1-800-855-2880)(TTY 711) 此 為 免 付 費 電 話 如 需 更 多 資 訊, 請 訪 問 www.empireblue.com/fida ENYDMEM-0035-15 151

? 如 果 您 有 疑 問, 請 於 當 地 時 間 週 一 至 週 五 上 午 8 點 至 晚 上 8 點 致 電 Empire FIDA Plan, 電 話 號 碼 為 1-855-817-5789( 聽 語 障 用 戶 請 致 電 1-800-855-2880)(TTY 711) 此 為 免 付 費 電 話 如 需 更 多 資 訊, 請 訪 問 www.empireblue.com/fida ENYDMEM-0035-15 152

存 在 疑 問 嗎? 請 於 當 地 時 間 週 一 至 週 五 上 午 8 點 至 下 午 8 點, 撥 打 免 費 電 話 1-855-817-5789 (TTY 711) 與 我 們 聯 絡 或 瀏 覽 網 站 www.empireblue.com/fida Empire BlueCross BlueShield HealthPlus Fully Integrated Duals Advantage (FIDA) Plan 為 一 項 照 護 管 理 計 劃, 與 Medicare 及 紐 約 州 衛 生 署 (Medicaid) 簽 約, 透 過 Fully Integrated Duals Advantage (FIDA) Demonstration 為 參 與 者 提 供 雙 重 計 劃 福 利 Empire BlueCross BlueShield HealthPlus 是 HealthPlus, LLC 的 商 標 名 稱, 該 公 司 屬 Blue Cross and Blue Shield Association 的 獨 立 持 照 組 織 福 利 給 付 藥 物 清 單 和 網 路 內 藥 房 以 及 醫 療 服 務 提 供 者 可 能 於 每 年 1 月 1 日 或 全 年 內 隨 時 變 動 有 關 Empire FIDA Plan 的 詳 細 資 訊, 請 聯 絡 Empire FIDA Plan 或 紐 約 州 參 保 者 經 紀 人 若 要 參 與 此 計 畫 或 其 他 醫 療 保 健 計 畫, 請 聯 絡 紐 約 州 參 保 者 經 紀 人, 電 話 號 碼 為 1-855-600-FIDA (TTY 1-888-329-1541), 週 一 至 週 五 上 午 8:30 至 下 午 8 點, 及 週 六 上 午 10 點 至 下 午 6 點, 或 瀏 覽 網 站 www.nymedicaidchoice.com 紐 約 州 建 立 了 一 個 參 與 者 監 察 員 計 劃, 稱 Independent Consumer Advocacy Network (ICAN), 提 供 參 與 者 任 何 Empire FIDA Plan 之 服 務 相 關 的 免 費 保 密 協 助 您 可 以 撥 打 電 話 1-844-614-8800 或 上 網 從 網 站 icannys.org 聯 絡 Participant Ombudsman( 參 與 者 監 察 員 ) 您 可 以 索 取 不 同 格 式 的 處 方 藥 物 清 單, 如 點 字 或 大 型 字 體 版 本 請 致 電 1-855-817-5789 (TTY 711), 週 一 至 週 五 上 午 8 點 至 下 午 8 點 處 方 藥 物 ID..00015333 版 本..14 發 佈 時 間 11/01/2015