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

H9345_MBR6_03c CMS Approved VillageCareMAX Full Advantage FIDA 計劃 (Medicare-Medicaid Plan, 即 醫療保險 紐約州衛生署計劃 ) 206 年給付藥品目錄 ( 處方一覽表 ) 該給付藥品清單已在 0/0/206 更新 欲了解更多最新信息或其他問題, 請撥打 VillageCareMAX 全部優勢 FIDA 計劃服務熱線 -800-469-6292, 聽障者電話 (TTY) 用戶請撥打 7, 辦公時間為上午 8 時到下午 8 時, 每週 7 天 或訪問 www.villagecaremax.org. Formulary ID: 65.000, Version 9

VillageCareMAX Full Advantage FIDA 計劃 206 年涵蓋藥品目錄 ( 處方一覽表 ) 這是參與者可在 VillageCareMAX Full Advantage FIDA 計劃中獲得藥品的清單 VillageCareMAX Full Advantage FIDA 計劃是一項管理式醫療計劃, 與醫療保險部門及紐約州衛生署簽訂合約, 以全面整合雙重優勢 (FIDA - 全面整合雙重優勢 ) 方案來為參與者同時提供兩項計劃的福利 給付藥品清單以及 / 可能會在一年之中作出更改 當我們作出的變更會影響到您之前, 我們會向您發送通知 福利可能會在每年的 0 月 0 日作出更改 您可上網 (www.villagecaremax.org) 查看 VillageCareMAX Full Advantage FIDA 計劃的最新給付藥品清單, 或撥打 VillageCareMAX Full Advantage FIDA 計劃參與者服務熱線 -800-469-629 隨時核查 聽障者電話 (TTY) 用戶請撥打 7 請注意可能存在的局限性和限制 若需要進一步的資訊, 請撥打 VillageCareMAX Full Advantage FIDA 計劃參與者服務熱線或閱讀 VillageCareMAX Full Advantage FIDA 參與者手冊 對於任何給付藥品都無需承擔自付額 ( 被保險人用於就醫或配藥所支付的小額費用 ) 您還可以免費索取大字版, 點字或語音等格式, 請撥打免付費專線 -800-469-6292 和 7, 上午 8 時至晚上 8 時, 每週 7 天 You can get this information for free in other languages. Call -800-469-6292 and TTY users should call 7, during the hours of 8:00 am to 8:00 pm, 7 days a week. The call is free. Puede obtener esta información gratis en Español.Llame a Servicios del Participante al -800-469-6292 durante las horas de 8:00 am a 8:00pm, 7 días de la semana. Usuarios de TTY llamar al 7.La llamada es gratuita. Lei puo ottenere questi informazioni in Italiano gratuitamente. Chiama il Servizio Partecipanti a -800-469-6292 durante il periodo da 8AM a 8PM, 7 giorni alla settimana. TTY utilizzatori dovressi chiamare 7. La chiamata è gratis. Ou ka jwenn enfòmasyon sa a gratis nan kreyòl Ayisyen. Rele sèvis patisipan nan -800-469-6292 pandan lè 8:00 am jiska 8:00 pm, 7 jou pà semèn. Itilisatè ATS yo dwe rele nan 7. Apèl sa a gratis. 如果您有任何疑問, 請撥打 VillageCareMAX Full Advantage FIDA 計劃免費專線 -800-469-6292, 上午 8 時至晚上 8 時, 每週 7 天 若需要進一步的資訊, 請上網 :www.villagecaremax.org ii

Вы можете получить эту информацию бесплатно на русском языке. Звоните в Отдел обслуживания участников плана по телефону -800-469-6292 с 8:00 до 20:00, без выходных. Пользователи TTY звоните по телефону 7. Звонок бесплатный. 您可免費獲得到以上的中文資訊, 請致電參與者服務電話 -800-469-6292, 辦公時間為上午 8 時到下午 8 時, 每週 7 天 聽障者電話服務專線 (TTY) 用戶請撥打 7 該電話為免付費通話 한국어로된정보를무료로얻을수있습니다. 주 7 일오전 8 시에서오후 8 시사이에 -800-469- 6292 번 (TTY 사용자는 7 번 ) 으로문의해주십시오. 통화는무료입니다. 紐約州備有參與者申訴方案稱為獨立消費者倡權網路 (ICAN), 可為參與者提供 VillageCareMAX Full Advantage FIDA 計劃的免費 保密協助 若需要使用參與者申訴服務 (ICAN), 請撥打免付費電話 :-844-64-8800, 或造訪網站 www.icannys.org 如果您有任何疑問, 請撥打 VillageCareMAX Full Advantage FIDA 計劃免費專線 -800-469-6292, 上午 8 時至晚上 8 時, 每週 7 天 若需要進一步的資訊, 請上網 :www.villagecaremax.org iii

常見問題 (FAQ) 您可在此處查找有關給付藥品清單疑問的答案 您可以閱讀所有的常見問題瞭解更多資訊, 也可以查找問題和答案. 給付藥品清單上有什麼處方藥? ( 此處我們將給付藥品清單簡稱為 藥品清單 ) 從給付藥品清單第一頁開始的所有藥品均為 VillageCareMAX Full Advantage FIDA 計劃給付藥品 這些藥品在我們藥房網路中的所有藥店內有售 如果一個藥房與我們簽署了合作為您提供服務的合約, 那麼這個藥房就在我們網路中 我們將這個藥房稱為 網路藥房 如果符合以下情況,VillageCareMAX Full Advantage FIDA 計劃將給付藥品清單上的所有藥品 : 您的醫生或其他處方開立者認為您需要這些藥品來獲得好轉或保持健康, 您需要此藥品治療病情, 且 您在 VillageCareMAX Full Advantage FIDA 計劃網路藥房內補藥 在獲得某些藥品的過程中,VillageCareMAX Full Advantage FIDA 計劃可能會採取額外的步驟 ( 詳見下文中的問題 5) 在某些情況下, 您在獲得某種藥品前可能必須先進行其它步驟, 比如先嘗試其它藥品等 您也可以前往我們的網站 www.villagecaremax.org 或者撥打參與者服務熱線 -800-469- 6292 獲得最新的藥品清單 聽障者電話 (TTY) 用戶請撥打 7 2. 藥品清單是否會不斷變化? 是 VillageCareMAX Full Advantage FIDA 計劃可能會隨時增加或減少藥品清單上的藥品 一般來說, 藥品清單只會在以下情況下更改 : 出現了一種與藥品清單上現有藥品效果一樣好的新藥, 或者 我們瞭解到清單上的某種藥品不安全 我們也有可能會更改有關藥品的規定 比如說, 我們可能會 : 如果您有任何疑問, 請撥打 VillageCareMAX Full Advantage FIDA 計劃免費專線 -800-469-6292, 上午 8 時至晚上 8 時, 每週 7 天 若需要進一步的資訊, 請上網 :www.villagecaremax.org iv

要求或取消要求某種藥物的事先許可 ( 事先許可即在您獲得某種藥品前, 來自 VillageCareMAX Full Advantage FIDA 計劃部門或者您的跨學科專業團隊 (Interdisciplinary Team,IDT) 的許可 ) 增加或更改您可獲得某種藥品的數量 ( 被稱為 限量 ) 增加或更改某種藥品的階段療法限制 ( 階段療法是指您在獲得某種藥品前必須先嘗試另一種藥品 ) ( 有關這些藥品規定的進一步資訊請參閱第 vi 頁 ) 當您正在使用的某種藥物被從藥品清單中移除時, 我們會通知您 當我們對某種藥品的給付規定進行更改時, 也會通知您 有關藥品清單更改時狀況的進一步資訊請查看下文中的問題 3 4 和 7 您可隨時上網 (www.villagecaremax.org) 查看 VillageCareMAX Full Advantage FIDA 計劃的最新藥品清單 您也可撥打參與者服務熱線 -800-469-6292 核查現行的藥品清單 聽障者電話 (TTY) 用戶請撥打 7 3. 當出現了一種與藥品清單上現有藥品效果一樣好且更便宜的新藥時, 會如何處理? 如果出現了一種與藥品清單上現有藥品效果一樣好且更便宜的新藥 : 當您下次補藥時, 您的藥師可能會給您比較便宜的那一款藥品 如果您和您的處方提供者認為便宜的那一款藥品不適合您, 那麼您的處方提供者可致電藥師, 請他 / 她繼續給您現在正在服用的這種藥品 VillageCareMAX Full Advantage FIDA 計劃部門可能會決定將比較貴的那一款藥品從藥品清單中移除 如果您正在服用的某種藥品因為存在效果同樣好且比較便宜的藥品上市而從藥品清單上被移除, 我們將會在將其從藥品清單上移除前至少 60 天 或者在您補藥時通知您 因此您可以在藥品清單更改前獲得 60 天劑量的該藥品 當您正在使用的某種藥物自藥品清單中移除時,VillageCareMAX Full Advantage FIDA 計劃部門會寄信通知您 我們的網站上列有關於藥品清單的最新資訊 如有任何疑問, 您可以隨時上網 (www.villagecaremax) 查看或者撥打參與者服務熱線諮詢 我們的電話號碼為 -800-469-6292 聽障者電話 (TTY) 用戶請撥打 7 我們的營業時間為每週 7 天, 上午 8:00 至晚上 8:00 如果您有任何疑問, 請撥打 VillageCareMAX Full Advantage FIDA 計劃免費專線 -800-469-6292, 上午 8 時至晚上 8 時, 每週 7 天 若需要進一步的資訊, 請上網 :www.villagecaremax.org v

4. 當我們發現某種藥品不安全時, 會如何處理? 如果美國食品藥物管理局 (FDA) 指出您正在服用的藥品不安全, 我們會直接將其從藥品清單上移除 我們也會寄信和致電給您, 讓您得知這種不安全藥物已從藥品清單上移除 如果您正在服用某種已由 FDA 確認為不安全的藥物, 請與您的醫生談一談 您的醫生可以開立另一種藥物來取代不再供應的藥物 5. 藥品給付是否存在任何限制或局限性? 或者說, 如要獲得某些藥品, 是否要求採取某些行動? 是的, 部分藥品具有給付規定或限量規定 在某些情況下, 在獲得藥品前您或您的醫生或其他處方開立者必須先進行其它步驟 例如 : 獲得事先許可 ( 或事先授權 ): 對於某些藥品, 在您獲得藥品前, 您或您的醫生或其他處方開立者必須先獲得來自 VillageCareMAX Full Advantage FIDA 計劃部門或者您的多專業團隊 (Interdisciplinary Team,IDT) 的許可 若您未獲得許可, 則 VillageCareMAX Full Advantage FIDA 計劃將不會為您給付此藥品 數量限制 : 某些情況下,VillageCareMAX Full Advantage FIDA 計劃會限制您可獲得藥品的數量 階段療法 : 某些情況下,VillageCareMAX Full Advantage FIDA 計劃會要求您進行階段療法 也就是說, 在病情治療過程中, 您將必須以某種特定順序嘗試不同藥品 您可能得在獲得某種藥品前, 先嘗試另一種藥品 若您的醫生認為第一種藥品對您無效, 那麼我們將為您給付第二種藥品 您可以在從開始自第一頁的表格中瞭解您的藥品是否有任何附加要求或限制 您也可以上網 (www.villagecaremax.org) 瞭解更多資訊 我們已在網站上公佈了一些文件來說明我們的事先授權和階段步驟療法限制 您也可以要求我們寄送一份至貴府 對於這些限制, 您可以請求 規則豁免 有關規則豁免的進一步資訊, 請查看問題 如果您在護理機構或其它長照機構中, 且需要某種不在藥品清單上的藥品或者無法輕易獲得所需藥品, 我們可以向您提供幫助 無論您是否為 VillageCareMAX Full Advantage FIDA 計劃的新參與者, 我們都將為您提供所需藥品的 3 天緊急藥品供應給付 ( 除非您已持有需用藥天數少於此天數的處方 ) 這可以讓您有充分的時間和您的醫生或其他處方開立者溝通 他或她可以幫您確認在藥品清單上是否有可取代的相似藥品, 或者是否能夠請求規則豁免 有關規則豁免的進一步資訊請查看問題 如果您有任何疑問, 請撥打 VillageCareMAX Full Advantage FIDA 計劃免費專線 -800-469-6292, 上午 8 時至晚上 8 時, 每週 7 天 若需要進一步的資訊, 請上網 :www.villagecaremax.org vi

6. 您將如何得知您所需藥品是否有限制, 或者在獲得藥品前是否要求採取某些行動? 第 頁上的給付藥品清單中, 有一欄為 使用時的必要行動 限制或局限性 7. 如果我們更改了有關如何給付某些藥品的規定 ( 例如, 如果我們對某種藥品增加了事先授權 ( 許可 ) 限量 及 / 或階段療法限制等場合 ), 會發生什麼情況? 如果我們對某種藥品增加了事先授權 ( 許可 ) 限量及 / 或階段步驟療法限制, 我們將通知您 我們將會在增加限制前至少 60 天 或者在您補藥時通知您 因此您可以在藥品清單更改前獲得 60 天劑量的該藥品 這可以讓您有充分時間與您的醫生或其它處方提供者商量下一步行動 8. 您如何在藥品清單上查找某種藥品? 有兩種查找藥品的方法 : 您可以按照首字母順序檢索 ( 如果您知道如何拼寫該藥品的英文名稱 ), 或者 根據醫療狀況查找 如果您要按照首字母順序進行檢索, 請查看第 I- 頁中的首字母順序排列部分 然後在清單中查找您所需藥品的名稱 如果您要按照醫療狀況查找, 請找到第 頁中的 根據醫療狀況分類的藥品清單 部分 在該部分, 藥物將根據它們被用於治療的醫療的類型被分類 例如, 如果您有心臟問題, 則應在心血管問題分類中查找 您將在該分類裡找到治療心臟病的藥物 9. 如果您要服用的藥品未列在藥品清單上, 該怎麼辦? 如果您未在藥品清單上找到所需藥品, 請撥打參與者服務熱線 -800-469-6292 並諮詢相關情況 聽障者電話 (TTY) 用戶請撥打 7 如果您得知 VillageCareMAX Full Advantage FIDA 計劃不會給付該藥品, 您可以採取以下行動之一 : 向參與者服務熱線工作人員索取一份您想服用藥品的相似藥品清單 然後將這份清單給您的醫生或其它處方提供者過目 他或她可以為您開立與您想服用藥品的相似藥品處方, 或者 您可以向本計劃工作人員或您的跨學科專業團隊 (IDT) 請求規則豁免, 來給付您的藥品 有關規則豁免的進一步資訊請查看問題 如果您有任何疑問, 請撥打 VillageCareMAX Full Advantage FIDA 計劃免費專線 -800-469-6292, 上午 8 時至晚上 8 時, 每週 7 天 若需要進一步的資訊, 請上網 :www.villagecaremax.org vii

0. 如果您是 VillageCareMAX Full Advantage FIDA 計劃的新成員, 且無法在藥品清單上找到您所需藥品或在獲取藥品的過程中出現了問題, 該怎麼辦? 我們能幫助您 在您成為 VillageCareMAX Full Advantage FIDA 計劃參與者的前 90 天中, 我們必須根據需要為您提供最多 90 天的臨時藥品供應服務 這可以讓您有充分的時間和您的醫生或其他處方提供者溝通 他或她可以幫您確認在藥品清單上是否有可取代的相似藥品, 或者是否能夠請求規則豁免 如符合以下情況, 我們將為您提供最多 90 天的臨時藥品供應服務 : 您正在使用不在我們藥品清單中的藥品 ; 或者 根據健康計劃規定, 您無法獲得您的處方提供者要求的藥品數量 ; 或 此藥品要求來自 VillageCareMAX Full Advantage FIDA 計劃或者您的跨學科專業團隊 (IDT) 的事先許可 ; 或 您正在服用的藥品屬於階段療法限制藥品 如果您生活在護理機構或其它長照機構中, 您可根據處方領取多達 98 天劑量的藥品 您可以在該計劃的頭 90 天內多次補藥 這可以讓您的處方開立者有足夠的時間將您使用的藥品更改為藥品清單上的藥品, 或者請求規則豁免 VillageCareMAX Full Advantage FIDA 計劃擁有一個過渡流程來確保向新進和目前的 D 部分 ( 聯邦醫療保險處方藥計劃 ) 成員提供持續的藥品給付服務 有時候, 您會經歷諸如入住或搬出長照機構 住院或出院等照護等級方面的變化 在這些情況下, VillageCareMAX Full Advantage FIDA 計劃將向您提供一次性的非處方藥物緊急供應 非處方藥品同時包括不在本計劃處方一覽表上的 D 部分藥品, 以及列於本計劃處方一覽表中 但根據本計劃使用管理規定需要獲得事先許可或進行階段療法的 D 部分藥品 如您有任何問題, 請致電參與者服務中心 您可在每週 7 天, 上午 8:00 至晚上 8:00 間撥打 -800-469-6292 聽障者電話 (TTY) 用戶請撥打 7. 您是否可以請求規則豁免來報銷藥品? 是 您可以向 VillageCareMAX Full Advantage FIDA 計劃部門或您的跨學科專業團隊 (IDT) 請求規則豁免來給付不在藥品清單上的藥品 你也可以請求 VillageCareMAX Full Advantage FIDA 計劃部門或者您的 IDT 來更改有關您所需藥品的規定 如果您有任何疑問, 請撥打 VillageCareMAX Full Advantage FIDA 計劃免費專線 -800-469-6292, 上午 8 時至晚上 8 時, 每週 7 天 若需要進一步的資訊, 請上網 :www.villagecaremax.org viii

例如,VillageCareMAX Full Advantage FIDA 計劃會限制可給付藥品量 如果您所需藥品有限量規定, 您可以要求我們或您的 IDT 團隊更改數量限制並給付更多藥品 其它例子 : 您可以要求我們或您的 IDT 取消階段療法限制或事先許可要求 2. 獲得規則豁免需要多長時間? 首先,VillageCareMAX Full Advantage FIDA 計劃部門或您的跨學科專業團隊 (IDT) 必須從您的處方提供者收到支援您規則豁免請求的聲明 在我們受到聲明之後, 您將在 72 小時內收到有關您規則豁免請求的判定 如果您或者您的處方提供者認為花費 72 小時等待決定將對您的健康產生傷害, 您可以要求加急 此為更快的判定 如果您的處方提供者支援您的請求, 您將在收到您的處方提供者支援聲明的 24 小時內獲得判定 3. 您需如何請求規則豁免? 如需請求規則豁免, 請致電您的醫療管理人員 您的醫療管理人員將和您及您的處方提供者一起幫您請求規則豁免 4. 什麼是仿學名藥? 學名藥是指由與品牌藥品相同成分製成的藥品 它們通常比品牌藥品價格更低廉且並無廣為人知的品名 學名藥由食品藥物管理局 (FDA) 審查核准 VillageCareMAX Full Advantage FIDA 計劃可同時給付品牌藥和學名藥 5. 什麼是 OTC 藥品? OTC 的意思是 成藥 當由您的處方提供者開立此類藥物的處方時,VillageCareMAX Full Advantage FIDA 計劃也可給付部分非處方 (OTC) 藥品 您可閱讀 VillageCareMAX Full Advantage FIDA 計劃藥品清單查看可給付的非處方藥品 非處方藥品位於第 4 級中 如果您有任何疑問, 請撥打 VillageCareMAX Full Advantage FIDA 計劃免費專線 -800-469-6292, 上午 8 時至晚上 8 時, 每週 7 天 若需要進一步的資訊, 請上網 :www.villagecaremax.org ix

6. VillageCareMAX Full Advantage FIDA 計劃是否可給付非藥物類非處方產品? 當由您的處方提供者開立此類藥物的處方時,VillageCareMAX Full Advantage FIDA 計劃也可報銷部分非藥物類非處方產品 樣例包括 : 紗布墊 酒精棉 / 墊 胰島素注射器和針頭等非處方類糖尿病用品 您可閱讀 VillageCareMAX Full Advantage FIDA 計劃藥品清單查看可報銷的非處方藥品 您可閱讀 VillageCareMAX Full Advantage FIDA 計劃藥品清單查看可報銷的非藥物類非處方產品 7. 你們的自付醫療費用如何計算? 您無需為藥品清單上的藥品承擔自付款 8. 什麼是藥品? 在 VillageCareMAX Full Advantage FIDA 計劃處方一覽表中, 您可以看到共有 4 種藥品等級 類別 的藥品為由醫療保險部門給付的學名藥 類別 2 的藥品為由醫療保險部門給付的品牌藥和專科用藥 類別 3 的藥品為由紐約衛生署給付的非 D 部分藥品和品牌藥 類別 4 的藥品為由紐約衛生署給付的非處方 (OTC) 藥品 作為我們計劃的成員, 您無需為這四類藥品承擔任何自付款 如果您有任何疑問, 請撥打 VillageCareMAX Full Advantage FIDA 計劃免費專線 -800-469-6292, 上午 8 時至晚上 8 時, 每週 7 天 若需要進一步的資訊, 請上網 :www.villagecaremax.org x

給付藥品清單 下文第 頁中的給付藥品清單向您提供了有關可由 VillageCareMAX Full Advantage FIDA 計劃給付藥品的資訊 如果您無法在清單中找到所需藥品, 請使用由第 I- 頁開始的索引 圖表中的第一列為藥品名稱 品牌藥品為大寫 ( 例如 : 立普妥 [LIPITOR]), 而學名藥為小寫斜體 ( 例 : 布洛芬 [ibuprofen]) 必要行動 限制或局限性一欄中資訊可讓您瞭解 VillageCareMAX Full Advantage FIDA 計劃是否對給付您的藥物設立任何規定 描述指南 此藥品清單採用以下縮寫和符號 : 縮寫 / 符號 描述 解釋說明 使用管理限制 在領取藥物前, 您 ( 或您的醫師 ) 需要獲得來自 VillageCareMAX Full PA Advantage FIDA 計劃的事先授權 若事先授權限制無事先許可, 則 VillageCareMAX Full Advantage FIDA 計劃可能不會報銷此 藥品 根據醫療保險部門的 Part B 或 Part D 保險計劃, 此藥品可能需要支付款項 在領取藥品前, 您 ( 或您的醫師 ) 需要 Part B 和 Part D 保險獲得來自 VillageCareMAX Full 計劃測定的事先授權 Advantage FIDA 計劃的事先授權來確 定此藥品是否可根據醫療保險部門的 Part D 保險計劃報銷 若無事先許可, 則 VillageCareMAX Full Advantage FIDA 計劃可能不會報銷此藥品 此藥已被 CMS 認為是潛在有害的, 因 PA-HRM 此,65 歲或以的上 Medicare 醫療保險高風險藥物的事先授權參加者要得到 VillageCareMAX Full 限制 Advantage FIDA 計劃的事先許可高風 險服藥的要求之後才得到此處方藥 若 如果您有任何疑問, 請撥打 VillageCareMAX Full Advantage FIDA 計劃免費專線 -800-469-6292, 上午 8 時至晚上 8 時, 每週 7 天 若需要進一步的資訊, 請上網 :www.villagecaremax.org xi

縮寫 / 符號 描述 解釋說明無事先許可, 則 VillageCareMAX Full Advantage FIDA 計劃可能不會報銷此藥品 PA NSO 僅針對新開方藥品的事先授權限制 如果您是新成員或您之前未服用過此藥品, 在領取藥物前, 您 ( 或您的醫師 ) 需獲得來自 VillageCareMAX Full Advantage FIDA 計劃的事先授權 若無事先許可, 則 VillageCareMAX Full Advantage FIDA 計劃可能不會報銷此藥品 VillageCareMAX Full Advantage FIDA QL 計劃限制了此藥品每次按處方領取的報數量限制規定銷數量, 或者特定時間框架內的數量 ST 階段療法限制 在 VillageCareMAX Full Advantage FIDA 計劃為此藥物提供報銷之前, 您必須首先嘗試另一種藥品來治療您的病情 在其它藥品對您無效的情況下, 才可報銷此藥品 其它保險相關縮寫 此藥方可能僅可在某些特定藥房中領取 藥品 欲知更多資訊, 請查看您的藥劑 目錄或在每天上午 8:00 至晚上 8:00 LA 藥品獲取限制間, 每週 7 天撥打我們的會員服務熱線 -800-469-6292 此為免費電話 聽障 者電話 TTY 用戶請撥打 7 您也許能夠獲得大多數的藥物多於 對 月的供應通過郵購處方以降低成本的份 NM 非郵購藥品額 如藥物無法通過郵購, 您處方的要 求 / 限制列中記下 NM * 非 Part D 藥品 此藥品不是可由醫療保險部門報銷的 Part D 藥品, 或者 OTC 藥品或產品 如果您有任何疑問, 請撥打 VillageCareMAX Full Advantage FIDA 計劃免費專線 -800-469-6292, 上午 8 時至晚上 8 時, 每週 7 天 若需要進一步的資訊, 請上網 :www.villagecaremax.org xii

注 : 所有類別 3 和類別 4 中的藥品均為非 Part D 藥品 這些藥品具有不同的申訴規定 申訴是一種在您認為有錯誤存在的情況下請求審核並更改保險決定的正式途徑 例如, VillageCareMAX Full Advantage FIDA 計劃或您的跨學科專業團隊 (IDT) 可能會規定您所需藥品不在受保範圍內, 或者決定不再由醫療保險部門或紐約州衛生署報銷此藥品 如果您或您的醫生或其他處方提供者不同意這項決定, 則您可進行申訴 如需有關如何申訴的指導, 請撥打參與者服務熱線 -800-469-6292 或獨立消費者倡權網路 (ICAN) 的電話 - 844-64-8800 您也可以通過閱讀參與者手冊來瞭解如何就某項決策進行申訴 藥品名單 - 按醫療狀況的類型分類 在本節中藥物將根據它們被用於治療的醫療狀況的類型被分類 例如, 如果您有心臟問題, 則應在心血管問題分類中查找 您將在該分類裡找到治療心臟病的藥物. 如果您有任何疑問, 請撥打 VillageCareMAX Full Advantage FIDA 計劃免費專線 -800-469-6292, 上午 8 時至晚上 8 時, 每週 7 天 若需要進一步的資訊, 請上網 :www.villagecaremax.org xiii

Table of Contents Analgesics... 3 Anesthetics... 4 Anti-Addiction/Substance Abuse Treatment Agents... 5 Antianxiety Agents... 7 Antibacterials... 8 Anticancer Agents... 29 Anticholinergic Agents... 39 Anticonvulsants... 40 Antidementia Agents... 44 Antidepressants... 45 Antidiabetic Agents... 48 Antifungals... 52 Antihistamines... 56 Anti-Infectives (Skin And Mucous Membrane)... 62 Antimigraine Agents... 62 Antimycobacterials... 63 Antinausea Agents... 64 Antiparasite Agents... 66 Antiparkinsonian Agents... 67 Antipsychotic Agents... 68 Antivirals (Systemic)... 72 Blood Products/Modifiers/Volume Expanders... 79 Caloric Agents... 83 VillageCareMAX Full Advantage FIDA Plan 206 Formulary Formulary ID:65.000 Version: 9 Effective: December 0, 206

Cardiovascular Agents... 88 Central Nervous System Agents... 04 Contraceptives... 06 Cough And Cold Products... 5 Dental And Oral Agents... 26 Dermatological Agents... 26 Devices... 35 Disinfectants (For Non-Dermatologic Use)... 36 Enzyme Replacement/Modifiers... 36 Eye, Ear, Nose, Throat Agents... 38 Gastrointestinal Agents... 46 Genitourinary Agents... 59 Heavy Metal Antagonists... 59 Hormonal Agents, Stimulant/Replacement/Modifying... 60 Immunological Agents... 66 Inflammatory Bowel Disease Agents... 75 Irrigating Solutions... 76 Metabolic Bone Disease Agents... 76 Miscellaneous Therapeutic Agents... 78 Ophthalmic Agents... 84 Replacement Preparations... 85 Respiratory Tract Agents... 95 Skeletal Muscle Relaxants... 99 Sleep Disorder Agents... 200 Vasodilating Agents... 20 Vitamins And Minerals... 203 VillageCareMAX Full Advantage FIDA Plan 206 Formulary Formulary ID:65.000 Version: 9 Effective: December 0, 206 2

Analgesics Analgesics, Miscellaneous acephen 20 mg suppository outer 20 mg * acephen 325 mg suppository outer 325 mg * acephen 650 mg suppository outer 650 mg * acetaminophen 20 mg suppos outer 20 mg * acetaminophen 60 mg rapid tab 60 mg * acetaminophen 60 mg/5 ml elx 60 mg/5 ml * acetaminophen 325 mg liqui-gel 325 mg * acetaminophen 650 mg suppos 650 mg * acetaminophen 80 mg rapid tab children's 80 mg * acetaminophen 80 mg/0.8 ml drp infants 80 mg/0.8 ml * acetaminophen-codeine 20 mg-2 mg/5 ml solution 20-2 mg/5 ml acetaminophen-codeine oral solution 300 mg-30 mg /2.5 ml acetaminophen-codeine oral tablet 300-5 mg, 300-30 mg acetaminophen-codeine oral tablet 300-60 mg ALLZITAL ORAL TABLET 25-325 MG (Acetaminophen) (Acetaminophen) (Acetaminophen) (Acetaminophen) (Acetaminophen) (Acetaminophen) (Acetaminophen) (Acetaminophen) (Acetaminophen) (Acetaminophen) (Acetaminophen with Codeine) (Acetaminophen with Codeine) (Tylenol-Codeine No.3) (Tylenol-Codeine No.3) $0 $0 $0 $0 $0 QL (360 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (240 per 30 days) QL (360 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (2700 per 30 days) QL (2700 per 30 days) QL (360 per 30 days) QL (80 per 30 days) 3

ascomp with codeine oral capsule 30-50-325-40 mg BELBUCA BUCCAL FILM 50 MCG, 300 MCG, 450 MCG, 600 MCG, 75 MCG, 750 MCG, 900 MCG buprenorphine hcl injection syringe 0.3 mg/ml butalbital compound w/codeine oral capsule 30-50-325-40 mg butalbital-acetaminop-caf-cod oral capsule 50-300-40-30 mg, 50-325- 40-30 mg butalbital-acetaminophen oral tablet 50-325 mg butalbital-acetaminophen-caff oral capsule 50-325-40 mg butalbital-acetaminophen-caff oral tablet 50-325-40 mg butalbital-aspirin-caffeine oral capsule 50-325-40 mg BUTRANS TRANSDERMAL PATCH WEEKLY 0 MCG/HOUR, 5 MCG/HOUR, 20 MCG/HOUR, 5 MCG/HOUR, 7.5 MCG/HOUR (Fiorinal with Codeine #3) (Buprenorphine HCl) (Fiorinal with Codeine #3) (Fioricet with Codeine) $0 $0 $0 $0 (Tencon) $0 (Esgic) $0 (Esgic) $0 (Fiorinal) $0 capacet oral capsule 50-325-40 mg (Esgic) $0 child non-aspirin 60 mg/5 ml children's 60 mg/5 ml * (Acetaminophen) PA-HRM; QL (80 per 30 days); AGE (Max 64 Years) ST; QL (60 per 30 days) PA-HRM; QL (80 per 30 days); AGE (Max 64 Years) PA-HRM; QL (80 per 30 days); AGE (Max 64 Years) PA-HRM; QL (80 per 30 days); AGE (Max 64 Years) PA-HRM; QL (80 per 30 days); AGE (Max 64 Years) PA-HRM; QL (80 per 30 days); AGE (Max 64 Years) PA-HRM; QL (80 per 30 days); AGE (Max 64 Years) QL (4 per 28 days) PA-HRM; QL (80 per 30 days); AGE (Max 64 Years) QL (240 per 30 days) 4

child pain-fever 60 mg/5 ml QL (240 per 30 days) (Infants' Tylenol) a/f,gluten/f,cherry 60 mg/5 ml * child tactinal 80 mg tab chw 80 mg QL (30 per 30 days) (Acetaminophen) * children's mapap 80 mg rapid 80 QL (30 per 30 days) (Acetaminophen) mg * codeine sulfate oral tablet 5 mg, 30 QL (80 per 30 days) (Codeine Sulfate) $0 mg, 60 mg cvs child non-asa 80 mg tb chw 80 QL (30 per 30 days) (Acetaminophen) mg * cvs non-aspirin jr tab chew 60 mg QL (30 per 30 days) (Acetaminophen) * cvs pain relief adult liquid 500 (Tylenol Sore QL (20 per 30 days) mg/5 ml * Throat) endocet oral tablet 0-325 mg, 2.5- QL (360 per 30 days) (Xolox) $0 325 mg, 5-325 mg, 7.5-325 mg endodan oral tablet 4.8355-325 mg (Percodan) $0 QL (360 per 30 days) fentanyl citrate buccal lozenge on a handle,200 mcg,,600 mcg, 200 (Actiq) $0 PA; QL (20 per 30 days) mcg, 400 mcg, 600 mcg, 800 mcg fentanyl transdermal patch 72 hour 00 mcg/hr, 2 mcg/hr, 25 mcg/hr, 37.5 mcg/hour, 50 mcg/hr, 62.5 mcg/hour, 75 mcg/hr, 87.5 mcg/hour (Duragesic) $0 QL (0 per 30 days) feverall 20 mg suppository QL (30 per 30 days) (Acetaminophen) children's, outer 20 mg * feverall 325 mg suppository junior QL (30 per 30 days) (Acetaminophen) str, outer 325 mg * feverall 650 mg suppository adult, QL (30 per 30 days) (Acetaminophen) outer 650 mg * hydrocodone-acetaminophen oral QL (2700 per 30 days) solution 0-325 mg/5 ml(5 ml), 2.5-67 mg/5 ml, 7.5-325 mg/5 ml (Hycet) $0 5

hydrocodone-acetaminophen oral tablet 0-300 mg, 5-300 mg, 7.5-300 mg hydrocodone-acetaminophen oral tablet 0-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg hydrocodone-ibuprofen oral tablet 0-200 mg, 2.5-200 mg, 5-200 mg, 7.5-200 mg hydromorphone (pf) injection solution 0 mg/ml hydromorphone (pf) injection solution 4 mg/ml hydromorphone injection solution 2 mg/ml hydromorphone injection syringe 2 mg/ml (Norco) $0 (Norco) $0 (Ibudone) $0 (Dilaudid-HP) $0 (Dilaudid) $0 (includes Vicodin, Vicodin ES and Vicodin HP); QL (390 per 30 days) QL (360 per 30 days) QL (50 per 30 days) (Hydromorphone HCl) $0 (Hydromorphone HCl) $0 hydromorphone oral liquid mg/ml (Dilaudid) $0 QL (200 per 30 days) hydromorphone oral tablet 2 mg, 4 QL (80 per 30 days) (Dilaudid) $0 mg hydromorphone oral tablet 8 mg (Dilaudid) $0 QL (240 per 30 days) HYSINGLA ER ORAL QL (30 per 30 days) TABLET,ORAL ONLY,EXT.REL.24 HR 00 MG, 20 MG, 20 MG, 30 MG, 40 MG, 60 MG, 80 MG junior mapap 60 mg rapid tab 60 mg * LAZANDA NASAL SPRAY,NON- AEROSOL 00 MCG/SPRAY, 300 MCG/SPRAY, 400 MCG/SPRAY (Acetaminophen) QL (30 per 30 days) PA; QL (30 per 30 days) lorcet (hydrocodone) oral tablet 5- QL (360 per 30 days) (Norco) $0 325 mg lorcet hd oral tablet 0-325 mg (Norco) $0 QL (360 per 30 days) lorcet plus oral tablet 7.5-325 mg (Norco) $0 QL (360 per 30 days) 6

mapap 60 mg/5 ml elixir 60 mg/5 (Tylenol Sore QL (240 per 30 days) ml * Throat) mapap 60 mg/5 ml suspension 60 QL (240 per 30 days) (Infants' Tylenol) mg/5 ml * mapap 325 mg tablet 325 mg * (Tylenol) QL (360 per 30 days) mapap 500 mg capsule 500 mg * (Acetaminophen) QL (240 per 30 days) mapap 500 mg tablet 500 mg * (Tylenol) QL (240 per 30 days) mapap 500 mg/5 ml liquid 500 (Tylenol Sore QL (20 per 30 days) mg/5 ml * Throat) mapap 80 mg tablet chew 80 mg * (Acetaminophen) QL (30 per 30 days) mapap arthritis er 650 mg cplt 650 QL (80 per 30 days) (Tylenol Arthritis) mg * PA-HRM; QL (80 per margesic oral capsule 50-325-40 (Esgic) $0 30 days); AGE (Max mg 64 Years) methadone injection solution 0 mg/ml (Methadone HCl) $0 methadone oral solution 0 mg/5 QL (800 per 30 days) (Methadone HCl) $0 ml, 5 mg/5 ml methadone oral tablet 0 mg, 5 mg (Diskets) $0 QL (360 per 30 days) methadose oral tablet,soluble 40 mg (Diskets) $0 QL (90 per 30 days) morphine (pf) in 0.9 % nacl intravenous pt controlled analgesia (Morphine Sulfate/0.9% $0 syring 50 mg/25 ml (2 mg/ml) Nacl/PF) morphine 0 mg/ml carpuject 0 mg/ml (Morphine Sulfate) $0 morphine 2 mg/ml carpuject outer, latex-f, p/f 2 mg/ml (Morphine Sulfate) $0 morphine 4 mg/ml carpuject 4 mg/ml (Morphine Sulfate) $0 morphine 8 mg/ml syringe 8 mg/ml (Morphine Sulfate) $0 morphine concentrate oral solution QL (200 per 30 days) (Morphine Sulfate) $0 00 mg/5 ml (20 mg/ml) morphine concentrate oral syringe 20 mg/ml (Morphine Sulfate) $0 7

morphine in dextrose 5 % injection pt controlled analgesia syring 00 mg/50 ml (2 mg/ml), 50 mg/25 ml (2 mg/ml) morphine injection solution 5 mg/ml, 8 mg/ml morphine injection syringe 0 mg/ml morphine intramuscular pen injector 0 mg/0.7 ml morphine intravenous cartridge 5 mg/ml morphine intravenous solution 25 mg/ml, 50 mg/ml morphine intravenous syringe 0 mg/ml, 2 mg/ml, 4 mg/ml, 8 mg/ml (Morphine Sulfate/D5W) $0 (Morphine Sulfate) $0 (Morphine Sulfate) $0 (Morphine Sulfate) $0 (Morphine Sulfate) $0 (Morphine Sulfate) $0 (Morphine Sulfate) $0 morphine oral solution 0 mg/5 ml (Morphine Sulfate) $0 QL (700 per 30 days) morphine oral solution 20 mg/5 ml QL (300 per 30 days) (Morphine Sulfate) $0 (4 mg/ml) MORPHINE ORAL TABLET 5 QL (80 per 30 days) MG, 30 MG morphine oral tablet extended QL (20 per 30 days) (MS Contin) $0 release 00 mg, 30 mg, 60 mg morphine oral tablet extended QL (80 per 30 days) (MS Contin) $0 release 5 mg, 200 mg morphine rectal suppository 0 mg, 20 mg, 30 mg, 5 mg (Morphine Sulfate) $0 non-aspirin x-str 67 mg/5 ml 500 (Tylenol Sore QL (20 per 30 days) mg/5 ml * Throat) nortemp 80 mg/0.8 ml drop 80 QL (30 per 30 days) (Acetaminophen) mg/0.8 ml * NUCYNTA ER ORAL TABLET QL (60 per 30 days) EXTENDED RELEASE 2 HR 00 MG, 50 MG, 200 MG, 250 MG, 50 MG 8

NUCYNTA ORAL TABLET 00 QL (8 per 30 days) MG, 50 MG, 75 MG oxycodone oral concentrate 20 QL (80 per 30 days) (Oxycodone HCl) $0 mg/ml oxycodone oral solution 5 mg/5 ml (Oxycodone HCl) $0 QL (300 per 30 days) oxycodone oral tablet 0 mg, 5 mg, QL (80 per 30 days) (Roxicodone) $0 20 mg, 30 mg, 5 mg oxycodone oral tablet,oral QL (60 per 30 days) only,ext.rel.2 hr 0 mg, 5 mg, 20 (Oxycontin) $0 mg, 30 mg, 40 mg, 60 mg oxycodone oral tablet,oral QL (20 per 30 days) (Oxycontin) only,ext.rel.2 hr 80 mg (Oxycodone QL (800 per 30 days) oxycodone-acetaminophen oral HCl/Acetaminophe $0 solution 5-325 mg/5 ml n) oxycodone-acetaminophen oral QL (360 per 30 days) tablet 0-325 mg, 2.5-325 mg, 5-325 (Xolox) $0 mg, 7.5-325 mg oxycodone-acetaminophen oral QL (80 per 30 days) (Xolox) $0 tablet 0-650 mg oxycodone-acetaminophen oral QL (240 per 30 days) (Xolox) $0 tablet 7.5-500 mg oxycodone-aspirin oral tablet QL (360 per 30 days) (Percodan) $0 4.8355-325 mg OXYCONTIN ORAL QL (60 per 30 days) TABLET,ORAL ONLY,EXT.REL.2 HR 0 MG, 5 MG, 20 MG, 30 MG, 40 MG, 60 MG OXYCONTIN ORAL QL (20 per 30 days) TABLET,ORAL ONLY,EXT.REL.2 HR 80 MG oxymorphone oral tablet 0 mg, 5 QL (80 per 30 days) (Opana) $0 mg oxymorphone oral tablet extended QL (60 per 30 days) release 2 hr 0 mg, 5 mg, 20 mg, (Opana ER) $0 5 mg, 7.5 mg 9

oxymorphone oral tablet extended QL (20 per 30 days) (Opana ER) $0 release 2 hr 30 mg, 40 mg pain relief 500 mg capsule 500 mg * (Acetaminophen) QL (240 per 30 days) pain reliever er 650 mg caplet 8 QL (80 per 30 days) (Tylenol Arthritis) hour, caplet 650 mg * pharbetol 325 mg tablet regular QL (360 per 30 days) (Tylenol) strength 325 mg * pharbetol 500 mg caplet extra-str, QL (240 per 30 days) (Tylenol) caplet 500 mg * pv non-aspirin 500 mg softgel exstr,liq filled 500 mg * QL (240 per 30 days) (Acetaminophen) q-pap 60 mg/5 ml solution a/f, (Tylenol Sore QL (240 per 30 days) cherry 60 mg/5 ml * Throat) q-pap 325 mg tablet 325 mg * (Tylenol) QL (360 per 30 days) q-pap 80 mg/0.8 ml drops 80 mg/0.8 QL (30 per 30 days) (Acetaminophen) ml * q-pap ex-str 500 mg tablet aspirin QL (240 per 30 days) (Tylenol) free 500 mg * ra jr acetaminophen 60 mg tab QL (30 per 30 days) (Acetaminophen) rapid melts 60 mg * reprexain oral tablet 0-200 mg, QL (50 per 30 days) (Ibudone) $0 2.5-200 mg, 5-200 mg (Oxycodone QL (800 per 30 days) roxicet oral solution 5-325 mg/5 ml HCl/Acetaminophe n) $0 silapap infant's drops infant 80 QL (30 per 30 days) (Acetaminophen) mg/0.8 ml * sm arthritis pain er 650 mg caplet QL (80 per 30 days) (Tylenol Arthritis) 650 mg * sm pain rel jr str tab chew 60 mg * (Acetaminophen) QL (30 per 30 days) sm pain reliever 80 mg tab QL (30 per 30 days) (Acetaminophen) children's 80 mg * tactinal 325 mg tablet 325 mg * (Tylenol) QL (360 per 30 days) tactinal 500 mg tablet extra-strength QL (240 per 30 days) (Tylenol) 500 mg * 0

tencon oral tablet 50-325 mg (Tencon) $0 PA-HRM; QL (80 per 30 days); AGE (Max 64 Years) tramadol oral tablet 50 mg (Ultram) $0 QL (240 per 30 days) tramadol-acetaminophen oral tablet 37.5-325 mg (Ultracet) $0 QL (240 per 30 days) vicodin es oral tablet 7.5-300 mg (Norco) $0 (includes Vicodin, Vicodin ES and Vicodin HP); QL (390 per 30 days) vicodin hp oral tablet 0-300 mg (Norco) $0 (includes Vicodin, Vicodin ES and Vicodin HP); QL (390 per 30 days) vicodin oral tablet 5-300 mg (Norco) $0 (includes Vicodin, Vicodin ES and Vicodin HP); QL (390 per 30 days) xylon 0 oral tablet 0-200 mg (Ibudone) $0 QL (50 per 30 days) zebutal oral capsule 50-325-40 mg (Esgic) $0 Nonsteroidal Anti- Inflammatory Agents ADVIL 00 MG TABLET JR STRENGTH,COATED 00 MG * ADVIL 200 MG TABLET 200 MG * ADVIL JR STR 00 MG TAB CHEW TB CHEW,8 HOUR,GRAPE 00 MG * aspirin 300 mg suppository 300 mg * (Aspirin) aspirin 325 mg tablet 325 mg * (Ecotrin) aspirin 600 mg suppository 600 mg * (Aspirin) PA-HRM; QL (80 per 30 days); AGE (Max 64 Years)

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

etodolac oral capsule 200 mg, 300 mg (Etodolac) $0 etodolac oral tablet 400 mg, 500 mg (Etodolac) $0 etodolac oral tablet extended release 24 hr 400 mg, 500 mg, 600 (Etodolac) $0 mg fenoprofen oral capsule 200 mg (Nalfon) $0 fenoprofen oral tablet 600 mg (Fenoprofen Calcium) $0 FLECTOR TRANSDERMAL PA PATCH 2 HOUR.3 % flurbiprofen oral tablet 00 mg, 50 mg (Flurbiprofen) $0 gnp ibuprofen jr str 00 mg tb 00 mg * (Advil) ibuprofen 00 mg/5 ml susp children's (otc) 00 mg/5 ml * (Children'S Advil) ibuprofen 200 mg tablet 200 mg * (Advil) ibuprofen oral suspension 00 mg/5 ml (Ibuprofen) $0 ibuprofen oral tablet 400 mg, 600 mg, 800 mg (Ibuprofen) $0 indomethacin oral capsule 25 mg (Indomethacin) $0 QL (240 per 30 days) indomethacin oral capsule 50 mg (Indomethacin) $0 QL (20 per 30 days) indomethacin oral capsule, extended QL (60 per 30 days) (Indomethacin) $0 release 75 mg indomethacin sodium intravenous (Indomethacin recon soln mg Sodium) $0 infant ibuprofen 50 mg/.25 ml d/f,a/f,non-staining 50 mg/.25 ml * (Infants' Motrin) INFANTS' MOTRIN 50 MG/.25 ML D/F, BERRY FLAVOR 50 3 $0 MG/.25 ML * ketoprofen oral capsule 50 mg, 75 mg (Ketoprofen) $0 3

ketoprofen oral capsule,ext rel. pellets 24 hr 200 mg (Ketoprofen) $0 ketorolac oral tablet 0 mg (Ketorolac Tromethamine) $0 mefenamic acid oral capsule 250 mg (Ponstel) $0 meloxicam oral suspension 7.5 mg/5 ml (Mobic) $0 meloxicam oral tablet 5 mg, 7.5 mg (Mobic) $0 nabumetone oral tablet 500 mg, 750 mg (Nabumetone) $0 naproxen oral suspension 25 mg/5 ml (Naprosyn) $0 naproxen oral tablet 250 mg, 375 mg, 500 mg (Naprosyn) $0 naproxen oral tablet,delayed release (Ec-Naprosyn) (dr/ec) 375 mg, 500 mg $0 naproxen sodium oral tablet 275 mg, 550 mg (Anaprox) $0 piroxicam oral capsule 0 mg, 20 mg (Feldene) $0 ra aspirin tri-buffered tb 325 mg * (Aspirin/Calcium Carbonate/Mag) sm ibuprofen ib 00 mg tablet junior (Advil) strength 00 mg * st. joseph aspirin 8 mg chew (Bayer Chewable orange 8 mg * Aspirin) st. joseph aspirin ec 8 mg tb enteric coated 8 mg * (Ecotrin) sulindac oral tablet 50 mg, 200 mg (Sulindac) $0 tolmetin oral capsule 400 mg (Tolmetin Sodium) $0 tolmetin oral tablet 200 mg, 600 mg (Tolmetin Sodium) $0 VOLTAREN TOPICAL GEL % $0 wal-profen 200 mg softgel softgel 200 mg * Anesthetics Local Anesthetics (Advil) QL (20 per 30 days) 4

glydo mucous membrane jelly in applicator 2 % (Lidocaine HCl) $0 lidocaine (pf) injection solution 5 mg/ml (.5 %), 40 mg/ml (4 %), 5 (Xylocaine-MPF) $0 mg/ml (0.5 %) lidocaine 2% viscous soln 2 % (Xylocaine) $0 lidocaine hcl injection solution 0 mg/ml ( %), 20 mg/ml (2 %) (Xylocaine) $0 lidocaine hcl mucous membrane gel 2 % (Lidocaine HCl) $0 lidocaine hcl mucous membrane solution 2 %, 4 % (40 mg/ml) (Xylocaine) $0 lidocaine topical adhesive patch,medicated 5 % (Lidoderm) $0 lidocaine topical ointment 5 % (Lidocaine) $0 lidocaine-prilocaine topical cream 2.5-2.5 % (EMLA) $0 Anti-Addiction/Substance Abuse Treatment Agents Anti-Addiction/Substance Abuse Treatment Agents acamprosate oral tablet,delayed release (dr/ec) 333 mg buprenorphine hcl sublingual tablet 2 mg, 8 mg buprenorphine-naloxone sublingual tablet 2-0.5 mg, 8-2 mg bupropion hcl sr 50 mg tablet f/c 50 mg CHANTIX CONTINUING MONTH BOX ORAL TABLET MG CHANTIX ORAL TABLET 0.5 MG, MG (Acamprosate Calcium) (Buprenorphine HCl) (Buprenorphine HCl/Naloxone HCl) $0 $0 $0 (Zyban) $0 PA PA; QL (90 per 30 days) PA; QL (90 per 30 days) QL (68 per 84 days) QL (68 per 84 days) 5

CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK 0.5 MG ()- MG (42) disulfiram oral tablet 250 mg, 500 mg (Antabuse) $0 naloxone injection solution 0.4 mg/ml (Naloxone HCl) $0 naloxone injection syringe 0.4 mg/ml, mg/ml (Naloxone HCl) $0 naltrexone oral tablet 50 mg (Revia) $0 NARCAN NASAL SPRAY,NON- AEROSOL 4 MG/ACTUATION NICODERM CQ 4 MG/24HR PATCH 4 MG/24 HR * NICODERM CQ 2 MG/24HR PATCH 2 MG/24 HR * NICODERM CQ 7 MG/24HR PATCH 7 MG/24 HR * nicorelief 2 mg gum 2 mg * (Nicorette) nicorelief 4 mg gum 4 mg * (Nicorette) nicorette 2 mg chewing gum white ice mint 2 mg * (Nicorette) nicotine 4 mg/24hr patch outer (otc) 4 mg/24 hr * (Nicoderm Cq) nicotine 2 mg chewing gum sugar free 2 mg * (Nicorette) nicotine 2 mg lozenge mint, 3 quittube 2 mg * (Nicorette) nicotine 2 mg/24hr patch step (otc) 2 mg/24 hr * (Nicoderm Cq) nicotine 22 mg/24hr patch week starter kit 22 mg/24 hr * (Nicoderm Cq) nicotine 4 mg chewing gum 4 mg * (Nicorette) nicotine 4 mg lozenge mint, 3 quittube 4 mg * (Nicorette) QL (53 per 28 days) QL (4 per 30 days) QL (68 per 365 days) QL (68 per 365 days) QL (80 per 365 days) QL (68 per 365 days) QL (68 per 365 days) 6

nicotine 7 mg/24hr patch (otc) 7 mg/24 hr * NICOTROL INHALATION CARTRIDGE 0 MG ZUBSOLV SUBLINGUAL TABLET.4-0.36 MG,.4-2.9 MG, 2.9-0.7 MG, 5.7-.4 MG, 8.6-2. MG Antianxiety Agents Benzodiazepines alprazolam oral tablet 0.25 mg, 0.5 (Nicoderm Cq) QL (80 per 365 days) QL (008 per 90 days) PA; QL (90 per 30 days) QL (20 per 30 days) (Xanax) $0 mg, mg, 2 mg chlordiazepoxide hcl oral capsule (Chlordiazepoxide QL (20 per 30 days) $0 0 mg, 25 mg, 5 mg HCl) clonazepam oral tablet 0.5 mg, mg (Klonopin) $0 QL (90 per 30 days) clonazepam oral tablet 2 mg (Klonopin) $0 QL (300 per 30 days) clonazepam oral tablet,disintegrating 0.25 mg, 0.25 mg, 0.5 mg, mg (Clonazepam) $0 QL (90 per 30 days) clonazepam oral QL (300 per 30 days) (Clonazepam) $0 tablet,disintegrating 2 mg clorazepate dipotassium oral tablet QL (20 per 30 days) (Tranxene T-Tab) $0 5 mg clorazepate dipotassium oral tablet QL (60 per 30 days) (Tranxene T-Tab) $0 3.75 mg, 7.5 mg diazepam injection syringe 5 mg/ml (Diazepam) $0 QL (0 per 28 days) diazepam intensol oral concentrate QL (200 per 30 days) (Diazepam) $0 5 mg/ml diazepam oral solution 5 mg/5 ml ( QL (200 per 30 days) (Diazepam) $0 mg/ml) diazepam oral tablet 0 mg, 2 mg, 5 QL (20 per 30 days) (Valium) $0 mg diazepam rectal kit 2.5-5-7.5-20 mg, 2.5 mg, 5-7.5-0 mg (Diastat) $0 lorazepam oral tablet 0.5 mg, mg, QL (90 per 30 days) (Ativan) $0 2 mg 7

ONFI ORAL SUSPENSION 2.5 MG/ML Antibacterials Aminoglycosides BETHKIS INHALATION SOLUTION FOR NEBULIZATION 300 MG/4 ML gentamicin in nacl (iso-osm) intravenous piggyback 00 mg/00 ml, 00 mg/50 ml, 60 mg/50 ml, 70 mg/50 ml, 80 mg/00 ml, 80 mg/50 ml, 90 mg/00 ml gentamicin injection solution 40 mg/ml gentamicin ped 20 mg/2 ml vial latex-free, sdv 20 mg/2 ml gentamicin sulfate (pf) intravenous solution 80 mg/8 ml (Gentamicin In Nacl, Iso-Osm) $0 (Gentamicin Sulfate) $0 (Gentamicin Sulfate/PF) $0 (Gentamicin Sulfate/PF) $0 neomycin oral tablet 500 mg (Neomycin Sulfate) $0 streptomycin intramuscular recon (Streptomycin soln gram Sulfate) $0 TOBI PODHALER INHALATION CAPSULE, W/INHALATION DEVICE 28 MG tobramycin in 0.225 % nacl inhalation solution for nebulization 300 mg/5 ml tobramycin in 0.9 % nacl intravenous piggyback 60 mg/50 ml, 80 mg/00 ml tobramycin sulfate injection solution 0 mg/ml, 40 mg/ml Antibacterials, Miscellaneous bacitracin intramuscular recon soln 50,000 unit (Tobi) $0 (Tobramycin/Sodiu m Chloride) (Tobramycin Sulfate) $0 $0 (Bacitracin) $0 PA NSO; QL (480 per 30 days) QL (224 per 28 days) 8

chloramphenicol sod succinate (Chloramphenicol intravenous recon soln gram Sod Succ) $0 clindamycin 75 mg/5 ml soln 75 mg/5 ml (Cleocin Palmitate) $0 clindamycin hcl oral capsule 50 mg, 300 mg, 75 mg (Cleocin HCl) $0 clindamycin in 5 % dextrose (Cleocin Phosphate intravenous piggyback 300 mg/50 In D5w) ml, 600 mg/50 ml, 900 mg/50 ml $0 clindamycin pediatric oral recon soln 75 mg/5 ml (Cleocin Palmitate) $0 clindamycin phosphate injection (Cleocin solution 50 mg/ml Phosphate) $0 clindamycin phosphate intravenous (Cleocin solution 600 mg/4 ml Phosphate) $0 colistin (colistimethate na) injection (Coly-Mycin M recon soln 50 mg Parenteral) $0 CUBICIN INTRAVENOUS RECON SOLN 500 MG daptomycin intravenous recon soln 500 mg (Cubicin) $0 linezolid intravenous parenteral solution 600 mg/300 ml (Zyvox) $0 linezolid oral suspension for reconstitution 00 mg/5 ml (Zyvox) $0 linezolid oral tablet 600 mg (Zyvox) $0 methenamine hippurate oral tablet gram (Hiprex) $0 metronidazole in nacl (iso-os) (Metronidazole/So intravenous piggyback 500 mg/00 dium Chloride) ml $0 metronidazole oral capsule 375 mg (Flagyl) $0 metronidazole oral tablet 250 mg, 500 mg (Flagyl) $0 9

nitrofurantoin macrocrystal oral capsule 00 mg, 25 mg, 50 mg nitrofurantoin monohyd/m-cryst oral capsule 00 mg nitrofurantoin monohyd/m-cryst oral capsule 00 mg (75/25) (Macrodantin) $0 (Macrobid) $0 (Macrobid) $0 polymyxin b sulfate injection recon (Polymyxin B soln 500,000 unit Sulfate) $0 SYNERCID INTRAVENOUS RECON SOLN 500 MG trimethoprim oral tablet 00 mg (Trimethoprim) $0 vancomycin hcl g/200 ml bag (Vancomycin Hcl gram/200 ml In Dextrose 5 %) $0 vancomycin intravenous recon soln,000 mg, 0 gram, 750 mg (Vancomycin HCl) $0 PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (20 per 30 days); AGE (Max 64 Years) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (20 per 30 days); AGE (Max 64 Years) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (20 per 30 days); AGE (Max 64 Years) 20

vancomycin intravenous recon soln (Vancomycin Hcl 500 mg In Dextrose 5 %) $0 vancomycin oral capsule 25 mg, 250 mg (Vancocin HCl) $0 XIFAXAN ORAL TABLET 200 MG XIFAXAN ORAL TABLET 550 MG ZYVOX ORAL SUSPENSION FOR RECONSTITUTION 00 MG/5 ML Cephalosporins cefaclor oral capsule 250 mg, 500 mg (Cefaclor) $0 cefaclor oral suspension for reconstitution 25 mg/5 ml, 250 (Cefaclor) $0 mg/5 ml, 375 mg/5 ml cefadroxil oral capsule 500 mg (Cefadroxil) $0 cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 (Cefadroxil) $0 mg/5 ml cefadroxil oral tablet gram (Cefadroxil) $0 cefazolin in dextrose (iso-os) (Cefazolin intravenous piggyback gram/50 Sodium/Dextrose, $0 ml, 2 gram/50 ml Iso) cefazolin injection recon soln gram, 0 gram, 500 mg (Cefazolin Sodium) $0 cefdinir oral capsule 300 mg (Cefdinir) $0 cefdinir oral suspension for reconstitution 25 mg/5 ml, 250 (Cefdinir) $0 mg/5 ml cefditoren pivoxil oral tablet 200 mg, 400 mg (Spectracef) $0 CEFEPIME 2 GM INJECTION 2 GRAM/00 ML PA; QL (9 per 30 days) PA 2

CEFEPIME IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK GRAM/50 ML, 2 GRAM/50 ML cefepime injection recon soln gram, 2 gram cefotaxime injection recon soln gram, 0 gram, 2 gram, 500 mg cefoxitin in dextrose, iso-osm intravenous piggyback 2 gram/50 ml (Maxipime) $0 (Claforan) $0 (Cefoxitin Sodium/Dextrose, Iso) $0 cefoxitin intravenous recon soln gram, 0 gram, 2 gram (Cefoxitin Sodium) $0 cefpodoxime oral suspension for (Cefpodoxime reconstitution 00 mg/5 ml, 50 mg/5 Proxetil) ml $0 cefpodoxime oral tablet 00 mg, 200 (Cefpodoxime mg Proxetil) $0 cefprozil oral suspension for reconstitution 25 mg/5 ml, 250 mg/5 ml (Cefprozil) $0 cefprozil oral tablet 250 mg, 500 mg (Cefprozil) $0 ceftazidime injection recon soln 2 gram, 6 gram (Fortaz) $0 ceftibuten oral capsule 400 mg (Cedax) $0 ceftibuten oral suspension for reconstitution 80 mg/5 ml (Cedax) $0 ceftriaxone gm piggyback 50ml (Ceftriaxone galaxycontainer gram/50 ml Na/Dextrose, Iso) $0 ceftriaxone gm vial 0's, fliptop,l/f gram (Rocephin) $0 ceftriaxone 2 gm piggyback 50ml (Ceftriaxone galaxycontainer 2 gram/50 ml Na/Dextrose, Iso) $0 ceftriaxone injection recon soln 0 gram, 250 mg, 500 mg (Rocephin) $0 ceftriaxone intravenous recon soln (Ceftriaxone gram, 2 gram Na/Dextrose, Iso) $0 22

cefuroxime axetil oral tablet 250 mg, 500 mg (Ceftin) $0 cefuroxime sodium injection recon soln.5 gram, 750 mg (Zinacef) $0 cefuroxime sodium intravenous recon soln 7.5 gram (Zinacef) $0 cephalexin oral capsule 250 mg, 500 mg, 750 mg (Keflex) $0 cephalexin oral suspension for reconstitution 25 mg/5 ml, 250 (Cephalexin) $0 mg/5 ml cephalexin oral tablet 250 mg, 500 mg (Cephalexin) $0 MEFOXIN IN DEXTROSE (ISO- OSM) INTRAVENOUS PIGGYBACK GRAM/50 ML, 2 GRAM/50 ML SUPRAX ORAL TABLET,CHEWABLE 00 MG, 200 MG tazicef injection recon soln 2 gram, 6 gram (Fortaz) $0 TEFLARO INTRAVENOUS RECON SOLN 400 MG, 600 MG Macrolides azithromycin intravenous recon soln 500 mg (Zithromax) $0 azithromycin oral packet gram (Zithromax) $0 azithromycin oral suspension for reconstitution 00 mg/5 ml, 200 (Zithromax) $0 mg/5 ml azithromycin oral tablet 250 mg, 250 mg (6 pack), 600 mg (Zithromax) $0 azithromycin oral tablet 500 mg (Zithromax) $0 23

clarithromycin oral suspension for reconstitution 25 mg/5 ml, 250 (Biaxin) $0 mg/5 ml clarithromycin oral tablet 250 mg, 500 mg (Biaxin) $0 clarithromycin oral tablet extended release 24 hr 500 mg (Clarithromycin) $0 DIFICID ORAL TABLET 200 MG QL (20 per 0 days) e.e.s. 400 oral tablet 400 mg (Erythromycin Ethylsuccinate) $0 e.e.s. granules oral suspension for reconstitution 200 mg/5 ml (Eryped 200) $0 ery-tab oral tablet,delayed release (dr/ec) 250 mg, 500 mg ERY-TAB ORAL TABLET,DELAYED RELEASE (DR/EC) 333 MG erythrocin (as stearate) oral tablet 250 mg ERYTHROCIN INTRAVENOUS RECON SOLN,000 MG, 500 MG erythromycin ethylsuccinate oral tablet 400 mg erythromycin oral capsule,delayed release(dr/ec) 250 mg erythromycin oral tablet 250 mg, 500 mg Miscellaneous B-Lactam Antibiotics aztreonam injection recon soln gram CAYSTON INHALATION SOLUTION FOR NEBULIZATION 75 MG/ML imipenem-cilastatin intravenous recon soln 250 mg, 500 mg (Erythromycin Base) (Erythromycin Stearate) (Erythromycin Ethylsuccinate) (Erythromycin Base) (Erythromycin Base) $0 $0 $0 $0 $0 (Azactam) $0 (Primaxin) $0 LA 24

INVANZ INJECTION RECON SOLN GRAM meropenem intravenous recon soln 500 mg meropenem iv gm vial outer, latexfree gram Penicillins amoxicillin oral capsule 250 mg, 500 mg amoxicillin oral suspension for reconstitution 25 mg/5 ml, 200 mg/5 ml, 250 mg/5 ml, 400 mg/5 ml amoxicillin oral tablet 500 mg, 875 mg amoxicillin oral tablet,chewable 25 mg, 250 mg amoxicillin-pot clavulanate oral suspension for reconstitution 200-28.5 mg/5 ml, 250-62.5 mg/5 ml, 400-57 mg/5 ml, 600-42.9 mg/5 ml amoxicillin-pot clavulanate oral tablet 250-25 mg, 500-25 mg, 875-25 mg amoxicillin-pot clavulanate oral tablet extended release 2 hr,000-62.5 mg amoxicillin-pot clavulanate oral tablet,chewable 200-28.5 mg, 400-57 mg ampicillin 2 gm vial 0's, latex-free 2 gram ampicillin oral capsule 250 mg, 500 mg ampicillin oral suspension for reconstitution 25 mg/5 ml, 250 mg/5 ml (Merrem) $0 (Merrem) $0 (Amoxicillin) $0 (Amoxicillin) $0 (Amoxicillin) $0 (Amoxicillin) $0 (Augmentin) $0 (Augmentin) $0 (Augmentin XR) $0 (Amoxicillin/Potas sium Clav) (Ampicillin Sodium) (Ampicillin Trihydrate) (Ampicillin Trihydrate) $0 $0 $0 $0 25

ampicillin sodium injection recon soln gram, 0 gram, 25 mg ampicillin sodium intravenous recon soln 2 gram ampicillin-sulbactam injection recon soln.5 gram, 5 gram, 3 gram BICILLIN C-R INTRAMUSCULAR SYRINGE,200,000 UNIT/ 2 ML(600K/600K),,200,000 UNIT/ 2 ML(900K/300K) BICILLIN L-A INTRAMUSCULAR SYRINGE,200,000 UNIT/2 ML, 2,400,000 UNIT/4 ML, 600,000 UNIT/ML dicloxacillin oral capsule 250 mg, 500 mg nafcillin 2 gm vial sterile, latex-free 2 gram nafcillin injection recon soln gram, 0 gram nafcillin intravenous recon soln 2 gram oxacillin gm add-vantage vl addvantage, inner gram oxacillin in dextrose(iso-osm) intravenous piggyback gram/50 ml, 2 gram/50 ml oxacillin injection recon soln 0 gram oxacillin intravenous recon soln 2 gram penicillin g pot in dextrose intravenous piggyback million unit/50 ml, 2 million unit/50 ml, 3 million unit/50 ml (Ampicillin Sodium) (Ampicillin Sodium) $0 $0 (Unasyn) $0 (Dicloxacillin Sodium) $0 (Nafcillin Sodium) $0 (Nafcillin Sodium) $0 (Nafcillin Sodium) $0 (Oxacillin Sodium) $0 (Oxacillin Sodium/Dextrose, Iso) $0 (Oxacillin Sodium) $0 (Oxacillin Sodium) $0 (Pen G Pot/Dextrose- Water) $0 26

penicillin g potassium injection recon soln 5 million unit penicillin g procaine intramuscular syringe.2 million unit/2 ml, 600,000 unit/ml penicillin gk 20 million unit 20 million unit penicillin v potassium oral recon soln 25 mg/5 ml, 250 mg/5 ml penicillin v potassium oral tablet 250 mg, 500 mg pfizerpen-g injection recon soln 20 million unit piperacillin-tazobactam intravenous recon soln 2.25 gram, 3.375 gram, 4.5 gram piperacil-tazobact 40.5 gram p/f, latex-free 40.5 gram Quinolones ciprofloxacin hcl oral tablet 00 mg, 250 mg, 500 mg, 750 mg ciprofloxacin in 5 % dextrose intravenous piggyback 200 mg/00 ml ciprofloxacin lactate intravenous solution 400 mg/40 ml ciprofloxacin oral suspension,microcapsule recon 250 mg/5 ml, 500 mg/5 ml ciprofloxacn-d5w 400 mg/200 ml p/f,latex/f, in d5w 400 mg/200 ml levofloxacin in d5w intravenous piggyback 500 mg/00 ml, 750 mg/50 ml levofloxacin intravenous solution 25 mg/ml (Penicillin G Potassium) (Penicillin G Procaine) (Penicillin G Potassium) (Penicillin V Potassium) (Penicillin V Potassium) (Penicillin G Potassium) $0 $0 $0 $0 $0 $0 (Zosyn) $0 (Zosyn) $0 (Cipro) $0 (Cipro I.V.) $0 (Ciprofloxacin Lactate) $0 (Cipro) $0 (Cipro I.V.) $0 (Levaquin) $0 (Levofloxacin) $0 27

levofloxacin oral solution 250 mg/0 ml (Levaquin) $0 levofloxacin oral tablet 250 mg, 500 mg, 750 mg (Levaquin) $0 moxifloxacin oral tablet 400 mg (Avelox) $0 ofloxacin oral tablet 400 mg (Ofloxacin) $0 Sulfonamides sulfadiazine oral tablet 500 mg (Sulfadiazine) $0 sulfamethoxazole-trimethoprim intravenous solution 400-80 mg/5 ml (Sulfamethoxazole/ Trimethoprim) $0 sulfamethoxazole-trimethoprim oral (Sulfamethoxazole/ suspension 200-40 mg/5 ml Trimethoprim) $0 sulfamethoxazole-trimethoprim oral tablet 400-80 mg, 800-60 mg (Bactrim) $0 sulfasalazine oral tablet 500 mg (Azulfidine) $0 sulfasalazine oral tablet,delayed release (dr/ec) 500 mg (Azulfidine) $0 sulfatrim oral suspension 200-40 (Sulfamethoxazole/ mg/5 ml Trimethoprim) $0 Tetracyclines doxy-00 intravenous recon soln (Doxycycline 00 mg Hyclate) $0 doxycycline hyclate 00 mg cap 00 mg (Morgidox) $0 doxycycline hyclate 00 mg tab 00 mg (Doryx) $0 doxycycline hyclate intravenous (Doxycycline recon soln 00 mg Hyclate) $0 doxycycline hyclate oral capsule 00 mg (Adoxa) $0 doxycycline hyclate oral capsule 50 mg (Morgidox) $0 doxycycline hyclate oral tablet 00 mg, 50 mg (Avidoxy) $0 28

doxycycline hyclate oral tablet 20 mg doxycycline mono 00 mg cap 00 mg doxycycline mono 00 mg tablet f/c 00 mg doxycycline mono 50 mg tablet 50 mg doxycycline monohydrate oral capsule 50 mg, 50 mg, 75 mg doxycycline monohydrate oral suspension for reconstitution 25 mg/5 ml doxycycline monohydrate oral tablet 50 mg, 75 mg minocycline oral capsule 00 mg, 50 mg, 75 mg minocycline oral tablet 00 mg, 50 mg, 75 mg tetracycline oral capsule 250 mg, 500 mg TYGACIL INTRAVENOUS RECON SOLN 50 MG Anticancer Agents Anticancer Agents ABRAXANE INTRAVENOUS SUSPENSION FOR RECONSTITUTION 00 MG ADCETRIS INTRAVENOUS RECON SOLN 50 MG adriamycin intravenous recon soln 0 mg, 20 mg, 50 mg adriamycin intravenous solution 0 mg/5 ml adrucil 2,500 mg/50 ml vial outer, latex-free 2.5 gram/50 ml (Doryx) $0 (Adoxa) $0 (Avidoxy) $0 (Avidoxy) $0 (Adoxa) $0 (Vibramycin) $0 (Avidoxy) $0 (Minocin) $0 (Minocycline HCl) $0 (Tetracycline HCl) $0 (Doxorubicin HCl) $0 (Doxorubicin HCl) $0 (Fluorouracil) $0 PA NSO; QL (4 per 2 days) 29

adrucil intravenous solution 500 mg/0 ml (Fluorouracil) $0 AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION 2 MG, 3 MG, 5 MG AFINITOR ORAL TABLET 0 MG AFINITOR ORAL TABLET 2.5 MG, 5 MG, 7.5 MG ALECENSA ORAL CAPSULE 50 MG ALIMTA INTRAVENOUS RECON SOLN 500 MG anastrozole oral tablet mg (Arimidex) $0 AVASTIN INTRAVENOUS SOLUTION 25 MG/ML, 25 MG/ML (6 ML) azacitidine injection recon soln 00 mg (Vidaza) $0 BELEODAQ INTRAVENOUS RECON SOLN 500 MG BENDEKA INTRAVENOUS SOLUTION 25 MG/ML bexarotene oral capsule 75 mg (Targretin) $0 bicalutamide oral tablet 50 mg (Casodex) $0 bleomycin injection recon soln 30 (Bleomycin unit Sulfate) $0 bleomycin sulfate 5 unit vial latexfree 5 unit Sulfate) (Bleomycin $0 BLINCYTO INTRAVENOUS KIT 35 MCG BOSULIF ORAL TABLET 00 MG BOSULIF ORAL TABLET 500 MG PA NSO; QL (2 per 28 days) PA NSO; QL (56 per 28 days) PA NSO; QL (28 per 28 days) PA NSO; QL (240 per 30 days) PA NSO PA NSO PA NSO PA NSO; QL (420 per 30 days) PA NSO; QL (40 per 365 days) PA NSO; QL (20 per 30 days) PA NSO; QL (30 per 30 days) 30

CABOMETYX ORAL TABLET 20 MG, 60 MG CABOMETYX ORAL TABLET 40 MG CAPRELSA ORAL TABLET 00 MG CAPRELSA ORAL TABLET 300 MG COMETRIQ ORAL CAPSULE 00 MG/DAY(80 MG X-20 MG X), 40 MG/DAY(80 MG X-20 MG X3), 60 MG/DAY (20 MG X 3/DAY) COTELLIC ORAL TABLET 20 MG cyclophosphamide intravenous recon soln gram, 2 gram, 500 mg CYCLOPHOSPHAMIDE ORAL CAPSULE 25 MG, 50 MG cyclophosphamide oral tablet 25 mg, 50 mg CYRAMZA INTRAVENOUS SOLUTION 0 MG/ML, 0 MG/ML (50 ML) dactinomycin intravenous recon soln 0.5 mg DARZALEX INTRAVENOUS SOLUTION 20 MG/ML decitabine intravenous recon soln 50 mg doxorubicin, peg-liposomal intravenous suspension 2 mg/ml DROXIA ORAL CAPSULE 200 MG, 300 MG, 400 MG (Cyclophosphamid e) (Cyclophosphamid e) $0 $0 (Dactinomycin) $0 (Dacogen) $0 (Doxil) $0 PA NSO; QL (30 per 30 days) PA NSO; QL (60 per 30 days) PA NSO; QL (60 per 30 days) PA NSO; QL (30 per 30 days) PA NSO; QL (2 per 28 days) PA NSO; LA; QL (63 per 28 days) ; ST ; ST PA NSO PA NSO; LA 3

ELIGARD (3 MONTH) SUBCUTANEOUS SYRINGE 22.5 MG ELIGARD (4 MONTH) SUBCUTANEOUS SYRINGE 30 MG ELIGARD (6 MONTH) SUBCUTANEOUS SYRINGE 45 MG ELIGARD SUBCUTANEOUS SYRINGE 7.5 MG ( MONTH) EMCYT ORAL CAPSULE 40 MG EMPLICITI INTRAVENOUS RECON SOLN 300 MG, 400 MG ERIVEDGE ORAL CAPSULE 50 MG ETOPOPHOS INTRAVENOUS RECON SOLN 00 MG etoposide intravenous solution 20 mg/ml (Etoposide) $0 exemestane oral tablet 25 mg (Aromasin) $0 FARESTON ORAL TABLET 60 MG FARYDAK ORAL CAPSULE 0 MG, 5 MG, 20 MG FASLODEX INTRAMUSCULAR SYRINGE 250 MG/5 ML floxuridine injection recon soln 0.5 gram (Floxuridine) $0 fluorouracil 5,000 mg/00 ml latexfree 5 gram/00 ml (Fluorouracil) $0 fluorouracil intravenous solution gram/20 ml, 2.5 gram/50 ml, 500 (Fluorouracil) $0 mg/0 ml flutamide oral capsule 25 mg (Flutamide) $0 QL ( per 84 days) QL ( per 2 days) QL ( per 68 days) PA NSO PA NSO; QL (30 per 30 days) PA NSO 32

GAZYVA INTRAVENOUS SOLUTION,000 MG/40 ML GILOTRIF ORAL TABLET 20 MG, 30 MG, 40 MG GLEOSTINE ORAL CAPSULE 0 MG, 00 MG, 40 MG HERCEPTIN INTRAVENOUS RECON SOLN 440 MG HEXALEN ORAL CAPSULE 50 MG hydroxyurea oral capsule 500 mg (Hydrea) $0 IBRANCE ORAL CAPSULE 00 MG, 25 MG, 75 MG ICLUSIG ORAL TABLET 5 MG ICLUSIG ORAL TABLET 45 MG ifosfamide gm/20 ml vial suv gram/20 ml ifosfamide intravenous recon soln gram ifosfamide-mesna intravenous kit - gram, 3,000-,000 mg (Ifex) $0 (Ifex) $0 (Ifosfamide/Mesna ) $0 imatinib oral tablet 00 mg (Gleevec) $0 imatinib oral tablet 400 mg (Gleevec) $0 IMBRUVICA ORAL CAPSULE 40 MG IMLYGIC INJECTION SUSPENSION 0EXP6 ( MILLION) PFU/ML IMLYGIC INJECTION SUSPENSION 0EXP8 (00 MILLION) PFU/ML PA NSO PA NSO; QL (30 per 30 days) PA NSO PA NSO; QL (2 per 28 days) PA NSO; QL (60 per 30 days) PA NSO; QL (30 per 30 days) PA NSO; QL (90 per 30 days) PA NSO; QL (60 per 30 days) PA NSO PA NSO; QL (4 per 365 days) PA NSO; QL (8 per 28 days) 33

INLYTA ORAL TABLET MG INLYTA ORAL TABLET 5 MG IRESSA ORAL TABLET 250 MG IXEMPRA 5 MG KIT WITH DILUENT 5 MG IXEMPRA INTRAVENOUS RECON SOLN 45 MG JAKAFI ORAL TABLET 0 MG, 5 MG, 20 MG, 25 MG, 5 MG KEYTRUDA INTRAVENOUS RECON SOLN 50 MG KEYTRUDA INTRAVENOUS SOLUTION 00 MG/4 ML (25 MG/ML) KYPROLIS INTRAVENOUS RECON SOLN 30 MG KYPROLIS INTRAVENOUS RECON SOLN 60 MG LENVIMA ORAL CAPSULE 0 MG/DAY (0 MG X /DAY), 4 MG/DAY(0 MG X -4 MG X ), 8 MG/DAY (0 MG X -4 MG X2), 20 MG/DAY (0 MG X 2), 24 MG/DAY(0 MG X 2-4 MG X ), 8 MG/DAY (4 MG X 2) letrozole oral tablet 2.5 mg (Femara) $0 LEUKERAN ORAL TABLET 2 MG leuprolide subcutaneous kit (Leuprolide mg/0.2 ml Acetate) $0 lipodox 50 intravenous suspension 2 mg/ml (Doxil) $0 PA NSO; QL (80 per 30 days) PA NSO; QL (60 per 30 days) PA NSO; QL (60 per 30 days) PA NSO; QL (60 per 30 days) PA NSO PA NSO PA NSO; QL (2 per 28 days) PA NSO; QL (6 per 28 days) PA NSO 34

lipodox intravenous suspension 2 mg/ml lomustine oral capsule 0 mg, 00 mg, 40 mg LONSURF ORAL TABLET 5-6.4 MG LONSURF ORAL TABLET 20-8.9 MG LUPRON DEPOT (3 MONTH) INTRAMUSCULAR SYRINGE KIT.25 MG, 22.5 MG LUPRON DEPOT (4 MONTH) INTRAMUSCULAR SYRINGE KIT 30 MG LUPRON DEPOT (6 MONTH) INTRAMUSCULAR SYRINGE KIT 45 MG LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 3.75 MG, 7.5 MG LYNPARZA ORAL CAPSULE 50 MG LYSODREN ORAL TABLET 500 MG MATULANE ORAL CAPSULE 50 MG megestrol oral tablet 20 mg, 40 mg MEKINIST ORAL TABLET 0.5 MG (Doxil) $0 (Lomustine) $0 (Megestrol Acetate) $0 MEKINIST ORAL TABLET 2 MG mercaptopurine oral tablet 50 mg (Mercaptopurine) $0 methotrexate 50 mg/2 ml vial latexfree, 5's, mdv 25 mg/ml (Methotrexate $0 Sodium) PA NSO; QL (00 per 28 days) PA NSO; QL (80 per 28 days) QL ( per 84 days) QL ( per 84 days) QL ( per 68 days) PA NSO; QL (480 per 30 days) PA NSO; QL (90 per 30 days) PA NSO; QL (30 per 30 days) 35

methotrexate sodium (pf) injection (Methotrexate recon soln gram Sodium/PF) $0 methotrexate sodium (pf) injection (Methotrexate solution 25 mg/ml Sodium) $0 methotrexate sodium oral tablet 2.5 (Methotrexate mg Sodium) $0 mitoxantrone intravenous (Mitoxantrone concentrate 2 mg/ml HCl) $0 NEXAVAR ORAL TABLET 200 MG NILANDRON ORAL TABLET 50 MG nilutamide oral tablet 50 mg (Nilandron) $0 NINLARO ORAL CAPSULE 2.3 MG, 3 MG, 4 MG ODOMZO ORAL CAPSULE 200 MG ONCASPAR INJECTION SOLUTION 750 UNIT/ML OPDIVO INTRAVENOUS SOLUTION 40 MG/4 ML POMALYST ORAL CAPSULE MG, 2 MG, 3 MG, 4 MG PORTRAZZA INTRAVENOUS SOLUTION 800 MG/50 ML (6 MG/ML) PROLEUKIN INTRAVENOUS RECON SOLN 22 MILLION UNIT PURIXAN ORAL SUSPENSION 20 MG/ML REVLIMID ORAL CAPSULE 0 MG, 5 MG, 2.5 MG, 20 MG, 25 MG, 5 MG RITUXAN INTRAVENOUS CONCENTRATE 0 MG/ML ; ST PA NSO; QL (20 per 30 days) PA NSO; QL (3 per 28 days) PA NSO; LA PA NSO PA NSO PA NSO; QL (2 per 28 days) PA NSO; QL (00 per 2 days) PA NSO; LA PA NSO 36

SOLTAMOX ORAL SOLUTION 0 MG/5 ML SPRYCEL ORAL TABLET 00 MG, 40 MG, 50 MG, 70 MG, 80 MG SPRYCEL ORAL TABLET 20 MG STIVARGA ORAL TABLET 40 MG SUTENT ORAL CAPSULE 2.5 MG, 25 MG, 37.5 MG, 50 MG SYLVANT INTRAVENOUS RECON SOLN 00 MG, 400 MG SYNRIBO SUBCUTANEOUS RECON SOLN 3.5 MG TABLOID ORAL TABLET 40 MG TAFINLAR ORAL CAPSULE 50 MG, 75 MG TAGRISSO ORAL TABLET 40 MG, 80 MG tamoxifen oral tablet 0 mg, 20 mg (Tamoxifen Citrate) $0 TARCEVA ORAL TABLET 00 MG, 25 MG TARCEVA ORAL TABLET 50 MG TARGRETIN ORAL CAPSULE 75 MG TARGRETIN TOPICAL GEL % TASIGNA ORAL CAPSULE 50 MG, 200 MG TECENTRIQ INTRAVENOUS SOLUTION,200 MG/20 ML (60 MG/ML) PA NSO; QL (30 per 30 days) PA NSO; QL (60 per 30 days) PA NSO; QL (84 per 28 days) PA NSO; QL (30 per 30 days) PA NSO PA NSO; QL (28 per 28 days) PA NSO; QL (20 per 30 days) PA NSO; LA; QL (30 per 30 days) PA NSO; QL (60 per 30 days) PA NSO; QL (90 per 30 days) PA NSO; QL (420 per 30 days) PA NSO; QL (60 per 28 days) PA NSO; QL (2 per 28 days) PA NSO; QL (20 per 2 days) 37

TEMODAR INTRAVENOUS RECON SOLN 00 MG thiotepa injection recon soln 5 mg (Thiotepa) $0 toposar intravenous solution 20 mg/ml (Etoposide) $0 TREANDA 25 MG VIAL 25 MG TREANDA INTRAVENOUS RECON SOLN 00 MG TREANDA INTRAVENOUS SOLUTION 80 MG/2 ML, 45 MG/0.5 ML TRELSTAR 22.5 MG SYRINGE OUTER 22.5 MG/2 ML TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 22.5 MG TRELSTAR INTRAMUSCULAR SYRINGE.25 MG/2 ML TRELSTAR INTRAMUSCULAR SYRINGE 3.75 MG/2 ML tretinoin (chemotherapy) oral capsule 0 mg (Tretinoin) $0 TREXALL ORAL TABLET 0 MG, 5 MG, 5 MG, 7.5 MG TYKERB ORAL TABLET 250 MG UNITUXIN INTRAVENOUS SOLUTION 3.5 MG/ML VALSTAR INTRAVESICAL SOLUTION 40 MG/ML VELCADE INJECTION RECON SOLN 3.5 MG VENCLEXTA ORAL TABLET 0 MG, 00 MG, 50 MG VENCLEXTA STARTING PACK ORAL TABLETS,DOSE PACK 0 MG-50 MG- 00 MG PA NSO; (vial only) QL ( per 68 days) QL ( per 68 days) QL ( per 84 days) (capsule: 0mg) ; ST PA NSO PA NSO PA NSO; LA PA NSO; LA 38

vinorelbine intravenous solution 50 mg/5 ml VOTRIENT ORAL TABLET 200 MG XALKORI ORAL CAPSULE 200 MG, 250 MG (Navelbine) $0 XTANDI ORAL CAPSULE 40 MG YERVOY INTRAVENOUS SOLUTION 50 MG/0 ML (5 MG/ML) YONDELIS INTRAVENOUS RECON SOLN MG ZELBORAF ORAL TABLET 240 MG ZOLADEX SUBCUTANEOUS IMPLANT 0.8 MG ZOLADEX SUBCUTANEOUS IMPLANT 3.6 MG ZOLINZA ORAL CAPSULE 00 MG ZYDELIG ORAL TABLET 00 MG, 50 MG ZYKADIA ORAL CAPSULE 50 MG ZYTIGA ORAL TABLET 250 MG Anticholinergic Agents Antimuscarinics/Antispasm odics atropine injection solution 0.4 mg/ml atropine injection syringe 0.05 mg/ml, 0. mg/ml propantheline oral tablet 5 mg (Atropine Sulfate) $0 (Atropine Sulfate) $0 (Propantheline Bromide) $0 PA NSO; QL (20 per 30 days) PA NSO; QL (60 per 30 days) PA NSO; QL (20 per 30 days) PA NSO PA NSO PA NSO; QL (240 per 30 days) QL ( per 84 days) QL ( per 28 days) PA NSO; QL (60 per 30 days) PA NSO; QL (40 per 28 days) PA NSO; QL (20 per 30 days) 39

STIOLTO RESPIMAT INHALATION MIST 2.5-2.5 MCG/ACTUATION Anticonvulsants Anticonvulsants APTIOM ORAL TABLET 200 MG, 400 MG, 600 MG, 800 MG BANZEL ORAL SUSPENSION 40 MG/ML BANZEL ORAL TABLET 200 MG, 400 MG BRIVIACT INTRAVENOUS SOLUTION 50 MG/5 ML BRIVIACT ORAL SOLUTION 0 MG/ML BRIVIACT ORAL TABLET 0 MG, 00 MG, 25 MG, 50 MG, 75 MG carbamazepine oral capsule, er multiphase 2 hr 00 mg, 200 mg, (Carbatrol) $0 300 mg carbamazepine oral suspension 00 mg/5 ml (Tegretol) $0 carbamazepine oral tablet 200 mg (Tegretol) $0 carbamazepine oral tablet extended release 2 hr 00 mg, 200 mg, 400 (Tegretol XR) $0 mg carbamazepine oral tablet,chewable 00 mg (Carbamazepine) $0 CELONTIN ORAL CAPSULE 300 MG DILANTIN ORAL CAPSULE 30 MG $0 divalproex oral capsule, sprinkle 25 mg (Depakote Sprinkle) $0 QL (4 per 28 days) ST ST ST QL (80 per 30 days) QL (600 per 30 days) QL (60 per 30 days) 40

divalproex oral tablet extended release 24 hr 250 mg, 500 mg (Depakote ER) $0 divalproex oral tablet,delayed release (dr/ec) 25 mg, 250 mg, 500 (Depakote) $0 mg epitol oral tablet 200 mg (Tegretol) $0 ethosuximide oral capsule 250 mg (Zarontin) $0 ethosuximide oral solution 250 mg/5 ml (Zarontin) $0 felbamate oral suspension 600 mg/5 ml (Felbatol) $0 felbamate oral tablet 400 mg, 600 mg (Felbatol) $0 fosphenytoin 500 mg pe/0 ml 0's,sdv,latex-free 500 mg pe/0 ml (Cerebyx) $0 fosphenytoin injection solution 00 mg pe/2 ml (Cerebyx) $0 FYCOMPA ORAL SUSPENSION 0.5 MG/ML FYCOMPA ORAL TABLET 0 MG, 2 MG, 2 MG, 4 MG, 6 MG, 8 MG gabapentin oral capsule 00 mg, 300 mg, 400 mg (Neurontin) $0 gabapentin oral solution 250 mg/5 ml (Neurontin) $0 gabapentin oral tablet 600 mg, 800 mg (Neurontin) $0 GABITRIL ORAL TABLET 2 MG, 6 MG LAMICTAL ORAL TABLET, CHEWABLE DISPERSIBLE 2 MG lamotrigine oral tablet 00 mg, 50 mg, 200 mg, 25 mg (Lamictal) $0 ST ST 4

lamotrigine oral tablet extended release 24hr 00 mg, 200 mg, 25 (Lamictal XR) $0 mg, 250 mg, 300 mg, 50 mg lamotrigine oral tablet, chewable dispersible 25 mg, 5 mg (Lamictal) $0 lamotrigine oral tablets,dose pack 25 mg (35) (Lamictal (Blue)) $0 levetiracetam intravenous solution 500 mg/5 ml (Keppra) $0 levetiracetam oral solution 00 mg/ml (Keppra) $0 levetiracetam oral tablet,000 mg, 250 mg, 500 mg, 750 mg (Roweepra) $0 levetiracetam oral tablet extended release 24 hr 500 mg, 750 mg (Keppra XR) $0 LYRICA ORAL CAPSULE 00 QL (90 per 30 days) MG, 50 MG, 200 MG, 225 MG, 25 MG, 300 MG, 50 MG, 75 MG LYRICA ORAL SOLUTION 20 QL (900 per 30 days) MG/ML oxcarbazepine oral suspension 300 mg/5 ml (Trileptal) $0 oxcarbazepine oral tablet 50 mg, 300 mg, 600 mg (Trileptal) $0 OXTELLAR XR ORAL TABLET ST EXTENDED RELEASE 24 HR 50 MG, 300 MG, 600 MG PEGANONE ORAL TABLET 250 MG phenobarbital oral elixir 20 mg/5 ml QL (500 per 30 days) (Phenobarbital) $0 (4 mg/ml) phenobarbital oral tablet 00 mg, QL (90 per 30 days) 5 mg, 6.2 mg, 32.4 mg, 60 mg, 64.8 mg, 97.2 mg (Phenobarbital) $0 phenobarbital oral tablet 30 mg (Phenobarbital) $0 QL (200 per 30 days) 42

phenobarbital sodium injection (Phenobarbital QL (2 per 30 days) $0 solution 30 mg/ml, 65 mg/ml Sodium) phenytoin oral suspension 25 mg/5 ml (Dilantin-25) $0 phenytoin oral tablet,chewable 50 mg (Dilantin) $0 phenytoin sodium extended oral capsule 00 mg, 200 mg, 300 mg (Dilantin) $0 phenytoin sodium intravenous (Phenytoin solution 50 mg/ml Sodium) $0 phenytoin sodium intravenous (Phenytoin syringe 50 mg/ml Sodium) $0 POTIGA ORAL TABLET 200 MG, QL (90 per 30 days) 300 MG, 400 MG POTIGA ORAL TABLET 50 MG QL (270 per 30 days) primidone oral tablet 250 mg, 50 mg (Mysoline) $0 ROWEEPRA ORAL TABLET 500 MG $0 SABRIL ORAL POWDER IN PACKET 500 MG SABRIL ORAL TABLET 500 MG SPRITAM ORAL TABLET FOR ST; QL (60 per 30 SUSPENSION,000 MG SPRITAM ORAL TABLET FOR SUSPENSION 250 MG, 500 MG, 750 MG tiagabine oral tablet 2 mg, 4 mg (Gabitril) $0 topiragen oral tablet 00 mg, 200 mg, 25 mg, 50 mg (Topamax) $0 topiramate oral capsule, sprinkle 5 mg, 25 mg (Topamax) $0 topiramate oral capsule,sprinkle,er 24hr 00 mg, 50 mg, 200 mg, 25 (Qudexy XR) $0 mg, 50 mg topiramate oral tablet 00 mg, 200 mg, 25 mg, 50 mg (Topamax) $0 days) ST; QL (20 per 30 days) 43

TROKENDI XR ORAL CAPSULE,EXTENDED RELEASE 24HR 00 MG, 200 MG, 25 MG, 50 MG valproate sodium intravenous solution 500 mg/5 ml (00 mg/ml) (Depacon) $0 valproic acid (as sodium salt) oral solution 250 mg/5 ml (Depakene) $0 valproic acid oral capsule 250 mg (Depakene) $0 VIMPAT INTRAVENOUS SOLUTION 200 MG/20 ML VIMPAT ORAL SOLUTION 0 MG/ML VIMPAT ORAL TABLET 00 MG, 50 MG, 200 MG, 50 MG zonisamide oral capsule 00 mg, 25 mg, 50 mg (Zonegran) $0 Antidementia Agents Antidementia Agents donepezil oral tablet 0 mg, 23 mg, ST QL (200 per 5 days) QL (200 per 30 days) QL (60 per 30 days) QL (30 per 30 days) (Aricept) $0 5 mg donepezil oral tablet,disintegrating QL (30 per 30 days) (Donepezil HCl) $0 0 mg, 5 mg galantamine oral capsule,ext rel. QL (30 per 30 days) (Razadyne ER) $0 pellets 24 hr 6 mg, 24 mg, 8 mg galantamine oral solution 4 mg/ml (Galantamine Hbr) $0 QL (200 per 30 days) galantamine oral tablet 2 mg, 4 QL (60 per 30 days) (Razadyne) $0 mg, 8 mg memantine oral solution 2 mg/ml (Namenda) $0 QL (360 per 30 days) memantine oral tablet 0 mg, 5 mg (Namenda) $0 QL (60 per 30 days) memantine oral tablets,dose pack 5- QL (49 per 28 days) (Namenda) $0 0 mg NAMENDA XR ORAL QL (28 per 28 days) CAP,SPRINKLE,ER 24HR DOSE PACK 7-4-2-28 MG 44

NAMENDA XR ORAL CAPSULE,SPRINKLE,ER 24HR 4 MG, 2 MG, 28 MG, 7 MG NAMZARIC ORAL CAPSULE,SPRINKLE,ER 24HR 4-0 MG, 2-0 MG, 28-0 MG, 7-0 MG rivastigmine tartrate oral capsule.5 mg, 3 mg, 4.5 mg, 6 mg rivastigmine transdermal patch 24 hour 3.3 mg/24 hour, 4.6 mg/24 hr, 9.5 mg/24 hr Antidepressants Antidepressants amitriptyline oral tablet 0 mg, 00 mg, 50 mg, 25 mg, 50 mg, 75 mg amoxapine oral tablet 00 mg, 50 mg, 25 mg, 50 mg BRINTELLIX ORAL TABLET 0 MG, 20 MG, 5 MG buproban oral tablet extended release 50 mg bupropion hcl (smoking deter) oral tablet extended release 50 mg bupropion hcl oral tablet 00 mg, 75 mg bupropion hcl oral tablet extended release 00 mg, 50 mg, 200 mg bupropion hcl oral tablet extended release 24 hr 50 mg, 300 mg citalopram oral solution 0 mg/5 ml citalopram oral tablet 0 mg, 20 mg, 40 mg clomipramine oral capsule 25 mg, 50 mg, 75 mg (Exelon) $0 (Exelon) $0 (Amitriptyline HCl) $0 (Amoxapine) $0 (Wellbutrin SR) $0 (Wellbutrin SR) $0 (Wellbutrin) $0 (Wellbutrin SR) $0 (Wellbutrin XL) $0 (Citalopram Hydrobromide) $0 (Celexa) $0 (Anafranil) $0 QL (30 per 30 days) QL (60 per 30 days) QL (30 per 30 days) PA NSO-HRM ST QL (30 per 30 days) PA NSO-HRM 45

desipramine oral tablet 0 mg, 00 mg, 50 mg, 25 mg, 50 mg, 75 mg (Norpramin) $0 doxepin oral capsule 0 mg, 00 PA NSO-HRM (Doxepin HCl) $0 mg, 50 mg, 25 mg, 50 mg, 75 mg doxepin oral concentrate 0 mg/ml (Doxepin HCl) $0 PA NSO-HRM duloxetine oral capsule,delayed (Cymbalta); QL (60 (Duloxetine) $0 release(dr/ec) 20 mg, 60 mg per 30 days) duloxetine oral capsule,delayed (Cymbalta); QL (30 (Duloxetine) $0 release(dr/ec) 30 mg per 30 days) duloxetine oral capsule,delayed (Irenka); QL (30 per 30 (Duloxetine) $0 release(dr/ec) 40 mg days) EMSAM TRANSDERMAL QL (30 per 30 days) PATCH 24 HOUR 2 MG/24 HR, 6 MG/24 HR, 9 MG/24 HR escitalopram oxalate oral solution 5 mg/5 ml (Lexapro) $0 escitalopram oxalate oral tablet 0 mg, 20 mg, 5 mg (Lexapro) $0 FETZIMA ORAL CAPSULE,EXT ST REL 24HR DOSE PACK 20 MG (2)- 40 MG (26) FETZIMA ORAL ST CAPSULE,EXTENDED RELEASE 24 HR 20 MG, 20 MG, 40 MG, 80 MG fluoxetine oral capsule 0 mg, 20 mg, 40 mg (Prozac) $0 fluoxetine oral capsule,delayed release(dr/ec) 90 mg (Prozac Weekly) $0 fluoxetine oral solution 20 mg/5 ml (4 mg/ml) (Fluoxetine HCl) $0 fluoxetine oral tablet 0 mg, 20 mg (Fluoxetine HCl) $0 fluvoxamine oral capsule,extended (Fluvoxamine release 24hr 00 mg, 50 mg Maleate) $0 fluvoxamine oral tablet 00 mg, 25 (Fluvoxamine mg, 50 mg Maleate) $0 46

imipramine hcl oral tablet 0 mg, 25 (Tofranil) mg, 50 mg $0 imipramine pamoate oral capsule 00 mg, 25 mg, 50 mg, 75 mg (Tofranil-Pm) $0 maprotiline oral tablet 25 mg, 50 mg, 75 mg (Maprotiline HCl) $0 MARPLAN ORAL TABLET 0 MG mirtazapine oral tablet 5 mg, 30 mg, 45 mg, 7.5 mg (Remeron) $0 mirtazapine oral tablet,disintegrating 5 mg, 30 mg, (Remeron) $0 45 mg nefazodone oral tablet 00 mg, 50 mg, 200 mg, 250 mg, 50 mg (Nefazodone HCl) $0 nortriptyline oral capsule 0 mg, 25 mg, 50 mg, 75 mg (Pamelor) $0 nortriptyline oral solution 0 mg/5 ml (Nortriptyline HCl) $0 olanzapine-fluoxetine oral capsule 2-25 mg, 2-50 mg, 3-25 mg, 6-25 (Symbyax) $0 mg, 6-50 mg paroxetine hcl oral tablet 0 mg, 20 mg, 30 mg, 40 mg (Paxil) $0 paroxetine hcl oral tablet extended release 24 hr 2.5 mg, 25 mg, 37.5 (Paxil CR) $0 mg PAXIL ORAL SUSPENSION 0 MG/5 ML perphenazine-amitriptyline oral (Perphenazine/Ami tablet 2-0 mg, 2-25 mg, 4-0 mg, triptyline HCl) 4-25 mg, 4-50 mg $0 phenelzine oral tablet 5 mg (Nardil) $0 PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR 00 MG, 25 MG, 50 MG PA NSO-HRM PA NSO-HRM PA NSO-HRM ST; QL (30 per 30 days) 47

protriptyline oral tablet 0 mg, 5 mg (Protriptyline HCl) $0 sertraline oral concentrate 20 mg/ml (Zoloft) $0 sertraline oral tablet 00 mg, 25 mg, 50 mg (Zoloft) $0 SILENOR ORAL TABLET 3 MG, 6 MG SURMONTIL ORAL CAPSULE 00 MG, 25 MG, 50 MG tranylcypromine oral tablet 0 mg (Parnate) $0 trazodone oral tablet 00 mg, 50 mg, 300 mg, 50 mg (Trazodone HCl) $0 trimipramine oral capsule 00 mg, (Trimipramine 25 mg, 50 mg Maleate) $0 TRINTELLIX ORAL TABLET 0 MG, 20 MG, 5 MG venlafaxine oral capsule,extended release 24hr 50 mg, 37.5 mg, 75 (Effexor XR) $0 mg venlafaxine oral tablet 00 mg, 25 mg, 37.5 mg, 50 mg, 75 mg (Venlafaxine HCl) $0 venlafaxine oral tablet extended release 24hr 50 mg, 37.5 mg, 75 (Venlafaxine HCl) $0 mg VIIBRYD ORAL TABLET 0 MG, 20 MG, 40 MG VIIBRYD ORAL TABLETS,DOSE PACK 0 MG (7)- 20 MG (23), 0 MG (7)-20 MG (7)-40 MG (6) Antidiabetic Agents Antidiabetic Agents, Miscellaneous acarbose oral tablet 00 mg, 25 mg, 50 mg CYCLOSET ORAL TABLET 0.8 MG (Precose) $0 QL (30 per 30 days) PA NSO-HRM PA NSO-HRM ST QL (90 per 30 days) QL (80 per 30 days) 48

GLYXAMBI ORAL TABLET 0-5 ST MG, 25-5 MG INVOKAMET ORAL TABLET ST 50-,000 MG, 50-500 MG, 50-,000 MG, 50-500 MG INVOKAMET XR ORAL ST TABLET, IR - ER, BIPHASIC 24HR 50-,000 MG, 50-500 MG, 50-,000 MG, 50-500 MG INVOKANA ORAL TABLET 00 ST MG, 300 MG JANUMET ORAL TABLET 50-,000 MG, 50-500 MG JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 00-,000 MG, 50-,000 MG, 50-500 MG JANUVIA ORAL TABLET 00 MG, 25 MG, 50 MG JARDIANCE ORAL TABLET 0 ST MG, 25 MG JENTADUETO ORAL TABLET 2.5-,000 MG, 2.5-500 MG, 2.5-850 MG JENTADUETO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 2.5-,000 MG, 5-,000 MG KORLYM ORAL TABLET 300 PA; QL (2 per 28 MG days) metformin oral tablet,000 mg (Glucophage) $0 QL (75 per 30 days) metformin oral tablet 500 mg (Glucophage) $0 QL (50 per 30 days) metformin oral tablet 850 mg (Glucophage) $0 QL (90 per 30 days) metformin oral tablet extended QL (20 per 30 days) (Glucophage XR) $0 release 24 hr 500 mg metformin oral tablet extended QL (90 per 30 days) (Glucophage XR) $0 release 24 hr 750 mg 49

metformin oral tablet extended release 24hr,000 mg (Fortamet) $0 metformin oral tablet extended release 24hr 500 mg (Fortamet) $0 miglitol oral tablet 00 mg, 25 mg, 50 mg (Glyset) $0 nateglinide oral tablet 20 mg, 60 mg (Starlix) $0 pioglitazone oral tablet 5 mg, 30 mg, 45 mg (Actos) $0 pioglitazone-glimepiride oral tablet 30-2 mg, 30-4 mg (Duetact) $0 pioglitazone-metformin oral tablet 5-500 mg, 5-850 mg (Actoplus Met) $0 repaglinide oral tablet 0.5 mg, mg, (Prandin) 2 mg $0 repaglinide-metformin oral tablet - 500 mg, 2-500 mg (Prandimet) $0 SYMLINPEN 20 SUBCUTANEOUS PEN INJECTOR 2,700 MCG/2.7 ML SYMLINPEN 60 SUBCUTANEOUS PEN INJECTOR,500 MCG/.5 ML SYNJARDY ORAL TABLET 2.5-,000 MG, 2.5-500 MG, 5-,000 MG, 5-500 MG TRADJENTA ORAL TABLET 5 MG TRULICITY SUBCUTANEOUS PEN INJECTOR 0.75 MG/0.5 ML,.5 MG/0.5 ML VICTOZA Insulins QL (60 per 30 days) QL (50 per 30 days) QL (90 per 30 days) QL (90 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (90 per 30 days) QL (240 per 30 days) QL (50 per 30 days) PA; QL (0.8 per 28 days) PA; QL (6 per 28 days) ST 50

HUMULIN R U-500 (CONC) KWIKPEN SUBCUTANEOUS INSULIN PEN 500 UNIT/ML (3 ML) HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS SOLUTION 500 UNIT/ML LANTUS SOLOSTAR SUBCUTANEOUS INSULIN PEN 00 UNIT/ML (3 ML) LANTUS SUBCUTANEOUS SOLUTION 00 UNIT/ML NOVOLIN 70/30 SUBCUTANEOUS SUSPENSION 00 UNIT/ML (70-30) NOVOLIN N SUBCUTANEOUS SUSPENSION 00 UNIT/ML NOVOLIN R INJECTION SOLUTION 00 UNIT/ML NOVOLOG FLEXPEN SUBCUTANEOUS INSULIN PEN 00 UNIT/ML NOVOLOG MIX 70-30 FLEXPEN SUBCUTANEOUS INSULIN PEN 00 UNIT/ML (70-30) NOVOLOG MIX 70-30 SUBCUTANEOUS SOLUTION 00 UNIT/ML (70-30) NOVOLOG PENFILL SUBCUTANEOUS CARTRIDGE 00 UNIT/ML NOVOLOG SUBCUTANEOUS SOLUTION 00 UNIT/ML TOUJEO SOLOSTAR SUBCUTANEOUS INSULIN PEN 300 UNIT/ML (.5 ML) QL (24 per 28 days) QL (40 per 28 days) QL (40 per 28 days) QL (40 per 28 days) QL (40 per 28 days) QL (30 per 28 days) QL (30 per 28 days) QL (40 per 28 days) QL (30 per 28 days) QL (40 per 28 days) 5

Sulfonylureas glimepiride oral tablet mg, 2 mg (Amaryl) $0 QL (30 per 30 days) glimepiride oral tablet 4 mg (Amaryl) $0 QL (60 per 30 days) glipizide oral tablet 0 mg (Glucotrol) $0 QL (20 per 30 days) glipizide oral tablet 5 mg (Glucotrol) $0 QL (60 per 30 days) glipizide oral tablet extended QL (60 per 30 days) (Glucotrol XL) $0 release 24hr 0 mg glipizide oral tablet extended QL (30 per 30 days) (Glucotrol XL) $0 release 24hr 2.5 mg, 5 mg glipizide-metformin oral tablet 2.5- (Glipizide/Metform QL (240 per 30 days) $0 250 mg in HCl) glipizide-metformin oral tablet 2.5- (Glipizide/Metform QL (20 per 30 days) $0 500 mg, 5-500 mg in HCl) glyburide micronized oral tablet.5 PA-HRM; AGE (Max (Glynase) $0 mg, 3 mg, 6 mg 64 Years) glyburide oral tablet.25 mg, 2.5 PA-HRM; AGE (Max (Glyburide) $0 mg, 5 mg 64 Years) glyburide-metformin oral tablet PA-HRM; AGE (Max (Glucovance) $0.25-250 mg, 2.5-500 mg, 5-500 mg 64 Years) tolazamide oral tablet 250 mg (Tolazamide) $0 QL (20 per 30 days) tolazamide oral tablet 500 mg (Tolazamide) $0 QL (60 per 30 days) tolbutamide oral tablet 500 mg (Tolbutamide) $0 QL (80 per 30 days) Antifungals Antifungals ABELCET INTRAVENOUS SUSPENSION 5 MG/ML aloe vesta 2% antifungal oint 2 % * (Miconazole Nitrate) AMBISOME INTRAVENOUS SUSPENSION FOR RECONSTITUTION 50 MG amphotericin b injection recon soln 50 mg (Amphotericin B) $0 anti-fungal % powder % * (Tolnaftate) antifungal 2% cream 2 % * (Nuzole) 52

baza antifungal 2% cream 2's 2 % (Nuzole) * blis-to-sol % liquid % * (Tolnaftate) CANCIDAS INTRAVENOUS RECON SOLN 50 MG, 70 MG ciclopirox topical cream 0.77 % (Loprox) $0 ciclopirox topical gel 0.77 % (Loprox) $0 ciclopirox topical shampoo % (Loprox) $0 ciclopirox topical solution 8 % (Penlac) $0 ciclopirox topical suspension 0.77 (Ciclopirox $0 % Olamine) ciclopirox-ure-camph-menth-euc (Ciclodan) $0 topical solution 8 % clotrim % vaginal cream % * (Gyne-Lotrimin) clotrimazole % cream (otc) % * (Lotrimin AF) clotrimazole % solution (otc) % (Clotrimazole) * clotrimazole insert 00 mg * (Clotrimazole) clotrimazole mucous membrane (Clotrimazole) $0 troche 0 mg clotrimazole topical cream % (Clotrimazole) $0 clotrimazole topical solution % (Clotrimazole) $0 clotrimazole-7 cream % * (Gyne-Lotrimin) clotrimazole-betamethasone topical (Lotrisone) $0 cream -0.05 % $0 cvs 3-day vaginal cream 2 % * (Gyne-Lotrimin) cvs af % spray powder % * (Tinactin) cvs miconazole 3 combo pack 3pref (Miconazole applic w/cream 4 % (200 mg)- 2 % Nitrate) (9 gram) * (Miconazole dermafungal 2% ointment 2 % * Nitrate) clotrimazole-betamethasone topical critic-aid clear af 2% oint 2's, w/ (Clotrimazole/Beta (Miconazole lotion -0.05 % antifungal 2 % * methasone Dip) Nitrate) 53

econazole topical cream % (Econazole Nitrate) $0 elon dual defense 25% solution 25 % * (Undecylenic Acid) fluconazole in dextrose(iso-o) (Fluconazole In intravenous piggyback 400 mg/200 Nacl,Iso-Osm) ml $0 fluconazole in nacl (iso-osm) intravenous piggyback 00 mg/50 ml, 200 mg/00 ml (Fluconazole In Nacl,Iso-Osm) $0 fluconazole oral suspension for reconstitution 0 mg/ml, 40 mg/ml (Diflucan) $0 fluconazole oral tablet 00 mg, 50 mg, 200 mg, 50 mg (Diflucan) $0 fluconazole-nacl 400 mg/200 ml (Fluconazole In 0's,latex-free, p/f 400 mg/200 ml Nacl,Iso-Osm) $0 flucytosine oral capsule 250 mg, 500 mg (Ancobon) $0 fungi cure intensive % spray % * (Clotrimazole) FUNGI-NAIL TINCTURE * fungoid-d % cream % * (Tinactin) gnp miconazole 3 combo pack 4 % (Miconazole (200 mg)- 2 % (9 gram) * Nitrate) griseofulvin microsize oral tablet 500 mg (Grifulvin V) $0 inzo antifungal 2% cream 2 % * (Nuzole) itraconazole oral capsule 00 mg (Sporanox) $0 ketoconazole oral tablet 200 mg (Ketoconazole) $0 ketoconazole topical cream 2 % (Ketoconazole) $0 ketoconazole topical shampoo 2 % (Nizoral) $0 lamisil af defens % spray pwd % * (Tinactin) lamisil af defense % powder % * (Tolnaftate) LAMISIL ANTIFUNGAL % SPRAY FOR ATHLETES FOOT % * LAMISIL AT % GEL % * 54

micatin 2% antifungal cream 2 % * (Nuzole) miconazole 3 combo pack 3 sup,9gm (Monistat 3) crm w/app 200 mg- 2 % (9 gram) * miconazole 7 00 mg vag supp 00 (Miconazole mg * Nitrate) (Miconazole miconazole nitrate 2% cream 2 % * Nitrate) miconazole-3 vaginal suppository (Miconazole $0 200 mg Nitrate) MONISTAT 3 COMBO PACK 3 SUPP, 9 GM CREAM 200 MG- 2 % (9 GRAM) * MONISTAT 3 COMBO PACK 4 % (200 MG)- 2 % (9 GRAM) * monistat 7 cream 7 applicators 2 % (Miconazole * Nitrate) myco nail a 25% solution 25 % * (Undecylenic Acid) NOXAFIL ORAL SUSPENSION 200 MG/5 ML (40 MG/ML) NOXAFIL ORAL TABLET,DELAYED RELEASE (DR/EC) 00 MG nyamyc topical powder 00,000 (Nystatin) $0 unit/gram nystatin oral suspension 00,000 (Nystatin) $0 unit/ml nystatin oral tablet 500,000 unit (Nystatin) $0 nystatin topical cream 00,000 (Nystatin) $0 unit/gram nystatin topical ointment 00,000 (Nystatin) $0 unit/gram nystatin topical powder 00,000 (Nystatin) $0 unit/gram $0 nystatin-triamcinolone topical (Nystatin/Triamcin cream 00,000-0. unit/g-% ) 55

nystatin-triamcinolone topical (Nystatin/Triamcin $0 ointment 00,000-0. unit/gram-% ) nystop topical powder 00,000 (Nystatin) $0 unit/gram pv foot odor control % powder % (Tinactin) * qc 3 day vaginal 4% cream 200 (Miconazole mg/5 gram (4 %) * Nitrate) ra antifungal % liquid spray liquid (Tolnaftate) spray % * remedy phytplx antifungal oint 2 % (Miconazole * Nitrate) terbinafine % cream % * (Lamisil At) terbinafine hcl oral tablet 250 mg (Lamisil) $0 tolnaftate % cream % * (Tinactin) tolnaftate % solution % * (Tolnaftate) (Miconazole triple paste af 2% ointment 2 % * Nitrate) voriconazole intravenous solution (Vfend IV) $0 200 mg voriconazole oral suspension for reconstitution 200 mg/5 ml (40 (Vfend) $0 mg/ml) voriconazole oral tablet 200 mg, 50 (Vfend) $0 mg Antihistamines Antihistamines alavert 0 mg odt non-drowsy, mint (Claritin) 0 mg * alavert d-2 allergy-sinus tab 5-20 mg * ALLEGRA ALLERGY 80 MG TABLET 80 MG * ALLEGRA ALLERGY 60 MG TABLET 60 MG * (Claritin-D 2 Hour) 56

aller-chlor 2 mg/5 ml syrup 2 mg/5 (Chlorpheniramine ml * Maleate) aller-chlor 4 mg tablet 4 mg * (Chlor-Trimeton) allerclear d-2hr tablet 5-20 mg * (Claritin-D 2 Hour) allerclear d-24hr er tablet nondrowsy 0-240 mg * Hour) (Claritin-D 24 allergy 4 mg tablet 4 mg * (Chlor-Trimeton) allerhist-.34 mg tablet.34 mg * (Clemastine Fumarate) aller-tec d 5-20 mg tablet 5-20 mg * (Zyrtec-D) ambi 60pse-4cpm tablet 4-60 mg * (Chlorpheniramine/ Pseudoephed) aprodine tablet 2.5-60 mg * (Triprolidine/Pseud oephedrine) banophen 25 mg capsule 25 mg * (Zzzquil) banophen 25 mg tablet 25 mg * (Diphenhydramine HCl) banophen allergy 2.5 mg/5 ml a/f 2.5 mg/5 ml * (Zzzquil) benadryl allergy 25 mg ultratb (Diphenhydramine ultratab 25 mg * HCl) cetirizine hcl mg/ ml soln children, s/f, grape (otc) mg/ml * (Children'S Zyrtec) cetirizine hcl 0 mg tablet indoor & outdoor 0 mg * (Zyrtec) cetirizine hcl 5 mg chew tab children's,outer,u-d 5 mg * (Zyrtec) cetirizine-pse er 5-20 mg tab 5-20 mg * (Zyrtec-D) child allegra allergy 30 mg/5 ml (Fexofenadine suspension 30 mg/5 ml * HCl) CHILD CLARITIN 5 MG/5 ML SOLN A/F,D/F,S/F,GRAPE 5 MG/5 ML * 57

child triaminic cold & allergy -2.5 mg/5 ml * child wal-tap cold-allergy elx -2.5 mg/5 ml * CHILD ZYRTEC MG/ML SOLUTION D/F,S/F,GRAPE MG/ML * children's allegra allergy oral tablet 30 mg * CHILDREN'S ZYRTEC 0 MG ODT 0 MG * child's aller-tec mg/ml soln mg/ml * CHILD'S CLARITIN 5 MG TAB CHEW 5 MG * child's wal-dryl 2.5 mg/5 ml a/f,s/f,d/f,bubb gum 2.5 mg/5 ml * child's wal-zyr 0 mg chew tab 0 mg * CLARITIN 0 MG LIQUI-GEL CAP 0 MG * CLARITIN 0 MG REDITABS 0 MG * CLARITIN 0 MG TABLET (OTC) 0 MG * CLARITIN 5 MG REDITABS 5 MG * cold-allergy-sinus oral tablet 2.5-60 mg * compoz 25 mg gelcap 25 mg * cvs allergy 25 mg tablet 25 mg * cvs allergy relief 0 mg sftgl 0 mg * (Dimetapp) (Dimetapp) (Children'S Zyrtec) (Zzzquil) (Zyrtec) (Triprolidine/Pseud oephedrine) (Diphenhydramine HCl) (Diphenhydramine HCl) (Zyrtec) 58

cvs child allergy 0 mg chw tb 24 hr,indoor/outdoor 0 mg * cvs cold & cough nighttime liq 6.25-2.5 mg/5 ml * cyproheptadine oral syrup 2 mg/5 ml cyproheptadine oral tablet 4 mg dailyhist-.34 mg tablet.34 mg * dayhist allergy.34 mg tablet 2 hr relief.34 mg * dimaphen elixir a/f, grape, gluten-f -2.5 mg/5 ml * dimetapp cold & congest liquid 6.25-2.5 mg/5 ml * (Zyrtec) (Triaminic Nighttime Cold- Cough) (Cyproheptadine HCl) (Cyproheptadine HCl) (Clemastine Fumarate) (Clemastine Fumarate) $0 $0 (Dimetapp) (Triaminic Nighttime Cold- Cough) diphenhist 2.5 mg/5 ml soln 2.5 (Zzzquil) mg/5 ml * diphenhist 25 mg capsule 25 mg * (Zzzquil) diphenhist 25 mg captab captab 25 (Diphenhydramine mg * HCl) diphenhydramine 25 mg capsule (Zzzquil) (otc) 25 mg * diphenhydramine 50 mg capsule (Zzzquil) (otc) 50 mg * diphenhydramine 50 mg tablet 50 (Diphenhydramine mg * HCl) diphenhydramine hcl injection (Diphenhydramine $0 solution 50 mg/ml HCl) (Chlorpheniramine ed chlorped jr syrup 2 mg/5 ml * Maleate) ed-a-hist 4 mg-0 mg tablet 4-0 mg (Chlorpheniramine/ * Phenylephrine) 59

fexofenadine hcl 80 mg tablet (Allegra Allergy) 24hr,original str (otc) 80 mg * fexofenadine hcl 30 mg/5 ml 30 (Fexofenadine mg/5 ml * HCl) fexofenadine hcl 60 mg tablet (Allegra Allergy) indoor/outdoor (otc) 60 mg * hm z-sleep 25 mg softgel 25 mg * (Zzzquil) levocetirizine oral solution 2.5 mg/5 (Xyzal) $0 ml levocetirizine oral tablet 5 mg (Xyzal) $0 loratadine 0 mg tablet 0 mg * (Claritin) loratadine allergy 5 mg/5 ml d/f, a/f, (Children'S s/f 5 mg/5 ml * Claritin) loratadine-d 2 hour tablet nondrowsy 5-20 mg * Hour) (Claritin-D 2 loratadine-d 24hr tablet 0-240 mg (Claritin-D 24 * Hour) $0 q-dryl 2.5 mg/5 ml liquid a/f 2.5 (Zzzquil) mg/5 ml * ra sleep aid 50 mg/30 ml liq 50 (Zzzquil) mg/30 ml * siladryl 2.5 mg/5 ml liquid 2.5 (Zzzquil) mg/5 ml * (Doxylamine sleep aid 25 mg tablet 25 mg * Succinate) promethazine oral syrup 6.25 mg/5 pv nyt-time sleep 25 mg caplet 25 simply sleep 25 mg caplet caplet 25 sm allergy relief.34 mg tab.34 sm sinus and allergy tablet (Promethazine (Diphenhydramine (Diphenhydramine (Clemastine (Chlorpheniramine/ ml mg * mg * mg * maximum strength 4-60 mg * HCl) HCl) HCl) Fumarate) Pseudoephed) PA-HRM; AGE (Max 64 Years) 60

sm z-sleep 50 mg/30 ml liquid (Zzzquil) berry,gluten-free 50 mg/30 ml * sudogest sinus & allergy tab 4-60 (Chlorpheniramine/ mg * Pseudoephed) TRIAMINIC NIGHTTIME COLD- COUGH CHILDREN'S, GRAPE 6.25-2.5 MG/5 ML * unisom 50 mg sleepgels softgel 50 (Zzzquil) mg * wal-act d cold & allergy tab 2.5-60 (Triprolidine/Pseud mg * oephedrine) wal-dryl allergy 25 mg capsule 25 (Zzzquil) mg * wal-dryl allergy 25 mg minitab (Diphenhydramine minitab, coated 25 mg * HCl) wal-fex allergy 80 mg tablet 80 (Allegra Allergy) mg * wal-fex allergy 60 mg tablet 60 mg * (Allegra Allergy) wal-finate 4 mg tablet 4 mg * (Chlor-Trimeton) (Chlorpheniramine/ wal-finate-d tablet 4-60 mg * Pseudoephed) wal-itin 0 mg odt non-drowsy 0 (Claritin) mg * wal-itin 0 mg tablet non-drowsy 0 (Claritin) mg * wal-itin 5 mg/5 ml syrup children's, (Children'S grape 5 mg/5 ml * Claritin) (Claritin-D 2 wal-itin d 2 hour tablet 5-20 mg * Hour) wal-itin d 24 hour tablet 0-240 mg (Claritin-D 24 * Hour) wal-phed pe sinus-allergy tab 4-0 wal-phed sinus and allergy tab 4-60 (Chlorpheniramine/ (Chlorpheniramine/ mg * mg * Phenylephrine) Pseudoephed) 6

wal-sleep z 25 mg odt 25 mg * (Unisom Sleepmelts) wal-sleep z 25 mg softgel 25 mg * (Zzzquil) wal-sleep z 50 mg/30 ml liquid berry, a/f, d/f, s/f 50 mg/30 ml * (Zzzquil) wal-som 25 mg tablet 25 mg * (Doxylamine Succinate) wal-som 50 mg softgel softgel 50 mg * (Zzzquil) wal-tap elixir -2.5 mg/5 ml * (Dimetapp) wal-zyr 0 mg tablet 0 mg * (Zyrtec) wal-zyr d tablet 2 hr 5-20 mg * (Zyrtec-D) wal-zyr solution children's, a/f mg/ml * (Children'S Zyrtec) ZYRTEC 0 MG LIQUID GELS 0 MG * ZYRTEC 0 MG ODT 0 MG * ZYRTEC 0 MG TABLET INDOOR/OUTDOOR 24 HR (OTC) 0 MG * Anti-Infectives (Skin And Mucous Membrane) Anti-Infectives (Skin And Mucous Membrane) ABREVA 0% CREAM 0 % * AVC VAGINAL VAGINAL CREAM 5 % clindamycin phosphate vaginal cream 2 % (Cleocin) $0 metronidazole vaginal gel 0.75 % (Metrogel-Vaginal) $0 terconazole vaginal cream 0.4 %, 0.8 % (Terazol 7) $0 terconazole vaginal suppository 80 mg (Terconazole) $0 Antimigraine Agents 62

Antimigraine Agents dihydroergotamine injection QL (30 per 28 days) (D.H.E.45) $0 solution mg/ml dihydroergotamine nasal spray,nonaerosol 0.5 mg/pump act. (4 mg/ml) QL (8 per 28 days) (Migranal) $0 ERGOMAR SUBLINGUAL QL (40 per 28 days) TABLET 2 MG naratriptan oral tablet mg, 2.5 mg (Amerge) $0 QL (8 per 28 days) rizatriptan oral tablet 0 mg, 5 mg (Maxalt) $0 QL (8 per 28 days) rizatriptan oral tablet,disintegrating QL (8 per 28 days) (Maxalt Mlt) $0 0 mg, 5 mg sumatriptan 6 mg/0.5 ml syrng p/f,dehp/f,pvc/f 6 mg/0.5 ml sumatriptan nasal spray,nonaerosol 20 mg/actuation, 5 mg/actuation sumatriptan succinate oral tablet 00 mg, 25 mg, 50 mg sumatriptan succinate subcutaneous cartridge 4 mg/0.5 ml sumatriptan succinate subcutaneous cartridge 6 mg/0.5 ml sumatriptan succinate subcutaneous pen injector 4 mg/0.5 ml sumatriptan succinate subcutaneous pen injector 6 mg/0.5 ml, 6 mg/0.5 ml (auto-injector) sumatriptan succinate subcutaneous solution 6 mg/0.5 ml zolmitriptan oral tablet 2.5 mg, 5 mg zolmitriptan oral tablet,disintegrating 2.5 mg, 5 mg Antimycobacterials Antimycobacterials (Sumatriptan Succinate) $0 (Imitrex) $0 (Imitrex) $0 (Sumatriptan Succinate) $0 (Imitrex) $0 (Sumatriptan Succinate) (Sumatriptan Succinate) $0 $0 (Imitrex) $0 (Zomig) $0 (Zomig Zmt) $0 QL (4 per 28 days) QL (2 per 28 days) QL (8 per 28 days) QL (4 per 28 days) QL (4 per 28 days) QL (4 per 28 days) QL (4 per 28 days) QL (4 per 28 days) QL (2 per 28 days) QL (2 per 28 days) 63

CAPASTAT INJECTION RECON SOLN GRAM dapsone oral tablet 00 mg, 25 mg (Dapsone) $0 ethambutol oral tablet 00 mg, 400 mg (Myambutol) $0 isoniazid oral solution 50 mg/5 ml (Isoniazid) $0 isoniazid oral tablet 00 mg, 300 mg (Isoniazid) $0 PASER ORAL GRANULES DR FOR SUSP IN PACKET 4 GRAM PRIFTIN ORAL TABLET 50 MG pyrazinamide oral tablet 500 mg (Pyrazinamide) $0 rifabutin oral capsule 50 mg (Mycobutin) $0 rifampin intravenous recon soln 600 mg (Rifadin) $0 rifampin oral capsule 50 mg, 300 mg (Rifadin) $0 RIFATER ORAL TABLET 50-20- 300 MG SIRTURO ORAL TABLET 00 MG TRECATOR ORAL TABLET 250 MG Antinausea Agents Antinausea Agents AKYNZEO ORAL CAPSULE 300- PA; QL (88 per 68 days) 0.5 MG compro rectal suppository 25 mg (Compazine) $0 cvs motion sickness 50 mg tab 50 mg * (Dimenhydrinate) dimenhydrinate injection solution 50 (Dimenhydrinate) mg/ml $0 dramamine 50 mg tablet 50 mg * (Dimenhydrinate) dramamine less drowsy 25 mg tb 25 mg * (Meclizine HCl) driminate 50 mg tablet 50 mg * (Dimenhydrinate) 64

dronabinol oral capsule 0 mg, 2.5 mg, 5 mg (Marinol) $0 EMEND INTRAVENOUS RECON QL (2 per 28 days) SOLN 50 MG EMEND ORAL CAPSULE 25 MG, 80 MG EMEND ORAL CAPSULE 40 MG EMEND ORAL CAPSULE,DOSE PACK 25 MG ()- 80 MG (2) EMEND ORAL SUSPENSION FOR RECONSTITUTION 25 MG (25 MG/ ML FINAL CONC.) granisetron (pf) intravenous (Granisetron solution 00 mcg/ml HCl/PF) $0 granisetron hcl intravenous solution mg/ml ( ml) (Granisetron HCl) $0 granisetron hcl oral tablet mg (Granisetron HCl) $0 meclizine 2.5 mg caplet caplet (otc) 2.5 mg * (Meclizine HCl) meclizine 25 mg tablet (otc) 25 mg * (Meclizine HCl) meclizine oral tablet 2.5 mg, 25 mg (Meclizine HCl) $0 motion sickness 25 mg tablet 25 mg * (Meclizine HCl) ondansetron hcl (pf) injection (Ondansetron solution 4 mg/2 ml HCl/PF) $0 ondansetron hcl (pf) injection (Ondansetron syringe 4 mg/2 ml HCl/PF) $0 ondansetron hcl oral solution 4 (Zofran) $0 mg/5 ml ondansetron hcl oral tablet 24 mg, 4 (Zofran) $0 mg, 8 mg ondansetron oral (Zofran Odt) $0 tablet,disintegrating 4 mg, 8 mg phenadoz rectal suppository 2.5 PA-HRM; AGE (Max (Phenergan) $0 mg, 25 mg 64 Years) 65

prochlorperazine edisylate injection solution 0 mg/2 ml (5 mg/ml) prochlorperazine maleate oral tablet 0 mg, 5 mg prochlorperazine rectal suppository 25 mg promethazine oral tablet 2.5 mg, 25 mg, 50 mg promethazine rectal suppository 2.5 mg, 25 mg, 50 mg promethegan rectal suppository 2.5 mg, 25 mg, 50 mg TRANSDERM-SCOP TRANSDERMAL PATCH 3 DAY.5 MG ( MG OVER 3 DAYS) travel sickness 25 mg tab chew 25 mg * (Prochlorperazine Edisylate) $0 (Compazine) $0 (Compazine) $0 (Promethazine HCl) $0 (Phenergan) $0 (Phenergan) $0 (Bonine) wal-dram 50 mg tablet 50 mg * (Dimenhydrinate) Antiparasite Agents Antiparasite Agents ALBENZA ORAL TABLET 200 MG ALINIA ORAL SUSPENSION FOR RECONSTITUTION 00 MG/5 ML ALINIA ORAL TABLET 500 MG atovaquone oral suspension 750 mg/5 ml (Mepron) $0 atovaquone-proguanil oral tablet 250-00 mg, 62.5-25 mg (Malarone) $0 chloroquine phosphate oral tablet (Chloroquine 250 mg, 500 mg Phosphate) $0 COARTEM ORAL TABLET 20-20 MG DARAPRIM ORAL TABLET 25 MG PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) QL (0 per 30 days) 66

EMVERM ORAL TABLET,CHEWABLE 00 MG $0 hydroxychloroquine oral tablet 200 mg (Plaquenil) $0 ivermectin oral tablet 3 mg (Stromectol) $0 mefloquine oral tablet 250 mg (Mefloquine HCl) $0 NEBUPENT INHALATION RECON SOLN 300 MG paromomycin oral capsule 250 mg (Paromomycin Sulfate) $0 PENTAM INJECTION RECON SOLN 300 MG PRIMAQUINE ORAL TABLET 26.3 MG QL (6 per 2 days) QL (90 per 30 days) quinine sulfate oral capsule 324 mg (Qualaquin) $0 PA; QL (42 per 7 days) Antiparkinsonian Agents Antiparkinsonian Agents amantadine hcl oral capsule 00 mg (Amantadine HCl) $0 amantadine hcl oral solution 50 mg/5 ml (Amantadine HCl) $0 amantadine hcl oral tablet 00 mg (Amantadine HCl) $0 APOKYN SUBCUTANEOUS CARTRIDGE 0 MG/ML AZILECT ORAL TABLET 0.5 MG, MG benztropine oral tablet 0.5 mg, (Benztropine mg, 2 mg Mesylate) $0 bromocriptine oral capsule 5 mg (Parlodel) $0 bromocriptine oral tablet 2.5 mg (Parlodel) $0 cabergoline oral tablet 0.5 mg (Cabergoline) $0 carbidopa oral tablet 25 mg (Lodosyn) $0 carbidopa-levodopa oral tablet 0-00 mg, 25-00 mg, 25-250 mg (Sinemet CR) $0 carbidopa-levodopa oral tablet extended release 25-00 mg, 50-200 (Sinemet CR) $0 mg QL (60 per 30 days) PA-HRM; AGE (Max 64 Years) 67

carbidopa-levodopa-entacapone oral tablet 2.5-50-200 mg, 8.75-75-200 mg, 25-00-200 mg, 3.25-25-200 mg, 37.5-50-200 mg, 50-200-200 mg (Stalevo 50) $0 entacapone oral tablet 200 mg (Comtan) $0 NEUPRO TRANSDERMAL PATCH 24 HOUR MG/24 HOUR, 2 MG/24 HOUR, 3 MG/24 HOUR, 4 MG/24 HOUR, 6 MG/24 HOUR, 8 MG/24 HOUR pramipexole oral tablet 0.25 mg, 0.25 mg, 0.5 mg, 0.75 mg, mg,.5 mg (Mirapex) $0 ropinirole oral tablet 0.25 mg, 0.5 mg, mg, 2 mg, 3 mg, 4 mg, 5 mg (Requip) $0 ropinirole oral tablet extended release 24 hr 2 mg, 2 mg, 4 mg, 6 (Requip XL) $0 mg, 8 mg selegiline hcl oral capsule 5 mg (Eldepryl) $0 selegiline hcl oral tablet 5 mg (Selegiline HCl) $0 trihexyphenidyl oral elixir 0.4 mg/ml (Trihexyphenidyl HCl) $0 trihexyphenidyl oral tablet 2 mg, 5 (Trihexyphenidyl mg HCl) $0 Antipsychotic Agents Antipsychotic Agents ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 300 MG ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 400 MG PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) QL ( per 28 days) 68

ABILIFY MAINTENA QL ( per 28 days) INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 300 MG, 400 MG aripiprazole oral solution mg/ml (Abilify) $0 QL (900 per 30 days) aripiprazole oral tablet 0 mg, 5 QL (30 per 30 days) (Abilify) $0 mg, 20 mg, 30 mg, 5 mg aripiprazole oral tablet 2 mg (Abilify) $0 QL (60 per 30 days) aripiprazole oral QL (90 per 30 days) (Abilify Discmelt) $0 tablet,disintegrating 0 mg aripiprazole oral QL (60 per 30 days) (Abilify Discmelt) $0 tablet,disintegrating 5 mg ARISTADA INTRAMUSCULAR QL (.6 per 28 days) SUSPENSION,EXTENDED REL SYRING 44 MG/.6 ML ARISTADA INTRAMUSCULAR QL (2.4 per 28 days) SUSPENSION,EXTENDED REL SYRING 662 MG/2.4 ML ARISTADA INTRAMUSCULAR QL (3.2 per 28 days) SUSPENSION,EXTENDED REL SYRING 882 MG/3.2 ML chlorpromazine injection solution (Chlorpromazine 25 mg/ml HCl) $0 chlorpromazine oral tablet 0 mg, (Chlorpromazine 00 mg, 200 mg, 25 mg, 50 mg HCl) $0 clozapine oral tablet 00 mg (Clozaril) $0 QL (270 per 30 days) clozapine oral tablet 200 mg (Clozaril) $0 QL (35 per 30 days) clozapine oral tablet 25 mg, 50 mg (Clozaril) $0 QL (90 per 30 days) clozapine oral tablet,disintegrating 00 mg, 2.5 mg, 50 mg, 200 mg, (Fazaclo) $0 ST 25 mg FANAPT ORAL TABLET MG, 0 MG, 2 MG, 2 MG, 4 MG, 6 MG, 8 MG ST; QL (60 per 30 days) 69

FANAPT ORAL TABLETS,DOSE PACK MG(2)-2MG(2)- 4MG(2)- 6MG(2) fluphenazine decanoate injection solution 25 mg/ml fluphenazine hcl injection solution 2.5 mg/ml fluphenazine hcl oral concentrate 5 mg/ml fluphenazine hcl oral elixir 2.5 mg/5 ml fluphenazine hcl oral tablet mg, 0 mg, 2.5 mg, 5 mg GEODON INTRAMUSCULAR RECON SOLN 20 MG/ML (FINAL CONC.) haloperidol decanoate intramuscular solution 00 mg/ml haloperidol decanoate intramuscular solution 50 mg/ml haloperidol lactate injection solution 5 mg/ml haloperidol lactate oral concentrate 2 mg/ml haloperidol oral tablet 0.5 mg, mg, 0 mg, 2 mg, 20 mg, 5 mg INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 7 MG/0.75 ML, 56 MG/ML, 234 MG/.5 ML, 39 MG/0.25 ML, 78 MG/0.5 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 273 MG/0.875 ML, 40 MG/.35 ML, 546 MG/.75 ML, 89 MG/2.625 ML (Fluphenazine Decanoate) (Fluphenazine HCl) (Fluphenazine HCl) (Fluphenazine HCl) (Fluphenazine HCl) (Haloperidol Decanoate) (Haldol Decanoate 50) (Haloperidol Lactate) (Haloperidol Lactate) $0 $0 $0 $0 $0 $0 $0 $0 $0 (Haloperidol) $0 ST; QL (8 per 28 days) QL (6 per 28 days) 70

LATUDA ORAL TABLET 20 MG, 20 MG, 40 MG, 60 MG, 80 MG loxapine succinate oral capsule 0 (Loxapine mg, 25 mg, 5 mg, 50 mg Succinate) $0 molindone oral tablet 0 mg (Molindone HCl) $0 QL (240 per 30 days) molindone oral tablet 25 mg (Molindone HCl) $0 QL (270 per 30 days) molindone oral tablet 5 mg (Molindone HCl) $0 QL (20 per 30 days) NUPLAZID ORAL TABLET 7 PA NSO; QL (60 per MG 30 days) olanzapine intramuscular recon soln QL (30 per 30 days) (Zyprexa) $0 0 mg olanzapine oral tablet 0 mg, 5 QL (30 per 30 days) (Zyprexa) $0 mg, 2.5 mg, 20 mg, 5 mg, 7.5 mg olanzapine oral tablet,disintegrating QL (30 per 30 days) (Zyprexa Zydis) $0 0 mg, 5 mg, 5 mg olanzapine oral tablet,disintegrating QL (3 per 30 days) (Zyprexa Zydis) $0 20 mg paliperidone oral tablet extended QL (30 per 30 days) (Invega) $0 release 24hr.5 mg, 3 mg, 9 mg paliperidone oral tablet extended QL (60 per 30 days) (Invega) $0 release 24hr 6 mg perphenazine oral tablet 6 mg, 2 mg, 4 mg, 8 mg (Perphenazine) $0 pimozide oral tablet mg, 2 mg (Orap) $0 quetiapine oral tablet 00 mg, 200 QL (90 per 30 days) (Seroquel) $0 mg, 25 mg, 300 mg, 400 mg, 50 mg REXULTI ORAL TABLET 0.25 QL (20 per 30 days) MG REXULTI ORAL TABLET 0.5 MG QL (60 per 30 days) REXULTI ORAL TABLET MG, QL (30 per 30 days) 2 MG, 3 MG, 4 MG RISPERDAL CONSTA QL (4 per 28 days) INTRAMUSCULAR SYRINGE 2.5 MG/2 ML, 25 MG/2 ML, 37.5 MG/2 ML, 50 MG/2 ML 7

risperidone oral solution mg/ml (Risperdal) $0 QL (480 per 30 days) risperidone oral tablet 0.25 mg, 0.5 QL (60 per 30 days) (Risperdal) $0 mg, mg, 2 mg, 3 mg, 4 mg risperidone oral QL (60 per 30 days) tablet,disintegrating 0.25 mg, 0.5 mg, mg, 2 mg (Risperdal M-Tab) $0 risperidone oral QL (20 per 30 days) (Risperdal M-Tab) $0 tablet,disintegrating 3 mg, 4 mg SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 0 MG, 2.5 MG, 5 MG ST; QL (60 per 30 days) thioridazine oral tablet 0 mg, 00 PA NSO-HRM (Thioridazine HCl) $0 mg, 25 mg, 50 mg thiothixene oral capsule mg, 0 (Thiothixene) $0 mg, 2 mg, 5 mg trifluoperazine oral tablet mg, 0 mg, 2 mg, 5 mg VERSACLOZ ORAL SUSPENSION 50 MG/ML VRAYLAR ORAL CAPSULE.5 MG, 3 MG, 4.5 MG, 6 MG VRAYLAR ORAL CAPSULE,DOSE PACK.5 MG ()- 3 MG (6) ziprasidone hcl oral capsule 20 mg, 40 mg, 60 mg, 80 mg ZYPREXA RELPREVV 405 MG VL KIT W/ DILUENT, OUTER 405 MG ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 20 MG (Trifluoperazine HCl) $0 (Geodon) $0 Antivirals (Systemic) Antiretrovirals abacavir oral tablet 300 mg (Ziagen) $0 ST; QL (540 per 30 days) QL (30 per 30 days) QL (7 per 30 days) QL (60 per 30 days) 72

abacavir-lamivudine-zidovudine oral tablet 300-50-300 mg APTIVUS ORAL CAPSULE 250 MG APTIVUS ORAL SOLUTION 00 MG/ML ATRIPLA ORAL TABLET 600-200-300 MG COMPLERA ORAL TABLET 200-25-300 MG CRIXIVAN ORAL CAPSULE 200 MG, 400 MG DESCOVY ORAL TABLET 200-25 MG didanosine oral capsule,delayed release(dr/ec) 25 mg, 200 mg, 250 mg, 400 mg EDURANT ORAL TABLET 25 MG EMTRIVA ORAL CAPSULE 200 MG EMTRIVA ORAL SOLUTION 0 MG/ML EPIVIR HBV ORAL SOLUTION 25 MG/5 ML (5 MG/ML) EPZICOM ORAL TABLET 600-300 MG EVOTAZ ORAL TABLET 300-50 MG FUZEON SUBCUTANEOUS RECON SOLN 90 MG GENVOYA ORAL TABLET 50-50-200-0 MG INTELENCE ORAL TABLET 00 MG, 200 MG, 25 MG (Trizivir) $0 (Videx EC) $0 73

INVIRASE ORAL CAPSULE 200 MG INVIRASE ORAL TABLET 500 MG ISENTRESS ORAL POWDER IN PACKET 00 MG ISENTRESS ORAL TABLET 400 MG ISENTRESS ORAL TABLET,CHEWABLE 00 MG, 25 MG KALETRA ORAL SOLUTION 400-00 MG/5 ML KALETRA ORAL TABLET 00-25 MG, 200-50 MG lamivudine oral solution 0 mg/ml (Epivir) $0 lamivudine oral tablet 00 mg, 50 mg, 300 mg (Epivir) $0 lamivudine-zidovudine oral tablet 50-300 mg (Combivir) $0 LEXIVA ORAL SUSPENSION 50 MG/ML LEXIVA ORAL TABLET 700 MG nevirapine oral suspension 50 mg/5 ml (Viramune) $0 nevirapine oral tablet 200 mg (Viramune) $0 nevirapine oral tablet extended release 24 hr 00 mg, 400 mg (Viramune XR) $0 NORVIR ORAL CAPSULE 00 MG NORVIR ORAL SOLUTION 80 MG/ML NORVIR ORAL TABLET 00 MG ODEFSEY ORAL TABLET 200-25-25 MG 74

PREZCOBIX ORAL TABLET 800-50 MG-MG PREZISTA ORAL SUSPENSION 00 MG/ML PREZISTA ORAL TABLET 50 MG, 400 MG, 600 MG, 75 MG, 800 MG RESCRIPTOR ORAL TABLET 200 MG RESCRIPTOR ORAL TABLET, DISPERSIBLE 00 MG RETROVIR INTRAVENOUS SOLUTION 0 MG/ML REYATAZ ORAL CAPSULE 50 MG, 200 MG, 300 MG REYATAZ ORAL POWDER IN PACKET 50 MG SELZENTRY ORAL TABLET 50 MG, 300 MG stavudine oral capsule 5 mg, 20 mg, 30 mg, 40 mg (Zerit) $0 stavudine oral recon soln mg/ml (Zerit) $0 STRIBILD ORAL TABLET 50-50-200-300 MG SUSTIVA ORAL CAPSULE 200 MG, 50 MG SUSTIVA ORAL TABLET 600 MG TIVICAY ORAL TABLET 0 MG, 25 MG, 50 MG TRIUMEQ ORAL TABLET 600-50-300 MG TRUVADA ORAL TABLET 00-50 MG, 33-200 MG, 67-250 MG, 200-300 MG 75

VIDEX 2 GRAM PEDIATRIC ORAL RECON SOLN 0 MG/ML (FINAL) VIDEX 4 GM PEDIATRIC SOLN 0 MG/ML (FINAL) VIRACEPT ORAL TABLET 250 MG, 625 MG VIRAMUNE XR ORAL TABLET EXTENDED RELEASE 24 HR 00 MG VIREAD ORAL POWDER 40 MG/SCOOP (40 MG/GRAM) VIREAD ORAL TABLET 50 MG, 200 MG, 250 MG, 300 MG VITEKTA ORAL TABLET 50 MG, 85 MG ZIAGEN ORAL SOLUTION 20 MG/ML zidovudine oral capsule 00 mg (Retrovir) $0 zidovudine oral syrup 0 mg/ml (Retrovir) $0 zidovudine oral tablet 300 mg (Zidovudine) $0 Antivirals, Miscellaneous foscarnet intravenous solution 24 mg/ml (Foscavir) $0 RELENZA DISKHALER INHALATION BLISTER WITH DEVICE 5 MG/ACTUATION rimantadine oral tablet 00 mg (Flumadine) $0 SYNAGIS 00 MG/ ML VIAL 00 MG/ML SYNAGIS INTRAMUSCULAR SOLUTION 50 MG/0.5 ML TAMIFLU ORAL CAPSULE 30 MG TAMIFLU ORAL CAPSULE 45 MG QL (84 per 80 days) QL (48 per 80 days) 76

TAMIFLU ORAL CAPSULE 75 MG TAMIFLU ORAL SUSPENSION FOR RECONSTITUTION 6 MG/ML Hcv Antivirals DAKLINZA ORAL TABLET 30 MG, 60 MG, 90 MG EPCLUSA ORAL TABLET 400-00 MG HARVONI ORAL TABLET 90-400 MG OLYSIO ORAL CAPSULE 50 MG SOVALDI ORAL TABLET 400 MG TECHNIVIE ORAL TABLET 2.5-75-50 MG VIEKIRA PAK ORAL TABLETS,DOSE PACK 2.5 MG- 75 MG -50 MG/250 MG VIEKIRA XR ORAL TABLET, IR - ER, BIPHASIC 24HR 8.33 MG- 50 MG- 33.33 MG-200 MG ZEPATIER ORAL TABLET 50-00 MG Interferons INTRON A 25 MILLION UNIT/2.5 ML 0 MILLION UNIT/ML INTRON A INJECTION RECON SOLN 0 MILLION UNIT ( ML) INTRON A INJECTION RECON SOLN 8 MILLION UNIT ( ML), 50 MILLION UNIT ( ML) INTRON A INJECTION SOLUTION 6 MILLION UNIT/ML QL (42 per 80 days) QL (540 per 80 days) PA; QL (28 per 28 days) PA; QL (28 per 28 days) PA; QL (30 per 30 days) PA; QL (28 per 28 days) PA; QL (28 per 28 days) PA; QL (56 per 28 days) PA; QL (2 per 28 days) PA; QL (84 per 28 days) PA; QL (30 per 30 days) PA NSO PA NSO PA NSO PA NSO 77

PEGASYS PROCLICK SUBCUTANEOUS PEN INJECTOR 35 MCG/0.5 ML, 80 MCG/0.5 ML PEGASYS SUBCUTANEOUS SOLUTION 80 MCG/ML PEGASYS SUBCUTANEOUS SYRINGE 80 MCG/0.5 ML PEGINTRON SUBCUTANEOUS KIT 20 MCG/0.5 ML, 50 MCG/0.5 ML, 50 MCG/0.5 ML, 80 MCG/0.5 ML SYLATRON SUBCUTANEOUS KIT 200 MCG, 300 MCG, 600 MCG Nucleosides And Nucleotides acyclovir oral capsule 200 mg (Zovirax) $0 acyclovir oral suspension 200 mg/5 ml (Zovirax) $0 acyclovir oral tablet 400 mg, 800 mg (Zovirax) $0 acyclovir sodium intravenous (Acyclovir solution 50 mg/ml Sodium) $0 adefovir oral tablet 0 mg (Hepsera) $0 entecavir oral tablet 0.5 mg, mg (Baraclude) $0 famciclovir oral tablet 25 mg, 250 mg, 500 mg (Famvir) $0 ganciclovir sodium intravenous recon soln 500 mg (Cytovene) $0 ribasphere oral capsule 200 mg (Rebetol) $0 ribasphere oral tablet 200 mg, 400 mg, 600 mg (Copegus) $0 TYZEKA ORAL TABLET 600 MG valacyclovir oral tablet gram, 500 mg (Valtrex) $0 PA PA PA PA PA NSO; QL (4 per 28 days) 78

valganciclovir oral tablet 450 mg (Valcyte) $0 VIRAZOLE INHALATION RECON SOLN 6 GRAM Blood Products/Modifiers/Volume Expanders Anticoagulants CEPROTIN (BLUE BAR) INTRAVENOUS RECON SOLN 500 UNIT ELIQUIS ORAL TABLET 2.5 MG, 5 MG enoxaparin subcutaneous solution 300 mg/3 ml enoxaparin subcutaneous syringe 00 mg/ml, 20 mg/0.8 ml, 50 mg/ml, 30 mg/0.3 ml, 40 mg/0.4 ml, 60 mg/0.6 ml, 80 mg/0.8 ml fondaparinux subcutaneous syringe 0 mg/0.8 ml fondaparinux subcutaneous syringe 2.5 mg/0.5 ml fondaparinux subcutaneous syringe 5 mg/0.4 ml fondaparinux subcutaneous syringe 7.5 mg/0.6 ml heparin (porcine) in 5 % dex intravenous parenteral solution 2,500 unit/250 ml, 20,000 unit/500 ml (40 unit/ml), 25,000 unit/500 ml (50 unit/ml) heparin (porcine) in 5 % dex intravenous parenteral solution 25,000 unit/250 ml(00 unit/ml) (Lovenox) $0 (Lovenox) $0 (Arixtra) $0 (Arixtra) $0 (Arixtra) $0 (Arixtra) $0 (Heparin Sodium,Porcine/D5 W) (Heparin Sod,Pork In 0.45% NaCl) $0 $0 QL (24 per 30 days) QL (5 per 30 days) QL (2 per 30 days) QL (8 per 30 days) 79

heparin (porcine) in nacl (pf) intravenous parenteral solution,000 unit/500 ml heparin (porcine) injection solution,000 unit/ml, 0,000 unit/ml, 20,000 unit/ml, 5,000 unit/ml heparin, porcine (pf) injection solution 5,000 unit/0.5 ml heparin, porcine (pf) injection syringe 5,000 unit/0.5 ml heparin-0.45% nacl 25,000 units/250 ml (00 units/ml) bag latex-free, inner 25,000 unit/250 ml heparin-d5w 25,000 units/250 ml (00 units/ml) bag excel container 25,000 unit/250 ml(00 unit/ml) IPRIVASK SUBCUTANEOUS RECON SOLN 5 MG jantoven oral tablet mg, 0 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg PRADAXA ORAL CAPSULE 0 MG, 50 MG, 75 MG warfarin oral tablet mg, 0 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg XARELTO ORAL TABLET 0 MG, 5 MG, 20 MG XARELTO ORAL TABLETS,DOSE PACK 5 MG (42)- 20 MG (9) Blood Formation Modifiers CINRYZE INTRAVENOUS RECON SOLN 500 UNIT (5 ML) (Heparin Sodium,Porcine/Ns /PF) (Heparin Sodium,Porcine) (Heparin Sodium,Porcine/PF ) (Heparin Sodium,Porcine/PF ) (Heparin Sod,Pork In 0.45% NaCl) (Heparin Sodium,Porcine/D5 W) $0 $0 $0 $0 $0 $0 (Coumadin) $0 (Coumadin) $0 PA; QL (24 per 28 days) ST; QL (60 per 30 days) PA 80

EPOGEN 0,000 UNITS/ML VIAL SDV, P/F, OUTER 0,000 UNIT/ML EPOGEN INJECTION SOLUTION 2,000 UNIT/ML, 20,000 UNIT/2 ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML GRANIX SUBCUTANEOUS SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML LEUKINE INJECTION RECON SOLN 250 MCG MIRCERA INJECTION SYRINGE 00 MCG/0.3 ML, 200 MCG/0.3 ML, 50 MCG/0.3 ML, 75 MCG/0.3 ML MOZOBIL SUBCUTANEOUS SOLUTION 24 MG/.2 ML (20 MG/ML) NEULASTA SUBCUTANEOUS SYRINGE 6 MG/0.6ML NEULASTA SUBCUTANEOUS SYRINGE, W/ WEARABLE INJECTOR 6 MG/0.6 ML NEUMEGA SUBCUTANEOUS RECON SOLN 5 MG NEUPOGEN INJECTION SOLUTION 300 MCG/ML, 480 MCG/.6 ML NEUPOGEN INJECTION SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML PROCRIT 0,000 UNITS/ML VIAL 4'S, MDV, OUTER 20,000 UNIT/2 ML PA; QL (2 per 28 days) PA; QL (2 per 28 days) PA; QL (0.6 per 28 days) PA; QL (2 per 28 days) 8

PROCRIT INJECTION SOLUTION 0,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML PROCRIT INJECTION SOLUTION 40,000 UNIT/ML PROMACTA ORAL TABLET 2.5 MG, 25 MG, 50 MG, 75 MG ZARXIO INJECTION SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML Hematologic Agents, Miscellaneous aminocaproic acid oral solution 250 mg/ml (25 %) aminocaproic acid oral tablet,000 mg, 500 mg anagrelide oral capsule 0.5 mg, mg protamine intravenous solution 0 mg/ml tranexamic acid intravenous solution,000 mg/0 ml (00 (Aminocaproic Acid) (Aminocaproic Acid) $0 $0 (Agrylin) $0 (Protamine Sulfate) $0 (Tranexamic Acid) $0 PA; QL (2 per 28 days) PA; QL (6 per 28 days) PA; QL (30 per 30 days) mg/ml) tranexamic acid oral tablet 650 mg (Lysteda) $0 QL (30 per 30 days) Platelet-Aggregation Inhibitors aspirin-dipyridamole oral capsule, er multiphase 2 hr 25-200 mg (Aggrenox) $0 BRILINTA ORAL TABLET 60 MG, 90 MG cilostazol oral tablet 00 mg, 50 mg (Pletal) $0 clopidogrel oral tablet 300 mg, 75 mg (Plavix) $0 dipyridamole oral tablet 25 mg, 50 mg, 75 mg (Persantine) $0 82

EFFIENT ORAL TABLET 0 MG, 5 MG pentoxifylline oral tablet extended release 400 mg Caloric Agents Caloric Agents AMINO ACIDS 5 % INTRAVENOUS PARENTERAL SOLUTION 5 % AMINOSYN 0 % INTRAVENOUS PARENTERAL SOLUTION 0 % (Pentoxifylline) $0 QL (30 per 30 days) AMINOSYN 3.5 % INTRAVENOUS PARENTERAL SOLUTION 3.5 % AMINOSYN 7 % INTRAVENOUS PARENTERAL SOLUTION 7 % AMINOSYN 7 % WITH ELECTROLYTES INTRAVENOUS PARENTERAL SOLUTION 7 % AMINOSYN 8.5 % INTRAVENOUS PARENTERAL SOLUTION 8.5 % AMINOSYN 8.5 %- ELECTROLYTES INTRAVENOUS PARENTERAL SOLUTION 8.5 % AMINOSYN II 0 % INTRAVENOUS PARENTERAL SOLUTION 0 % AMINOSYN II 5 % INTRAVENOUS PARENTERAL SOLUTION 5 % AMINOSYN II 7 % INTRAVENOUS PARENTERAL SOLUTION 7 % 83

AMINOSYN II 8.5 % INTRAVENOUS PARENTERAL SOLUTION 8.5 % AMINOSYN II 8.5 %- ELECTROLYTES INTRAVENOUS PARENTERAL SOLUTION 8.5 % AMINOSYN M 3.5 % INTRAVENOUS PARENTERAL SOLUTION 3.5 % AMINOSYN-HBC 7% INTRAVENOUS PARENTERAL SOLUTION 7 % AMINOSYN-PF 0 % INTRAVENOUS PARENTERAL SOLUTION 0 % AMINOSYN-PF 7 % (SULFITE- FREE) INTRAVENOUS PARENTERAL SOLUTION 7 % AMINOSYN-RF 5.2 % INTRAVENOUS PARENTERAL SOLUTION 5.2 % CLINIMIX 5%/D5W SULFITE FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX 5%/D25W SULFITE- FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX 2.75%/D5W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 2.75 % CLINIMIX 4.25%/D0W SULF FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % 84

CLINIMIX 4.25%/D5W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX 4.25%-D20W SULF- FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX 4.25%-D25W SULF- FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX 5%-D20W(SULFITE- FREE) INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX E 2.75%/D0W SUL FREE INTRAVENOUS PARENTERAL SOLUTION 2.75 % CLINIMIX E 2.75%/D5W SULF FREE INTRAVENOUS PARENTERAL SOLUTION 2.75 % CLINIMIX E 4.25%/D0W SUL FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX E 4.25%/D25W SUL FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX E 4.25%/D5W SULF FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % 85

CLINIMIX E 5%/D5W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX E 5%/D20W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX E 5%/D25W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINISOL SF 5 % INTRAVENOUS PARENTERAL SOLUTION 5 % cysteine (l-cysteine) intravenous solution 50 mg/ml dex4 glucose 4 gm tablet chew grape flavor 4 gram * dextrose 0 % in water (d0w) intravenous parenteral solution 0 % dextrose 0 % in water (d0w) intravenous solution dextrose 20 % in water (d20w) intravenous parenteral solution 20 % dextrose 25 % in water (d25w) intravenous syringe dextrose 40 % in water (d40w) intravenous parenteral solution 40 % (Cysteine HCl) $0 (Dextrose) (Dextrose 0 % in Water) (Dextrose 0 % in Water) (Dextrose 20 % in Water) (Dextrose 25 % in Water) (Dextrose 40 % in Water) $0 $0 $0 $0 $0 dextrose 5 % in ringers intravenous (Dextrose 5 % In parenteral solution 5 % Ringers) $0 dextrose 5 % in water (d5w) (Dextrose 5 % in intravenous parenteral solution Water) $0 dextrose 50 % in water (d50w) (Dextrose 50 % in $0 intravenous parenteral solution Water) dextrose 50 % in water (d50w) (Dextrose 50 % in $0 intravenous syringe Water) 86

dextrose 70 % in water (d70w) (Dextrose 70 % in $0 intravenous parenteral solution Water) FREAMINE HBC 6.9 % INTRAVENOUS PARENTERAL SOLUTION 6.9 % FREAMINE III 0 % INTRAVENOUS PARENTERAL SOLUTION 0 % gluco burst 40% gel 40 % * (Dextrose) glucose 4 gram tablet chew na/f, (Dextrose) caffeine free 4 gram * glucose 40% gel tropical fruit 40 % (Dextrose) * glutose 5 gel 3 pak, outer, u-d 40 (Dextrose) % * HEPATAMINE 8% INTRAVENOUS PARENTERAL SOLUTION 8 % HEPATASOL 8 % INTRAVENOUS PARENTERAL SOLUTION 8 % insta-glucose gel 24 gram/3 gram * insta-glucose gel 24 gram/3 gram (Dextrose/Dextrin/ * Maltose) INTRALIPID INTRAVENOUS EMULSION 20 %, 30 % KABIVEN INTRAVENOUS EMULSION 3.3-9.8-3.9 % NEPHRAMINE 5.4 % INTRAVENOUS PARENTERAL SOLUTION 5.4 % NUTRILIPID INTRAVENOUS EMULSION 20 % PERIKABIVEN INTRAVENOUS EMULSION 2.36-6.8-3.5 % 87

PREMASOL 0 % INTRAVENOUS PARENTERAL SOLUTION 0 % PREMASOL 6 % INTRAVENOUS PARENTERAL SOLUTION 6 % PROCALAMINE 3% INTRAVENOUS PARENTERAL SOLUTION 3 % PROSOL 20 % INTRAVENOUS PARENTERAL SOLUTION smoflipid intravenous emulsion 20 % TRAVASOL 0 % INTRAVENOUS PARENTERAL SOLUTION 0 % TROPHAMINE 0 % INTRAVENOUS PARENTERAL SOLUTION 0 % TROPHAMINE 6% INTRAVENOUS PARENTERAL SOLUTION 6 % Cardiovascular Agents Alpha-Adrenergic Agents clonidine hcl oral tablet 0. mg, 0.2 mg, 0.3 mg clonidine transdermal patch weekly 0. mg/24 hr, 0.2 mg/24 hr clonidine transdermal patch weekly 0.3 mg/24 hr clorpres oral tablet 0.-5 mg, 0.2-5 mg, 0.3-5 mg doxazosin oral tablet mg, 2 mg, 4 mg, 8 mg (Fat Emul/Soy/Mct/Oli v/fish Oil) (Catapres) $0 (Catapres-Tts ) $0 (Catapres-Tts ) $0 (Clonidine HCl/Chlorthalidon e) $0 (Cardura) $0 QL (4 per 28 days) QL (8 per 28 days) 88

guanfacine oral tablet mg, 2 mg (Tenex) $0 midodrine oral tablet 0 mg, 2.5 mg, (Midodrine HCl) 5 mg $0 NORTHERA ORAL CAPSULE 00 MG, 200 MG, 300 MG phenylephrine hcl injection solution 0 mg/ml (Vazculep) $0 prazosin oral capsule mg, 2 mg, 5 mg (Minipress) $0 Angiotensin Ii Receptor Antagonists BENICAR HCT ORAL TABLET 20-2.5 MG, 40-2.5 MG, 40-25 MG BENICAR ORAL TABLET 20 MG, 40 MG, 5 MG candesartan oral tablet 6 mg, 32 mg, 4 mg, 8 mg (Atacand) $0 candesartan-hydrochlorothiazid oral tablet 6-2.5 mg, 32-2.5 mg, (Atacand HCT) $0 32-25 mg ENTRESTO ORAL TABLET 24-26 MG, 49-5 MG, 97-03 MG irbesartan oral tablet 50 mg, 300 mg, 75 mg (Avapro) $0 irbesartan-hydrochlorothiazide oral tablet 50-2.5 mg, 300-2.5 mg (Avalide) $0 losartan oral tablet 00 mg, 25 mg, 50 mg (Cozaar) $0 losartan-hydrochlorothiazide oral tablet 00-2.5 mg, 00-25 mg, 50- (Hyzaar) $0 2.5 mg telmisartan oral tablet 20 mg, 40 mg, 80 mg (Micardis) $0 PA-HRM; AGE (Max 64 Years) PA; QL (80 per 30 days) PA; QL (60 per 30 days) 89

telmisartan-hydrochlorothiazid oral tablet 40-2.5 mg, 80-2.5 mg, 80-25 mg TRIBENZOR ORAL TABLET 20-5-2.5 MG, 40-0-2.5 MG, 40-0- 25 MG, 40-5-2.5 MG, 40-5-25 MG valsartan oral tablet 60 mg, 320 mg, 40 mg, 80 mg valsartan-hydrochlorothiazide oral tablet 60-2.5 mg, 60-25 mg, 320-2.5 mg, 320-25 mg, 80-2.5 mg Angiotensin-Converting Enzyme Inhibitors benazepril oral tablet 0 mg, 20 mg, 40 mg, 5 mg benazepril-hydrochlorothiazide oral tablet 0-2.5 mg, 20-2.5 mg, 20-25 mg, 5-6.25 mg captopril oral tablet 00 mg, 2.5 mg, 25 mg, 50 mg captopril-hydrochlorothiazide oral tablet 25-5 mg, 25-25 mg, 50-5 mg, 50-25 mg enalapril maleate oral tablet 0 mg, 2.5 mg, 20 mg, 5 mg enalaprilat intravenous solution.25 mg/ml enalapril-hydrochlorothiazide oral tablet 0-25 mg, 5-2.5 mg fosinopril oral tablet 0 mg, 20 mg, 40 mg fosinopril-hydrochlorothiazide oral tablet 0-2.5 mg, 20-2.5 mg lisinopril oral tablet 0 mg, 2.5 mg, 20 mg, 30 mg, 40 mg, 5 mg (Micardis HCT) $0 (Diovan) $0 (Diovan HCT) $0 (Lotensin) $0 (Lotensin HCT) $0 (Captopril) $0 (Captopril/Hydroch lorothiazide) $0 (Vasotec) $0 (Enalaprilat Dihydrate) $0 (Vaseretic) $0 (Fosinopril Sodium) (Fosinopril/Hydroc hlorothiazide) $0 $0 (Zestril) $0 ST 90

lisinopril-hydrochlorothiazide oral tablet 0-2.5 mg, 20-2.5 mg, 20- (Zestoretic) $0 25 mg moexipril oral tablet 5 mg, 7.5 mg (Moexipril HCl) $0 moexipril-hydrochlorothiazide oral tablet 5-2.5 mg, 5-25 mg, 7.5-2.5 mg perindopril erbumine oral tablet 2 mg, 4 mg, 8 mg quinapril oral tablet 0 mg, 20 mg, 40 mg, 5 mg quinapril-hydrochlorothiazide oral tablet 0-2.5 mg, 20-2.5 mg, 20-25 mg ramipril oral capsule.25 mg, 0 mg, 2.5 mg, 5 mg trandolapril oral tablet mg, 2 mg, 4 mg Antiarrhythmic Agents amiodarone oral tablet 00 mg, 200 mg, 400 mg disopyramide phosphate oral capsule 00 mg, 50 mg dofetilide oral capsule 25 mcg, 250 mcg, 500 mcg flecainide oral tablet 00 mg, 50 mg, 50 mg lidocaine (pf) intravenous syringe 50 mg/5 ml ( %) lidocaine in 5 % dextrose (pf) intravenous parenteral solution 8 mg/ml (0.8 %) mexiletine oral capsule 50 mg, 200 mg, 250 mg MULTAQ ORAL TABLET 400 MG (Moexipril/Hydroc hlorothiazide) $0 (Aceon) $0 (Accupril) $0 (Accuretic) $0 (Altace) $0 (Mavik) $0 (Cordarone) $0 (Norpace) $0 (Tikosyn) $0 (Tambocor) $0 (Lidocaine HCl/PF) (Lidocaine HCl/D5w/PF) $0 $0 (Mexiletine HCl) $0 9

pacerone oral tablet 00 mg, 200 mg, 400 mg (Cordarone) $0 procainamide injection solution 00 (Procainamide mg/ml, 500 mg/ml HCl) $0 propafenone oral capsule,extended release 2 hr 225 mg, 325 mg, 425 mg (Rythmol SR) $0 propafenone oral tablet 50 mg, 225 (Rythmol) mg, 300 mg $0 quinidine gluconate oral tablet (Quinidine extended release 324 mg Gluconate) $0 quinidine sulfate oral tablet 200 mg, 300 mg (Quinidine Sulfate) $0 quinidine sulfate oral tablet extended release 300 mg (Quinidine Sulfate) $0 Beta-Adrenergic Blocking Agents acebutolol oral capsule 200 mg, 400 mg (Sectral) $0 atenolol oral tablet 00 mg, 25 mg, 50 mg (Tenormin) $0 atenolol-chlorthalidone oral tablet 00-25 mg, 50-25 mg (Tenoretic 50) $0 betaxolol oral tablet 0 mg, 20 mg (Betaxolol HCl) $0 bisoprolol fumarate oral tablet 0 mg, 5 mg (Zebeta) $0 bisoprolol-hydrochlorothiazide oral tablet 0-6.25 mg, 2.5-6.25 mg, 5- (Ziac) $0 6.25 mg BYSTOLIC ORAL TABLET 0 MG, 2.5 MG, 20 MG, 5 MG carvedilol oral tablet 2.5 mg, 25 mg, 3.25 mg, 6.25 mg (Coreg) $0 esmolol intravenous solution 00 mg/0 ml (0 mg/ml) (Brevibloc) $0 92

labetalol intravenous solution 5 mg/ml (Labetalol HCl) $0 labetalol oral tablet 00 mg, 200 mg, 300 mg (Trandate) $0 metoprolol succinate oral tablet extended release 24 hr 00 mg, 200 (Toprol XL) $0 mg, 25 mg, 50 mg metoprolol ta-hydrochlorothiaz oral tablet 00-25 mg, 00-50 mg, 50-25 mg (Lopressor HCT) $0 metoprolol tartrate intravenous (Metoprolol solution 5 mg/5 ml Tartrate) $0 metoprolol tartrate intravenous (Metoprolol syringe 5 mg/5 ml Tartrate) $0 metoprolol tartrate oral tablet 00 mg, 25 mg, 37.5 mg, 50 mg, 75 mg (Lopressor) $0 nadolol oral tablet 20 mg, 40 mg, 80 (Corgard) mg $0 pindolol oral tablet 0 mg, 5 mg (Pindolol) $0 propranolol intravenous solution mg/ml (Propranolol HCl) $0 propranolol oral capsule,extended release 24 hr 20 mg, 60 mg, 60 (Inderal LA) $0 mg, 80 mg propranolol oral solution 20 mg/5 ml (4 mg/ml), 40 mg/5 ml (8 mg/ml) (Propranolol HCl) $0 propranolol oral tablet 0 mg, 20 mg, 40 mg, 60 mg, 80 mg (Propranolol HCl) $0 propranolol-hydrochlorothiazid (Propranolol/Hydro oral tablet 40-25 mg, 80-25 mg chlorothiazid) $0 sorine oral tablet 20 mg, 60 mg, 240 mg, 80 mg (Betapace) $0 sotalol 20 mg tablet 20 mg (Betapace) $0 sotalol af oral tablet 20 mg (Betapace) $0 sotalol oral tablet 60 mg, 240 mg, 80 mg (Betapace) $0 93

timolol maleate oral tablet 0 mg, 20 mg, 5 mg (Timolol Maleate) $0 Calcium-Channel Blocking Agents cartia xt oral capsule,extended release 24hr 20 mg, 80 mg, 240 (Cardizem CD) $0 mg, 300 mg diltiazem 24hr er 80 mg cap 80 mg (Cardizem CD) $0 diltiazem 24hr er 360 mg cap 360 mg (Cardizem CD) $0 diltiazem hcl intravenous recon soln 00 mg (Cardizem CD) $0 diltiazem hcl intravenous solution 5 mg/ml (Cardizem CD) $0 diltiazem hcl oral capsule, extended release 80 mg, 360 mg, 420 mg (Cardizem CD) $0 diltiazem hcl oral capsule,extended release 2 hr 20 mg, 60 mg, 90 mg (Cardizem CD) $0 diltiazem hcl oral capsule,extended release 24hr 20 mg, 240 mg, 300 (Cardizem CD) $0 mg diltiazem hcl oral tablet 20 mg, 30 mg, 60 mg, 90 mg (Cardizem CD) $0 diltiazem hcl oral tablet extended release 24 hr 80 mg, 240 mg, 300 (Cardizem LA) $0 mg, 360 mg, 420 mg dilt-xr oral capsule,ext release (Cardizem CD) degradable 20 mg, 80 mg, 240 mg $0 matzim la oral tablet extended release 24 hr 80 mg, 240 mg, 300 (Cardizem CD) $0 mg, 360 mg, 420 mg taztia xt oral capsule, extended release 20 mg, 80 mg, 240 mg, (Cardizem CD) $0 300 mg, 360 mg verapamil intravenous syringe 2.5 mg/ml (Verapamil HCl) $0 94

verapamil oral capsule, 24 hr er pellet ct 00 mg, 200 mg, 300 mg verapamil oral capsule,ext rel. pellets 24 hr 20 mg, 80 mg, 240 mg, 360 mg verapamil oral tablet 20 mg, 40 mg, 80 mg verapamil oral tablet extended release 20 mg, 80 mg, 240 mg Cardiovascular Agents, Miscellaneous CORLANOR ORAL TABLET 5 MG, 7.5 MG DEMSER ORAL CAPSULE 250 MG (Verelan Pm) $0 (Verelan) $0 (Calan) $0 (Calan SR) $0 digitek oral tablet 25 mcg (Lanoxin) $0 digitek oral tablet 250 mcg (Lanoxin) $0 digox 25 mcg tablet 25 mcg (Lanoxin) $0 ST (High Risk Med for Ages 65 and Older and Dose is Greater Than 25mcg Per Day); QL (30 per 30 days) PA-HRM; (High Risk Med for Ages 65 and Older and Dose is Greater Than 25mcg Per Day); QL (30 per 30 days); AGE (Max 64 Years) (High Risk Med for Ages 65 and Older and Dose is Greater Than 25mcg Per Day); QL (30 per 30 days) 95

digox 250 mcg tablet 250 mcg (Lanoxin) $0 digoxin 0.25 mg/ml syringe 250 mcg/ml digoxin injection solution 250 mcg/ml DIGOXIN ORAL SOLUTION 50 MCG/ML (Digoxin) $0 (Digoxin) $0 digoxin oral tablet 25 mcg (Lanoxin) $0 digoxin oral tablet 250 mcg (Lanoxin) $0 dobutamine in d5w intravenous parenteral solution,000 mg/250 ml (4,000 mcg/ml), 250 mg/250 ml ( mg/ml), 500 mg/250 ml (2,000 mcg/ml) dobutamine intravenous solution 250 mg/20 ml (2.5 mg/ml) (Dobutamine HCl/D5W) $0 (Dobutamine HCl) $0 PA-HRM; (High Risk Med for Ages 65 and Older and Dose is Greater Than 25mcg Per Day); QL (30 per 30 days); AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA-HRM; QL (300 per 30 days); AGE (Max 64 Years) (High Risk Med for Ages 65 and Older and Dose is Greater Than 25mcg Per Day); QL (30 per 30 days) PA-HRM; (High Risk Med for Ages 65 and Older and Dose is Greater Than 25mcg Per Day); QL (30 per 30 days); AGE (Max 64 Years) 96

dopamine in 5 % dextrose intravenous solution 200 mg/250 ml (800 mcg/ml), 400 mg/250 ml (,600 mcg/ml), 800 mg/250 ml (3,200 mcg/ml) dopamine intravenous solution 200 mg/5 ml (40 mg/ml), 400 mg/5 ml (80 mg/ml), 800 mg/0 ml (80 mg/ml), 800 mg/5 ml (60 mg/ml) ephedrine sulfate injection solution 50 mg/ml epinephrine hcl (pf) intravenous solution mg/ml ( ml) epinephrine injection auto-injector 0.5 mg/0.5 ml, 0.3 mg/0.3 ml epinephrine injection solution mg/ml ( ml) epinephrine injection syringe 0. mg/ml EPIPEN 2-PAK INJECTION AUTO-INJECTOR 0.3 MG/0.3 ML EPIPEN JR 2-PAK INJECTION AUTO-INJECTOR 0.5 MG/0.3 ML ethamolin intravenous solution 5 % FIRAZYR SUBCUTANEOUS SYRINGE 30 MG/3 ML hydralazine injection solution 20 mg/ml hydralazine oral tablet 0 mg, 00 mg, 25 mg, 50 mg (Dopamine HCl/D5W) $0 (Dopamine HCl) $0 (Ephedrine Sulfate) $0 (Epinephrine HCl/PF) $0 (Adrenaclick) $0 (Epinephrine) $0 (Epinephrine) $0 (Ethanolamine Oleate) $0 (Hydralazine HCl) $0 (Hydralazine HCl) $0 97

LANOXIN ORAL TABLET 87.5 MCG LANOXIN ORAL TABLET 62.5 MCG milrinone in 5 % dextrose intravenous piggyback 20 mg/00 ml (200 mcg/ml), 40 mg/200 ml (200 mcg/ml) milrinone intravenous solution mg/ml norepinephrine bitartrate intravenous solution mg/ml papaverine injection solution 30 mg/ml papaverine oral capsule, extended release 50 mg RANEXA ORAL TABLET EXTENDED RELEASE 2 HR,000 MG, 500 MG Dihydropyridines afeditab cr oral tablet extended release 30 mg, 60 mg amlodipine oral tablet 0 mg, 2.5 mg, 5 mg amlodipine-benazepril oral capsule 0-20 mg, 0-40 mg, 2.5-0 mg, 5-0 mg, 5-20 mg, 5-40 mg (Milrinone Lactate/D5W) $0 (Milrinone Lactate) $0 (Levophed Bitartrate) $0 (Papaverine HCl) $0 (Papaverine HCl) $0 (Adalat CC) $0 (Norvasc) $0 (Lotrel) $0 PA-HRM; (High Risk Med for Ages 65 and Older and Dose is Greater Than 25mcg Per Day); QL (30 per 30 days); AGE (Max 64 Years) (High Risk Med for Ages 65 and Older and Dose is Greater Than 25mcg Per Day); QL (30 per 30 days) PA PA 98

amlodipine-valsartan oral tablet 0-60 mg, 0-320 mg, 5-60 mg, 5- (Exforge) $0 320 mg amlodipine-valsartan-hcthiazid oral tablet 0-60-2.5 mg, 0-60-25 mg, 0-320-25 mg, 5-60-2.5 mg, (Exforge HCT) $0 5-60-25 mg AZOR ORAL TABLET 0-20 MG, 0-40 MG, 5-20 MG, 5-40 MG CLEVIPREX INTRAVENOUS EMULSION 50 MG/00 ML felodipine oral tablet extended release 24 hr 0 mg, 2.5 mg, 5 mg (Felodipine) $0 isradipine oral capsule 2.5 mg, 5 mg (Isradipine) $0 nicardipine oral capsule 20 mg, 30 mg (Nicardipine HCl) $0 nifedical xl oral tablet extended release 24hr 30 mg, 60 mg (Procardia XL) $0 nifedipine er 30 mg tablet f/c 30 mg (Adalat CC) $0 nifedipine oral tablet extended release 24hr 30 mg (Adalat CC) $0 nifedipine oral tablet extended release 24hr 60 mg, 90 mg (Procardia XL) $0 Diuretics amiloride oral tablet 5 mg (Amiloride HCl) $0 amiloride-hydrochlorothiazide oral (Amiloride/Hydroc tablet 5-50 mg hlorothiazide) $0 bumetanide injection solution 0.25 mg/ml (Bumetanide) $0 bumetanide oral tablet 0.5 mg, mg, 2 mg (Bumetanide) $0 chlorothiazide oral tablet 250 mg, 500 mg (Chlorothiazide) $0 chlorothiazide sodium intravenous recon soln 500 mg (Sodium Diuril) $0 ST 99

chlorthalidone oral tablet 25 mg, 50 mg (Chlorthalidone) $0 DYRENIUM ORAL CAPSULE 00 MG, 50 MG furosemide injection solution 0 mg/ml (Furosemide) $0 furosemide injection syringe 0 mg/ml (Furosemide) $0 furosemide oral solution 0 mg/ml, 40 mg/5 ml (8 mg/ml) (Furosemide) $0 furosemide oral tablet 20 mg, 40 mg, 80 mg (Lasix) $0 hydrochlorothiazide oral capsule 2.5 mg (Microzide) $0 hydrochlorothiazide oral tablet 2.5 (Hydrochlorothiazi mg, 25 mg, 50 mg de) $0 indapamide oral tablet.25 mg, 2.5 mg (Indapamide) $0 methyclothiazide oral tablet 5 mg (Methyclothiazide) $0 metolazone oral tablet 0 mg, 2.5 mg, 5 mg (Zaroxolyn) $0 torsemide oral tablet 0 mg, 00 mg, 20 mg, 5 mg (Demadex) $0 triamterene-hydrochlorothiazid oral capsule 37.5-25 mg, 50-25 mg (Dyazide) $0 triamterene-hydrochlorothiazid oral tablet 37.5-25 mg, 75-50 mg (Maxzide) $0 Dyslipidemics amlodipine-atorvastatin oral tablet 0-0 mg, 0-20 mg, 0-40 mg, 0-80 mg, 2.5-0 mg, 2.5-20 mg, 2.5-40 (Caduet) $0 mg, 5-0 mg, 5-20 mg, 5-40 mg, 5-80 mg atorvastatin oral tablet 0 mg, 20 mg, 40 mg, 80 mg (Lipitor) $0 00

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

niacin oral tablet extended release 24 hr,000 mg, 500 mg, 750 mg (Niaspan) $0 niacin tr 500 mg caplet caplet 500 mg * (Slo-Niacin) niacinamide 500 mg tablet 500 mg * (Niacinamide) niacor oral tablet 500 mg (Niacin) $0 omega-3 acid ethyl esters oral capsule gram (Lovaza) $0 PRALUENT PEN PA; QL (2 per 28 days) SUBCUTANEOUS PEN INJECTOR 50 MG/ML, 75 MG/ML PRALUENT SYRINGE PA; QL (2 per 28 days) SUBCUTANEOUS SYRINGE 50 MG/ML, 75 MG/ML pravastatin oral tablet 0 mg, 20 mg, 40 mg, 80 mg (Pravachol) $0 prevalite oral powder 4 gram (Cholestyramine/A spartame) $0 prevalite packet outer 4 gram (Cholestyramine/A spartame) $0 REPATHA PUSHTRONEX SUBCUTANEOUS WEARABLE PA; QL (3.5 per 28 days) INJECTOR 420 MG/3.5 ML REPATHA SURECLICK PA; QL (3 per 28 days) SUBCUTANEOUS PEN INJECTOR 40 MG/ML REPATHA SYRINGE SUBCUTANEOUS SYRINGE 40 MG/ML PA; QL (3 per 28 days) rosuvastatin oral tablet 0 mg, 20 mg, 40 mg, 5 mg (Crestor) $0 simvastatin oral tablet 0 mg, 20 mg, 40 mg, 5 mg (Zocor) $0 simvastatin oral tablet 80 mg (Zocor) $0 QL (30 per 30 days) 02

VASCEPA ORAL CAPSULE GRAM WELCHOL ORAL POWDER IN PACKET 3.75 GRAM WELCHOL ORAL TABLET 625 MG ZETIA ORAL TABLET 0 MG Renin-Angiotensin- Aldosterone System Inhibitors eplerenone oral tablet 25 mg, 50 mg (Inspra) $0 spironolactone oral tablet 00 mg, 25 mg, 50 mg (Aldactone) $0 spironolacton-hydrochlorothiaz oral (Aldactazide) tablet 25-25 mg $0 Vasodilators BIDIL ORAL TABLET 20-37.5 MG isosorbide dinitrate oral tablet 0 mg, 20 mg, 30 mg, 5 mg (Isochron) $0 isosorbide dinitrate oral tablet extended release 40 mg (Isochron) $0 isosorbide dinitrate sublingual (Isosorbide tablet 2.5 mg, 5 mg Dinitrate) $0 isosorbide mononitrate oral tablet (Isosorbide 0 mg, 20 mg Mononitrate) $0 isosorbide mononitrate oral tablet extended release 24 hr 20 mg, 30 (Imdur) $0 mg, 60 mg minitran transdermal patch 24 hour 0. mg/hr, 0.2 mg/hr, 0.6 mg/hr (Nitro-Dur) $0 minitran transdermal patch 24 hour 0.4 mg/hr (Nitro-Dur) $0 minoxidil oral tablet 0 mg, 2.5 mg (Minoxidil) $0 NITRO-BID TRANSDERMAL OINTMENT 2 % $0 QL (30 per 30 days) QL (60 per 30 days) 03

nitroglycerin in 5 % dextrose intravenous solution 00 mg/250 ml (400 mcg/ml), 25 mg/250 ml (00 mcg/ml), 50 mg/250 ml (200 mcg/ml) nitroglycerin intravenous solution 50 mg/0 ml (5 mg/ml) nitroglycerin sublingual tablet 0.3 mg, 0.4 mg, 0.6 mg nitroglycerin transdermal patch 24 hour 0. mg/hr, 0.2 mg/hr, 0.6 mg/hr nitroglycerin transdermal patch 24 hour 0.4 mg/hr NITROSTAT SUBLINGUAL TABLET 0.3 MG, 0.4 MG, 0.6 MG PROGLYCEM ORAL SUSPENSION 50 MG/ML Central Nervous System Agents Central Nervous System Agents AMPYRA ORAL TABLET EXTENDED RELEASE 2 HR 0 MG caffeine citrated intravenous solution 60 mg/3 ml (20 mg/ml) caffeine citrated oral solution 60 mg/3 ml (20 mg/ml) caffeine-sodium benzoate injection solution 250 mg/ml (25 mg/ml caffeine) clonidine hcl oral tablet extended release 2 hr 0. mg dexmethylphenidate oral tablet 0 mg, 2.5 mg, 5 mg (Nitroglycerin/D5 W) $0 (Nitroglycerin) $0 (Nitrostat) $0 (Nitro-Dur) $0 (Nitro-Dur) $0 (Cafcit) $0 (Cafcit) $0 (Caffeine/Sodium Benzoate) $0 (Kapvay) $0 (Focalin) $0 QL (30 per 30 days) QL (60 per 30 days) PA; QL (60 per 30 days) QL (60 per 30 days) 04

dextroamphetamine oral capsule, extended release 0 mg, 5 mg, 5 mg dextroamphetamine oral tablet 0 mg, 5 mg dextroamphetamine-amphetamine oral capsule,extended release 24hr 0 mg, 5 mg, 5 mg dextroamphetamine-amphetamine oral capsule,extended release 24hr 20 mg, 25 mg, 30 mg dextroamphetamine-amphetamine oral tablet 0 mg, 2.5 mg, 5 mg, 20 mg, 30 mg, 5 mg, 7.5 mg flumazenil intravenous solution 0. mg/ml guanfacine oral tablet extended release 24 hr mg, 2 mg, 3 mg, 4 mg lithium carbonate oral capsule 50 mg, 300 mg, 600 mg lithium carbonate oral tablet 300 mg lithium carbonate oral tablet extended release 300 mg, 450 mg lithium citrate oral solution 8 meq/5 ml methylphenidate cd 20 mg cap 20 mg methylphenidate cd 40 mg cap 40 mg methylphenidate oral capsule, er biphasic 30-70 0 mg, 50 mg, 60 mg methylphenidate oral capsule, er biphasic 30-70 30 mg (Dexedrine) $0 (Dexedrine) $0 (Adderall XR) $0 (Adderall XR) $0 (Adderall) $0 (Romazicon) $0 (Intuniv) $0 (Lithium Carbonate) $0 (Lithobid) $0 (Lithobid) $0 (Lithium Citrate) $0 (Metadate Cd) $0 (Metadate Cd) $0 (Metadate Cd) $0 (Metadate Cd) $0 QL (20 per 30 days) QL (80 per 30 days) QL (30 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (60 per 30 days) 05

methylphenidate oral capsule,er biphasic 50-50 20 mg, 40 mg (Metadate Cd) $0 methylphenidate oral solution 0 mg/5 ml, 5 mg/5 ml (Methylin) $0 methylphenidate oral tablet 0 mg, 20 mg, 5 mg (Ritalin) $0 methylphenidate oral tablet (Methylphenidate extended release 0 mg, 20 mg HCl) $0 methylphenidate oral tablet extended release 24hr 8 mg, 27 (Concerta) $0 mg, 54 mg methylphenidate oral tablet extended release 24hr 36 mg (Concerta) $0 NUEDEXTA ORAL CAPSULE 20-0 MG QUILLIVANT XR ORAL SUSPENSION,EXT REL 24HR,RECON 5 MG/ML (25 MG/5 ML) riluzole oral tablet 50 mg (Rilutek) $0 SAVELLA ORAL TABLET 00 MG, 2.5 MG, 25 MG, 50 MG SAVELLA ORAL TABLETS,DOSE PACK 2.5 MG (5)-25 MG(8)-50 MG(42) STRATTERA ORAL CAPSULE 0 MG, 00 MG, 8 MG, 25 MG, 40 MG, 60 MG, 80 MG tetrabenazine oral tablet 2.5 mg, 25 mg (Xenazine) $0 Contraceptives Contraceptives AFTERA.5 MG TABLET.5 MG * 3 $0 altavera (28) oral tablet 0.5-0.03 mg (Amethyst) $0 QL (30 per 30 days) QL (900 per 30 days) QL (90 per 30 days) QL (90 per 30 days) QL (30 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (60 per 30 days) PA; QL (2 per 28 days) QL (6 per 365 days) 06

alyacen /35 (28) oral tablet -35 mg-mcg (Modicon) $0 alyacen 7/7/7 (28) oral tablet 0.5/0.75/ mg- 35 mcg (Modicon) $0 amethia lo oral tablets,dose pack,3 month 0.0 mg-20 mcg (84)/0 mcg (7) (Seasonique) $0 amethia oral tablets,dose pack,3 month 0.5 mg-30 mcg (84)/0 mcg (Seasonique) $0 (7) apri oral tablet 0.5-0.03 mg (Desogen) $0 aranelle (28) oral tablet 0.5//0.5-35 mg-mcg (Modicon) $0 ashlyna oral tablets,dose pack,3 month 0.5 mg-30 mcg (84)/0 mcg (Seasonique) $0 (7) aubra oral tablet 0.-20 mg-mcg (Amethyst) $0 aviane oral tablet 0.-20 mg-mcg (Amethyst) $0 azurette (28) oral tablet 0.5-0.02 mgx2 /0.0 mg x 5 (Mircette) $0 balziva (28) oral tablet 0.4-35 mgmcg (Modicon) $0 bekyree (28) oral tablet 0.5-0.02 mgx2 /0.0 mg x 5 (Mircette) $0 blisovi 24 fe oral tablet mg-20 mcg (24)/75 mg (4) (Loestrin Fe) $0 blisovi fe.5/30 (28) oral tablet.5 mg-30 mcg (2)/75 mg (7) (Loestrin Fe) $0 blisovi fe /20 (28) oral tablet mg- 20 mcg (2)/75 mg (7) (Loestrin Fe) $0 briellyn oral tablet 0.4-35 mg-mcg (Modicon) $0 camila oral tablet 0.35 mg (Nor-Q-D) $0 camrese lo oral tablets,dose pack,3 month 0.0 mg-20 mcg (84)/0 mcg (Seasonique) $0 (7) QL (9 per 84 days) QL (9 per 84 days) QL (9 per 84 days) 07

camrese oral tablets,dose pack,3 month 0.5 mg-30 mcg (84)/0 mcg (7) caziant (28) oral tablet 0./.25/.5-25 mg-mcg cryselle (28) oral tablet 0.3-30 mgmcg cyclafem /35 (28) oral tablet -35 mg-mcg cyclafem 7/7/7 (28) oral tablet 0.5/0.75/ mg- 35 mcg (Seasonique) $0 (Desogen) $0 (Norgestrel-Ethinyl Estradiol) $0 (Modicon) $0 (Modicon) $0 cyred oral tablet 0.5-0.03 mg (Desogen) $0 dasetta /35 (28) oral tablet -35 mg-mcg (Modicon) $0 dasetta 7/7/7 (28) oral tablet 0.5/0.75/ mg- 35 mcg (Modicon) $0 daysee oral tablets,dose pack,3 month 0.5 mg-30 mcg (84)/0 mcg (7) (Seasonique) $0 deblitane oral tablet 0.35 mg (Nor-Q-D) $0 delyla (28) oral tablet 0.-20 mgmcg (Amethyst) $0 desog-e.estradiol/e.estradiol oral tablet 0.5-0.02 mgx2 /0.0 mg x 5 (Mircette) $0 desogestrel-ethinyl estradiol oral tablet 0.5-0.03 mg (Desogen) $0 drospirenone-ethinyl estradiol oral tablet 3-0.02 mg, 3-0.03 mg (Yaz) $0 econtra ez.5 mg tablet inner.5 mg * (Aftera) QL (9 per 84 days) QL (9 per 84 days) QL (6 per 365 days) (Norgestrel-Ethinyl elinest oral tablet 0.3-30 mg-mcg $0 Estradiol) ELLA ORAL TABLET 30 MG QL (6 per 365 days) emoquette oral tablet 0.5-0.03 mg (Desogen) $0 enpresse oral tablet 50-30 (6)/75-40 (5)/25-30(0) (Amethyst) $0 08

enskyce oral tablet 0.5-0.03 mg (Desogen) $0 errin oral tablet 0.35 mg (Nor-Q-D) $0 estarylla oral tablet 0.25-35 mg-mcg (Ortho-Cyclen) $0 fallback solo.5 mg tablet inner.5 mg * (Aftera) falmina (28) oral tablet 0.-20 mgmcg (Amethyst) $0 gianvi (28) oral tablet 3-0.02 mg (Yaz) $0 gildagia oral tablet 0.4-35 mg-mcg (Modicon) $0 gildess.5/30 (2) oral tablet.5-30 (Loestrin) mg-mcg $0 gildess /20 (2) oral tablet -20 mg-mcg (Loestrin) $0 gildess 24 fe oral tablet mg-20 mcg (24)/75 mg (4) (Loestrin Fe) $0 gildess fe.5/30 (28) oral tablet.5 mg-30 mcg (2)/75 mg (7) (Loestrin Fe) $0 gildess fe /20 (28) oral tablet mg- 20 mcg (2)/75 mg (7) (Loestrin Fe) $0 heather oral tablet 0.35 mg (Nor-Q-D) $0 introvale oral tablets,dose pack,3 (Levonorgestrelmonth 0.5 mg-30 mcg Ethin Estradiol) $0 jencycla oral tablet 0.35 mg (Nor-Q-D) $0 jolessa oral tablets,dose pack,3 (Levonorgestrelmonth 0.5 mg-30 mcg Ethin Estradiol) $0 jolivette oral tablet 0.35 mg (Nor-Q-D) $0 juleber oral tablet 0.5-0.03 mg (Desogen) $0 junel.5/30 (2) oral tablet.5-30 mg-mcg (Loestrin) $0 junel /20 (2) oral tablet -20 mgmcg (Loestrin) $0 junel fe.5/30 (28) oral tablet.5 mg-30 mcg (2)/75 mg (7) (Loestrin Fe) $0 junel fe /20 (28) oral tablet mg- 20 mcg (2)/75 mg (7) (Loestrin Fe) $0 QL (6 per 365 days) QL (9 per 84 days) QL (9 per 84 days) 09

junel fe 24 oral tablet mg-20 mcg (24)/75 mg (4) (Loestrin Fe) $0 kariva (28) oral tablet 0.5-0.02 mgx2 /0.0 mg x 5 (Mircette) $0 kelnor /35 (28) oral tablet -35 mg-mcg (Demulen -50-2) $0 kimidess (28) oral tablet 0.5-0.02 mgx2 /0.0 mg x 5 (Mircette) $0 kurvelo oral tablet 0.5-0.03 mg (Amethyst) $0 l norgest/e.estradiol-e.estrad oral QL (9 per 84 days) tablets,dose pack,3 month 0.0 mg- 20 mcg (84)/0 mcg (7), 0.5 mg-30 mcg (84)/0 mcg (7) (Seasonique) $0 larin.5/30 (2) oral tablet.5-30 mg-mcg (Loestrin) $0 larin /20 (2) oral tablet -20 mgmcg (Loestrin) $0 larin 24 fe oral tablet mg-20 mcg (24)/75 mg (4) (Loestrin Fe) $0 larin fe.5/30 (28) oral tablet.5 mg-30 mcg (2)/75 mg (7) (Loestrin Fe) $0 larin fe /20 (28) oral tablet mg- 20 mcg (2)/75 mg (7) (Loestrin Fe) $0 larissia oral tablet 0.-20 mg-mcg (Amethyst) $0 leena 28 oral tablet 0.5//0.5-35 mg-mcg (Modicon) $0 lessina oral tablet 0.-20 mg-mcg (Amethyst) $0 levonest (28) oral tablet 50-30 (6)/75-40 (5)/25-30(0) (Amethyst) $0 levonor-eth estrad 0.5-0.03 outer QL (9 per 84 days) (Amethyst) $0 0.5-0.03 mg levonorgestrel.5 mg tablet (otc) QL (6 per 365 days) (Aftera).5 mg * levonorgestrel oral tablet 0.75 mg (Plan B One-Step) $0 QL (2 per 365 days) levonorgestrel oral tablet.5 mg (Plan B One-Step) $0 QL (6 per 365 days) 0

levonorgestrel-ethinyl estrad oral tablet 0.-20 mg-mcg (Amethyst) $0 levonorgestrel-ethinyl estrad oral QL (9 per 84 days) tablets,dose pack,3 month 0.5 mg- 30 mcg (Amethyst) $0 levonorg-eth estrad triphasic oral QL (9 per 84 days) tablet 50-30 (6)/75-40 (5)/25-30(0) (Amethyst) $0 levora-28 oral tablet 0.5-0.03 mg (Amethyst) $0 lomedia 24 fe oral tablet mg-20 mcg (24)/75 mg (4) (Loestrin Fe) $0 loryna (28) oral tablet 3-0.02 mg (Yaz) $0 low-ogestrel (28) oral tablet 0.3-30 (Norgestrel-Ethinyl mg-mcg Estradiol) $0 lutera (28) oral tablet 0.-20 mgmcg (Amethyst) $0 lyza oral tablet 0.35 mg (Nor-Q-D) $0 marlissa oral tablet 0.5-0.03 mg (Amethyst) $0 microgestin.5/30 (2) oral tablet.5-30 mg-mcg (Loestrin) $0 microgestin /20 (2) oral tablet - 20 mg-mcg (Loestrin) $0 microgestin fe.5/30 (28) oral tablet.5 mg-30 mcg (2)/75 mg (7) (Loestrin Fe) $0 microgestin fe /20 (28) oral tablet mg-20 mcg (2)/75 mg (7) (Loestrin Fe) $0 mono-linyah oral tablet 0.25-35 mgmcg (Ortho-Cyclen) $0 mononessa (28) oral tablet 0.25-35 mg-mcg (Ortho-Cyclen) $0 my way.5 mg tablet (otc).5 mg * (Aftera) QL (6 per 365 days) myzilra oral tablet 50-30 (6)/75-40 (5)/25-30(0) (Amethyst) $0 necon 0.5/35 (28) oral tablet 0.5-35 mg-mcg (Modicon) $0

necon /35 (28) oral tablet -35 mgmcg (Modicon) $0 necon /50 (28) oral tablet -50 mgmcg (Norinyl +50) $0 necon 0/ (28) oral tablet 0.5-35/-35 mg-mcg/mg-mcg (Modicon) $0 necon 7/7/7 (28) oral tablet 0.5/0.75/ mg- 35 mcg (Modicon) $0 next choice one dose.5 mg tb (otc).5 mg * (Aftera) next choice one dose oral tablet.5 mg (Plan B One-Step) $0 nikki (28) oral tablet 3-0.02 mg (Yaz) $0 nora-be oral tablet 0.35 mg (Nor-Q-D) $0 norethindrone (contraceptive) oral tablet 0.35 mg (Nor-Q-D) $0 norethindrone ac-eth estradiol oral tablet -20 mg-mcg (Loestrin) $0 norethindrone-e.estradiol-iron oral tablet mg-20 mcg (24)/75 mg (4) (Loestrin Fe) $0 norg-ee 0.8-0.25-0.25/0.035 3x28 day regimen 0.8/0.25/0.25 mg-35 (Ortho-Cyclen) $0 mcg (28) norgestimate-ethinyl estradiol oral tablet 0.8/0.25/0.25 mg-25 mcg, (Ortho-Cyclen) $0 0.25-35 mg-mcg norlyroc oral tablet 0.35 mg (Nor-Q-D) $0 nortrel 0.5/35 (28) oral tablet 0.5-35 (Modicon) mg-mcg $0 nortrel /35 (2) oral tablet -35 mg-mcg (Modicon) $0 nortrel /35 (28) oral tablet -35 mg-mcg (Modicon) $0 nortrel 7/7/7 (28) oral tablet 0.5/0.75/ mg- 35 mcg (Modicon) $0 QL (6 per 365 days) QL (6 per 365 days) 2

NUVARING VAGINAL RING ST; QL ( per 28 days) 0.2-0.05 MG/24 HR ocella oral tablet 3-0.03 mg (Yaz) $0 ogestrel (28) oral tablet 0.5-50 mgmcg Estradiol) (Norgestrel-Ethinyl $0 opcicon one-step.5 mg tablet.5 QL (6 per 365 days) (Aftera) mg * option 2.5 mg tablet.5 mg * (Aftera) QL (6 per 365 days) orsythia oral tablet 0.-20 mg-mcg (Amethyst) $0 philith oral tablet 0.4-35 mg-mcg (Modicon) $0 pimtrea (28) oral tablet 0.5-0.02 mgx2 /0.0 mg x 5 (Mircette) $0 pirmella oral tablet 0.5/0.75/ mg- 35 mcg, -35 mg-mcg (Modicon) $0 PLAN B ONE-STEP.5 MG QL (6 per 365 days) 3 $0 TABLET (OTC).5 MG * portia oral tablet 0.5-0.03 mg (Amethyst) $0 previfem oral tablet 0.25-35 mg-mcg (Ortho-Cyclen) $0 quasense oral tablets,dose pack,3 (Levonorgestrel- QL (9 per 84 days) $0 month 0.5 mg-30 mcg Ethin Estradiol) react.5 mg tablet.5 mg * (Aftera) QL (6 per 365 days) reclipsen (28) oral tablet 0.5-0.03 mg (Desogen) $0 setlakin oral tablets,dose pack,3 (Levonorgestrel- QL (9 per 84 days) $0 month 0.5 mg-30 mcg Ethin Estradiol) sharobel oral tablet 0.35 mg (Nor-Q-D) $0 sprintec (28) oral tablet 0.25-35 mgmcg (Ortho-Cyclen) $0 sronyx oral tablet 0.-20 mg-mcg (Amethyst) $0 syeda oral tablet 3-0.03 mg (Yaz) $0 tarina fe /20 (28) oral tablet mg- 20 mcg (2)/75 mg (7) (Loestrin Fe) $0 tilia fe oral tablet -20(5)/-30(7) /mg-35mcg (9) (Loestrin Fe) $0 tri-estarylla oral tablet 0.8/0.25/0.25 mg-35 mcg (28) (Ortho-Cyclen) $0 3

tri-legest fe oral tablet -20(5)/- 30(7) /mg-35mcg (9) (Loestrin Fe) $0 tri-linyah oral tablet 0.8/0.25/0.25 mg-35 mcg (28) (Ortho-Cyclen) $0 tri-lo-estarylla oral tablet 0.8/0.25/0.25 mg-25 mcg (Ortho-Cyclen) $0 tri-lo-marzia oral tablet 0.8/0.25/0.25 mg-25 mcg (Ortho-Cyclen) $0 tri-lo-sprintec oral tablet 0.8/0.25/0.25 mg-25 mcg (Ortho-Cyclen) $0 trinessa (28) oral tablet 0.8/0.25/0.25 mg-35 mcg (28) (Ortho-Cyclen) $0 tri-previfem (28) oral tablet 0.8/0.25/0.25 mg-35 mcg (28) (Ortho-Cyclen) $0 tri-sprintec (28) oral tablet 0.8/0.25/0.25 mg-35 mcg (28) (Ortho-Cyclen) $0 trivora (28) oral tablet 50-30 (6)/75-40 (5)/25-30(0) (Amethyst) $0 velivet triphasic regimen (28) oral tablet 0./.25/.5-25 mg-mcg (Desogen) $0 vestura (28) oral tablet 3-0.02 mg (Yaz) $0 vienva oral tablet 0.-20 mg-mcg (Amethyst) $0 viorele (28) oral tablet 0.5-0.02 mgx2 /0.0 mg x 5 (Mircette) $0 vyfemla (28) oral tablet 0.4-35 mgmcg (Modicon) $0 wera (28) oral tablet 0.5-35 mg-mcg (Modicon) $0 xulane transdermal patch weekly 50-35 mcg/24 hr (Ortho Evra) $0 zarah oral tablet 3-0.03 mg (Yaz) $0 zenchent (28) oral tablet 0.4-35 mgmcg (Modicon) $0 zovia /35e (28) oral tablet -35 mg-mcg (Demulen -50-2) $0 zovia /50e (28) oral tablet -50 mg-mcg (Demulen -50-2) $0 QL (3 per 28 days) 4

Cough And Cold Products Cough And Cold Products 5dm-5peh-2cpm liquid strawberry 2-5-5 mg/5 ml * 25cpd-200gfn liquid 25-200 mg/5 ml * 30pse-50gfn-5dm liquid 30-5- 50 mg/5 ml * 30pse-3brm-5dm oral liquid 3-30- 5 mg/5 ml * 3brm-5dm-30pse liquid 3-30-5 mg/5 ml * 3brm-30dm-50pse liquid (otc) 3-50- 30 mg/5 ml * 50pse-3brm-30dm oral liquid 3-50- 30 mg/5 ml * actinel pediatric liquid 5-5-50 mg/5 ml * adt robitussin linger cold syr 5 mg/5 ml * adt robitussin peak cld dm max 0-200 mg/5 ml * adult robitussin peak cold liq nondrowsy 0-00 mg/5 ml * adult wal-tussin dm max liq a/f,cherry menthol 0-200 mg/5 ml * adult wal-tussin dm syrup a/f,cherry,adult 0-00 mg/5 ml * adult wal-tussin liquid 00 mg/5 ml * (Chlorpheniramine/ Phenyleph/Dm) (Vanacof G) (Trispec Pse) (Neo Dm) (Neo Dm) (Neo Dm) (Neo Dm) (Trispec Pse) (Dextromethorphan Hbr) (G-Zyncof) (G-Zyncof) (G-Zyncof) (Cough Formula Dm) (Robitussin Mucus-Chest Congest) alka-seltzer plus mucus-conges 0- (Guaifenesin/Dextr 200 mg * omethorphan) ambi 0peh-4cpm-20dm tablet 4-0- (Chlorpheniramine/ 20 mg * Phenyleph/Dm) ambi 20dm-4cpm tablet 4-20 mg * (Coricidin Hbp) 5

ambi 40pse-400gfn-20dm tablet 40-20-400 mg * (Poly-Vent Dm) ambi 60pse-4cpm-20dm tablet 4-60- (Chlorpheniramin/ 20 mg * Pseudoephed/Dm) benzonatate 00 mg capsule 00 mg * (Zonatuss) 3 $0 benzonatate 50 mg capsule 50 mg * (Zonatuss) 3 $0 benzonatate 200 mg capsule 200 mg * (Zonatuss) 3 $0 bio-dtuss dmx liquid -30-20 mg/5 ml * (Neo Dm) bionel pediatric liquid 5-5-50 mg/5 ml * (Trispec Pse) biospec dmx liquid 5-25 mg/5 ml * (G-Zyncof) bp 8 cough oral suspension a/f, (Guaifenesin/Dm/P grape (otc) 30-5-75 mg/5 ml * seudoephedrine) bpm-pse-dm liquid a/f, cotton candy (otc) 4-20-20 mg/5 ml * (Neo Dm) bromfed dm cough syrup 2-30-0 (Brompheniramine/ mg/5 ml * Pseudoephed/Dm) 3 $0 bromphenir-pseudoephed-dm syr (Brompheniramine/ (rx) 2-30-0 mg/5 ml * Pseudoephed/Dm) brom-pse-dm cough syrup butter (Brompheniramine/ scotch (otc) 2-30-0 mg/5 ml * Pseudoephed/Dm) centergy dm pediatric drops -2-3 (Chlorpheniramine/ mg/ml * Phenyleph/Dm) cheracol d cough formula 0-00 mg/5 ml * (G-Zyncof) cheratussin dac syrup 30-0-00 mg/5 ml * (Tusnel C) child sudafed pe cough-cold lq 2.5-5 (Dextromethorphan mg/5 ml * /Phenylephrine) child triaminic cgh-congst syr 5-00 (Cough Formula mg/5 ml * Dm) 6

(Dextromethorphan child wal-tussin 7.5 mg odt 7.5 mg * Hbr) children's mucinex cough liq a/f 5- (G-Zyncof) 00 mg/5 ml * children's silfedrine liq 5 mg/5 ml (Pseudoephedrine * HCl) (Robitussin chl mucinex chest congest liq a/f Mucus-Chest 00 mg/5 ml * Congest) cold multi-symptom day-night (Dm pseudoephedrine-free 2-5-0-325 Hb/Pe/Acetaminop mg * hen/chlorph) (Dm cold relief multi-symp caplet cplt,2 Hb/Pe/Acetaminop day,2 night 2-5-0-325 mg * hen/chlorph) (Dcold-flu relief liquid 2.5-30-,000 Methorphan/Aceta mg/30 ml * min/doxylamn) congestac tablet 60-400 mg * (Poly-Vent Ir) congest-eze 60-400 mg caplet 60- (Poly-Vent Ir) 400 mg * childs sudafed 5 mg/5 ml liq nondrowsy,a/f,s/f 5 mg/5 ml * chld triaminic cgh-sor thr sus 60-5 codituss dm syrup 8.33-5-0 mg/5 cold-flu relief d/n softgel 0-5- (Pseudoephedrine (Child Tylenol Plus (Pyrilamine/Pe/De (Vicks Dayquilmg/5 ml * ml * 325mg(d)/ 5-325-6.25mg * HCl) Cough-Sore) xtromethorphan) Nyquil) coricidin hbp cold-multi sympt 6.25-5-325 mg/5 ml * coricidin hbp softgel 0-200 mg * cough & cold syrup 5-0-00 mg/5 ml * (D- Methorphan/Aceta min/doxylamn) (Guaifenesin/Dextr omethorphan) (Maxiphen Dmx) 7

cough & cold tablet 4-30 mg * (Coricidin Hbp) cvs chest cong relief pe tab 0-400 mg * (Maxiphen) cvs chest congest relief dm tb 20-400 mg * (Allfen Dm) cvs child cold-cough day liq 2.5-5 (Dextromethorphan mg/5 ml * /Phenylephrine) (Robitussin cvs child's chest congest liq 00 Mucus-Chest mg/5 ml * Congest) cvs cough & sore throat susp 60-5 (Child Tylenol Plus mg/5 ml * Cough-Sore) cvs daytime-nighttime cold-flu multi-symp,twin pack 6.25-5-0-325 mg/5 ml * cvs tussin cgh 5 mg liq gels nondrowsy, liq gels 5 mg * cvs tussin dm cough-chest liq 0-200 mg/5 ml * daytime cold & cough liquid,000-30 mg/30 ml * daytime cold-flu liquid a/f, glutenfree 5-0-325 mg/5 ml * (Dm/Pe/Acetamino phen/doxylamine) (Robitussin) (G-Zyncof) (Triaminic) (D- Methorphan/Pe/Ac etaminophen) (Dextromethorphan Hbr) (Dextromethorphan Hb/Doxylamine) daytime cough liquid a/f, gluten-free 5 mg/5 ml * daytime-nighttime cough liquid 5mg/5ml(d)/ 2.5-30mg/30ml * delsym cough+chest cngst dm lq 5-00 mg/5 ml * (G-Zyncof) despec-dm tablet 30-0-200 mg * (Poly-Vent Dm) dextromethorphan er 30 mg/5 ml 30 mg/5 ml * (Delsym) diabetic tussin dm liquid 0-00 mg/5 ml * (G-Zyncof) 8

diabetic tussin dm max-str liq 0-200 mg/5 ml * (G-Zyncof) ed bron gp liquid 5-00 mg/5 ml * (Despec) entre-cough liquid 30-5-75 mg/5 ml * (Trispec Pse) expectorant 00 mg/5 ml syrup 00 mg/5 ml * expectorant dm cough liquid 20-300 mg/5 ml * expectorant max cough-cold 30-5 mg/5 ml * geri-tussin dm syrup 0-00 mg/5 ml * guaifenesin 200 mg tablet (otc) 200 mg * guaifenesin dac oral solution 30-0- 00 mg/5 ml * guaifenesin er 600 mg tablet 600 mg * head congestion day-night pack 2-5- 0-325 mg * hydrocodone-chlorphen er susp 0-8 mg/5 ml * hydrocodone-homatropine 5-.5 mg tablet 5-.5 mg * hydromet syrup 5-.5 mg/5 ml * (Robitussin Mucus-Chest Congest) (G-Zyncof) (Dextromethorphan /Pseudoephed) (Cough Formula Dm) (Allfen) (Tusnel C) (Mucinex) (Dm Hb/Pe/Acetaminop hen/chlorph) (Tussionex) 3 $0 (Tussigon) 3 $0 (Hydrocodone Bit/Homatrop Me- Br) 3 $0 liquibid d-r tablet 0-400 mg * (Maxiphen) lohist-dm syrup 2-5-0 mg/5 ml * (Ala-Hist Dm) 3 $0 lortuss ex liquid 30-0-00 mg/5 ml (Tusnel C) * mar-cof bp liquid 2-30-7.5 mg/5 ml * (Bromphenira/Pseu doephed/codein) 3 $0 9

mar-cof cg liquid 7.5-225 mg/5 ml * (M-Clear Wc) 3 $0 M-END DM SYRUP 2-5-5 MG/5 ML * mesehist dm oral syrup 2-5-5 (Chlorpheniramin/ mg/5 ml * Pseudoephed/Dm) mucus dm 600-30 mg tablet 30-600 mg * (Mucinex Dm) mucus dm max tablet 60-,200 mg * (Mucinex Dm) mucus relief 400 mg tablet d/f 400 mg * (Allfen) nasal-sinus decongest tab 30 mg * (Sudafed 2-Hour) nasohist dm pediatric drops -2-3 (Chlorpheniramine/ mg/ml * Phenyleph/Dm) NEO DM SYRUP 3-50-30 MG/5 ML * neo-tuss liquid 30-200 mg/5 ml * (G-Zyncof) NEXAFED 30 MG TABLET 30 MG * night time cold med liquid 6.25-30- 5-500 mg/5 ml * NIGHT TIME COLD-FLU RLF SFTGL SFTGL, MULTI- SYMPTOM 6.25-5-325 MG * night time cough & sore throat 2.5-30-,000 mg/30 ml * nighttime cough liquid gluten-free, cherry 6.25-5 mg/5 ml * nohist-dm liquid 4-0-5 mg/5 ml * pecgen dmx 25-5 mg/5 ml liq 5-25 mg/5 ml * pedia relief cough-cold liquid a/f, cherry -5-5 mg/5 ml * (Dm/P- Ephed/Acetaminop h/doxylam) (D- Methorphan/Aceta min/doxylamn) (Dextromethorphan Hb/Doxylamine) (Chlorpheniramine/ Phenyleph/Dm) (G-Zyncof) (Chlorpheniramin/ Pseudoephed/Dm) 20

pediacare multi-symt cold liq non drowsy, grape 2.5-5 mg/5 ml * phenylhistine dh liquid (otc) 2-30-0 mg/5 ml * poly-tussin liquid 9.375-0 mg/5 ml * promethazine vc-codeine syrup 6.25-5-0 mg/5 ml * promethazine-codeine syrup 6.25-0 mg/5 ml * promethazine-dm syrup 6.25-5 mg/5 ml * pseudoephed 30 mg/5 ml soln 30 mg/5 ml * pseudoephedrine 30 mg tablet 30 mg * pseudoephedrine 60 mg tablet exstr, non drowsy (otc) 60 mg * pv flu relief therapy liquid daytime 5-0-325 mg/5 ml * pv night-time softgel multisympt.,softgel 6.25-30-5-325 mg * (Dextromethorphan /Phenylephrine) (P-Ephed HCl/Cod/Chlorphe nir) (Chlorcyclizine/Co deine) (Promethazine/Phe nyleph/codeine) (Promethazine HCl/Codeine) (Promethazine/Dex tromethorphan) (Pseudoephedrine HCl) 3 $0 3 $0 3 $0 (Sudafed 2-Hour) (Sudafed 2-Hour) (D- Methorphan/Pe/Ac etaminophen) (Dm/P- Ephed/Acetaminop h/doxylam) pv tussin pe liquid 5-00 mg/5 ml * (Despec) q-tapp dm elixir -5-5 mg/5 ml * (Brompheniramine/ Pseudoephed/Dm) (Robitussin q-tussin 00 mg/5 ml solution a/f, Mucus-Chest non-drowsy 00 mg/5 ml * Congest) q-tussin dm syrup 0-00 mg/5 ml * ra child plus cough-runny nose pseudoephedrine free -5-60 mg/5 ml * (Cough Formula Dm) (Dextromethorphn/ Acetaminoph/Cp) 2

ra daytime-nighttime softgel cold-flu relief 0-5-325mg(d)/ 5-325- 6.25mg * ra flu formula gelcap 2.5-5-0-325 mg * ra maximum strength flu tablet 2-5-500 mg * ra mucus relief 400 mg tablet 400 mg * ra multi-symptom cold caplet nighttime,cplt 2-5-0-325 mg * (Vicks Dayquil- Nyquil) (Dm/Pe/Acetamino ph/diphenhydram) (Coricidin Hbp) (Allfen) (Dm Hb/Pe/Acetaminop hen/chlorph) (Cough Formula Dm) (Dextromethorphan ra tussin dm syrup a/f 0-00 mg/5 ml * ra tussin max strn cough syrup 5 mg/5 ml * Hbr) refenesen 200 mg tablet 200 mg * (Allfen) refenesen pe caplet 0-400 mg * (Maxiphen) relcof c liquid 6.3-00 mg/5 ml * (M-Clear Wc) 3 $0 REZIRA SOLUTION 60-5 MG/5 ML * robafen 00 mg/5 ml syrup 00 mg/5 ml * robafen cough 5 mg liquidgel nondrowsy,liquidgel 5 mg * robafen-dm syrup 0-00 mg/5 ml * robitussin cough-chest-cong dm 0-200 mg * ROBITUSSIN LONG-ACTING LIQ -7.5 MG/5 ML * robitussin pediatric cough syp a/f,long-acting 7.5 mg/5 ml * rydex liquid.3-0-6.3 mg/5 ml * (Robitussin Mucus-Chest Congest) 3 $0 (Robitussin) (Cough Formula Dm) (Guaifenesin/Dextr omethorphan) (Dextromethorphan Hbr) (Bromphenira/Pseu doephed/codein) 22

rynex dm liquid a/f, prof use only - 2.5-5 mg/5 ml * safetussin dm liquid 0-00 mg/5 ml * scot-tussin 00 mg/5 ml liq 00 mg/5 ml * scot-tussin dm s-f liquid 2-5 mg/5 ml * siltussin sa 00 mg/5 ml syr 00 mg/5 ml * sm adult nasal decongestant lq 5 mg/5 ml * sm childrens plus cold susp grape,multi-symptom -2.5-5-60 mg/5 ml * sm cold-cough child elixir -5-5 mg/5 ml * sm cough & runny nose liquid -5 mg/5 ml * sm cough-head congestion lq 20-0- 66.7 mg/5 ml * sm flu severe cold-congestion maximum strength 4-60-30-,000 mg * sm mucus relief cough liquid childrens, a/f 5-00 mg/5 ml * sm nite time cold-flu liquid 7.5-60- 30-,000 mg/30 ml * sm nite time cold-flu rel sfgl softgel 6.25-30-5-325 mg * sm pain reliever cold caplet 2-30- 5-325 mg * (Brompheniram/Ph enylephrine/dm) (G-Zyncof) (Robitussin Mucus-Chest Congest) (Vicks Children'S Nyquil) (Robitussin Mucus-Chest Congest) (Pseudoephedrine HCl) (Dm Hb/Pe/Acetaminop hen/chlorph) (Brompheniramine/ Pseudoephed/Dm) (Vicks Children'S Nyquil) (Trispec Pse) (Dm Hb/Pseudoephed/A cetamin/cp) (G-Zyncof) (Dm/P- Ephed/Acetaminop h/doxylam) (Dm/P- Ephed/Acetaminop h/doxylam) (Dm Hb/Pseudoephed/A cetamin/cp) 23

sm pedia relief liquid -5-5 mg/5 (Chlorpheniramin/ ml * Pseudoephed/Dm) sm severe cold m-s caplet 30-5-500 (Dm/Pseudoephed/ mg * Acetaminophen) sm tussin cf syrup 30-0-00 mg/5 (Guaifenesin/Dm/P ml * seudoephedrine) sudafed 30 mg tablet nondrowsy,max-str 30 mg * (Sudafed 2-Hour) sudogest 30 mg tablet boxed 30 mg * (Sudafed 2-Hour) sudogest 60 mg tablet 60 mg * (Sudafed 2-Hour) suphedrin liquid 5 mg/5 ml * (Pseudoephedrine HCl) suphedrine pe combo pack cplt 5- (Diphenhydram/Pe/ 0-325 mg * Dm/Acetamin/Gg) THERAFLU COLD AND COUGH POWDER 0-20-650 MG * THERAFLU MULTI-SYMP COLD CPLT 5-0-325 MG * TRIAMINIC COUGH-SORE THROAT LQ A/F,CHILDREN'S 60-5 MG/5 ML * triaminic daytime cold-cough (Dextromethorphan children's, cherry 2.5-5 mg/5 ml * /Phenylephrine) tri-dex pe oral syrup 2-0-5 mg/5 (Chlorpheniramine/ ml * Phenyleph/Dm) trymine cg liquid 7.5-225 mg/5 ml * (M-Clear Wc) tusnel diabetic liquid (otc) 0-00 mg/5 ml * (G-Zyncof) TUSNEL LIQUID A/F,A/F,D/F 30-5-200 MG/5 ML * TUSNEL PEDIATRIC LIQUID (RX) 5-5-50 MG/5 ML * TUSSI PRES-B LIQUID 4-0-30 MG/5 ML * 24

tussin cf cough-cold syrup a/f 5-0- 00 mg/5 ml * (Maxiphen Dmx) tussin cold-congestion gelcap liquid (Guaifenesin/Dm/P gelcap 30-0-200 mg * seudoephedrine) tussin dm syrup 5-00 mg/5 ml * (Cough Formula Dm) VANACOF LIQUID -30-2.5 MG/5 ML * vicks dayquil cough liquid a/f,8 hr (Dextromethorphan rlf 5 mg/5 ml * Hbr) (Dvicks dayquil liquicaps cold & flu 5- Methorphan/Pe/Ac 0-325 mg * etaminophen) vicks nature fusion cough liq 5 mg/5 (Dextromethorphan ml * Hbr) vicks nyquil severe cold-flu 6.25-5- (Dm/Pe/Acetamino 0-325 mg/5 ml * phen/doxylamine) virdec dm drops -3.5-3 mg/ml * (Chlorpheniramine/ Phenyleph/Dm) virtussin ac liquid 0-00 mg/5 ml * (M-Clear Wc) v-r infant non-asa cold drp 5-5-60 (Dm/Pseudoephed/ mg/.6 ml * Acetaminophen) v-r non-aspirin flu gelcap gelatin (Dm/Pseudoephed/ caplet 30-5-500 mg * Acetaminophen) v-r pedia relief inf drops (Dextromethorphan decongestant + 7.5-2.5 mg/0.8 ml * /Pseudoephed) vr triacting cold-cough liq -5-5 (Chlorpheniramin/ mg/5 ml * Pseudoephed/Dm) v-r tussin cf syrup 30-0-00 mg/5 (Guaifenesin/Dm/P ml * seudoephedrine) wal-phed 30 mg tablet non-drowsy 30 mg * (Sudafed 2-Hour) wal-phed pe day-night combo pk (Diphenhydram/Pe/ gluten-free 5-0-325 mg * Dm/Acetamin/Gg) wal-tussin cough 5 mg softgel 5 mg * (Robitussin) 25

wal-tussin cough 5 mg/5 ml 5 (Dextromethorphan mg/5 ml * Hbr) wal-tussin cough-cold cf liq pseudoephedrine free 5-0-00 (Maxiphen Dmx) mg/5 ml * zephrex-d 30 mg tablet 30 mg * (Sudafed 2-Hour) ZONATUSS 50 MG CAPSULE 50 MG * 3 $0 zyncof 20-400 mg/5 ml liquid 20-400 mg/5 ml * (G-Zyncof) Dental And Oral Agents Dental And Oral Agents cevimeline oral capsule 30 mg (Evoxac) $0 chlorhexidine gluconate mucous membrane mouthwash 0.2 % oralone dental paste 0. % periogard mucous membrane mouthwash 0.2 % pilocarpine hcl oral tablet 5 mg, 7.5 mg PREVIDENT 5000 SENSITIVE DENTAL PASTE.-5 % triamcinolone acetonide dental paste 0. % (Peridex) $0 (Triamcinolone Acetonide) $0 (Peridex) $0 (Salagen) $0 (Triamcinolone Acetonide) $0 $0 Dermatological Agents Dermatological Agents, Other 8-MOP ORAL CAPSULE 0 MG acitretin oral capsule 0 mg, 7.5 mg, 25 mg (Soriatane) $0 acne medication 0% lotion 0 % * (Benzoyl Peroxide) ACNE MEDICATION 5% LOTION 5 % * acneclear gel 0 % * (Benzoyl Peroxide) acyclovir topical ointment 5 % (Zovirax) $0 QL (30 per 30 days) 26

ALCOHOL PADS TOPICAL PADS, MEDICATED $0 ALCOHOL PREP PADS $0 amlactin 2% lotion 2 % * (Ammonium Lactate) ammonium lactate 2% cream (Ammonium fragrance free (otc) 2 % * Lactate) ammonium lactate 2% lotion (otc) (Ammonium 2 % * Lactate) ammonium lactate topical cream 2 % (Lac-Hydrin) $0 ammonium lactate topical lotion 2 % (Lac-Hydrin) $0 ANACAINE TOPICAL OINTMENT 0 % benzoyl peroxide 0% gel aqueous (otc) 0 % * (Benzoyl Peroxide) benzoyl peroxide 5% gel aqueous (otc) 5 % * (Benzoyl Peroxide) BETADINE 5% SPRAY 5 % * calcipotriene scalp solution 0.005 % (Calcipotriene) $0 calcipotriene topical cream 0.005 % (Dovonex) $0 calcipotriene topical ointment 0.005 % (Calcipotriene) $0 calcitrene topical ointment 0.005 % (Calcipotriene) $0 calcitriol topical ointment 3 mcg/gram (Vectical) $0 CASTELLANI PAINT MODIFIED.5 % * CONDYLOX TOPICAL GEL 0.5 % COSENTYX (50 MG/ML) 300 MG DOSE-2 PENS 50 MG/ML COSENTYX (50 MG/ML) 300 MG DOSE-2 SYRINGES 50 MG/ML PA PA 27

COSENTYX PEN SUBCUTANEOUS PEN INJECTOR 50 MG/ML COSENTYX SUBCUTANEOUS SYRINGE 50 MG/ML cvs skin treatment body lotion 2 % * fluorouracil topical cream 0.5 %, 5 % fluorouracil topical solution 2 %, 5 % geri-hydrolac 2% lotion 2 % * geri-hydrolac 5% lotion 5 % * (Ammonium Lactate) (Carac) $0 (Fluorouracil) $0 (Ammonium Lactate) (Ammonium Lactate) imiquimod topical cream in packet 5 (Aldara) % $0 LACTINOL HX CREAM * lobana bath oil * (Mineral Oil) methoxsalen rapid oral capsule 0 PA PA PA NSO; QL (24 per 30 days) mg (Oxsoralen-Ultra) $0 PANRETIN TOPICAL GEL 0. % persa-gel 0% 2's,max-strength 0 % * (Benzoyl Peroxide) PICATO TOPICAL GEL 0.05 % QL (3 per 56 days) PICATO TOPICAL GEL 0.05 % QL (2 per 56 days) podocon topical liquid 25 % (Podophyllum Resin) $0 podofilox topical solution 0.5 % (Condylox) $0 potassium hydroxide topical (Potassium solution 5 % Hydroxide) $0 pv acne pimple 0% gel 0 % * (Benzoyl Peroxide) SANTYL TOPICAL OINTMENT 250 UNIT/GRAM 28

TALTZ AUTOINJECTOR PA SUBCUTANEOUS AUTO- INJECTOR 80 MG/ML TALTZ SYRINGE PA SUBCUTANEOUS SYRINGE 80 MG/ML TOLAK TOPICAL CREAM 4 % VALCHLOR TOPICAL GEL 0.06 % zenatane oral capsule 0 mg, 20 mg, (Isotretinoin) 30 mg, 40 mg $0 zinc oxide 20% ointment 20 % * (Boudreauxs) ZOVIRAX TOPICAL CREAM 5 % QL (5 per 30 days) Dermatological Antibacterials bacitracin 500 unit/gm ointmnt 500 unit/gram * (Bacitracin) bacitraycin plus 500 unit/gm 500 unit/gram * (Bacitracin) clindamycin phosphate topical gel % (Cleocin T) $0 clindamycin phosphate topical lotion % (Cleocin T) $0 clindamycin phosphate topical solution % (Cleocin T) $0 clindamycin phosphate topical swab % cvs triple antibiotic ointment 3.5mg- 400 unit- 5,000 unit/gram * ery pads topical swab 2 % erythromycin with ethanol topical gel 2 % erythromycin with ethanol topical solution 2 % (Cleocin T) $0 (Neomycin Su/Bacitrac Zn/Poly) (Erythromycin Base/Ethanol) $0 (Erygel) $0 (Erythromycin Base/Ethanol) $0 29

erythromycin with ethanol topical (Erythromycin swab 2 % Base/Ethanol) $0 gentamicin topical cream 0. % (Gentamicin Sulfate) $0 gentamicin topical ointment 0. % (Gentamicin Sulfate) $0 metronidazole topical cream 0.75 % (Metrocream) $0 metronidazole topical gel 0.75 %, % (Rosadan) $0 metronidazole topical lotion 0.75 % (Metrolotion) $0 mupirocin calcium topical cream 2 % (Bactroban) $0 mupirocin topical ointment 2 % (Centany) $0 neomycin-polymyxin b gu irrigation (Neosporin G.U. solution 40 mg-200,000 unit/ml Irrigant) $0 (Neomycin neosporin ointment 3.5mg-400 unit- Su/Bacitrac 5,000 unit/gram * Zn/Poly) rosadan topical cream 0.75 % (Metrocream) $0 selenium sulfide topical lotion 2.5 % (Selenium Sulfide) $0 selenium sulfide topical shampoo 2.25 % (Selenium Sulfide) $0 silver nitrate topical ointment 0 % (Silver Nitrate) $0 silver nitrate topical solution 0.5 %, 0 %, 25 %, 50 % (Silver Nitrate) $0 silver sulfadiazine topical cream % (Silvadene) $0 ssd topical cream % (Silvadene) $0 sulfacetamide sodium (acne) topical suspension 0 % (Klaron) $0 (Neomycin triple antibiotic ointment carton Su/Bacitrac 3.5mg-400 unit- 5,000 unit/gram * Zn/Poly) Dermatological Anti- Inflammatory Agents ala-cort topical cream % (Anusol-HC) $0 30

ala-scalp topical lotion 2 % (Scalacort) $0 (Alclometasone alclometasone topical cream 0.05 % $0 Dipropionate) alclometasone topical ointment 0.05 (Alclometasone $0 % Dipropionate) aquanil hc % lotion % * (Cortizone-0) beta hc % lotion % * (Cortizone-0) $0 $0 $0 $0 betamethasone valerate topical (Luxiq) $0 foam 0.2 % $0 $0 betamethasone, augmented topical (Diprolene AF) $0 cream 0.05 % $0 betamethasone, augmented topical (Diprolene) $0 lotion 0.05 % betamethasone, augmented topical (Diprolene) $0 ointment 0.05 % clobetasol 0.05% cream 0.05 % (Temovate) $0 (Clobetasol clobetasol scalp solution 0.05 % $0 Propionate) clobetasol topical foam 0.05 % (Olux) $0 (Clobetasol clobetasol topical gel 0.05 % $0 Propionate) clobetasol topical lotion 0.05 % (Clobex) $0 betamethasone dipropionate topical betamethasone dipropionate topical betamethasone dipropionate topical betamethasone valerate topical betamethasone valerate topical betamethasone valerate topical betamethasone, augmented topical (Betamethasone (Betamethasone (Betamethasone (Betamethasone (Betamethasone (Betamethasone (Betamethasone cream 0.05 % lotion 0.05 % ointment 0.05 % cream 0. % lotion 0. % ointment 0. % gel 0.05 % Dipropionate) Dipropionate) Dipropionate) Valerate) Valerate) Valerate) Dipropionate) 3

clobetasol topical ointment 0.05 % (Temovate) $0 clobetasol topical shampoo 0.05 % (Clobex) $0 clobetasol-emollient topical cream 0.05 % (Temovate) $0 clocortolone pivalate topical cream 0. % (Cloderm) $0 colocort rectal enema 00 mg/60 ml (Cortenema) $0 cormax scalp solution 0.05 % (Clobetasol Propionate) $0 cortizone-0 % creme maximum strength % * (Hydrocortisone) CORTIZONE-0 % LOTION % * cortizone-0 % ointment % * (Hydrocortisone) dermarest eczema % lotion % * (Cortizone-0) desonide topical cream 0.05 % (Desowen) $0 desonide topical ointment 0.05 % (Desonide) $0 desoximetasone topical cream 0.05 %, 0.25 % (Topicort) $0 desoximetasone topical gel 0.05 % (Topicort) $0 desoximetasone topical ointment 0.05 %, 0.25 % (Topicort) $0 ELIDEL TOPICAL CREAM % fluocinonide topical cream 0.05 % (Vanos) $0 fluocinonide topical gel 0.05 % (Fluocinonide) $0 fluocinonide topical ointment 0.05 % (Fluocinonide) $0 fluocinonide topical solution 0.05 % (Fluocinonide) $0 fluticasone topical cream 0.05 % (Cutivate) $0 fluticasone topical ointment 0.005 % (Fluticasone Propionate) $0 halobetasol propionate topical cream 0.05 % (Ultravate) $0 halobetasol propionate topical ointment 0.05 % (Ultravate) $0 hydro skin % lotion % * (Cortizone-0) 32

hydrocortisone 0.5% cream (otc) (Hydrocortisone) 0.5 % * hydrocortisone 0.5% ointment 0.5 % (Hydrocortisone) * hydrocortisone % cream maximum (Hydrocortisone) strength (otc) % * hydrocortisone % cream maximum (Hydrocortisone strength % * Acetate) hydrocortisone % lotion (otc) % (Cortizone-0) 3 $0 * hydrocortisone % ointment carton (Hydrocortisone) (otc) % * hydrocortisone acet-aloe vera (Hydrocortisone $0 topical gel 2 % Acetate/Aloe V) hydrocortisone buty 0.% cream 0. (Hydrocortisone $0 % Butyrate) hydrocortisone butyrate topical (Locoid) $0 ointment 0. % hydrocortisone butyrate topical (Locoid) $0 solution 0. % $0 hydrocortisone rectal enema 00 (Cortenema) $0 mg/60 ml hydrocortisone topical cream %, (Anusol-HC) $0 2.5 % hydrocortisone topical lotion 2.5 % (Scalacort) $0 hydrocortisone topical ointment (Hydrocortisone) $0 %, 2.5 % $0 hydrocortisone valerate topical (Westcort) $0 ointment 0.2 % mometasone topical cream 0. % (Elocon) $0 mometasone topical ointment 0. % (Elocon) $0 mometasone topical solution 0. % (Elocon) $0 hydrocortisone butyr-emollient hydrocortisone valerate topical (Hydrocortisone (Hydrocortisone topical cream 0. % cream 0.2 % Butyrate) Valerate) 33

neosporin % anti-itch cream % * (Hydrocortisone) ONFI ORAL TABLET 0 MG, 20 MG prednicarbate topical cream 0. % (Dermatop) $0 prednicarbate topical ointment 0. % (Dermatop) $0 preparation h hc % cream % * (Hydrocortisone) procto-med hc topical cream with perineal applicator 2.5 % (Hydrocortisone) $0 procto-pak topical cream with perineal applicator % (Anusol-HC) $0 proctosol hc rectal cream 2.5 % (Hydrocortisone) $0 proctosol-hc 2.5% cream 2.5 % (Hydrocortisone) $0 proctozone-hc topical cream with perineal applicator 2.5 % (Hydrocortisone) $0 recort plus % cream % * (Hydrocortisone) tacrolimus topical ointment 0.03 %, 0. % (Protopic) $0 triamcinolone acetonide topical (Triamcinolone cream 0.025 %, 0. %, 0.5 % Acetonide) $0 triamcinolone acetonide topical (Triamcinolone lotion 0.025 %, 0. % Acetonide) $0 triamcinolone acetonide topical (Triamcinolone ointment 0.025 %, 0. %, 0.5 % Acetonide) $0 trianex topical ointment 0.05 % (Triamcinolone Acetonide) $0 u-cort topical cream -0 % (Hydrocortisone Acetate/Urea) $0 Dermatological Retinoids adapalene topical cream 0. % (Differin) $0 adapalene topical gel 0. % (Differin) $0 TAZORAC TOPICAL CREAM 0.05 %, 0. % tretinoin gel micro 0.04% tube 0.04 % (Retin-A Micro) $0 tretinoin gel micro 0.% tube 0. % (Retin-A Micro) $0 PA PA NSO; QL (60 per 30 days) PA 34

tretinoin microspheres topical gel with pump 0.04 %, 0. % tretinoin topical cream 0.025 %, 0.05 %, 0. % tretinoin topical gel 0.0 %, 0.025 %, 0.05 % Scabicides And Pediculicides cvs lice killing shampoo maximum strength 0.33-4 % * (Retin-A Micro) $0 (Retin-A) $0 (Retin-A) $0 (Piperonyl Butoxide/Pyrethrin s) cvs permethrin % lotion % * (Nix) malathion topical lotion 0.5 % (Ovide) $0 NIX % CREME RINSE LIQUID W/ NIT COMB % * permethrin topical cream 5 % (Elimite) $0 ra lice treatment % crm rinse 2x59ml, 2 combs % * (Nix) sm lice treatment permethrin 2's % * (Nix) v-r lice cream rinse % * (Nix) Devices Devices ASSURE ID INSULIN SAFETY SYRINGE ML 29 GAUGE X /2" $0 BD INSULIN SYR 0.3 ML 3GX5/6 0.3 ML 3 GAUGE X $0 5/6 BD INSULIN SYR 0.5 ML 3GX5/6" 0.5 ML 3 GAUGE X $0 5/6 BD INSULIN SYR ML 3GX5/6" ML 3 GAUGE X 5/6 $0 PA PA PA 35

BD ULTRA-FINE PEN NDL 8MMX3G SHORT 3 GAUGE X 5/6" INSULIN SYRINGE-NEEDLE U- 00 SYRINGE 0.3 ML 29 GAUGE, ML 29 GAUGE X /2", /2 ML 28 GAUGE PEN NEEDLE, DIABETIC NEEDLE 29 GAUGE X /2" $0 $0 $0 VGO 40 DISPOSABLE DEVICE $0 Disinfectants (For Non- Dermatologic Use) Disinfectants (For Non- Dermatologic Use) sm iodine tincture * (Iodine) Enzyme Replacement/Modifiers Enzyme Replacement/Modifiers ADAGEN INTRAMUSCULAR SOLUTION 250 UNIT/ML ALDURAZYME INTRAVENOUS SOLUTION 2.9 MG/5 ML CEREZYME INTRAVENOUS RECON SOLN 400 UNIT CREON ORAL CAPSULE,DELAYED RELEASE(DR/EC) 2,000-38,000-60,000 UNIT, 24,000-76,000-20,000 UNIT, 3,000-9,500-5,000 UNIT, 36,000-4,000-80,000 UNIT, 6,000-9,000-30,000 UNIT ELAPRASE INTRAVENOUS SOLUTION 6 MG/3 ML ELITEK INTRAVENOUS RECON SOLN.5 MG, 7.5 MG 36

FABRAZYME INTRAVENOUS RECON SOLN 35 MG KANUMA INTRAVENOUS SOLUTION 2 MG/ML KRYSTEXXA INTRAVENOUS SOLUTION 8 MG/ML KUVAN ORAL TABLET,SOLUBLE 00 MG MYOZYME INTRAVENOUS RECON SOLN 50 MG NAGLAZYME INTRAVENOUS SOLUTION 5 MG/5 ML ORFADIN ORAL CAPSULE 0 MG, 2 MG, 20 MG, 5 MG pancrelipase 5000 oral capsule,delayed release(dr/ec) 5,000-7,000-27,000 unit PULMOZYME INHALATION SOLUTION MG/ML STRENSIQ SUBCUTANEOUS SOLUTION 00 MG/ML, 40 MG/ML VIMIZIM INTRAVENOUS SOLUTION 5 MG/5 ML ( MG/ML) VPRIV INTRAVENOUS RECON SOLN 400 UNIT ZAVESCA ORAL CAPSULE 00 MG (Zenpep) $0 PA PA; LA PA QL (90 per 30 days) 37

ZENPEP ORAL CAPSULE,DELAYED RELEASE(DR/EC) 0,000-34,000-55,000 UNIT, 5,000-5,000-82,000 UNIT, 20,000-68,000-09,000 UNIT, 25,000-85,000-36,000 UNIT, 3,000-0,000-6,000 UNIT, 40,000-36,000-28,000 UNIT, 5,000-7,000-27,000 UNIT Eye, Ear, Nose, Throat Agents Eye, Ear, Nose, Throat Agents, Miscellaneous AKTEN (PF) OPHTHALMIC GEL 3.5 % alcaine ophthalmic drops 0.5 % (Proparacaine HCl) $0 altacaine ophthalmic drops 0.5 % (Tetravisc) $0 altamist 0.65% nose spray 0.65 % * (Little Remedies) apraclonidine ophthalmic drops 0.5 % (Iopidine) $0 artificial tears.4 % drops.4 % * (Polyvinyl Alcohol) (Dextran artificial tears drops p/f, sterile 0.- 70/Hypromellose/P 0.3 % * F) artificial tears eye drops strl 0.-0.3 % * (Tears Naturale) artificial tears eye ointment 83-5 % (Genteal Pm) * atropine ophthalmic drops % (Isopto Atropine) $0 atropine ophthalmic ointment % (Atropine Sulfate) $0 atropine-care ophthalmic drops % (Isopto Atropine) $0 ayr saline 0.65% nose drops 0.65 % * (Sodium Chloride) ayr saline 0.65% nose spray 0.65 % * (Little Remedies) 38

azelastine nasal aerosol,spray 37 mcg (0. %) (Astepro) $0 azelastine ophthalmic drops 0.05 % (Azelastine HCl) $0 (Dextran bion tears eye drops 0.-0.3 % * 70/Hypromellose/P F) carteolol ophthalmic drops % (Carteolol HCl) $0 cromolyn ophthalmic drops 4 % (Cromolyn Sodium) $0 cvs artificial tears drops sterile - (Glycerin/Propylen 0.3 % * e Glycol) cvs lubricant 0.5% eye drops sterile 0.5 % * (Refresh Tears) cvs lubricant dry eye rlf % % * (Carboxymethylcel lulose Sodium) cvs lubricant eye ointment p/f 57.3- (Genteal Pm) 42.5 % * cvs lubricant gel eye drops 0.25-0.3 % * cvs lubricating eye drops dry eye soln 0.5-0.9 % * cvs natural tears drops 0.-0.3 % * (Carboxymethylcel l/hypromellose) (Refresh Optive) (Dextran 70/Hypromellose/P F) cyclopentolate ophthalmic drops 0.5 (Cyclogyl) $0 %, %, 2 % CYSTARAN OPHTHALMIC DROPS 0.44 % deep sea 0.65% nose spray 0.65 % * (Little Remedies) (Oxymetazoline dristan long lasting mist 0.05 % * HCl) epinastine ophthalmic drops 0.05 % (Elestat) $0 (Genteal Mild To eq gentle 0.3% eye drops 0.3 % * Moderate) eq revive plus 0.5% eye drops 0.5 % (Carboxymethylcel * lulose Sodium) QL (30 per 25 days) 39

flucaine ophthalmic drops 0.25-0.5 (Proparacaine/Fluo $0 % rescein Sod) GENTEAL GEL DROPS 0.25-0.3 % * GENTEAL MILD 0.2% EYE DROPS 0.2 % * GENTEAL MILD-MODERATE EYE DROP P/F, DRY EYE RELIEF 0.3 % * GENTEAL SEVERE 0.3% EYE GEL P/F, STRL, INNER 0.3 % * genteal tears 0.%-0.3% drop 0.- (Tears Naturale) 0.3 % * (Isopto homatropaire ophthalmic drops 5 % $0 Homatropine) $0 ipratropium bromide nasal (Atrovent) $0 spray,non-aerosol 0.03 % ipratropium bromide nasal (Atrovent) $0 spray,non-aerosol 0.06 % (Genteal Mild To isopto tears 0.5% eye drops 0.5 % * Moderate) LACRISERT OPHTHALMIC INSERT 5 MG lubricant 0.5-0.9% eye drops 0.5- (Refresh Optive) 0.9 % * lubricant 0.6% eye drops 0.6 % * (Propylene Glycol) lubrifresh pm eye ointment 83-5 % (Genteal Pm) * muro-28 2% eye drops 2 % * (Sodium Chloride) muro-28 5% eye drops 5 % * (Sodium Chloride) muro-28 5% eye ointment 5 % * (Sodium Chloride) naphazoline ophthalmic drops 0. % (Naphazoline HCl) $0 homatropine hbr ophthalmic drops lubricant 0.5-0.9% eye drops 0.5- (Isopto (Carboxymethylcel 5 % 0.9 % * Homatropine) l/glycerin/pf) QL (30 per 28 days) QL (5 per 0 days) 40

nasal decongestant 0.05% spray (Afrin) 0.05 % * (Genteal Mild To natural balance tears drops 0.4 % * Moderate) (Genteal Mild To nature's tears drops 0.4 % * Moderate) neo-synephrine 2 hour spray 0.05 (Oxymetazoline % * HCl) ocean 0.65% nasal spray 0.65 % * olopatadine ophthalmic drops 0. % (Patanol) $0 PATADAY OPHTHALMIC DROPS 0.2 % phenylephrine hcl ophthalmic drops (Mydfrin) $0 0 %, 2.5 % proparacaine ophthalmic drops 0.5 (Proparacaine HCl) $0 % pure & gentle eye drops lubricant (Genteal Mild To 0.3 % * Moderate) (Genteal Mild To pv artificial tears 0.4 % * Moderate) pv lubricant.4 % eye drops.4 % (Polyvinyl * Alcohol) REFRESH CELLUVISC % EYE DROPS % * REFRESH CLASSIC EYE DROPS U-D,P/F,30X.4ML.4-0.6 % * REFRESH LACRI-LUBE OINTMENT 56.8-42.5 % * pv pure-gentle eye drops sterile 0.3 (Genteal Mild To % * Moderate) REFRESH OPTIVE EYE DROPS 0.5-0.9 % * retaine cmc 0.5% eye drops 0.5 % * saline mist 0.65% nose spry 0.65 % * (Carboxymethylcel lulose Sodium) (Little Remedies) ST 4

sea soft 0.65% nasal mist 0.65 % * (Little Remedies) sm lubricant eye drops strl 0.4-0.3 % * (Systane) sodium chloride 5% eye drop 5 % * (Sodium Chloride) sodium chloride 5% eye oint 5 % * (Sodium Chloride) SYSTANE 0.3-0.4% EYE DROPS 0.4-0.3 % * SYSTANE GEL EYE DROPS 0.4-0.3 % * tears again.4 % drops.4 % * (Polyvinyl Alcohol) tears again eye ointment 80-20 % * (Genteal Pm) (Dextran tears naturale free drops u- 70/Hypromellose/P d,36x.9ml,p/f 0.-0.3 % * F) tetracaine hcl (pf) ophthalmic drops (Tetracaine 0.5 % HCl/PF) $0 ultra fresh pm ointment * (Lanolin/Mineral Oil/Petrolatum) vicks qlearquil 0.05% mist 0.05 % * (Oxymetazoline HCl) vicks sinex 2 hour spray 0.05 % * (Afrin) Eye, Ear, Nose, Throat Anti-Infectives Agents acetic acid otic solution 2 % (Acetic Acid) $0 bacitracin ophthalmic ointment 500 unit/gram (Bacitracin) $0 bacitracin-polymyxin b ophthalmic (Bacitracin/Polymy ointment 500-0,000 unit/gram xin B Sulfate) $0 bleph-0 ophthalmic drops 0 % (Sulfacetamide Sodium) $0 CIPRODEX OTIC DROPS,SUSPENSION 0.3-0. % ciprofloxacin hcl ophthalmic drops 0.3 % (Ciloxan) $0 42

ciprofloxacin hcl otic dropperette 0.2 % (Cetraxal) $0 COLY-MYCIN S OTIC DROPS,SUSPENSION 3.3-3-0-0.5 MG/ML erythromycin ophthalmic ointment 5 mg/gram (0.5 %) (Ilotycin) $0 gatifloxacin ophthalmic drops 0.5 % (Zymaxid) $0 gentak ophthalmic ointment 0.3 % (3 mg/gram) (Garamycin) $0 gentamicin ophthalmic drops 0.3 % (Garamycin) $0 gentamicin ophthalmic ointment 0.3 % (3 mg/gram) (Garamycin) $0 levofloxacin ophthalmic drops 0.5 % (Levofloxacin) $0 MOXEZA OPHTHALMIC DROPS, VISCOUS 0.5 % NATACYN OPHTHALMIC DROPS,SUSPENSION 5 % neomycin-bacitracin-poly-hc (Neomycin Su/Baci ophthalmic ointment 3.5-400-0,000 Zn/Poly/HC) mg-unit/g-% $0 neomycin-bacitracin-polymyxin ophthalmic ointment 3.5-400-0,000 mg-unit-unit/g neomycin-polymyxin b-dexameth ophthalmic drops,suspension 3.5mg/ml-0,000 unit/ml-0. % neomycin-polymyxin b-dexameth ophthalmic ointment 3.5 mg/g- 0,000 unit/g-0. % neomycin-polymyxin-gramicidin ophthalmic drops.75 mg-0,000 unit-0.025mg/ml neomycin-polymyxin-hc ophthalmic drops,suspension 3.5-0,000-0 mgunit-mg/ml (Neomycin Su/Bacitra/Polymy xin) $0 (Maxitrol) $0 (Maxitrol) $0 (Neosporin) $0 (Neomycin/Polymy xin B Sulf/HC) $0 43

neomycin-polymyxin-hc otic drops,suspension 3.5-0,000- mg/ml-unit/ml-% neomycin-polymyxin-hc otic solution 3.5-0,000- mg/mlunit/ml-% neo-polycin hc ophthalmic ointment 3.5-400-0,000 mg-unit/g-% (Neomycin/Polymy xin B Sulf/HC) $0 (Cortisporin) $0 (Neomycin Su/Baci Zn/Poly/HC) $0 (Neomycin neo-polycin ophthalmic ointment Su/Bacitra/Polymy 3.5-400-0,000 mg-unit-unit/g xin) $0 ofloxacin ophthalmic drops 0.3 % (Floxin) $0 ofloxacin otic drops 0.3 % (Floxin) $0 polymyxin b sulf-trimethoprim ophthalmic drops 0,000 unit- mg/ml REFRESH OPTIVE ADVANCED DROPS 0.5--0.5 % * sulfacetamide sodium ophthalmic drops 0 % sulfacetamide sodium ophthalmic ointment 0 % sulfacetamide-prednisolone ophthalmic drops 0 %-0.23 % (0.25 %) TOBRADEX OPHTHALMIC OINTMENT 0.3-0. % TOBRADEX ST OPHTHALMIC DROPS,SUSPENSION 0.3-0.05 % (Polytrim) $0 (Sulfacetamide Sodium) (Sulfacetamide Sodium) (Sulfacetamide/Pre dnisolone Sp) $0 $0 $0 tobramycin ophthalmic drops 0.3 % (Tobrex) $0 tobramycin-dexamethasone ophthalmic drops,suspension 0.3-0. (Tobradex) $0 % trifluridine ophthalmic drops % (Viroptic) $0 VIGAMOX OPHTHALMIC DROPS 0.5 % 44

ZIRGAN OPHTHALMIC GEL 0.5 % ZYLET OPHTHALMIC DROPS,SUSPENSION 0.3-0.5 % Eye, Ear, Nose, Throat Anti-Inflammatory Agents ALREX OPHTHALMIC DROPS,SUSPENSION 0.2 % bromfenac ophthalmic drops 0.09 % dexamethasone sodium phosphate ophthalmic drops 0. % diclofenac sodium ophthalmic drops 0. % DUREZOL OPHTHALMIC DROPS 0.05 % flunisolide nasal spray,non-aerosol 25 mcg (0.025 %) fluorometholone ophthalmic drops,suspension 0. % flurbiprofen sodium ophthalmic drops 0.03 % fluticasone nasal spray,suspension 50 mcg/actuation ILEVRO OPHTHALMIC DROPS,SUSPENSION 0.3 % ketorolac ophthalmic drops 0.4 %, 0.5 % LOTEMAX OPHTHALMIC DROPS,GEL 0.5 % LOTEMAX OPHTHALMIC DROPS,SUSPENSION 0.5 % LOTEMAX OPHTHALMIC OINTMENT 0.5 % NEVANAC OPHTHALMIC DROPS,SUSPENSION 0. % (Bromfenac Sodium) $0 (Dexasol) $0 (Diclofenac Sodium) $0 (Flunisolide) $0 (FML) $0 (Ocufen) $0 (Fluticasone Propionate) $0 (Acular) $0 ST QL (50 per 25 days) 45

prednisolone acetate ophthalmic drops,suspension % prednisolone sodium phosphate ophthalmic drops % PROLENSA OPHTHALMIC DROPS 0.07 % RESTASIS OPHTHALMIC DROPPERETTE 0.05 % XIIDRA OPHTHALMIC DROPPERETTE 5 % Gastrointestinal Agents Antiflatulents bicarsim forte 25 mg tablet 25 mg (Omnipred) $0 (Prednisolone Sod Phosphate) $0 * (Simethicone) cvs gas relief 25 mg chew tab extra strength 25 mg * (Gas-X) cvs gas relief 25 mg softgel softgel 25 mg * (Phazyme) cvs gas relief 80 mg tab chew 80 mg * (Gas-X) gas relief 25 mg chew tablet max str,lactose-free 25 mg * (Gas-X) gas relief 80 mg tablet chew lactosefree 80 mg * (Gas-X) gas-x ultra strength softgel 80 mg * (Phazyme) inf gas rel 20 mg/0.3 ml drop (Simethicone) 20mg/0.3ml, dye free 40 mg/0.6 ml * mi-acid gas 80 mg tab chew 80 mg * (Gas-X) mytab gas 80 mg tablet chew 80 mg * (Gas-X) mytab gas max str 25 mg tab 25 mg * (Gas-X) simethicone 80 mg softgel 80 mg * (Phazyme) QL (60 per 30 days) PA; QL (60 per 30 days) 46

v-r anti-gas 66 mg softgel 66 mg * (Phazyme) Antiulcer Agents And Acid Suppressants acid reducer 20 mg tablet maximum strength 20 mg * (Pepcid Ac) amoxicil-clarithromy-lansopraz oral (Prevpac) combo pack 500-500-30 mg $0 CARAFATE ORAL SUSPENSION 00 MG/ML cimetidine hcl oral solution 300 mg/5 ml (Cimetidine HCl) $0 cimetidine oral tablet 200 mg, 300 (Rx Product Only) (Cimetidine) $0 mg, 400 mg, 800 mg cvs cimetidine 200 mg tablet (otc) 200 mg * (Tagamet Hb) esomeprazole sodium intravenous recon soln 20 mg, 40 mg (Nexium I.V.) $0 famotidine (pf) intravenous solution 20 mg/2 ml (Famotidine) $0 famotidine (pf)-nacl (iso-os) (Famotidine In intravenous piggyback 20 mg/50 ml Nacl,Iso-Osm/PF) $0 famotidine 40 mg/4 ml vial 25's,outer 0 mg/ml (Famotidine) $0 famotidine oral tablet 20 mg, 40 mg (Pepcid) $0 (Rx Product Only) gnp acid reducer 0 mg tablet 0 mg * (Pepcid Ac) lansoprazole dr 5 mg capsule na/f (otc) 5 mg * (Prevacid 24hr) lansoprazole oral capsule,delayed (Rx Product Only) (Prevacid) $0 release(dr/ec) 5 mg, 30 mg misoprostol oral tablet 00 mcg, 200 mcg (Cytotec) $0 omeprazole dr 20 mg tablet 20 mg * (Omeprazole) omeprazole mag dr 20.6 mg cap two (Omeprazole 4-days course 20 mg * Magnesium) 47

omeprazole oral capsule,delayed release(dr/ec) 0 mg, 20 mg, 40 mg (Prilosec) $0 omeprazole-sodium bicarbonate (Rx Product Only) (Zegerid) $0 oral capsule 20-. mg-gram pantoprazole intravenous recon soln (Protonix IV) 40 mg $0 pantoprazole oral tablet,delayed release (dr/ec) 20 mg, 40 mg (Protonix) $0 PRILOSEC OTC 20.6 MG TABLET OTC 20 MG * pub famotidine 20 mg tablet max strength (otc) 20 mg * (Pepcid Ac) pv acid relief 200 mg tablet 200 mg * (Tagamet Hb) ra omeprazole-bicarb 20-,00 3x4 day course (otc) 20-. mggram (Zegerid Otc) * ranitidine 50 mg tablet maximum strength (otc) 50 mg * (Zantac) ranitidine 75 mg tablet s/f, sodiumfree 75 mg * (Zantac) ranitidine hcl injection solution 50 (Rx Product Only) (Ranitidine HCl) $0 mg/2 ml (25 mg/ml) ranitidine hcl oral capsule 50 mg, (Rx Product Only) (Ranitidine HCl) $0 300 mg ranitidine hcl oral syrup 5 mg/ml (Ranitidine HCl) $0 (Rx Product Only) ranitidine hcl oral tablet 50 mg, (Rx Product Only) (Zantac) $0 300 mg sucralfate oral suspension 00 mg/ml (Sucralfate) $0 sucralfate oral tablet gram (Carafate) $0 wal-zan 75 mg tablet 75 mg * (Zantac) ZANTAC 50 MG TABLET TWIN PACK(2X45TABS) (OTC) 50 MG * 48

ZANTAC 50 MG TABLET TWIN PK, MAX STRGTH (OTC) 50 MG * ZANTAC 75 MG TABLET 75 MG * Gastrointestinal Agents, Other acid gone antacid liquid 95-358 mg/5 ml * almacone liquid 200-200-20 mg/5 ml * almacone-2 liquid 400-400-40 mg/5 ml * aluminum hydroxide gel sugar-free 320 mg/5 ml * AMITIZA ORAL CAPSULE 24 MCG, 8 MCG antacid plus x-stren susp 500-450- 40 mg/5 ml * antacid ultra tablet chew 400 mg (,000 mg) * antacid xtra strength chew tab extra-strength 300 mg (750 mg) * antacid-antigas liquid 200-200-20 mg/5 ml * anti-diarrheal 2 mg caplet caplet 2 mg * bismatrol suspension 262 mg/5 ml * BUPHENYL ORAL TABLET 500 MG calci-chew tablet 500 mg calcium (,250 mg) * calcium 500 mg chewable tablet tab chew,p/f 500 mg calcium (,250 mg) * (Gaviscon) (Maalox Maximum Strength) (Maalox Maximum Strength) (Aluminum Hydroxide) (Maalox Maximum Strength) (Tums) (Tums) (Maalox Maximum Strength) (Imodium A-D) (Pepto-Bismol) (Tums) (Tums) QL (60 per 30 days) 49

calcium antacid 500 mg chw tab assorted fruit 200 mg calcium (500 mg) * CALCIUM-500 MG TABLET CHEWABLE SOY FREE, YEAST FREE 500-00 MG-UNIT * cal-gest 500 mg tablet chew 200 mg calcium (500 mg) * CARBAGLU ORAL TABLET, DISPERSIBLE 200 MG child soothe 400 mg tab chew 400 mg * children pepto 400 mg tab chew bubble gum, na/f 400 mg * comfort gel max str susp max-str 400-400-40 mg/5 ml * comfort gel suspension regular str, cherry 200-200-20 mg/5 ml * constulose oral solution 0 gram/5 ml cromolyn oral concentrate 00 mg/5 ml cvs antacid-antigas tab chew,000-60 mg * (Tums) (Tums) (Tums) (Tums) (Maalox Maximum Strength) (Maalox Maximum Strength) (Lactulose) $0 (Gastrocrom) $0 (Calcium Carbonate/Simethi cone) cvs anti-diarrheal 2 mg sftgel softgel (Loperamide HCl) 2 mg * cvs anti-diarrheal suspension 262 mg/5 ml * (Pepto-Bismol) cvs loperamide mg/7.5 ml liq mint mg/7.5 ml * (Loperamide HCl) diamode 2 mg tablet outer, f/c 2 mg * (Imodium A-D) dicyclomine oral capsule 0 mg (Bentyl) $0 dicyclomine oral solution 0 mg/5 ml (Dicyclomine HCl) $0 50

dicyclomine oral tablet 20 mg (Bentyl) $0 diphenoxylate-atropine oral liquid (Diphenoxylate 2.5-0.025 mg/5 ml HCl/Atropine) $0 diphenoxylate-atropine oral tablet 2.5-0.025 mg (Lomotil) $0 enulose oral solution 0 gram/5 ml (Lactulose) $0 flanax antacid liquid 200-200-20 (Maalox Maximum mg/5 ml * Strength) foaming antacid liquid 95-358 mg/5 ml * (Gaviscon) GATTEX 5 MG 30-VIAL KIT 5 MG GATTEX ONE-VIAL SUBCUTANEOUS KIT 5 MG gelusil antacid & antigas liq 400- (Maalox Maximum 400-40 mg/5 ml * Strength) gelusil tablet chewable cool mint 200-200-25 mg * (Almacone) generlac oral solution 0 gram/5 ml (Lactulose) $0 glycopyrrolate injection solution 0.2 mg/ml $0 glycopyrrolate oral tablet mg, 2 mg (Robinul) $0 imodium a-d mg/7.5 ml liquid mint (Loperamide HCl) mg/7.5 ml * IMODIUM A-D 2 MG CAPLET CAPLET 2 MG * kaopectate 262 mg/5 ml susp vanilla flavor 262 mg/5 ml * (Pepto-Bismol) (Sodium kionex 5 gm/60 ml suspension 5- Polystyrene 9.3 gram/60 ml Sulfon/Sorb) $0 (Sodium kionex oral powder Polystyrene $0 Sulfon/Sorb) PA PA 5

lactulose oral solution 0 gram/5 (Lactulose) $0 ml LINZESS ORAL CAPSULE 45 MCG, 290 MCG loperamide mg/5 ml liquid mg/5 (Loperamide HCl) ml * loperamide oral capsule 2 mg (Loperamide HCl) $0 LOTRONEX ORAL TABLET 0.5 MG, MG maalox advanced suspension (Maalox Maximum regular strength 200-200-20 mg/5 Strength) ml * MAGNEBIND 300 TABLET 250-300 MG * magnesium 500 mg capsule s/f,na/f (Uromag) 500 mg * magnesium oxide 250 mg tablet 250 (Magox 400) mg * magnesium oxide 400 mg tablet (Magox 400) s/f,p/f,gluten-free 400 mg * magnesium oxide 500 mg tablet (Magox 400) p/f,s/f,lactose-free 500 mg * masanti liquid 400-400-40 mg/5 ml (Maalox Maximum * Strength) $0 $0 $0 metoclopramide hcl oral tablet 0 (Reglan) $0 mg, 5 mg mgo 400 mg tablet 400 mg * (Magox 400) medi-first pep-t-med tab chew 262 methscopolamine oral tablet 2.5 mg, metoclopramide hcl injection metoclopramide hcl oral solution 5 (Pepto-Bismol To- (Methscopolamine (Metoclopramide (Metoclopramide mg * 5 mg solution 5 mg/ml mg/5 ml Go) Bromide) HCl) HCl) QL (30 per 30 days) 52

mi acid suspension 200-200-20 (Maalox Maximum mg/5 ml, 400-400-40 mg/5 ml * Strength) mi-acid ds tablet 700-300 mg * (Rolaids) mintox maximum strength susp max (Maalox Maximum str, lemon creme 400-400-40 mg/5 Strength) ml * mintox plus tablet chewable 200-200-25 mg * (Almacone) mintox suspension mint creme 200- (Maalox Maximum 200-20 mg/5 ml * Strength) MOVANTIK ORAL TABLET 2.5 MG, 25 MG NUTRESTORE ORAL POWDER IN PACKET 5 GRAM OCALIVA ORAL TABLET 0 MG, 5 MG phillips 500 mg caplet 500 mg * (Magox 400) pink bismuth tablet chew 262 mg * (Pepto-Bismol To- Go) ra loperamide mg/7.5 ml susp mint (Loperamide HCl) mg/7.5 ml * ra magnesium 500 mg capsule 500 mg * (Uromag) RAVICTI ORAL LIQUID. GRAM/ML RELISTOR ORAL TABLET 50 MG RELISTOR SUBCUTANEOUS SOLUTION 2 MG/0.6 ML RELISTOR SUBCUTANEOUS SYRINGE 2 MG/0.6 ML, 8 MG/0.4 ML ri-gel ii suspension 400-400-40 (Maalox Maximum mg/5 ml * Strength) ri-mox suspension 200-200-20 mg/5 (Maalox Maximum ml * Strength) QL (30 per 30 days) PA; QL (30 per 30 days) PA PA; QL (90 per 30 days) PA; QL (28 per 28 days) PA; QL (28 per 28 days) 53

sm foaming antacid tablet chew 80-20 mg * sm stomach relief caplet 262 mg * sodium bicarb 650 mg tablet 0 gr 650 mg * sodium polystyrene (sorb free) oral suspension 5 gram/60 ml sodium polystyrene sulfonate rectal enema 30 gram/20 ml soothe 262 mg caplet caplet 262 mg * soothe 262 mg/5 ml suspension s/f,cherry 262 mg/5 ml * sps (with sorbitol) oral suspension 5-20 gram/60 ml (Gaviscon) (Bismuth Subsalicylate) (Sodium Bicarbonate) (Sodium Polystyrene Sulfonate) (Sodium Polystyrene Sulfonate) (Bismuth Subsalicylate) $0 $0 (Pepto-Bismol) (Sodium Polystyrene Sulfon/Sorb) $0 ursodiol oral capsule 300 mg (Actigall) $0 ursodiol oral tablet 250 mg, 500 mg (Urso) $0 VIBERZI ORAL TABLET 00 MG, 75 MG Laxatives alophen pills 5 mg * (Dulcolax) bisac-evac 0 mg suppository 0 mg * (Dulcolax) bisacodyl 0 mg suppository 0 mg * (Dulcolax) bisacodyl ec 5 mg tablet 5 mg * (Dulcolax) biscolax 0 mg suppository 0 mg * (Dulcolax) BLADDER CONTROL PAD X- LONG 9'S,X-LONG * COLACE 00 MG CAPSULE 00 MG * ST; QL (60 per 30 days) 54

cvs enema disposable 9-7 gram/8 ml * (Enema) cvs fiber therapy 500 mg caplt soluble, caplet 500 mg * (Citrucel) cvs kids 00 mg mini enema 00 mg/5 ml * (Docusate Sodium) cvs purelax powder 4 once-daily doses 7 gram/dose * (Gavilax) cvs purelax powder packet s/f, 0 daily doses 7 gram * (Miralax) cvs senna laxative 8.6 mg tab 8.6 mg (Senokot) * cvs stool softener softgel softgel 240 mg * (Surfak) doc-q-lace 00 mg softgel 00 mg * (Colace) docu liquid 50 mg/5 ml 50 mg/5 ml * (Docusate Sodium) docusate sodium 00 mg tablet crushable 00 mg * (Docusate Sodium) docusate sodium-senna tablet 8.6-50 (Sennosides/Docus mg * ate Sodium) docusol mini-enema outer 283 mg * (Docusate Sodium) dok 00 mg softgel softgel 00 mg * (Colace) dok 00 mg tablet 00 mg * (Docusate Sodium) dulcolax ss 00 mg softgel 00 mg * (Colace) enema disposable 9-7 gram/8 ml * (Enema) enema ready to use latex-free 9-7 gram/8 ml * (Enema) enemeez mini enema 5cc tubes, outer 283 mg/5 ml * (Docusate Sodium) enemeez plus mini enema outer 283-20 mg/5 ml * (Docusol Plus) eq fiber therapy powder * (Psyllium Seed (With Sugar)) 55

equalactin 500 mg tab chew 500 mg (Calcium * Polycarbophil) fiber tablet unboxed 625 mg * (Fibercon) fiber therapy (psyllium) oral powder (Psyllium Seed) * fiber therapy powder 2 gram/9 (Citrucel) gram * fiber-lax captabs 500mg (Fibercon) polycarbophil 625 mg * fibertab oral tablet 625 mg * (Fibercon) FLEET BISACODYL 0 MG ENEMA 0 MG/30 ML * gavilyte-c oral recon soln 240- (Golytely) $0 22.72-6.72-5.84 gram gavilyte-g oral recon soln 236- (Golytely) $0 22.74-6.74-5.86 gram (Nulytely with gavilyte-n oral recon soln 420 gram $0 Flavor Packs) gentlelax powder 30 once-daily (Gavilax) doses 7 gram/dose * glycolax powder 7 doses (otc) 7 (Gavilax) 3 $0 gram/dose * healthylax powder packet 4x7gm, (Miralax) outer 7 gram * hydrocil instant packet * (Psyllium Seed) KONSYL 6 GM PACKET S/F, GLUTEN-F, OUTER 6 GRAM * konsyl fiber 625 mg caplet caplet, s/f (Fibercon) 625 mg * magic bullet 0 mg suppos 0 mg * (Dulcolax) mineral oil laxative * (Mineral Oil) konsyl psyllium fiber packet orange, milk of magnesia suspension 400 (Psyllium Husk (Milk Of gluten free 3.4 gram * mg/5 ml * (With Sugar)) Magnesia) 56

MOVIPREP ORAL POWDER IN PACKET 00-7.5-2.69 GRAM natural fiber lax powder * (Psyllium Seed (With Sugar)) oral saline laxative liquid s/f, ginger (Na Phos,M-B/Na lemon 7.2-2.7 gram/5 ml * Phos,Di-Ba) peg 3350-electrolytes oral recon soln 236-22.74-6.74-5.86 gram, 240-22.72-6.72-5.84 gram (Golytely) $0 peg-electrolyte soln oral recon soln (Nulytely with 420 gram Flavor Packs) $0 peri-colace tablet 8.6-50 mg * (Sennosides/Docus ate Sodium) phillips' lax liqui-gels 00 mg * (Colace) phosphate oral saline laxative s/f, (Na Phos,M-B/Na ginger lemon 7.2-2.7 gram/5 ml * Phos,Di-Ba) polyethylene glycol 3350 oral (Polyethylene powder 7 gram/dose Glycol 3350) $0 polyethylene glycol 3350 oral (Polyethylene powder in packet 7 gram Glycol 3350) $0 polyethylene glycol 3350 powd 4 once-daily doses (otc) 7 gram/dose (Gavilax) * polyethylene glycol 3350 powd 7 grams pkts,outer (otc) 7 gram * (Miralax) polyethylene glycol 3350 powd outer,s/f (otc) 7 gram * (Miralax) promolaxin 00 mg tablet 00 mg * (Docusate Sodium) pv senna 8.6 mg softgel 8.6 mg * (Sennosides) ra enema twin pack 2 x 4.5oz, rtu 9-7 gram/8 ml * (Enema) ra laxative peg 3350 powder 4 once-daily doses 7 gram/dose * (Gavilax) reguloid powder orange * (Psyllium Seed (With Sugar)) 57

senexon 8.8 mg/5 ml liquid 8.8 mg/5 ml * (Sennosides) senexon tablet 8.6 mg * (Senokot) senna 8.8 mg/5 ml syrup a/f, chocolate 8.8 mg/5 ml * (Sennosides) senna-lax 8.6 mg tablet 8.6 mg * (Senokot) senokot-s tablet 8.6-50 mg * (Sennosides/Docus ate Sodium) silace 50 mg/5 ml liquid 50 mg/5 ml * (Docusate Sodium) silace 60 mg/5 ml syrup 60 mg/5 ml * (Docusate Sodium) sm clearlax powder 4 once-daily doses 7 gram/dose * (Gavilax) sm fiber laxative 500 mg cplt 500 mg * (Citrucel) sm fiber smooth powder * (Psyllium Seed) smoothlax powder packet 0 oncedaily doses 7 gram * (Miralax) trilyte with flavor packets oral recon (Nulytely with soln 420 gram Flavor Packs) $0 Phosphate Binders calcium acetate oral capsule 667 mg (Phoslo) $0 calcium acetate oral tablet 667 mg (Calcium Acetate) $0 calphron 667 mg tablet 667 mg * (Calcium Acetate) eliphos oral tablet 667 mg (Calcium Acetate) $0 (Calcium magnebind 400 oral tablet 400-200- Carbonate/Mag mg Carb/Fa) $0 PHOSLYRA ORAL SOLUTION 667 MG (69 MG CALCIUM)/5 ML RENAGEL ORAL TABLET 400 MG, 800 MG RENVELA ORAL POWDER IN PACKET 0.8 GRAM, 2.4 GRAM 58

RENVELA ORAL TABLET 800 MG Genitourinary Agents Antispasmodics, Urinary MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HR 25 MG, 50 MG oxybutynin chloride oral syrup 5 mg/5 ml (Oxybutynin Chloride) $0 oxybutynin chloride oral tablet 5 mg (Oxybutynin Chloride) $0 oxybutynin chloride oral tablet extended release 24hr 0 mg, 5 (Ditropan XL) $0 mg, 5 mg tolterodine oral capsule,extended release 24hr 2 mg, 4 mg (Detrol LA) $0 tolterodine oral tablet mg, 2 mg (Detrol) $0 TOVIAZ ORAL TABLET EXTENDED RELEASE 24 HR 4 MG, 8 MG trospium oral capsule,extended (Trospium release 24hr 60 mg Chloride) $0 trospium oral tablet 20 mg (Trospium Chloride) $0 Genitourinary Agents, Miscellaneous alfuzosin oral tablet extended release 24 hr 0 mg tamsulosin oral capsule,extended release 24hr 0.4 mg terazosin oral capsule mg, 0 mg, 2 mg, 5 mg Heavy Metal Antagonists Heavy Metal Antagonists deferoxamine injection recon soln 2 gram, 500 mg (Uroxatral) $0 (Flomax) $0 (Terazosin HCl) $0 (Desferal) $0 59

DEPEN TITRATABS ORAL TABLET 250 MG EXJADE ORAL TABLET, DISPERSIBLE 25 MG, 250 MG, 500 MG FERRIPROX ORAL SOLUTION 00 MG/ML FERRIPROX ORAL TABLET 500 MG sodium thiosulfate intravenous solution gram/0 ml (00 mg/ml), 2.5 gram/50 ml (250 mg/ml) SYPRINE ORAL CAPSULE 250 MG Hormonal Agents, Stimulant/Replacement/Modif ying Androgens ANDRODERM TRANSDERMAL PATCH 24 HOUR 2 MG/24 HOUR, 4 MG/24 HR ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP 20.25 MG/.25 GRAM (.62 %) ANDROGEL TRANSDERMAL GEL IN PACKET.62 % (20.25 MG/.25 GRAM),.62 % (40.5 MG/2.5 GRAM) (Sodium Thiosulfate) $0 androxy oral tablet 0 mg (Fluoxymesterone) $0 danazol oral capsule 00 mg, 200 mg, 50 mg (Danazol) $0 oxandrolone oral tablet 0 mg, 2.5 mg (Oxandrin) $0 testosterone cypionate (Depointramuscular oil 00 mg/ml, 200 Testosterone) mg/ml $0 PA; QL (30 per 30 days) PA; QL (50 per 30 days) PA; QL (50 per 30 days) PA 60

testosterone enanthate intramuscular oil 200 mg/ml testosterone transdermal gel 50 mg/5 gram ( %) testosterone transdermal gel in metered-dose pump.25 gram/ actuation ( %) testosterone transdermal gel in packet % (25 mg/2.5gram) testosterone transdermal gel in packet % (50 mg/5 gram) Estrogens And Antiestrogens amabelz oral tablet 0.5-0. mg, - 0.5 mg COMBIPATCH TRANSDERMAL PATCH SEMIWEEKLY 0.05-0.4 MG/24 HR, 0.05-0.25 MG/24 HR DUAVEE ORAL TABLET 0.45-20 MG ESTRACE VAGINAL CREAM 0.0 % (0. MG/GRAM) estradiol oral tablet 0.5 mg, mg, 2 mg estradiol transdermal patch semiweekly 0.025 mg/24 hr, 0.0375 mg/24 hr, 0.05 mg/24 hr, 0.075 mg/24 hr, 0. mg/24 hr estradiol transdermal patch weekly 0.025 mg/24 hr, 0.0375 mg/24 hr, 0.05 mg/24 hr, 0.06 mg/24 hr, 0.075 mg/24 hr, 0. mg/24 hr estradiol valerate intramuscular oil 0 mg/ml, 20 mg/ml, 40 mg/ml estradiol-norethindrone acet oral tablet 0.5-0. mg, -0.5 mg (Testosterone Enanthate) $0 (Testim) $0 (Vogelxo) $0 (Androgel) $0 (Testim) $0 (Activella) $0 (Estrace) $0 (Vivelle-Dot) $0 (Climara) $0 (Delestrogen) $0 (Activella) $0 PA; QL (5 per 28 days) PA; QL (300 per 30 days) PA; QL (300 per 30 days) PA; QL (300 per 30 days) PA; QL (300 per 30 days) PA-HRM; AGE (Max 64 Years) PA-HRM; QL (8 per 28 days); AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA-HRM; QL (8 per 28 days); AGE (Max 64 Years) PA-HRM; QL (4 per 28 days); AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) 6

estropipate oral tablet 0.75 mg,.5 mg, 3 mg FEMRING VAGINAL RING 0.05 MG/24 HR, 0. MG/24 HR MENEST ORAL TABLET 0.3 MG, 0.625 MG,.25 MG, 2.5 MG (Estropipate) $0 mimvey lo oral tablet 0.5-0. mg (Activella) $0 mimvey oral tablet -0.5 mg (Activella) $0 PREMARIN INJECTION RECON SOLN 25 MG PREMARIN ORAL TABLET 0.3 MG, 0.45 MG, 0.625 MG, 0.9 MG,.25 MG PREMARIN VAGINAL CREAM 0.625 MG/GRAM PREMPHASE ORAL TABLET 0.625 MG (4)/ 0.625MG-5MG(4) PREMPRO ORAL TABLET 0.3-.5 MG, 0.45-.5 MG, 0.625-2.5 MG, 0.625-5 MG raloxifene oral tablet 60 mg (Evista) $0 VAGIFEM VAGINAL TABLET 0 MCG Glucocorticoids/Mineraloco rticoids a-hydrocort injection recon soln 00 (Hydrocortisone mg Sod Succinate) $0 betamethasone acet,sod phos injection suspension 6 mg/ml (Celestone) $0 cortisone oral tablet 25 mg (Cortisone Acetate) $0 dexamethasone oral elixir 0.5 mg/5 (Dexamethasone) $0 ml PA-HRM; AGE (Max 64 Years) QL ( per 84 days) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) QL (8 per 28 days) 62

dexamethasone oral tablet 0.5 mg, 0.75 mg, mg,.5 mg, 2 mg, 4 mg, 6 mg dexamethasone sodium phosphate injection solution 0 mg/ml, 4 mg/ml fludrocortisone oral tablet 0. mg (Dexamethasone) $0 (Dexamethasone Sod Phosphate) (Fludrocortisone Acetate) $0 $0 hydrocortisone oral tablet 0 mg, 20 (Cortef) $0 mg, 5 mg methylprednisolone acetate injection suspension 40 mg/ml, 80 mg/ml (Depo-Medrol) $0 methylprednisolone oral tablet 6 (Medrol) $0 mg, 32 mg, 4 mg, 8 mg methylprednisolone oral (Medrol) $0 tablets,dose pack 4 mg methylprednisolone sodium succ injection recon soln 25 mg, 40 mg (Solu-Medrol) $0 methylprednisolone ss gm vl mdv,latex-free,000 mg (Solu-Medrol) $0 prednisolone sodium phosphate oral solution 5 mg/5 ml (3 mg/ml), 25 mg/5 ml (5 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml) (Pediapred) $0 prednisone oral solution 5 mg/5 ml (Prednisone) $0 prednisone oral tablet mg, 2.5 mg, (Prednisone) $0 20 mg, 5 mg, 50 mg prednisone oral tablet 0 mg (Prednisone) $0 prednisone oral tablets,dose pack 0 mg, 0 mg (48 pack), 5 mg, 5 mg (48 pack) (Prednisone) $0 SOLU-CORTEF (PF) INJECTION RECON SOLN 00 MG/2 ML triamcinolone acetonide injection (Triamcinolone suspension 0 mg/ml, 40 mg/ml Acetonide) $0 Pituitary 63

desmopressin injection solution 4 mcg/ml desmopressin nasal solution 0. mg/ml (refrigerate) desmopressin nasal spray,nonaerosol 0 mcg/spray (0. ml) desmopressin oral tablet 0. mg, 0.2 mg GENOTROPIN MINIQUICK SUBCUTANEOUS SYRINGE 0.2 MG/0.25 ML, 0.4 MG/0.25 ML, 0.6 MG/0.25 ML, 0.8 MG/0.25 ML, MG/0.25 ML,.2 MG/0.25 ML,.4 MG/0.25 ML,.6 MG/0.25 ML,.8 MG/0.25 ML, 2 MG/0.25 ML GENOTROPIN SUBCUTANEOUS CARTRIDGE 2 MG/ML (36 UNIT/ML), 5 MG/ML (5 UNIT/ML) INCRELEX SUBCUTANEOUS SOLUTION 0 MG/ML LUPRON DEPOT-PED (3 MONTH) INTRAMUSCULAR SYRINGE KIT 30 MG LUPRON DEPOT-PED INTRAMUSCULAR KIT.25 MG, 5 MG, 7.5 MG (PED) NORDITROPIN FLEXPRO SUBCUTANEOUS PEN INJECTOR 0 MG/.5 ML (6.7 MG/ML), 5 MG/.5 ML (0 MG/ML), 30 MG/3 ML (0 MG/ML), 5 MG/.5 ML (3.3 MG/ML) octreotide acet 50 mcg/ml syr outer,single-dose,0 50 mcg/ml ( ml) (Desmopressin Acetate) $0 (DDAVP) $0 (Desmopressin Acetate) $0 (DDAVP) $0 (Octreotide Acetate) $0 QL (5 per 30 days) QL (5 per 30 days) PA PA QL ( per 84 days) PA 64

octreotide acetate injection solution,000 mcg/ml, 00 mcg/ml, 200 mcg/ml, 500 mcg/ml octreotide acetate injection solution 50 mcg/ml SAIZEN CLICK.EASY SUBCUTANEOUS CARTRIDGE 8.8 MG/.5 ML (FNL) SAIZEN SUBCUTANEOUS RECON SOLN 5 MG, 8.8 MG SANDOSTATIN LAR 0 MG KIT 0 MG SANDOSTATIN LAR 20 MG KIT 20 MG SANDOSTATIN LAR 30 MG KIT 30 MG SANDOSTATIN LAR DEPOT INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 0 MG, 20 MG, 30 MG SEROSTIM SUBCUTANEOUS RECON SOLN 4 MG, 5 MG, 6 MG SOMATULINE DEPOT SUBCUTANEOUS SYRINGE 20 MG/0.5 ML, 60 MG/0.2 ML, 90 MG/0.3 ML SOMAVERT SUBCUTANEOUS RECON SOLN 0 MG, 5 MG, 20 MG, 25 MG, 30 MG SUPPRELIN LA IMPLANT KIT 50 MG (65 MCG/DAY) Progestins DEPO-PROVERA INTRAMUSCULAR SOLUTION 400 MG/ML hydroxyprogesterone caproate intramuscular oil 250 mg/ml (Sandostatin) $0 (Octreotide Acetate) (Hydroxyprogester one Caproate) $0 $0 PA PA PA QL ( per 28 days) QL ( per 360 days) QL (0 per 28 days) PA NSO 65

medroxyprogesterone intramuscular suspension 50 mg/ml medroxyprogesterone intramuscular syringe 50 mg/ml medroxyprogesterone oral tablet 0 mg, 2.5 mg, 5 mg MEGACE ES ORAL SUSPENSION 625 MG/5 ML megestrol oral suspension 400 mg/0 ml (40 mg/ml), 625 mg/5 ml norethindrone acetate oral tablet 5 mg progesterone in oil intramuscular oil 50 mg/ml progesterone micronized oral capsule 00 mg, 200 mg Thyroid And Antithyroid Agents levothyroxine intravenous recon soln 00 mcg, 200 mcg, 500 mcg levothyroxine oral tablet 00 mcg, 2 mcg, 25 mcg, 37 mcg, 50 mcg, 75 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg liothyronine oral tablet 25 mcg, 5 mcg, 50 mcg (Depo-Provera) $0 (Medroxyprogester one Acetate) $0 (Provera) $0 (Megace Es) $0 (Aygestin) $0 (Progesterone) $0 (Prometrium) $0 (Levothyroxine Sodium) $0 (Levoxyl) $0 (Cytomel) $0 methimazole oral tablet 0 mg, 5 mg (Tapazole) $0 propylthiouracil oral tablet 50 mg (Propylthiouracil) $0 Immunological Agents Immunological Agents ARCALYST SUBCUTANEOUS RECON SOLN 220 MG ASTAGRAF XL ORAL CAPSULE,EXTENDED RELEASE 24HR 0.5 MG, MG, 5 MG QL ( per 84 days) QL ( per 84 days) 66

AUBAGIO ORAL TABLET 4 PA; QL (28 per 28 MG, 7 MG days) azathioprine oral tablet 50 mg (Imuran) $0 azathioprine sodium injection recon (Azathioprine $0 soln 00 mg Sodium) CARIMUNE NF NANOFILTERED INTRAVENOUS RECON SOLN 6 GRAM CELLCEPT INTRAVENOUS INTRAVENOUS RECON SOLN 500 MG CIMZIA POWDER FOR PA RECONST SUBCUTANEOUS KIT 400 MG (200 MG X 2 VIALS) CIMZIA SUBCUTANEOUS PA SYRINGE KIT 400 MG/2 ML (200 MG/ML X 2) cyclosporine intravenous solution (Sandimmune) $0 250 mg/5 ml cyclosporine modified oral capsule (Neoral) $0 00 mg, 25 mg, 50 mg cyclosporine modified oral solution (Neoral) $0 00 mg/ml cyclosporine oral capsule 00 mg, (Sandimmune) $0 25 mg ENBREL SUBCUTANEOUS PA RECON SOLN 25 MG ( ML) ENBREL SUBCUTANEOUS PA SYRINGE 25 MG/0.5ML (0.5), 50 MG/ML (0.98 ML) ENBREL SURECLICK PA SUBCUTANEOUS PEN INJECTOR 50 MG/ML (0.98 ML) ENVARSUS XR ORAL TABLET EXTENDED RELEASE 24 HR 0.75 MG, MG, 4 MG 67

FLEBOGAMMA DIF INTRAVENOUS SOLUTION 0 %, 5 % GAMASTAN S/D INTRAMUSCULAR SOLUTION 5-8 % RANGE GAMMAGARD LIQUID INJECTION SOLUTION 0 % GAMMAPLEX INTRAVENOUS SOLUTION 5 % gengraf oral capsule 00 mg, 25 (Neoral) $0 mg, 50 mg gengraf oral solution 00 mg/ml (Neoral) $0 HUMIRA PEDIATRIC CROHN'S PA START SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML, 40 MG/0.8 ML (6 PACK) HUMIRA PEN CROHN'S-UC-HS PA START SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML HUMIRA PEN PSORIASIS- PA UVEITIS SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML HUMIRA PEN SUBCUTANEOUS PA PEN INJECTOR KIT 40 MG/0.8 ML HUMIRA SUBCUTANEOUS PA SYRINGE KIT 0 MG/0.2 ML, 20 MG/0.4 ML, 40 MG/0.8 ML HYPERRAB S/D (PF) INTRAMUSCULAR SOLUTION 50 UNIT/ML, 50 UNIT/ML (0 ML) HYQVIA IG COMPONENT SUBCUTANEOUS SOLUTION 2.5 GRAM/25 ML (0 %) 68

HYQVIA SUBCUTANEOUS SOLUTION 0 GRAM /00 ML (0 %), 2.5 GRAM /25 ML (0 %), 20 GRAM /200 ML (0 %), 30 GRAM /300 ML (0 %), 5 GRAM /50 ML (0 %) ILARIS (PF) SUBCUTANEOUS RECON SOLN 80 MG/.2 ML (50 MG/ML) IMOGAM RABIES-HT (PF) INTRAMUSCULAR SOLUTION 50 UNIT/ML KINERET SUBCUTANEOUS SYRINGE 00 MG/0.67 ML leflunomide oral tablet 0 mg, 20 mg mycophenolate mofetil oral capsule 250 mg mycophenolate mofetil oral suspension for reconstitution 200 mg/ml mycophenolate mofetil oral tablet 500 mg mycophenolate sodium oral tablet,delayed release (dr/ec) 80 mg, 360 mg NULOJIX INTRAVENOUS RECON SOLN 250 MG OCTAGAM INTRAVENOUS SOLUTION 0 %, 5 % ORENCIA (WITH MALTOSE) INTRAVENOUS RECON SOLN 250 MG ORENCIA SUBCUTANEOUS SYRINGE 25 MG/ML PRIVIGEN INTRAVENOUS SOLUTION 0 % (Arava) $0 (Cellcept) $0 (Cellcept) $0 (Cellcept) $0 (Myfortic) $0 PA PA; QL (8.76 per 28 days) PA PA 69

PROGRAF INTRAVENOUS SOLUTION 5 MG/ML RAPAMUNE ORAL SOLUTION MG/ML RIDAURA ORAL CAPSULE 3 MG sirolimus oral tablet 0.5 mg, mg, 2 mg tacrolimus oral capsule 0.5 mg, mg, 5 mg TYSABRI INTRAVENOUS SOLUTION 300 MG/5 ML ZORTRESS ORAL TABLET 0.25 MG, 0.5 MG, 0.75 MG Vaccines ACTHIB (PF) INTRAMUSCULAR RECON SOLN 0 MCG/0.5 ML ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SUSPENSION 2 LF-(2.5-5-3-5 MCG)-5LF/0.5 ML ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SYRINGE 2 LF-(2.5-5-3-5 MCG)-5LF/0.5 ML BCG (TICE STRAIN) VIAL LATEX-FREE, OUTER 50 MG BCG VACCINE, LIVE (PF) PERCUTANEOUS SUSPENSION FOR RECONSTITUTION 50 MG BEXSERO (PF) INTRAMUSCULAR SYRINGE 50-50-50-25 MCG/0.5 ML (Rapamune) $0 (Hecoria) $0 PA; LA; QL (5 per 28 days) ; QL (20 per 30 days) 70

BOOSTRIX TDAP INTRAMUSCULAR SUSPENSION 2.5-8-5 LF-MCG- LF/0.5ML BOOSTRIX TDAP INTRAMUSCULAR SYRINGE 2.5-8-5 LF-MCG-LF/0.5ML CERVARIX VACCINE (PF) INTRAMUSCULAR SYRINGE 20-20 MCG/0.5 ML COMVAX (PF) INTRAMUSCULAR SUSPENSION 5-7.5-25 MCG/0.5 ML DAPTACEL (DTAP PEDIATRIC) (PF) INTRAMUSCULAR SUSPENSION 5-0-5 LF-MCG- LF/0.5ML ENGERIX-B (PF) INTRAMUSCULAR SYRINGE 20 MCG/ML ENGERIX-B 20 MCG/ML VIAL 0'S,ADULT,P/F,OUTER 20 MCG/ML ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SUSPENSION 0 MCG/0.5 ML ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SYRINGE 0 MCG/0.5 ML GARDASIL (PF) INTRAMUSCULAR SUSPENSION 20-40-40-20 MCG/0.5 ML GARDASIL (PF) INTRAMUSCULAR SYRINGE 20-40-40-20 MCG/0.5 ML ; QL (3 per 365 days) ; QL (3 per 365 days) ; QL (3 per 365 days) ; QL (3 per 365 days) QL (.5 per 365 days) QL (.5 per 365 days) 7

GARDASIL 9 (PF) INTRAMUSCULAR SUSPENSION 0.5 ML GARDASIL 9 (PF) INTRAMUSCULAR SYRINGE 0.5 ML HAVRIX (PF) INTRAMUSCULAR SUSPENSION,440 ELISA UNIT/ML HAVRIX (PF) INTRAMUSCULAR SYRINGE,440 ELISA UNIT/ML, 720 ELISA UNIT/0.5 ML HIBERIX (PF) INTRAMUSCULAR RECON SOLN 0 MCG/0.5 ML IMOVAX RABIES VACCINE (PF) INTRAMUSCULAR RECON SOLN 2.5 UNIT INFANRIX (DTAP) (PF) INTRAMUSCULAR SUSPENSION 25-58-0 LF-MCG- LF/0.5ML IPOL INJECTION SUSPENSION 40-8-32 UNIT/0.5 ML IPOL INJECTION SYRINGE 40-8- 32 UNIT/0.5 ML IXIARO (PF) INTRAMUSCULAR SYRINGE 6 MCG/0.5 ML KINRIX (PF) INTRAMUSCULAR SUSPENSION 25 LF-58 MCG-0 LF/0.5 ML KINRIX (PF) INTRAMUSCULAR SYRINGE 25 LF-58 MCG-0 LF/0.5 ML QL (.5 per 365 days) QL (.5 per 365 days) 72

MENACTRA (PF) INTRAMUSCULAR SOLUTION 4 MCG/0.5 ML MENHIBRIX (PF) INTRAMUSCULAR RECON SOLN 5-2.5 MCG/0.5 ML MENOMUNE - A/C/Y/W-35 (PF) SUBCUTANEOUS RECON SOLN 50 MCG MENVEO A-C-Y-W-35-DIP (PF) INTRAMUSCULAR KIT 0-5 MCG/0.5 ML MENVEO MENA COMPONENT (PF) INTRAMUSCULAR RECON SOLN 0 MCG /0.5 ML (FINAL) MENVEO MENCYW-35 COMPNT (PF) INTRAMUSCULAR RECON SOLN 5 MCG X 3/ 0.5 ML (FINAL) M-M-R II (PF) SUBCUTANEOUS RECON SOLN,000-2,500 TCID50/0.5 ML PEDIARIX (PF) INTRAMUSCULAR SYRINGE 0 MCG-25LF-25 MCG-0LF/0.5 ML PEDVAX HIB (PF) INTRAMUSCULAR SOLUTION 7.5 MCG/0.5 ML PENTACEL (PF) INTRAMUSCULAR KIT 5 LF UNIT-20 MCG-5 LF/0.5 ML PROQUAD (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 0EXP3-4.3-3- 3.99 TCID50/0.5 QL (2 per 365 days) QL (2 per 365 days) 73

QUADRACEL (PF) INTRAMUSCULAR SUSPENSION 5 LF-48 MCG- 5 LF UNIT/0.5ML RABAVERT (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 2.5 UNIT RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION 0 MCG/ML, 40 MCG/ML RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 0 MCG/ML, 5 MCG/0.5 ML ROTARIX ORAL SUSPENSION FOR RECONSTITUTION 0EXP6 CCID50/ML ROTATEQ VACCINE ORAL SUSPENSION 2 ML TENIVAC (PF) INTRAMUSCULAR SYRINGE 5-2 LF UNIT/0.5 ML TETANUS TOXOID,ADSORBED (PF) INTRAMUSCULAR SUSPENSION 5 LF UNIT/0.5 ML TETANUS,DIPHTHERIA TOX PED(PF) INTRAMUSCULAR SUSPENSION 5-25 LF UNIT/0.5 ML tetanus-diphtheria toxoids-td intramuscular suspension 2-2 lf unit/0.5 ml TRUMENBA INTRAMUSCULAR SYRINGE 20 MCG/0.5 ML (Tetanus, Diphtheria Tox,Adult) ; QL (3 per 365 days) ; QL (3 per 365 days) 74

TWINRIX (PF) INTRAMUSCULAR SUSPENSION 720 ELISA UNIT - 20 MCG/ML TWINRIX (PF) INTRAMUSCULAR SYRINGE 720 ELISA UNIT -20 MCG/ML TYPHIM VI INTRAMUSCULAR SOLUTION 25 MCG/0.5 ML TYPHIM VI INTRAMUSCULAR SYRINGE 25 MCG/0.5 ML VAQTA (PF) INTRAMUSCULAR SUSPENSION 50 UNIT/ML VAQTA (PF) INTRAMUSCULAR SYRINGE 25 UNIT/0.5 ML, 50 UNIT/ML VAQTA 25 UNITS/0.5 ML VIAL SDV, OUTER 25 UNIT/0.5 ML VARIVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION,350 UNIT/0.5 ML YF-VAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 0 EXP4.74 UNIT/0.5 ML ZOSTAVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 9,400 UNIT/0.65 ML Inflammatory Bowel Disease Agents Inflammatory Bowel Disease Agents alosetron oral tablet 0.5 mg, mg (Alosetron HCl) $0 QL (2 per 365 days) QL ( per 365 days) 75

APRISO ORAL CAPSULE,EXTENDED RELEASE 24HR 0.375 GRAM ASACOL HD ORAL TABLET,DELAYED RELEASE (DR/EC) 800 MG balsalazide oral capsule 750 mg (Colazal) $0 budesonide oral capsule,delayed,extend.release 3 mg (Entocort EC) $0 DELZICOL ORAL CAPSULE (WITH DEL REL TABLETS) 400 MG DIPENTUM ORAL CAPSULE 250 MG mesalamine oral tablet,delayed release (dr/ec) 800 mg (Asacol Hd) $0 Irrigating Solutions Irrigating Solutions acetic acid irrigation solution 0.25 % (Acetic Acid) $0 LACTATED RINGERS IRRIGATION SOLUTION ringers irrigation solution (Ringers Solution) $0 sodium chloride irrigation solution (Sodium Chloride 0.9 % Irrig Solution) $0 sorbitol irrigation solution 3 %, 3.3 % (Sorbitol Solution) $0 sorbitol-mannitol urethral solution (Mannitol/Sorbitol 2.7-0.54 g/00 ml Solution) $0 water for irrigation, sterile (Water For irrigation solution Irrigation,Sterile) $0 Metabolic Bone Disease Agents Metabolic Bone Disease Agents ST 76

alendronate oral solution 70 mg/75 (Alendronate QL (300 per 28 days) $0 ml Sodium) alendronate oral tablet 0 mg, 40 mg, 5 mg (Fosamax) $0 alendronate oral tablet 35 mg, 70 QL (4 per 28 days) (Fosamax) $0 mg calcitonin (salmon) nasal QL (3.7 per 28 days) spray,non-aerosol 200 unit/actuation (Miacalcin) $0 calcitriol intravenous solution mcg/ml (Calcitriol) $0 calcitriol oral capsule 0.25 mcg, 0.5 mcg (Rocaltrol) $0 calcitriol oral solution mcg/ml (Rocaltrol) $0 doxercalciferol intravenous solution 4 mcg/2 ml (Doxercalciferol) $0 doxercalciferol oral capsule 0.5 mcg, mcg, 2.5 mcg (Hectorol) $0 FORTEO SUBCUTANEOUS PEN INJECTOR 20 MCG/DOSE - 600 PA; QL (2.4 per 28 days) MCG/2.4 ML FORTICAL NASAL SPRAY,NON- AEROSOL 200 UNIT/ACTUATION QL (3.7 per 28 days) ibandronate intravenous solution 3 (Ibandronate QL (3 per 84 days) $0 mg/3 ml Sodium) ibandronate intravenous syringe 3 QL (3 per 84 days) (Boniva) $0 mg/3 ml ibandronate oral tablet 50 mg (Boniva) $0 QL ( per 28 days) MIACALCIN INJECTION SOLUTION 200 UNIT/ML NATPARA SUBCUTANEOUS CARTRIDGE 00 MCG/DOSE, 25 MCG/DOSE, 50 MCG/DOSE, 75 MCG/DOSE PA; QL (2 per 28 days) 77

PARICALCITOL HEMODIALYSIS PORT INJECTION SOLUTION 2 MCG/ML, 5 MCG/ML paricalcitol oral capsule mcg, 2 mcg, 4 mcg PROLIA SUBCUTANEOUS $0 (Zemplar) $0 QL ( per 80 days) SYRINGE 60 MG/ML risedronate oral tablet 50 mg (Actonel) $0 QL ( per 28 days) risedronate oral tablet 30 mg, 5 mg (Actonel) $0 QL (30 per 28 days) ZEMPLAR INTRAVENOUS SOLUTION 2 MCG/ML, 5 MCG/ML zoledronic acid intravenous solution 4 mg/5 ml zoledronic acid-mannitol-water intravenous piggyback 4 mg/00 ml zoledronic acid-mannitol-water intravenous solution 5 mg/00 ml ZOMETA INTRAVENOUS SOLUTION 4 MG/00 ML Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents ACTEMRA INTRAVENOUS SOLUTION 200 MG/0 ML (20 MG/ML), 400 MG/20 ML (20 MG/ML), 80 MG/4 ML (20 MG/ML) ACTEMRA SUBCUTANEOUS SYRINGE 62 MG/0.9 ML ACTIMMUNE SUBCUTANEOUS SOLUTION 00 MCG/0.5 ML (Zometa) $0 (Zoledronic Acid/Mannitol- Water) $0 (Reclast) $0 QL (00 per 300 days) PA PA 78

allopurinol oral tablet 00 mg, 300 mg (Zyloprim) $0 amifostine crystalline intravenous recon soln 500 mg (Ethyol) $0 anticoag citrate phos dextrose (Citrate Phosphate solution 2.63-222 gram-mg/00ml Dextros Soln) $0 AVONEX (WITH ALBUMIN) INTRAMUSCULAR KIT 30 MCG AVONEX INTRAMUSCULAR PEN INJECTOR KIT 30 MCG/0.5 ML AVONEX INTRAMUSCULAR SYRINGE KIT 30 MCG/0.5 ML BENLYSTA INTRAVENOUS RECON SOLN 20 MG, 400 MG BETASERON SUBCUTANEOUS KIT 0.3 MG bethanechol chloride oral tablet 0 mg, 25 mg, 5 mg, 50 mg (Urecholine) $0 buspirone oral tablet 0 mg, 5 mg, 30 mg, 5 mg, 7.5 mg (Buspirone HCl) $0 CERDELGA ORAL CAPSULE 84 MG CETYLEV ORAL TABLET, EFFERVESCENT 2.5 GRAM, 500 MG colchicine oral tablet 0.6 mg (Colcrys) $0 COPAXONE SUBCUTANEOUS SYRINGE 20 MG/ML, 40 MG/ML CYSTADANE ORAL POWDER GRAM/.7 ML droperidol injection solution 2.5 mg/ml (Droperidol) $0 dutasteride oral capsule 0.5 mg (Avodart) $0 dutasteride-tamsulosin oral capsule, er multiphase 24 hr 0.5-0.4 mg (Jalyn) $0 ST ST ST PA ST PA QL (30 per 30 days) 79

ELMIRON ORAL CAPSULE 00 MG ergoloid oral tablet mg (Ergoloid Mesylates) $0 EXONDYS 5 INTRAVENOUS SOLUTION 50 MG/ML EXTAVIA SUBCUTANEOUS KIT 0.3 MG finasteride oral tablet 5 mg (Proscar) $0 fomepizole intravenous solution gram/ml (Fomepizole) $0 FUSILEV INTRAVENOUS RECON SOLN 50 MG GAUZE PAD TOPICAL BANDAGE 2 X 2 " $0 GILENYA ORAL CAPSULE 0.5 MG GLUCAGEN HYPOKIT INJECTION RECON SOLN MG GLUCAGON EMERGENCY KIT (HUMAN) INJECTION KIT MG guanidine oral tablet 25 mg (Guanidine HCl) $0 hydroxyzine hcl intramuscular solution 25 mg/ml, 50 mg/ml (Hydroxyzine HCl) $0 hydroxyzine hcl oral solution 0 mg/5 ml (Hydroxyzine HCl) $0 hydroxyzine hcl oral tablet 0 mg, 25 mg, 50 mg (Hydroxyzine HCl) $0 hydroxyzine pamoate oral capsule 00 mg, 25 mg, 50 mg (Vistaril) $0 KEVEYIS ORAL TABLET 50 MG LEMTRADA INTRAVENOUS SOLUTION 2 MG/.2 ML leucovorin calcium 200 mg vial sdv, p/f, latex-free 200 mg (Leucovorin Calcium) $0 PA; LA ST QL (28 per 28 days) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA NSO; QL (20 per 30 days) PA 80

leucovorin calcium injection recon (Leucovorin soln 00 mg, 350 mg, 50 mg Calcium) $0 leucovorin calcium oral tablet 0 (Leucovorin mg, 5 mg, 25 mg, 5 mg Calcium) $0 levocarnitine (with sugar) oral (Levocarnitine solution 00 mg/ml (With Sugar)) $0 levocarnitine oral tablet 330 mg (Carnitor) $0 levoleucovorin intravenous recon soln 50 mg (Fusilev) $0 mesna intravenous solution 00 mg/ml (Mesnex) $0 MESNEX ORAL TABLET 400 MG MESTINON ORAL SYRUP 60 MG/5 ML MESTINON TIMESPAN ORAL TABLET EXTENDED RELEASE 80 MG MINERAL OIL HEAVY * morrhuate sodium intravenous (Sodium solution 5 % Morrhuate) $0 ORENCIA CLICKJECT SUBCUTANEOUS AUTO- INJECTOR 25 MG/ML ORFADIN ORAL SUSPENSION 4 MG/ML OTEZLA ORAL TABLET 30 MG OTEZLA STARTER ORAL TABLETS,DOSE PACK 0 MG (4)-20 MG (4)-30 MG (47), 0 MG (4)-20 MG (4)-30 MG(9) PA PA; QL (60 per 30 days) PA; QL (60 per 30 days) 8

OTREXUP (PF) SUBCUTANEOUS AUTO- INJECTOR 0 MG/0.4 ML, 2.5 MG/0.4 ML, 5 MG/0.4 ML, 7.5 MG/0.4 ML, 20 MG/0.4 ML, 22.5 MG/0.4 ML, 25 MG/0.4 ML, 7.5 MG/0.4 ML PANTILINERS PAD * PLEGRIDY SUBCUTANEOUS PEN INJECTOR 25 MCG/0.5 ML, 63 MCG/0.5 ML- 94 MCG/0.5 ML PLEGRIDY SUBCUTANEOUS SYRINGE 25 MCG/0.5 ML, 63 MCG/0.5 ML- 94 MCG/0.5 ML probenecid oral tablet 500 mg (Probenecid) $0 probenecid-colchicine oral tablet (Colchicine/Proben 500-0.5 mg ecid) $0 PROCYSBI ORAL CAPSULE, DELAYED REL SPRINKLE 25 MG, 75 MG pv extra cleansing douche * (Acetic Acid) pyridostigmine bromide oral tablet 60 mg (Mestinon) $0 pyridostigmine bromide oral tablet extended release 80 mg (Mestinon) $0 qc mineral oil heavy * (Mineral Oil) ra feminine care douche * (Acetic Acid) RASUVO (PF) SUBCUTANEOUS AUTO-INJECTOR 0 MG/0.2 ML, 2.5 MG/0.25 ML, 5 MG/0.3 ML, 7.5 MG/0.35 ML, 20 MG/0.4 ML, 22.5 MG/0.45 ML, 25 MG/0.5 ML, 27.5 MG/0.55 ML, 30 MG/0.6 ML, 7.5 MG/0.5 ML REBIF (WITH ALBUMIN) SUBCUTANEOUS SYRINGE 22 MCG/0.5 ML, 44 MCG/0.5 ML ST ST 82

REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 22 MCG/0.5 ML, 44 MCG/0.5 ML, 8.8MCG/0.2ML-22 MCG/0.5ML (6) REBIF TITRATION PACK SUBCUTANEOUS SYRINGE 8.8MCG/0.2ML-22 MCG/0.5ML (6) REMICADE INTRAVENOUS RECON SOLN 00 MG sb disp douche extra clns v&w * (Acetic Acid) SENSIPAR ORAL TABLET 30 MG, 60 MG, 90 MG SIGNIFOR SUBCUTANEOUS SOLUTION 0.3 MG/ML ( ML), 0.6 MG/ML ( ML), 0.9 MG/ML ( ML) SIMPONI ARIA INTRAVENOUS SOLUTION 2.5 MG/ML SIMPONI SUBCUTANEOUS PEN INJECTOR 00 MG/ML, 50 MG/0.5 ML SIMPONI SUBCUTANEOUS SYRINGE 00 MG/ML, 50 MG/0.5 ML STELARA SUBCUTANEOUS SYRINGE 45 MG/0.5 ML, 90 MG/ML STERILE PADS 2" X 2" 2 X 2 " $0 summer's eve dche-xtra clns 2's,extra-cleansing * (Acetic Acid) summer's eve douche-ultra clns 2's,2pk,ultra clns * (Acetic Acid) SYNAREL NASAL SPRAY,NON- AEROSOL 2 MG/ML PA QL (60 per 30 days) PA PA PA PA 83

TECFIDERA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 20 MG TECFIDERA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 20 MG (4)- 240 MG (46), 240 MG THALOMID ORAL CAPSULE 00 MG, 50 MG, 200 MG, 50 MG topical light mineral oil * (Mineral Oil) QL (4 per 30 days) QL (60 per 30 days) PA NSO; QL (60 per 30 days) TYBOST ORAL TABLET 50 MG QL (30 per 30 days) ULORIC ORAL TABLET 40 MG, QL (30 per 30 days) 80 MG XELJANZ ORAL TABLET 5 MG PA; QL (60 per 30 days) XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HR MG PA; QL (30 per 30 days) ZINBRYTA SUBCUTANEOUS ST SYRINGE 50 MG/ML Ophthalmic Agents Antiglaucoma Agents acetazolamide oral capsule, extended release 500 mg (Diamox Sequels) $0 acetazolamide oral tablet 25 mg, 250 mg (Acetazolamide) $0 acetazolamide sodium injection (Acetazolamide recon soln 500 mg Sodium) $0 ALPHAGAN P OPHTHALMIC DROPS 0. % AZOPT OPHTHALMIC DROPS,SUSPENSION % betaxolol ophthalmic drops 0.5 % (Betaxolol HCl) $0 bimatoprost ophthalmic drops 0.03 % (Bimatoprost) $0 84

brimonidine ophthalmic drops 0.5 %, 0.2 % (Alphagan P) $0 COMBIGAN OPHTHALMIC DROPS 0.2-0.5 % dorzolamide ophthalmic drops 2 % (Trusopt) $0 dorzolamide-timolol ophthalmic drops 22.3-6.8 mg/ml (Cosopt) $0 latanoprost ophthalmic drops 0.005 % (Xalatan) $0 levobunolol ophthalmic drops 0.25 %, 0.5 % (Betagan) $0 LUMIGAN OPHTHALMIC DROPS 0.0 % methazolamide oral tablet 25 mg, 50 (Neptazane) mg $0 metipranolol ophthalmic drops 0.3 % (Metipranolol) $0 PHOSPHOLINE IODIDE OPHTHALMIC DROPS 0.25 % pilocarpine hcl ophthalmic drops %, 2 %, 4 % (Isopto Carpine) $0 SIMBRINZA OPHTHALMIC DROPS,SUSPENSION -0.2 % timolol maleate ophthalmic drops 0.25 %, 0.5 % (Timoptic) $0 timolol maleate ophthalmic gel forming solution 0.25 %, 0.5 % (Timoptic-Xe) $0 TRAVATAN Z OPHTHALMIC DROPS 0.004 % travoprost (benzalkonium) (Travoprost ophthalmic drops 0.004 % (Benzalkonium)) $0 Replacement Preparations Replacement Preparations calcitrate + vit d caplet 35-250 mg-unit * (Citracal-Vitamin D) (drops: 0.5%, 0.20%) QL (2.5 per 25 days) QL (2.5 per 25 days) QL (2.5 per 25 days) 85

calcitrate 200 mg (950 mg) tab 200 mg (950 mg) * calcium,000 + d3 caplet,000 mg(2,500 mg)-800 unit * calcium 500+d tablet chew 500 mg(,250mg) -400 unit * calcium 600 + vit d 400 caplet s/f, p/f, caplet 600 mg(,500mg) -400 unit * calcium 600 + vit d 400 softgl 600 mg(,500mg) -400 unit * calcium 600 + vit d tablet 600-25 mg-unit * calcium 600 + vitamin d sftgl rapid release, sftgl 600 mg(,500mg) -500 unit * calcium 600 mg tablet 600 mg (,500 mg) * calcium 600+d softgel 600 mg calcium- 200 unit * calcium 600-vit d3 200 tablet 600 mg(,500mg) -200 unit * calcium 600-vit d3 400 tablet 600 mg(,500mg) -400 unit * calcium carb,250 mg/5 ml sus 500 mg/5 ml (,250 mg/5 ml) * calcium carbonate 648 mg tab 260 mg calcium (648 mg) * calcium chloride intravenous solution 00 mg/ml (0 %) calcium chloride intravenous syringe 00 mg/ml (0 %) calcium citrate - vit d caplet caplet, coated 35-200 mg-unit * (Calcium Citrate) (Caltrate 600 Plus D3) (Calcium 600 + Vit D) (Caltrate 600 Plus D3) (Calcium Carbonate/Vitamin D3) (Caltrate 600 Plus D3) (Calcium Carbonate/Vitamin D3) (Calcium Carbonate) (Calcium Carbonate/Vitamin D3) (Caltrate 600 Plus D3) (Caltrate 600 Plus D3) (Calcium Carbonate) (Calcium Carbonate) (Calcium Chloride) $0 (Calcium Chloride) $0 (Citracal-Vitamin D) 86

calcium citrate-vit d3 caplet s/f, p/f 35-250 mg-unit * calcium gluconate 500 mg tab 45 mg (500 mg) * calcium gluconate intravenous solution 00 mg/ml (0%) calcium with vit d tablet 600-25 mg-unit * CALTRATE 600 + D SOFT CHEW TAB VANILLA CREME 600 MG (,500 MG)-800 UNIT * CALTRATE 600 PLUS D3 TABLET 600 MG(,500MG) -800 UNIT * citracal + d maximum caplet 35-250 mg-unit * citrus calcium + d tablet 35-250 mg-unit * cvs calcium + vitamin d3 sftgl absorbable 600 mg(,500mg) -500 unit * cvs calcium 500 + vit d 200 tb 500 mg(,250mg) -200 unit * cvs calcium 500 + vit d tablet oyster shell 500 mg(,250mg) -25 unit * cvs calcium 600-vit d3 800 tab p/f, s/f,gluten-free 600 mg(,500mg) - 800 unit * cvs magnesium 250 mg tablet 250 mg * (Citracal-Vitamin D) (Calcium Gluconate) (Calcium Gluconate) (Calcium Carbonate/Vitamin D2) (Citracal-Vitamin D) (Citracal-Vitamin D) (Calcium Carbonate/Vitamin D3) (Caltrate 600 Plus D3) (Caltrate 600 Plus D3) (Caltrate 600 Plus D3) $0 (Magnesium) cvs pediatric electrolyte soln * (Pedialyte) cvs pediatric electrolyte soln a/f, p/f * (Pedialyte) d0 %-0.45 % sodium chloride (Dextrose 0 % intravenous parenteral solution and 0.45 % NaCl) $0 87

d2.5 %-0.45 % sodium chloride intravenous parenteral solution d5 % and 0.9 % sodium chloride intravenous parenteral solution d5 %-0.45 % sodium chloride intravenous parenteral solution dextrose 0 % and 0.2 % nacl intravenous parenteral solution dextrose 5 %-lactated ringers intravenous parenteral solution dextrose 5%-0.2 % sod chloride intravenous parenteral solution dextrose 5%-0.3 % sod.chloride intravenous parenteral solution dextrose with sodium chloride intravenous parenteral solution 5-0.2 % dextrose-kcl-nacl intravenous solution 5-0.224-0.225 % effer-k oral tablet, effervescent 25 meq electrolyte-48 in d5w intravenous parenteral solution eql calcium 600 mg + d softgel 600 mg(,500mg) -00 unit * gnp calcium 500-vit d3 600 tab 500mg (,250mg) -600 unit * gnp calcium 600+d3+min chew tb p/f,gluten/f,yeast/f 600 mg calcium- 800 unit-40 mg * hm calcium 600+d plus tab chew gluten-free 600 mg calcium- 800 unit-40 mg * (Dextrose 2.5 % and 0.45 % NaCl) (Dextrose 5 % and 0.9 % NaCl) (Dextrose 5 %-0.45 % NaCl) (Dextrose 0 % and 0.2 % NaCl) (Dextrose 5%- Lactated Ringers) (Dextrose 5 %-0.2 % NaCl) (Dextrose 5 % and 0.3 % NaCl) (Dextrose 5 %-0.2 % NaCl) (Potassium Chloride/D5-0.2%NaCl) $0 $0 $0 $0 $0 $0 $0 $0 $0 (Klor-Con-Ef) $0 (Electrolyte-48 Solution/D5W) (Calcium Carbonate/Vitamin D3) (Caltrate 600 Plus D3) (Ca/D3/Mag Ox/Zinc/Cop/Mang /Bor) (Ca/D3/Mag Ox/Zinc/Cop/Mang /Bor) $0 88

hm calcium citrate-vit d cplt caplet, gluten-free 35-250 mg-unit * HYPERLYTE CR INTRAVENOUS SOLUTION 25-20-5-5-30-30 MEQ/20 ML IONOSOL-B IN D5W INTRAVENOUS PARENTERAL SOLUTION 5 % IONOSOL-MB IN D5W INTRAVENOUS PARENTERAL SOLUTION 5 % ISOLYTE M IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION ISOLYTE-H IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION 5 % ISOLYTE-P IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION 5 % ISOLYTE-S INTRAVENOUS PARENTERAL SOLUTION k-effervescent oral tablet, effervescent 25 meq KELP 50 MCG TABLET 50 MCG * KLOR-CON 0 ORAL TABLET EXTENDED RELEASE 0 MEQ klor-con m0 oral tablet,er particles/crystals 0 meq klor-con m5 oral tablet,er particles/crystals 5 meq klor-con m20 oral tablet,er particles/crystals 20 meq klor-con sprinkle oral capsule, extended release 0 meq, 8 meq (Citracal-Vitamin D) (Klor-Con-Ef) $0 (Potassium Chloride) (Potassium Chloride) (Potassium Chloride) (Potassium Chloride) $0 $0 $0 $0 $0 89

liquid calcium 600-vit d3 sfgl 600 mg(,500mg) -400 unit * liquid calcium 600-vit d3 sfgl softgel,p/f,gluten-f 600 mg(,500mg) -500 unit * liquid calcium with vitamin d softgel, s/f, p/f 600 mg calcium- 200 (Calcium Carbonate/Vitamin D3) (Calcium Carbonate/Vitamin D3) (Calcium Carbonate/Vitamin unit * D3) mag delay dr 64 mg tablet 64 mg * (Slow-Mag) mag64 dr 64 mg tablet 64 mg * (Slow-Mag) mag-g 500 mg tablet 27 mg (500 mg) * (Magonate) magnesium 250 mg tablet 250 mg * (Magnesium) (Magnesium magnesium 300 mg capsule 300 mg Oxide/Mag Aa * Chelate) magnesium chloride injection (Magnesium solution 200 mg/ml (20 %) Chloride) $0 magnesium gluc 500 mg tablet 27 mg (500 mg) * (Magonate) magnesium sulf in 0.45% nacl (Magnesium Sulf intravenous solution 20 gram/500 In 0.45% NaCl) ml (40 mg/ml) $0 magnesium sulfate in d5w (Magnesium intravenous piggyback gram/00 Sulfate/D5W) ml, 4 gram/00 ml $0 magnesium sulfate in water intravenous parenteral solution 20 (Magnesium gram/500 ml (4 %), 40 gram/,000 Sulfate in Water) $0 ml (4 %) magnesium sulfate in water intravenous piggyback 2 gram/50 ml (Magnesium (4 %), 4 gram/00 ml (4 %), 4 Sulfate in Water) $0 gram/50 ml (8 %) magnesium sulfate injection solution (Magnesium 4 meq/ml (50 %) Sulfate) $0 90

magnesium sulfate injection syringe (Magnesium 4 meq/ml Sulfate) $0 natural calcium 500 mg tablet 500 (Calcium mg calcium (,250 mg) * Carbonate) NORMOSOL-M IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION NORMOSOL-R PH 7.4 INTRAVENOUS PARENTERAL SOLUTION nu-mag 7.5 mg tablet 7.5 mg * (Slow-Mag) NUTRILYTE II INTRAVENOUS SOLUTION 35-20-5 MEQ/20 ML NUTRILYTE INTRAVENOUS SOLUTION 25-40.6-5 MEQ/20 ML oysco 500-vit d3 200 tablet 500 (Caltrate 600 Plus mg(,250mg) -200 unit * D3) oysco d tablet 250-25 mg-unit * (Caltrate 600 Plus D3) oysco-500 tablet 500 mg calcium (Calcium (,250 mg) * Carbonate) oyster shell 250 mg + vit d tb 250- (Caltrate 600 Plus 25 mg-unit * D3) oyster shell 500-vit d3 200 tb 500 (Caltrate 600 Plus mg(,250mg) -200 unit * D3) oyster shell calcium 500 mg tb (Calcium 500mg elemental ca 500 mg calcium Carbonate) (,250 mg) * oyster shell calcium tablet 500 (Caltrate 600 Plus mg(,250mg) -400 unit * D3) oyster shell calcium-vit d tab p/f,s/f,gluten-free 500 mg(,250mg) -400 unit * oystercal-d 500 mg-400 unit tb 500 mg(,250mg) -400 unit * (Caltrate 600 Plus D3) (Caltrate 600 Plus D3) pediatric electrolyte solution * (Pedialyte) 9

PHOS-NAK PACKET 280-60-250 MG * phospha 250 neutral oral tablet 250 mg PLASMA-LYTE 48 INTRAVENOUS PARENTERAL SOLUTION PLASMA-LYTE A INTRAVENOUS PARENTERAL SOLUTION PLASMA-LYTE-56 IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION 5 % potassium acetate intravenous solution 2 meq/ml, 4 meq/ml potassium bicarb and chloride oral tablet, effervescent 25 meq potassium bicarb-citric acid oral tablet, effervescent 25 meq potassium chlorid-d5-0.45%nacl intravenous parenteral solution 0 meq/l, 20 meq/l, 30 meq/l, 40 meq/l potassium chloride in 0.9%nacl intravenous parenteral solution 20 meq/l, 40 meq/l potassium chloride in 5 % dex intravenous parenteral solution 20 meq/l, 30 meq/l, 40 meq/l potassium chloride in lr-d5 intravenous parenteral solution 20 meq/l potassium chloride intravenous piggyback 0 meq/00 ml, 20 meq/00 ml, 30 meq/00 ml, 40 meq/00 ml potassium chloride intravenous solution 2 meq/ml (K-Phos Neutral) $0 (Potassium Acetate) (Pot Chloride/Pot Bicarb/Cit Ac) $0 $0 (Klor-Con-Ef) $0 (Potassium Chloride/D5-0.45nacl) (Potassium Chloride In 0.9%NaCl) (Potassium Chloride In D5w) (Potassium Chloride In Lr-D5) (Potassium Chloride) (Potassium Chloride) $0 $0 $0 $0 $0 $0 92

potassium chloride oral capsule, extended release 0 meq, 8 meq potassium chloride oral liquid 20 meq/5 ml, 40 meq/5 ml potassium chloride oral packet 20 meq potassium chloride oral tablet extended release 8 meq potassium chloride oral tablet,er particles/crystals 0 meq potassium chloride oral tablet,er particles/crystals 20 meq potassium chloride-0.45 % nacl intravenous parenteral solution 20 meq/l potassium chloride-d5-0.2%nacl intravenous parenteral solution 0 meq/l, 20 meq/l, 30 meq/l, 40 meq/l potassium chloride-d5-0.3%nacl intravenous parenteral solution 20 meq/l potassium chloride-d5-0.9%nacl intravenous parenteral solution 20 meq/l, 40 meq/l potassium citrate oral tablet extended release 0 meq (,080 mg), 5 meq, 5 meq (540 mg) potassium citrate-citric acid oral packet 3,300-,002 mg potassium cl 0 meq/50 ml sol 0 meq/50 ml potassium cl 20 meq/50 ml sol 20 meq/50 ml potassium cl er 0 meq tablet 0 meq (Potassium Chloride) (Potassium Chloride) $0 $0 (Klor-Con) $0 (Klor-Con 0) $0 (Klor-Con 0) $0 (Potassium Chloride) (Potassium Chloride-0.45% NaCl) (Potassium Chloride/D5-0.2%NaCl) (Potassium Chloride/D5-0.3%NaCl) (Potassium Chloride/D5-0.9%NaCl) $0 $0 $0 $0 $0 (Urocit-K) $0 (Potassium Citrate/Citric Acid) (Potassium Chloride) (Potassium Chloride) (Potassium Chloride) $0 $0 $0 $0 93

potassium cl er 0 meq tablet f/c 0 meq (Klor-Con 0) $0 potassium cl er 20 meq tablet 20 (Potassium meq Chloride) $0 (Potassium potassium phosphate m-/d-basic Phos,M-Basic-Dintravenous solution 3 mmol/ml Basic) $0 (Ca/D3/Mag ra cal 600-vit d3-min chew tab 600 Ox/Zinc/Cop/Mang mg calcium- 400 unit-40 mg * /Bor) ra hi-cal plus vitamin d tab 500 (Caltrate 600 Plus mg(,250mg) -200 unit * D3) (Calcium ra oyster shell-vitamin d tab s/f, p/f Carbonate/Vitamin 250 (625)-25 mg-unit * D2) ra pediatric electrolyte soln a/f * (Pedialyte) ra pediatric freezer pops * (Pedialyte) ringers intravenous parenteral solution (Ringers Solution) $0 sm calcium 600-vit d3 800 tab 600 (Caltrate 600 Plus mg(,500mg) -800 unit * D3) sm pediatric electrolyte soln * (Pedialyte) sodium acetate intravenous solution 2 meq/ml, 4 meq/ml (Sodium Acetate) $0 sodium bicarbonate intravenous (Sodium solution meq/ml (8.4 %) Bicarbonate) $0 sodium bicarbonate intravenous syringe 0 meq/0 ml (8.4 %), 4.2 % (Sodium (0.5 meq/ml), 7.5 % (0.9 meq/ml), Bicarbonate) $0 8.4 % ( meq/ml) sodium chloride 0.45 % intravenous (Sodium Chloride parenteral solution 0.45 % 0.45 %) $0 sodium chloride 0.9 % intravenous (0.9 % Sodium parenteral solution 0.9 % Chloride) $0 sodium chloride 3 % intravenous (Sodium Chloride parenteral solution 3 % 3 %) $0 94

sodium chloride 5 % intravenous parenteral solution 5 % sodium chloride intravenous parenteral solution 2.5 meq/ml, 4 meq/ml sodium lactate intravenous parenteral solution 67 meq/l sodium lactate intravenous solution 5 meq/ml sodium phosphate intravenous solution 3 mmol/ml TPN ELECTROLYTES II IV SOLN 25'S,20ML/50ML FTV 8-8-5-4.5-35 MEQ/20 ML TPN ELECTROLYTES INTRAVENOUS SOLUTION 35-20-5 MEQ/20 ML virt-phos 250 neutral oral tablet 250 mg v-r calcium 400 + d 33 caplet 400-33.3 mg-unit * Respiratory Tract Agents Anti-Inflammatories, Inhaled Corticosteroids ADVAIR DISKUS INHALATION BLISTER WITH DEVICE 00-50 MCG/DOSE, 250-50 MCG/DOSE, 500-50 MCG/DOSE ADVAIR HFA INHALATION HFA AEROSOL INHALER 5-2 MCG/ACTUATION, 230-2 MCG/ACTUATION, 45-2 MCG/ACTUATION BREO ELLIPTA INHALATION BLISTER WITH DEVICE 00-25 MCG/DOSE, 200-25 MCG/DOSE (Sodium Chloride 5 %) $0 (Sodium Chloride) $0 (Sodium Lactate) $0 (Sodium Lactate) $0 (Sodium Phos,M- Basic-D-Basic) $0 (K-Phos Neutral) $0 (Caltrate 600 Plus D3) QL (60 per 30 days) QL (2 per 28 days) QL (60 per 30 days) 95

DULERA INHALATION HFA AEROSOL INHALER 00-5 MCG/ACTUATION, 200-5 MCG/ACTUATION FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 00 MCG/ACTUATION, 50 MCG/ACTUATION FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 250 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 0 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 220 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 44 MCG/ACTUATION QVAR INHALATION AEROSOL 40 MCG/ACTUATION, 80 MCG/ACTUATION Antileukotrienes montelukast oral granules in packet 4 mg (Singulair) $0 montelukast oral tablet 0 mg (Singulair) $0 montelukast oral tablet,chewable 4 mg, 5 mg (Singulair) $0 zafirlukast oral tablet 0 mg, 20 mg (Accolate) $0 Bronchodilators albuterol sulfate inhalation solution for nebulization 0.63 mg/3 ml,.25 mg/3 ml, 2.5 mg /3 ml (0.083 %), 5 (Albuterol Sulfate) $0 mg/ml albuterol sulfate oral syrup 2 mg/5 ml (Albuterol Sulfate) $0 QL (3 per 28 days) QL (60 per 30 days) QL (20 per 30 days) QL (2 per 28 days) QL (24 per 28 days) QL (2.2 per 28 days) QL (7.4 per 25 days) 96

albuterol sulfate oral tablet 2 mg, 4 mg albuterol sulfate oral tablet extended release 2 hr 4 mg, 8 mg ATROVENT HFA INHALATION HFA AEROSOL INHALER 7 MCG/ACTUATION COMBIVENT RESPIMAT INHALATION MIST 20-00 MCG/ACTUATION ipratropium bromide inhalation solution 0.02 % ipratropium-albuterol inhalation solution for nebulization 0.5 mg-3 mg(2.5 mg base)/3 ml metaproterenol oral syrup 0 mg/5 ml metaproterenol oral tablet 0 mg, 20 mg PROAIR HFA INHALATION HFA AEROSOL INHALER 90 MCG/ACTUATION PROAIR RESPICLICK INHALATION AEROSOL POWDR BREATH ACTIVATED 90 MCG/ACTUATION SEREVENT DISKUS INHALATION BLISTER WITH DEVICE 50 MCG/DOSE SPIRIVA RESPIMAT INHALATION MIST.25 MCG/ACTUATION, 2.5 MCG/ACTUATION SPIRIVA WITH HANDIHALER INHALATION CAPSULE, W/INHALATION DEVICE 8 MCG (Albuterol Sulfate) $0 (Vospire ER) $0 (Ipratropium Bromide) (Ipratropium/Albut erol Sulfate) (Metaproterenol Sulfate) (Metaproterenol Sulfate) $0 $0 $0 $0 QL (25.8 per 28 days) QL (8 per 30 days) 97

STRIVERDI RESPIMAT INHALATION MIST 2.5 MCG/ACTUATION terbutaline oral tablet 2.5 mg, 5 mg terbutaline subcutaneous solution mg/ml theochron oral tablet extended release 2 hr 00 mg, 200 mg, 300 mg theophylline in dextrose 5 % intravenous parenteral solution 200 mg/00 ml, 200 mg/50 ml, 400 mg/250 ml, 400 mg/500 ml, 800 mg/250 ml theophylline oral solution 80 mg/5 ml theophylline oral tablet extended release 2 hr 00 mg, 200 mg, 300 mg, 450 mg theophylline oral tablet extended release 24 hr 400 mg, 600 mg TUDORZA PRESSAIR INHALATION AEROSOL POWDR BREATH ACTIVATED 400 MCG/ACTUATION, 400 MCG/ACTUATION (30 ACTUAT) VENTOLIN HFA INHALATION HFA AEROSOL INHALER 90 MCG/ACTUATION Respiratory Tract Agents, Other acetylcysteine intravenous solution 200 mg/ml (20 %) acetylcysteine solution 00 mg/ml (0 %), 200 mg/ml (20 %) (Terbutaline Sulfate) (Terbutaline Sulfate) (Theophylline Anhydrous) (Theophylline/D5 W) (Theophylline Anhydrous) (Theophylline Anhydrous) (Theophylline Anhydrous) $0 $0 $0 $0 $0 $0 $0 (Acetadote) $0 (Acetadote) $0 QL (2 per 28 days) 98

CINQAIR INTRAVENOUS SOLUTION 0 MG/ML cromolyn inhalation solution for nebulization 20 mg/2 ml cromolyn sodium nasal spray 5.2 mg/spray (4 %) * DALIRESP ORAL TABLET 500 MCG ESBRIET ORAL CAPSULE 267 MG KALYDECO ORAL GRANULES IN PACKET 50 MG, 75 MG KALYDECO ORAL TABLET 50 MG NUCALA SUBCUTANEOUS RECON SOLN 00 MG OFEV ORAL CAPSULE 00 MG, 50 MG ORKAMBI ORAL TABLET 200-25 MG PROLASTIN-C INTRAVENOUS RECON SOLN,000 MG sodium chloride 0.9% inhal vl u-d, suv, p/f (rx) 0.9 % * XOLAIR SUBCUTANEOUS RECON SOLN 50 MG (Cromolyn Sodium) $0 (Nasalcrom) (Pulmosal) 3 $0 Skeletal Muscle Relaxants Skeletal Muscle Relaxants baclofen oral tablet 0 mg, 20 mg (Baclofen) $0 carisoprodol oral tablet 250 mg, 350 mg chlorzoxazone oral tablet 500 mg cyclobenzaprine oral tablet 0 mg, 5 mg (Soma) $0 (Parafon Forte DSC) $0 (Fexmid) $0 PA QL (30 per 30 days) PA; QL (270 per 30 days) PA; QL (60 per 30 days) PA; QL (60 per 30 days) PA; LA; QL ( per 28 days) PA PA; QL (20 per 30 days) PA PA-HRM; QL (20 per 30 days); AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) 99

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

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

ADEMPAS ORAL TABLET 0.5 MG, MG,.5 MG, 2 MG, 2.5 MG epoprostenol (glycine) intravenous recon soln 0.5 mg,.5 mg LETAIRIS ORAL TABLET 0 MG, 5 MG (Flolan) $0 OPSUMIT ORAL TABLET 0 MG ORENITRAM ORAL TABLET EXTENDED RELEASE 0.25 MG, 0.25 MG, MG, 2.5 MG REMODULIN INJECTION SOLUTION MG/ML, 0 MG/ML, 2.5 MG/ML, 5 MG/ML sildenafil intravenous solution 0 mg/2.5 ml (Revatio) $0 sildenafil oral tablet 20 mg (Revatio) $0 TRACLEER ORAL TABLET 25 MG, 62.5 MG TYVASO INHALATION SOLUTION FOR NEBULIZATION.74 MG/2.9 ML (0.6 MG/ML) TYVASO REFILL KIT INHALATION SOLUTION FOR NEBULIZATION.74 MG/2.9 ML (0.6 MG/ML) TYVASO STARTER KIT INHALATION SOLUTION FOR NEBULIZATION.74 MG/2.9 ML UPTRAVI ORAL TABLET,000 MCG,,200 MCG,,400 MCG,,600 MCG, 400 MCG, 600 MCG, 800 MCG UPTRAVI ORAL TABLET 200 MCG PA; QL (90 per 30 days) PA; QL (30 per 30 days) PA; QL (30 per 30 days) PA PA; QL (37.5 per day) PA; QL (90 per 30 days) PA; LA; QL (60 per 30 days) PA; QL (60 per 30 days) PA; QL (240 per 30 days) 202

UPTRAVI ORAL TABLETS,DOSE PACK 200 MCG (40)- 800 MCG (60) Vitamins And Minerals Vitamins And Minerals a thru z advanced formula tab gluten-free 8-400 mg-mcg * a thru z advanced formula tab new formula * a thru z select 50+ formula tb advanced formula 0.4-300-250 mgmcg-mcg * a thru z select men 50+ tablet 300-600-300 mcg * a thru z select multivit tab 500-300- 250 mcg * a thru z select tablet adults 50+,iron-free 0.4-300-250 mg-mcgmcg * a thru z select tablet new formulation * a thru z select women's tablet * abc plus tablet 0.4-300-250 mgmcg-mcg * (Multivitamin/Iron/ Folic Acid) (Multivitamin with Minerals/Lut) (Biocel) (Biocel) (Biocel) (Biocel) (Multivitamin with Minerals/Lut) (Mv,Fe,Min/Lutein ) (Biocel) adult multi gummies 200 mcg * (One-A-Day Vitacraves) adult one daily gummies 200 mcg * (One-A-Day Vitacraves) adults' 50+ daily formula tab 0.4-300-250 mg-mcg-mcg * (Biocel) adults 50+ multivitamin tablet 0.4-300-250 mg-mcg-mcg * (Biocel) adults' daily formula tablet 8-400 (Multivitamin/Iron/ mg-mcg * Folic Acid) animal chews tablet * (Multivitamin) PA; QL (200 per 365 days) 203

antioxidant softgel softgel * (Beta-Carotene(A)- Vits C,E/Mins) apatate forte liquid * (Multivitamin with Minerals) b complete tablet * (Vitamin B Complex) b complex capsule * (Vitamin B Complex) b complex formula # tablet * (Vitamin B Complex) b complex tablet * (Vitamin B Complex) b-2 500 mcg tablet 500 mcg * (B-2) b-2 dots 500 mcg tablet 500 mcg * (B-2) balance b-00 tablet * (Vitamin B Complex) balance b-50 tablet * (Vitamin B Complex) balance b-50 tablet inner,p/f,gluten/f (Vitamin B * Complex) balanced b-00 tablet * (Vitamin B Complex) balanced b-00 tablet 00 mg * (Vit B Complex 00 No.3/Herbal) balanced b-50 tablet * (Vitamin B Complex) balanced b-50 tablet * (Vitamin B Complex) balanced b-complex caplet p/f,nolactose 400 mcg * (Dialyvite 800) b-complex plus vitamin c cplt caplet * (Vita-Bee with C) b-complex with b2 tablet * (Vitamin B Complex) b-complex with c tablet * (Vita-Bee with C) 204

b-complex with vit c caplet s/f,p/f,gluten-free 400 mcg * (Dialyvite 800) biosupp liquid * (Multivitamin with Minerals) biotin 300 mcg tablet 300 mcg * (Biotin) biovol syrup * (Multivitamin with Minerals) c complex 500 mg tablet sa 500 mg * (Ascorbic Acid) calcidol drops 8,000 unit/ml * (Drisdol) centamin liquid 9 mg iron/5 ml * (Multivit- Minerals/Ferrous Gluc) central-vite seniors tablet * (Multivit with Iron- Minerals) centram-care multivit-min liq 9 mg iron/5 ml * centravites 50 plus tablet * centrum complete multivit tab 8-400 mg-mcg * centrum multivit-mineral liq 9 mg iron/5 ml * centrum silver tablet adults 50 + 0.4-300-250 mg-mcg-mcg * century adults 50+ tablet gluten free 0.4-300-250 mg-mcg-mcg * century mature tablet * century ultimate women's tab 8-400 mg-mcg * cerovite advanced form tab 8-400 mg-mcg * (Multivit- Minerals/Ferrous Gluc) (Multivit with Iron- Minerals) (Multivitamin/Iron/ Folic Acid) (Multivit- Minerals/Ferrous Gluc) (Biocel) (Biocel) (Multivitamin with Minerals/Lut) (Multivitamin/Iron/ Folic Acid) (Multivitamin/Iron/ Folic Acid) 205

cerovite liquid 9 mg iron/5 ml * certavite sr-antioxidant tab 0.4-300- 250 mg-mcg-mcg * certavite-antioxidant liquid 9 mg iron/5 ml * certavite-antioxidant tablet 8-400 mg-mcg * child chew + iron tab chew * (Multivit- Minerals/Ferrous Gluc) (Biocel) (Multivit- Minerals/Ferrous Gluc) (Multivitamin/Iron/ Folic Acid) (Multivitamin with Iron) child chew vitamin tablet * (Multivitamin) child ferrous sulfate 5 mg/ml 5 mg iron (75 mg)/ml * (Fer-In-Sol) children's chewable vitamin * (Multivitamin) childrens multivit tab chew * (Multivitamin) complete multi 50+ tablet 500-300- 250 mcg * (Biocel) complete multivitamin tab * (Multivit,Th Iron,Other Min) complete senior tablet * (Multivit with Iron- Minerals) cvs bal b-00 tablet * (Vitamin B Complex) cvs bal b-50 tablet * (Vitamin B Complex) cvs balanced b-50 tablet * (Vitamin B Complex) cvs b-complex-vit c caplet caplet * (Vita-Bee with C) cvs child vit-mineral tab * (Multivit with Iron- Minerals) cvs children's chewable vit * (Multivitamin) cvs childs vit with c tab chew * (Multivitamin) cvs child's vitamin-iron tb * (Multivitamin with Iron) 206

cvs daily gummies complete adult vit (One-A-Day 200 mcg * Vitacraves) cvs daily multiple tablet * (Multivitamin) cvs daily multiple tablet for women * (Multivitamin) cvs daily teen multi-vitamin 8-400 (Multivitamin/Iron/ mg-mcg * Folic Acid) cvs gummy swirls chewable * (Multivitamin) cvs iron 27 mg tablet 240 mg (27 mg (Fergon) iron) * cvs men's daily gummies p/f, glutenfree 200 mcg * Vitacraves) (One-A-Day cvs men's multi-vit tablet * (Multivitamin) cvs prenatal vitamin tablet * (Prenatal Vit Calc,Iron,Folic) cvs spectravite adult 50+ tabs 0.4-300-250 mg-mcg-mcg * (Biocel) cvs spectravite advanced tab 8-400 (Multivitamin/Iron/ mg-mcg * Folic Acid) cvs spectravite liquid * (Pediavit) cvs spectravite senior * (Multivitamin with Minerals/Lut) cvs spectravite senior tab * (Multivit with Iron- Minerals) cvs spectravite senior tablet 500-300-250 mcg * (Biocel) cvs spectravite tablet chew * (Multivitamin with Iron) cvs spectravite ultra women tb 8- (Multivitamin/Iron/ 400 mg-mcg * Folic Acid) cvs super b complx & c cplt caplet, p/f * (Vita-Bee with C) (Vits cvs vision formula tablet,000 unit- A,C,E/Lutein/Mine 200 mg-60 unit-2 mg * rals) 207

(Vitamin B cvs vitamin b-00 complx tb * Complex) cvs vitamin c,000 mg tb chw,000 (Ascorbic Acid) mg * cvs vitamin d3,000 unit sfgl softgel (D3-50),000 unit * cvs women's daily gummies p/f, (One-A-Day gluten-free 200 mcg * Vitacraves) cyanocobalamin,000 mcg/ml 25's (Cyanocobalamin 3 $0,000 mcg/ml * (Vitamin B-2)) d3 dots 2,000 unit tablet p/f 2,000 (Vitamin D3) unit * (Multivitamin with daily multi vitamin-iron tab * Iron) daily multiple tablet 8-400 mg-mcg (Multivitamin/Iron/ * Folic Acid) daily multiple vitamin tab sugar (Multivitamin) coated * daily value multivitamin tab s/f * (Multivitamin) (Multivitamin with daily vitamin + iron tablet * Iron) daily vitamin formula tablet * (Multivitamin) (Multivitamin with daily vitamin formula tablet * Minerals) daily vitamin tablet p/f,na/f * (Multivitamin) daily vite tablet s/f, p/f * (Multivitamin) daily vite tablet s/f,p/f * (Multivitamin) (Multivitamin with daily vite with iron tablet * Iron) dino-life extra c tab chew * (Multivitamin) (Multivit with Irondino-life iron-zinc tb chew * Minerals) daily multivitamin-iron tablet 8- daily vit formula + iron tab 8-400 (Multivitamin/Iron/ (Multivitamin/Iron/ 400 mg-mcg * mg-mcg * Folic Acid) Folic Acid) 208

dino-life tablet chewable * (Multivitamin) eldertonic elixir 0.5-0.6-7-0.7 mg * (B,B2,B3,B6,B2 /Dexpan/Zn/Mang) ellis tonic * (Multivitamin with Minerals) (Pedi Mv eq child complete chew tablet 8 mg No.58/Ferrous iron * Fumarate) eq complete multivitamin tab 0.4-300-250 mg-mcg-mcg * (Biocel) eq complete multivitamin tab glutenfree 8-400 mg-mcg * Folic Acid) (Multivitamin/Iron/ eql central-vite select tablet * (Multivitamin with Minerals/Lut) eql century mature tablet 500-300- 250 mcg * (Biocel) eql chewable multi vitamin tab * (Multivitamin) eql child's multivit tab chew with vitamin c * (Multivitamin) eql childs multivit-mineral tb * (Multivit with Iron- Minerals) (Vits eql eye health plus lutein tab,000 A,C,E/Lutein/Mine unit-200 mg-60 unit-2 mg * rals) eql one daily 50 plus tablet * (Multivitamin with Minerals) eql one daily essential tablet * (Multivitamin) eql one daily maximum tablet 8-0.4 mg * eql one daily men's tablet * ergocalciferol 8,000 units/ml 8,000 unit/ml * essentia tablet 8-400 mg-mcg * (Tab A Vite) (Multivitamin with Minerals) (Drisdol) (Multivitamin/Iron/ Folic Acid) 209

essential balance tablet * essential daily tablet w/iron & calcium 8-0.4 mg * ferocon capsule 0-0.5 mg * ferretts 325 mg tablet 325 mg (06 mg iron) * ferrex 50 capsule outer, u-d 50 mg iron * ferrex 50 plus capsule 50-50-50 mg * (Mv,Fe,Min/Lutein ) (Tab A Vite) (Iron Fum/Vit C/B2-If/Fa) 3 $0 (Ferrous Fumarate) (Pic 200) (Iron Aspgly,Ps/C/Succi nic Acid) ferrocite tablet 324 mg (06 mg iron) * (Ferrous Fumarate) ferrous fumarate 324 mg tab 324 mg (Ferrous Fumarate) (06 mg iron) * ferrous gluconate 240 mg tab 240mg=27mg elemental 240 mg (27 (Fergon) mg iron) * ferrous gluconate 324 mg tab 324 mg (36 mg iron), 324 mg (37.5 mg iron), 324 mg (38 mg iron) * (Fergon) ferrous sulf 220 mg/5 ml elix 220 mg (Ferrous Sulfate) (44 mg iron)/5 ml * ferrous sulf 300 mg/5 ml liq 300 mg (60 mg iron)/5 ml * (Ferrous Sulfate) ferrous sulf ec 324 mg tablet 324 mg (Ferrous Sulfate) (65 mg iron) * ferrous sulfate 325 mg tablet red 325 mg (65 mg iron) * (Slow Fe) flintstones complete tablet * (Multivit with Iron- Minerals) flintstones extra c tab chew * (Multivitamin) flintstones tablet chewable * (Multivitamin) 20

flintstones with iron tab chew 8 mg iron * (Pedi Mv No.79/Ferrous Fumarate) folic acid mg tablet (rx) mg * (Folic Acid) 3 $0 folic acid,000 mcg tablet p/f,s/f (otc) mg * (Folic Acid) FOLIC ACID 20 MG CAPSULE 20 MG * folic acid 400 mcg tablet s/f,p/f,lactose-free 400 mcg * (Folic Acid) fosfree tablet 75.5-4.5 mg * (Calcium/Multivita min with Iron) geravim liquid * (Pediavit) geriaton liquid * (Pediavit) gnp century mature tablet gluten- (Biocel) free 0.4-300-250 mg-mcg-mcg * gnp century tablet gluten-free 8- (Multivitamin/Iron/ 400 mg-mcg * Folic Acid) gnp one daily essential tablet * (Multivitamin) gs prenatal vitamins tablet 28-800 (Pnv33/Ferrous mg-mcg * Fumarate/Fa) gummi bear multivit tab chew (Multivitamin) multivit & minerals * hair vitamins * healthy eyes caplet caplet,000 unit-200 mg-60 unit-2 mg * hemocyte tablet u-u,blister pk 324 mg (06 mg iron) * hi-b complex tablet * hm complete 50+ tablet 0.4-300-250 mg-mcg-mcg * hm one daily with iron tablet glutenfree 8-400 mg-mcg * (Multivitamin with Iron) (Vits A,C,E/Lutein/Mine rals) (Ferrous Fumarate) (Vitamin B Complex) (Biocel) (Multivitamin/Iron/ Folic Acid) 2

hm super vitamin b complex glutenfree 400 mcg * (Dialyvite 800) honey bears chew tab * (Multivitamin) honey bears-iron-zinc tab chew * (Multivit with Iron- Minerals) icaps plus tablet lactose free * (Multivitamin with Minerals) iferex 50 capsule 50 mg iron * (Pic 200) iron 27 mg tablet 236 mg (27 mg iron) * (Fergon) iron 28 mg tablet 256 mg (28 mg iron) * (Fergon) kenwood therapeutic liquid * (Multivitamin,Ther apeutic) life-pack women's p/f,s/f 0.8 mg * (Multivit with Iron- Minerals) LIQUI-E LIQUID 400 UNIT/5 ML * little animals child tb chw * (Multivitamin) little animals-iron tab chew * (Multivitamin with Iron) lysiplex plus liquid * (Pediavit) MACUVITE EYE CARE TABLET 7,60 UNIT-3 MG-00 UNIT * MACUVITE TABLET 5,000-60-30 UNIT-MG-UNIT * mega multivitamin-mineral tab * (Multivitamin with Minerals) mega multivit-chelated min tab * (Multivitamin with Minerals) MEPHYTON 5 MG TABLET 5 MG * 3 $0 milltrium senior multivit tab * (Multivitamin with multi complete-iron tablet 8-400 mg-mcg * Minerals/Lut) (Multivitamin/Iron/ Folic Acid) 22

multi-day plus iron tablet 8-400 (Multivitamin/Iron/ mg-mcg * Folic Acid) multi-delyn with iron liquid 0 mg (Multivitamin/Ferr iron/5 ml * ous Gluconate) multiple vitamin with iron tab * (Multivitamin with Iron) multiple vitamin w-minerals tb * (Multivitamin with Minerals) multiple vitamins tablet one daily * (Multivitamin) multivitamin child tab chew * (Multivitamin) multi-vitamin daily tablet * (Multivitamin) multivitamin-mineral liquid 9 mg iron/5 ml * (Multivit- Minerals/Ferrous Gluc) multivit-fluor 0.5 mg tab chew (Pedi M.Vit No.7 chewable, d/f, s/f 0.5 mg with Fluoride) $0 multivit-iron child tab chew (Multivitamin with children's * Iron) multivit-mineral hp cap * (Multivitamin,Ther and Minerals) multivit-minerals tablet s/f,p/f * (Multivitamin with Minerals) my favorite multiple liquid * (Multivitamin) myvitalife soft-gel capsule * (Multivitamin with Minerals) NASCOBAL 500 MCG NASAL SPRAY 500 MCG/SPRAY * 3 $0 nephplex rx tablet -60-300-2.5 mg-mg-mcg-mg * nephron fa tablet 66.6-75- mg * nephro-vite rx tablet -60-300 mgmg-mcg * (Vit B Cmplx No3/Fa/C/Biot/Zin c) (Iron Fum/Doss/Fa/Vit Bcomp,C) (Vit B Cmplx 3/Fa/Vit C/Biotin) 3 $0 3 $0 3 $0 23

niacinamide er 500 mg tablet 500 mg * (Niacinamide) nu-iron 50 capsule 50 mg iron * (Pic 200) ocutabs tablet s/f, w/lutein * (Beta-Carotene(A)- Vits C,E/Mins) oncovite tablet * (Multivitamin,Ther apeutic) one daily complete tablet * (Multivitamin with Minerals) one daily essential tablet * (Multivitamin) one daily multivitamin tab * (Multivitamin) one daily multivitamin tablet * (Multivitamin with Iron) one daily multivitamin tablet 400 mcg * (Quintabs) one daily multivitamin-iron tb 8- (Multivitamin/Iron/ 400 mg-mcg * Folic Acid) one daily plus iron tablet 8-400 (Multivitamin/Iron/ mg-mcg * Folic Acid) one daily tablet * (Multivitamin) one daily tablet * (Multivitamin with Iron) one daily tablet men's formula * (Multivitamin) one daily with minerals tablet * (Multivitamin with Minerals) one-a-day essential tablet * (Multivitamin) one-a-day max formula tab * (Multivitamin with Minerals) one-a-day teen advantage tab 8- (Multivitamin/Iron/ 400 mg-mcg * Folic Acid) one-a-day teen advantage tab 9 mg (Multivits,Ca,Mine iron-400 mcg * rals/iron/fa) pharmacist multi-vite tab * (Multivitamin) pnv prenatal plus multivit tab s/f, (Pnv with gluten-free 27 mg iron- mg Ca,No.72/Iron/Fa) (All Rx Prenatal Vitamins Covered) 24

poly-iron 50 mg capsule 50 mg iron * poly-vita drops,500-35-400 unitmg-unit/ml * poly-vita with iron drops,500 unit- 400 unit-0 mg/ml * poly-vitamin drops,500-35-400 unit-mg-unit/ml * (Pic 200) (Pediatric Multivitamin No.20) (Ped Multivit #46/Iron Sulfate) (Pediatric Multivitamin No.20) poly-vitamin tab chew * (Multivitamin) polyvitamin w-iron drops,500 (Ped Multivit unit-400 unit-0 mg/ml * #46/Iron Sulfate) (Prenatal Vit prenatal tablet (otc) 27-0.8 mg * No.30/Iron/Fa) (Prenatal prenatal tablet 27 mg iron- 800 mcg Vit#96/Ferrous * Fum/Fa) prenatal tablet 28 mg iron- 800 mcg (Prenatal Vit/Iron * Fumarate/Fa) prenatal vitamins tablet phosphorus (Prenatal) free 28 mg iron- 800 mcg * (Multivitamin with pub multivitamin 50 plus tab * Minerals/Lut) (Vitamin B pv b-00 complex * Complex) (Vitamin B pv b-50 complex * Complex) pv kid's gummy bear tab chew (Multivitamin) chewable * prenatal vitamin plus low iron oral prenatal vitamin tablet 28 mg ironprosight tablet 5,000-60-30 unit-mgunit * (Pnv with (Prenatal Vit/Iron (A/C/E/Zinc/Sod tablet 27 mg iron- mg 800 mcg * Ca,No.72/Iron/Fa) Fumarate/Fa) Selenate/Copper) (All Rx Prenatal Vitamins Covered) 25

pv kid's vit + extra c chew tb * (Multivitamin) pv kid's vit + iron tab chew * (Multivitamin with Iron) pv kid's vit complete tab chew * (Multivitamin) pv kid's vitamins chew tab * (Multivitamin) pv kids vitamins+iron tab chew 5 (Ped Multivit mg iron * #7/Iron Fumarate) pv multivital platinum tablet * (Multivitamin with Minerals/Lut) pv multivital platinum tablet w/lutein & lycopene 500-300-250 mcg * (Biocel) pv prenatal formula tablet 28 mg (Prenatal Vit iron- 800 mcg * No.3/Iron/Fa) pv prenatal formula tablet 28 mg (Prenatal Vit/Iron iron- 800 mcg * Fumarate/Fa) pv stress 500 plus zinc tab * (Multivitamin,Stres s Formula/Zn) pyridoxine 00 mg/ml vial 25's 00 mg/ml * (Pyridoxine HCl) 3 $0 qc child complete vit chew tab 8 mg iron * (Pedi Mv No.67/Ferrous Fumarate) qc children's chewable tablet * (Multivitamin) qc maximum daily multivit tab 8- (Tab A Vite) 0.4 mg * qc multi-vite 50 & over tablet (Multivitamin with w/lycopene * Minerals/Lut) qc multi-vite tablet 8-400 mg-mcg (Multivitamin/Iron/ * Folic Acid) qc women's daily multivit tab 8-0.4 (Tab A Vite) mg * (Vitamin B ra balanced b-00 tablet 0.4 mg * Complex/Folic Acid) 26

ra b-complex tablet p/f * (Vitamin B Complex) ra b-complex tablet p/f * (Vitamin B Complex) ra central vite select tab p/f * (Multivitamin with Minerals/Lut) ra central-vite select tab p/f * (Multivit with Iron- Minerals) ra central-vite senior tablet 0.4-300- 250 mg-mcg-mcg * (Biocel) ra central-vite tablet 0.4-300-250 mg-mcg-mcg * (Biocel) ra central-vite tablet 8-400 mgmcg * Folic Acid) (Multivitamin/Iron/ ra one daily energy tablet * (Multivitamin with Minerals) ra one daily plus iron tablet * (Multivitamin with Iron) ra one daily tablet p/f * (Multivitamin) ra prenatal tablet 28 mg iron- 800 (Prenatal Vit/Iron mcg * Fumarate/Fa) ra therapeutic m multivit tab 8-0.4 mg * (Tab A Vite) ra vit b-2,000 mcg/ml liq,000 (Cyanocobalamin mcg/ml * (Vitamin B-2)) ra vitamin b-2,000 mcg tab timed-release,000 mcg * (B-2) ra vitamin c,000 mg tab sa w/bioflavonoids,000 mg * (Ascorbic Acid) ra vitamin c 500 mg tab chew p/f 500 mg * (Ascorbic Acid) ra vitamin c tr 500 mg caplet caplet,p/f,s/f 500 mg * (Ascorbic Acid) rena-vite rx tablet -60-300 mg-mgmcg * 3/Fa/Vit C/Biotin) (Vit B Cmplx 3 $0 27

scooby-doo one a day tablet * (Multivit with Iron- Minerals) senior tabs 0.4-300-250 mg-mcgmcg * (Biocel) sentry senior multivitamin tab sodium/f,yeast/f 500-300-250 mcg * (Biocel) sentry senior tablet 0.4-300-250 mgmcg-mcg * (Biocel) sentry tablet 8-400 mg-mcg * (Multivitamin/Iron/ Folic Acid) sm airshield effervescent tab 5,000- (Vit A,C,E/Dietary 000-30 unit-mg-unit * Supp No.2) sm animal shapes tab chew * (Multivitamin) sm animal shapes tab chew toddlers * (Multivitamin) sm animal shapes w-iron tab (Multivitamin with children's * Iron) (Vits sm antioxidant vitamins tablet,000 A,C,E/Lutein/Mine unit-200 mg-60 unit-2 mg * rals) sm b complex with vit c tablet gluten-free * (Vita-Bee with C) sm complete multi-vit-mineral (Multivitamin/Iron/ advanced formula 8-400 mg-mcg * Folic Acid) sm complete senior formula tab * (Multivit with Iron- Minerals) sm complete senior formula tab 0.4-300-250 mg-mcg-mcg * (Biocel) sm hair, skin and nails caplet caplet, (Multivitamin with gluten-free * Minerals) sm multivitamin w-iron tab * (Multivitamin with Iron) sm natural balanced b-00 tab 00 mg * (Vit B Complex 00 Cmb #2/Herbs) 28

sm opti-vitamin tablet,000 unit- 200 mg-60 unit-2 mg * sm prenatal vitamins tablet 28 mg iron- 800 mcg * sm super b complex-c caplet caplet * sm therapeutic m tablet 27-0.4 mg * sm vitamin b complex tablet glutenfree 0.4 mg * sm vitamin b-00 complex tab gluten-free 0.4 mg * sm vitamin d3 4,000 unit sftgl softgel, gluten-free 4,000 unit * sodium fluoride oral tablet mg fluoride (2.2 mg) stress b tablet * stress b with zinc tablet * stress formula tablet * stress formula with iron tab * stress formula with iron tab 500 mg- 400 mcg- 8 mg iron * stress formula with zinc tab * stress-c with iron tablet 500 mg-400 mcg- 8 mg iron * (Vits A,C,E/Lutein/Mine rals) (Prenatal) (Vita-Bee with C) (Multivit,Tx,Iron/C alcm/fa/mins) (Vitamin B Complex/Folic Acid) (Vitamin B Complex/Folic Acid) (D3-50) (Pedi M.Vit No.7 with Fluoride) (Vitamin B Complex) (Multivitamin,Stres s Formula/Zn) (Multivitamin,Stres s Formula) (Iron/Mv,Stress Form) (Vit B Comp/C/Fa/Iron/Vi t E) (Multivitamin,Stres s Formula/Zn) (Vit B Comp/C/Fa/Iron/Vi t E) $0 29

sunvite tablet 8 mg iron-400 mcg- 25 mcg * (Mv-Min/Iron Fum/Fa/K/Lyco/Lu tn) super b complex-c caplet caplet * (Vita-Bee with C) (Vitamin B super b maxi complex caplet 0.4 mg Complex/Folic * Acid) super b with vit c capsule * super b-50 complex capsule * super b-50 complex plus tab * (B Complex with Vitamin C) (Vitamin B Complex) (Vitamin B Complex) super b-complex folic-vit c tb p/f 400 mcg * (Dialyvite 800) super multiple vit-mineral tab * (Multivit with Iron- Minerals) super multivitamin tablet * (Multivitamin) super quints b-50 tablet 0.4 mg * (Vitamin B Complex/Folic Acid) super quints b-50 tablets * (Vitamin B Complex) super thera vite m tablet * (Multivitamin,Ther and Minerals) superior 35 vit-mineral tab sa * (Multivit with Iron- Minerals) superplex-t tablet * (Vita-Bee with C) support liquid * (Multivitamin with Minerals) support-500 softgel * (B Complex with Vitamin C) 3 $0 sv hair, skin and nails caplet mg (Mv,Ca,Min/Iron iron-66.7 mcg-,000 mcg * Gluc/Fa/Biotin) tab-a-vite tablet * (Multivitamin) 220

tab-a-vite with iron tablet * (Multivitamin with Iron) tab-a-vite-minerals tablet * (Multivitamin with Minerals) thera m plus tablet 9 mg iron-400 (Multivits,Ca,Mine mcg * rals/iron/fa) thera tablet * (Multivitamin,Ther apeutic) thera-d 2000 tablet 2,000 unit * (Vitamin D3) theradex m tablet 27-0.4 mg * (Multivit,Tx,Iron/C alcm/fa/mins) thera-m caplet caplet 27-0.4 mg * (Multivit,Tx,Iron/C alcm/fa/mins) thera-m tablet w/beta carotene 9 mg (Multivits,Ca,Mine iron-400 mcg * rals/iron/fa) therapeutic-m caplet p/f, s/f, caplet 9 (Multivits,Ca,Mine mg iron-400 mcg * rals/iron/fa) thera-tabs tablet * (Multivitamin,Ther apeutic) theratrum compl 50 plus tab * (Multivitamin with Minerals/Lut) theratrum complete 50 plus (Multivit with Ironp/f,caplet * Minerals) thiamine 200 mg/2 ml vial 25's,mdv,outer 00 mg/ml * (Thiamine HCl) 3 $0 thiamine 500 mg tablet 500 mg * (Thiamine HCl) total b with vit c caplet * (Vita-Bee with C) totalday multiple tablet sa * (Multivitamin with Minerals) (Vit A tri-vi-sol drops 750 unit-35 mg -400 Palmitate/Vit C/Vit unit/ml * D3) tri-vita drops,500-35-400 unit-mgunit/ml * (Pedi Multivit A,C,And D3 No.2) 22

tri-vitamin drops,500-35-400 unitmg-unit/ml * ultra b-00 complex tablet * v-c forte capsule mg * vic-forte capsule mg * vision plus lutein vitamin tab * vision vitamins * vision vitamins tablet w/lutein,p/f,000 unit-200 mg-60 unit-2 mg * (Pedi Multivit A,C,And D3 No.2) (Vitamin B Complex) (Multivitamin- Minerals No.7/Fa) (Multivitamin- Minerals No.7/Fa) (Multivitamin with Minerals/Lut) (Beta-Carotene(A)- Vits C,E/Mins) (Vits A,C,E/Lutein/Mine rals) 3 $0 3 $0 vit d2.25 mg (50,000 unit) 50,000 unit * (Drisdol) 3 $0 VITAFOL FE+ (WITH DOCUSATE) ORAL CAPSULE 90 MG IRON- MG -50 MG-200 MG vitalets tablet chewable child, (Multivitamin with orange,s/f * Iron) vitamin a 0,000 units capsule soluble 0,000 unit * (Vitamin A) vitamin a 25,000 units capsule softgel 25,000 unit * (Vitamin A) vitamin and minerals tablet * (Multivitamin,Ther and Minerals) (Vit B vitamin b complex tablet 500 mg- Comp/C/Fa/Iron/Vi 400 mcg- 8 mg iron * t E) vitamin b complex-vit c cap * (B Complex with Vitamin C) vitamin b complex-vit c tablet * (Vita-Bee with C) 222

vitamin b-2,000 mcg tablet,000 mcg * (B-2) vitamin b-2 00 mcg tablet 00 mcg * (B-2) vitamin b-2 250 mcg tablet 250 mcg * (B-2) vitamin b2 500 mcg tablet 500 mcg * (B-2) vitamin b-2 tr,000 mcg tab (Cyanocobalamin lactose free,000 mcg * (Vitamin B-2)) vitamin b2-folic acid tablet 500- (Cyanocobalamin/ 400 mcg * Folic Acid) vitamin b-6 250 mg tablet p/f 250 mg * (Pyridoxine HCl) vitamin b-6 50 mg tablet 50 mg * (Pyridoxine HCl) (Folic Acid/B vitamin b-complex & c caplet p/f,no Cmplx C/Rice lactose,cplt 400-500 mcg-mg * Bran) vitamin c,000 mg tablet,000 mg * (Ascorbic Acid) vitamin c,500 mg tablet sa na/f,s/f,starch/free,500 mg * (Ascorbic Acid) vitamin c 250 mg tablet 250 mg * (Ascorbic Acid) vitamin c 250 mg tablet chew 250 mg * (Ascorbic Acid) vitamin c 500 mg tablet chew 500 mg * (Ascorbic Acid) vitamin c 500 mg/5 ml liquid 500 mg/5 ml * (Ascorbic Acid) vitamin d,000 unit tablet,000 unit * (Vitamin D3) vitamin d3,000 unit tablet s/f,p/f,000 unit * (Vitamin D3) vitamin d3,000 units softgel softgel, p/f, s/f,000 unit * (D3-50) 223

vitamin d3 0,000 unit softgel softgel 0,000 unit * (D3-50) vitamin d3 2,000 unit tablet s/f,p/f 2,000 unit * (Vitamin D3) vitamin d3 400 unit tab chew orange, p/f 400 unit * (Vitamin D3) vitamin d3 400 unit tablet s/f,p/f 400 unit * (Vitamin D3) vitamin d3 400 unit/5 ml liq 400 (Cholecalciferol unit/5 ml * (Vitamin D3)) vitamin d3 5,000 unit capsule s/f, p/f 5,000 unit * (D3-50) vitamin d3 5,000 unit/ml drops a/f, p/f,gluten-free 5,000 unit/ml * (Just D) vitamin k 00 mcg tablet p/f, glutenfree 00 mcg * (Phytonadione) vitamins for hair tablet * (Multivitamin) vitrum 50+ senior tablet 500-300- 250 mcg * (Biocel) vitrum senior tablet f/f,p/f * (Multivitamin with Minerals/Lut) v-r natural b-00 tablet * (Vitamin B Complex) yelets tablet 8-400 mg-mcg * (Multivitamin/Iron/ Folic Acid) zoo chews gummie tablet * (Multivitamin) 224

INDEX 3 3 day vaginal... 56 30pse-50gfn-5dm... 5 30pse-3brm-5dm... 5 3-day vaginal... 53 5 50pse-3brm-30dm... 5 8 8-MOP... 26 A a thru z advanced formula... 203 a thru z high potency... 203 a thru z select... 203 a thru z select 50+ formula... 203 a thru z select women's... 203 abacavir... 72 abacavir-lamivudine-zidovudine... 73 abc plus... 203 ABELCET... 52 ABILIFY MAINTENA... 68, 69 ABRAXANE... 29 ABREVA... 62 acamprosate... 5 acarbose... 48 acebutolol... 92 acephen... 3 acetaminophen... 3 acetaminophen-codeine... 3 acetazolamide... 84 acetazolamide sodium... 84 acetic acid... 42, 76 acetylcysteine... 98 acid gone antacid... 49 acid reducer (famotidine)... 47 acid relief (cimetidine)... 48 acitretin... 26 acne medication... 26, 28 ACNE MEDICATION... 26 acne-clear... 26 ACTEMRA... 78 ACTHIB (PF)... 70 ACTIMMUNE... 78 actinel pediatric... 5 acyclovir... 78, 26 acyclovir sodium... 78 ADACEL(TDAP ADOLESN/ADULT)(PF) 70 ADAGEN... 36 adapalene... 34 ADCETRIS... 29 ADCIRCA... 20 adefovir... 78 ADEMPAS... 202 adriamycin... 29 adrucil... 29, 30 adt robitussin peak cld dm max... 5 adult multivitamin gummies 203 adult nasal decongestant... 23 adult one daily gummies... 203 adult robitussin lingering cld 5 adult robitussin peak cold dm... 5 adult wal-tussin... 5 adult wal-tussin dm max... 5 adults 50 plus... 203 adults 50+ daily formula... 203 adults' daily formula... 203 ADVAIR DISKUS... 95 ADVAIR HFA... 95 ADVIL... af 53 afeditab cr... 98 AFINITOR... 30 AFINITOR DISPERZ... 30 AFTERA... 06 a-hydrocort... 62 airshield... 28 AKTEN (PF)... 38 AKYNZEO... 64 ala-cort... 30 ala-scalp... 3 alavert... 56 alavert d-2 allergy-sinus... 56 ALBENZA... 66 albuterol sulfate... 96, 97 alcaine... 38 alclometasone... 3 ALCOHOL PADS... 27 ALCOHOL PREP PADS... 27 ALDURAZYME... 36 ALECENSA... 30 alendronate... 76, 77 alfuzosin... 59 ALIMTA... 30 ALINIA... 66 alka-seltzer plus mucus-conges... 5 ALLEGRA ALLERGY... 56 aller-chlor... 57 allerclear d-2hr... 57 allerclear d-24hr... 57 allergy (chlorpheniramine)... 57 allergy (diphenhydramine)... 58 allergy relief (cetirizine)... 58 allergy relief (clemastine)... 60 allerhist-... 57 aller-tec d... 57 allopurinol... 79 ALLZITAL... 3 almacone... 49 almacone-2... 49 aloe vesta antifungal (micon). 52 I- VillageCareMAX Full Advantage FIDA Plan 206 Formulary Formulary ID:65.000 Version: 9 Effective: December 0, 206

alophen... 54 alosetron... 75 ALPHAGAN P... 84 alprazolam... 7 ALREX... 45 altacaine... 38 altamist... 38 altavera (28)... 06 aluminum hydroxide gel... 49 alyacen /35 (28)... 07 alyacen 7/7/7 (28)... 07 amabelz... 6 amantadine hcl... 67 ambi 0peh-4cpm-20dm... 5 ambi 20dm-4cpm... 5 ambi 40pse-400gfn-20dm... 6 ambi 60pse-4cpm... 57 ambi 60pse-4cpm-20dm... 6 AMBISOME... 52 amethia... 07 amethia lo... 07 amifostine crystalline... 79 amiloride... 99 amiloride-hydrochlorothiazide99 AMINO ACIDS 5 %... 83 aminocaproic acid... 82 AMINOSYN 0 %... 83 AMINOSYN 3.5 %... 83 AMINOSYN 7 %... 83 AMINOSYN 7 % WITH ELECTROLYTES... 83 AMINOSYN 8.5 %... 83 AMINOSYN 8.5 %- ELECTROLYTES... 83 AMINOSYN II 0 %... 83 AMINOSYN II 5 %... 83 AMINOSYN II 7 %... 83 AMINOSYN II 8.5 %... 84 AMINOSYN II 8.5 %- ELECTROLYTES... 84 AMINOSYN M 3.5 %... 84 AMINOSYN-HBC 7%... 84 AMINOSYN-PF 0 %... 84 AMINOSYN-PF 7 % (SULFITE-FREE)... 84 AMINOSYN-RF 5.2 %... 84 amiodarone... 9 AMITIZA... 49 amitriptyline... 45 amlactin... 27 amlodipine... 98 amlodipine-atorvastatin... 00 amlodipine-benazepril... 98 amlodipine-valsartan... 99 amlodipine-valsartan-hcthiazid... 99 ammonium lactate... 27 amoxapine... 45 amoxicil-clarithromy-lansopraz... 47 amoxicillin... 25 amoxicillin-pot clavulanate... 25 amphotericin b... 52 ampicillin... 25 ampicillin sodium... 25, 26 ampicillin-sulbactam... 26 AMPYRA... 04 ANACAINE... 27 anagrelide... 82 anastrozole... 30 ANDRODERM... 60 ANDROGEL... 60 androxy... 60 animal chews... 203 animal shape vitamins... 28 animal shapes plus iron... 28 antacid anti-gas... 49 antacid anti-gas (ca carb-sim)... 50 antacid extra-strength... 49 antacid plus extra strength... 49 anticoag citrate phos dextrose... 79 anti-diarrheal... 50 anti-diarrheal (loperamide).. 49, 50 antifungal (tolnaftate)... 52, 56 antifungal cream... 52 anti-gas maximum strength.. 47 antioxidant... 204 antioxidant vitamins... 28 apatate forte... 204 APOKYN... 67 apraclonidine... 38 apri... 07 APRISO... 76 aprodine... 57 APTIOM... 40 APTIVUS... 73 aquanil hc... 3 aranelle (28)... 07 ARCALYST... 66 aripiprazole... 69 ARISTADA... 69 armodafinil... 200 arthritis pain relief (acetam)... 0 artificial tears (petro/min)... 38 artificial tears (pf)... 38 artificial tears (polyvin alc).. 38 artificial tears(dext70-hypro) 38 artificial tears(glycerin-peg). 39 artificial tears(hypromellose) 4 ASACOL HD... 76 ascomp with codeine... 4 ascorbic acid (vitamin c)... 208, 223 ashlyna... 07 aspirin..., 2 aspirin, buffered... 2 aspirin-dipyridamole... 82 aspir-low... 2 ASSURE ID INSULIN SAFETY... 35 ASTAGRAF XL... 66 atenolol... 92 atenolol-chlorthalidone... 92 I-2 VillageCareMAX Full Advantage FIDA Plan 206 Formulary Formulary ID:65.000 Version: 9 Effective: December 0, 206

atorvastatin... 00 atovaquone... 66 atovaquone-proguanil... 66 ATRIPLA... 73 atropine... 39, 38 atropine-care... 38 ATROVENT HFA... 97 AUBAGIO... 67 aubra... 07 AVASTIN... 30 AVC VAGINAL... 62 aviane... 07 AVONEX... 79 AVONEX (WITH ALBUMIN)... 79 ayr saline... 38 azacitidine... 30 azathioprine... 67 azathioprine sodium... 67 azelastine... 39 AZILECT... 67 azithromycin... 23 AZOPT... 84 AZOR... 99 aztreonam... 24 azurette (28)... 07 B b complete... 204 b complex... 204 b complex 00... 29 b complex-vitamin b2... 204 b complex-vitamin c-folic acid... 204, 205, 22, 220 b-00 complex... 25 b-2 dots... 204 b-50 complex... 25 bacitracin... 8, 29, 42 bacitracin-polymyxin b... 42 bacitraycin plus... 29 baclofen... 99 bal b-00... 206 bal b-50... 206 balance b-00... 204 balance b-50... 204 balanced b-00... 204, 26 balanced b-50... 206 balanced b-50... 204 balanced b-50 complex... 204 balsalazide... 76 balziva (28)... 07 banophen... 57 banophen allergy... 57 BANZEL... 40 baza antifungal... 53 BCG VACCINE, LIVE (PF) 70 b-complex... 27 b-complex with vitamin c... 204, 206, 28, 222, 223 BD INSULIN PEN NEEDLE UF SHORT... 36 BD INSULIN SYRINGE ULTRA-FINE... 35 bekyree (28)... 07 BELBUCA... 4 BELEODAQ... 30 BELSOMRA... 200 benadryl allergy... 57 benazepril... 90 benazepril-hydrochlorothiazide... 90 BENDEKA... 30 BENICAR... 89 BENICAR HCT... 89 BENLYSTA... 79 benzonatate... 6 benzoyl peroxide... 27 benztropine... 67 BETADINE... 27 beta-hc... 3 betamethasone acet,sod phos 62 betamethasone dipropionate. 3 betamethasone valerate... 3 betamethasone, augmented.. 3 BETASERON... 79 betaxolol... 92, 84 bethanechol chloride... 79 BETHKIS... 8 bexarotene... 30 BEXSERO (PF)... 70 bicalutamide... 30 bicarsim forte... 46 BICILLIN C-R... 26 BICILLIN L-A... 26 BIDIL... 03 bimatoprost... 84 bio-dtuss dmx... 6 bion tears (pf)... 39 bionel pediatric... 6 biospec dmx... 6 biosupp... 205 biotin... 205 biovol... 205 bisac-evac... 54 bisacodyl... 54 biscolax... 54 bismatrol... 49 bisoprolol fumarate... 92 bisoprolol-hydrochlorothiazide... 92 bleomycin... 30 bleph-0... 42 BLINCYTO... 30 blisovi 24 fe... 07 blisovi fe.5/30 (28)... 07 blisovi fe /20 (28)... 07 blis-to-sol (tolnaftate)... 53 BOOSTRIX TDAP... 7 BOSULIF... 30 bp 8 cough... 6 BREO ELLIPTA... 95 briellyn... 07 BRILINTA... 82 brimonidine... 85 BRINTELLIX... 45 BRIVIACT... 40 bromfed dm... 6 I-3 VillageCareMAX Full Advantage FIDA Plan 206 Formulary Formulary ID:65.000 Version: 9 Effective: December 0, 206

bromfenac... 45 bromocriptine... 67 brompheniramine-pseudoephdm... 5, 6 budesonide... 76 bufferin... 2 bumetanide... 99 BUPHENYL... 49 buprenorphine hcl... 4, 5 buprenorphine-naloxone... 5 buproban... 45 bupropion hcl... 45 bupropion hcl (smoking deter)... 5, 45 buspirone... 79 butalbital compound w/codeine 4 butalbital-acetaminop-caf-cod. 4 butalbital-acetaminophen... 4 butalbital-acetaminophen-caff. 4 butalbital-aspirin-caffeine... 4 BUTRANS... 4 BYSTOLIC... 92 C c complex... 205 cabergoline... 67 CABOMETYX... 3 ca-d3-mag ox-zinc-cop-mangbor... 88, 94 caffeine citrated... 04 caffeine-sodium benzoate... 04 calci-chew... 49 calcidol... 205 calcipotriene... 27 calcitonin (salmon)... 77 calcitrate... 86 calcitrate-vitamin d... 85 calcitrene... 27 calcitriol... 27, 77 calcium 500 + d... 87 calcium 500 + d (d3)... 87 calcium 600... 86 calcium 600 + d(3)... 86 calcium 600 with vitamin d3 90 calcium acetate... 58 calcium antacid... 50 calcium carbonate... 49, 86 calcium carbonate-vitamin d2... 87 calcium carbonate-vitamin d3... 86, 87, 88, 94 CALCIUM CARBONATE- VITAMIN D3... 50 calcium chloride... 86 calcium citrate-vitamin d3.. 86, 87, 89 calcium gluconate... 87 calcium+d... 95 CALDOLOR... 2 cal-gest antacid... 50 calphron... 58 CALTRATE 600 + D... 87 CALTRATE WITH VITAMIN D3... 87 camila... 07 camrese... 08 camrese lo... 07 CANCIDAS... 53 candesartan... 89 candesartan-hydrochlorothiazid... 89 capacet... 4 CAPASTAT... 63, 64 CAPRELSA... 3 captopril... 90 captopril-hydrochlorothiazide 90 CARAFATE... 47 CARBAGLU... 50 carbamazepine... 40 carbidopa... 67 carbidopa-levodopa... 67 carbidopa-levodopa-entacapone... 68 CARIMUNE NF NANOFILTERED... 67 carisoprodol... 99 carteolol... 39 cartia xt... 94 carvedilol... 92 CASTELLANI PAINT MODIFIED... 27 CAYSTON... 24 caziant (28)... 08 cefaclor... 2 cefadroxil... 2 cefazolin... 2 cefazolin in dextrose (iso-os). 2 cefdinir... 2 cefditoren pivoxil... 2 cefepime... 22 CEFEPIME IN DEXTROSE 5 %... 22 CEFEPIME IN DEXTROSE,ISO-OSM... 2 cefotaxime... 22 cefoxitin... 22 cefoxitin in dextrose, iso-osm 22 cefpodoxime... 22 cefprozil... 22 ceftazidime... 22 ceftibuten... 22 ceftriaxone... 22 ceftriaxone in dextrose,iso-os. 22 cefuroxime axetil... 23 cefuroxime sodium... 23 celecoxib... 2 CELLCEPT INTRAVENOUS... 67 CELONTIN... 40 centamin... 205 centergy dm... 6 central vite with lutein... 27 central-vite... 27 central-vite for seniors... 205 central-vite select... 209, 27 central-vite senior... 27 centram-care... 205 I-4 VillageCareMAX Full Advantage FIDA Plan 206 Formulary Formulary ID:65.000 Version: 9 Effective: December 0, 206

centravites 50 plus... 205 centrum... 205 centrum complete... 205 centrum silver... 205 century... 2 century adults 50+... 205 century mature... 205, 209, 2 century ultimate women's... 205 cephalexin... 23 CEPROTIN (BLUE BAR)... 79 CERDELGA... 79 CEREZYME... 36 cerovite... 206 cerovite advanced formula... 205 certavite senior-antioxidant.. 206 certavite-antioxid (iron gluc) 206 certavite-antioxidant... 206 CERVARIX VACCINE (PF)... 7 cetirizine... 57 cetirizine-pseudoephedrine... 57 CETYLEV... 79 cevimeline... 26 CHANTIX... 5 CHANTIX CONTINUING MONTH BOX... 5 CHANTIX STARTING MONTH BOX... 6 cheracol d... 6 cheratussin dac... 6 chest congestion relief + dm 8 chest congestion relief pe... 8 chewable multi vitamin... 209 child allergy relf(cetirizine)... 59 child complete multivitamin 209 child cough and sore throat.. 8 child mucinex chest congestion... 7 child plus cough and runnynose... 2 child triaminic cold-allergy... 58 child triaminic cough-congest... 6 child triaminic cough-sore thr... 7 child vitamin with minerals.. 206 child wal-tap cold-allergy... 58 child wal-tussin cough relief 7 CHILDREN'S ADVIL... 2 children's allegra allergy.. 57, 58 children's aller-tec... 58 children's chest congestion... 8 children's chewable... 26 children's chewable complete... 206 children's chewable vitamin. 206 children's chewable w/minerals... 209 CHILDREN'S CLARITIN57, 58 children's cold-cough daytime... 8 children's complete vitamin. 26 children's mapap... 5 children's mucinex cough... 7 children's multivit w/extra c. 209 children's non-aspirin... 4, 5 children's pain reliever... 0 children's pain-fever relief... 5 children's pepto... 50 childrens plus multi-symp cold... 23 children's silfedrine... 7 children's soothe... 50 children's sudafed... 7 children's sudafed pe cough. 6 children's tactinal... 5 children's wal-dryl allergy... 58 children's wal-zyr... 58 CHILDREN'S ZYRTEC ALLERGY... 58 childs chew vite... 206 child's vitamin with iron... 206 child's vitamin with vitamin c... 206 childs/iron... 206 chlophedianol-guaifenesin... 5 chloramphenicol sod succinate... 9 chlordiazepoxide hcl... 7 chlorhexidine gluconate... 26 chloroquine phosphate... 66 chlorothiazide... 99 chlorothiazide sodium... 99 chlorpheniramine-phenyleph-dm... 5 chlorpromazine... 69 chlorthalidone... 00 chlorzoxazone... 99 cholecalciferol (vitamin d3) 208, 224 cholestyramine (with sugar). 0 cholestyramine light... 0 choline,magnesium salicylate 2 ciclopirox... 53 ciclopirox-ure-camph-menth-euc... 53 cilostazol... 82 cimetidine... 47 cimetidine hcl... 47 CIMZIA... 67 CIMZIA POWDER FOR RECONST... 67 CINQAIR... 99 CINRYZE... 80 CIPRODEX... 42 ciprofloxacin... 27 ciprofloxacin hcl... 27, 42, 43 ciprofloxacin in 5 % dextrose 27 ciprofloxacin lactate... 27 citalopram... 45 citracal + d maximum... 87 citrus calcium... 87 clarithromycin... 24 CLARITIN... 58 I-5 VillageCareMAX Full Advantage FIDA Plan 206 Formulary Formulary ID:65.000 Version: 9 Effective: December 0, 206

CLARITIN LIQUI-GEL... 58 CLARITIN REDITABS... 58 clearlax... 58 CLEVIPREX... 99 clindamycin hcl... 9 clindamycin in 5 % dextrose.. 9 clindamycin palmitate hcl... 9 clindamycin pediatric... 9 clindamycin phosphate... 9, 62, 29 CLINIMIX 5%/D5W SULFITE FREE... 84 CLINIMIX 5%/D25W SULFITE-FREE... 84 CLINIMIX 2.75%/D5W SULFIT FREE... 84 CLINIMIX 4.25%/D0W SULF FREE... 84 CLINIMIX 4.25%/D5W SULFIT FREE... 85 CLINIMIX 4.25%-D20W SULF-FREE... 85 CLINIMIX 4.25%-D25W SULF-FREE... 85 CLINIMIX 5%- D20W(SULFITE-FREE)... 85 CLINIMIX E 2.75%/D0W SUL FREE... 85 CLINIMIX E 2.75%/D5W SULF FREE... 85 CLINIMIX E 4.25%/D0W SUL FREE... 85 CLINIMIX E 4.25%/D25W SUL FREE... 85 CLINIMIX E 4.25%/D5W SULF FREE... 85 CLINIMIX E 5%/D5W SULFIT FREE... 86 CLINIMIX E 5%/D20W SULFIT FREE... 86 CLINIMIX E 5%/D25W SULFIT FREE... 86 CLINISOL SF 5 %... 86 clobetasol... 3, 32 clobetasol-emollient... 32 clocortolone pivalate... 32 clomipramine... 45 clonazepam... 7 clonidine... 88 clonidine hcl... 88, 04 clopidogrel... 82 clorazepate dipotassium... 7 clorpres... 88 clotrimazole... 53 clotrimazole-7... 53 clotrimazole-betamethasone... 53 clozapine... 69 COARTEM... 66 codeine sulfate... 5 codituss dm... 7 COLACE... 54 colchicine... 79 cold and cough (diphenhydr-pe)... 59 cold multi-symptom day/night... 7 cold relief m/s day/night... 7 cold-allergy-sinus... 58 cold-flu relief... 7 cold-flu relief, day/night... 7 colestipol... 0 colistin (colistimethate na)... 9 colocort... 32 COLY-MYCIN S... 43 COMBIGAN... 85 COMBIPATCH... 6 COMBIVENT RESPIMAT. 97 COMETRIQ... 3 comfort gel... 50 comfort gel extra strength... 50 COMPLERA... 73 complete 50+... 2 complete multi 50+... 206 complete multivitamin. 206, 209 complete multivitamin-mineral... 209, 28 complete senior... 206, 28 compoz... 58 compro... 64 COMVAX (PF)... 7 CONDYLOX... 27 congestac... 7 congest-eze... 7 constulose... 50 COPAXONE... 79 coricidin hbp... 7 coricidin hbp cold-multi sympt... 7 CORLANOR... 95 cormax... 32 cortisone... 62 cortizone-0... 32 CORTIZONE-0... 32 COSENTYX... 28 COSENTYX (2 SYRINGES)... 27 COSENTYX PEN... 28 COSENTYX PEN (2 PENS) 27 COTELLIC... 3 cough and cold... 7, 8 cough and runny nose... 23 CREON... 36 critic-aid clear af... 53 CRIXIVAN... 73 cromolyn... 39, 50, 99 cryselle (28)... 08 CUBICIN... 9 cyanocobalamin (vitamin b-2)... 204, 208, 27, 223 cyclafem /35 (28)... 08 cyclafem 7/7/7 (28)... 08 cyclobenzaprine... 99 cyclopentolate... 39 cyclophosphamide... 3 CYCLOPHOSPHAMIDE... 3 CYCLOSET... 48 I-6 VillageCareMAX Full Advantage FIDA Plan 206 Formulary Formulary ID:65.000 Version: 9 Effective: December 0, 206

cyclosporine... 67 cyclosporine modified... 67 cyproheptadine... 59 CYRAMZA... 3 cyred... 08 CYSTADANE... 79 CYSTARAN... 39 cysteine (l-cysteine)... 86 D d0 %-0.45 % sodium chloride... 87 d2.5 %-0.45 % sodium chloride... 88 d3 dots... 208 d5 % and 0.9 % sodium chloride... 88 d5 %-0.45 % sodium chloride... 88 dactinomycin... 3 daily gummies... 207 daily multiple... 207, 208 daily multi-vitamin... 23 daily multivitamin with iron 208 daily multi-vitamins/iron... 208 daily teen multi-vitamin... 207 daily value... 208 daily vitamin... 208 daily vitamin formula... 208 daily vitamin formula + iron 208 daily vitamin formula-minerals... 208 daily vitamin with iron... 208 daily vites/iron... 208 dailyhist-... 59 daily-vite... 208 DAKLINZA... 77 DALIRESP... 99 danazol... 60 dantrolene... 200 dapsone... 64 DAPTACEL (DTAP PEDIATRIC) (PF)... 7 daptomycin... 9 DARAPRIM... 66 DARZALEX... 3 dasetta /35 (28)... 08 dasetta 7/7/7 (28)... 08 dayhist allergy... 59 daysee... 08 daytime cold and cough... 8 daytime cold-flu... 8 day-time cough... 8 daytime-nighttime... 22 daytime-nighttime cold-flu.. 8 daytime-nighttime cough... 8 deblitane... 08 decitabine... 3 decongestant cough... 23 deep sea nasal... 39 deferoxamine... 59 delsym cough-chest congest dm... 8 delyla (28)... 08 DELZICOL... 76 DEMSER... 95 DEPEN TITRATABS... 60 DEPO-PROVERA... 65 dermafungal... 53 dermarest eczema (hydrocort)... 32 DESCOVY... 73 desipramine... 46 desmopressin... 63, 64 desog-e.estradiol/e.estradiol. 08 desogestrel-ethinyl estradiol 08 desonide... 32 desoximetasone... 32 despec-dm (pseudoeph-dmguaif)... 8 dex4 glucose... 86 dexamethasone... 62, 63 dexamethasone sodium phosphate... 45, 63 dexmethylphenidate... 04 dextroamphetamine... 05 dextroamphetamineamphetamine... 05 dextromethorphan polistirex 8 dextrose 0 % and 0.2 % nacl... 88 dextrose 0 % in water (d0w)... 86 dextrose 20 % in water (d20w)... 86 dextrose 25 % in water (d25w)... 86 dextrose 40 % in water (d40w)... 86 dextrose 5 % in ringers... 86 dextrose 5 % in water (d5w).. 86 dextrose 5 %-lactated ringers88 dextrose 5%-0.2 % sod chloride... 88 dextrose 5%-0.3 % sod.chloride... 88 dextrose 50 % in water (d50w)... 86 dextrose 70 % in water (d70w)... 87 dextrose with sodium chloride... 88 dextrose-kcl-nacl... 88 diabetic tussin dm... 8, 9 diamode... 50 diazepam... 7 diazepam intensol... 7 diclofenac potassium... 2 diclofenac sodium... 2, 45 diclofenac-misoprostol... 2 dicloxacillin... 26 dicyclomine... 50, 5 didanosine... 73 DIFICID... 24 diflunisal... 2 digitek... 95 digox... 95, 96 I-7 VillageCareMAX Full Advantage FIDA Plan 206 Formulary Formulary ID:65.000 Version: 9 Effective: December 0, 206

digoxin... 96 DIGOXIN... 96 dihydroergotamine... 62, 63 DILANTIN... 40 diltiazem hcl... 94 dilt-xr... 94 dimaphen (pe)... 59 dimenhydrinate... 64 dimetapp cold-congestion... 59 dino-life... 209 dino-life with extra c... 208 dino-life with iron-zinc... 208 DIPENTUM... 76 diphenhist... 59 diphenhydramine hcl... 59 diphenoxylate-atropine... 5 dipyridamole... 82 disopyramide phosphate... 9 disulfiram... 6 divalproex... 40, 4 dobutamine... 96 dobutamine in d5w... 96 doc-q-lace... 55 docu... 55 docusate sodium... 55 docusol... 55 dofetilide... 9 dok... 55 donepezil... 44 dopamine... 97 dopamine in 5 % dextrose... 97 dorzolamide... 85 dorzolamide-timolol... 85 douche vinegar and water extra... 83 doxazosin... 88 doxepin... 46 doxercalciferol... 77 doxorubicin, peg-liposomal... 3 doxy-00... 28 doxycycline hyclate... 28, 29 doxycycline monohydrate... 29 dramamine... 64 dramamine less drowsy... 64 driminate... 64 dristan long lasting... 39 dronabinol... 65 droperidol... 79 drospirenone-ethinyl estradiol... 08 DROXIA... 3 DUAVEE... 6 dulcolax stool softener (dss) 55 DULERA... 96 duloxetine... 46 DUREZOL... 45 dutasteride... 79 dutasteride-tamsulosin... 79 DYRENIUM... 00 E e.c. prin... 2 e.e.s. 400... 24 e.e.s. granules... 24 econazole... 54 econtra ez... 08 ed a-hist... 59 ed bron gp... 9 ed chlorped jr... 59 EDURANT... 73 effer-k... 88 EFFIENT... 83 ELAPRASE... 36 eldertonic... 209 electrolyte-48 in d5w... 88 ELIDEL... 32 ELIGARD... 32 ELIGARD (3 MONTH)... 32 ELIGARD (4 MONTH)... 32 ELIGARD (6 MONTH)... 32 elinest... 08 eliphos... 58 ELIQUIS... 79 ELITEK... 36 ELLA... 08 ellis tonic... 209 ELMIRON... 80 elon dual defense... 54 EMCYT... 32 EMEND... 65 emoquette... 08 EMPLICITI... 32 EMSAM... 46 EMTRIVA... 73 EMVERM... 67 enalapril maleate... 90 enalaprilat... 90 enalapril-hydrochlorothiazide 90 ENBREL... 67 ENBREL SURECLICK... 67 endocet... 5 endodan... 5 endur-acin... 0 enema... 55, 57 enema disposable... 55 enemeez... 55 enemeez plus... 55 ENGERIX-B (PF)... 7 ENGERIX-B PEDIATRIC (PF)... 7 enoxaparin... 79 enpresse... 08 enskyce... 09 entacapone... 68 entecavir... 78 entre-cough... 9 ENTRESTO... 89 enulose... 5 ENVARSUS XR... 67 EPCLUSA... 77 ephedrine sulfate... 97 epinastine... 39 epinephrine... 97 epinephrine hcl (pf)... 97 EPIPEN 2-PAK... 97 EPIPEN JR 2-PAK... 97 epitol... 4 I-8 VillageCareMAX Full Advantage FIDA Plan 206 Formulary Formulary ID:65.000 Version: 9 Effective: December 0, 206

EPIVIR HBV... 73 eplerenone... 03 EPOGEN... 8 epoprostenol (glycine)... 202 EPZICOM... 73 eq gentle... 39 equalactin... 56 ergocalciferol (vitamin d2). 209, 222 ergoloid... 80 ERGOMAR... 63 ERIVEDGE... 32 errin... 09 ery pads... 29 ery-tab... 24 ERY-TAB... 24 ERYTHROCIN... 24 erythrocin (as stearate)... 24 erythromycin... 24, 43 erythromycin ethylsuccinate.. 24 erythromycin with ethanol.. 29, 30 ESBRIET... 99 escitalopram oxalate... 46 esmolol... 92 esomeprazole sodium... 47 essentia... 209 essential balance with lutein 20 essential daily... 20 estarylla... 09 ESTRACE... 6 estradiol... 6 estradiol valerate... 6 estradiol-norethindrone acet. 6 estropipate... 62 eszopiclone... 200 ethambutol... 64 ethamolin... 97 ethosuximide... 4 etodolac... 3 ETOPOPHOS... 32 etoposide... 32 EVOTAZ... 73 exemestane... 32 EXJADE... 60 EXONDYS 5... 80 expectorant... 9 expectorant dm... 9 expectorant max strength... 9 EXTAVIA... 80 extra cleansing douche... 82 eye health plus lutein... 209 F FABRAZYME... 37 fallback solo... 09 falmina (28)... 09 famciclovir... 78 famotidine... 47, 48 famotidine (pf)... 47 famotidine (pf)-nacl (iso-os) 47 FANAPT... 69, 70 FARESTON... 32 FARYDAK... 32 FASLODEX... 32 felbamate... 4 felodipine... 99 feminine care douche... 82 FEMRING... 62 fenofibrate... 0 fenofibrate micronized... 0 fenofibrate nanocrystallized. 0 fenofibric acid... 0 fenofibric acid (choline)... 0 fenoprofen... 3 fentanyl... 5 fentanyl citrate... 5 ferocon... 20 ferretts... 20 ferrex 50... 20 ferrex 50 plus... 20 FERRIPROX... 60 ferrocite... 20 ferrous fumarate... 20 ferrous gluconate... 20, 22 ferrous sulfate... 206, 20 FETZIMA... 46 feverall... 5 fexofenadine... 60 fiber (calcium polycarbophil)... 56 fiber laxative (methylcellulo)58 fiber smooth... 58 fiber therapy (m-cell/sugar).. 56 fiber therapy (m-cellulose)... 55 fiber therapy (psyllium)... 56 fiber therapy (psyllium/sugar)... 55 fiber-lax... 56 fibertab... 56 finasteride... 80 FIRAZYR... 97 flanax antacid... 5 FLEBOGAMMA DIF... 68 flecainide... 9 FLECTOR... 3 FLEET BISACODYL... 56 flintstones complete (iron)... 20 flintstones multivitamin... 20 flintstones with iron... 2 flintstones/extra c... 20 FLOVENT DISKUS... 96 FLOVENT HFA... 96 floxuridine... 32 flu formula daytime-nighttime... 22 flu relief therapy daytime... 2 flu severe cold-congestion... 23 flucaine... 40 fluconazole... 54 fluconazole in dextrose(iso-o) 54 fluconazole in nacl (iso-osm). 54 flucytosine... 54 fludrocortisone... 63 flumazenil... 05 flunisolide... 45 fluocinonide... 32 I-9 VillageCareMAX Full Advantage FIDA Plan 206 Formulary Formulary ID:65.000 Version: 9 Effective: December 0, 206

fluorometholone... 45 fluorouracil... 32, 28 fluoxetine... 46 fluphenazine decanoate... 70 fluphenazine hcl... 70 flurbiprofen... 3 flurbiprofen sodium... 45 flutamide... 32 fluticasone... 32, 45 fluvoxamine... 46 foaming antacid... 5, 54 folic acid... 2 FOLIC ACID... 2 fomepizole... 80 fondaparinux... 79 foot odor control... 56 FORTEO... 77 FORTICAL... 77 foscarnet... 76 fosfree... 2 fosinopril... 90 fosinopril-hydrochlorothiazide... 90 fosphenytoin... 4 FREAMINE HBC 6.9 %... 87 FREAMINE III 0 %... 87 fungi cure... 54 FUNGI-NAIL... 54 fungoid-d... 54 furosemide... 00 FUSILEV... 80 FUZEON... 73 FYCOMPA... 4 G gabapentin... 4 GABITRIL... 4 galantamine... 44 GAMASTAN S/D... 68 GAMMAGARD LIQUID... 68 GAMMAPLEX... 68 ganciclovir sodium... 78 GARDASIL (PF)... 7 GARDASIL 9 (PF)... 72 gas relief... 46 gas relief extra strength... 46 gas-x ultra-strength... 46 gatifloxacin... 43 GATTEX 30-VIAL... 5 GATTEX ONE-VIAL... 5 GAUZE PAD... 80 gavilyte-c... 56 gavilyte-g... 56 gavilyte-n... 56 GAZYVA... 33 gelusil antacid and anti-gas.. 5 gemfibrozil... 0 generlac... 5 gengraf... 68 GENOTROPIN... 64 GENOTROPIN MINIQUICK... 64 gentak... 43 gentamicin... 8, 30, 43 gentamicin in nacl (iso-osm).. 8 gentamicin sulfate (ped) (pf).. 8 gentamicin sulfate (pf)... 8 GENTEAL MILD TO MODERATE... 40 GENTEAL GEL... 40 GENTEAL MILD... 40 GENTEAL SEVERE... 40 genteal tears... 40 gentlelax... 56 GENVOYA... 73 GEODON... 70 geravim... 2 geriaton... 2 geri-hydrolac... 28 geri-tussin dm... 9 gianvi (28)... 09 gildagia... 09 gildess.5/30 (2)... 09 gildess /20 (2)... 09 gildess 24 fe... 09 gildess fe.5/30 (28)... 09 gildess fe /20 (28)... 09 GILENYA... 80 GILOTRIF... 33 GLEOSTINE... 33 glimepiride... 52 glipizide... 52 glipizide-metformin... 52 GLUCAGEN HYPOKIT... 80 GLUCAGON EMERGENCY KIT (HUMAN)... 80 gluco burst... 87 glucose... 87 glucose gel... 87 glutose 5... 87 glyburide... 52 glyburide micronized... 52 glyburide-metformin... 52 glycolax... 56 glycopyrrolate... 5 glydo... 4, 5 GLYXAMBI... 49 granisetron (pf)... 65 granisetron hcl... 65 GRANIX... 8 griseofulvin microsize... 54 guaifenesin... 9 guaifenesin dac... 9 guanfacine... 89, 05 guanidine... 80 gummi bear multivitamin... 2, 25 gummy swirls... 207 H hair vitamins... 2 hair,skin and nails... 28, 220 halobetasol propionate... 32 haloperidol... 70 haloperidol decanoate... 70 haloperidol lactate... 70 HARVONI... 77 HAVRIX (PF)... 72 I-0 VillageCareMAX Full Advantage FIDA Plan 206 Formulary Formulary ID:65.000 Version: 9 Effective: December 0, 206

head congestion day-night... 9 healthy eyes... 2 healthylax... 56 heather... 09 hemocyte... 2 heparin (porcine)... 80 heparin (porcine) in 5 % dex. 79, 80 heparin (porcine) in nacl (pf). 80 heparin(porcine) in 0.45% nacl... 80 heparin, porcine (pf)... 80 HEPATAMINE 8%... 87 HEPATASOL 8 %... 87 HERCEPTIN... 33 HETLIOZ... 200 HEXALEN... 33 hi-b complex... 2 HIBERIX (PF)... 72 hi-cal plus vit d... 94 homatropaire... 40 homatropine hbr... 40 honey bears... 22 honey bears with iron-zinc... 22 HUMIRA... 68 HUMIRA PEDIATRIC CROHN'S START... 68 HUMIRA PEN... 68 HUMIRA PEN CROHN'S-UC- HS START... 68 HUMIRA PEN PSORIASIS- UVEITIS... 68 HUMULIN R U-500 (CONC) KWIKPEN... 50, 5 HUMULIN R U-500 (CONCENTRATED)... 5 hydralazine... 97 hydrochlorothiazide... 00 hydrocil instant... 56 hydrocodone-acetaminophen 5, 6 hydrocodone-chlorpheniramine... 9 hydrocodone-homatropine... 9 hydrocodone-ibuprofen... 6 hydrocortisone... 33, 63 hydrocortisone acet-aloe vera... 33 hydrocortisone acetate... 33 hydrocortisone butyrate... 33 hydrocortisone butyr-emollient... 33 hydrocortisone valerate... 33 hydromet... 9 hydromorphone... 6 hydromorphone (pf)... 6 hydroskin... 32 hydroxychloroquine... 67 hydroxyprogesterone caproate... 65 hydroxyurea... 33 hydroxyzine hcl... 80 hydroxyzine pamoate... 80 HYPERLYTE CR... 89 HYPERRAB S/D (PF)... 68 HYQVIA... 69 HYQVIA IG COMPONENT... 68 HYSINGLA ER... 6 I ibandronate... 77 IBRANCE... 33 ibuprofen... 2, 3, 4 ibuprofen jr strength... 3 icaps plus... 22 ICLUSIG... 33 iferex 50... 22 ifosfamide... 33 ifosfamide-mesna... 33 ILARIS (PF)... 69 ILEVRO... 45 imatinib... 33 IMBRUVICA... 33 imipenem-cilastatin... 24 imipramine hcl... 47 imipramine pamoate... 47 imiquimod... 28 IMLYGIC... 33 imodium a-d... 5 IMODIUM A-D... 5 IMOGAM RABIES-HT (PF)... 69 IMOVAX RABIES VACCINE (PF)... 72 INCRELEX... 64 indapamide... 00 indomethacin... 3 indomethacin sodium... 3 INFANRIX (DTAP) (PF)... 72 infants gas relief... 46 infant's ibuprofen... 3 INFANT'S MOTRIN... 3 infants' non-aspirin cold... 25 INLYTA... 34 insta-glucose... 87 INSULIN SYRINGE-NEEDLE U-00... 36 INTELENCE... 73 INTRALIPID... 87 INTRON A... 77 introvale... 09 INVANZ... 25 INVEGA SUSTENNA... 70 INVEGA TRINZA... 70 INVIRASE... 74 INVOKAMET... 49 INVOKAMET XR... 49 INVOKANA... 49 inzo antifungal... 54 iodine... 36 IONOSOL-B IN D5W... 89 IONOSOL-MB IN D5W... 89 IPOL... 72 ipratropium bromide... 40, 97 ipratropium-albuterol... 97 IPRIVASK... 80 irbesartan... 89 I- VillageCareMAX Full Advantage FIDA Plan 206 Formulary Formulary ID:65.000 Version: 9 Effective: December 0, 206

irbesartan-hydrochlorothiazide... 89 IRESSA... 34 iron high potency... 207 ISENTRESS... 74 ISOLYTE M IN 5 % DEXTROSE... 89 ISOLYTE-H IN 5 % DEXTROSE... 89 ISOLYTE-P IN 5 % DEXTROSE... 89 ISOLYTE-S... 89 isoniazid... 64 isopto tears... 40 isosorbide dinitrate... 03 isosorbide mononitrate... 03 isradipine... 99 itraconazole... 54 ivermectin... 67 IXEMPRA... 34 IXIARO (PF)... 72 J JAKAFI... 34 jantoven... 80 JANUMET... 49 JANUMET XR... 49 JANUVIA... 49 JARDIANCE... 49 jencycla... 09 JENTADUETO... 49 JENTADUETO XR... 49 jolessa... 09 jolivette... 09 jr. acetaminophen... 0 juleber... 09 junel.5/30 (2)... 09 junel /20 (2)... 09 junel fe.5/30 (28)... 09 junel fe /20 (28)... 09 junel fe 24... 0 junior mapap... 6 JUXTAPID... 0 K KABIVEN... 87 KALETRA... 74 KALYDECO... 99 KANUMA... 37 kaopectate (bismuth subsalicy)... 5 kariva (28)... 0 k-effervescent... 89 kelnor /35 (28)... 0 KELP (IODINE)... 89 ketoconazole... 54 ketoprofen... 3, 4 ketorolac... 4, 45 KEVEYIS... 80 KEYTRUDA... 34 kids mini enema... 55 kid's vitamins... 26 kid's vitamins + extra c... 26 kids vitamins + iron... 26 kid's vitamins + iron... 26 kimidess (28)... 0 KINERET... 69 KINRIX (PF)... 72 kionex... 5 kionex (with sorbitol)... 5 KLOR-CON 0... 89 klor-con m0... 89 klor-con m5... 89 klor-con m20... 89 klor-con sprinkle... 89 konsyl (sugar)... 56 konsyl fiber... 56 KONSYL SUGAR-FREE... 56 KORLYM... 49 KRYSTEXXA... 37 kurvelo... 0 KUVAN... 37 KYNAMRO... 0 KYPROLIS... 34 L l norgest/e.estradiol-e.estrad 0 labetalol... 93 LACRISERT... 40 LACTATED RINGERS... 76 LACTINOL HX... 28 lactulose... 52 LAMICTAL... 4 LAMISIL (AEROSOL)... 54 lamisil af... 54 LAMISIL AT... 54 lamivudine... 74 lamivudine-zidovudine... 74 lamotrigine... 4, 42 LANOXIN... 98 lansoprazole... 47 LANTUS... 5 LANTUS SOLOSTAR... 5 larin.5/30 (2)... 0 larin /20 (2)... 0 larin 24 fe... 0 larin fe.5/30 (28)... 0 larin fe /20 (28)... 0 larissia... 0 latanoprost... 85 LATUDA... 7 laxative peg 3350... 57 LAZANDA... 6 leena 28... 0 leflunomide... 69 LEMTRADA... 80 LENVIMA... 34 lessina... 0 LETAIRIS... 202 letrozole... 34 leucovorin calcium... 80, 8 LEUKERAN... 34 LEUKINE... 8 leuprolide... 34 levetiracetam... 42 levobunolol... 85 levocarnitine... 8 levocarnitine (with sugar)... 8 levocetirizine... 60 I-2 VillageCareMAX Full Advantage FIDA Plan 206 Formulary Formulary ID:65.000 Version: 9 Effective: December 0, 206

levofloxacin... 27, 28, 43 levofloxacin in d5w... 27 levoleucovorin... 8 levonest (28)... 0 levonorgestrel... 0 levonorgestrel-ethinyl estrad0, levonorg-eth estrad triphasic levora-28... levothyroxine... 66 LEXIVA... 74 lice cream rinse... 35 lice killing... 35 lice treatment... 35 lice treatment (permethrin).. 35 lidocaine... 5 lidocaine (pf)... 5, 9 lidocaine hcl... 5 lidocaine in 5 % dextrose (pf) 9 lidocaine viscous... 5 lidocaine-prilocaine... 5 life-pack women's... 22 linezolid... 9 LINZESS... 52 liothyronine... 66 lipodox... 35 lipodox 50... 34 liquibid d-r... 9 liquid calcium with vitamin d... 90 LIQUI-E... 22 lisinopril... 90 lisinopril-hydrochlorothiazide 9 lithium carbonate... 05 lithium citrate... 05 little animals... 22 little animals-iron... 22 LIVALO... 0 lobana bath... 28 lohist-dm... 9 lomedia 24 fe... lomustine... 35 LONSURF... 35 loperamide... 50, 52, 53 loratadine... 60 loratadine-d... 60 lorazepam... 7 lorcet (hydrocodone)... 6 lorcet hd... 6 lorcet plus... 6 lortuss ex... 9 loryna (28)... losartan... 89 losartan-hydrochlorothiazide. 89 LOTEMAX... 45 LOTRONEX... 52 lovastatin... 0 low-ogestrel (28)... loxapine succinate... 7 lubricant dry eye relief... 39 lubricant eye... 39 lubricant eye (cmc-glycer)(pf)... 40 lubricant eye (cmc-glycerin) 40 lubricant eye (pg-peg 400)... 42 lubricant eye (polyv alcohol) 4 lubricant eye (propyl glycol) 40 lubricant eye drops... 39 lubricant gel... 39 lubricating drops... 39 lubrifresh pm... 40 LUMIGAN... 85 LUPRON DEPOT... 35 LUPRON DEPOT (3 MONTH)... 35 LUPRON DEPOT (4 MONTH)... 35 LUPRON DEPOT (6 MONTH)... 35 LUPRON DEPOT-PED... 64 LUPRON DEPOT-PED (3 MONTH)... 64 lutera (28)... LYNPARZA... 35 LYRICA... 42 lysiplex plus... 22 LYSODREN... 35 lyza... M maalox advanced... 52 MACUVITE... 22 MACUVITE EYE CARE... 22 mag 64... 90 mag-delay... 90 mag-g... 90 MAGNEBIND 300... 52 magnebind 400... 58 magnesium... 87, 90 magnesium (oxide/aa chelate)... 90 magnesium chloride... 90 magnesium gluconate... 90 magnesium oxide... 52, 53 magnesium sulf in 0.45% nacl... 90 magnesium sulfate... 90, 9 magnesium sulfate in d5w... 90 magnesium sulfate in water.. 90 malathion... 35 mapap (acetaminophen)... 7 mapap arthritis pain... 7 mapap extra strength... 7 maprotiline... 47 mar-cof bp... 9 mar-cof cg... 20 margesic... 7 marlissa... MARPLAN... 47 masanti double strength... 52 MATULANE... 35 matzim la... 94 maximum daily multivitamin... 26 maximum strength flu... 22 meclizine... 65 medroxyprogesterone... 66 I-3 VillageCareMAX Full Advantage FIDA Plan 206 Formulary Formulary ID:65.000 Version: 9 Effective: December 0, 206

mefenamic acid... 4 mefloquine... 67 MEFOXIN IN DEXTROSE (ISO-OSM)... 23 mega multiple/chelated mineral... 22 mega multivitamin with mineral... 22 MEGACE ES... 66 megestrol... 35, 66 MEKINIST... 35 meloxicam... 4 memantine... 44 MENACTRA (PF)... 73 M-END DM... 20 MENEST... 62 MENHIBRIX (PF)... 73 MENOMUNE - A/C/Y/W-35 (PF)... 73 men's daily gummies... 207 men's multi-vitamin... 207 men's one daily... 209 MENVEO A-C-Y-W-35-DIP (PF)... 73 MENVEO MENA COMPONENT (PF)... 73 MENVEO MENCYW-35 COMPNT (PF)... 73 MEPHYTON... 22 mercaptopurine... 35 meropenem... 25 mesalamine... 76 mesehist dm... 20 mesna... 8 MESNEX... 8 MESTINON... 8 MESTINON TIMESPAN... 8 metaproterenol... 97 metaxall... 200 metaxalone... 200 metformin... 49, 50 methadone... 7 methadose... 7 methazolamide... 85 methenamine hippurate... 9 methimazole... 66 methocarbamol... 200 methotrexate sodium... 35, 36 methotrexate sodium (pf)... 36 methoxsalen rapid... 28 methscopolamine... 52 methyclothiazide... 00 methylphenidate... 05, 06 methylprednisolone... 63 methylprednisolone acetate.. 63 methylprednisolone sodium succ... 63 metipranolol... 85 metoclopramide hcl... 52 metolazone... 00 metoprolol succinate... 93 metoprolol ta-hydrochlorothiaz... 93 metoprolol tartrate... 93 metronidazole... 9, 62, 30 metronidazole in nacl (iso-os) 9 mexiletine... 9 mgo... 52 MIACALCIN... 77 mi-acid... 53 mi-acid gas relief... 46 micatin... 55 miconazole 7... 55 miconazole nitrate... 53, 54, 55 miconazole-3... 55 microgestin.5/30 (2)... microgestin /20 (2)... microgestin fe.5/30 (28)... microgestin fe /20 (28)... midodrine... 89 miglitol... 50 milk of magnesia... 56 milltrium senior... 22 milrinone... 98 milrinone in 5 % dextrose... 98 mimvey... 62 mimvey lo... 62 mineral oil... 82, 84 MINERAL OIL... 8 mineral oil laxative... 56 minitran... 03 minocycline... 29 minoxidil... 03 mintox... 53 mintox maximum strength... 53 mintox plus... 53 MIRCERA... 8 mirtazapine... 47 misoprostol... 47 mitoxantrone... 36 M-M-R II (PF)... 73 moexipril... 9 moexipril-hydrochlorothiazide... 9 molindone... 7 mometasone... 33 MONISTAT 3... 55 monistat 7... 55 mono-linyah... mononessa (28)... montelukast... 96 morphine... 7, 8 MORPHINE... 8 morphine (pf) in 0.9 % nacl... 7 morphine concentrate... 7 morphine in dextrose 5 %... 8 morrhuate sodium... 8 motion sickness... 64 motion sickness (meclizine)... 65 MOVANTIK... 53 MOVIPREP... 57 MOXEZA... 43 moxifloxacin... 28 MOZOBIL... 8 mucus dm... 20 mucus dm max... 20 I-4 VillageCareMAX Full Advantage FIDA Plan 206 Formulary Formulary ID:65.000 Version: 9 Effective: December 0, 206

mucus relief... 20, 22 mucus relief cough... 23 MULTAQ... 9 multi complete with iron... 22 multi-day with iron... 23 multi-delyn with iron... 23 multiple vitamin-minerals... 23 multiple vitamins... 23 multiple vitamins with iron.. 23 multi-symptom cold night time... 22 multivital platinum... 26 multivitamin 50 plus... 25 multi-vitamin hp/minerals... 23 multivitamin with fluoride... 23 multivitamin with iron. 23, 28 multivitamin with minerals.. 23 multi-vite... 26 multi-vite 50 and over... 26 mupirocin... 30 mupirocin calcium... 30 muro 28... 40 my favorite multiple... 23 my way... myco nail a... 55 mycophenolate mofetil... 69 mycophenolate sodium... 69 MYOZYME... 37 MYRBETRIQ... 59 mytab gas... 46 mytab gas maximum strength... 46 my-vitalife... 23 myzilra... N nabumetone... 4 nadolol... 93 nafcillin... 26 NAGLAZYME... 37 naloxone... 6 naltrexone... 6 NAMENDA XR... 44, 45 NAMZARIC... 45 naphazoline... 40 naproxen... 4 naproxen sodium... 4 naratriptan... 63 NARCAN... 6 nasal and sinus decongestant 20 nasal decongestant (oxymetazl)... 4 NASCOBAL... 23 nasohist dm... 20 NATACYN... 43 nateglinide... 50 NATPARA... 77 natural b-00... 224 natural b-00 complex... 28 natural balance... 4 natural calcium... 9 natural fiber laxative therapy 57 natural tears (pf)... 39 nature's tears (hypromellose) 4 NEBUPENT... 67 necon 0.5/35 (28)... necon /35 (28)... 2 necon /50 (28)... 2 necon 0/ (28)... 2 necon 7/7/7 (28)... 2 nefazodone... 47 NEO DM... 20 neomycin... 8 neomycin-bacitracin-poly-hc 43 neomycin-bacitracin-polymyxin... 43 neomycin-polymyxin b gu... 30 neomycin-polymyxin b- dexameth... 43 neomycin-polymyxingramicidin... 43 neomycin-polymyxin-hc... 43, 44 neo-polycin... 44 neo-polycin hc... 44 neosporin (neo-bac-polym).. 30 neosporin anti-itch... 34 neo-synephrine 2 h spr (oxym)... 4 neo-tuss... 20 nephplex rx... 23 NEPHRAMINE 5.4 %... 87 nephron fa... 23 nephro-vite rx... 23 NEULASTA... 8 NEUMEGA... 8 NEUPOGEN... 8 NEUPRO... 68 NEVANAC... 45 nevirapine... 74 NEXAFED... 20 NEXAVAR... 36 next choice one dose... 2 niacin... 0, 02 niacinamide... 02, 24 niacor... 02 nicardipine... 99 NICODERM CQ... 6 nicorelief... 6 nicorette... 6 nicotine... 6, 7 nicotine (polacrilex)... 6 NICOTROL... 7 nifedical xl... 99 nifedipine... 99 night time... 2 night time cold medicine... 20 night time cold-flu... 23 night time cold-flu relief... 23 night time cough-sore throat 20 nighttime cough... 20 nikki (28)... 2 NILANDRON... 36 nilutamide... 36 NINLARO... 36 NITE TIME COLD-FLU RELIEF... 20 I-5 VillageCareMAX Full Advantage FIDA Plan 206 Formulary Formulary ID:65.000 Version: 9 Effective: December 0, 206

NITRO-BID... 03 nitrofurantoin macrocrystal... 20 nitrofurantoin monohyd/m-cryst... 20 nitroglycerin... 04 nitroglycerin in 5 % dextrose 04 NITROSTAT... 04 NIX CREME RINSE... 35 nohist-dm... 20 non-aspirin cold... 23 non-aspirin extra strength.. 8, 0 non-aspirin flu... 25 non-aspirin jr strength... 5 nora-be... 2 NORDITROPIN FLEXPRO 64 norepinephrine bitartrate... 98 norethindrone (contraceptive)... 2 norethindrone acetate... 66 norethindrone ac-eth estradiol... 2 norethindrone-e.estradiol-iron... 2 norgestimate-ethinyl estradiol... 2 norlyroc... 2 NORMOSOL-M IN 5 % DEXTROSE... 9 NORMOSOL-R PH 7.4... 9 nortemp... 8 NORTHERA... 89 nortrel 0.5/35 (28)... 2 nortrel /35 (2)... 2 nortrel /35 (28)... 2 nortrel 7/7/7 (28)... 2 nortriptyline... 47 NORVIR... 74 NOVOLIN 70/30... 5 NOVOLIN N... 5 NOVOLIN R... 5 NOVOLOG... 5 NOVOLOG FLEXPEN... 5 NOVOLOG MIX 70-30... 5 NOVOLOG MIX 70-30 FLEXPEN... 5 NOVOLOG PENFILL... 5 NOXAFIL... 55 NUCALA... 99 NUCYNTA... 9 NUCYNTA ER... 8 NUEDEXTA... 06 nu-iron... 24 NULOJIX... 69 nu-mag... 9 NUPLAZID... 7 NUTRESTORE... 53 NUTRILIPID... 87 NUTRILYTE... 9 NUTRILYTE II... 9 NUVARING... 3 nyamyc... 55 nystatin... 55 nystatin-triamcinolone... 55, 56 nystop... 56 nyt-time sleep... 60 O OCALIVA... 53 ocean nasal... 4 ocella... 3 OCTAGAM... 69 octreotide acetate... 64, 65 ocutabs... 24 ODEFSEY... 74 ODOMZO... 36 OFEV... 99 ofloxacin... 28, 44 ogestrel (28)... 3 olanzapine... 7 olanzapine-fluoxetine... 47 olopatadine... 4 OLYSIO... 77 omega-3 acid ethyl esters... 02 omeprazole... 47, 48 omeprazole magnesium... 47 omeprazole-sodium bicarbonate... 48 ONCASPAR... 36 oncovite... 24 ondansetron... 65 ondansetron hcl... 65 ondansetron hcl (pf)... 65 one daily... 24, 27 one daily 50 plus... 209 one daily complete... 24 one daily energy... 27 one daily essential 209, 2, 24 one daily maximum (with ca)... 209 one daily multi-vit w-mineral... 24 one daily multivitamin... 24 one daily multivit-iron(folic) 24 one daily plus iron 2, 24, 27 one daily plus minerals... 24 one daily with iron... 24 one-a-day essential... 24 one-a-day maximum formula24 one-a-day teen advantage... 24 ONFI... 8, 34 opcicon one-step... 3 OPDIVO... 36 OPSUMIT... 202 option 2... 3 opti-vitamins... 29 oral saline laxative... 57 oralone... 26 ORENCIA... 69 ORENCIA (WITH MALTOSE)... 69 ORENCIA CLICKJECT... 8 ORENITRAM... 202 ORFADIN... 37, 8 ORKAMBI... 99 orsythia... 3 OTEZLA... 8 OTEZLA STARTER... 8 I-6 VillageCareMAX Full Advantage FIDA Plan 206 Formulary Formulary ID:65.000 Version: 9 Effective: December 0, 206

OTREXUP (PF)... 82 oxacillin... 26 oxacillin in dextrose(iso-osm) 26 oxandrolone... 60 oxcarbazepine... 42 OXTELLAR XR... 42 oxybutynin chloride... 59 oxycodone... 9 oxycodone-acetaminophen... 9 oxycodone-aspirin... 9 OXYCONTIN... 9 oxymorphone... 9, 0 oysco 500/d... 9 oysco d... 9 oysco-500... 9 oyster shell calcium 500... 9 oyster shell calcium-vit d2... 94 oyster shell calcium-vit d3... 9 oystercal-d... 9 P pacerone... 92 pain relief... 0 pain relief adult... 5 pain reliever jr strength... 0 paliperidone... 7 pancrelipase 5000... 37 PANRETIN... 28 PANTILINERS... 82 pantoprazole... 48 papaverine... 98 paricalcitol... 78 PARICALCITOL... 78 paromomycin... 67 paroxetine hcl... 47 PASER... 64 PATADAY... 4 PAXIL... 47 pecgen dmx... 20 pedia relief... 24 pedia relief cough-cold... 20 pedia relief infant... 25 pediacare multi-symptom cold... 2 PEDIARIX (PF)... 73 pediatric electrolyte... 87, 9, 94 pediatric freezer pops... 94 pediatric multivitamin.. 23, 28 PEDVAX HIB (PF)... 73 peg 3350-electrolytes... 57 PEGANONE... 42 PEGASYS... 78 PEGASYS PROCLICK... 78 peg-electrolyte soln... 57 PEGINTRON... 78 PEN NEEDLE, DIABETIC. 36 penicillin g pot in dextrose... 26 penicillin g potassium... 27 penicillin g procaine... 27 penicillin v potassium... 27 PENTACEL (PF)... 73 PENTAM... 67 pentoxifylline... 83 pep-t-med... 52 peri-colace... 57 PERIKABIVEN... 87 perindopril erbumine... 9 periogard... 26 permethrin... 35 perphenazine... 7 perphenazine-amitriptyline... 47 persa-gel... 28 pfizerpen-g... 27 pharbetol... 0 pharmacist favorite multi-vit 24 phenadoz... 65 phenelzine... 47 phenobarbital... 42 phenobarbital sodium... 43 phenylephrine hcl... 89, 4 phenylhistine dh... 2 phenytoin... 43 phenytoin sodium... 43 phenytoin sodium extended... 43 philith... 3 phillips... 53 phillips liqui-gels... 57 PHOSLYRA... 58 PHOS-NAK... 92 phospha 250 neutral... 92 phosphate laxative... 57 PHOSPHOLINE IODIDE... 85 phytonadione (vitamin k)... 224 PICATO... 28 pilocarpine hcl... 26, 85 pimozide... 7 pimtrea (28)... 3 pindolol... 93 pink bismuth... 53 pioglitazone... 50 pioglitazone-glimepiride... 50 pioglitazone-metformin... 50 piperacillin-tazobactam... 27 pirmella... 3 piroxicam... 4 PLAN B ONE-STEP... 3 PLASMA-LYTE 48... 92 PLASMA-LYTE A... 92 PLASMA-LYTE-56 IN 5 % DEXTROSE... 92 PLEGRIDY... 82 podocon... 28 podofilox... 28 polyethylene glycol 3350... 57 poly-iron... 25 polymyxin b sulfate... 20 polymyxin b sulf-trimethoprim... 44 poly-tussin... 2 poly-vita... 25 poly-vita (iron)... 25 poly-vitamin... 25 poly-vitamin with iron... 25 poly-vitamins... 25 POMALYST... 36 I-7 VillageCareMAX Full Advantage FIDA Plan 206 Formulary Formulary ID:65.000 Version: 9 Effective: December 0, 206

portia... 3 PORTRAZZA... 36 potassium acetate... 92 potassium bicarb and chloride... 92 potassium bicarb-citric acid. 92 potassium chlorid-d5-0.45%nacl... 92 potassium chloride 92, 93, 94 potassium chloride in 0.9%nacl... 92 potassium chloride in 5 % dex... 92 potassium chloride in lr-d5.. 92 potassium chloride-0.45 % nacl... 93 potassium chloride-d5-0.2%nacl... 93 potassium chloride-d5-0.3%nacl... 93 potassium chloride-d5-0.9%nacl... 93 potassium citrate... 93 potassium citrate-citric acid. 93 potassium hydroxide... 28 potassium phosphate m-/d-basic... 94 POTIGA... 43 PRADAXA... 80 PRALUENT PEN... 02 PRALUENT SYRINGE... 02 pramipexole... 68 pravastatin... 02 prazosin... 89 prednicarbate... 34 prednisolone acetate... 46 prednisolone sodium phosphate... 46, 63 prednisone... 63 PREMARIN... 62 PREMASOL 0 %... 88 PREMASOL 6 %... 88 PREMPHASE... 62 PREMPRO... 62 prenatal... 2, 25, 29 prenatal formula... 26 prenatal plus (calcium carb). 24 prenatal tablet... 27 prenatal vit#96-ferrous fum-fa... 25 prenatal vitamin... 207, 25 prenatal vitamin plus low iron... 25 prenatal vitamin with minerals... 25 prenatal vit-iron fumarate-fa 25 preparation h hydrocortisone 34 PREVAIL BLADDER CONTROL PAD... 54 prevalite... 02 PREVIDENT 5000 SENSITIVE... 26 previfem... 3 PREZCOBIX... 75 PREZISTA... 75 PRIFTIN... 64 PRILOSEC OTC... 48 PRIMAQUINE... 67 primidone... 43 PRISTIQ... 47 PRIVIGEN... 69 PROAIR HFA... 97 PROAIR RESPICLICK... 97 probenecid... 82 probenecid-colchicine... 82 procainamide... 92 PROCALAMINE 3%... 88 prochlorperazine... 66 prochlorperazine edisylate... 66 prochlorperazine maleate... 66 PROCRIT... 8, 82 procto-med hc... 34 procto-pak... 34 proctosol hc... 34 proctozone-hc... 34 PROCYSBI... 82 progesterone in oil... 66 progesterone micronized... 66 PROGLYCEM... 04 PROGRAF... 70 PROLASTIN-C... 99 PROLENSA... 46 PROLEUKIN... 36 PROLIA... 78 PROMACTA... 82 promethazine... 60, 66 promethazine vc-codeine... 2 promethazine-codeine... 2 promethazine-dm... 2 promethegan... 66 promolaxin... 57 propafenone... 92 propantheline... 39 proparacaine... 4 propranolol... 93 propranolol-hydrochlorothiazid... 93 propylthiouracil... 66 PROQUAD (PF)... 73 prosight... 25 PROSOL 20 %... 88 protamine... 82 protriptyline... 48 pseudoephedrine hcl... 2 PULMOZYME... 37 pure and gentle eye... 4 purelax... 55 PURIXAN... 36 pyrazinamide... 64 pyridostigmine bromide... 82 pyridoxine (vitamin b6)... 26 Q q-dryl... 60 q-pap... 0 q-pap extra strength... 0 q-tapp dm... 2 I-8 VillageCareMAX Full Advantage FIDA Plan 206 Formulary Formulary ID:65.000 Version: 9 Effective: December 0, 206

q-tussin... 2 q-tussin dm... 2 QUADRACEL (PF)... 74 quasense... 3 quetiapine... 7 QUILLIVANT XR... 06 quinapril... 9 quinapril-hydrochlorothiazide 9 quinidine gluconate... 92 quinidine sulfate... 92 quinine sulfate... 67 QVAR... 96 R RABAVERT (PF)... 74 raloxifene... 62 ramipril... 9 RANEXA... 98 ranitidine hcl... 48 RAPAMUNE... 70 RASUVO (PF)... 82 RAVICTI... 53 react... 3 REBIF (WITH ALBUMIN) 82 REBIF REBIDOSE... 83 REBIF TITRATION PACK 83 reclipsen (28)... 3 RECOMBIVAX HB (PF)... 74 recort plus... 34 refenesen... 22 refenesen pe... 22 REFRESH CELLUVISC... 4 REFRESH CLASSIC (PF).. 4 REFRESH LACRI-LUBE... 4 REFRESH OPTIVE... 4 REFRESH OPTIVE ADVANCED... 44 reguloid... 57 relcof c... 22 RELENZA DISKHALER... 76 RELISTOR... 53 remedy phytoplex antifungal. 56 REMICADE... 83 REMODULIN... 202 RENAGEL... 58 rena-vite rx... 27 RENVELA... 58, 59 repaglinide... 50 repaglinide-metformin... 50 REPATHA PUSHTRONEX 02 REPATHA SURECLICK... 02 REPATHA SYRINGE... 02 reprexain... 0 RESCRIPTOR... 75 RESTASIS... 46 retaine cmc... 4 RETROVIR... 75 revive plus... 39 REVLIMID... 36 revonto... 200 REXULTI... 7 REYATAZ... 75 REZIRA... 22 ribasphere... 78 RIDAURA... 70 rifabutin... 64 rifampin... 64 RIFATER... 64 ri-gel ii... 53 riluzole... 06 rimantadine... 76 ri-mox... 53 ringers... 76, 94 risedronate... 78 RISPERDAL CONSTA... 7 risperidone... 72 RITUXAN... 36 rivastigmine... 45 rivastigmine tartrate... 45 rizatriptan... 63 robafen... 22 robafen cough... 22 robafen dm... 22 robitussin cough-chest cong dm... 22 ROBITUSSIN LONG-ACTING... 22 robitussin pediatric... 22 ropinirole... 68 rosadan... 30 rosuvastatin... 02 ROTARIX... 74 ROTATEQ VACCINE... 74 ROWEEPRA... 43 roxicet... 0 ROZEREM... 200 rydex... 22 rynex dm... 23 S SABRIL... 43 safe tussin dm... 23 SAIZEN... 65 SAIZEN CLICK.EASY... 65 saline mist... 4 SANDOSTATIN LAR DEPOT... 65 SANTYL... 28 SAPHRIS (BLACK CHERRY)... 72 SAVELLA... 06 scooby-doo one a day... 28 scot-tussin dm... 23 scot-tussin expectorant... 23 sea soft nasal mist... 42 selegiline hcl... 68 selenium sulfide... 30 SELZENTRY... 75 senexon... 58 senior tabs... 28 senna... 57, 58 senna lax... 58 senna laxative... 55 senna with docusate sodium. 55 senokot-s... 58 SENSIPAR... 83 sentry... 28 sentry senior... 28 I-9 VillageCareMAX Full Advantage FIDA Plan 206 Formulary Formulary ID:65.000 Version: 9 Effective: December 0, 206

SEREVENT DISKUS... 97 SEROSTIM... 65 sertraline... 48 setlakin... 3 sharobel... 3 SIGNIFOR... 83 silace... 58 siladryl sa... 60 silapap... 0 sildenafil... 202 SILENOR... 48 siltussin sa... 23 silver nitrate... 30 silver sulfadiazine... 30 SIMBRINZA... 85 simethicone... 46 simply sleep... 60 SIMPONI... 83 SIMPONI ARIA... 83 simvastatin... 02 sinus and allergy(pseudoephed)... 60 sirolimus... 70 SIRTURO... 64 skin treatment... 28 sleep aid (diphenhydramine).. 60 sleep aid (doxylamine)... 60 smoflipid... 88 smoothlax... 58 sodium acetate... 94 sodium bicarbonate... 54, 94 sodium chloride... 42, 76, 95, 99 sodium chloride 0.45 %... 94 sodium chloride 0.9 %... 94 sodium chloride 3 %... 94 sodium chloride 5 %... 95 sodium fluoride... 29 sodium lactate... 95 sodium phosphate... 95 sodium polystyrene (sorb free)... 54 sodium polystyrene sulfonate... 54 sodium thiosulfate... 60 SOLTAMOX... 37 SOLU-CORTEF (PF)... 63 SOMATULINE DEPOT... 65 SOMAVERT... 65 soothe (bismuth subsalicylate)... 54 soothe regular strength... 54 sorbitol... 76 sorbitol-mannitol... 76 sorine... 93 sotalol... 93 sotalol af... 93 SOVALDI... 77 spectravite... 207 spectravite adult 50+... 207 spectravite advanced formula... 207 spectravite senior... 207 spectravite senior w-lycopene... 207 spectravite ultra women... 207 SPIRIVA RESPIMAT... 97 SPIRIVA WITH HANDIHALER... 97 spironolactone... 03 spironolacton-hydrochlorothiaz... 03 sprintec (28)... 3 SPRITAM... 43 SPRYCEL... 37 sps (with sorbitol)... 54 sronyx... 3 ssd... 30 st joseph aspirin... 4 st. joseph aspirin... 4 stavudine... 75 STELARA... 83 STERILE PADS... 83 STIOLTO RESPIMAT... 40 STIVARGA... 37 stomach relief... 54 stool softener... 55 STRATTERA... 06 STRENSIQ... 37 streptomycin... 8 stress 500 plus zinc... 26 stress b with zinc... 29 stress b-biotin... 29 stress formula... 29 stress formula plus iron... 29 stress formula with iron... 29 stress formula with zinc... 29 STRIBILD... 75 STRIVERDI RESPIMAT... 98 sucralfate... 48 sudafed... 24 sudogest... 24 sudogest sinus and allergy... 6 sulfacetamide sodium... 44 sulfacetamide sodium (acne) 30 sulfacetamide-prednisolone.. 44 sulfadiazine... 28 sulfamethoxazole-trimethoprim... 28 sulfasalazine... 28 sulfatrim... 28 sulindac... 4 sumatriptan... 63 sumatriptan succinate... 63 summer's eve disposable douche... 83 summers eve extra cleansing 83 sunvite... 220 super b complex-vitamin c.. 207, 29, 220 super b maxi complex... 220 super b/c... 220 super b-50 complex... 220 super b-50 complex plus... 220 super multiple... 220 super multivitamin... 220 I-20 VillageCareMAX Full Advantage FIDA Plan 206 Formulary Formulary ID:65.000 Version: 9 Effective: December 0, 206

super quints... 220 super quints b-50... 220 super thera vite m... 220 superior 35... 220 superplex-t... 220 suphedrin... 24 suphedrine pe day-night... 24 suphedrine severe cold max str... 24 support... 220 support-500... 220 SUPPRELIN LA... 65 SUPRAX... 23 SURMONTIL... 48 SUSTIVA... 75 SUTENT... 37 syeda... 3 SYLATRON... 78 SYLVANT... 37 SYMLINPEN 20... 50 SYMLINPEN 60... 50 SYNAGIS... 76 SYNAREL... 83 SYNERCID... 20 SYNJARDY... 50 SYNRIBO... 37 SYPRINE... 60 SYSTANE (PROPYLENE GLYCOL)... 42 SYSTANE GEL... 42 T tab-a-vite... 220 tab-a-vite/iron... 22 tab-a-vite-minerals... 22 TABLOID... 37 tacrolimus... 34, 70 tactinal... 0 tactinal extra strength... 0 TAFINLAR... 37 TAGRISSO... 37 TALTZ AUTOINJECTOR.. 29 TALTZ SYRINGE... 29 TAMIFLU... 76, 77 tamoxifen... 37 tamsulosin... 59 TARCEVA... 37 TARGRETIN... 37 tarina fe /20 (28)... 3 TASIGNA... 37 tazicef... 23 TAZORAC... 34 taztia xt... 94 tears again... 42 tears again (pva)... 42 tears naturale free (pf)... 42 TECENTRIQ... 37 TECFIDERA... 84 TECHNIVIE... 77 TEFLARO... 23 telmisartan... 89 telmisartan-hydrochlorothiazid... 90 TEMODAR... 38 tencon... TENIVAC (PF)... 74 terazosin... 59 terbinafine hcl... 56 terbutaline... 98 terconazole... 62 testosterone... 6 testosterone cypionate... 60 testosterone enanthate... 6 TETANUS TOXOID,ADSORBED (PF)... 74 TETANUS,DIPHTHERIA TOX PED(PF)... 74 tetanus-diphtheria toxoids-td 74 tetrabenazine... 06 tetracaine hcl (pf)... 42 tetracycline... 29 THALOMID... 84 the magic bullet... 56 theochron... 98 theophylline... 98 theophylline in dextrose 5 % 98 thera m plus (ferrous fumarat)... 22 thera vitamin... 22 thera-d... 22 theradex m... 22 THERAFLU DAYTIME COLD-COUGH... 24 THERAFLU MULTI- SYMPTOM COLD... 24 thera-m... 22 therapeutic liquid... 22 therapeutic m + beta-carotene... 27 therapeutic-m... 22 therapeutic-m vitamin/minerals... 29 thera-tabs... 22 theratrum complete 50 plus.. 22 theratrum complete 50 plus/lut... 22 thiamine hcl (vitamin b)... 22 thioridazine... 72 thiotepa... 38 thiothixene... 72 tiagabine... 43 TICE BCG... 70 tilia fe... 3 timolol maleate... 94, 85 TIVICAY... 75 tizanidine... 200 TOBI PODHALER... 8 TOBRADEX... 44 TOBRADEX ST... 44 tobramycin... 44 tobramycin in 0.225 % nacl... 8 tobramycin in 0.9 % nacl... 8 tobramycin sulfate... 8 tobramycin-dexamethasone.. 44 TOLAK... 29 tolazamide... 52 I-2 VillageCareMAX Full Advantage FIDA Plan 206 Formulary Formulary ID:65.000 Version: 9 Effective: December 0, 206

tolbutamide... 52 tolmetin... 4 tolnaftate... 56 tolterodine... 59 topiragen... 43 topiramate... 43 toposar... 38 torsemide... 00 total b/c... 22 totalday multiple... 22 TOUJEO SOLOSTAR... 5 TOVIAZ... 59 TPN ELECTROLYTES... 95 TPN ELECTROLYTES II... 95 TRACLEER... 202 TRADJENTA... 50 tramadol... tramadol-acetaminophen... trandolapril... 9 tranexamic acid... 82 TRANSDERM-SCOP... 66 tranylcypromine... 48 TRAVASOL 0 %... 88 TRAVATAN Z... 85 travel sickness (meclizine)... 66 travoprost (benzalkonium)... 85 trazodone... 48 TREANDA... 38 TRECATOR... 64 TRELSTAR... 38 tretinoin... 35 tretinoin (chemotherapy)... 38 tretinoin microspheres.. 34, 35 TREXALL... 38 triacting m-sym cold/cough. 25 triamcinolone acetonide... 26, 34, 63 triaminic cold and cough (pe)... 24 TRIAMINIC COLD AND COUGHNT(PE)... 6 TRIAMINIC COUGH-SORE THROAT... 24 triamterene-hydrochlorothiazid... 00 trianex... 34 TRIBENZOR... 90 tri-buffered aspirin... 4 tri-dex pe... 24 tri-estarylla... 3 trifluoperazine... 72 trifluridine... 44 trihexyphenidyl... 68 tri-legest fe... 4 tri-linyah... 4 tri-lo-estarylla... 4 tri-lo-marzia... 4 tri-lo-sprintec... 4 trilyte with flavor packets... 58 trimethoprim... 20 trimipramine... 48 trinessa (28)... 4 TRINTELLIX... 48 triple antibiotic... 29, 30 triple paste af... 56 tri-previfem (28)... 4 tri-sprintec (28)... 4 TRIUMEQ... 75 tri-vi-sol... 22 tri-vita... 22 tri-vitamin... 222 trivora (28)... 4 TROKENDI XR... 44 TROPHAMINE 0 %... 88 TROPHAMINE 6%... 88 trospium... 59 TRULICITY... 50 TRUMENBA... 74 TRUVADA... 75 trymine cg... 24 TUDORZA PRESSAIR... 98 tusnel diabetic... 24 TUSNEL NEW FORMULA 24 TUSNEL PEDIATRIC... 24 TUSSI PRES-B... 24 tussin cf... 24, 25 tussin cf cough-cold... 25 tussin cold-congestion... 25 tussin cough (dm only)... 8 tussin dm... 22, 25 tussin dm cough and chest... 8 tussin maximum strength... 22 tussin pe... 2 TWINRIX (PF)... 75 TYBOST... 84 TYGACIL... 29 TYKERB... 38 TYPHIM VI... 75 TYSABRI... 70 TYVASO... 202 TYVASO REFILL KIT... 202 TYVASO STARTER KIT... 202 TYZEKA... 78 U u-cort... 34 ULORIC... 84 ultra b-00 complex... 222 ultra fresh pm... 42 ultra strength antacid... 49 unisom sleepgels... 6 UNITUXIN... 38 UPTRAVI... 202, 203 ursodiol... 54 V VAGIFEM... 62 valacyclovir... 78 VALCHLOR... 29 valganciclovir... 79 valproate sodium... 44 valproic acid... 44 valproic acid (as sodium salt). 44 valsartan... 90 valsartan-hydrochlorothiazide 90 VALSTAR... 38 valu-tapp dm... 23 I-22 VillageCareMAX Full Advantage FIDA Plan 206 Formulary Formulary ID:65.000 Version: 9 Effective: December 0, 206

VANACOF... 25 vancomycin... 20, 2 vancomycin in dextrose 5 %.. 20 VAQTA (PF)... 75 VARIVAX (PF)... 75 VASCEPA... 03 v-c forte... 222 VELCADE... 38 velivet triphasic regimen (28)... 4 VENCLEXTA... 38 VENCLEXTA STARTING PACK... 38 venlafaxine... 48 VENTOLIN HFA... 98 verapamil... 94, 95 VERSACLOZ... 72 vestura (28)... 4 VGO 40... 36 VIBERZI... 54 vic-forte... 222 vicks dayquil cold-flu relief. 25 vicks dayquil cough... 25 vicks nature fusion cough... 25 vicks nyquil severe cold-flu. 25 vicks qlearquil(oxymetazoline)... 42 vicks sinex 2-hour... 42 vicodin... vicodin es... vicodin hp... VICTOZA 3-PAK... 50 VIDEX 2 GRAM PEDIATRIC... 76 VIDEX 4 GRAM PEDIATRIC... 76 VIEKIRA PAK... 77 VIEKIRA XR... 77 vienva... 4 VIGAMOX... 44 VIIBRYD... 48 VIMIZIM... 37 VIMPAT... 44 vinorelbine... 39 viorele (28)... 4 VIRACEPT... 76 VIRAMUNE XR... 76 VIRAZOLE... 79 virdec dm... 25 VIREAD... 76 virt-phos 250 neutral... 95 virtussin ac... 25 vision... 222 vision formula (with lutein) 207, 222 vision plus lutein... 222 vit b complex-folic acid... 29 VITAFOL FE+ (WITH DOCUSATE)... 222 vitalets... 222 vitamin a... 222 vitamin b complex... 204, 27 vitamin b-00 complex... 208 vitamin b2-folic acid... 223 vitamin b-6... 223 vitamin c... 27, 223 vitamin d3... 29, 223, 224 vitamins and minerals... 222 vitamins b complex... 204, 222 vitamins for hair... 224 VITEKTA... 76 vitrum senior... 224 VOLTAREN... 4 voriconazole... 56 VOTRIENT... 39 VPRIV... 37 VRAYLAR... 72 vyfemla (28)... 4 W wal-act d cold and allergy... 6 wal-dram... 66 wal-dryl allergy... 6 wal-fex allergy... 6 wal-finate... 6 wal-finate-d... 6 wal-itin... 6 wal-itin d... 6 wal-itin d 2 hour... 6 wal-phed... 6, 25 wal-phed pe day-night... 25 wal-phed pe sinus and allergy 6 wal-profen... 4 wal-sleep z... 62 wal-som (diphenhydramine).. 62 wal-som (doxylamine)... 62 wal-tap... 62 wal-tussin cough... 25, 26 wal-tussin cough and cold cf 26 wal-tussin dm... 5 wal-zan 75... 48 wal-zyr (cetirizine)... 62 wal-zyr d... 62 warfarin... 80 water for irrigation, sterile... 76 WELCHOL... 03 wera (28)... 4 womens daily gummies... 208 women's daily multivitamin. 26 X XALKORI... 39 XARELTO... 80 XELJANZ... 84 XELJANZ XR... 84 XIFAXAN... 2 XIIDRA... 46 XOLAIR... 99 XTANDI... 39 xulane... 4 xylon 0... XYREM... 200 Y yelets... 224 YERVOY... 39 YF-VAX (PF)... 75 YONDELIS... 39 I-23 VillageCareMAX Full Advantage FIDA Plan 206 Formulary Formulary ID:65.000 Version: 9 Effective: December 0, 206

Z zafirlukast... 96 zaleplon... 20 ZANTAC... 48, 49 ZANTAC 75... 49 zarah... 4 ZARXIO... 82 ZAVESCA... 37 zebutal... ZELBORAF... 39 ZEMPLAR... 78 zenatane... 29 zenchent (28)... 4 ZENPEP... 38 ZEPATIER... 77 zephrex-d... 26 ZETIA... 03 ZIAGEN... 76 zidovudine... 76 ZINBRYTA... 84 zinc oxide... 29 ziprasidone hcl... 72 ZIRGAN... 45 ZOLADEX... 39 zoledronic acid... 78 zoledronic acid-mannitol-water... 78 ZOLINZA... 39 zolmitriptan... 63 zolpidem... 20 ZOMETA... 78 ZONATUSS... 26 zonisamide... 44 zoo chews... 224 ZORTRESS... 70 ZOSTAVAX (PF)... 75 zovia /35e (28)... 4 zovia /50e (28)... 4 ZOVIRAX... 29 z-sleep... 60, 6 ZUBSOLV... 7 ZYDELIG... 39 ZYKADIA... 39 ZYLET... 45 zyncof... 26 ZYPREXA RELPREVV... 72 ZYRTEC... 62 ZYTIGA... 39 ZYVOX... 2 I-24 VillageCareMAX Full Advantage FIDA Plan 206 Formulary Formulary ID:65.000 Version: 9 Effective: December 0, 206

Formulary ID: 65.000, Version 9