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

2014 Formulary (List of Covered Drugs) Central Health Medicare Plan (HMO), Central Health Medi- Medi Plan (HMO SNP), & Central Health Premier Plan (HMO) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN This formulary was updated 10/28/2014. For more recent information or other questions, please contact Central Health Medicare Plan at 1-866-314-2427, or for TTY users, 1-888-205-7671, 7 days a week, 8:00 AM to 8:00 PM (PST), or visit www.centralhealthplan.com. The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan. Limitations, copayments, and restrictions may apply. Benefits, formulary, pharmacy network, premium, and/or copayments/co-insurance may change on January 1 of each year. Central Health Medicare Plan is an HMO plan with a Medicare contract. Enrollment in Central Health Medicare Plan depends on contract renewal. This information is available for free in other languages. Please call our customer service number at 1-866-314-2427, TTY 1-888-205-7671, 7 days a week, 8:00 AM to 8:00 PM (PT). Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details. H5649_112713_1085_CF Accepted HPMS Approved Formulary File submission ID and version number: 14560v17 1

Esta información es disponible gratuitamente en otros lenguajes. Favor de llamar al número de servicio al cliente al 1-866-314-2427, TTY 1-888-205-7671, los 7 días de la semana, 8:00 AM a 8:00 PM (Tiempo Pacifico). Favor de llamar si usted necesita esta información en otro formato. Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. When this drug list (formulary) refers to we, us, or our, it means Central Health Medicare Plan. When it refers to plan or our plan, it means Central Health Medicare Plan. This document includes a list of the drugs (formulary) for our plan which is current as of 10/28/2014. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, premium and/or copayments/coninsurance may change on January 1, 2015. What is the Central Health Medicare Plan Formulary? A formulary is a list of covered drugs selected by Central Health Medicare Plan in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Central Health Medicare Plan will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Central Health Medicare Plan network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. Can the Formulary (drug list) change? Generally, if you are taking a drug on our 2014 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2014 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder 2

of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If we remove drugs from our formulary, add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of 10/28/2014. To get updated information about the drugs covered by Central Health Medicare Plan, please contact us. Our contact information appears on the front and back cover pages. In the event of non-maintenance changes to the formulary throughout the plan year, Central Health Medicare Plan may make changes via errata sheets mailed to you. Additionally, you may visit our Web site for a link to the errata sheets. How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 26. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, CARDIOVASCULAR AGENTS. If you know what your drug is used for, look for the category name in the list that begins on page 26. Then look under the category name for your drug. Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page 197. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list. 3

What are generic drugs? Central Health Medicare Plan covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs. Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: Prior Authorization: Central Health Medicare Plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Central Health Medicare Plan before you fill your prescriptions. If you don t get approval, Central Health Medicare Plan may not cover the drug. Quantity Limits: For certain drugs, Central Health Medicare Plan limits the amount of the drug that Central Health Medicare Plan will cover. For example, Central Health Medicare Plan provides 60 capsules per prescription for CELEBREX. This may be in addition to a standard one-month or three-month supply. Step Therapy: In some cases, Central Health Medicare Plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Central Health Medicare Plan may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Central Health Medicare Plan will then cover Drug B. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 26. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask Central Health Medicare Plan to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, How do I request an exception to the Central Health Medicare Plan formulary? on page 5 for information about how to request an exception. 4

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

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

For more information For more detailed information about your Central Health Medicare Plan prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about Central Health Medicare Plan, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY users should call 1-877-486-2048. Or, visit www.medicare.gov. 7

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

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

Formulario 2014 (Lista de Medicamentos Cubiertos) Central Health Medicare Plan (HMO), Central Health Medi- Medi Plan (HMO SNP), & Central Health Premier Plan (HMO) FAVOR DE LEER: ÉSTE DOCUMENTO CONTIENE INFORMACIÓN ACERCA DE LOS MEDICAMENTOS CUBIERTOS EN ÉSTE PLAN Este formulario fue actualizado el 10/28/2014. Para información más reciente u otras preguntas, favor de ponerse en contacto con nuestro Departamento de Servicio al Miembro al 1-866-314-2427 o, para usuarios de TTY deben llamar al 1-888-205-7671, los 7 días a la semana, de 8:00 AM a 8:00 PM (Tiempo Pacifico), o visite el sitio web www.centralhealthplan.com. La información de beneficios proveída aquí es un resumen breve, no es una descripción completa de los beneficios. Para más información, póngase en contacto con el plan. Limitaciones, copagos, y restricciones tal vez apliquen. Los beneficios, el formulario, la red de farmacias, primas y /o co-pagos / co-seguros quizás cambien en Enero 1 de cada año. Central Health Medicare Plan es una HMO plan con un contrato de Medicare. La inscripción a Central Health Medicare Plan depende en la renovación del contrato. Las primas, los co-pagos, el co-seguro, y los deducibles tal vez varíen basado en el nivel de Ayuda Adicional que usted reciba. Para más detalles, póngase en contacto con el plan. H5649_112713_1085_CF_S Accepted Last Updated: 10/28/2014 HPMS Approved Formulary File submission ID and version number: 14560v17 10

Nota para los miembros existentes: Éste formulario a cambiado desde el año pasado. Favor de revisar éste documento para asegurarse que todavía contiene los medicamentos que usted toma. Cuando esta lista de medicamentos (formulario) se refiere a nosotros, o nuestro, esto significa que nos estamos refiriendo a Central Health Medicare Plan. Cuando se refiere al plan o a nuestro plan, esto significa que nos estamos refiriendo a Central Health Medicare Plan. Este documento incluye una lista de los medicamentos (formulario) para nuestro plan que es actualizada a 10/28/2014. Para conseguir un formulario actualizado, favor de ponerse en contacto con nosotros. Nuestra información de contacto, junto con la fecha de la ultima vez que se actualizo el formulario, aparece en las portadas del formulario. Usted tiene que utilizar las farmacias dentro de la red para acezar su beneficio de medicamentos recetados. Los beneficios, el formulario, la red de farmacias, las primas y /o co-pagos / coseguro tal vez cambien a partir de Enero 1, 2015. Esta información es disponible gratuitamente en otros lenguajes. Favor de llamar al número de servicio al cliente al 1-866-314-2427, TTY 1-888-205-7671, los 7 días de la semana, 8:00 AM a 8:00 PM (Tiempo Pacifico). Favor de llamar si usted necesita esta información en otro formato. This information is available for free in other languages. Please call our customer service number at 1-866-314-2427, TTY 1-888-205-7671, 7 days a week, 8:00 AM to 8:00 PM (PT). Que es el Formulario de Central Health Medicare Plan? Un formulario es una lista de medicamentos seleccionados que son cubiertos por Central Health Medicare Plan, que representa la receta que los terapéuticos creen necesaria como parte de un programa de tratamiento de calidad. Por lo general, Central Health Medicare Plan cubre los medicamentos en la lista de nuestro formulario, siempre y cuando el medicamento sea médicamente necesario, la receta es surtida en una farmacia en la red de Central Health Medicare Plan, y bajo otras reglas del plan. Para más información en como surtir sus recetas, favor de revisar su Evidencia de Cobertura. Puede cambiar la (lista de medicamentos) del Formulario? Por lo general, si usted está tomando un medicamento de nuestro formulario en el 2014 que estaba cubierto al principio del año, no descontinuaremos ni reduciremos la cobertura del medicamento durante la cobertura del año 2014, solo y cuando un medicamento genérico nuevo y más barato sea disponible o cuando nueva información adversa acerca de la seguridad o efectividad de un medicamento sea disponible. Otro tipo de cambio, como removiendo un medicamento de nuestro formulario, no afectara a los miembros que estén actualmente tomando 11

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

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

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

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

Para más información Para más información detallada de su cobertura de medicamentos recetados de Central Health Medicare Plan, favor de revisar su Evidencia de Cobertura y otros materiales del plan. Si tiene preguntas acerca de Central Health Medicare Plan, favor de ponerse en contacto con nosotros. Nuestra información de contacto, junto con la fecha más reciente que se actualizo el formulario, aparece en las portadas de este formulario. Si usted tiene preguntas generales acerca de su cobertura de medicamentos recetados de Medicare, favor de llamar a Medicare al 1-800-MEDICARE (1-800-633-4227) las 24 horas al día / los 7 días a la semana. Usuarios TTY deben llamar al 1-877-486-2048. O, visite www.medicare.gov. Formulario de Central Health Medicare Plan El formulario en la página 26 provee información de cobertura de algunos de los medicamentos cubiertos por Central Health Medicare Plan. Si usted tiene problemas para encontrar su medicamento en la lista, vea el índice que empieza en la página 197. La primera columna en la lista menciona el nombre del medicamento. Medicamentos de marca están escritos en mayúsculas (ej., CELEBREX) y medicamentos genéricos están escritos en minúsculas itálicas (ej., lisinopril). La información en la columna de Requisitos / Limites le notifica si Central Health Medicare Plan tiene algún requisito especial para la cobertura de sus medicamentos. Ofrecemos cobertura adicional para medicamentos en los Niveles 1 y 2 a través de la brecha de cobertura. Consulte nuestra Evidencia de Cobertura para obtener más información sobre esta cobertura. Todos los medicamentos en los cinco niveles del formulario están disponibles a través de pedidos por correo. Compruebe por favor con la farmacia de pedidos por correo de las limitaciones y / o exclusiones. 16

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

中心健保聯邦紅藍卡計劃 (HMO) 以及, 中心健保聯邦紅藍白卡 計劃 (HMO SNP), & 中心健保特選計劃 (HMO) 2014 處方集 ( 含保藥品目錄 ) 請閱讀 : 以下目錄包含計劃含保的藥品資訊本處方集最近更新日期為 10/28/2014 有關更新修訂或其他資訊, 請聯絡中心健保 :1-866-314-2427 或聽障 / 語障專線 1-888-205-7671, 一週七天, 上午 8:00 到下午 8:00( 太平洋時間 ) 或上網 www.centralhealthplan.com. 上述文字內容只是福利摘要, 並非完整福利解說 請與計劃聯繫以獲得更多資訊 福利可能有條件限制及共付額 福利內容 處方集 合約藥局 保費 及 / 或共付 額 / 共同保險在每年的 1 月 1 日起可能會有所更動 中心健保聯邦健保計劃是個與聯邦醫療保險簽約的健康管理組織 HMO 計劃 中心 健保聯邦健保計劃登記資格取決於續訂合約與否 以上的資訊有其他免費語言版本 請致電會員服務中心 1-866-314-2427, 聽障 / 語障專線 1-888-205-7671, 一週七天, 上午 8:00 到下午 8:00( 太平洋時間 ) H5649_112713_1085_CF_C Accepted Last Updated: 10/28/2014 HPMS Approved Formulary File submission ID and version number: 14560v17 18

保費 共付額 共同保險 以及自付扣除額可能因您的額外補助等級不同而有變動 詳情請與計劃聯繫 This information is available for free in other languages. Please call our customer service number at 1-866-314-2427, TTY 1-888-205-7671, 7 days a week, 8:00 AM to 8:00 PM (PT). 現有會員請注意 : 本含保藥品處方目錄內容與去年相較己有更動, 請仔細查閱您正 在使用的藥品是否仍然在處方集內 本藥品目錄由中心健保聯邦醫療保險公司所提供, 中心健保聯邦醫療保險公司在福 利說明書中稱之為 我們 或 我們的 中心健保聯邦保險計劃則稱之為 計劃 或是 本計劃 會員必須使用合約藥局領取處方藥以獲得福利 福利內容 處方集 合約藥局 保 費 及 / 或共付額 / 共同保險可能於 2015 年 1 月 1 日以後有所更改 何謂 中心健保藥品處方集? 本藥品處方集是由中心健保的專業醫藥團隊在經過仔細的研究和比較後, 得出的一個相信能提供會員高品質的藥品目錄 處方集內的藥物只要是有醫療上的需要 且在中心健保的簽約藥局內配領藥物 並符合其他的規定, 中心健保都會含保給付在藥品處方集內的藥物 如欲了解更多有關取得藥物的訊息, 請參閱福利說明 (Evidence of Coverage) 處方藥品 ( 藥品目錄 ) 內容會改變嗎? 一般而言, 如果我們 2014 年的藥品目錄已含保您目前使用的藥品, 除非在市場上有更新 更加安全 有效及經濟的藥品問世, 我們將不會減少或取消您已經在 2014 年使用的藥品 如果您正在使用的藥品在藥品目錄內被移除, 您使用該藥品的福利將不被影響 會員將仍然可在同一年度內給付原來自付的費用至到保障年度結束 我們認為當會員加入中心健保時, 在同一年度內可以持續使用原來的處方是一件至關重要 19

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

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

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

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

如果您對一般有關於聯邦醫療保險 (Medicare) 處方藥品計劃有疑問, 請撥打 Medi care 每週 7 天, 每天 24 小時免費電話 1-800-MEDICARE (1-800-633-4227) 詢問 聽障或語障人士請致電 1-877-486-2048 或上網到 www.medicare.gov 中心健保處方集 第 26 頁開始的處方集提供部分中心健保含保的藥品資訊 如果您找不到您需要的藥品, 請翻到第 197 頁索引查尋 處方集內的第一欄為藥品名稱 (Drug Name) 在本目錄內名牌藥品以英文正楷大寫標示( 譬如 : CELEBREX), 一般藥品以英文斜體小寫標示 ( 譬如 :lisinopril), 以示區分 在特殊限制藥品欄目 (Requirements/Limits) 內會告知您中心健保是否對您使用的處方藥品有特殊限制 我們在保障缺口階段針對第 1 及第 2 等級藥品提供額外保障 詳情請查閱福利說明書 所有 5 個等級的藥品均可經由郵購取得 相關限制及規定請與郵購藥局聯繫 加入中心健保之後, 我的藥品部分負擔費用為何? 您的自付費用會因為您使用的藥品層級和您是否獲得藥品額外補助而有所不同 如果您是中心健保聯邦紅藍卡計劃 (HMO) 的會員, 當您在藥品保障初始階段時, 請參閱下表以了解您在不同藥品給付層級應該自付的費用 : 藥品層級 (Drug Tier) 網路藥局 (30 天份藥量 ) 網路藥局 (90 天份藥量 ) 郵寄藥品 (90 天份藥量 ) 層級一 : 優先一般藥 $0 $0 $0 層級二 : 非優先一般藥 $5 $15 $10 層級三 : 優先名牌藥 $25 $75 $50 層級四 : 非優先名牌藥 $50 $150 $100 層級五 : 特殊用藥 33% 33% 33% 24

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

ANALGESICS Analgesics, Other butalbital-acetaminophen tab 50-325 mg 2** butalbital-acetaminophen tab 50-650 mg 2** butalbital-acetaminophencaffeine cap 50-325-40 mg 2** butalbital-acetaminophencaffeine soln 50-325-40 mg/15ml 2** butalbital-acetaminophencaffeine tab 50-325-40 mg 2** butalbital-acetaminophencaffeine tab 50-500-40 mg 2** butalbital-aspirin-caffeine cap 50-325-40 mg 2** butalbital-aspirin-caffeine tab 50-325-40 mg 2** Nonsteroidal Anti-Inflammatory Drugs CELEBREX CAP100MG 3 Quantity limitation 60 per 30 days; Step therapy protocols apply CELEBREX CAP200MG 3 Quantity limitation 60 per 30 days; Step therapy protocols apply Quantity limitation 60 per 30 days; CELEBREX CAP400MG 3 CELEBREX CAP50MG 3 diclofenac potassium tab 50 mg 1* diclofenac sodium tab delayed release 25 mg 1* diclofenac sodium tab delayed release 50 mg 1* diclofenac sodium tab delayed release 75 mg 1* diclofenac sodium tab sr 24hr 100 mg 1* diflunisal tab 500 mg 1* etodolac cap 200 mg 1* etodolac cap 300 mg 1 etodolac tab 400 mg 1* Step therapy protocols apply Quantity limitation 60 per 30 days; Step therapy protocols apply 26 *We provide additional coverage of this drug in the coverage gap for Medicare

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

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

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

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

mg tramadol hcl tab sr 24hr 100 mg 2** Quantity limitation 30 per 30 days tramadol hcl tab sr 24hr 200 mg 2** Quantity limitation 30 per 30 days tramadol hcl tab sr 24hr biphasic release 300 mg 2** Opioid Analgesics, Short-Acting acetaminophen w/ codeine soln 120-12 mg/5ml 1* acetaminophen w/ codeine tab 300-15 mg 1* Quantity limitation 400 per 30 days acetaminophen w/ codeine tab 300-30 mg 1* Quantity limitation 400 per 30 days acetaminophen w/ codeine tab 300-60 mg 1* Quantity limitation 400 per 30 days acetaminophen-caffeinedihydrocodeine tab 712.8-60-32 mg 1* butalbital-acetaminophen-caff w/ cod cap 50-325-40-30 mg 2** Quantity limitation 360 per 30 days butalbital-aspirin-caff w/ codeine cap 50-325-40-30 mg 1* Quantity limitation 180 per 30 days butorphanol tartrate nasal soln 10 mg/ml 1* Quantity limitation 10 per 30 days hydrocodone-acetaminophen cap 5-500 mg 1* Quantity limitation 240 per 30 days hydrocodone-acetaminophen soln 7.5-325 mg/15ml 2** hydrocodone-acetaminophen soln 7.5-325 mg/15ml 2** Quantity limitation 3600 per 30 days hydrocodone-acetaminophen soln 7.5-500 mg/15ml 2** Quantity limitation 3600 per 30 days hydrocodone-acetaminophen tab 10-300 mg 2** Quantity limitation 360 per 30 days hydrocodone-acetaminophen tab 10-325 mg 2** Quantity limitation 360 per 30 days hydrocodone-acetaminophen tab 10-400 mg 4 hydrocodone-acetaminophen tab 10-500 mg 2** Quantity limitation 240 per 30 days hydrocodone-acetaminophen tab 10-650 mg 2** Quantity limitation 180 per 30 days 31 *We provide additional coverage of this drug in the coverage gap for Medicare

hydrocodone-acetaminophen tab 10-660 mg 2** Quantity limitation 180 per 30 days hydrocodone-acetaminophen tab 10-750 mg 2** Quantity limitation 150 per 30 days hydrocodone-acetaminophen tab 2.5-500 mg 2** Quantity limitation 240 per 30 days hydrocodone-acetaminophen tab 5-300 mg 2** Quantity limitation 360 per 30 days hydrocodone-acetaminophen tab 5-325 mg 2** Quantity limitation 360 per 30 days hydrocodone-acetaminophen tab 5-400 mg 4 hydrocodone-acetaminophen tab 5-500 mg 1* Quantity limitation 240 per 30 days hydrocodone-acetaminophen tab 5-500 mg 2** Quantity limitation 240 per 30 days hydrocodone-acetaminophen tab 7.5-300 mg 2** Quantity limitation 360 per 30 days hydrocodone-acetaminophen tab 7.5-325 mg 2** Quantity limitation 360 per 30 days hydrocodone-acetaminophen tab 7.5-400 mg 4 hydrocodone-acetaminophen tab 7.5-500 mg 2** Quantity limitation 240 per 30 days hydrocodone-acetaminophen tab 7.5-650 mg 2** Quantity limitation 180 per 30 days hydrocodone-acetaminophen tab 7.5-750 mg 2** Quantity limitation 150 per 30 days hydrocodone-ibuprofen tab 7.5-200 mg 2** Quantity limitation 480 per 30 days hydromorphone hcl tab 2 mg 1* Quantity limitation 120 per 30 days hydromorphone hcl tab 4 mg 1* Quantity limitation 120 per 30 days hydromorphone hcl tab 8 mg 1* Quantity limitation 120 per 30 days nalbuphine hcl inj 10 mg/ml 4 nalbuphine hcl inj 20 mg/ml 4 32 *We provide additional coverage of this drug in the coverage gap for Medicare

oxycodone w/ acetaminophen cap 5-500 mg 1* Quantity limitation 240 per 30 days oxycodone w/ acetaminophen soln 5-325 mg/5ml 1* Quantity limitation 1800 per 30 days oxycodone w/ acetaminophen tab 10-325 mg 1* Quantity limitation 360 per 30 days oxycodone w/ acetaminophen tab 10-650 mg 1* oxycodone w/ acetaminophen tab 2.5-325 mg 1* oxycodone w/ acetaminophen tab 5-325 mg 1* Quantity limitation 360 per 30 days oxycodone w/ acetaminophen tab 7.5-325 mg 1* Quantity limitation 360 per 30 days oxycodone w/ acetaminophen tab 7.5-500 mg 1* Quantity limitation 240 per 30 days oxycodone-aspirin tab 4.8355-325 mg 1* Quantity limitation 360 per 30 days oxycodone-ibuprofen tab 5-400 mg 1* SUBOXONE MIS12-3MG 4 tramadol hcl tab 50 mg 2** Quantity limitation 240 per 30 days tramadol-acetaminophen tab 37.5-325 mg 2** Quantity limitation 240 per 30 days ANESTHETICS Local Anesthetics lidocaine hcl gel 2% 1* lidocaine hcl local preservative free (pf) inj 0.5% 4 lidocaine hcl local preservative 4 33 *We provide additional coverage of this drug in the coverage gap for Medicare

free (pf) inj 1% lidocaine hcl soln 4% 1* lidocaine-prilocaine cream 2.5-2.5% 1* ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS Alcohol Deterrents/Anti-craving CAMPRAL TAB333MG 4 disulfiram tab 250 mg 2** disulfiram tab 500 mg 2** Opioid Antagonists buprenorphine hcl inj 0.3 mg/ml (base equiv) 4 buprenorphine hcl sl tab 2 mg (base equiv) 1* buprenorphine hcl sl tab 8 mg (base equiv) 1* buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg (base equiv) 2** buprenorphine hcl-naloxone hcl sl tab 8-2 mg (base equiv) 2** naloxone hcl inj 1 mg/ml 4 naltrexone hcl tab 50 mg 1* SUBOXONE MIS2-0.5MG 4 Quantity limitation 90 per 30 days 34 *We provide additional coverage of this drug in the coverage gap for Medicare

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

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

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

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

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

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

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

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

cephalexin cap 500 mg 1* cephalexin for susp 125 mg/5ml 1* cephalexin for susp 250 mg/5ml 1* cephalexin tab 250 mg 1* cephalexin tab 500 mg 1* SUPRAX SUS100/5ML 4 SUPRAX SUS200/5ML 4 SUPRAX SUS500/5ML 4 Beta-lactam, Other AZACTAM/DEX INJ1GM 3 AZACTAM/DEX INJ2GM 3 INVANZ INJ1GM 4 Beta-lactam, Penicillins amoxicillin & k clavulanate chew tab 200-28.5 mg 1* amoxicillin & k clavulanate chew tab 400-57 mg 1* amoxicillin & k clavulanate for susp 200-28.5 mg/5ml 1* amoxicillin & k clavulanate for susp 250-62.5 mg/5ml 1* amoxicillin & k clavulanate for susp 400-57 mg/5ml 1* amoxicillin & k clavulanate for susp 600-42.9 mg/5ml 1* amoxicillin & k clavulanate tab 1* 250-125 mg amoxicillin & k clavulanate tab 500-125 mg 1* amoxicillin & k clavulanate tab 875-125 mg 1* 43 *We provide additional coverage of this drug in the coverage gap for Medicare

amoxicillin & k clavulanate tab sr 12hr 1000-62.5 mg 2** amoxicillin (trihydrate) cap 250 mg 1* amoxicillin (trihydrate) cap 500 mg 1* amoxicillin (trihydrate) chew tab 125 mg 1* amoxicillin (trihydrate) chew tab 250 mg 1* amoxicillin (trihydrate) for susp 125 mg/5ml 1* amoxicillin (trihydrate) for susp 200 mg/5ml 1* amoxicillin (trihydrate) for susp 250 mg/5ml 1* amoxicillin (trihydrate) for susp 400 mg/5ml 1* amoxicillin (trihydrate) tab 500 mg 1* amoxicillin (trihydrate) tab 875 mg 1* ampicillin & sulbactam sodium for inj 2-1 gm 4 ampicillin & sulbactam sodium for iv soln 10-5 gm 4 ampicillin cap 250 mg 1* ampicillin cap 500 mg 1* ampicillin for susp 125 mg/5ml 1* ampicillin for susp 250 mg/5ml 1* ampicillin sodium for inj 1 gm 4 44 *We provide additional coverage of this drug in the coverage gap for Medicare

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

PENICILL GK/INJDEX 3MU 4 penicillin g potassium for inj 5000000 unit 4 penicillin g procaine intramuscular susp 600000 unit/ml 4 penicillin g sodium for inj 5000000 unit 4 penicillin v potassium for soln 125 mg/5ml 1* penicillin v potassium for soln 250 mg/5ml 1* penicillin v potassium tab 250 mg 1* penicillin v potassium tab 500 mg 1* piperacillin sodium-tazobactam sodium for inj 3-0.375 gm 4 46 *We provide additional coverage of this drug in the coverage gap for Medicare

piperacillin sodium-tazobactam sodium for inj 4-0.5 gm 4 Macrolides azithromycin for susp 100 mg/5ml 2** Quantity limitation 30 per 5 days azithromycin for susp 200 mg/5ml 2** Quantity limitation 90 per 5 days azithromycin iv for soln 500 mg 4 azithromycin tab 250 mg 2** Quantity limitation 6 per 5 days azithromycin tab 500 mg 2** Quantity limitation 6 per 5 days azithromycin tab 600 mg 2** Quantity limitation 6 per 5 days clarithromycin for susp 125 mg/5ml 2** clarithromycin for susp 250 mg/5ml 2** clarithromycin tab 250 mg 2** Quantity limitation 28 per 14 days clarithromycin tab 500 mg 2** Quantity limitation 28 per 14 days clarithromycin tab sr 24hr 500 mg 2** Quantity limitation 28 per 14 days ERYTHROCIN INJ500MG 4 ERYTHROM ETHTAB400MG 2** erythromycin gel 2% 2** erythromycin ophth oint 5 mg/gm 2** erythromycin pads 2% 2** erythromycin soln 2% 2** erythromycin stearate tab 250 mg 2** 47 *We provide additional coverage of this drug in the coverage gap for Medicare

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

levofloxacin ophth soln 0.5% 2** levofloxacin oral soln 25 mg/ml 1* levofloxacin tab 250 mg 1* Quantity limitation 14 per 14 days levofloxacin tab 500 mg 1* Quantity limitation 14 per 14 days levofloxacin tab 750 mg 1* Quantity limitation 14 per 14 days NOROXIN TAB400MG 4 ofloxacin ophth soln 0.3% 2** ofloxacin otic soln 0.3% 2** ofloxacin tab 200 mg 2** ofloxacin tab 300 mg 2** ofloxacin tab 400 mg 2** VIGAMOX DRO0.5% 4 Sulfonamides silver sulfadiazine cream 1% 1* sulfacetamide sodium lotion 10% (acne) 1* sulfacetamide sodium ophth oint 10% 1* sulfacetamide sodium ophth soln 10% 1* sulfadiazine tab 500 mg 1* sulfamethoxazole-trimethoprim iv soln 400-80 mg/5ml 4 sulfamethoxazole-trimethoprim susp 200-40 mg/5ml 1* sulfamethoxazole-trimethoprim tab 400-80 mg 1* sulfamethoxazole-trimethoprim tab 800-160 mg 1* Tetracyclines demeclocycline hcl tab 150 mg 1* demeclocycline hcl tab 300 mg 1* doxycycline hyclate cap 100 mg 1* doxycycline hyclate cap 50 mg 1* doxycycline hyclate for inj 100 4 49 *We provide additional coverage of this drug in the coverage gap for Medicare

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

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

primidone tab 250 mg 1* primidone tab 50 mg 1* Quantity limitation 180 per 30 days; This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at 1-800- 546-5677 24 hours a day- seven days a week. TTY users should SABRIL POW500MG 5 SABRIL TAB500MG 5 STAVZOR CAP125MG 4 STAVZOR CAP250MG 4 STAVZOR CAP500MG 4 valproate sodium inj 100 mg/ml 4 valproate sodium syrup 250 1* mg/5ml (base equiv) valproic acid cap 250 mg 1* Glutamate Reducing Agents felbamate susp 600 mg/5ml 2** felbamate tab 400 mg 2** felbamate tab 600 mg 2** lamotrigine tab 100 mg 1* lamotrigine tab 150 mg 1* lamotrigine tab 200 mg 1* lamotrigine tab 25 mg 1* lamotrigine tab chewable dispersible 25 mg 1* lamotrigine tab chewable dispersible 5 mg 1* topiramate sprinkle cap 15 mg 2** topiramate sprinkle cap 25 mg 2** topiramate tab 100 mg 2** call 1- Quantity limitation 180 per 30 days; This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call 1-800-546-5677 24 hours a day- seven days a week. TTY users should call 1-52 *We provide additional coverage of this drug in the coverage gap for Medicare

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

OXTELLAR XR TAB150MG 4 Quantity limitation 480 per 30 days OXTELLAR XR TAB300MG 4 Quantity limitation 240 per 30 days OXTELLAR XR TAB600MG 4 Quantity limitation 120 per 30 days PEGANONE TAB250MG 4 phenytoin chew tab 50 mg 1* phenytoin sodium extended cap 100 mg 1* phenytoin sodium extended cap 200 mg 2** phenytoin sodium extended cap 300 mg 2** phenytoin sodium inj 50 mg/ml 4 phenytoin susp 125 mg/5ml 1* POTIGA TAB200MG 4 Quantity limitation 180 per 30 days POTIGA TAB300MG 4 Quantity limitation 120 per 30 days POTIGA TAB400MG 4 Quantity limitation 90 per 30 days POTIGA TAB50MG 4 Quantity limitation 720 per 30 days VIMPAT INJ200MG/20 4 Quantity limitation 1200 per 30 days Quantity limitation 1200 per 30 days VIMPAT SOL10MG/ML 4 VIMPAT TAB100MG 4 Quantity limitation 60 per 30 days VIMPAT TAB150MG 4 Quantity limitation 60 per 30 days VIMPAT TAB200MG 4 Quantity limitation 60 per 30 days VIMPAT TAB50MG 4 Quantity limitation 60 per 30 days Cholinesterase Inhibitors donepezil hydrochloride orally disintegrating tab 10 mg 2** Quantity limitation 30 per 30 days donepezil hydrochloride orally disintegrating tab 5 mg 2** Quantity limitation 30 per 30 days donepezil hydrochloride tab 10 mg 2** Quantity limitation 30 per 30 days donepezil hydrochloride tab 5 mg 2** Quantity limitation 30 per 30 days EXELON DIS13.3/24 3 54 *We provide additional coverage of this drug in the coverage gap for Medicare

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

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

olanzapine-fluoxetine hcl cap 12-25 mg 2** olanzapine-fluoxetine hcl cap 12-50 mg 2** olanzapine-fluoxetine hcl cap 3-25 mg 2** olanzapine-fluoxetine hcl cap 6-25 mg 2** olanzapine-fluoxetine hcl cap 6-50 mg 2** perphenazine-amitriptyline tab 2-10 mg 1* perphenazine-amitriptyline tab 2-25 mg 1* perphenazine-amitriptyline tab 4-10 mg 1* perphenazine-amitriptyline tab 4-25 mg 1* perphenazine-amitriptyline tab 4-50 mg 1* trazodone hcl tab 100 mg 1* trazodone hcl tab 150 mg 1* trazodone hcl tab 300 mg 1* trazodone hcl tab 50 mg 1* VIIBRYD KIT 4 VIIBRYD TAB10MG 4 Quantity limitation 120 per 30 days VIIBRYD TAB20MG 4 Quantity limitation 60 per 30 days VIIBRYD TAB40MG 4 Quantity limitation 30 per 30 days Monoamine Oxidase Inhibitors EMSAM DIS12MG/24H 4 Quantity limitation 30 per 30 days EMSAM DIS6MG/24HR 4 Quantity limitation 30 per 30 days EMSAM DIS9MG/24HR 4 Quantity limitation 30 per 30 days MARPLAN TAB10MG 4 phenelzine sulfate tab 15 mg 2** tranylcypromine sulfate tab 10 mg 1* Serotonin/ Norepinephrine Reuptake Inhibitors citalopram hydrobromide oral soln 10 mg/5ml 1* citalopram hydrobromide tab 10 mg (base equiv) 1* Quantity limitation 30 per 30 days 57 *We provide additional coverage of this drug in the coverage gap for Medicare

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

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

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

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

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

EMEND CAP80MG 3 Quantity limitation 30 per 30 days; EMEND PAK80 & 125 3 Quantity limitation 30 per 30 days; granisetron hcl tab 1 mg 1* Quantity limitation 60 per 30 days ondansetron hcl oral soln 4 mg/5ml 1* Quantity limitation 450 per 30 days ondansetron hcl tab 24 mg 1* Quantity limitation 60 per 30 days ondansetron hcl tab 4 mg 1* Quantity limitation 60 per 30 days ondansetron hcl tab 8 mg 1* Quantity limitation 60 per 30 days ondansetron orally disintegrating tab 4 mg 1* Quantity limitation 60 per 30 days ondansetron orally disintegrating tab 8 mg 1* Quantity limitation 60 per 30 days ANTIFUNGALS Antifungals ABELCET INJ5MG/ML 5 amphotericin b for inj 50 mg 4 63 *We provide additional coverage of this drug in the coverage gap for Medicare

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

fluconazole tab 100 mg 1* fluconazole tab 150 mg 1* Quantity limitation 2 per 7 days fluconazole tab 200 mg 1* fluconazole tab 50 mg 1* flucytosine cap 250 mg 2** flucytosine cap 500 mg 2** griseofulvin microsize susp 125 mg/5ml 4 itraconazole cap 100 mg 1* ketoconazole cream 2% 1* ketoconazole shampoo 2% 1* ketoconazole tab 200 mg 1* miconazole nitrate vaginal suppos 200 mg 1* Quantity limitation 3 per 3 days NAFTIN CRE1% 4 NAFTIN GEL1% 4 NATACYN SUS5% OP 3 NOXAFIL SUS40MG/ML 5 nystatin cream 100000 unit/gm 1* nystatin oint 100000 unit/gm 1* nystatin susp 100000 unit/ml 1* nystatin tab 500000 unit 1* nystatin topical powder 1* nystatin-triamcinolone cream 100000-0.1 unit/gm-% 1* nystatin-triamcinolone oint 100000-0.1 unit/gm-% 1* OXISTAT CRE1% 4 OXISTAT LOT1% 4 terbinafine hcl tab 250 mg 1* terconazole vaginal cream 0.4% 1* Quantity limitation 45 per 7 days terconazole vaginal cream 0.8% 1* terconazole vaginal suppos 80 mg 1* Quantity limitation 3 per 3 days VFEND SUS40MG/ML 5 65 *We provide additional coverage of this drug in the coverage gap for Medicare

voriconazole tab 200 mg 2** voriconazole tab 50 mg 2** ZAZOLE CRE0.4% 4 Quantity limitation 45 per 7 days ZOLINZA CAP100MG 5 ANTIGOUT AGENTS Antigout Agents allopurinol tab 100 mg 1* allopurinol tab 300 mg 1* colchicine w/ probenecid tab 0.5-500 mg 1* COLCRYS TAB0.6MG 4 Quantity limitation 120 per 30 days probenecid tab 500 mg 1* ULORIC TAB40MG 4 Step therapy protocols apply ULORIC TAB80MG 4 Step therapy protocols apply ANTIMIGRAINE AGENTS Ergot Alkaloids dihydroergotamine mesylate inj 1 mg/ml 3 ergotamine w/ caffeine suppos 2-100 mg 1* MIGRANAL SPR4MG/ML 4 Quantity limitation 16 per 30 days Prophylactic divalproex sodium tab sr 24 hr 250 mg 1* divalproex sodium tab sr 24 hr 500 mg 1* timolol maleate tab 10 mg 1* timolol maleate tab 20 mg 1* timolol maleate tab 5 mg 1* Serotonin (5-HT) 1b/1d Receptor Agonists 66 *We provide additional coverage of this drug in the coverage gap for Medicare

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

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

Antiangiogenic Agents REVLIMID CAP2.5MG 5 REVLIMID CAP20MG 5 REVLIMID CAP10MG 5 REVLIMID CAP15MG 5 REVLIMID CAP25MG 5 This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at 1-800-546-5677 24 hours a day- seven days This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at 1-800-546-5677 24 hours a day- seven days This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at 1-800-546-5677 24 hours a day- seven days This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at 1-800-546-5677 24 hours a day- seven days This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at 1-800-546-69 *We provide additional coverage of this drug in the coverage gap for Medicare

5677 24 hours a day- seven days REVLIMID CAP5MG 5 THALOMID CAP100MG 5 THALOMID CAP150MG 5 THALOMID CAP200MG 5 THALOMID CAP50MG 5 Antiestrogens/Modifiers FARESTON TAB60MG 4 SOLTAMOX SOL10MG/5ML 4 tamoxifen citrate tab 10 mg (base equivalent) 1* tamoxifen citrate tab 20 mg (base equivalent) 1* Antimetabolites DACOGEN INJ50MG 5 This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at 1-800-546-5677 24 hours a day- seven days decitabine inj50mg 5 DROXIA CAP200MG 4 DROXIA CAP300MG 4 DROXIA CAP400MG 4 gemcitabine hcl for inj 1 gm 4 70 *We provide additional coverage of this drug in the coverage gap for Medicare

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

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

FASLODEX INJ250MG 5 FUSILEV INJ50MG 4 HALAVEN INJ1MG/2ML 5 ISTODAX INJ10MG 5 JAKAFI TAB10MG 5 JAKAFI TAB15MG 5 Quantity limitation 60 per 30 days; This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at 1-800-546-5677 24 hours a day- seven days Quantity limitation 60 per 30 days; This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at 1-800-546-5677 24 hours a day- seven days 73 *We provide additional coverage of this drug in the coverage gap for Medicare

JAKAFI TAB20MG 5 Quantity limitation 60 per 30 days; This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at 1-800-546-5677 24 hours a day- seven days JAKAFI TAB25MG 5 Quantity limitation 60 per 30 days; This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at 1-800-546-5677 24 hours a day- seven days JAKAFI TAB5MG 5 Quantity limitation 60 per 30 days; This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at 1-800-546-5677 24 hours a day- seven days JEVTANA INJ60/1.5ML 5 leucovorin calcium for inj 100 mg 4 74 *We provide additional coverage of this drug in the coverage gap for Medicare

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

TAFINLAR CAP50MG 5 Quantity limitation 180 per 30 days TAFINLAR CAP75MG 5 Quantity limitation 120 per 30 days TRISENOX SOL10MG/10M 4 VELCADE INJ3.5MG 5 VIDAZA INJ100MG 5 Quantity limitation 240 per 30 days; This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at 1-800- 546-5677 24 hours a day- seven days a week. TTY users should call 1- ZELBORAF TAB240MG 5 ZYDELIG TAB100MG 5 Quantity limitation 90 per 30 days ZYDELIG TAB150MG 5 Quantity limitation 60 per 30 days Aromatase Inhibitors, 3rd Generation anastrozole tab 1 mg 1* Quantity limitation 30 per 30 days exemestane tab 25 mg 2** letrozole tab 2.5 mg 2** Quantity limitation 30 per 30 days 76 *We provide additional coverage of this drug in the coverage gap for Medicare

Enzyme Inhibitors ETOPOPHOS INJ100MG 4 etoposide inj 20 mg/ml 4 etoposide inj 20 mg/ml 3 topotecan hcl for inj 4 mg 4 Molecular Target Inhibitors BOSULIF TAB100MG 5 Quantity limitation 120 per 30 days BOSULIF TAB500MG 5 Quantity limitation 30 per 30 days CAPRELSA TAB100MG 5 Quantity limitation 60 per 30 days; This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at 1-800-546-5677 24 hours a day- seven days CAPRELSA TAB300MG 5 Quantity limitation 30 per 30 days; 77 *We provide additional coverage of this drug in the coverage gap for Medicare

This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at 1-800-546-5677 24 hours a day- seven days COMETRIQ KIT100MG 5 Quantity limitation 56 per 28 days COMETRIQ KIT140MG 5 Quantity limitation 112 per 28 days COMETRIQ KIT60MG 5 Quantity limitation 84 per 28 days GILOTRIF TAB20MG 5 Quantity limitation 30 per 30 days GILOTRIF TAB30MG 5 Quantity limitation 30 per 30 days GILOTRIF TAB40MG 5 Quantity limitation 30 per 30 days GLEEVEC TAB100MG 5 Quantity limitation 90 per 30 days GLEEVEC TAB400MG 5 Quantity limitation 60 per 30 days ICLUSIG TAB15MG 5 Quantity limitation 60 per 30 days ICLUSIG TAB45MG 5 Quantity limitation 30 per 30 days IMBRUVICA CAP140MG 5 Quantity limitation 30 per 30 days INLYTA TAB1MG 4 INLYTA TAB5MG 4 MEKINIST TAB0.5MG 5 Quantity limitation 120 per 30 days MEKINIST TAB2MG 5 Quantity limitation 30 per 30 days Quantity limitation 120 per 30 days; This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at 1-800- 546-5677 24 hours a day- seven days a week. TTY users should call 1- NEXAVAR TAB200MG 5 SPRYCEL TAB100MG 5 SPRYCEL TAB140MG 5 SPRYCEL TAB20MG 5 SPRYCEL TAB50MG 5 SPRYCEL TAB70MG 5 SPRYCEL TAB80MG 5 STIVARGA TAB40MG 5 Quantity limitation 84 per 28 days SUTENT CAP12.5MG 5 SUTENT CAP25MG 5 78 *We provide additional coverage of this drug in the coverage gap for Medicare

SUTENT CAP37.5MG 5 SUTENT CAP50MG 5 TARCEVA TAB100MG 5 TARCEVA TAB150MG 5 TARCEVA TAB25MG 5 TASIGNA CAP150MG 5 TASIGNA CAP200MG 5 TYKERB TAB250MG 5 This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at 1-800-546-5677 24 hours a day- seven days VOTRIENT TAB200MG 5 XALKORI CAP200MG 5 Quantity limitation 60 per 30 days; This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at 1-800-546-5677 24 hours a day- seven days Quantity limitation 60 per 30 days; This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at 1-800-546-5677 24 hours a day- seven days XALKORI CAP250MG 5 ZYKADIA CAP150MG 5 Quantity limitation 150 per 30 days Monoclonal Antibodies ARZERRA CON100/5ML 5 79 *We provide additional coverage of this drug in the coverage gap for Medicare

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

Retinoids PANRETIN GEL0.1% 5 RETIN-A MICRGEL0.04% 4 RETIN-A MICRGEL0.08% 4 RETIN-A MICRGEL0.1% 4 TARGRETIN CAP75MG 5 TARGRETIN GEL1% 5 Quantity limitation 60 per 30 days tretinoin cap 10 mg 1* tretinoin cream 0.025% 1* tretinoin cream 0.05% 1* tretinoin cream 0.1% 1* tretinoin gel 0.01% 1* tretinoin gel 0.025% 1* ANTIPARASITICS Anthelmintics ALBENZA TAB200MG 3 BILTRICIDE TAB600MG 4 STROMECTOL TAB3MG 4 Antiprotozoals ALINIA SUS100MG/5M 4 ALINIA TAB500MG 4 atovaquone-proguanil hcl tab 250-100 mg 2** chloroquine phosphate tab 250 mg 1* chloroquine phosphate tab 500 mg 1* DARAPRIM TAB25MG 4 hydroxychloroquine sulfate tab 200 mg 1* mefloquine hcl tab 250 mg 1* MEPRON SUS 3 81 *We provide additional coverage of this drug in the coverage gap for Medicare

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

Member Services at 1-800-546-5677 24 hours a day- seven days ; This medication requires prior authorization. To obtain an exception please call 1-800-546-5677 - 24 hours a dayseven days a week. TTY users should call 1- bromocriptine mesylate cap 5 mg 1* bromocriptine mesylate tab 2.5 mg 1* pramipexole dihydrochloride tab 0.125 mg 2** Quantity limitation 90 per 30 days pramipexole dihydrochloride tab 0.25 mg 2** Quantity limitation 90 per 30 days pramipexole dihydrochloride tab 0.5 mg 2** Quantity limitation 90 per 30 days pramipexole dihydrochloride tab 0.75 mg 2 Quantity limitation 90 per 30 days pramipexole dihydrochloride tab 1 mg 2** Quantity limitation 90 per 30 days pramipexole dihydrochloride tab 1.5 mg 2** Quantity limitation 90 per 30 days ropinirole hydrochloride tab 0.25 mg 1* ropinirole hydrochloride tab 0.5 mg 1* ropinirole hydrochloride tab 1 mg 1* ropinirole hydrochloride tab 2 mg 1* ropinirole hydrochloride tab 3 mg 1* ropinirole hydrochloride tab 4 mg 1* ropinirole hydrochloride tab 5 mg 1* Dopamine Precursors/L-Amino Acid Decarboxylase Inhibitors carbidopa & levodopa orally 1* 83 *We provide additional coverage of this drug in the coverage gap for Medicare

disintegrating tab 10-100 mg carbidopa & levodopa orally disintegrating tab 25-100 mg 1* carbidopa & levodopa orally disintegrating tab 25-250 mg 1* carbidopa & levodopa tab 10-100 mg 1* carbidopa & levodopa tab 25-100 mg 1* carbidopa & levodopa tab 25-250 mg 1* carbidopa & levodopa tab cr 25-100 mg 1* carbidopa & levodopa tab cr 50-200 mg 1* LODOSYN TAB25MG 4 Monoamine Oxidase B (MAO-B) Inhibitors AZILECT TAB0.5MG 4 AZILECT TAB0.5MG AZILECT TAB1MG 4 AZILECT TAB1MG selegiline hcl cap 5 mg 1* selegiline hcl cap 5 mg selegiline hcl tab 5 mg 1* selegiline hcl tab 5 mg ANTIPSYCHOTICS 1st Generation/Typical fluphenazine decanoate inj 25 mg/ml 4 fluphenazine hcl elixir 2.5 mg/5ml 1* fluphenazine hcl inj 2.5 mg/ml 4 fluphenazine hcl oral conc 5 mg/ml 1* fluphenazine hcl tab 1 mg 1* fluphenazine hcl tab 10 mg 1* fluphenazine hcl tab 2.5 mg 1* fluphenazine hcl tab 5 mg 1* haloperidol decanoate im soln 100 mg/ml 4 84 *We provide additional coverage of this drug in the coverage gap for Medicare

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

FANAPT TAB6MG 4 Quantity limitation 120 per 30 days FANAPT TAB8MG 4 Quantity limitation 90 per 30 days GEODON INJ20MG 4 INVEGA TAB1.5MG 4 Quantity limitation 240 per 30 days INVEGA TAB3MG 4 Quantity limitation 120 per 30 days INVEGA TAB6MG 4 Quantity limitation 60 per 30 days INVEGA TAB9MG 4 Quantity limitation 60 per 30 days INVEGA SUST INJ117/0.75 5 INVEGA SUST INJ156MG/ML 5 INVEGA SUST INJ234/1.5 5 INVEGA SUST INJ39/0.25 4 INVEGA SUST INJ78/0.5ML 4 LATUDA TAB120MG 4 Quantity limitation 30 per 30 days LATUDA TAB20MG 4 Quantity limitation 120 per 30 days LATUDA TAB40MG 4 Quantity limitation 60 per 30 days LATUDA TAB60MG 4 Quantity limitation 60 per 30 days LATUDA TAB80MG 4 Quantity limitation 30 per 30 days Quantity limitation 30 per 30 days; olanzapine for im inj 10 mg 4 olanzapine orally disintegrating tab 10 mg 2** Quantity limitation 60 per 30 days olanzapine orally disintegrating tab 15 mg 2** Quantity limitation 60 per 30 days olanzapine orally disintegrating tab 20 mg 2** Quantity limitation 30 per 30 days olanzapine orally disintegrating tab 5 mg 2** Quantity limitation 120 per 30 days olanzapine tab 10 mg 2** Quantity limitation 60 per 30 days olanzapine tab 15 mg 2** Quantity limitation 60 per 30 days olanzapine tab 2.5 mg 2** Quantity limitation 240 per 30 days olanzapine tab 20 mg 2** Quantity limitation 30 per 30 days olanzapine tab 5 mg 2** Quantity limitation 120 per 30 days olanzapine tab 7.5 mg 2** Quantity limitation 90 per 30 days quetiapine fumarate tab 100 mg 2** Quantity limitation 240 per 30 days quetiapine fumarate tab 200 mg 2** Quantity limitation 120 per 30 days 86 *We provide additional coverage of this drug in the coverage gap for Medicare

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

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

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

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

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

SUSTIVA CAP200MG 4 SUSTIVA CAP50MG 4 SUSTIVA TAB600MG 4 VIRAMUNE SUS50MG/5ML 3 VIRAMUNE XR TAB100MG 3 VIRAMUNE XR TAB400MG 3 Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors abacavir sulfate tab 300 mg (base equiv) 2** abacavir/lamivudine/zidovudine 2 ATRIPLA TAB 5 COMPLERA TAB 5 Quantity limitation 30 per 30 days didanosine delayed release capsule 125 mg 1* didanosine delayed release capsule 200 mg 1* didanosine delayed release capsule 250 mg 1* didanosine delayed release capsule 400 mg 1* EMTRIVA CAP200MG 4 EMTRIVA SOL10MG/ML 4 EPIVIR SOL10MG/ML 4 EPZICOM TAB600-300 5 lamivudine tab 100 mg 2** lamivudine tab 150 mg 2** lamivudine tab 300 mg 2** lamivudine-zidovudine tab 150-300 mg 1* RETROVIR INJ10MG/ML 4 stavudine cap 15 mg 1* stavudine cap 20 mg 1* stavudine cap 30 mg 1* stavudine cap 40 mg 1* stavudine for oral soln 1 mg/ml 1* STRIBILD TAB 4 TRIZIVIR TAB 5 TRUVADA TAB200-300 5 VIDEX SOL2GM 4 VIREAD POW40MG/GM 4 VIREAD TAB150MG 4 92 *We provide additional coverage of this drug in the coverage gap for Medicare

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

VIRACEPT TAB250MG 5 VIRACEPT TAB625MG 5 Anti-influenza Agents RELENZA MISDISKHALE 3 Quantity limitation 60 per 180 days rimantadine hydrochloride tab 100 mg 1* TAMIFLU CAP30MG 3 Quantity limitation 84 per 180 days TAMIFLU CAP45MG 3 Quantity limitation 42 per 180 days TAMIFLU CAP75MG 3 Quantity limitation 42 per 180 days TAMIFLU SUS6MG/ML 3 Quantity limitation 900 per 180 days ANXIOLYTICS Anxiolytics, Other alprazolam orally disintegrating tab 0.25 mg 2** Quantity limitation 120 per 30 days alprazolam orally disintegrating tab 0.5 mg 2** Quantity limitation 120 per 30 days alprazolam orally disintegrating tab 1 mg 2** Quantity limitation 120 per 30 days alprazolam orally disintegrating tab 2 mg 2** Quantity limitation 120 per 30 days alprazolam tab 0.25 mg 2** Quantity limitation 120 per 30 days alprazolam tab 0.5 mg 2** Quantity limitation 120 per 30 days alprazolam tab 1 mg 2** Quantity limitation 120 per 30 days alprazolam tab 2 mg 2** Quantity limitation 120 per 30 days alprazolam tab sr 24hr 0.5 mg 2** Quantity limitation 90 per 30 days alprazolam tab sr 24hr 1 mg 2** Quantity limitation 90 per 30 days alprazolam tab sr 24hr 2 mg 2** Quantity limitation 90 per 30 days alprazolam tab sr 24hr 3 mg 2** Quantity limitation 90 per 30 days buspirone hcl tab 10 mg 1* buspirone hcl tab 15 mg 1* buspirone hcl tab 30 mg 1* buspirone hcl tab 5 mg 1* buspirone hcl tab 7.5 mg 1* clonazepam orally disintegrating tab 0.125 mg 2** clonazepam orally disintegrating tab 0.25 mg 2** clonazepam orally disintegrating tab 0.5 mg 2** 94 *We provide additional coverage of this drug in the coverage gap for Medicare

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

phenobarbital tab 15 mg 2** phenobarbital tab 16.2 mg 2** Quantity limitation 360 per 30 days phenobarbital tab 30 mg 2** Quantity limitation 195 per 30 days phenobarbital tab 32.4 mg 2** Quantity limitation 180 per 30 days phenobarbital tab 60 mg 2** temazepam cap 15 mg 1* Quantity limitation 30 per 30 days temazepam cap 22.5 mg 1* Quantity limitation 30 per 30 days temazepam cap 30 mg 1* Quantity limitation 30 per 30 days temazepam cap 7.5 mg 1* Quantity limitation 30 per 30 days BIPOLAR AGENTS Bipolar Agents, Other SAPHRIS SUB10MG 4 Quantity limitation 60 per 30 days SAPHRIS SUB5MG 4 Quantity limitation 120 per 30 days Mood Stabilizers lithium carbonate cap 150 mg 1* lithium carbonate cap 300 mg 1* lithium carbonate cap 600 mg 1* lithium carbonate tab 300 mg 1* lithium carbonate tab cr 300 mg 1* lithium carbonate tab cr 450 mg 1* LITHIUM CITRSOL8MEQ/5ML 4 BLOOD GLUCOSE REGULATORS Antidiabetic Agents acarbose tab 100 mg 1* acarbose tab 25 mg 1* acarbose tab 50 mg 1* Quantity limitation 2.4 per 30 days; BYETTA INJ10MCG 4 Step therapy protocols apply Quantity limitation 2.4 per 30 days; BYETTA INJ5MCG 4 Step therapy protocols apply glimepiride tab 1 mg 1* Quantity limitation 60 per 30 days glimepiride tab 2 mg 1* Quantity limitation 60 per 30 days glimepiride tab 4 mg 1* Quantity limitation 60 per 30 days glipizide tab 10 mg 1* Quantity limitation 120 per 30 days glipizide tab 5 mg 1* Quantity limitation 240 per 30 days glipizide tab sr 24hr 10 mg 1* Quantity limitation 60 per 30 days glipizide tab sr 24hr 2.5 mg 1* Quantity limitation 240 per 30 days glipizide tab sr 24hr 5 mg 1* Quantity limitation 120 per 30 days glipizide-metformin hcl tab 2.5-250 mg 1* Quantity limitation 240 per 30 days 96 *We provide additional coverage of this drug in the coverage gap for Medicare

glipizide-metformin hcl tab 2.5-500 mg 1* Quantity limitation 120 per 30 days glipizide-metformin hcl tab 5-500 mg 1* Quantity limitation 120 per 30 days glyburide micronized tab 1.5 mg 1* Quantity limitation 120 per 30 days glyburide micronized tab 3 mg 1* Quantity limitation 60 per 30 days glyburide micronized tab 6 mg 1* Quantity limitation 30 per 30 days glyburide tab 1.25 mg 1* Quantity limitation 480 per 30 days glyburide tab 2.5 mg 1* Quantity limitation 240 per 30 days glyburide tab 5 mg 1* Quantity limitation 120 per 30 days glyburide-metformin tab 1.25-250 mg 1* Quantity limitation 240 per 30 days glyburide-metformin tab 2.5-500 mg 1* Quantity limitation 120 per 30 days glyburide-metformin tab 5-500 mg 1* Quantity limitation 120 per 30 days GLYSET TAB100MG 4 Quantity limitation 90 per 30 days GLYSET TAB25MG 4 Quantity limitation 90 per 30 days GLYSET TAB50MG 4 Quantity limitation 90 per 30 days Quantity limitation 60 per 30 days; JANUMET TAB50-1000 4 Step therapy protocols apply Quantity limitation 60 per 30 days; Step therapy protocols apply JANUMET TAB50-500MG 4 JANUMET XR TAB100-1000 4 Quantity limitation 60 per 30 days JANUMET XR TAB50-1000 4 Quantity limitation 60 per 30 days JANUMET XR TAB50-500MG 4 Quantity limitation 60 per 30 days JANUVIA TAB100MG 4 Quantity limitation 30 per 30 days JANUVIA TAB25MG 4 Quantity limitation 30 per 30 days JANUVIA TAB50MG 4 Quantity limitation 30 per 30 days JUVISYNC TAB100-10MG 4 Quantity limitation 30 per 30 days JUVISYNC TAB100-20MG 4 Quantity limitation 30 per 30 days JUVISYNC TAB100-40MG 4 Quantity limitation 30 per 30 days JUVISYNC TAB50-10MG 4 Quantity limitation 30 per 30 days JUVISYNC TAB50-20MG 4 Quantity limitation 30 per 30 days JUVISYNC TAB50-40MG 4 Quantity limitation 30 per 30 days metformin hcl tab 1000 mg 1* Quantity limitation 90 per 30 days metformin hcl tab 500 mg 1* Quantity limitation 150 per 30 days metformin hcl tab 850 mg 1* Quantity limitation 90 per 30 days metformin hcl tab sr 24hr 500 mg 1* Quantity limitation 120 per 30 days metformin hcl tab sr 24hr 750 1* Quantity limitation 90 per 30 days 97 *We provide additional coverage of this drug in the coverage gap for Medicare

mg nateglinide tab 120 mg 2** Quantity limitation 90 per 30 days nateglinide tab 60 mg 2** Quantity limitation 90 per 30 days pioglitazone hcl tab 15 mg (base equiv) 2** Quantity limitation 30 per 30 days pioglitazone hcl tab 30 mg (base equiv) 2** Quantity limitation 30 per 30 days pioglitazone hcl tab 45 mg (base equiv) 2** Quantity limitation 30 per 30 days pioglitazone hcl-glimepiride tab 30-2 mg 2** Quantity limitation 30 per 30 days pioglitazone hcl-glimepiride tab 30-4 mg 2** Quantity limitation 30 per 30 days pioglitazone hcl-metformin hcl tab 15-500 mg 2** Quantity limitation 30 per 30 days pioglitazone hcl-metformin hcl tab 15-850 mg 2** Quantity limitation 90 per 30 days PRANDIMET TAB1-500MG 4 Quantity limitation 150 per 30 days PRANDIMET TAB2-500MG 4 Quantity limitation 150 per 30 days PRANDIN TAB0.5MG 4 Quantity limitation 120 per 30 days PRANDIN TAB1MG 4 Quantity limitation 120 per 30 days PRANDIN TAB2MG 4 Quantity limitation 240 per 30 days Quantity limitation 10.8 per 30 SYMLINPEN 60INJ1000MCG 4 days SYMLNPEN 120INJ1000MCG 4 Quantity limitation 10.8 per 30 days tolazamide tab 250 mg 1* tolazamide tab 500 mg 1* tolbutamide tab 500 mg 1* Blood Glucose Regulators ALCOHOL PREPPAD 3 GAUZE PADS & DRESSING 3 INSULIN NEEDLE 3 INSULIN PEN NEEDLE 3 INSULIN SYRINGE 3 Glycemic Agents GLUCAGEN INJHYPOKIT 3 Quantity limitation 30 per 30 days GLUCAGON KIT1MG 3 Quantity limitation 2 per 30 days PROGLYCEM SUS50MG/ML 4 Insulins APIDRA INJSOLOSTAR 3 Quantity limitation 30 per 30 days 98 *We provide additional coverage of this drug in the coverage gap for Medicare

APIDRA INJU-100 3 Quantity limitation 30 per 30 days HUMALOG INJ100/ML 3 HUMALOG KWIKINJ100/ML 3 HUMALOG MIX INJ50/50 3 Quantity limitation 30 per 30 days HUMALOG MIX INJ50/50KWP 3 Quantity limitation 30 per 30 days HUMALOG MIX INJ75/25KWP 3 Quantity limitation 30 per 30 days HUMALOG MIX SUS75/25 3 Quantity limitation 30 per 30 days HUMULIN INJ70/30 3 Quantity limitation 30 per 30 days HUMULIN N INJU-100 3 Quantity limitation 30 per 30 days HUMULIN N PNINJU-100 3 Quantity limitation 30 per 30 days HUMULIN PEN INJ70/30 3 Quantity limitation 30 per 30 days HUMULIN R INJU-100 3 Quantity limitation 30 per 30 days HUMULIN R INJU-500 3 Quantity limitation 30 per 30 days LANTUS INJ100/ML 3 Quantity limitation 30 per 30 days LANTUS INJSOLOSTAR 3 Quantity limitation 30 per 30 days LEVEMIR INJ 3 Quantity limitation 30 per 30 days LEVEMIR INJFLEXPEN 3 Quantity limitation 30 per 30 days NOVOLIN INJ70/30 3 Quantity limitation 30 per 30 days NOVOLIN N INJU-100 3 Quantity limitation 30 per 30 days NOVOLIN R INJU-100 3 Quantity limitation 30 per 30 days NOVOLOG INJ100/ML 3 Quantity limitation 30 per 30 days NOVOLOG INJFLEXPEN 3 Quantity limitation 30 per 30 days NOVOLOG MIX INJ70/30 3 Quantity limitation 30 per 30 days NOVOLOG MIX INJFLEXPEN 3 Quantity limitation 30 per 30 days BLOOD PRODUCTS/MODIFIERS/ VOLUME EXPANDERS Anticoagulants COUMADIN INJ5 MG 3 enoxaparin sodium inj 100 mg/ml 4 Quantity limitation 28 per 30 days; 99 *We provide additional coverage of this drug in the coverage gap for Medicare

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

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

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

HEP SOD/NACLINJ25000UNT 4 HEP SOD/NACLINJ25000UNT 4 heparin sodium (porcine) 2 unit/ml in sodium chloride 0.9% 4 heparin sodium (porcine) 40 unit/ml in d5w 4 heparin sodium (porcine) inj 1000 unit/ml 4 heparin sodium (porcine) inj 10000 unit/ml 4 103 *We provide additional coverage of this drug in the coverage gap for Medicare

heparin sodium (porcine) inj 20000 unit/ml 4 heparin sodium (porcine) inj 5000 unit/ml 4 PRADAXA CAP150MG 4 Quantity limitation 60 per 30 days; Quantity limitation 60 per 30 days; PRADAXA CAP75MG 4 warfarin sodium tab 1 mg 1* warfarin sodium tab 10 mg 1* warfarin sodium tab 2 mg 1* warfarin sodium tab 2.5 mg 1* warfarin sodium tab 3 mg 1* warfarin sodium tab 4 mg 1* warfarin sodium tab 5 mg 1* warfarin sodium tab 6 mg 1* warfarin sodium tab 7.5 mg 1* XARELTO TAB10MG 4 Quantity limitation 30 per 30 days 104 *We provide additional coverage of this drug in the coverage gap for Medicare

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

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

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

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

PROCRIT INJ40000/ML 5 This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at 1-800-546-5677 24 hours a day- seven days PROMACTA TAB12.5MG 5 PROMACTA TAB25MG 5 Quantity limitation 90 per 30 days; This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at 1-800-546-5677 24 hours a day- seven days ; This medication requires prio PROMACTA TAB50MG 5 Quantity limitation 90 per 30 days; This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at 1-800-546-5677 24 hours a day- seven days ; This medication requires prio PROMACTA TAB75MG 5 This prescription may be available only at certain pharmacies. For more information consult your 109 *We provide additional coverage of this drug in the coverage gap for Medicare

Pharmacy Directory or call Member Services at 1-800-546-5677 24 hours a day- seven days Coagulants CYKLOKAPRON INJ100MG/ML 3 tranexamic acid inj 100 mg/ml 4 Platelet Modifying Agents AGGRENOX CAP25-200MG 4 cilostazol tab 100 mg 1* cilostazol tab 50 mg 1* clopidogrel bisulfate tab 300 mg (base equiv) 2** Quantity limitation 30 per 30 days clopidogrel bisulfate tab 75 mg (base equiv) 2** Quantity limitation 30 per 30 days EFFIENT TAB10MG 4 Quantity limitation 30 per 30 days EFFIENT TAB5MG 4 Quantity limitation 30 per 30 days ERWINAZE INJ10000UNT 5 ONCASPAR INJ750/ML 5 ticlopidine hcl tab 250 mg 1* CARDIOVASCULAR AGENTS Alpha-adrenergic Agonists.. 110 *We provide additional coverage of this drug in the coverage gap for Medicare

clonidine hcl tab 0.1 mg 1* clonidine hcl tab 0.2 mg 1* clonidine hcl tab 0.3 mg 1* clonidine hcl td patch weekly 0.1 mg/24hr 2** Quantity limitation 4 per 28 days clonidine hcl td patch weekly 0.2 mg/24hr 2** Quantity limitation 4 per 28 days clonidine hcl td patch weekly 0.3 mg/24hr 2** Quantity limitation 4 per 28 days guanfacine hcl tab 1 mg 1* guanfacine hcl tab 2 mg 1* methyldopa & hydrochlorothiazide tab 250-15 mg 1* methyldopa & hydrochlorothiazide tab 250-25 mg 1* methyldopa tab 250 mg 1* methyldopa tab 500 mg 1* methyldopate hcl inj 250 mg/5ml 4 midodrine hcl tab 10 mg 1* midodrine hcl tab 2.5 mg 1* midodrine hcl tab 5 mg 1* Alpha-adrenergic Blocking Agents doxazosin mesylate tab 1 mg 1* Quantity limitation 30 per 30 days doxazosin mesylate tab 2 mg 1* Quantity limitation 30 per 30 days doxazosin mesylate tab 4 mg 1* Quantity limitation 30 per 30 days doxazosin mesylate tab 8 mg 1* Quantity limitation 60 per 30 days prazosin hcl cap 1 mg 1* prazosin hcl cap 2 mg 1* prazosin hcl cap 5 mg 1* RESERPINE TAB0.1MG 4 RESERPINE TAB0.25MG 4 terazosin hcl cap 1 mg 1* Quantity limitation 30 per 30 days terazosin hcl cap 10 mg 1* Quantity limitation 60 per 30 days 111 *We provide additional coverage of this drug in the coverage gap for Medicare

terazosin hcl cap 2 mg 1* Quantity limitation 30 per 30 days terazosin hcl cap 5 mg 1* Quantity limitation 30 per 30 days Angiotensin II Receptor Antagonists BENICAR TAB20MG 4 Quantity limitation 30 per 30 days BENICAR TAB40MG 4 Quantity limitation 30 per 30 days BENICAR TAB5MG 4 Quantity limitation 30 per 30 days BENICAR HCT TAB20-12.5 4 Quantity limitation 30 per 30 days BENICAR HCT TAB40-12.5 4 Quantity limitation 30 per 30 days BENICAR HCT TAB40-25MG 4 Quantity limitation 30 per 30 days candesartan cilexetilhydrochlorothiazide tab 16-12.5 mg 2** Quantity limitation 30 per 30 days candesartan cilexetilhydrochlorothiazide tab 32-12.5 mg 2** Quantity limitation 30 per 30 days candesartan cilexetilhydrochlorothiazide tab 32-25 mg 2** Quantity limitation 30 per 30 days eprosartan mesylate tab 600 mg 1* irbesartan tab 150 mg 2** irbesartan tab 300 mg 2** irbesartan tab 75 mg 2** irbesartan-hydrochlorothiazide tab 150-12.5 mg 2** irbesartan-hydrochlorothiazide tab 300-12.5 mg 2** losartan potassium & hydrochlorothiazide tab 100-12.5 mg 1* Quantity limitation 30 per 30 days losartan potassium & hydrochlorothiazide tab 100-25 mg 1* Quantity limitation 30 per 30 days losartan potassium & hydrochlorothiazide tab 50-12.5 mg 1* Quantity limitation 30 per 30 days losartan potassium tab 100 mg 1* Quantity limitation 30 per 30 days losartan potassium tab 25 mg 1* Quantity limitation 30 per 30 days losartan potassium tab 50 mg 1* Quantity limitation 30 per 30 days Quantity limitation 30 per 30 days; TEKAMLO TAB150-10MG 4 Step therapy protocols apply TEKAMLO TAB150-5MG 4 Quantity limitation 30 per 30 days; 112 *We provide additional coverage of this drug in the coverage gap for Medicare

Step therapy protocols apply Quantity limitation 30 per 30 days; TEKAMLO TAB300-10MG 4 Step therapy protocols apply TEKAMLO TAB300-5MG 4 Quantity limitation 30 per 30 days; Step therapy protocols apply TEKTURNA TAB150MG 4 Quantity limitation 30 per 30 days; Step therapy protocols apply TEKTURNA TAB300MG 4 Quantity limitation 30 per 30 days; Step therapy protocols apply Quantity limitation 30 per 30 days; TEKTURNA HCTTAB150-12.5 4 Step therapy protocols apply TEKTURNA HCTTAB150-25MG 4 Quantity limitation 30 per 30 days; Step therapy protocols apply TEKTURNA HCTTAB300-12.5 4 Quantity limitation 30 per 30 days; Step therapy protocols apply TEKTURNA HCTTAB300-25MG 4 Quantity limitation 30 per 30 days; Step therapy protocols apply valsartan-hydrochlorothiazide tab 160-12.5 mg 2** Quantity limitation 30 per 30 days valsartan-hydrochlorothiazide tab 160-25 mg 2** Quantity limitation 30 per 30 days valsartan-hydrochlorothiazide tab 320-12.5 mg 2** Quantity limitation 30 per 30 days valsartan-hydrochlorothiazide tab 320-25 mg 2** Quantity limitation 30 per 30 days valsartan-hydrochlorothiazide tab 80-12.5 mg 2** Quantity limitation 30 per 30 days Angiotensin-converting Enzyme (ACE) Inhibitors benazepril & hydrochlorothiazide tab 10-12.5 mg 1* benazepril & hydrochlorothiazide tab 20-12.5 mg 1* benazepril & hydrochlorothiazide tab 20-25 mg 1* benazepril & hydrochlorothiazide tab 5-6.25 mg 1* benazepril hcl tab 10 mg 1* benazepril hcl tab 20 mg 1* benazepril hcl tab 40 mg 1* benazepril hcl tab 5 mg 1* captopril & hydrochlorothiazide 1* 113 *We provide additional coverage of this drug in the coverage gap for Medicare

tab 25-15 mg captopril & hydrochlorothiazide tab 25-25 mg 1* captopril & hydrochlorothiazide tab 50-15 mg 1* captopril & hydrochlorothiazide tab 50-25 mg 1* captopril tab 100 mg 1* captopril tab 12.5 mg 1* captopril tab 25 mg 1* captopril tab 50 mg 1* enalapril maleate & hydrochlorothiazide tab 10-25 mg 1* enalapril maleate & hydrochlorothiazide tab 5-12.5 mg 1* enalapril maleate tab 10 mg 1* enalapril maleate tab 2.5 mg 1* enalapril maleate tab 20 mg 1* enalapril maleate tab 5 mg 1* fosinopril sodium & hydrochlorothiazide tab 10-12.5 mg 1* fosinopril sodium & hydrochlorothiazide tab 20-12.5 mg 1* fosinopril sodium tab 10 mg 1* fosinopril sodium tab 20 mg 1* fosinopril sodium tab 40 mg 1* lisinopril & hydrochlorothiazide tab 10-12.5 mg 1* lisinopril & hydrochlorothiazide tab 20-12.5 mg 1* lisinopril & hydrochlorothiazide tab 20-25 mg 1* lisinopril tab 10 mg 1* lisinopril tab 2.5 mg 1* lisinopril tab 20 mg 1* lisinopril tab 30 mg 1* lisinopril tab 40 mg 1* 114 *We provide additional coverage of this drug in the coverage gap for Medicare

lisinopril tab 5 mg 1* moexipril hcl tab 15 mg 1* moexipril hcl tab 7.5 mg 1* moexipril-hydrochlorothiazide tab 15-12.5 mg 1* moexipril-hydrochlorothiazide tab 15-25 mg 1* moexipril-hydrochlorothiazide tab 7.5-12.5 mg 1* quinapril hcl tab 10 mg 1* quinapril hcl tab 20 mg 1* quinapril hcl tab 40 mg 1* quinapril hcl tab 5 mg 1* quinapril-hydrochlorothiazide tab 10-12.5 mg 1* quinapril-hydrochlorothiazide tab 20-12.5 mg 1* quinapril-hydrochlorothiazide tab 20-25 mg 1* ramipril cap 1.25 mg 1* Quantity limitation 60 per 30 days ramipril cap 10 mg 1* Quantity limitation 60 per 30 days ramipril cap 2.5 mg 1* Quantity limitation 60 per 30 days ramipril cap 5 mg 1* Quantity limitation 60 per 30 days trandolapril tab 1 mg 1* trandolapril tab 2 mg 1* trandolapril tab 4 mg 1* Antiarrhythmics acebutolol hcl cap 200 mg 1* acebutolol hcl cap 400 mg 1* amiodarone hcl tab 100 mg 1* amiodarone hcl tab 200 mg 1* amiodarone hcl tab 400 mg 1* disopyramide phosphate cap 100 mg 1* disopyramide phosphate cap 150 mg 1* flecainide acetate tab 100 mg 1* flecainide acetate tab 150 mg 1* flecainide acetate tab 50 mg 1* mexiletine hcl cap 150 mg 1* mexiletine hcl cap 200 mg 1* 115 *We provide additional coverage of this drug in the coverage gap for Medicare

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

bisoprolol & hydrochlorothiazide tab 10-6.25 mg 1* bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg 1* bisoprolol & hydrochlorothiazide tab 5-6.25 mg 1* bisoprolol fumarate tab 10 mg 1* bisoprolol fumarate tab 5 mg 1* carvedilol tab 12.5 mg 1* Quantity limitation 60 per 30 days carvedilol tab 25 mg 1* Quantity limitation 60 per 30 days carvedilol tab 3.125 mg 1* Quantity limitation 60 per 30 days carvedilol tab 6.25 mg 1* Quantity limitation 60 per 30 days COREG CR CAP10MG 3 Quantity limitation 30 per 30 days COREG CR CAP20MG 3 Quantity limitation 30 per 30 days COREG CR CAP40MG 3 Quantity limitation 30 per 30 days COREG CR CAP80MG 3 Quantity limitation 30 per 30 days INNOPRAN XL CAP120MG 4 INNOPRAN XL CAP80MG 4 labetalol hcl tab 100 mg 1* labetalol hcl tab 200 mg 1* labetalol hcl tab 300 mg 1* LEVATOL TAB20MG 4 metoprolol & hydrochlorothiazide tab 100-25 mg 1* metoprolol & hydrochlorothiazide tab 100-50 mg 1* metoprolol & hydrochlorothiazide tab 50-25 mg 1* metoprolol succinate tab sr 24hr 100 mg 1* Quantity limitation 30 per 30 days metoprolol succinate tab sr 24hr 200 mg 1* Quantity limitation 60 per 30 days metoprolol succinate tab sr 24hr 25 mg 1* Quantity limitation 30 per 30 days metoprolol succinate tab sr 24hr 50 mg 1* Quantity limitation 30 per 30 days metoprolol tartrate inj 1 mg/ml 4 117 *We provide additional coverage of this drug in the coverage gap for Medicare

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

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

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

mg verapamil hcl cap sr 24hr 240 mg 1* verapamil hcl cap sr 24hr 300 mg 1* verapamil hcl cap sr 24hr 360 mg 1* verapamil hcl iv soln 2.5 mg/ml 4 verapamil hcl tab 120 mg 1* verapamil hcl tab 40 mg 1* verapamil hcl tab 80 mg 1* verapamil hcl tab cr 120 mg 1* verapamil hcl tab cr 180 mg 1* verapamil hcl tab cr 240 mg 1* Cardiovascular Agents, Other DIGOXIN SOL50MCG/ML 4 digoxin inj 0.25 mg/ml 4 digoxin tab 0.125 mg 1* digoxin tab 0.25 mg 1* pentoxifylline tab cr 400 mg 1* RANEXA TAB1000MG 3 Quantity limitation 120 per 30 days RANEXA TAB500MG 3 Quantity limitation 120 per 30 days Diuretics, Carbonic Anhydrase Inhibitors acetazolamide cap sr 12hr 500 mg 1* acetazolamide sodium for inj 500 mg 4 acetazolamide tab 125 mg 1* acetazolamide tab 250 mg 1* methazolamide tab 25 mg 1* methazolamide tab 50 mg 1* Diuretics, Loop amiloride & hydrochlorothiazide tab 5-50 mg 1* amiloride hcl tab 5 mg 1* 121 *We provide additional coverage of this drug in the coverage gap for Medicare

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

hydrochlorothiazide tab 25-25 mg triamterene & hydrochlorothiazide cap 37.5-25 mg 1* triamterene & hydrochlorothiazide tab 37.5-25 mg 1* triamterene & hydrochlorothiazide tab 75-50 mg 1* Dyslipidemics, Fibric Acid Derivatives fenofibrate micronized cap 134 mg 2** Quantity limitation 30 per 30 days fenofibrate micronized cap 200 mg 2** Quantity limitation 30 per 30 days fenofibrate micronized cap 67 mg 2** Quantity limitation 30 per 30 days fenofibrate tab 160 mg 2** Quantity limitation 30 per 30 days fenofibrate tab 54 mg 2** Quantity limitation 30 per 30 days gemfibrozil tab 600 mg 1* Dyslipidemics, HMG CoA Reductase Inhibitors atorvastatin calcium tab 10 mg (base equivalent) 1* Quantity limitation 30 per 30 days atorvastatin calcium tab 20 mg (base equivalent) 1* Quantity limitation 30 per 30 days atorvastatin calcium tab 40 mg (base equivalent) 1* Quantity limitation 30 per 30 days atorvastatin calcium tab 80 mg (base equivalent) 1* Quantity limitation 30 per 30 days Quantity limitation 30 per 30 days; CRESTOR TAB10MG 4 Step therapy protocols apply CRESTOR TAB20MG 4 Quantity limitation 30 per 30 days; Step therapy protocols apply Quantity limitation 30 per 30 days; CRESTOR TAB40MG 4 Step therapy protocols apply Quantity limitation 30 per 30 days; Step therapy protocols apply CRESTOR TAB5MG 4 lovastatin tab 10 mg 1* Quantity limitation 30 per 30 days lovastatin tab 20 mg 1* Quantity limitation 30 per 30 days lovastatin tab 40 mg 1* Quantity limitation 60 per 30 days 123 *We provide additional coverage of this drug in the coverage gap for Medicare

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

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

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

amphetaminedextroamphetamine tab 7.5 mg 2** dextroamphetamine sulfate tab 10 mg 2** dextroamphetamine sulfate tab 5 mg 2** INTUNIV TAB1MG 4 INTUNIV TAB2MG 4 INTUNIV TAB3MG 4 INTUNIV TAB4MG 4 STRATTERA CAP100MG 3 Quantity limitation 60 per 30 days STRATTERA CAP10MG 3 Quantity limitation 60 per 30 days STRATTERA CAP18MG 3 Quantity limitation 60 per 30 days STRATTERA CAP25MG 3 Quantity limitation 60 per 30 days STRATTERA CAP40MG 3 Quantity limitation 60 per 30 days STRATTERA CAP60MG 3 Quantity limitation 60 per 30 days STRATTERA CAP80MG 3 Quantity limitation 60 per 30 days Attention Deficit Hyperactivity Disorder Agents, Non-amphetamines dexmethylphenidate hcl tab 10 mg 2** Quantity limitation 90 per 30 days dexmethylphenidate hcl tab 2.5 mg 2** Quantity limitation 90 per 30 days dexmethylphenidate hcl tab 5 mg 2** Quantity limitation 90 per 30 days methylphenidate hcl tab 10 mg 2** methylphenidate hcl tab 20 mg 2** methylphenidate hcl tab 5 mg 2** methylphenidate hcl tab cr 20 mg 2** Central Nervous System, Other NUEDEXTA CAP20-10MG 4 Quantity limitation 60 per 30 days RILUTEK TAB50MG 3 XENAZINE TAB12.5MG 5 This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at 1-800-546-5677 24 hours a day- seven days ; This medication requires prior authorization. To 127 *We provide additional coverage of this drug in the coverage gap for Medicare

obtain an exception please call 1-800-546-5677 - 24 hours a dayseven days a week. TTY users should call 1- This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at 1-800-546-5677 24 hours a day- seven days ; This medication requires prior authorization. To obtain an exception please call 1-800-546-5677 - 24 hours a dayseven days a week. TTY users XENAZINE TAB25MG 5 should call 1- Multiple Sclerosis Agents AVONEX KIT30MCG 5 AVONEX PREFLKIT30MCG 5 BETASERON INJ0.3MG 3 COPAXONE KIT20MG/ML 5 Quantity limitation 4 per 28 days; Quantity limitation 4 per 28 days; Quantity limitation 15 per 30 days; 128 *We provide additional coverage of this drug in the coverage gap for Medicare

GILENYA CAP0.5MG 5 REBIF INJ22/0.5 5 Quantity limitation 12 per 30 days; REBIF INJ44/0.5 5 Quantity limitation 12 per 30 days; Quantity limitation 6 per 30 days; REBIF TITRTNSOLPACK 5 This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at 1-800-546-5677 24 hours a day- seven days ; This medication requires prior authorization. To obtain an exception please call 1-800-546-5677 - 24 hours a day- TYSABRI INJ 5 seven days a week. TTY users 129 *We provide additional coverage of this drug in the coverage gap for Medicare

should call 1- DENTAL AND ORAL AGENTS Dental and Oral Agents chlorhexidine gluconate soln 0.12% 1* chlorhexidine gluconate soln 0.12% 1* lidocaine hcl viscous soln 2% 1* pilocarpine hcl tab 5 mg 1* pilocarpine hcl tab 7.5 mg 1* triamcinolone acetonide dental paste 0.1% 1* DERMATOLOGICAL AGENTS Dermatological Agents 8-MOP CAP10MG 3 adapalene cream 0.1% 1* adapalene gel 0.1% 1* benzoyl peroxide-erythromycin gel 5-3% 2** calcipotriene cream 0.005% 2** calcipotriene oint 0.005% 2** calcipotriene soln 0.005% (50 mcg/ml) 2** clotrimazole w/ betamethasone cream 1-0.05% 1* 130 *We provide additional coverage of this drug in the coverage gap for Medicare

clotrimazole w/ betamethasone lotion 1-0.05% 1* DIFFERIN GEL0.3% 4 DIFFERIN LOT0.1% 4 ELIDEL CRE1% 3 fluorouracil cream 5% 1* Quantity limitation 30 per 30 days; imiquimod cream 5% 2 authorization for new starts only. To obtain an exception please call 1-800-546-5677 - 24 hours a dayseven days a week. TTY users should call 1- lactic acid (ammonium lactate) cream 12% 1* lactic acid (ammonium lactate) lotion 12% 1* lidocaine oint 5% 1* LIDODERM DIS5% 4 Quantity limitation 90 per 30 days OXSORALEN-ULCAP10MG 4 podofilox soln 0.5% 1* authorization for new starts only. To obtain an exception please call 1-800-546-5677 - 24 hours a dayseven days a week. TTY users should call 1- Quantity limitation 30 per 30 days; authorization for new starts only. To obtain an exception please call 1-800-546-5677 - 24 hours a day- PROTOPIC OIN0.03% 4 seven days a week. TTY users 131 *We provide additional coverage of this drug in the coverage gap for Medicare

should call 1- Quantity limitation 30 per 30 days; authorization for new starts only. To obtain an exception please call 1-800-546-5677 - 24 hours a dayseven days a week. TTY users PROTOPIC OIN0.1% 4 should call 1- SANTYL OIN250/GM 3 Quantity limitation 30 per 30 days selenium sulfide lotion 2.5% 1* SOLARAZE GEL3% W/W 3 Quantity limitation 100 per 30 days; This medication requires prior SORIATANE CAP10MG 4 Quantity limitation 60 per 30 days SORIATANE CAP17.5MG 4 Quantity limitation 60 per 30 days SORIATANE CAP25MG 4 Quantity limitation 60 per 30 days TAZORAC CRE0.05% 4 TAZORAC CRE0.1% 4 TAZORAC GEL0.05% 4 TAZORAC GEL0.1% 4 VOLTAREN GEL1% 4 Step therapy protocols apply ENZYME REPLACEMENTS/ MODIFIERS Enzyme Replacements/ Modifiers ADAGEN INJ250/ML 5 This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at 1-800-546-5677 24 hours a day- seven days ; This medication requires prior authorization. To obtain an exception please call 1-800-546-5677 - 24 hours a dayseven days a week. TTY users should call 1- ALDURAZYME INJ2.9MG/5M 5 132 *We provide additional coverage of this drug in the coverage gap for Medicare

BUPHENYL POW 4 BUPHENYL TAB500MG 4 CEREZYME INJ200UNIT 5 CREON CAP12000UNT 3 CREON CAP24000UNT 3 CREON CAP3000UNIT 3 CREON CAP36000UNT 3 CREON CAP6000UNIT 3 CYSTADANE POW 4 CYSTAGON CAP150MG 4 CYSTAGON CAP50MG 4 This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at 1-800-546-5677 24 hours a day- seven days This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at 1-800-546-5677 24 hours a day- seven days ELAPRASE INJ6MG/3ML 5 FABRAZYME INJ35MG 5 133 *We provide additional coverage of this drug in the coverage gap for Medicare

KUVAN TAB100MG 5 This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at 1-800-546-5677 24 hours a day- seven days ; This medication requires prior authorization. To obtain an exception please call 1-800-546-5677 - 24 hours a dayseven days a week. TTY users should call 1- MYOZYME INJ50MG 5 This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at 1-800-546-5677 24 hours a day- seven days ; This medication requires prior authorization. To obtain an exception please call 1-800-546-5677 - 24 hours a dayseven days a week. TTY users NAGLAZYME INJ1MG/ML 5 should call 1- This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call ORFADIN CAP10MG 5 Member Services at 1-800-546-134 *We provide additional coverage of this drug in the coverage gap for Medicare

5677 24 hours a day- seven days ; This medication requires prior authorization. To obtain an exception please call 1-800-546-5677 - 24 hours a dayseven days a week. TTY users should call 1- This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at 1-800-546-5677 24 hours a day- seven days ; This medication requires prior authorization. To obtain an exception please call 1-800-546-5677 - 24 hours a dayseven days a week. TTY users ORFADIN CAP2MG 5 ORFADIN CAP5MG 5 PANCREAZE CAP10500UNT 4 PANCREAZE CAP16800UNT 4 PANCREAZE CAP21000UNT 4 PANCREAZE CAP4200UNIT 4 ZAVESCA CAP100MG 4 should call 1- This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at 1-800-546-5677 24 hours a day- seven days ; This medication requires prior authorization. To obtain an exception please call 1-800-546-5677 - 24 hours a dayseven days a week. TTY users should call 1- This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call 135 *We provide additional coverage of this drug in the coverage gap for Medicare

Member Services at 1-800-546-5677 24 hours a day- seven days ZENPEP CAP10000UNT 4 ZENPEP CAP15000UNT 4 ZENPEP CAP20000UNT 4 ZENPEP CAP25000UNT 4 ZENPEP CAP3000UNIT 4 ZENPEP CAP5000UNIT 4 GASTROINTESTINAL AGENTS Antispasmodics, Gastrointestinal atropine sulfate inj 0.1 mg/ml 4 CANTIL TAB25MG 4 dicyclomine hcl cap 10 mg 2** dicyclomine hcl oral soln 10 mg/5ml 2** dicyclomine hcl tab 20 mg 2** glycopyrrolate tab 1 mg 1* glycopyrrolate tab 2 mg 1* methscopolamine bromide tab 2.5 mg 1* methscopolamine bromide tab 5 mg 1* Gastrointestinal Agents, Other HELIDAC MIS 4 loperamide hcl cap 2 mg 2** peg 3350-kcl-sod bicarb-nacl for soln 420 gm 1* RELISTOR KIT12/0.6ML 4 136 *We provide additional coverage of this drug in the coverage gap for Medicare

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

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

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

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

0.05% clobetasol propionate oint 0.05% 1* clobetasol propionate shampoo 0.05% 1* clobetasol propionate soln 0.05% 1* desonide cream 0.05% 1* desonide lotion 0.05% 1* desonide oint 0.05% 1* desoximetasone cream 0.05% 1* desoximetasone gel 0.05% 1* desoximetasone oint 0.25% 1* diflorasone diacetate cream 0.05% 1* diflorasone diacetate oint 0.05% 1* fludrocortisone acetate tab 0.1 mg 1* fluocinolone acetonide cream 0.01% 1* fluocinolone acetonide cream 0.025% 1* fluocinolone acetonide oint 0.025% 1* fluocinolone acetonide soln 0.01% 1* fluocinonide emulsified base cream 0.05% 1* fluocinonide gel 0.05% 1* fluocinonide oint 0.05% 1* fluocinonide soln 0.05% 1* fluticasone propionate cream 0.05% 1* fluticasone propionate lotion 0.05% 1* fluticasone propionate oint 0.005% 1* halobetasol propionate cream 0.05% 1* halobetasol propionate oint 0.05% 1* HALOG CRE0.1% 4 141 *We provide additional coverage of this drug in the coverage gap for Medicare

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

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

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

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

HUMATROPE INJ24MG 5 HUMATROPE INJ5MG 5 HUMATROPE INJ6MG 5 INCRELEX INJ40MG/4ML 5 NORDITROPIN INJ10/1.5ML 5 NORDITROPIN INJ15/1.5ML 5 NORDITROPIN INJ30/3ML 5 NORDITROPIN INJ5/1.5ML 5 This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at 1-800-546-5677 24 hours a day- seven days ; This medication requires prior authorization. To obtain an exception please call 1-800-546-5677 - 24 hours a dayseven days a week. TTY users should call 1- NUTROPIN INJ10MG 5 146 *We provide additional coverage of this drug in the coverage gap for Medicare

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

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

Estrogens ALORA DIS0.025MG 3 Quantity limitation 8 per 28 days ALORA DIS0.05MG 3 Quantity limitation 8 per 28 days ALORA DIS0.075MG 3 Quantity limitation 8 per 28 days ALORA DIS0.1MG 3 Quantity limitation 8 per 28 days COMBIPATCH DIS.05/.14 4 COMBIPATCH DIS.05/.25 4 desogest-eth estrad & eth estrad tab 0.15-0.02/0.01 mg(21/5) 1* desogest-ethin est tab 0.1-0.025/0.125-0.025/0.15-0.025mg-mg 1* desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg 1* DUAVEE TAB0.45-20 3 Quantity limitation 300 per 30 days esterified estrogens tab 0.3 mg 4 esterified estrogens tab 0.625 mg 4 esterified estrogens tab 1.25 mg 4 esterified estrogens tab 2.5 mg 4 ESTRACE VAG CRE0.1MG/GM 4 estradiol tab 0.5 mg 1* estradiol tab 1 mg 1* estradiol tab 2 mg 1* ESTRING MIS2MG 4 Quantity limitation 1 per 90 days estropipate tab 0.75 mg 2** estropipate tab 1.5 mg 2** estropipate tab 3 mg 2** ethynodiol diacetate & ethinyl estradiol tab 1 mg-35 mcg 1* ethynodiol diacetate & ethinyl estradiol tab 1 mg-50 mcg 1* levonorgestrel & ethinyl estradiol (91-day) tab 0.15-0.03 mg 1* levonorgestrel & ethinyl estradiol tab 0.1 mg-20 mcg 1* levonorgestrel & ethinyl estradiol 1* 149 *We provide additional coverage of this drug in the coverage gap for Medicare

tab 0.15 mg-30 mcg levonorgestrel-eth estra tab 0.05-30/0.075-40/0.125-30mgmcg 1* norethindrone & ethinyl estradiol tab 0.4 mg-35 mcg 1* norethindrone & ethinyl estradiol tab 0.5 mg-35 mcg 1* norethindrone & ethinyl estradiol tab 1 mg-35 mcg 1* norethindrone ace & ethinyl estradiol tab 1 mg-20 mcg 1* norethindrone ace & ethinyl estradiol tab 1.5 mg-30 mcg 1* norethindrone ace & ethinyl estradiol-fe tab 1 mg-20 mcg 1* norethindrone ace & ethinyl estradiol-fe tab 1.5 mg-30 mcg 1* norethindrone acetate-ethinyl estradiol tab 1 mg-5 mcg 2** norethindrone ac-ethinyl estradfe tab 1-20/1-30/1-35 mg-mcg 1* norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35 mg-mcg 1* norethindrone-eth estradiol tab 0.5-35/1-35 mg-mcg (10/11) 1* norethindrone-eth estradiol tab 0.5-35/1-35/0.5-35 mg-mcg 1* norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg 1* norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35 mgmcg 1* norgestrel & ethinyl estradiol tab 0.3 mg-30 mcg 1* norgestrel & ethinyl estradiol tab 0.5 mg-50 mcg 1* NUVARING MIS 4 ORTHO EVRA DISWEEK 4 PREFEST TAB 3 PREMARIN TAB0.3MG 3 150 *We provide additional coverage of this drug in the coverage gap for Medicare

PREMARIN TAB0.45MG 3 PREMARIN TAB0.625MG 3 PREMARIN TAB0.9MG 3 PREMARIN TAB1.25MG 3 PREMARIN VAGCRE0.625MG 3 PREMPHASE TAB 3 PREMPRO TAB.625-2.5 3 PREMPRO TAB0.3-1.5 3 PREMPRO TAB0.45-1.5 3 PREMPRO TAB0.625-5 3 Progestins CRINONE GEL4% VAG 4 CRINONE GEL8% VAG 4 medroxyprogesterone acetate im susp 150 mg/ml 4 Quantity limitation 1 per 90 days medroxyprogesterone acetate tab 10 mg 1* medroxyprogesterone acetate tab 2.5 mg 1* medroxyprogesterone acetate tab 5 mg 1* MEGACE ES SUS625/5ML 4 megestrol acetate susp 40 mg/ml 1* megestrol acetate tab 20 mg 1* megestrol acetate tab 40 mg 1* norethindrone acetate tab 5 mg 1* norethindrone tab 0.35 mg 1* norethindrone tab 0.35 mg 1* Selective Estrogen Receptor Modifying Agents EVISTA TAB60MG 3 Quantity limitation 30 per 30 days HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (THYROID) Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) LEVOTHROID TAB100MCG 1* LEVOTHROID TAB112MCG 1* LEVOTHROID TAB125MCG 1* LEVOTHROID TAB137MCG 1* LEVOTHROID TAB150MCG 1* 151 *We provide additional coverage of this drug in the coverage gap for Medicare

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

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

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

This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at 1-800-546-5677 24 hours a day- seven days ; This medication requires prior authorization. To obtain an exception please call 1-800-546-5677 - 24 hours a dayseven days a week. TTY users SOMAVERT INJ10MG 5 should call 1- SOMAVERT INJ15MG 5 This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at 1-800-546-5677 24 hours a day- seven days ; This medication requires prior authorization. To obtain an exception please call 1-800-546-5677 - 24 hours a dayseven days a week. TTY users should call 1- SOMAVERT INJ20MG 5 This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at 1-800-546-5677 24 hours a day- seven days ; This medication requires prior authorization. To obtain an exception please call 1-800-546-5677 - 24 hours a dayseven days a week. TTY users should call 1- SYNAREL SOL2MG/ML 5 155 *We provide additional coverage of this drug in the coverage gap for Medicare

HORMONAL AGENTS, SUPPRESSANT (SEX HORMONES/MODIFIERS) Antiandrogens bicalutamide tab 50 mg 2 Quantity limitation 30 per 30 days flutamide cap 125 mg 1* NILANDRON TAB150MG 4 Quantity limitation 120 per 30 days; This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at 1-800- 546-5677 24 hours a day- seven days a week. TTY users should XTANDI CAP40MG 5 ZYTIGA TAB250MG 5 call 1- Quantity limitation 120 per 30 days; This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at 1-800- 546-5677 24 hours a day- seven days a week. TTY users should call 1- HORMONAL AGENTS, SUPPRESSANT (THYROID) Antithyroid Agents methimazole tab 10 mg 1* methimazole tab 5 mg 1* propylthiouracil tab 50 mg 1* methimazole tab 10 mg 1* IMMUNOLOGICAL AGENTS Immune Suppressants ASTAGRAF XL CAP0.5MG 4 156 *We provide additional coverage of this drug in the coverage gap for Medicare

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

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

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

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

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

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

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

tacrolimus cap 5 mg 2** Quantity limitation 60 per 30 days; ZORTRESS TAB0.25MG 4 ZORTRESS TAB0.5MG 5 Quantity limitation 60 per 30 days; Quantity limitation 60 per 30 days; ZORTRESS TAB0.75MG 5 Immunizing Agents, Passive CARIMUNE NF INJ3GM 5 GAMASTAN S/DINJ 3 164 *We provide additional coverage of this drug in the coverage gap for Medicare

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

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

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

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

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

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

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

naphazoline hcl ophth soln 0.1% 1* neomycin-bacitrac zn-polymyx 5(3.5)mg-400unt-10000unt op oin 1* neomycin-polymyxin b- gramicidin ophth soln 1* neomycin-polymyxindexamethasone ophth oint 0.1% 1* neomycin-polymyxindexamethasone ophth susp 0.1% 1* neomycin-polymyxin-hc ophth susp 1* polymyxin b-trimethoprim ophth soln 10000 unit/ml-0.1% 1* PRED-G SUSOP 4 PRED-G S.O.POINOP 4 proparacaine hcl ophth soln 0.5% 1* RESTASIS EMU0.05% 4 sulfacetamide sodiumprednisolone ophth oint 10-0.2% 4 sulfacetamide sodiumprednisolone ophth soln 10-0.23(0.25)% 1* TOBRADEX OIN0.3-0.1% 4 tobramycin-dexamethasone ophth susp 0.3-0.1% 1* Ophthalmic Anti-allergy Agents ALOCRIL SOL2% 4 ALOMIDE SOL0.1% OP 4 azelastine hcl ophth soln 0.05% 1* cromolyn sodium ophth soln 4% 1* PATANOL SOL0.1% OP 4 Ophthalmic Antiglaucoma Agents Quantity limitation 60 per 30 days; 172 *We provide additional coverage of this drug in the coverage gap for Medicare

apraclonidine hcl ophth soln 0.5% (base equivalent) 1* AZOPT SUS1% OP 4 betaxolol hcl ophth soln 0.5% 1* BETIMOL SOL0.25% 4 BETIMOL SOL0.5% 4 BETOPTIC-S SUS0.25% OP 4 brimonidine tartrate ophth soln 0.15% 1* brimonidine tartrate ophth soln 0.2% 1* carteolol hcl ophth soln 1% 1* dorzolamide hcl ophth soln 2% 1* dorzolamide hcl-timolol maleate ophth soln 22.3-6.8 mg/ml 1* IOPIDINE SOL1% OP 4 levobunolol hcl ophth soln 0.5% 1* metipranolol ophth soln 0.3% 1* PHOSPHOLINE SOL0.125%OP 4 PILOPINE HS GEL4% OP 4 timolol maleate ophth gel forming soln 0.25% 1* timolol maleate ophth gel forming soln 0.5% 1* timolol maleate ophth soln 0.25% 1* timolol maleate ophth soln 0.5% 1* Ophthalmic Anti-inflammatories ALREX SUS0.2% 4 bromfenac sodium ophth soln 0.09% (base equivalent) 1 dexamethasone sodium phosphate ophth soln 0.1% 1* diclofenac sodium ophth soln 0.1% 1* FLAREX SUS0.1% OP 4 flurbiprofen sodium ophth soln 0.03% 1* FML OIN0.1% OP 4 FML FORTE SUS0.25% OP 4 ketorolac tromethamine ophth 1* 173 *We provide additional coverage of this drug in the coverage gap for Medicare

soln 0.4% ketorolac tromethamine ophth soln 0.5% 1* LOTEMAX SUS0.5% 4 MAXIDEX SUS0.1% OP 4 NEVANAC SUS0.1% 4 PRED MILD SUS0.12% OP 4 prednisolone acetate ophth susp 1% 1* prednisolone sodium phosphate ophth soln 1% 1* VEXOL SUS1% OP 4 Ophthalmic Prostaglandin and Prostamide Analogs latanoprost ophth soln 0.005% 2** Quantity limitation 5 per 30 days LUMIGAN SOL0.01% 4 Quantity limitation 7.5 per 30 days OTIC AGENTS Otic Agents acetic acid otic soln 2% 1* CIPRO HC SUSOTIC 3 CIPRODEX SUS0.3-0.1% 4 COLY-MYCIN SSUSOTIC 4 hydrocortisone w/ acetic acid otic soln 1-2% 1* neomycin-polymyxin-hc otic soln 1% 1* neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000 unit/ml- 1% 1* RESPIRATORY TRACT AGENTS Antihistamines azelastine hcl nasal spray 137 mcg/spray (1 mg/ml) 1* Quantity limitation 30 per 30 days clemastine fumarate tab 2.68 mg 1* cyproheptadine hcl syrup 2 mg/5ml 2** cyproheptadine hcl tab 4 mg 2** levocetirizine dihydrochloride tab 5 mg 2** Anti-inflammatories, Inhaled Corticosteroids 174 *We provide additional coverage of this drug in the coverage gap for Medicare

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

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

days COMBIVENT AERRESPIMAT 3 EPIPEN 2-PAKINJ0.3MG 4 Quantity limitation 1 per 30 days EPIPEN-JR INJ2-PAK 4 Quantity limitation 1 per 30 days FORADIL CAPAEROLIZE 4 Quantity limitation 60 per 30 days metaproterenol sulfate syrup 10 mg/5ml 1* metaproterenol sulfate tab 10 mg 1* metaproterenol sulfate tab 20 mg 1* PROAIR HFA AER 4 Quantity limitation 17 per 30 days PROVENTIL AERHFA 4 Quantity limitation 13.4 per 30 days SEREVENT DISAER50MCG 3 Quantity limitation 60 per 30 days SYMBICORT AER160-4.5 4 Quantity limitation 10.2 per 30 days SYMBICORT AER80-4.5 4 Quantity limitation 6.9 per 30 days terbutaline sulfate inj 1 mg/ml 4 terbutaline sulfate tab 2.5 mg 1* terbutaline sulfate tab 5 mg 1* VENTOLIN HFAAER 3 Quantity limitation 36 per 30 days XOPENEX HFA AER 3 Quantity limitation 30 per 30 days Mast Cell Stabilizers cromolyn sodium soln nebu 20 mg/2ml 2** Pulmonary Antihypertensives ADCIRCA TAB20MG 5 Quantity limitation 60 per 30 days; 177 *We provide additional coverage of this drug in the coverage gap for Medicare

This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at 1-800-546-5677 24 hours a day- seven days ; This medication requires prior authorization. To obtain an exception please call 1-800-546-5677 - 24 hours a dayseven days a week. TTY users LETAIRIS TAB10MG 5 should call 1- LETAIRIS TAB5MG 5 This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at 1-800-546-5677 24 hours a day- seven days ; This medication requires prior authorization. To obtain an exception please call 1-800-546-5677 - 24 hours a dayseven days a week. TTY users should call 1- This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at 1-800-546-5677 24 hours a day- seven days ; This medication requires prior authorization. To obtain an exception please call 1-800-546-5677 - 24 hours a day- REMODULIN INJ10MG/ML 5 seven days a week. TTY users 178 *We provide additional coverage of this drug in the coverage gap for Medicare

should call 1- REMODULIN INJ1MG/ML 5 This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at 1-800-546-5677 24 hours a day- seven days ; This medication requires prior authorization. To obtain an exception please call 1-800-546-5677 - 24 hours a dayseven days a week. TTY users should call 1- REMODULIN INJ2.5MG/ML 5 This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at 1-800-546-5677 24 hours a day- seven days ; This medication requires prior authorization. To obtain an exception please call 1-800-546-5677 - 24 hours a dayseven days a week. TTY users should call 1- REMODULIN INJ5MG/ML 5 This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at 1-800-546-5677 24 hours a day- seven days ; This medication requires prior authorization. To obtain an exception please call 1-800-546-5677 - 24 hours a dayseven days a week. TTY users should call 1- This prescription may be available TRACLEER TAB125MG 5 only at certain pharmacies. For 179 *We provide additional coverage of this drug in the coverage gap for Medicare

more information consult your Pharmacy Directory or call Member Services at 1-800-546-5677 24 hours a day- seven days ; This medication requires prior authorization. To obtain an exception please call 1-800-546-5677 - 24 hours a dayseven days a week. TTY users should call 1- This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at 1-800-546-5677 24 hours a day- seven days ; This medication requires prior authorization. To obtain an exception please call 1-800-546-5677 - 24 hours a dayseven days a week. TTY users TRACLEER TAB62.5MG 5 should call 1- Respiratory Tract Agents, Other acetylcysteine inhal soln 10% 2** acetylcysteine inhal soln 20% 2** ARALAST NP INJ400MG 5 This prescription may be available only at certain pharmacies. For more information please call 1-180 *We provide additional coverage of this drug in the coverage gap for Medicare

800-546-5677 24 hours a dayseven days a week. TTY users should call 1-866-706-4757; This medication requires prior authorization for new starts only. DALIRESP TAB500MCG 4 Quantity limitation 30 per 30 days PULMOZYME SOL1MG/ML 5 tetrahydrozoline hcl nasal soln 0.05% 4 tetrahydrozoline hcl nasal soln 0.1% 4 XOLAIR SOL150MG 5 ZEMAIRA INJ1000MG 4 This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at 1-800-546-5677 24 hours a day- seven days ; This medication requires prior authorization. To obtain an exception please call 1-800-546-5677 - 24 hours a dayseven days a week. TTY users should call 1- This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at 1-800-546-5677 24 hours a day- seven days ; This medication requires prior authorization. To obtain an exception please call 1-800-546-5677 - 24 hours a dayseven days a week. TTY users should call 1-181 *We provide additional coverage of this drug in the coverage gap for Medicare

SKELETAL MUSCLE RELAXANTS Skeletal Muscle Relaxants carisoprodol tab 350 mg 2** cyclobenzaprine hcl tab 10 mg 2** cyclobenzaprine hcl tab 5 mg 2** SLEEP DISORDER AGENTS GABA Receptor Modulators zaleplon cap 10 mg 1* Quantity limitation 60 per 30 days zaleplon cap 5 mg 1* Quantity limitation 30 per 30 days zolpidem tartrate tab 10 mg 2** Quantity limitation 30 per 30 days zolpidem tartrate tab 5 mg 2** Quantity limitation 30 per 30 days zolpidem tartrate tab cr 12.5 mg 2** Quantity limitation 30 per 30 days zolpidem tartrate tab cr 6.25 mg 2** Quantity limitation 30 per 30 days Sleep Disorders, Other NUVIGIL TAB150MG 4 Quantity limitation 30 per 30 days NUVIGIL TAB250MG 4 Quantity limitation 30 per 30 days NUVIGIL TAB50MG 4 Quantity limitation 30 per 30 days ROZEREM TAB8MG 4 Quantity limitation 30 per 30 days; Step therapy protocols apply XYREM SOL500MG/ML 4 This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at 1-800-546-5677 24 hours a day- seven days 182 *We provide additional coverage of this drug in the coverage gap for Medicare

; This medication requires prior authorization. To obtain an exception please call 1-800-546-5677 - 24 hours a dayseven days a week. TTY users should call 1- THERAPEUTIC NUTRIENTS/MINERALS/ELECTROLYTES Electrolyte/Mineral Modifiers EXJADE TAB125MG 4 EXJADE TAB500MG 5 levocarnitine oral soln 1 gm/10ml (10%) 1* levocarnitine tab 330 mg 1* sodium polystyrene sulfonate oral susp 15 gm/60ml 1* This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at 1-800-546-5677 24 hours a day- seven days ; This medication requires prior authorization. To obtain an exception please call 1-800-546-5677 - 24 hours a dayseven days a week. TTY users should call 1- This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at 1-800-546-5677 24 hours a day- seven days ; This medication requires prior authorization. To obtain an exception please call 1-800-546-5677 - 24 hours a dayseven days a week. TTY users should call 1-183 *We provide additional coverage of this drug in the coverage gap for Medicare

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

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

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

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

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

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

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

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

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

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

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

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

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

Index of Drugs Therapeutic Classes and Categories Therapeutic Categories are listed in Bold Therapeutic Classes are also listed in Bold 1st Generation/Typical... 84 2nd Generation/Atypical... 85 8-MOP CAP10MG... 130 abacavir sulfate tab 300 mg (base equiv)... 92 abacavir/lamivudine/zidovudine... 92 ABELCET INJ5MG/ML... 63 ABILIFY INJ9.75MG... 55 ABILIFY SOL1MG/ML... 55 ABILIFY TAB10MG... 55 ABILIFY TAB15MG... 55 ABILIFY TAB20MG... 55 ABILIFY TAB2MG... 55 ABILIFY TAB30MG... 55 ABILIFY TAB5MG... 56 ABILIFY DISCTAB10MG... 56 ABILIFY DISCTAB15MG... 56 ABILIFY MAININJ300MG... 56 acarbose tab 100 mg... 96 acarbose tab 25 mg... 96 acarbose tab 50 mg... 96 acebutolol hcl cap 200 mg... 115 acebutolol hcl cap 400 mg... 115 acetaminophen w/ codeine soln 120-12 mg/5ml... 31 acetaminophen w/ codeine tab 300-15 mg... 31 acetaminophen w/ codeine tab 300-30 mg... 31 acetaminophen w/ codeine tab 300-60 mg... 31 acetaminophen-caffeine-dihydrocodeine tab 712.8-60-32 mg... 31 acetazolamide cap sr 12hr 500 mg.. 121 acetazolamide sodium for inj 500 mg121 acetazolamide tab 125 mg... 121 acetazolamide tab 250 mg... 121 acetic acid otic soln 2%... 174 acetylcysteine inhal soln 10%... 180 acetylcysteine inhal soln 20%... 180 ACTHIB INJ... 165 ACTIMMUNE INJ2MU/0.5... 165 ACTONEL TAB150MG... 168 ACTONEL TAB35MG... 168 ACTONEL TAB5MG... 168 acyclovir cap 200 mg... 91 acyclovir oint 5%... 91 acyclovir sodium for inj 500 mg... 91 acyclovir susp 200 mg/5ml... 91 acyclovir tab 400 mg... 91 acyclovir tab 800 mg... 91 ADACEL INJ... 165 ADAGEN INJ250/ML... 132 adapalene cream 0.1%... 130 adapalene gel 0.1%... 130 ADCIRCA TAB20MG... 177 ADVAIR DISKUAER100/50... 176 ADVAIR DISKUAER250/50... 176 ADVAIR DISKUAER500/50... 176 ADVAIR HFA AER115/21... 176 ADVAIR HFA AER230/21... 176 ADVAIR HFA AER45/21... 176 AFINITOR TAB10MG... 71 AFINITOR TAB2.5MG... 71 AFINITOR TAB5MG... 71 AFINITOR TAB7.5MG... 71 AFINITOR DISTAB2MG... 71 AFINITOR DISTAB3MG... 71 AFINITOR DISTAB5MG... 71 AGGRENOX CAP25-200MG... 110 ALBENZA TAB200MG... 81 albuterol sulfate soln nebu 0.083% (2.5 mg/3ml)... 176 albuterol sulfate soln nebu 0.5% (5 mg/ml)... 176 albuterol sulfate soln nebu 0.63 mg/3ml (base equiv)... 176 albuterol sulfate soln nebu 1.25 mg/3ml (base equiv)... 176 albuterol sulfate syrup 2 mg/5ml... 176 197

albuterol sulfate tab 2 mg... 176 albuterol sulfate tab 4 mg... 176 albuterol sulfate tab sr 12hr 4 mg... 176 albuterol sulfate tab sr 12hr 8 mg... 176 alclometasone dipropionate cream 0.05%... 140 alclometasone dipropionate oint 0.05%... 140 Alcohol Deterrents/Anti-craving... 34 ALCOHOL PREPPAD... 98 ALDURAZYME INJ2.9MG/5M... 132 alendronate sodium tab 10 mg... 168 alendronate sodium tab 35 mg... 168 alendronate sodium tab 40 mg... 168 alendronate sodium tab 5 mg... 168 alendronate sodium tab 70 mg... 168 alfuzosin hcl tab sr 24hr 10 mg... 139 ALIMTA INJ500MG... 71 ALINIA SUS100MG/5M... 81 ALINIA TAB500MG... 81 Alkylating Agents... 68 allopurinol tab 100 mg... 66 allopurinol tab 300 mg... 66 ALOCRIL SOL2%... 172 ALOMIDE SOL0.1% OP... 172 ALORA DIS0.025MG... 149 ALORA DIS0.05MG... 149 ALORA DIS0.075MG... 149 ALORA DIS0.1MG... 149 ALOXI INJ0.25MG/5... 61 Alpha-adrenergic Agonists... 110 Alpha-adrenergic Blocking Agents... 111 alprazolam orally disintegrating tab 0.25 mg... 94 alprazolam orally disintegrating tab 0.5 mg... 94 alprazolam orally disintegrating tab 1 mg... 94 alprazolam orally disintegrating tab 2 mg... 94 alprazolam tab 0.25 mg... 94 alprazolam tab 0.5 mg... 94 alprazolam tab 1 mg... 94 alprazolam tab 2 mg... 94 alprazolam tab sr 24hr 0.5 mg... 94 alprazolam tab sr 24hr 1 mg... 94 alprazolam tab sr 24hr 2 mg... 94 alprazolam tab sr 24hr 3 mg... 94 ALREX SUS0.2%... 173 amantadine hcl cap 100 mg... 82 amantadine hcl syrup 50 mg/5ml... 82 amantadine hcl tab 100 mg... 82 amcinonide cream 0.1%... 140 amcinonide lotion 0.1%... 140 amcinonide oint 0.1%... 140 amifostine crystalline for inj 500 mg... 71 amiloride & hydrochlorothiazide tab 5-50 mg... 121 amiloride hcl tab 5 mg... 121 Aminoglycosides... 35 Aminosalicylates... 167 aminosalicylic acid cr granules packet 4 gm... 67 AMINOSYN INJ8.5/LYTE... 184 AMINOSYN II INJ10%... 184 AMINOSYN II INJ7%... 184 AMINOSYN II INJ8.5%... 184 AMINOSYN II INJ8.5/LYTE... 184 AMINOSYN M INJ3.5%... 184 AMINOSYN-HBCINJ7%... 185 AMINOSYN-PF INJ10%... 185 AMINOSYN-PF INJ7%... 185 amiodarone hcl tab 100 mg... 115 amiodarone hcl tab 200 mg... 115 amiodarone hcl tab 400 mg... 115 AMITIZA CAP24MCG... 138 AMITIZA CAP8MCG... 138 amitriptyline hcl tab 10 mg... 59 amitriptyline hcl tab 100 mg... 59 amitriptyline hcl tab 150 mg... 59 amitriptyline hcl tab 25 mg... 59 amitriptyline hcl tab 50 mg... 59 amitriptyline hcl tab 75 mg... 59 amlodipine besylate tab 10 mg... 119 amlodipine besylate tab 2.5 mg... 119 amlodipine besylate tab 5 mg... 119 amlodipine besylate-benazepril hcl cap 10-20 mg... 119 amlodipine besylate-benazepril hcl cap 10-40 mg... 119 198

amlodipine besylate-benazepril hcl cap 2.5-10 mg... 119 amlodipine besylate-benazepril hcl cap 5-10 mg... 119 amlodipine besylate-benazepril hcl cap 5-20 mg... 119 amlodipine besylate-benazepril hcl cap 5-40 mg... 119 amoxapine tab 100 mg... 59 amoxapine tab 150 mg... 59 amoxapine tab 25 mg... 59 amoxapine tab 50 mg... 59 amoxicillin & k clavulanate chew tab 200-28.5 mg... 43 amoxicillin & k clavulanate chew tab 400-57 mg... 43 amoxicillin & k clavulanate for susp 200-28.5 mg/5ml... 43 amoxicillin & k clavulanate for susp 250-62.5 mg/5ml... 43 amoxicillin & k clavulanate for susp 400-57 mg/5ml... 43 amoxicillin & k clavulanate for susp 600-42.9 mg/5ml... 43 amoxicillin & k clavulanate tab 250-125 mg... 43 amoxicillin & k clavulanate tab 500-125 mg... 43 amoxicillin & k clavulanate tab 875-125 mg... 43 amoxicillin & k clavulanate tab sr 12hr 1000-62.5 mg... 44 amoxicillin (trihydrate) cap 250 mg... 44 amoxicillin (trihydrate) cap 500 mg... 44 amoxicillin (trihydrate) chew tab 125 mg... 44 amoxicillin (trihydrate) chew tab 250 mg... 44 amoxicillin (trihydrate) for susp 125 mg/5ml... 44 amoxicillin (trihydrate) for susp 200 mg/5ml... 44 amoxicillin (trihydrate) for susp 250 mg/5ml... 44 amoxicillin (trihydrate) for susp 400 mg/5ml... 44 amoxicillin (trihydrate) tab 500 mg... 44 amoxicillin (trihydrate) tab 875 mg... 44 amphetamine-dextroamphetamine cap sr 24hr 10 mg... 126 amphetamine-dextroamphetamine cap sr 24hr 15 mg... 126 amphetamine-dextroamphetamine cap sr 24hr 20 mg... 126 amphetamine-dextroamphetamine cap sr 24hr 25 mg... 126 amphetamine-dextroamphetamine cap sr 24hr 30 mg... 126 amphetamine-dextroamphetamine cap sr 24hr 5 mg... 126 amphetamine-dextroamphetamine tab 10 mg... 126 amphetamine-dextroamphetamine tab 12.5 mg... 126 amphetamine-dextroamphetamine tab 15 mg... 126 amphetamine-dextroamphetamine tab 20 mg... 126 amphetamine-dextroamphetamine tab 30 mg... 126 amphetamine-dextroamphetamine tab 5 mg... 126 amphetamine-dextroamphetamine tab 7.5 mg... 127 amphotericin b for inj 50 mg... 63 ampicillin & sulbactam sodium for inj 2-1 gm... 44 ampicillin & sulbactam sodium for iv soln 10-5 gm... 44 ampicillin cap 250 mg... 44 ampicillin cap 500 mg... 44 ampicillin for susp 125 mg/5ml... 44 ampicillin for susp 250 mg/5ml... 44 ampicillin sodium for inj 1 gm... 44 ampicillin sodium for inj 125 mg... 45 ampicillin sodium for iv soln 10 gm... 45 Anabolic Steroids... 148 anagrelide hcl cap 0.5 mg... 105 anagrelide hcl cap 1 mg... 105 ANALGESICS... 26 Analgesics, Other... 26 anastrozole tab 1 mg... 76 199

ANDROGEL GEL1%(50MG)... 148 ANDROGEL GEL1.62%... 148 Androgens... 148 ANDROXY TAB10MG... 148 ANESTHETICS... 33 Angiotensin II Receptor Antagonists... 112 Angiotensin-converting Enzyme (ACE) Inhibitors... 113 Anthelmintics... 81 ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS... 34 Antiandrogens... 156 Antiangiogenic Agents... 69 Antiarrhythmics... 115 ANTIBACTERIALS... 35 Antibacterials, Other... 36 Anticholinergics... 82 Anticoagulants... 99 ANTICONVULSANTS... 50 Anticonvulsants, Other... 50 Anti-cytomegalovirus (CMV) Agents... 88 ANTIDEPRESSANTS... 55 Antidepressants, Other... 55 Antidiabetic Agents... 96 ANTIEMETICS... 60 Antiemetics, Other... 60 Antiestrogens/Modifiers... 70 ANTIFUNGALS... 63 ANTIGOUT AGENTS... 66 Antihepatitis Agents... 88 Antiherpetic Agents... 91 Antihistamines... 174 Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors 91 Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors... 92 Anti-HIV Agents, Other... 93 Anti-HIV Agents, Protease Inhibitors... 93 Anti-inflammatories, Inhaled Corticosteroids... 174 Anti-influenza Agents... 94 Antileukotrienes... 175 Antimetabolites... 70 ANTIMIGRAINE AGENTS... 66 ANTIMYASTHENIC AGENTS... 67 ANTIMYCOBACTERIALS... 67 Antimycobacterials, Other... 67 ANTINEOPLASTICS... 68 Antineoplastics, Other... 71 ANTIPARASITICS... 81 ANTIPARKINSON AGENTS... 82 Antiparkinson Agents, Other... 82 Antiprotozoals... 81 ANTIPSYCHOTICS... 84 Antispasmodics, Gastrointestinal 136 Antispasmodics, Urinary... 138 ANTISPASTICITY AGENTS... 88 Antithyroid Agents... 156 Antituberculars... 67 ANTIVIRALS... 88 ANXIOLYTICS... 94 Anxiolytics, Other... 94 ANZEMET INJ20MG/ML... 62 ANZEMET TAB100MG... 62 ANZEMET TAB50MG... 62 APIDRA INJSOLOSTAR... 98 APIDRA INJU-100... 99 APLENZIN TAB174MG... 56 APLENZIN TAB348MG... 56 APLENZIN TAB522MG... 56 APOKYN INJ10MG/ML... 82 apraclonidine hcl ophth soln 0.5% (base equivalent)... 173 APTIOM TAB200MG... 53 APTIOM TAB400MG... 53 APTIOM TAB600MG... 53 APTIOM TAB800MG... 53 APTIVUS CAP250MG... 93 APTIVUS SOL... 93 ARALAST NP INJ400MG... 180 ARANESP INJ100MCG... 105 ARANESP INJ150MCG... 105 ARANESP INJ200MCG... 105 ARANESP INJ25MCG... 105 ARANESP INJ300MCG... 105 ARANESP INJ40MCG... 105 ARANESP INJ500MCG... 106 ARANESP INJ60MCG... 106 200

ARCALYST INJ220MG... 165 ARCAPTA CAP75MCG... 176 Aromatase Inhibitors, 3rd Generation... 76 ARRANON INJ5MG/ML... 71 ARZERRA CON100/5ML... 79 ASMANEX 120 AER220MCG... 175 ASMANEX 30 AER110MCG... 175 ASMANEX 30 AER220MCG... 175 ASMANEX 60 AER220MCG... 175 ASTAGRAF XL CAP0.5MG... 156 ASTAGRAF XL CAP1MG... 157 ASTAGRAF XL CAP5MG... 157 atenolol & chlorthalidone tab 100-25 mg... 116 atenolol & chlorthalidone tab 50-25 mg... 116 atenolol tab 100 mg... 116 atenolol tab 25 mg... 116 atenolol tab 50 mg... 116 atorvastatin calcium tab 10 mg (base equivalent)... 123 atorvastatin calcium tab 20 mg (base equivalent)... 123 atorvastatin calcium tab 40 mg (base equivalent)... 123 atorvastatin calcium tab 80 mg (base equivalent)... 123 atovaquone-proguanil hcl tab 250-100 mg... 81 ATRIPLA TAB... 92 atropine sulfate inj 0.1 mg/ml... 136 ATROVENT HFAAER17MCG... 176 Attention Deficit Hyperactivity Disorder Agents, Amphetamines... 126 Attention Deficit Hyperactivity Disorder Agents, Nonamphetamines... 127 AVASTIN INJ... 80 AVELOX INJ... 48 AVINZA CAP120MG... 28 AVINZA CAP30MG... 28 AVINZA CAP45MG... 28 AVINZA CAP60MG... 28 AVINZA CAP75MG... 28 AVINZA CAP90MG... 28 AVODART CAP0.5MG... 139 AVONEX KIT30MCG... 128 AVONEX PREFLKIT30MCG... 128 AXERT TAB12.5MG... 67 AXERT TAB6.25MG... 67 azacitidine... 71 AZACTAM/DEX INJ1GM... 43 AZACTAM/DEX INJ2GM... 43 azathioprine tab 100 mg... 157 azathioprine tab 50 mg... 157 azathioprine tab 75 mg... 157 azelastine hcl nasal spray 137 mcg/spray (1 mg/ml)... 174 azelastine hcl ophth soln 0.05%... 172 AZILECT TAB0.5MG... 84 AZILECT TAB1MG... 84 azithromycin for susp 100 mg/5ml... 47 azithromycin for susp 200 mg/5ml... 47 azithromycin iv for soln 500 mg... 47 azithromycin tab 250 mg... 47 azithromycin tab 500 mg... 47 azithromycin tab 600 mg... 47 AZOPT SUS1% OP... 173 bacitracin intramuscular for soln 50000 unit... 36 bacitracin ophth oint 500 unit/gm... 37 bacitracin-polymyxin b ophth oint... 171 bacitracin-polymyxin-neomycin-hc ophth oint 1%... 171 baclofen tab 10 mg... 88 baclofen tab 20 mg... 88 balsalazide disodium cap 750 mg... 167 BANZEL SUS40MG/ML... 53 BANZEL TAB200MG... 53 BANZEL TAB400MG... 53 BARACLUDE SOL.05MG/ML... 88 BARACLUDE TAB0.5MG... 88 BARACLUDE TAB1MG... 89 BECONASE AQ SUS0.042%... 175 BELEODAQ INJ500MG... 72 benazepril & hydrochlorothiazide tab 10-12.5 mg... 113 benazepril & hydrochlorothiazide tab 20-12.5 mg... 113 201

benazepril & hydrochlorothiazide tab 20-25 mg... 113 benazepril & hydrochlorothiazide tab 5-6.25 mg... 113 benazepril hcl tab 10 mg... 113 benazepril hcl tab 20 mg... 113 benazepril hcl tab 40 mg... 113 benazepril hcl tab 5 mg... 113 BENICAR TAB20MG... 112 BENICAR TAB40MG... 112 BENICAR TAB5MG... 112 BENICAR HCT TAB20-12.5... 112 BENICAR HCT TAB40-12.5... 112 BENICAR HCT TAB40-25MG... 112 Benign Prostatic Hypertrophy Agents... 139 benzoyl peroxide-erythromycin gel 5-3%... 130 benztropine mesylate tab 0.5 mg... 82 benztropine mesylate tab 1 mg... 82 benztropine mesylate tab 2 mg... 82 BESIVANCE SUS0.6%... 48 Beta-adrenergic Blocking Agents. 116 Beta-lactam, Cephalosporins... 39 Beta-lactam, Other... 43 Beta-lactam, Penicillins... 43 betamethasone dipropionate augmented cream 0.05%... 140 betamethasone dipropionate augmented gel 0.05%... 140 betamethasone dipropionate augmented lotion 0.05%... 140 betamethasone dipropionate augmented oint 0.05%... 140 betamethasone dipropionate cream 0.05%... 140 betamethasone dipropionate lotion 0.05%... 140 betamethasone dipropionate oint 0.05%... 140 betamethasone valerate cream 0.1%... 140 betamethasone valerate lotion 0.1% 140 betamethasone valerate oint 0.1%... 140 BETASERON INJ0.3MG... 128 betaxolol hcl ophth soln 0.5%... 173 betaxolol hcl tab 10 mg... 116 betaxolol hcl tab 20 mg... 116 bethanechol chloride tab 10 mg... 139 bethanechol chloride tab 25 mg... 139 bethanechol chloride tab 5 mg... 139 bethanechol chloride tab 50 mg... 139 BETIMOL SOL0.25%... 173 BETIMOL SOL0.5%... 173 BETOPTIC-S SUS0.25% OP... 173 bicalutamide tab 50 mg... 156 BILTRICIDE TAB600MG... 81 BIPOLAR AGENTS... 96 Bipolar Agents, Other... 96 bisoprolol & hydrochlorothiazide tab 10-6.25 mg... 117 bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg... 117 bisoprolol & hydrochlorothiazide tab 5-6.25 mg... 117 bisoprolol fumarate tab 10 mg... 117 bisoprolol fumarate tab 5 mg... 117 bleomycin sulfate for inj 30 unit... 72 BLEPHAMIDE SUSOP... 171 Blood Formation Modifiers... 105 Blood Formation Products... 105 BLOOD GLUCOSE REGULATORS.. 96 BLOOD PRODUCTS/MODIFIERS/ VOLUME EXPANDERS... 99 BONIVA INJ3MG/3ML... 168 BOOSTRIX INJ... 165 BOSULIF TAB100MG... 77 BOSULIF TAB500MG... 77 brimonidine tartrate ophth soln 0.15%... 173 brimonidine tartrate ophth soln 0.2% 173 BRINTELLIX TAB10MG... 56 BRINTELLIX TAB20MG... 56 BRINTELLIX TAB5MG... 56 bromfenac sodium ophth soln 0.09% (base equivalent)... 173 bromocriptine mesylate cap 5 mg... 83 bromocriptine mesylate tab 2.5 mg... 83 Bronchodilators, Anticholinergic.. 176 Bronchodilators, Phosphodiesterase Inhibitors (Xanthines)... 176 202

Bronchodilators, Sympathomimetic... 176 budesonide cap sr 24hr 3 mg... 167 bumetanide tab 0.5 mg... 122 bumetanide tab 1 mg... 122 bumetanide tab 2 mg... 122 BUPHENYL POW... 133 BUPHENYL TAB500MG... 133 buprenorphine hcl inj 0.3 mg/ml (base equiv)... 34 buprenorphine hcl sl tab 2 mg (base equiv)... 34 buprenorphine hcl sl tab 8 mg (base equiv)... 34 buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg (base equiv)... 34 buprenorphine hcl-naloxone hcl sl tab 8-2 mg (base equiv)... 34 bupropion hcl (smoking deterrent) tab sr 12hr 150 mg... 35 bupropion hcl tab 100 mg... 56 bupropion hcl tab 75 mg... 56 bupropion hcl tab sr 12hr 100 mg... 56 bupropion hcl tab sr 12hr 150 mg... 56 bupropion hcl tab sr 12hr 200 mg... 56 bupropion hcl tab sr 24hr 150 mg... 56 bupropion hcl tab sr 24hr 300 mg... 56 buspirone hcl tab 10 mg... 94 buspirone hcl tab 15 mg... 94 buspirone hcl tab 30 mg... 94 buspirone hcl tab 5 mg... 94 buspirone hcl tab 7.5 mg... 94 butalbital-acetaminophen tab 50-325 mg... 26 butalbital-acetaminophen tab 50-650 mg... 26 butalbital-acetaminophen-caff w/ cod cap 50-325-40-30 mg... 31 butalbital-acetaminophen-caffeine cap 50-325-40 mg... 26 butalbital-acetaminophen-caffeine soln 50-325-40 mg/15ml... 26 butalbital-acetaminophen-caffeine tab 50-325-40 mg... 26 butalbital-acetaminophen-caffeine tab 50-500-40 mg... 26 butalbital-aspirin-caff w/ codeine cap 50-325-40-30 mg... 31 butalbital-aspirin-caffeine cap 50-325-40 mg... 26 butalbital-aspirin-caffeine tab 50-325-40 mg... 26 butorphanol tartrate nasal soln 10 mg/ml... 31 BYETTA INJ10MCG... 96 BYETTA INJ5MCG... 96 cabergoline tab 0.5 mg... 153 calcipotriene cream 0.005%... 130 calcipotriene oint 0.005%... 130 calcipotriene soln 0.005% (50 mcg/ml)... 130 calcitonin (salmon) nasal soln 200 unit/act... 169 calcitriol cap 0.25 mcg... 169 calcitriol cap 0.5 mcg... 169 calcitriol inj 1 mcg/ml... 169 calcitriol oral soln 1 mcg/ml... 169 calcium acetate (phosphate binder) cap 667 mg (169 mg ca)... 139 Calcium Channel Blocking Agents 119 Calcium Channel Modifying Agents 51 CAMPRAL TAB333MG... 34 CANASA SUP1000MG... 167 CANCIDAS INJ50MG... 64 CANCIDAS INJ70MG... 64 candesartan cilexetilhydrochlorothiazide tab 16-12.5 mg... 112 candesartan cilexetilhydrochlorothiazide tab 32-12.5 mg... 112 candesartan cilexetilhydrochlorothiazide tab 32-25 mg. 112 CANTIL TAB25MG... 136 CAPASTAT SULINJ1GM... 67 CAPEX SHA0.01%... 140 CAPRELSA TAB100MG... 77 CAPRELSA TAB300MG... 77 captopril & hydrochlorothiazide tab 25-15 mg... 113 captopril & hydrochlorothiazide tab 25-25 mg... 114 203

captopril & hydrochlorothiazide tab 50-15 mg... 114 captopril & hydrochlorothiazide tab 50-25 mg... 114 captopril tab 100 mg... 114 captopril tab 12.5 mg... 114 captopril tab 25 mg... 114 captopril tab 50 mg... 114 carbamazepine cap sr 12hr 100 mg... 53 carbamazepine cap sr 12hr 200 mg... 53 carbamazepine cap sr 12hr 300 mg... 53 carbamazepine chew tab 100 mg... 53 carbamazepine susp 100 mg/5ml... 53 carbamazepine tab 200 mg... 53 carbamazepine tab sr 12hr 200 mg... 53 carbamazepine tab sr 12hr 400 mg... 53 carbidopa & levodopa orally disintegrating tab 10-100 mg... 83 carbidopa & levodopa orally disintegrating tab 25-100 mg... 84 carbidopa & levodopa orally disintegrating tab 25-250 mg... 84 carbidopa & levodopa tab 10-100 mg. 84 carbidopa & levodopa tab 25-100 mg. 84 carbidopa & levodopa tab 25-250 mg. 84 carbidopa & levodopa tab cr 25-100 mg... 84 carbidopa & levodopa tab cr 50-200 mg... 84 CARDIOVASCULAR AGENTS... 3, 110 Cardiovascular Agents, Other... 121 CARIMUNE NF INJ3GM... 164 carisoprodol tab 350 mg... 182 carteolol hcl ophth soln 1%... 173 carvedilol tab 12.5 mg... 117 carvedilol tab 25 mg... 117 carvedilol tab 3.125 mg... 117 carvedilol tab 6.25 mg... 117 CAVERJECT... 192 CAVERJECT INJ 20MCG, 40MCG.. 192 CEENU CAP10MG... 68 CEENU CAP40MG... 68 cefaclor cap 250 mg... 39 cefaclor cap 500 mg... 39 cefaclor monohydrate tab sr 12hr 500 mg... 39 cefadroxil cap 500 mg... 39 cefadroxil for susp 250 mg/5ml... 39 cefadroxil for susp 500 mg/5ml... 39 cefadroxil tab 1 gm... 39 cefazolin in d5w inj 1 gm/50ml... 39 cefazolin sodium for inj 1 gm... 39 cefazolin sodium for inj 10 gm... 40 cefazolin sodium for inj 500 mg... 40 cefdinir cap 300 mg... 40 cefdinir for susp 125 mg/5ml... 40 cefdinir for susp 250 mg/5ml... 40 cefepime hcl for inj 1 gm... 40 cefepime hcl for inj 2 gm... 40 cefoxitin sodium for inj 1 gm... 40 cefoxitin sodium for inj 10 gm... 41 cefoxitin sodium for inj 2 gm... 41 cefoxitin sodium iv for soln 1 gm and dextrose 4%... 41 cefoxitin sodium iv for soln 2 gm and dextrose 2.2%... 41 cefpodoxime proxetil for susp 100 mg/5ml... 41 cefpodoxime proxetil for susp 50 mg/5ml... 41 cefpodoxime proxetil tab 100 mg... 41 cefpodoxime proxetil tab 200 mg... 41 cefprozil for susp 125 mg/5ml... 41 cefprozil for susp 250 mg/5ml... 41 cefprozil tab 250 mg... 41 cefprozil tab 500 mg... 41 ceftriaxone sodium for inj 10 gm... 41 ceftriaxone sodium for inj 250 mg... 41 ceftriaxone sodium for inj 500 mg... 42 ceftriaxone sodium for iv soln 1 gm... 42 ceftriaxone sodium for iv soln 2 gm... 42 cefuroxime axetil tab 250 mg... 42 cefuroxime axetil tab 500 mg... 42 cefuroxime sodium for inj 1.5 gm... 42 cefuroxime sodium for inj 7.5 gm... 42 cefuroxime sodium for inj 750 mg... 42 CELEBREX CAP100MG... 26 CELEBREX CAP200MG... 26 CELEBREX CAP400MG... 26 CELEBREX CAP50MG... 26 CELESTONE SOL0.6MG/5... 167 CELLCEPT SUS200MG/ML... 157 204

CELLCEPT IV INJ500MG... 158 CELONTIN CAP300MG... 51 CENTRAL NERVOUS SYSTEM AGENTS... 126 Central Nervous System, Other... 127 cephalexin cap 250 mg... 42 cephalexin cap 500 mg... 43 cephalexin for susp 125 mg/5ml... 43 cephalexin for susp 250 mg/5ml... 43 cephalexin tab 250 mg... 43 cephalexin tab 500 mg... 43 CEREZYME INJ200UNIT... 133 CERVARIX INJ... 165 CHANTIX PAK0.5& 1MG... 35 CHANTIX TAB0.5MG... 35 CHANTIX TAB1MG... 35 chloramphenicol sodium succinate for iv inj 1 gm... 37 chlorhexidine gluconate soln 0.12%. 130 chloroquine phosphate tab 250 mg... 81 chloroquine phosphate tab 500 mg... 81 chlorothiazide tab 250 mg... 122 chlorothiazide tab 500 mg... 122 chlorpromazine hcl inj 25 mg/ml... 60 chlorpromazine hcl tab 10 mg... 60 chlorpromazine hcl tab 100 mg... 60 chlorpromazine hcl tab 200 mg... 60 chlorpromazine hcl tab 25 mg... 60 chlorpromazine hcl tab 50 mg... 60 chlorthalidone tab 25 mg... 122 chlorthalidone tab 50 mg... 122 cholestyramine light powder 4 gm/dose... 124 cholestyramine light powder packets 4 gm... 124 Cholinesterase Inhibitors... 54 CIALIS... 192 CIALIS 10MG AND 20MG... 192 ciclopirox gel 0.77%... 64 ciclopirox olamine cream 0.77% (base equiv)... 64 ciclopirox olamine susp 0.77% (base equiv)... 64 ciclopirox shampoo 1%... 64 ciclopirox solution 8%... 64 cilostazol tab 100 mg... 110 cilostazol tab 50 mg... 110 CILOXAN OIN0.3% OP... 48 cimetidine hcl soln 300 mg/5ml... 137 cimetidine tab 200 mg... 137 cimetidine tab 300 mg... 137 cimetidine tab 400 mg... 137 cimetidine tab 800 mg... 137 CIPRO HC SUSOTIC... 174 CIPRODEX SUS0.3-0.1%... 174 ciprofloxacin hcl ophth soln 0.3%... 48 ciprofloxacin hcl tab 100 mg (base equiv)... 48 ciprofloxacin hcl tab 250 mg (base equiv)... 48 ciprofloxacin hcl tab 500 mg (base equiv)... 48 ciprofloxacin hcl tab 750 mg (base equiv)... 48 ciprofloxacin-ciprofloxacin hcl tab sr 24hr 1000 mg(base eq)... 48 ciprofloxacin-ciprofloxacin hcl tab sr 24hr 500 mg (base eq)... 48 citalopram hydrobromide oral soln 10 mg/5ml... 57 citalopram hydrobromide tab 10 mg (base equiv)... 57 citalopram hydrobromide tab 20 mg (base equiv)... 58 citalopram hydrobromide tab 40 mg (base equiv)... 58 clarithromycin for susp 125 mg/5ml... 47 clarithromycin for susp 250 mg/5ml... 47 clarithromycin tab 250 mg... 47 clarithromycin tab 500 mg... 47 clarithromycin tab sr 24hr 500 mg... 47 clemastine fumarate tab 2.68 mg... 174 CLEOCIN SUP100MG... 37 clindamycin hcl cap 150 mg... 37 clindamycin hcl cap 300 mg... 37 clindamycin hcl cap 75 mg... 37 clindamycin phosphate foam 1%... 37 clindamycin phosphate gel 1%... 37 clindamycin phosphate in d5w iv soln 300 mg/50ml... 37 clindamycin phosphate in d5w iv soln 600 mg/50ml... 37 205

clindamycin phosphate in d5w iv soln 900 mg/50ml... 37 clindamycin phosphate iv soln 600 mg/4ml... 37 clindamycin phosphate lotion 1%... 37 clindamycin phosphate soln 1%... 37 clindamycin phosphate swab 1%... 37 clindamycin phosphate vaginal cream 2%... 37 clindamycin sol75mg/5ml... 37 clobetasol propionate emollient base cream 0.05%... 140 clobetasol propionate foam 0.05%... 140 clobetasol propionate gel 0.05%... 140 clobetasol propionate lotion 0.05%.. 140 clobetasol propionate oint 0.05%... 141 clobetasol propionate shampoo 0.05%... 141 clobetasol propionate soln 0.05%... 141 clomipramine hcl cap 25 mg... 59 clomipramine hcl cap 50 mg... 59 clomipramine hcl cap 75 mg... 59 clonazepam orally disintegrating tab 0.125 mg... 94 clonazepam orally disintegrating tab 0.25 mg... 94 clonazepam orally disintegrating tab 0.5 mg... 94 clonazepam orally disintegrating tab 1 mg... 95 clonazepam orally disintegrating tab 2 mg... 95 clonazepam tab 0.5 mg... 95 clonazepam tab 1 mg... 95 clonazepam tab 2 mg... 95 clonidine hcl tab 0.1 mg... 111 clonidine hcl tab 0.2 mg... 111 clonidine hcl tab 0.3 mg... 111 clonidine hcl td patch weekly 0.1 mg/24hr... 111 clonidine hcl td patch weekly 0.2 mg/24hr... 111 clonidine hcl td patch weekly 0.3 mg/24hr... 111 clopidogrel bisulfate tab 300 mg (base equiv)... 110 clopidogrel bisulfate tab 75 mg (base equiv)... 110 clorazepate dipotassium tab 15 mg... 95 clorazepate dipotassium tab 3.75 mg. 95 clorazepate dipotassium tab 7.5 mg... 95 clotrimazole cream 1%... 64 clotrimazole soln 1%... 64 clotrimazole troche 10 mg... 64 clotrimazole w/ betamethasone cream 1-0.05%... 130 clotrimazole w/ betamethasone lotion 1-0.05%... 131 clozapine tab 100 mg... 87 clozapine tab 200 mg... 87 clozapine tab 25 mg... 87 clozapine tab 50 mg... 88 Coagulants... 110 colchicine w/ probenecid tab 0.5-500 mg... 66 COLCRYS TAB0.6MG... 66 colestipol hcl granules 5 gm... 124 colestipol hcl tab 1 gm... 124 colistimethate sodium for inj 150 mg.. 37 COLY-MYCIN SSUSOTIC... 174 COMBIPATCH DIS.05/.14... 149 COMBIPATCH DIS.05/.25... 149 COMBIVENT AER... 176 COMBIVENT AERRESPIMAT... 177 COMETRIQ KIT100MG... 78 COMETRIQ KIT140MG... 78 COMETRIQ KIT60MG... 78 COMPLERA TAB... 92 COMTAN TAB200MG... 82 COMVAX INJ... 165 COPAXONE KIT20MG/ML... 128 COREG CR CAP10MG... 117 COREG CR CAP20MG... 117 COREG CR CAP40MG... 117 COREG CR CAP80MG... 117 cortisone acetate tab 25 mg... 167 COUMADIN INJ5 MG... 99 CREON CAP12000UNT... 133 CREON CAP24000UNT... 133 CREON CAP3000UNIT... 133 CREON CAP36000UNT... 133 CREON CAP6000UNIT... 133 206

CRESTOR TAB10MG... 123 CRESTOR TAB20MG... 123 CRESTOR TAB40MG... 123 CRESTOR TAB5MG... 123 CRINONE GEL4% VAG... 151 CRINONE GEL8% VAG... 151 CRIXIVAN CAP200MG... 93 CRIXIVAN CAP400MG... 93 cromolyn sodium ophth soln 4%... 172 cromolyn sodium soln nebu 20 mg/2ml... 177 cyclobenzaprine hcl tab 10 mg... 182 cyclobenzaprine hcl tab 5 mg... 182 CYCLOPHOSPH CAP25MG... 68 CYCLOPHOSPH CAP50MG... 68 cyclophosphamide tab 25 mg... 68 cyclophosphamide tab 50 mg... 68 cycloserine cap 250 mg... 68 CYCLOSET TAB0.8MG... 82 cyclosporine cap 100 mg... 158 cyclosporine cap 25 mg... 158 cyclosporine iv soln 50 mg/ml... 158 cyclosporine modified cap 100 mg... 158 cyclosporine modified cap 25 mg... 158 cyclosporine modified cap 50 mg... 159 cyclosporine modified oral soln 100 mg/ml... 159 CYKLOKAPRON INJ100MG/ML... 110 CYMBALTA CAP20MG... 58 CYMBALTA CAP30MG... 58 CYMBALTA CAP60MG... 58 cyproheptadine hcl syrup 2 mg/5ml.. 174 cyproheptadine hcl tab 4 mg... 174 CYSTADANE POW... 133 CYSTAGON CAP150MG... 133 CYSTAGON CAP50MG... 133 D10W/NACL INJ0.2%... 185 D10W/NACL INJ0.45%... 185 D5W/NACL INJ0.225%... 185 DACOGEN INJ50MG... 70 DALIRESP TAB500MCG... 181 danazol cap 100 mg... 148 danazol cap 200 mg... 148 danazol cap 50 mg... 148 dantrolene sodium cap 100 mg... 88 dantrolene sodium cap 25 mg... 88 dantrolene sodium cap 50 mg... 88 dapsone tab 100 mg... 67 dapsone tab 25 mg... 67 DAPTACEL INJ... 165 DARAPRIM TAB25MG... 81 decitabine inj50mg... 70 DELZICOL CAP400MG... 167 demeclocycline hcl tab 150 mg... 49 demeclocycline hcl tab 300 mg... 49 DENAVIR CRE1%... 91 DENTAL AND ORAL AGENTS... 130 DEPEN TITRA TAB250MG... 139 DERMATOLOGICAL AGENTS... 130 desipramine hcl tab 10 mg... 59 desipramine hcl tab 100 mg... 59 desipramine hcl tab 150 mg... 59 desipramine hcl tab 25 mg... 59 desipramine hcl tab 50 mg... 59 desipramine hcl tab 75 mg... 59 desmopressin acetate inj 4 mcg/ml.. 143 desmopressin acetate tab 0.1 mg... 144 desmopressin acetate tab 0.2 mg... 144 desogest-eth estrad & eth estrad tab 0.15-0.02/0.01 mg(21/5)... 149 desogest-ethin est tab 0.1-0.025/0.125-0.025/0.15-0.025mg-mg... 149 desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg... 149 desonide cream 0.05%... 141 desonide lotion 0.05%... 141 desonide oint 0.05%... 141 desoximetasone cream 0.05%... 141 desoximetasone gel 0.05%... 141 desoximetasone oint 0.25%... 141 DESVENLAFAXINE TAB100MG ER.. 58 DESVENLAFAXINE TAB50MG ER... 58 dexamethasone conc 1 mg/ml... 167 dexamethasone elixir 0.5 mg/5ml... 167 dexamethasone sodium phosphate inj 4 mg/ml... 167 dexamethasone sodium phosphate ophth soln 0.1%... 173 dexamethasone tab 0.5 mg... 168 dexamethasone tab 0.75 mg... 168 dexamethasone tab 1 mg... 168 dexamethasone tab 1.5 mg... 168 207

dexamethasone tab 2 mg... 168 dexamethasone tab 4 mg... 168 dexamethasone tab 6 mg... 168 dexmethylphenidate hcl tab 10 mg... 127 dexmethylphenidate hcl tab 2.5 mg.. 127 dexmethylphenidate hcl tab 5 mg... 127 dextroamphetamine sulfate tab 10 mg... 127 dextroamphetamine sulfate tab 5 mg 127 dextrose 2.5% w/ sodium chloride 0.45%... 186 dextrose 5% in lactated ringers... 186 dextrose 5% w/ sodium chloride 0.2%... 186 dextrose 5% w/ sodium chloride 0.33%... 186 dextrose 5% w/ sodium chloride 0.45%... 186 dextrose 5% w/ sodium chloride 0.9%... 186 dextrose inj 10%... 187 dextrose inj 5%... 187 DIASTAT ACUDIAL GEL 10MG... 95 DIASTAT ACUDIAL GEL 20MG... 95 DIASTAT PEDIATRIC GEL 2.5MG... 95 DIAZEPAM GEL10MG... 95 DIAZEPAM GEL2.5MG... 95 DIAZEPAM GEL20MG... 95 diazepam conc 5 mg/ml... 95 diazepam soln 1 mg/ml... 95 diazepam tab 10 mg... 95 diazepam tab 2 mg... 95 diazepam tab 5 mg... 95 diclofenac potassium tab 50 mg... 26 diclofenac sodium ophth soln 0.1%.. 173 diclofenac sodium tab delayed release 25 mg... 26 diclofenac sodium tab delayed release 50 mg... 26 diclofenac sodium tab delayed release 75 mg... 26 diclofenac sodium tab sr 24hr 100 mg 26 dicloxacillin sodium cap 250 mg... 45 dicloxacillin sodium cap 500 mg... 45 dicyclomine hcl cap 10 mg... 136 dicyclomine hcl oral soln 10 mg/5ml. 136 dicyclomine hcl tab 20 mg... 136 didanosine delayed release capsule 125 mg... 92 didanosine delayed release capsule 200 mg... 92 didanosine delayed release capsule 250 mg... 92 didanosine delayed release capsule 400 mg... 92 DIFFERIN GEL0.3%... 131 DIFFERIN LOT0.1%... 131 diflorasone diacetate cream 0.05%.. 141 diflorasone diacetate oint 0.05%... 141 diflunisal tab 500 mg... 26 DIGOXIN SOL50MCG/ML... 121 digoxin inj 0.25 mg/ml... 121 digoxin tab 0.125 mg... 121 digoxin tab 0.25 mg... 121 dihydroergotamine mesylate inj 1 mg/ml... 66 diltiazem hcl cap sr 12hr 120 mg... 119 diltiazem hcl cap sr 12hr 60 mg... 119 diltiazem hcl cap sr 12hr 90 mg... 119 diltiazem hcl cap sr 24hr 180 mg... 119 diltiazem hcl cap sr 24hr 240 mg... 119 diltiazem hcl coated beads cap sr 24hr 120 mg... 119 diltiazem hcl coated beads cap sr 24hr 180 mg... 119 diltiazem hcl coated beads cap sr 24hr 240 mg... 119 diltiazem hcl coated beads cap sr 24hr 300 mg... 119 diltiazem hcl extended release beads cap sr 24hr 120 mg... 119 diltiazem hcl extended release beads cap sr 24hr 180 mg... 119 diltiazem hcl extended release beads cap sr 24hr 240 mg... 119 diltiazem hcl extended release beads cap sr 24hr 300 mg... 120 diltiazem hcl extended release beads cap sr 24hr 360 mg... 120 diltiazem hcl extended release beads cap sr 24hr 420 mg... 120 diltiazem hcl tab 120 mg... 120 208

diltiazem hcl tab 30 mg... 120 diltiazem hcl tab 60 mg... 120 diltiazem hcl tab 90 mg... 120 DIPENTUM CAP250MG... 167 diphenhydramine hcl inj 50 mg/ml... 60 DIPHTHERIA/TETANUS INJ... 165 disopyramide phosphate cap 100 mg... 115 disopyramide phosphate cap 150 mg... 115 disulfiram tab 250 mg... 34 disulfiram tab 500 mg... 34 Diuretics, Carbonic Anhydrase Inhibitors... 121 Diuretics, Loop... 121 Diuretics, Potassium-sparing... 122 Diuretics, Thiazide... 122 divalproex sodium cap sprinkle 125 mg... 51 divalproex sodium tab delayed release 125 mg... 51 divalproex sodium tab delayed release 250 mg... 51 divalproex sodium tab delayed release 500 mg... 51 divalproex sodium tab sr 24 hr 250 mg... 66 divalproex sodium tab sr 24 hr 500 mg... 66 DOCEFREZ INJ20MG... 72 DOCEFREZ INJ80MG... 72 docetaxel for inj conc 80 mg/4ml (20 mg/ml)... 72 donepezil hydrochloride orally disintegrating tab 10 mg... 54 donepezil hydrochloride orally disintegrating tab 5 mg... 54 donepezil hydrochloride tab 10 mg... 54 donepezil hydrochloride tab 5 mg... 54 Dopamine Agonists... 82 Dopamine Precursors/L-Amino Acid Decarboxylase Inhibitors... 83 dorzolamide hcl ophth soln 2%... 173 dorzolamide hcl-timolol maleate ophth soln 22.3-6.8 mg/ml... 173 doxazosin mesylate tab 1 mg... 111 doxazosin mesylate tab 2 mg... 111 doxazosin mesylate tab 4 mg... 111 doxazosin mesylate tab 8 mg... 111 doxepin hcl cap 10 mg... 59 doxepin hcl cap 100 mg... 59 doxepin hcl cap 150 mg... 60 doxepin hcl cap 25 mg... 60 doxepin hcl cap 50 mg... 60 doxepin hcl cap 75 mg... 60 doxepin hcl conc 10 mg/ml... 60 doxycycline hyclate cap 100 mg... 49 doxycycline hyclate cap 50 mg... 49 doxycycline hyclate for inj 100 mg... 49 doxycycline hyclate tab 100 mg... 50 doxycycline hyclate tab 20 mg... 50 doxycycline hyclate tab delayed release 100 mg... 50 doxycycline hyclate tab delayed release 150 mg... 50 doxycycline hyclate tab delayed release 75 mg... 50 doxycycline monohydrate cap 75 mg. 50 doxycycline monohydrate tab 50 mg.. 50 doxycycline monohydrate tab 75 mg.. 50 dronabinol cap 10 mg... 62 dronabinol cap 2.5 mg... 62 dronabinol cap 5 mg... 62 DROXIA CAP200MG... 70 DROXIA CAP300MG... 70 DROXIA CAP400MG... 70 DRUG NAME... 26 DUAVEE TAB0.45-20... 149 duloxetine cap20mg... 58 duloxetine cap30mg... 58 duloxetine cap60mg... 58 dyphylline tab 200 mg... 176 dyphylline tab 400 mg... 176 Dyslipidemics... 123 Dyslipidemics, Fibric Acid Derivatives... 123 Dyslipidemics, HMG CoA Reductase Inhibitors... 123 Dyslipidemics, Other... 124 econazole nitrate cream 1%... 64 EDEX KIT... 193 EDEX KIT 20 MCG... 193 209

EDURANT TAB25MG... 91 EFFIENT TAB10MG... 110 EFFIENT TAB5MG... 110 ELAPRASE INJ6MG/3ML... 133 Electrolyte/Mineral Modifiers... 183 Electrolyte/Mineral Replacement.. 184 ELIDEL CRE1%... 131 ELITEK INJ1.5MG... 72 EMCYT CAP140MG... 68 EMEND CAP125MG... 62 EMEND CAP40MG... 62 EMEND CAP80MG... 63 EMEND PAK80 & 125... 63 Emetogenic Therapy Adjuncts... 61 EMSAM DIS12MG/24H... 57 EMSAM DIS6MG/24HR... 57 EMSAM DIS9MG/24HR... 57 EMTRIVA CAP200MG... 92 EMTRIVA SOL10MG/ML... 92 ENABLEX TAB15MG... 138 ENABLEX TAB7.5MG... 139 enalapril maleate & hydrochlorothiazide tab 10-25 mg... 114 enalapril maleate & hydrochlorothiazide tab 5-12.5 mg... 114 enalapril maleate tab 10 mg... 114 enalapril maleate tab 2.5 mg... 114 enalapril maleate tab 20 mg... 114 enalapril maleate tab 5 mg... 114 ENBREL INJ25/0.5ML... 159 ENBREL INJ25MG... 159 ENBREL INJ50MG/ML... 159 ENGERIX-B INJ10/0.5ML... 165 ENGERIX-B INJ20MCG/ML... 166 ENHANCED COVERAGE DRUGS.. 192 enoxaparin sodium inj 100 mg/ml... 99 enoxaparin sodium inj 120 mg/0.8ml 100 enoxaparin sodium inj 150 mg/ml... 100 enoxaparin sodium inj 30 mg/0.3ml.. 100 enoxaparin sodium inj 300 mg/3ml... 100 enoxaparin sodium inj 40 mg/0.4ml.. 100 enoxaparin sodium inj 60 mg/0.6ml.. 100 enoxaparin sodium inj 80 mg/0.8ml.. 100 Enzyme Inhibitors... 77 ENZYME REPLACEMENTS/ MODIFIERS... 132 EPIPEN 2-PAKINJ0.3MG... 177 EPIPEN-JR INJ2-PAK... 177 EPIVIR SOL10MG/ML... 92 EPIVIR HBV SOL5MG/ML... 89 EPIVIR HBV TAB100MG... 89 eplerenone tab 25 mg... 122 eplerenone tab 50 mg... 122 EPOGEN INJ10000/ML... 106 EPOGEN INJ2000/ML... 106 EPOGEN INJ20000/ML... 106 EPOGEN INJ3000/ML... 106 EPOGEN INJ4000/ML... 107 eprosartan mesylate tab 600 mg... 112 EPZICOM TAB600-300... 92 ERAXIS INJ100MG... 64 Ergot Alkaloids... 66 ergotamine w/ caffeine suppos 2-100 mg... 66 ERIVEDGE CAP150MG... 80 ERWINAZE INJ10000UNT... 110 ERYTHROCIN INJ500MG... 47 ERYTHROM ETHTAB400MG... 47 erythromycin gel 2%... 47 erythromycin ophth oint 5 mg/gm... 47 erythromycin pads 2%... 47 erythromycin soln 2%... 47 erythromycin stearate tab 250 mg... 47 erythromycin tab 250 mg... 48 erythromycin tab 500 mg... 48 erythromycin tab delayed release 250 mg... 48 erythromycin tab delayed release 333 mg... 48 erythromycin tab delayed release 500 mg... 48 escitalopram oxalate soln 5 mg/5ml (base equiv)... 58 escitalopram oxalate tab 10 mg (base equiv)... 58 escitalopram oxalate tab 20 mg (base equiv)... 58 escitalopram oxalate tab 5 mg (base equiv)... 58 esterified estrogens tab 0.3 mg... 149 esterified estrogens tab 0.625 mg... 149 esterified estrogens tab 1.25 mg... 149 210

esterified estrogens tab 2.5 mg... 149 ESTRACE VAG CRE0.1MG/GM... 149 estradiol tab 0.5 mg... 149 estradiol tab 1 mg... 149, 150 estradiol tab 2 mg... 149 ESTRING MIS2MG... 149 Estrogens... 149 estropipate tab 0.75 mg... 149 estropipate tab 1.5 mg... 149 estropipate tab 3 mg... 149 ethambutol hcl tab 100 mg... 68 ethambutol hcl tab 400 mg... 68 ethosuximide cap 250 mg... 51 ethosuximide soln 250 mg/5ml... 51 ethynodiol diacetate & ethinyl estradiol tab 1 mg-35 mcg... 149 ethynodiol diacetate & ethinyl estradiol tab 1 mg-50 mcg... 149 etidronate disodium tab 200 mg... 169 etidronate disodium tab 400 mg... 169 etodolac cap 200 mg... 26 etodolac cap 300 mg... 26 etodolac tab 400 mg... 26 etodolac tab 500 mg... 27 etodolac tab sr 24hr 400 mg... 27 etodolac tab sr 24hr 500 mg... 27 etodolac tab sr 24hr 600 mg... 27 ETOPOPHOS INJ100MG... 77 etoposide inj 20 mg/ml... 77 EURAX CRE10%... 82 EURAX LOT10%... 82 EVISTA TAB60MG... 151 EXELDERM CRE1%... 64 EXELDERM SOL1%... 64 EXELON DIS13.3/24... 54 EXELON DIS4.6MG/24... 55 EXELON DIS9.5MG/24... 55 EXELON SOL2MG/ML... 55 exemestane tab 25 mg... 76 EXJADE TAB125MG... 183 EXJADE TAB500MG... 183 FABRAZYME INJ35MG... 133 famciclovir tab 125 mg... 91 famciclovir tab 250 mg... 91 famciclovir tab 500 mg... 91 famotidine for susp 40 mg/5ml... 137 famotidine in nacl 0.9% iv soln 20 mg/50ml... 137 famotidine inj 10 mg/ml... 137 famotidine tab 20 mg... 137 famotidine tab 40 mg... 137 FANAPT PAK... 85 FANAPT TAB10MG... 85 FANAPT TAB12MG... 85 FANAPT TAB1MG... 85 FANAPT TAB2MG... 85 FANAPT TAB4MG... 85 FANAPT TAB6MG... 86 FANAPT TAB8MG... 86 FARESTON TAB60MG... 70 FASLODEX INJ250MG... 73 fat emulsion iv soln 20%... 187 FAZACLO TAB100/ODT... 88 FAZACLO TAB12.5/ODT... 88 FAZACLO TAB150MG... 88 FAZACLO TAB200MG... 88 FAZACLO TAB25MG ODT... 88 felbamate susp 600 mg/5ml... 52 felbamate tab 400 mg... 52 felbamate tab 600 mg... 52 felodipine tab sr 24hr 10 mg... 120 felodipine tab sr 24hr 2.5 mg... 120 felodipine tab sr 24hr 5 mg... 120 fenofibrate micronized cap 134 mg.. 123 fenofibrate micronized cap 200 mg.. 123 fenofibrate micronized cap 67 mg... 123 fenofibrate tab 160 mg... 123 fenofibrate tab 54 mg... 123 fenoprofen calcium tab 600 mg... 27 fentanyl citrate lollipop 1200 mcg... 28 fentanyl citrate lollipop 1600 mcg... 28 fentanyl citrate lollipop 200 mcg... 28 fentanyl citrate lollipop 400 mcg... 28 fentanyl citrate lollipop 600 mcg... 28 fentanyl citrate lollipop 800 mcg... 29 fentanyl td patch 72hr 100 mcg/hr... 29 fentanyl td patch 72hr 12 mcg/hr... 29 fentanyl td patch 72hr 25 mcg/hr... 29 fentanyl td patch 72hr 50 mcg/hr... 29 fentanyl td patch 72hr 75 mcg/hr... 29 FETZIMA CAP120... 58 FETZIMA CAP20... 58 211

FETZIMA CAP40... 58 FETZIMA CAP80... 58 FETZIMA CAPTITRATION... 58 finasteride tab 5 mg... 139 FLAREX SUS0.1% OP... 173 flavoxate hcl tab 100 mg... 139 flecainide acetate tab 100 mg... 115 flecainide acetate tab 150 mg... 115 flecainide acetate tab 50 mg... 115 FLOVENT DISKAER100MCG... 175 FLOVENT DISKAER250MCG... 175 FLOVENT DISKAER50MCG... 175 FLOVENT HFA AER110MCG... 175 FLOVENT HFA AER220MCG... 175 FLOVENT HFA AER44MCG... 175 fluconazole for susp 10 mg/ml... 64 fluconazole for susp 40 mg/ml... 64 fluconazole in dextrose inj 400 mg/200ml... 64 fluconazole tab 100 mg... 65 fluconazole tab 150 mg... 65 fluconazole tab 200 mg... 65 fluconazole tab 50 mg... 65 flucytosine cap 250 mg... 65 flucytosine cap 500 mg... 65 fludrocortisone acetate tab 0.1 mg... 141 flunisolide nasal soln 0.025%... 175 flunisolide nasal soln 29 mcg/act (0.025%)... 175 fluocinolone acetonide cream 0.01% 141 fluocinolone acetonide cream 0.025%... 141 fluocinolone acetonide oint 0.025%.. 141 fluocinolone acetonide soln 0.01%... 141 fluocinonide emulsified base cream 0.05%... 141 fluocinonide gel 0.05%... 141 fluocinonide oint 0.05%... 141 fluocinonide soln 0.05%... 141 fluorouracil cream 5%... 131 fluoxetine hcl cap 10 mg... 58 fluoxetine hcl cap 20 mg... 58 fluoxetine hcl cap 40 mg... 58 fluoxetine hcl solution 20 mg/5ml... 58 fluoxetine hcl tab 10 mg... 58 fluoxetine hcl tab 20 mg... 58 fluphenazine decanoate inj 25 mg/ml. 84 fluphenazine hcl elixir 2.5 mg/5ml... 84 fluphenazine hcl inj 2.5 mg/ml... 84 fluphenazine hcl oral conc 5 mg/ml... 84 fluphenazine hcl tab 1 mg... 84 fluphenazine hcl tab 10 mg... 84 fluphenazine hcl tab 2.5 mg... 84 fluphenazine hcl tab 5 mg... 84 flurbiprofen sodium ophth soln 0.03%... 173 flurbiprofen tab 100 mg... 27 flurbiprofen tab 50 mg... 27 flutamide cap 125 mg... 156 fluticasone propionate cream 0.05% 141 fluticasone propionate lotion 0.05%.. 141 fluticasone propionate nasal susp 50 mcg/act... 175 fluticasone propionate oint 0.005%.. 141 fluvoxamine maleate tab 100 mg... 58 fluvoxamine maleate tab 25 mg... 58 fluvoxamine maleate tab 50 mg... 58 FML OIN0.1% OP... 173 FML FORTE SUS0.25% OP... 173 folic acid... 193 folic acid 1mg... 193 fondaparinux sodium inj 10 mg/0.8ml... 101 fondaparinux sodium inj 2.5 mg/0.5ml... 101 fondaparinux sodium inj 5 mg/0.4ml. 101 fondaparinux sodium inj 7.5 mg/0.6ml... 101 FORADIL CAPAEROLIZE... 177 FORFIVO XL TAB450MG... 56 FORTEO SOL600/2.4... 169 foscarnet sodium inj 24 mg/ml... 88 fosinopril sodium & hydrochlorothiazide tab 10-12.5 mg... 114 fosinopril sodium & hydrochlorothiazide tab 20-12.5 mg... 114 fosinopril sodium tab 10 mg... 114 fosinopril sodium tab 20 mg... 114 fosinopril sodium tab 40 mg... 114 fosphenytoin sodium inj 100 mg/2ml (phenytoin equiv)... 53 FOSRENOL CHW1000MG... 140 212

FOSRENOL CHW500MG... 140 FOSRENOL CHW750MG... 140 FRAGMIN INJ10000/ML... 101 FRAGMIN INJ12500UNT... 101 FRAGMIN INJ15000UNT... 102 FRAGMIN INJ18000UNT... 102 FRAGMIN INJ2500/0.2... 102 FRAGMIN INJ25000/ML... 102 FRAGMIN INJ5000/0.2... 102 FRAGMIN INJ7500/0.3... 102 FREAMINE IIIINJ8.5%... 187 furosemide inj 10 mg/ml... 122 furosemide oral soln 10 mg/ml... 122 furosemide oral soln 8 mg/ml... 122 furosemide tab 20 mg... 122 furosemide tab 40 mg... 122 furosemide tab 80 mg... 122 FUSILEV INJ50MG... 73 FUZEON INJ90MG... 93 FYCOMPA TAB10MG... 51 FYCOMPA TAB12MG... 51 FYCOMPA TAB2MG... 51 FYCOMPA TAB4MG... 51 FYCOMPA TAB6MG... 51 FYCOMPA TAB8MG... 51 GABA Receptor Modulators... 182 gabapentin cap 100 mg... 51 gabapentin cap 300 mg... 51 gabapentin cap 400 mg... 51 gabapentin oral soln 250 mg/5ml... 51 gabapentin tab 600 mg... 51 gabapentin tab 800 mg... 51 GABITRIL TAB12MG... 51 GABITRIL TAB16MG... 51 galantamine hydrobromide cap sr 24hr 16 mg... 55 galantamine hydrobromide cap sr 24hr 24 mg... 55 galantamine hydrobromide cap sr 24hr 8 mg... 55 galantamine hydrobromide oral soln 4 mg/ml... 55 galantamine hydrobromide tab 12 mg 55 galantamine hydrobromide tab 4 mg.. 55 galantamine hydrobromide tab 8 mg.. 55 GAMASTAN S/DINJ... 164 Gamma-aminobutyric Acid (GABA) Augmenting Agents... 51 GAMMAGARD INJ2.5GM/25... 165 ganciclovir sodium for inj 500 mg... 88 GARDASIL INJ... 166 GASTROINTESTINAL AGENTS... 136 Gastrointestinal Agents, Other... 136 GAUZE PADS & DRESSING... 98 gemcitabine hcl for inj 1 gm... 70 gemfibrozil tab 600 mg... 123 GENITOURINARY AGENTS... 138 Genitourinary Agents, Other... 139 GENOTROPIN INJ0.2MG... 144 GENOTROPIN INJ0.4MG... 144 GENOTROPIN INJ0.6MG... 144 GENOTROPIN INJ0.8MG... 144 GENOTROPIN INJ1.2MG... 144 GENOTROPIN INJ1.4MG... 144 GENOTROPIN INJ1.6MG... 145 GENOTROPIN INJ1.8MG... 145 GENOTROPIN INJ12MG... 145 GENOTROPIN INJ1MG... 145 GENOTROPIN INJ2MG... 145 GENOTROPIN INJ5MG... 145 GENTAMICIN CRE0.1%... 35 GENTAMICIN OIN0.1%... 35 gentamicin sulfate inj 40 mg/ml... 35 gentamicin sulfate iv soln 10 mg/ml... 35 gentamicin sulfate ophth oint 0.3%... 36 gentamicin sulfate ophth soln 0.3%... 36 GEODON INJ20MG... 86 GILENYA CAP0.5MG... 129 GILOTRIF TAB20MG... 78 GILOTRIF TAB30MG... 78 GILOTRIF TAB40MG... 78 GLEEVEC TAB100MG... 78 GLEEVEC TAB400MG... 78 glimepiride tab 1 mg... 96 glimepiride tab 2 mg... 96 glimepiride tab 4 mg... 96 glipizide tab 10 mg... 96 glipizide tab 5 mg... 96 glipizide tab sr 24hr 10 mg... 96 glipizide tab sr 24hr 2.5 mg... 96 glipizide tab sr 24hr 5 mg... 96 213

glipizide-metformin hcl tab 2.5-250 mg... 96 glipizide-metformin hcl tab 2.5-500 mg... 97 glipizide-metformin hcl tab 5-500 mg.. 97 GLUCAGEN INJHYPOKIT... 98 GLUCAGON KIT1MG... 98 Glucocorticoids... 140, 167 Glucocorticoids/Mineralocorticoids... 140 Glutamate Pathway Modifiers... 55 Glutamate Reducing Agents... 52 glyburide micronized tab 1.5 mg... 97 glyburide micronized tab 3 mg... 97 glyburide micronized tab 6 mg... 97 glyburide tab 1.25 mg... 97 glyburide tab 2.5 mg... 97 glyburide tab 5 mg... 97 glyburide-metformin tab 1.25-250 mg. 97 glyburide-metformin tab 2.5-500 mg... 97 glyburide-metformin tab 5-500 mg... 97 Glycemic Agents... 98 glycopyrrolate tab 1 mg... 136 glycopyrrolate tab 2 mg... 136 GLYSET TAB100MG... 97 GLYSET TAB25MG... 97 GLYSET TAB50MG... 97 granisetron hcl tab 1 mg... 63 griseofulvin microsize susp 125 mg/5ml... 65 guanfacine hcl tab 1 mg... 111 guanfacine hcl tab 2 mg... 111 GUANIDINE TAB125MG... 67 HALAVEN INJ1MG/2ML... 73 halobetasol propionate cream 0.05%141 halobetasol propionate oint 0.05%... 141 HALOG CRE0.1%... 141 HALOG OIN0.1%... 142 haloperidol decanoate im soln 100 mg/ml... 84 haloperidol decanoate im soln 50 mg/ml... 85 haloperidol lactate inj 5 mg/ml... 85 haloperidol lactate oral conc 2 mg/ml. 85 haloperidol tab 0.5 mg... 85 haloperidol tab 1 mg... 85 haloperidol tab 10 mg... 85 haloperidol tab 2 mg... 85 haloperidol tab 20 mg... 85 haloperidol tab 5 mg... 85 HAVRIX INJ1440UNIT... 166 HAVRIX INJ720UNIT... 166 HECTOROL CAP0.5MCG... 169 HECTOROL CAP1MCG... 169 HECTOROL CAP2.5MCG... 169 HECTOROL INJ4MCG/2ML... 169 HELIDAC MIS... 136 HEP SOD/NACLINJ25000UNT... 103 heparin sodium (porcine) 2 unit/ml in sodium chloride 0.9%... 103 heparin sodium (porcine) 40 unit/ml in d5w... 103 heparin sodium (porcine) inj 1000 unit/ml... 103 heparin sodium (porcine) inj 10000 unit/ml... 103 heparin sodium (porcine) inj 20000 unit/ml... 104 heparin sodium (porcine) inj 5000 unit/ml... 104 HEPSERA TAB10MG... 89 HERCEPTIN INJ440MG... 80 HEXALEN CAP50MG... 68 Histamine2 (H2) Receptor Antagonists... 137 HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (Adrenal)... 140 HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (PITUITARY)... 143 HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (SEX HORMONES/MODIFIERS)... 148 HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (THYROID)... 151 HORMONAL AGENTS, SUPPRESSANT (ADRENAL)... 153 HORMONAL AGENTS, SUPPRESSANT (PARATHYROID)... 153 214

HORMONAL AGENTS, SUPPRESSANT (PITUITARY)... 153 HORMONAL AGENTS, SUPPRESSANT (SEX HORMONES/MODIFIERS)... 156 HORMONAL AGENTS, SUPPRESSANTS (THYROID)... 156 HUMALOG INJ100/ML... 99 HUMALOG KWIKINJ100/ML... 99 HUMALOG MIX INJ50/50... 99 HUMALOG MIX INJ50/50KWP... 99 HUMALOG MIX INJ75/25KWP... 99 HUMALOG MIX SUS75/25... 99 HUMATROPE INJ12MG... 145 HUMATROPE INJ24MG... 146 HUMATROPE INJ5MG... 146 HUMATROPE INJ6MG... 146 HUMIRA KIT20MG/0.4... 159 HUMIRA KIT40MG/0.8... 160 HUMIRA PEN KITCROHNS... 160 HUMULIN INJ70/30... 99 HUMULIN N INJU-100... 99 HUMULIN N PNINJU-100... 99 HUMULIN PEN INJ70/30... 99 HUMULIN R INJU-100... 99 HUMULIN R INJU-500... 99 hydralazine hcl inj 20 mg/ml... 124 hydralazine hcl tab 10 mg... 125 hydralazine hcl tab 100 mg... 125 hydralazine hcl tab 25 mg... 125 hydralazine hcl tab 50 mg... 125 hydrochlorothiazide cap 12.5 mg... 122 hydrochlorothiazide tab 12.5 mg... 122 hydrochlorothiazide tab 25 mg... 122 hydrochlorothiazide tab 50 mg... 122 hydrocodone-acetaminophen cap 5-500 mg... 31 hydrocodone-acetaminophen soln 7.5-325 mg/15ml... 31 hydrocodone-acetaminophen soln 7.5-500 mg/15ml... 31 hydrocodone-acetaminophen tab 10-300 mg... 31 hydrocodone-acetaminophen tab 10-325 mg... 31 hydrocodone-acetaminophen tab 10-400 mg... 31 hydrocodone-acetaminophen tab 10-500 mg... 31 hydrocodone-acetaminophen tab 10-650 mg... 31 hydrocodone-acetaminophen tab 10-660 mg... 32 hydrocodone-acetaminophen tab 10-750 mg... 32 hydrocodone-acetaminophen tab 2.5-500 mg... 32 hydrocodone-acetaminophen tab 5-300 mg... 32 hydrocodone-acetaminophen tab 5-325 mg... 32 hydrocodone-acetaminophen tab 5-400 mg... 32 hydrocodone-acetaminophen tab 5-500 mg... 32 hydrocodone-acetaminophen tab 7.5-300 mg... 32 hydrocodone-acetaminophen tab 7.5-325 mg... 32 hydrocodone-acetaminophen tab 7.5-400 mg... 32 hydrocodone-acetaminophen tab 7.5-500 mg... 32 hydrocodone-acetaminophen tab 7.5-650 mg... 32 hydrocodone-acetaminophen tab 7.5-750 mg... 32 hydrocodone-ibuprofen tab 7.5-200 mg... 32 hydrocortisone cream 1%... 142 hydrocortisone cream 2.5%... 142 hydrocortisone enema 100 mg/60ml 168 hydrocortisone lotion 2.5%... 142 hydrocortisone oint 1%... 142 hydrocortisone oint 2.5%... 142 hydrocortisone rectal cream 1%... 168 hydrocortisone rectal cream 2.5%... 168 hydrocortisone tab 10 mg... 142 hydrocortisone tab 20 mg... 142 hydrocortisone tab 5 mg... 142 hydrocortisone valerate cream 0.2% 142 215

hydrocortisone valerate oint 0.2%... 142 hydrocortisone w/ acetic acid otic soln 1-2%... 174 hydromorphone hcl tab 2 mg... 32 hydromorphone hcl tab 4 mg... 32 hydromorphone hcl tab 8 mg... 32 hydroxychloroquine sulfate tab 200 mg... 81 hydroxyurea cap 500 mg... 71 ibandronate sodium tab 150 mg (base equivalent)... 169 ibuprofen susp 100 mg/5ml... 27 ibuprofen tab 400 mg... 27 ibuprofen tab 600 mg... 27 ibuprofen tab 800 mg... 27 ICLUSIG TAB15MG... 78 ICLUSIG TAB45MG... 78 IMBRUVICA CAP140MG... 78 imipramine hcl tab 10 mg... 60 imipramine hcl tab 25 mg... 60 imipramine hcl tab 50 mg... 60 imiquimod cream 5%... 131 Immune Suppressants... 156 Immunizing Agents, Passive... 164 IMMUNOLOGICAL AGENTS... 156 Immunomodulators... 165 IMOVAX RABIEINJ2.5/ML... 166 INCIVEK TAB375MG... 89 INCRELEX INJ40MG/4ML... 146 indapamide tab 1.25 mg... 122 indapamide tab 2.5 mg... 122 indomethacin cap 25 mg... 27 indomethacin cap 50 mg... 27 indomethacin cap cr 75 mg... 27 INFANRIX INJ... 166 INFERGEN INJ15MCG... 89 INFLAMMATORY BOWEL DISEASE AGENTS... 167 INLYTA TAB1MG... 78 INLYTA TAB5MG... 78 INNOPRAN XL CAP120MG... 117 INNOPRAN XL CAP80MG... 117 INSULIN NEEDLE... 98 INSULIN PEN NEEDLE... 98 INSULIN SYRINGE... 98 Insulins... 98 INTELENCE TAB100MG... 91 INTELENCE TAB200MG... 91 INTELENCE TAB25MG... 91 INTRON-A INJ10MU... 89 INTRON-A INJ18MU... 89 INTUNIV TAB1MG... 127 INTUNIV TAB2MG... 127 INTUNIV TAB3MG... 127 INTUNIV TAB4MG... 127 INVANZ INJ1GM... 43 INVEGA TAB1.5MG... 86 INVEGA TAB3MG... 86 INVEGA TAB6MG... 86 INVEGA TAB9MG... 86 INVEGA SUST INJ117/0.75... 86 INVEGA SUST INJ156MG/ML... 86 INVEGA SUST INJ234/1.5... 86 INVEGA SUST INJ39/0.25... 86 INVEGA SUST INJ78/0.5ML... 86 INVIRASE CAP200MG... 93 INVIRASE TAB500MG... 93 IOPIDINE SOL1% OP... 173 IPOL INJINACTIVE... 166 ipratropium bromide nasal soln 0.03% (21 mcg/spray)... 176 ipratropium bromide nasal soln 0.06% (42 mcg/spray)... 176 irbesartan tab 150 mg... 112 irbesartan tab 300 mg... 112 irbesartan tab 75 mg... 112 irbesartan-hydrochlorothiazide tab 150-12.5 mg... 112 irbesartan-hydrochlorothiazide tab 300-12.5 mg... 112 Irritable Bowel Syndrome Agents. 138 ISENTRESS CHW100MG... 93 ISENTRESS CHW25MG... 93 ISENTRESS POW100MG... 93 ISENTRESS TAB400MG... 93 isoniazid syrup 50 mg/5ml... 68 isoniazid tab 100 mg... 68 isoniazid tab 300 mg... 68 isosorbide dinitrate sl tab 2.5 mg... 125 isosorbide dinitrate tab 10 mg... 125 isosorbide dinitrate tab 20 mg... 125 isosorbide dinitrate tab 30 mg... 125 216

isosorbide dinitrate tab 5 mg... 125 isosorbide dinitrate tab cr 40 mg... 125 isosorbide mononitrate tab 10 mg... 125 isosorbide mononitrate tab 20 mg... 125 isosorbide mononitrate tab sr 24hr 120 mg... 125 isosorbide mononitrate tab sr 24hr 30 mg... 125 isosorbide mononitrate tab sr 24hr 60 mg... 125 isradipine cap 2.5 mg... 120 isradipine cap 5 mg... 120 ISTODAX INJ10MG... 73 itraconazole cap 100 mg... 65 IXIARO INJ... 166 JAKAFI TAB10MG... 73 JAKAFI TAB15MG... 73 JAKAFI TAB20MG... 74 JAKAFI TAB25MG... 74 JAKAFI TAB5MG... 74 JANUMET TAB50-1000... 97 JANUMET TAB50-500MG... 97 JANUMET XR TAB100-1000... 97 JANUMET XR TAB50-1000... 97 JANUMET XR TAB50-500MG... 97 JANUVIA TAB100MG... 97 JANUVIA TAB25MG... 97 JANUVIA TAB50MG... 97 JEVTANA INJ60/1.5ML... 74 JUVISYNC TAB100-10MG... 97 JUVISYNC TAB100-20MG... 97 JUVISYNC TAB100-40MG... 97 JUVISYNC TAB50-10MG... 97 JUVISYNC TAB50-20MG... 97 JUVISYNC TAB50-40MG... 97 KADCYLA INJ100MG... 80 KADIAN CAP10MG CR... 29 KADIAN CAP200MG CR... 29 KALETRA SOL... 93 KALETRA TAB100-25MG... 93 KALETRA TAB200-50MG... 93 kcl 10 meq/l (0.075%) in dextrose 5% & nacl 0.45% inj... 187 kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.2% inj... 187 kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.33% inj... 188 kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.45% inj... 188 kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.9% inj... 188 kcl 20 meq/l (0.15%) in nacl 0.45% inj... 188 kcl 20 meq/l (0.15%) in nacl 0.9% inj 188 kcl 30 meq/l (0.224%) in dextrose 5% & nacl 0.45% inj... 188 kcl 40 meq/l (0.3%) in dextrose 5% & nacl 0.45% inj... 189 kcl 40 meq/l (0.3%) in dextrose 5% & nacl 0.9% inj... 189 KCL/D5W/NACLINJ0.15/0.2... 189 KETEK TAB300MG... 48 KETEK TAB400MG... 48 ketoconazole cream 2%... 65 ketoconazole shampoo 2%... 65 ketoconazole tab 200 mg... 65 ketoprofen cap 50 mg... 27 ketoprofen cap 75 mg... 27 ketoprofen cap sr 24hr 200 mg... 27 ketorolac tromethamine ophth soln 0.4%... 173 ketorolac tromethamine ophth soln 0.5%... 174 KHEDEZLA TAB100MG ER... 58 KHEDEZLA TAB50MG ER... 58 KINERET INJ... 160 KUVAN TAB100MG... 134 labetalol hcl tab 100 mg... 117 labetalol hcl tab 200 mg... 117 labetalol hcl tab 300 mg... 117 lactated ringer's solution... 189 lactic acid (ammonium lactate) cream 12%... 131 lactic acid (ammonium lactate) lotion 12%... 131 lactulose (encephalopathy) solution 10 gm/15ml... 138 lactulose solution 10 gm/15ml... 138 lamivudine tab 100 mg... 92 lamivudine tab 150 mg... 92 lamivudine tab 300 mg... 92 217

lamivudine-zidovudine tab 150-300 mg... 92 lamotrigine tab 100 mg... 52 lamotrigine tab 150 mg... 52 lamotrigine tab 200 mg... 52 lamotrigine tab 25 mg... 52 lamotrigine tab chewable dispersible 25 mg... 52 lamotrigine tab chewable dispersible 5 mg... 52 lansoprazole cap delayed release 15 mg... 138 lansoprazole cap delayed release 30 mg... 138 LANTUS INJ100/ML... 99 LANTUS INJSOLOSTAR... 99 latanoprost ophth soln 0.005%... 174 LATUDA TAB120MG... 86 LATUDA TAB20MG... 86 LATUDA TAB40MG... 86 LATUDA TAB60MG... 86 LATUDA TAB80MG... 86 Laxatives... 138 LAZANDA SPR100MCG... 29 LAZANDA SPR400MCG... 29 leflunomide tab 10 mg... 165 leflunomide tab 20 mg... 165 LETAIRIS TAB10MG... 178 LETAIRIS TAB5MG... 178 letrozole tab 2.5 mg... 76 leucovorin calcium for inj 100 mg... 74 leucovorin calcium for inj 350 mg... 75 leucovorin calcium tab 10 mg... 75 leucovorin calcium tab 15 mg... 75 leucovorin calcium tab 25 mg... 75 leucovorin calcium tab 5 mg... 75 LEUKERAN TAB2MG... 68 LEUKINE INJ250MCG... 107 LEUKINE INJ500 MCG... 107 leuprolide acetate inj kit 5 mg/ml... 153 LEVATOL TAB20MG... 117 LEVEMIR INJ... 99 LEVEMIR INJFLEXPEN... 99 levetiracetam inj 500 mg/5ml (100 mg/ml)... 50 levetiracetam oral soln 100 mg/ml... 50 levetiracetam tab 1000 mg... 50 levetiracetam tab 250 mg... 50 levetiracetam tab 500 mg... 50 levetiracetam tab 750 mg... 50 levetiracetam tab sr 24hr 500 mg... 50 levetiracetam tab sr 24hr 750 mg... 51 LEVITRA... 194 LEVITRA 2.5MG, 5MG,10MG, 20MG... 194 levobunolol hcl ophth soln 0.5%... 173 levocarnitine oral soln 1 gm/10ml (10%)... 183 levocarnitine tab 330 mg... 183 levocetirizine dihydrochloride tab 5 mg... 174 levofloxacin iv soln 25 mg/ml... 48 levofloxacin ophth soln 0.5%... 49 levofloxacin oral soln 25 mg/ml... 49 levofloxacin tab 250 mg... 49 levofloxacin tab 500 mg... 49 levofloxacin tab 750 mg... 49 levonorgestrel & ethinyl estradiol (91- day) tab 0.15-0.03 mg... 149 levonorgestrel & ethinyl estradiol tab 0.1 mg-20 mcg... 149 levonorgestrel & ethinyl estradiol tab 0.15 mg-30 mcg... 149 levonorgestrel-eth estra tab 0.05-30/0.075-40/0.125-30mg-mcg... 150 levorphanol tartrate tab 2 mg... 29 LEVOTHROID TAB100MCG... 151 LEVOTHROID TAB112MCG... 151 LEVOTHROID TAB125MCG... 151 LEVOTHROID TAB137MCG... 151 LEVOTHROID TAB150MCG... 151 LEVOTHROID TAB175MCG... 152 LEVOTHROID TAB200MCG... 152 LEVOTHROID TAB25MCG... 152 LEVOTHROID TAB300MCG... 152 LEVOTHROID TAB50MCG... 152 LEVOTHROID TAB75MCG... 152 LEVOTHROID TAB88MCG... 152 levothyroxine sodium tab 100 mcg... 152 levothyroxine sodium tab 112 mcg... 152 levothyroxine sodium tab 125 mcg... 152 levothyroxine sodium tab 137 mcg... 152 218

levothyroxine sodium tab 150 mcg... 152 levothyroxine sodium tab 175 mcg... 152 levothyroxine sodium tab 200 mcg... 152 levothyroxine sodium tab 25 mcg... 152 levothyroxine sodium tab 300 mcg... 152 levothyroxine sodium tab 50 mcg... 152 levothyroxine sodium tab 75 mcg... 152 levothyroxine sodium tab 88 mcg... 152 LEXIVA SUS50MG/ML... 93 LEXIVA TAB700MG... 93 LIALDA TAB1.2GM... 167 lidocaine hcl gel 2%... 33 lidocaine hcl local preservative free (pf) inj 0.5%... 33 lidocaine hcl local preservative free (pf) inj 1%... 33 lidocaine hcl soln 4%... 34 lidocaine hcl viscous soln 2%... 130 lidocaine oint 5%... 131 lidocaine-prilocaine cream 2.5-2.5%.. 34 LIDODERM DIS5%... 131 lindane lotion 1%... 82 lindane shampoo 1%... 82 liothyronine sodium tab 25 mcg... 152 liothyronine sodium tab 5 mcg... 152 liothyronine sodium tab 50 mcg... 152 lisinopril & hydrochlorothiazide tab 10-12.5 mg... 114 lisinopril & hydrochlorothiazide tab 20-12.5 mg... 114 lisinopril & hydrochlorothiazide tab 20-25 mg... 114 lisinopril tab 10 mg... 114 lisinopril tab 2.5 mg... 114 lisinopril tab 20 mg... 114 lisinopril tab 30 mg... 114 lisinopril tab 40 mg... 114 lisinopril tab 5 mg... 115 lithium carbonate cap 150 mg... 96 lithium carbonate cap 300 mg... 96 lithium carbonate cap 600 mg... 96 lithium carbonate tab 300 mg... 96 lithium carbonate tab cr 300 mg... 96 lithium carbonate tab cr 450 mg... 96 LITHIUM CITRSOL8MEQ/5ML... 96 Local Anesthetics... 33 LODOSYN TAB25MG... 84 LOMUSTINE CAP100MG... 68 LOMUSTINE CAP10MG... 68 LOMUSTINE CAP40MG... 68 loperamide hcl cap 2 mg... 136 lorazepam conc 2 mg/ml... 95 lorazepam tab 0.5 mg... 95 lorazepam tab 1 mg... 95 lorazepam tab 2 mg... 95 losartan potassium & hydrochlorothiazide tab 100-12.5 mg... 112 losartan potassium & hydrochlorothiazide tab 100-25 mg... 112 losartan potassium & hydrochlorothiazide tab 50-12.5 mg... 112 losartan potassium tab 100 mg... 112 losartan potassium tab 25 mg... 112 losartan potassium tab 50 mg... 112 LOTEMAX SUS0.5%... 174 LOTRONEX TAB0.5MG... 138 LOTRONEX TAB1MG... 138 lovastatin tab 10 mg... 123 lovastatin tab 20 mg... 123 lovastatin tab 40 mg... 123 LOVAZA CAP1GM... 124 loxapine succinate cap 10 mg... 85 loxapine succinate cap 25 mg... 85 loxapine succinate cap 5 mg... 85 loxapine succinate cap 50 mg... 85 LUMIGAN SOL0.01%... 174 LUPR DEP-PEDINJ11.25MG... 153 LUPRON DEPOTINJ22.5MG... 153 LUPRON DEPOTINJ3.75MG... 153 LUPRON DEPOTINJ30MG... 153 LUPRON DEPOTINJ45MG... 153 LUPRON DEPOTINJ7.5MG... 153 LYRICA CAP100MG... 51 LYRICA CAP150MG... 51 LYRICA CAP200MG... 51 LYRICA CAP225MG... 51 LYRICA CAP25MG... 51 LYRICA CAP300MG... 51 LYRICA CAP50MG... 51 219

LYRICA CAP75MG... 51 LYRICA SOL20MG/ML... 51 LYSODREN TAB500MG... 153 Macrolides... 47 magnesium sulfate inj 50%... 189 malathion lotion 0.5%... 82 maprotiline hcl tab 25 mg... 56 maprotiline hcl tab 50 mg... 56 maprotiline hcl tab 75 mg... 56 MARPLAN TAB10MG... 57 Mast Cell Stabilizers... 177 MATULANE CAP50MG... 68 MAXIDEX SUS0.1% OP... 174 meclizine hcl tab 12.5 mg... 60 meclizine hcl tab 25 mg... 60 meclofenamate sodium cap 100 mg.. 27 meclofenamate sodium cap 50 mg... 27 medroxyprogesterone acetate im susp 150 mg/ml... 151 medroxyprogesterone acetate tab 10 mg... 151 medroxyprogesterone acetate tab 2.5 mg... 151 medroxyprogesterone acetate tab 5 mg... 151 mefloquine hcl tab 250 mg... 81 MEGACE ES SUS625/5ML... 151 megestrol acetate susp 40 mg/ml... 151 megestrol acetate tab 20 mg... 151 megestrol acetate tab 40 mg... 151 MEKINIST TAB0.5MG... 78 MEKINIST TAB2MG... 78 meloxicam tab 15 mg... 27 meloxicam tab 7.5 mg... 27 MENACTRA INJ... 166 MENOMUNE INJA/C/Y/W... 166 MENVEO INJ... 166 meprobamate tab 200 mg... 95 meprobamate tab 400 mg... 95 MEPRON SUS... 81 mercaptopurine tab 50 mg... 71 MESNEX TAB400MG... 75 MESTINON SYP60MG/5ML... 67 MESTINON TABTIMESPAN... 67 METABOLIC BONE DISEASE AGENTS... 168 metaproterenol sulfate syrup 10 mg/5ml... 177 metaproterenol sulfate tab 10 mg... 177 metaproterenol sulfate tab 20 mg... 177 metformin hcl tab 1000 mg... 97 metformin hcl tab 500 mg... 97 metformin hcl tab 850 mg... 97 metformin hcl tab sr 24hr 500 mg... 97 metformin hcl tab sr 24hr 750 mg... 97 METHADONE INJ10MG/ML... 29 methadone hcl conc 10 mg/ml... 30 methadone hcl soln 10 mg/5ml... 30 methadone hcl soln 5 mg/5ml... 30 methadone hcl tab 10 mg... 30 methadone hcl tab 5 mg... 30 methazolamide tab 25 mg... 121 methazolamide tab 50 mg... 121 methenamine hippurate tab 1 gm... 38 methimazole tab 10 mg... 156 methimazole tab 5 mg... 156 methotrexate sodium for inj 1 gm... 160 methotrexate sodium inj pf 25 mg/ml 160 methotrexate sodium tab 10 mg (base equiv)... 160 methotrexate sodium tab 15 mg (base equiv)... 160 methotrexate sodium tab 2.5 mg (base equiv)... 160 methotrexate sodium tab 5 mg (base equiv)... 161 methotrexate sodium tab 7.5 mg (base equiv)... 161 methscopolamine bromide tab 2.5 mg... 136 methscopolamine bromide tab 5 mg 136 methyclothiazide tab 5 mg... 122 methyldopa & hydrochlorothiazide tab 250-15 mg... 111 methyldopa & hydrochlorothiazide tab 250-25 mg... 111 methyldopa tab 250 mg... 111 methyldopa tab 500 mg... 111 methyldopate hcl inj 250 mg/5ml... 111 methylergonovine maleate tab 0.2 mg... 107 methylphenidate hcl tab 10 mg... 127 220

methylphenidate hcl tab 20 mg... 127 methylphenidate hcl tab 5 mg... 127 methylphenidate hcl tab cr 20 mg... 127 methylprednisolone acetate inj susp 40 mg/ml... 142 methylprednisolone acetate inj susp 80 mg/ml... 142 methylprednisolone sodium succinate for inj 125 mg... 142 methylprednisolone sodium succinate for inj 40 mg... 142 methylprednisolone tab 16 mg... 143 methylprednisolone tab 32 mg... 143 methylprednisolone tab 4 mg... 143 methylprednisolone tab 4 mg dose pack... 143 methylprednisolone tab 8 mg... 143 metipranolol ophth soln 0.3%... 173 metoclopramide hcl inj 5 mg/ml... 60 metoclopramide hcl soln 5 mg/5ml (10 mg/10ml)... 61 metoclopramide hcl tab 10 mg... 61 metoclopramide hcl tab 5 mg... 61 metolazone tab 10 mg... 122 metolazone tab 2.5 mg... 122 metolazone tab 5 mg... 122 metoprolol & hydrochlorothiazide tab 100-25 mg... 117 metoprolol & hydrochlorothiazide tab 100-50 mg... 117 metoprolol & hydrochlorothiazide tab 50-25 mg... 117 metoprolol succinate tab sr 24hr 100 mg... 117 metoprolol succinate tab sr 24hr 200 mg... 117 metoprolol succinate tab sr 24hr 25 mg... 117 metoprolol succinate tab sr 24hr 50 mg... 117 metoprolol tartrate inj 1 mg/ml... 117 metoprolol tartrate tab 100 mg... 118 metoprolol tartrate tab 25 mg... 118 metoprolol tartrate tab 50 mg... 118 METROGEL GEL1%... 38 metronidazole cream 0.75%... 38 metronidazole gel 0.75%... 38 metronidazole lotion 0.75%... 38 metronidazole tab 250 mg... 38 metronidazole tab 500 mg... 38 metronidazole vaginal gel 0.75%... 38 mexiletine hcl cap 150 mg... 115 mexiletine hcl cap 200 mg... 115 mexiletine hcl cap 250 mg... 116 miconazole nitrate vaginal suppos 200 mg... 65 midodrine hcl tab 10 mg... 111 midodrine hcl tab 2.5 mg... 111 midodrine hcl tab 5 mg... 111 MIGRANAL SPR4MG/ML... 66 minocycline hcl cap 100 mg... 50 minocycline hcl cap 50 mg... 50 minocycline hcl cap 75 mg... 50 minocycline hcl tab 100 mg... 50 minocycline hcl tab 50 mg... 50 minocycline hcl tab 75 mg... 50 minocycline hcl tab sr 24hr 135 mg... 50 minocycline hcl tab sr 24hr 45 mg... 50 minocycline hcl tab sr 24hr 90 mg... 50 minoxidil tab 10 mg... 125 minoxidil tab 2.5 mg... 125 mirtazapine orally disintegrating tab 15 mg... 56 mirtazapine orally disintegrating tab 30 mg... 56 mirtazapine orally disintegrating tab 45 mg... 56 mirtazapine tab 15 mg... 56 mirtazapine tab 30 mg... 56 mirtazapine tab 45 mg... 56 mirtazapine tab 7.5 mg... 56 misoprostol tab 100 mcg... 138 misoprostol tab 200 mcg... 138 mitoxantrone hcl inj conc 25 mg/12.5ml (2 mg/ml)... 75 M-M-R II INJLIVE... 166 moexipril hcl tab 15 mg... 115 moexipril hcl tab 7.5 mg... 115 moexipril-hydrochlorothiazide tab 15-12.5 mg... 115 moexipril-hydrochlorothiazide tab 15-25 mg... 115 221

moexipril-hydrochlorothiazide tab 7.5-12.5 mg... 115 Molecular Target Inhibitors... 77 mometasone furoate cream 0.1%... 143 mometasone furoate oint 0.1%... 143 mometasone furoate solution 0.1% (lotion)... 143 Monoamine Oxidase B (MAO-B) Inhibitors... 84 Monoamine Oxidase Inhibitors... 57 Monoclonal Antibodies... 79 montelukast sodium chew tab 4 mg (base equiv)... 175 montelukast sodium chew tab 5 mg (base equiv)... 175 montelukast sodium oral granules packet 4 mg (base equiv)... 175 montelukast sodium tab 10 mg (base equiv)... 175 MONUROL PAKGRANULES... 38 Mood Stabilizers... 96 morphine sulfate inj pf 0.5 mg/ml... 30 morphine sulfate inj pf 1 mg/ml... 30 morphine sulfate tab 15 mg... 30 morphine sulfate tab 30 mg... 30 morphine sulfate tab cr 100 mg... 30 morphine sulfate tab cr 15 mg... 30 morphine sulfate tab cr 200 mg... 30 morphine sulfate tab cr 30 mg... 30 morphine sulfate tab sr 12hr 60 mg... 30 MULTAQ TAB400MG... 116 Multiple Sclerosis Agents... 128 mupirocin calcium cream 2%... 38 mupirocin oint 2%... 38 MUSE SUPPPOSITORY... 195 MUSE SUPPPOSITORY 50MCG, 100MCG, 125MCG, 250MCG... 195 MYCOBUTIN CAP150MG... 67 mycophenolate mofetil cap 250 mg.. 161 mycophenolate mofetil tab 500 mg.. 161 mycophenolictab180mg dr... 161 mycophenolictab360mg dr... 161 MYFORTIC TAB180MG... 161 MYFORTIC TAB360MG... 161 MYOZYME INJ50MG... 134 nabumetone tab 500 mg... 27 nabumetone tab 750 mg... 27 nadolol & bendroflumethiazide tab 40-5 mg... 118 nadolol & bendroflumethiazide tab 80-5 mg... 118 nadolol tab 20 mg... 118 nadolol tab 40 mg... 118 nadolol tab 80 mg... 118 nafcillin sodium for inj 1 gm... 45 nafcillin sodium for inj 10 gm... 45 NAFTIN CRE1%... 65 NAFTIN GEL1%... 65 NAGLAZYME INJ1MG/ML... 134 nalbuphine hcl inj 10 mg/ml... 32 nalbuphine hcl inj 20 mg/ml... 32 naloxone hcl inj 1 mg/ml... 34 naltrexone hcl tab 50 mg... 34 NAMENDA SOL10MG/5ML... 55 NAMENDA TAB10MG... 55 NAMENDA TAB5-10MG... 55 NAMENDA TAB5MG... 55 naphazoline hcl ophth soln 0.1%... 172 naproxen sodium tab 275 mg... 27 naproxen sodium tab 550 mg... 27 naproxen susp 125 mg/5ml... 27 naproxen tab 250 mg... 27 naproxen tab 375 mg... 27 naproxen tab 500 mg... 27 naproxen tab ec 375 mg... 27 naproxen tab ec 500 mg... 27 naratriptan hcl tab 1 mg (base equiv). 67 naratriptan hcl tab 2.5 mg (base equiv)... 67 NATACYN SUS5% OP... 65 nateglinide tab 120 mg... 98 nateglinide tab 60 mg... 98 NEBUPENT INH300MG... 82 nefazodone hcl tab 100 mg... 56 nefazodone hcl tab 150 mg... 56 nefazodone hcl tab 200 mg... 56 nefazodone hcl tab 250 mg... 56 nefazodone hcl tab 50 mg... 56 neomycin sulfate tab 500 mg... 36 neomycin-bacitrac zn-polymyx 5(3.5)mg-400unt-10000unt op oin 172 222

neomycin-polymyxin b gu irrigation soln... 38 neomycin-polymyxin b-gramicidin ophth soln... 172 neomycin-polymyxin-dexamethasone ophth oint 0.1%... 172 neomycin-polymyxin-dexamethasone ophth susp 0.1%... 172 neomycin-polymyxin-hc ophth susp. 172 neomycin-polymyxin-hc otic soln 1% 174 neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000 unit/ml-1%... 174 NEULASTA INJ6MG/0.6M... 107 NEUMEGA INJ5MG... 107 NEUPOGEN INJ300/0.5... 107 NEUPOGEN INJ480/0.8... 108 NEUPOGEN INJ480MCG... 108 NEVANAC SUS0.1%... 174 nevirapine sus50mg/5ml... 91 nevirapine tab 200 mg... 91 nevirapine tab 400 mg er... 91 NEXAVAR TAB200MG... 78 niacin (antihyperlipidemic) tab 500 mg... 124 NIASPAN TAB1000 ER... 124 NIASPAN TAB500MG ER... 124 NIASPAN TAB750MG ER... 124 nicardipine hcl cap 20 mg... 120 nicardipine hcl cap 30 mg... 120 NICOTROL NS SPR10MG/ML... 35 nifedipine tab sr 24hr 30 mg... 120 nifedipine tab sr 24hr 60 mg... 120 nifedipine tab sr 24hr 90 mg... 120 nifedipine tab sr 24hr osmotic 30 mg 120 nifedipine tab sr 24hr osmotic 60 mg 120 nifedipine tab sr 24hr osmotic 90 mg 120 NILANDRON TAB150MG... 156 nimodipine cap 30 mg... 120 nisoldipine tab sr 24hr 17 mg... 120 nisoldipine tab sr 24hr 20 mg... 120 nisoldipine tab sr 24hr 25.5 mg... 120 nisoldipine tab sr 24hr 30 mg... 120 nisoldipine tab sr 24hr 34 mg... 120 nisoldipine tab sr 24hr 40 mg... 120 nisoldipine tab sr 24hr 8.5 mg... 120 NITRO-DUR DIS0.3MG/HR... 125 NITRO-DUR DIS0.8MG/HR... 125 nitrofurantoin macrocrystalline cap 50 mg... 38 nitrofurantoin monohydrate macrocrystalline cap 100 mg... 38 nitrofurantoin susp 25 mg/5ml... 38 nitroglycerin iv soln 5 mg/ml... 125 nitroglycerin td patch 24hr 0.1 mg/hr 125 nitroglycerin td patch 24hr 0.2 mg/hr 125 nitroglycerin td patch 24hr 0.4 mg/hr 126 nitroglycerin td patch 24hr 0.6 mg/hr 126 NITROLINGUALSPRPUMPSPRA... 126 NITROSTAT SUB0.3MG... 126 NITROSTAT SUB0.4MG... 126 NITROSTAT SUB0.6MG... 126 nizatidine cap 150 mg... 137 nizatidine cap 300 mg... 137 nizatidine oral soln 15 mg/ml... 137 N-methyl-D-aspartate (NMDA) Receptor Antagonist... 55 Nonsteroidal Anti-Inflammatory Drugs... 26 NORDITROPIN INJ10/1.5ML... 146 NORDITROPIN INJ15/1.5ML... 146 NORDITROPIN INJ30/3ML... 146 NORDITROPIN INJ5/1.5ML... 146 norethindrone & ethinyl estradiol tab 0.4 mg-35 mcg... 150 norethindrone & ethinyl estradiol tab 0.5 mg-35 mcg... 150 norethindrone & ethinyl estradiol tab 1 mg-35 mcg... 150 norethindrone ace & ethinyl estradiol tab 1 mg-20 mcg... 150 norethindrone ace & ethinyl estradiol tab 1.5 mg-30 mcg... 150 norethindrone ace & ethinyl estradiol-fe tab 1 mg-20 mcg... 150 norethindrone ace & ethinyl estradiol-fe tab 1.5 mg-30 mcg... 150 norethindrone acetate tab 5 mg... 151 norethindrone acetate-ethinyl estradiol tab 1 mg-5 mcg... 150 norethindrone ac-ethinyl estrad-fe tab 1-20/1-30/1-35 mg-mcg... 150 norethindrone tab 0.35 mg... 151 223

norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35 mg-mcg... 150 norethindrone-eth estradiol tab 0.5-35/1-35 mg-mcg (10/11)... 150 norethindrone-eth estradiol tab 0.5-35/1-35/0.5-35 mg-mcg... 150 norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg... 150 norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35 mg-mcg... 150 norgestrel & ethinyl estradiol tab 0.3 mg- 30 mcg... 150 norgestrel & ethinyl estradiol tab 0.5 mg- 50 mcg... 150 NOROXIN TAB400MG... 49 nortriptyline hcl cap 10 mg... 60 nortriptyline hcl cap 25 mg... 60 nortriptyline hcl cap 50 mg... 60 nortriptyline hcl cap 75 mg... 60 nortriptyline sol10mg/5ml... 60 NORVIR CAP100MG... 93 NORVIR SOL80MG/ML... 93 NORVIR TAB100MG... 93 NOVOLIN INJ70/30... 99 NOVOLIN N INJU-100... 99 NOVOLIN R INJU-100... 99 NOVOLOG INJ100/ML... 99 NOVOLOG INJFLEXPEN... 99 NOVOLOG MIX INJ70/30... 99 NOVOLOG MIX INJFLEXPEN... 99 NOXAFIL SUS40MG/ML... 65 NUEDEXTA CAP20-10MG... 127 NULOJIX INJ250MG... 161 NUTROPIN INJ10MG... 146 NUTROPIN AQ INJ10MG/2ML... 147 NUTROPIN AQ INJ20MG/2ML... 147 NUTROPIN AQ INJNUSPIN 5... 147 NUVARING MIS... 150 NUVIGIL TAB150MG... 182 NUVIGIL TAB250MG... 182 NUVIGIL TAB50MG... 182 nystatin cream 100000 unit/gm... 65 nystatin oint 100000 unit/gm... 65 nystatin susp 100000 unit/ml... 65 nystatin tab 500000 unit... 65 nystatin topical powder... 65 nystatin-triamcinolone cream 100000-0.1 unit/gm-%... 65 nystatin-triamcinolone oint 100000-0.1 unit/gm-%... 65 octreotide acetate inj 100 mcg/ml (0.1 mg/ml)... 153 octreotide acetate inj 1000 mcg/ml (1 mg/ml)... 153 octreotide acetate inj 200 mcg/ml (0.2 mg/ml)... 154 octreotide acetate inj 50 mcg/ml (0.05 mg/ml)... 154 octreotide acetate inj 500 mcg/ml (0.5 mg/ml)... 154 ofloxacin ophth soln 0.3%... 49 ofloxacin otic soln 0.3%... 49 ofloxacin tab 200 mg... 49 ofloxacin tab 300 mg... 49 ofloxacin tab 400 mg... 49 olanzapine for im inj 10 mg... 86 olanzapine orally disintegrating tab 10 mg... 86 olanzapine orally disintegrating tab 15 mg... 86 olanzapine orally disintegrating tab 20 mg... 86 olanzapine orally disintegrating tab 5 mg... 86 olanzapine tab 10 mg... 86 olanzapine tab 15 mg... 86 olanzapine tab 2.5 mg... 86 olanzapine tab 20 mg... 86 olanzapine tab 5 mg... 86 olanzapine tab 7.5 mg... 86 olanzapine-fluoxetine hcl cap 12-25 mg... 57 olanzapine-fluoxetine hcl cap 12-50 mg... 57 olanzapine-fluoxetine hcl cap 3-25 mg57 olanzapine-fluoxetine hcl cap 6-25 mg57 olanzapine-fluoxetine hcl cap 6-50 mg57 omeprazole cap delayed release 10 mg... 138 omeprazole cap delayed release 20 mg... 138 224

omeprazole cap delayed release 40 mg... 138 ONCASPAR INJ750/ML... 110 ondansetron hcl oral soln 4 mg/5ml... 63 ondansetron hcl tab 24 mg... 63 ondansetron hcl tab 4 mg... 63 ondansetron hcl tab 8 mg... 63 ondansetron orally disintegrating tab 4 mg... 63 ondansetron orally disintegrating tab 8 mg... 63 ONFI SUS2.5MG/ML... 95 ONFI TAB10MG... 95 ONFI TAB20MG... 95 ONFI TAB5MG... 95 ONTAK INJ150/ML... 75 OPHTHALMIC AGENTS... 171 Ophthalmic Agents, Other... 171 Ophthalmic Anti-allergy Agents... 172 Ophthalmic Antiglaucoma Agents 172 Ophthalmic Anti-inflammatories... 173 Ophthalmic Prostaglandins and Prostamide Analogs... 174 Opioid Analgesics, Long-Acting... 28 Opioid Analgesics, Short-Acting... 31 Opioid Antagonists... 34 ORACEA CAP40MG... 50 ORAP TAB1MG... 85 ORAP TAB2MG... 85 ORENCIA INJ125MG/ML... 161 ORENCIA INJ250MG... 161 ORFADIN CAP10MG... 134 ORFADIN CAP2MG... 135 ORFADIN CAP5MG... 135 ORTHO EVRA DISWEEK... 150 OTIC AGENTS... 174 oxandrolone tab 10 mg... 148 oxandrolone tab 2.5 mg... 148 oxaprozin tab 600 mg... 27 oxcarbazepine susp 300 mg/5ml (60 mg/ml)... 53 oxcarbazepine tab 150 mg... 53 oxcarbazepine tab 300 mg... 53 oxcarbazepine tab 600 mg... 53 OXISTAT CRE1%... 65 OXISTAT LOT1%... 65 OXSORALEN-ULCAP10MG... 131 OXTELLAR XR TAB150MG... 54 OXTELLAR XR TAB300MG... 54 OXTELLAR XR TAB600MG... 54 oxybutynin chloride syrup 5 mg/5ml. 139 oxybutynin chloride tab 5 mg... 139 oxybutynin chloride tab sr 24hr 10 mg... 139 oxybutynin chloride tab sr 24hr 15 mg... 139 oxybutynin chloride tab sr 24hr 5 mg 139 oxycodone hcl cap 5 mg... 30 oxycodone hcl conc 20 mg/ml... 30 oxycodone hcl tab 10 mg... 30 oxycodone hcl tab 15 mg... 30 oxycodone hcl tab 20 mg... 30 oxycodone hcl tab 30 mg... 30 oxycodone hcl tab 5 mg... 30 oxycodone w/ acetaminophen cap 5-500 mg... 33 oxycodone w/ acetaminophen soln 5-325 mg/5ml... 33 oxycodone w/ acetaminophen tab 10-325 mg... 33 oxycodone w/ acetaminophen tab 10-650 mg... 33 oxycodone w/ acetaminophen tab 2.5-325 mg... 33 oxycodone w/ acetaminophen tab 5-325 mg... 33 oxycodone w/ acetaminophen tab 7.5-325 mg... 33 oxycodone w/ acetaminophen tab 7.5-500 mg... 33 oxycodone-aspirin tab 4.8355-325 mg 33 oxycodone-ibuprofen tab 5-400 mg... 33 oxymorphone er... 30 oxymorphone hcl tab 10 mg... 30 oxymorphone hcl tab 5 mg... 30 oxymorphone hcl tab sr 12hr 15 mg... 30 oxymorphone hcl tab sr 12hr 7.5 mg.. 30 OXYTROL DIS3.9MG/24... 139 pamidronate disodium iv soln 3 mg/ml... 169 pamidronate disodium iv soln 6 mg/ml... 170 225

pamidronate disodium iv soln 9 mg/ml... 170 PANCREAZE CAP10500UNT... 135 PANCREAZE CAP16800UNT... 135 PANCREAZE CAP21000UNT... 135 PANCREAZE CAP4200UNIT... 135 PANRETIN GEL0.1%... 81 pantoprazole sodium ec tab 20 mg (base equiv)... 138 pantoprazole sodium ec tab 40 mg (base equiv)... 138 Parasympathomimetics... 67 paromomycin sulfate cap 250 mg... 36 paroxetine hcl tab 10 mg... 58 paroxetine hcl tab 20 mg... 58 paroxetine hcl tab 30 mg... 58 paroxetine hcl tab 40 mg... 59 paroxetine hcl tab sr 24hr 12.5 mg... 59 paroxetine hcl tab sr 24hr 25 mg... 59 paroxetine hcl tab sr 24hr 37.5 mg... 59 PATANOL SOL0.1% OP... 172 PAXIL SUS10MG/5ML... 59 Pediculicides/Scabicides... 82 PEDVAX HIB INJ... 166 peg 3350-kcl-sod bicarb-nacl for soln 420 gm... 136 PEGANONE TAB250MG... 54 PEGASYS INJ... 89 PEGASYS INJ180MCG/M... 89 PEGASYS INJPROCLICK... 89 PEG-INTRON KIT120 RP... 89 PEG-INTRON KIT150 RP... 89 PEG-INTRON KIT50MCG... 90 PEG-INTRON KIT50MCG RP... 90 PEG-INTRON KIT80MCG RP... 90 PENICILL GK/INJDEX 2MU... 45 PENICILL GK/INJDEX 3MU... 46 penicillin g potassium for inj 5000000 unit... 46 penicillin g procaine intramuscular susp 600000 unit/ml... 46 penicillin g sodium for inj 5000000 unit... 46 penicillin v potassium for soln 125 mg/5ml... 46 penicillin v potassium for soln 250 mg/5ml... 46 penicillin v potassium tab 250 mg... 46 penicillin v potassium tab 500 mg... 46 PENTAM 300 INJ300MG... 82 PENTASA CAP250MG CR... 167 PENTASA CAP500MG CR... 167 pentoxifylline tab cr 400 mg... 121 PERJETA INJ420/14ML... 80 permethrin cream 5%... 82 perphenazine tab 16 mg... 61 perphenazine tab 2 mg... 61 perphenazine tab 4 mg... 61 perphenazine tab 8 mg... 61 perphenazine-amitriptyline tab 2-10 mg... 57 perphenazine-amitriptyline tab 2-25 mg... 57 perphenazine-amitriptyline tab 4-10 mg... 57 perphenazine-amitriptyline tab 4-25 mg... 57 perphenazine-amitriptyline tab 4-50 mg... 57 phenelzine sulfate tab 15 mg... 57 PHENOBARB TAB64.8MG... 95 PHENOBARB TAB97.2MG... 95 phenobarbital elixir 20 mg/5ml... 95 phenobarbital tab 100 mg... 95 phenobarbital tab 15 mg... 96 phenobarbital tab 16.2 mg... 96 phenobarbital tab 30 mg... 96 phenobarbital tab 32.4 mg... 96 phenobarbital tab 60 mg... 96 phenytoin chew tab 50 mg... 54 phenytoin sodium extended cap 100 mg... 54 phenytoin sodium extended cap 200 mg... 54 phenytoin sodium extended cap 300 mg... 54 phenytoin sodium inj 50 mg/ml... 54 phenytoin susp 125 mg/5ml... 54 Phosphate Binders... 139 PHOSPHOLINE SOL0.125%OP... 173 pilocarpine hcl tab 5 mg... 130 226

pilocarpine hcl tab 7.5 mg... 130 PILOPINE HS GEL4% OP... 173 pindolol tab 10 mg... 118 pindolol tab 5 mg... 118 pioglitazone hcl tab 15 mg (base equiv)... 98 pioglitazone hcl tab 30 mg (base equiv)... 98 pioglitazone hcl tab 45 mg (base equiv)... 98 pioglitazone hcl-glimepiride tab 30-2 mg... 98 pioglitazone hcl-glimepiride tab 30-4 mg... 98 pioglitazone hcl-metformin hcl tab 15-500 mg... 98 pioglitazone hcl-metformin hcl tab 15-850 mg... 98 piperacillin sodium-tazobactam sodium for inj 3-0.375 gm... 46 piperacillin sodium-tazobactam sodium for inj 4-0.5 gm... 47 piroxicam cap 10 mg... 27 piroxicam cap 20 mg... 27 Platelet Modifying Agents... 110 podofilox soln 0.5%... 131 polyethylene glycol 3350 oral powder... 138 polymyxin b-trimethoprim ophth soln 10000 unit/ml-0.1%... 172 POMALYST CAP1MG... 75 POMALYST CAP2MG... 75 POMALYST CAP3MG... 75 POMALYST CAP4MG... 75 potassium chloride 20 meq/l (0.15%) in d5w lactated ringers... 189 potassium chloride 20 meq/l (0.15%) in dextrose 5% inj... 190 potassium chloride 40 meq/l (0.3%) in dextrose 5% inj... 190 potassium chloride cap cr 10 meq... 190 potassium chloride cap cr 8 meq... 190 potassium chloride inj 2 meq/ml... 190 potassium chloride microencapsulated crys cr tab 10 meq... 190 potassium chloride microencapsulated crys cr tab 15 meq... 190 potassium chloride microencapsulated crys cr tab 20 meq... 190 potassium chloride tab cr 10 meq... 190 potassium chloride tab cr 8 meq (600 mg)... 190 potassium citrate tab cr 10 meq (1080 mg)... 139 potassium citrate tab cr 5 meq (540 mg)... 139 POTIGA TAB200MG... 54 POTIGA TAB300MG... 54 POTIGA TAB400MG... 54 POTIGA TAB50MG... 54 PRADAXA CAP150MG... 104 PRADAXA CAP75MG... 104 pramipexole dihydrochloride tab 0.125 mg... 83 pramipexole dihydrochloride tab 0.25 mg... 83 pramipexole dihydrochloride tab 0.5 mg... 83 pramipexole dihydrochloride tab 0.75 mg... 83 pramipexole dihydrochloride tab 1 mg 83 pramipexole dihydrochloride tab 1.5 mg... 83 PRANDIMET TAB1-500MG... 98 PRANDIMET TAB2-500MG... 98 PRANDIN TAB0.5MG... 98 PRANDIN TAB1MG... 98 PRANDIN TAB2MG... 98 pravastatin sodium tab 10 mg... 124 pravastatin sodium tab 20 mg... 124 pravastatin sodium tab 40 mg... 124 pravastatin sodium tab 80 mg... 124 prazosin hcl cap 1 mg... 111 prazosin hcl cap 2 mg... 111 prazosin hcl cap 5 mg... 111 PRED MILD SUS0.12% OP... 174 PRED-G SUSOP... 172 PRED-G S.O.POINOP... 172 prednicarbate cream 0.1%... 143 prednicarbate oint 0.1%... 143 prednisolone acetate ophth susp 1% 174 227

prednisolone sod phosph oral soln 6.7 mg/5ml (5 mg/5ml base)... 143 prednisolone sod phosphate oral soln 15 mg/5ml (base equiv)... 143 prednisolone sodium phosphate ophth soln 1%... 174 prednisone conc 5 mg/ml... 168 prednisone oral soln 5 mg/5ml... 168 prednisone tab 1 mg... 168 prednisone tab 10 mg... 168 prednisone tab 2.5 mg... 168 prednisone tab 20 mg... 168 prednisone tab 5 mg... 168 prednisone tab 50 mg... 168 PREFEST TAB... 150 PREMARIN TAB0.3MG... 150 PREMARIN TAB0.45MG... 151 PREMARIN TAB0.625MG... 151 PREMARIN TAB0.9MG... 151 PREMARIN TAB1.25MG... 151 PREMARIN VAGCRE0.625MG... 151 PREMPHASE TAB... 151 PREMPRO TAB.625-2.5... 151 PREMPRO TAB0.3-1.5... 151 PREMPRO TAB0.45-1.5... 151 PREMPRO TAB0.625-5... 151 prenatal vitamin min fa... 190 PREZISTA SUS100MG/ML... 93 PREZISTA TAB150MG... 93 PREZISTA TAB400MG... 93 PREZISTA TAB600MG... 93 PREZISTA TAB75MG... 93 PREZISTA TAB800MG... 93 PRIFTIN TAB150MG... 68 PRIMAQUINE TAB26.3MG... 82 primidone tab 250 mg... 52 primidone tab 50 mg... 52 PRISTIQ TAB100MG... 59 PRISTIQ TAB50MG... 59 PROAIR HFA AER... 177 probenecid tab 500 mg... 66 procainamide hcl inj 100 mg/ml... 116 prochlorperazine edisylate inj 5 mg/ml 61 prochlorperazine maleate tab 10 mg.. 61 prochlorperazine maleate tab 5 mg... 61 prochlorperazine suppos 25 mg... 61 PROCRIT INJ10000/ML... 108 PROCRIT INJ2000/ML... 108 PROCRIT INJ20000/ML... 108 PROCRIT INJ3000/ML... 108 PROCRIT INJ4000/ML... 108 PROCRIT INJ40000/ML... 109 Progestins... 151 PROGLYCEM SUS50MG/ML... 98 PROGRAF INJ5MG/ML... 162 PROLEUKIN INJ22MU... 75 PROLIA SOL60MG/ML... 170 PROMACTA TAB12.5MG... 109 PROMACTA TAB25MG... 109 PROMACTA TAB50MG... 109 PROMACTA TAB75MG... 109 promethazine hcl inj 25 mg/ml... 61 promethazine hcl inj 50 mg/ml... 61 promethazine hcl suppos 12.5 mg... 61 promethazine hcl suppos 25 mg... 61 promethazine hcl suppos 50 mg... 61 propafenone hcl tab 150 mg... 116 propafenone hcl tab 225 mg... 116 propafenone hcl tab 300 mg... 116 proparacaine hcl ophth soln 0.5%... 172 Prophylactic... 66 propranolol & hydrochlorothiazide tab 40-25 mg... 118 propranolol & hydrochlorothiazide tab 80-25 mg... 118 propranolol hcl cap sr 24hr 120 mg.. 118 propranolol hcl cap sr 24hr 160 mg.. 118 propranolol hcl cap sr 24hr 60 mg... 118 propranolol hcl cap sr 24hr 80 mg... 118 propranolol hcl inj 1 mg/ml... 118 propranolol hcl oral soln 20 mg/5ml.. 118 propranolol hcl oral soln 40 mg/5ml.. 118 propranolol hcl tab 10 mg... 119 propranolol hcl tab 20 mg... 119 propranolol hcl tab 40 mg... 119 propranolol hcl tab 60 mg... 119 propranolol hcl tab 80 mg... 119 propylthiouracil tab 50 mg... 156 PROQUAD INJ... 166 Protectants... 138 Proton Pump Inhibitors... 138 PROTONIX INJ40MG... 138 228

PROTOPIC OIN0.03%... 131 PROTOPIC OIN0.1%... 132 protriptyline hcl tab 10 mg... 60 protriptyline hcl tab 5 mg... 60 PROVENTIL AERHFA... 177 PULMICORT INH180MCG... 175 PULMICORT INH90MCG... 175 Pulmonary Antihypertensives... 177 PULMOZYME SOL1MG/ML... 181 pyridostigmine bromide tab 60 mg... 67 quetiapine fumarate tab 100 mg... 86 quetiapine fumarate tab 200 mg... 86 quetiapine fumarate tab 25 mg... 87 quetiapine fumarate tab 300 mg... 87 quetiapine fumarate tab 400 mg... 87 quetiapine fumarate tab 50 mg... 87 quinapril hcl tab 10 mg... 115 quinapril hcl tab 20 mg... 115 quinapril hcl tab 40 mg... 115 quinapril hcl tab 5 mg... 115 quinapril-hydrochlorothiazide tab 10-12.5 mg... 115 quinapril-hydrochlorothiazide tab 20-12.5 mg... 115 quinapril-hydrochlorothiazide tab 20-25 mg... 115 quinidine gluconate tab cr 324 mg... 116 quinidine sulfate tab 200 mg... 116 quinidine sulfate tab 300 mg... 116 quinidine sulfate tab cr 300 mg... 116 Quinolones... 48 QVAR AER40MCG... 175 QVAR AER80MCG... 175 RABAVERT INJ... 166 ramipril cap 1.25 mg... 115 ramipril cap 10 mg... 115 ramipril cap 2.5 mg... 115 ramipril cap 5 mg... 115 RANEXA TAB1000MG... 121 RANEXA TAB500MG... 121 ranitidine hcl cap 150 mg... 137 ranitidine hcl cap 300 mg... 137 ranitidine hcl inj 150 mg/6ml (25 mg/ml)... 137 ranitidine hcl syrup 15 mg/ml (75 mg/5ml)... 137 ranitidine hcl tab 150 mg... 137 ranitidine hcl tab 300 mg... 138 RAPAMUNE SOL1MG/ML... 162 RAPAMUNE TAB0.5MG... 162 RAPAMUNE TAB1MG... 162 RAPAMUNE TAB2MG... 162 REBETOL SOL40MG/ML... 90 REBIF INJ22/0.5... 129 REBIF INJ44/0.5... 129 REBIF TITRTNSOLPACK... 129 RECOMBIVA HBINJ10MCG/ML... 166 RECOMBIVA HBINJ5MCG/0.5ML... 166 RECOMBIVA-HBINJ40MCG/ML... 167 RELENZA MISDISKHALE... 94 RELISTOR KIT12/0.6ML... 136 RELPAX TAB20MG... 67 RELPAX TAB40MG... 67 REMICADE INJ100MG... 162 REMODULIN INJ10MG/ML... 178 REMODULIN INJ1MG/ML... 179 REMODULIN INJ2.5MG/ML... 179 REMODULIN INJ5MG/ML... 179 RESCRIPTOR TAB100 MG... 91 RESCRIPTOR TAB200MG... 91 RESERPINE TAB0.1MG... 111 RESERPINE TAB0.25MG... 111 RESPIRATORY TRACT AGENTS.. 174 Respiratory Tract Agents, Other... 180 RESTASIS EMU0.05%... 172 RETIN-A MICRGEL0.04%... 81 RETIN-A MICRGEL0.08%... 81 RETIN-A MICRGEL0.1%... 81 Retinoids... 81 RETROVIR INJ10MG/ML... 92 REVLIMID CAP10MG... 69 REVLIMID CAP15MG... 69 REVLIMID CAP2.5MG... 69 REVLIMID CAP20MG... 69 REVLIMID CAP25MG... 69 REVLIMID CAP5MG... 70 REYATAZ CAP100MG... 93 REYATAZ CAP150MG... 93 REYATAZ CAP200MG... 93 REYATAZ CAP300MG... 93 RHINOCORT SUSAQUA... 175 ribavirin cap 200 mg... 90 229

ribavirin tab 200 mg... 90 ribavirin tab 400 mg... 90 ribavirin tab 400 mg & ribavirin tab 600 mg dose pack... 90 ribavirin tab 600 mg... 90 RIDAURA CAP3MG... 165 rifampin cap 150 mg... 68 rifampin cap 300 mg... 68 rifampin for inj 600 mg... 68 RIFATER TAB... 68 RILUTEK TAB50MG... 127 rimantadine hydrochloride tab 100 mg 94 RISPERDAL INJ12.5MG... 87 RISPERDAL INJ25MG... 87 RISPERDAL INJ37.5MG... 87 RISPERDAL INJ50MG... 87 risperidone orally disintegrating tab 0.25 mg... 87 risperidone orally disintegrating tab 0.5 mg... 87 risperidone orally disintegrating tab 1 mg... 87 risperidone orally disintegrating tab 2 mg... 87 risperidone orally disintegrating tab 3 mg... 87 risperidone orally disintegrating tab 4 mg... 87 risperidone soln 1 mg/ml... 87 risperidone tab 0.25 mg... 87 risperidone tab 0.5 mg... 87 risperidone tab 1 mg... 87 risperidone tab 2 mg... 87 risperidone tab 3 mg... 87 risperidone tab 4 mg... 87 RITUXAN INJ500MG... 80 rivastigmine tartrate cap 1.5 mg... 55 rivastigmine tartrate cap 3 mg... 55 rivastigmine tartrate cap 4.5 mg... 55 rivastigmine tartrate cap 6 mg... 55 rizatriptan benzoate orally disintegrating tab 10 mg... 67 rizatriptan benzoate orally disintegrating tab 5 mg... 67 rizatriptan benzoate tab 10 mg... 67 rizatriptan benzoate tab 5 mg... 67 ropinirole hydrochloride tab 0.25 mg.. 83 ropinirole hydrochloride tab 0.5 mg... 83 ropinirole hydrochloride tab 1 mg... 83 ropinirole hydrochloride tab 2 mg... 83 ropinirole hydrochloride tab 3 mg... 83 ropinirole hydrochloride tab 4 mg... 83 ropinirole hydrochloride tab 5 mg... 83 ROTATEQ SUS... 167 ROZEREM TAB8MG... 182 SABRIL POW500MG... 52 SABRIL TAB500MG... 52 SAIZEN INJ5MG... 147 SAIZEN INJ8.8MG... 147 SANDIMMUNE SOL100MG/ML... 163 SANDOSTATIN KITLAR 10MG... 154 SANDOSTATIN KITLAR 20MG... 154 SANDOSTATIN KITLAR 30MG... 154 SANTYL OIN250/GM... 132 SAPHRIS SUB10MG... 96 SAPHRIS SUB5MG... 96 Selective Estrogen Receptor Modifying Agents... 151 selegiline hcl cap 5 mg... 84 selegiline hcl tab 5 mg... 84 selenium sulfide lotion 2.5%... 132 SELZENTRY TAB150MG... 93 SELZENTRY TAB300MG... 93 SENSIPAR TAB30MG... 153 SENSIPAR TAB60MG... 153 SENSIPAR TAB90MG... 153 SEREVENT DISAER50MCG... 177 SEROQUEL XR TAB150MG... 87 SEROQUEL XR TAB200MG... 87 SEROQUEL XR TAB300MG... 87 SEROQUEL XR TAB400MG... 87 SEROQUEL XR TAB50MG... 87 SEROSTIM INJ4MG... 147 SEROSTIM INJ5MG... 147 SEROSTIM INJ6MG... 147 Serotonin (5-HT) 1b/1d Receptor Agonists... 66 Serotonin/ Norepinephrine Reuptake Inhibitors... 57 sertraline hcl oral conc 20 mg/ml... 59 sertraline hcl tab 100 mg... 59 sertraline hcl tab 25 mg... 59 230

sertraline hcl tab 50 mg... 59 silver sulfadiazine cream 1%... 49 SIMCOR TAB1000-20... 124 SIMCOR TAB1000-40... 124 SIMCOR TAB500-20MG... 124 SIMCOR TAB500-40MG... 124 SIMCOR TAB750-20MG... 124 SIMPONI INJ50MG... 163 SIMULECT INJ20MG... 163 simvastatin tab 10 mg... 124 simvastatin tab 20 mg... 124 simvastatin tab 40 mg... 124 simvastatin tab 5 mg... 124 simvastatin tab 80 mg... 124 sirolimus tab 0.5 mg... 163 SKELETAL MUSCLE RELAXANTS 182 SLEEP DISORDER AGENTS... 182 Sleep Disorders, Other... 182 Smoking Cessation Agents... 35 Sodium Channel Agents... 53 Sodium Channel Inhibitors... 53 sodium chloride inj 0.45%... 190 sodium chloride inj 2.5 meq/ml (14.6%)... 191 sodium chloride inj 3%... 191 sodium chloride inj 5%... 191 sodium chloride irrigation soln 0.9%. 191 sodium chloride iv soln 0.9%... 191 sodium fluoride 2.2mg... 191 sodium polystyrene sulfonate oral susp 15 gm/60ml... 183 SOLARAZE GEL3% W/W... 132 SOLTAMOX SOL10MG/5ML... 70 SOMATULINE INJ120/.5ML... 147 SOMATULINE INJ60/0.2ML... 148 SOMATULINE INJ90/0.3ML... 148 SOMAVERT INJ10MG... 155 SOMAVERT INJ15MG... 155 SOMAVERT INJ20MG... 155 SORIATANE CAP10MG... 132 SORIATANE CAP17.5MG... 132 SORIATANE CAP25MG... 132 sotalol hcl (afib/afl) tab 120 mg... 116 sotalol hcl tab 120 mg... 116 sotalol hcl tab 160 mg... 116 sotalol hcl tab 240 mg... 116 sotalol hcl tab 80 mg... 116 SOVALDI TAB400MG... 90 SPIRIVA CAPHANDIHLR... 176 spironolactone & hydrochlorothiazide tab 25-25 mg... 122 spironolactone tab 100 mg... 122 spironolactone tab 25 mg... 122 spironolactone tab 50 mg... 122 SPRYCEL TAB100MG... 78 SPRYCEL TAB140MG... 78 SPRYCEL TAB20MG... 78 SPRYCEL TAB50MG... 78 SPRYCEL TAB70MG... 78 SPRYCEL TAB80MG... 78 stavudine cap 15 mg... 92 stavudine cap 20 mg... 92 stavudine cap 30 mg... 92 stavudine cap 40 mg... 92 stavudine for oral soln 1 mg/ml... 92 STAVZOR CAP125MG... 52 STAVZOR CAP250MG... 52 STAVZOR CAP500MG... 52 STIMATE SOL1.5MG/ML... 148 STIVARGA TAB40MG... 78 STRATTERA CAP100MG... 127 STRATTERA CAP10MG... 127 STRATTERA CAP18MG... 127 STRATTERA CAP25MG... 127 STRATTERA CAP40MG... 127 STRATTERA CAP60MG... 127 STRATTERA CAP80MG... 127 streptomycin sulfate for inj 1 gm... 36 STRIBILD TAB... 92 STROMECTOL TAB3MG... 81 SUBOXONE MIS12-3MG... 33 SUBOXONE MIS2-0.5MG... 34 SUBOXONE MIS4-1MG... 35 SUBOXONE MIS8-2MG... 35 sucralfate tab 1 gm... 138 sulfacetamide sodium lotion 10% (acne)... 49 sulfacetamide sodium ophth oint 10% 49 sulfacetamide sodium ophth soln 10% 49 sulfacetamide sodium-prednisolone ophth oint 10-0.2%... 172 231

sulfacetamide sodium-prednisolone ophth soln 10-0.23(0.25)%... 172 sulfadiazine tab 500 mg... 49 sulfamethoxazole-trimethoprim iv soln 400-80 mg/5ml... 49 sulfamethoxazole-trimethoprim susp 200-40 mg/5ml... 49 sulfamethoxazole-trimethoprim tab 400-80 mg... 49 sulfamethoxazole-trimethoprim tab 800-160 mg... 49 SULFAMYLON CRE85MG/GM... 38 sulfasalazine tab 500 mg... 168 sulfasalazine tab delayed release 500 mg... 168 Sulfonamides... 49, 168 sulindac tab 150 mg... 27 sulindac tab 200 mg... 27 sumatriptan succinate inj 6 mg/0.5ml. 67 sumatriptan succinate tab 100 mg... 67 sumatriptan succinate tab 25 mg... 67 sumatriptan succinate tab 50 mg... 67 SUPRAX SUS100/5ML... 43 SUPRAX SUS200/5ML... 43 SUPRAX SUS500/5ML... 43 SUSTIVA CAP200MG... 92 SUSTIVA CAP50MG... 92 SUSTIVA TAB600MG... 92 SUTENT CAP12.5MG... 78 SUTENT CAP25MG... 78 SUTENT CAP37.5MG... 79 SUTENT CAP50MG... 79 SYLATRON KIT296MCG... 165 SYLATRON KIT444MCG... 165 SYLATRON KIT888MCG... 165 SYMBICORT AER160-4.5... 177 SYMBICORT AER80-4.5... 177 SYMLINPEN 60INJ1000MCG... 98 SYMLNPEN 120INJ1000MCG... 98 SYNAREL SOL2MG/ML... 155 SYNRIBO INJ3.5MG... 75 SYNTHROID TAB100MCG... 152 SYNTHROID TAB112MCG... 152 SYNTHROID TAB125MCG... 152 SYNTHROID TAB137MCG... 152 SYNTHROID TAB150MCG... 152 SYNTHROID TAB175MCG... 152 SYNTHROID TAB200MCG... 152 SYNTHROID TAB25MCG... 153 SYNTHROID TAB300MCG... 153 SYNTHROID TAB50MCG... 153 SYNTHROID TAB75MCG... 153 SYNTHROID TAB88MCG... 153 SYPRINE CAP250MG... 184 TABLOID TAB40MG... 71 tacrolimus cap 0.5 mg... 163 tacrolimus cap 1 mg... 163 tacrolimus cap 5 mg... 164 TAFINLAR CAP50MG... 76 TAFINLAR CAP75MG... 76 TAMIFLU CAP30MG... 94 TAMIFLU CAP45MG... 94 TAMIFLU CAP75MG... 94 TAMIFLU SUS6MG/ML... 94 tamoxifen citrate tab 10 mg (base equivalent)... 70 tamoxifen citrate tab 20 mg (base equivalent)... 70 tamsulosin hcl cap 0.4 mg... 139 TARCEVA TAB100MG... 79 TARCEVA TAB150MG... 79 TARCEVA TAB25MG... 79 TARGRETIN CAP75MG... 81 TARGRETIN GEL1%... 81 TASIGNA CAP150MG... 79 TASIGNA CAP200MG... 79 TASMAR TAB100MG... 82 TAZORAC CRE0.05%... 132 TAZORAC CRE0.1%... 132 TAZORAC GEL0.05%... 132 TAZORAC GEL0.1%... 132 TEKAMLO TAB150-10MG... 112 TEKAMLO TAB150-5MG... 112 TEKAMLO TAB300-10MG... 113 TEKAMLO TAB300-5MG... 113 TEKTURNA TAB150MG... 113 TEKTURNA TAB300MG... 113 TEKTURNA HCTTAB150-12.5... 113 TEKTURNA HCTTAB150-25MG... 113 TEKTURNA HCTTAB300-12.5... 113 TEKTURNA HCTTAB300-25MG... 113 temazepam cap 15 mg... 96 232

temazepam cap 22.5 mg... 96 temazepam cap 30 mg... 96 temazepam cap 7.5 mg... 96 terazosin hcl cap 1 mg... 111 terazosin hcl cap 10 mg... 111 terazosin hcl cap 2 mg... 112 terazosin hcl cap 5 mg... 112 terbinafine hcl tab 250 mg... 65 terbutaline sulfate inj 1 mg/ml... 177 terbutaline sulfate tab 2.5 mg... 177 terbutaline sulfate tab 5 mg... 177 terconazole vaginal cream 0.4%... 65 terconazole vaginal cream 0.8%... 65 terconazole vaginal suppos 80 mg... 65 TESTIM GEL1%(50MG)... 148 testosterone enanthate im in oil 200 mg/ml... 148 TET/DIP TOX INJ2-2 LF... 167 TETANUS TOX INJ5LF ADS... 167 Tetracyclines... 49 tetrahydrozoline hcl nasal soln 0.05%... 181 tetrahydrozoline hcl nasal soln 0.1% 181 THALOMID CAP100MG... 70 THALOMID CAP150MG... 70 THALOMID CAP200MG... 70 THALOMID CAP50MG... 70 theophylline tab sr 12hr 100 mg... 176 theophylline tab sr 12hr 200 mg... 176 theophylline tab sr 12hr 300 mg... 176 theophylline tab sr 12hr 450 mg... 176 theophylline tab sr 24hr 400 mg... 176 theophylline tab sr 24hr 600 mg... 176 THERAPEUTIC NUTRIENTS/MINERALS/ELECTROL YTES... 183 thioridazine hcl tab 10 mg... 85 thioridazine hcl tab 100 mg... 85 thioridazine hcl tab 25 mg... 85 thioridazine hcl tab 50 mg... 85 thiothixene cap 1 mg... 85 thiothixene cap 10 mg... 85 thiothixene cap 2 mg... 85 thiothixene cap 5 mg... 85 THYMOGLOBULNINJ25MG... 165 ticlopidine hcl tab 250 mg... 110 TIKOSYN CAP125MCG... 116 TIKOSYN CAP250MCG... 116 TIKOSYN CAP500MCG... 116 timolol maleate ophth gel forming soln 0.25%... 173 timolol maleate ophth gel forming soln 0.5%... 173 timolol maleate ophth soln 0.25%... 173 timolol maleate ophth soln 0.5%... 173 timolol maleate tab 10 mg... 66 timolol maleate tab 20 mg... 66 timolol maleate tab 5 mg... 66 TIVICAY TAB50MG... 93 tizanidine hcl cap 2 mg... 88 tizanidine hcl cap 4 mg... 88 tizanidine hcl cap 6 mg... 88 tizanidine hcl tab 2 mg... 88 tizanidine hcl tab 4 mg... 88 TOBI NEB300/5ML... 36 TOBRADEX OIN0.3-0.1%... 172 tobramycin sulfate inj 10 mg/ml... 36 tobramycin sulfate inj 80 mg/2ml (40 mg/ml)... 36 tobramycin sulfate ophth soln 0.3%... 36 tobramycin-dexamethasone ophth susp 0.3-0.1%... 172 tolazamide tab 250 mg... 98 tolazamide tab 500 mg... 98 tolbutamide tab 500 mg... 98 tolmetin sodium cap 400 mg... 27 tolmetin sodium tab 200 mg... 27 tolmetin sodium tab 600 mg... 27 tolterodine tartrate tab 1 mg... 139 tolterodine tartrate tab 2 mg... 139 topiramate sprinkle cap 15 mg... 52 topiramate sprinkle cap 25 mg... 52 topiramate tab 100 mg... 52 topiramate tab 200 mg... 53 topiramate tab 25 mg... 53 topiramate tab 50 mg... 53 topotecan hcl for inj 4 mg... 77 torsemide tab 10 mg... 122 torsemide tab 100 mg... 122 torsemide tab 20 mg... 122 torsemide tab 5 mg... 122 TOVIAZ TAB4MG... 139 233

TOVIAZ TAB8MG... 139 TPN ELECTROLINJ... 191 TRACLEER TAB125MG... 179 TRACLEER TAB62.5MG... 180 tramadol hcl tab 50 mg... 33 tramadol hcl tab sr 24hr 100 mg... 31 tramadol hcl tab sr 24hr 200 mg... 31 tramadol hcl tab sr 24hr biphasic release 300 mg... 31 tramadol-acetaminophen tab 37.5-325 mg... 33 trandolapril tab 1 mg... 115 trandolapril tab 2 mg... 115 trandolapril tab 4 mg... 115 tranexamic acid inj 100 mg/ml... 110 tranylcypromine sulfate tab 10 mg... 57 trazodone hcl tab 100 mg... 57 trazodone hcl tab 150 mg... 57 trazodone hcl tab 300 mg... 57 trazodone hcl tab 50 mg... 57 Treatment Resistent... 87 TRECATOR TAB250MG... 68 tretinoin cap 10 mg... 81 tretinoin cream 0.025%... 81 tretinoin cream 0.05%... 81 tretinoin cream 0.1%... 81 tretinoin gel 0.01%... 81 tretinoin gel 0.025%... 81 triamcinolone acetonide cream 0.025%... 143 triamcinolone acetonide cream 0.1% 143 triamcinolone acetonide cream 0.5% 143 triamcinolone acetonide dental paste 0.1%... 130 triamcinolone acetonide lotion 0.025%... 143 triamcinolone acetonide lotion 0.1%. 143 triamcinolone acetonide nasal inhal 55 mcg/act... 175 triamcinolone acetonide oint 0.025% 143 triamcinolone acetonide oint 0.1%... 143 triamcinolone acetonide oint 0.5%... 143 triamterene & hydrochlorothiazide cap 37.5-25 mg... 123 triamterene & hydrochlorothiazide tab 37.5-25 mg... 123 triamterene & hydrochlorothiazide tab 75-50 mg... 123 Tricyclics... 59 trifluoperazine hcl tab 1 mg... 85 trifluoperazine hcl tab 10 mg... 85 trifluoperazine hcl tab 2 mg... 85 trifluoperazine hcl tab 5 mg... 85 trifluridine ophth soln 1%... 91 trihexyphenidyl hcl elixir 0.4 mg/ml... 82 trihexyphenidyl hcl tab 2 mg... 82 trihexyphenidyl hcl tab 5 mg... 82 trimethoprim tab 100 mg... 38 trimipramine maleate cap 100 mg... 60 trimipramine maleate cap 25 mg... 60 trimipramine maleate cap 50 mg... 60 TRISENOX SOL10MG/10M... 76 TRIZIVIR TAB... 92 TROKENDI XR... 53 TROPHAMINE INJ10%... 192 trospium chloride cap sr 24hr 60 mg 139 trospium chloride tab 20 mg... 139 TRUVADA TAB200-300... 92 TWINRIX INJ... 167 TYGACIL INJ50MG... 38 TYKERB TAB250MG... 79 TYPHIM VI INJ... 167 TYSABRI INJ... 129 TYZEKA TAB600MG... 91 ULORIC TAB40MG... 66 ULORIC TAB80MG... 66 urea-hc acetate cream 1%... 143 ursodiol cap 300 mg... 137 ursodiol tab 250 mg... 137 ursodiol tab 500 mg... 137 Vaccines... 165 valacyclovir hcl tab 1 gm... 91 valacyclovir hcl tab 500 mg... 91 VALCYTE SOL50MG/ML... 88 VALCYTE TAB450MG... 88 valproate sodium inj 100 mg/ml... 52 valproate sodium syrup 250 mg/5ml (base equiv)... 52 valproic acid cap 250 mg... 52 valsartan-hydrochlorothiazide tab 160-12.5 mg... 113 234

valsartan-hydrochlorothiazide tab 160-25 mg... 113 valsartan-hydrochlorothiazide tab 320-12.5 mg... 113 valsartan-hydrochlorothiazide tab 320-25 mg... 113 valsartan-hydrochlorothiazide tab 80-12.5 mg... 113 vancomycin hcl for inj 10 gm... 38 vancomycin hcl for inj 1000 mg... 38 vancomycin hcl for inj 500 mg... 38 VAQTA INJ25/0.5ML... 167 VAQTA INJ50UNT/ML... 167 VARIVAX INJ... 167 Vasodilators, Direct-acting Arterial... 124, 125 Vasodilators, Direct-acting Arterial/Venous... 125 VELCADE INJ3.5MG... 76 venlafaxine hcl cap sr 24hr 150 mg (base equivalent)... 59 venlafaxine hcl cap sr 24hr 37.5 mg (base equivalent)... 59 venlafaxine hcl cap sr 24hr 75 mg (base equivalent)... 59 VENTOLIN HFAAER... 177 VERAMYST SPR27.5MCG... 175 verapamil hcl cap sr 24hr 100 mg... 120 verapamil hcl cap sr 24hr 120 mg... 120 verapamil hcl cap sr 24hr 180 mg... 120 verapamil hcl cap sr 24hr 200 mg... 120 verapamil hcl cap sr 24hr 240 mg... 121 verapamil hcl cap sr 24hr 300 mg... 121 verapamil hcl cap sr 24hr 360 mg... 121 verapamil hcl iv soln 2.5 mg/ml... 121 verapamil hcl tab 120 mg... 121 verapamil hcl tab 40 mg... 121 verapamil hcl tab 80 mg... 121 verapamil hcl tab cr 120 mg... 121 verapamil hcl tab cr 180 mg... 121 verapamil hcl tab cr 240 mg... 121 VERSACLOZ SUS50MG/ML... 88 VEXOL SUS1% OP... 174 VFEND SUS40MG/ML... 65 VIAGRA... 195 VIAGRA 100MG, 25MG, 50MG,... 195 VICTRELIS CAP200MG... 91 VIDAZA INJ100MG... 76 VIDEX SOL2GM... 92 VIGAMOX DRO0.5%... 49 VIIBRYD KIT... 57 VIIBRYD TAB10MG... 57 VIIBRYD TAB20MG... 57 VIIBRYD TAB40MG... 57 VIMPAT INJ200MG/20... 54 VIMPAT SOL10MG/ML... 54 VIMPAT TAB100MG... 54 VIMPAT TAB150MG... 54 VIMPAT TAB200MG... 54 VIMPAT TAB50MG... 54 VIRACEPT TAB250MG... 94 VIRACEPT TAB625MG... 94 VIRAMUNE SUS50MG/5ML... 92 VIRAMUNE XR TAB100MG... 92 VIRAMUNE XR TAB400MG... 92 VIRAZOLE INH6GM... 91 VIREAD POW40MG/GM... 92 VIREAD TAB150MG... 92 VIREAD TAB200MG... 93 VIREAD TAB250MG... 93 VIREAD TAB300MG... 93 VOLTAREN GEL1%... 132 voriconazole tab 200 mg... 66 voriconazole tab 50 mg... 66 VOTRIENT TAB200MG... 79 VYTORIN TAB10-10MG... 124 VYTORIN TAB10-20MG... 124 VYTORIN TAB10-40MG... 124 VYTORIN TAB10-80MG... 124 warfarin sodium tab 1 mg... 104 warfarin sodium tab 10 mg... 104 warfarin sodium tab 2 mg... 104 warfarin sodium tab 2.5 mg... 104 warfarin sodium tab 3 mg... 104 warfarin sodium tab 4 mg... 104 warfarin sodium tab 5 mg... 104 warfarin sodium tab 6 mg... 104 warfarin sodium tab 7.5 mg... 104 WELCHOL PAK3.75GM... 124 WELCHOL TAB625MG... 124 XALKORI CAP200MG... 79 XALKORI CAP250MG... 79 235

XARELTO TAB10MG... 104 XARELTO TAB15MG... 105 XARELTO TAB20MG... 105 XENAZINE TAB12.5MG... 127 XENAZINE TAB25MG... 128 XGEVA INJ... 170 XOLAIR SOL150MG... 181 XOPENEX HFA AER... 177 XTANDI CAP40MG... 156 XYREM SOL500MG/ML... 182 YERVOY INJ50MG... 80 YF-VAX INJ... 167 zafirlukast tab 10 mg... 175 zafirlukast tab 20 mg... 175 zaleplon cap 10 mg... 182 zaleplon cap 5 mg... 182 ZALTRAP INJ100/4ML... 80 ZANOSAR INJ1GM... 68 ZAVESCA CAP100MG... 135 ZAZOLE CRE0.4%... 66 ZELBORAF TAB240MG... 76 ZEMAIRA INJ1000MG... 181 ZEMPLAR CAP1MCG... 170 ZEMPLAR CAP2MCG... 170 ZEMPLAR CAP4MCG... 171 ZEMPLAR INJ2MCG/ML... 171 ZEMPLAR INJ5MCG/ML... 171 ZENPEP CAP10000UNT... 136 ZENPEP CAP15000UNT... 136 ZENPEP CAP20000UNT... 136 ZENPEP CAP25000UNT... 136 ZENPEP CAP3000UNIT... 136 ZENPEP CAP5000UNIT... 136 ZETIA TAB10MG... 124 ZIAGEN SOL20MG/ML... 93 zidovudine cap 100 mg... 93 zidovudine syrup 10 mg/ml... 93 zidovudine tab 300 mg... 93 ziprasidone hcl cap 20 mg... 87 ziprasidone hcl cap 40 mg... 87 ziprasidone hcl cap 60 mg... 87 ziprasidone hcl cap 80 mg... 87 ZIRGAN GEL0.15%... 88 ZMAX SUS2GM... 48 zoledronic acid inj conc for iv infusion 4 mg/5ml... 171 zoledronic acid iv soln 5 mg/100ml.. 171 ZOLINZA CAP100MG... 66 zolpidem tartrate tab 10 mg... 182 zolpidem tartrate tab 5 mg... 182 zolpidem tartrate tab cr 12.5 mg... 182 zolpidem tartrate tab cr 6.25 mg... 182 ZOMIG... 4 zonisamide cap 100 mg... 51 zonisamide cap 25 mg... 51 zonisamide cap 50 mg... 51 ZORBTIVE INJ8.8MG... 148 ZORTRESS TAB0.25MG... 164 ZORTRESS TAB0.5MG... 164 ZORTRESS TAB0.75MG... 164 ZOSTAVAX INJ... 167 ZOVIRAX CRE5%... 91 ZOVIRAX OIN5%... 91 ZYDELIG TAB100MG... 76 ZYDELIG TAB150MG... 76 ZYFLO CR TAB600MG... 175 ZYKADIA CAP150MG... 79 ZYTIGA TAB250MG... 156 ZYVOX SOL2MG/ML... 39 ZYVOX SUS100MG/5M... 39 ZYVOX TAB600MG... 39 236

This formulary was updated 10/28/2014. For more recent information or other questions, please contact Central Health Medicare Plan at 1-866-314-2427, or for TTY users, 1-888-205-7671, 7 days a week, 8:00 AM to 8:00 PM (PST), or visit www.centralhealthplan.com. 237

Este formulario fue actualizado el 10/28/2014. Para información más reciente u otras preguntas, favor de ponerse en contacto con nuestro Departamento de Servicio al Miembro al 1-866-314-2427 o, para usuarios de TTYdeben llamar al 1-888-205-7671, los 7 días a la semana, de 8:00 AM a 8:00 PM (Tiempo Pacifico), o visite el sitio web www.centralhealthplan.com. 238

本處方集最近更新日期為 10/28/2014 有關更新修訂或其他資訊, 請聯絡中心健保 :1-866-314-2427 或聽障 / 語障專線 1-888-205-7671, 一週七天, 上午 8:00 到下午 8:00( 太平洋時間 ) 或上網 www.centralhealthplan.com. 239