HMSA QUEST Formulary Eff 10/01/2019

Home , Clidinium bromide, Latanoprost, Pyridoxine, Tolnaftate

HMSA QUEST Integration Managed Medicaid Formulary

(Effective 12/01/2019)

LEGEND

AL Age Limit OTC Over the Counter PA Prior Authorization QL Quantity Limit SP Specialty Drug ST Step Therapy + Indicates both the generic is covered as well as the brand-name product equivalent, with dispense as written code 1 (DAW 1). This includes State-mandated drug classes (HIV and AIDS, Antidepressants, Antipsychotics, Antianxiety Agents, and Immunosuppressants). lowercase lowercase type indicates generic availability UPPERCASE UPPERCASE type indicates brand availability

NOTE The status of a drug on this list is current as of the date of this publication.

The list serves as a guide to product selection for our providers and members. The list is subject to change. Participating pharmacies have the most up-to-date formulary information at the time prescriptions are filled. New drugs, strengths, forms, and/or therapeutic categories introduced in the marketplace will be reflected in the formulary, as applicable, following the completion of HMSA’s review process.

Not all generic drugs may be listed.

Coverage of a drug will depend on your drug plan.

HMSA's mission is to provide the people of Hawaii access to a sustainable, quality health care system that improves the overall health and well-being of our state.

HMSA CENTERS Convenient evening and Saturday hours:

HMSA Center @ Honolulu 818 Keeaumoku St. Monday through Friday, 8 a.m. - 6 p.m. | Saturday, 9 a.m. - 2 p.m.

HMSA Center @ Pearl City Pearl City Gateway | 1132 Kuala St., Suite 400 Monday through Friday, 9 a.m. - 7 p.m. | Saturday, 9 a.m. - 2 p.m.

HMSA Center @ Hilo Waiakea Center | 303A E. Makaala St. Monday through Friday, 9 a.m. - 7 p.m. | Saturday, 9 a.m. - 2 p.m.

OFFICES Visit your local HMSA office Monday through Friday, 8 a.m. - 4 p.m.:

PHONE 948-6372 on Oahu

If you are calling from the U.S. Mainland, please call 1 (800) 776-4672. If you need to call a local Hawaii telephone number from the Mainland, the area code is 808.

Check hmsa.com/contact for our holiday schedule.

This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers.

Plan member privacy is important to us. Our employees are trained regarding the appropriate way to handle members' private health information.

2 Drug Name Requirements/Limits ANALGESICS COX-II INHIBITORS celecoxib cap 50 mg ST (Must have recently been on 30 days supply of NSAID or GI protectant OR be taking a drug that could cause adverse GI events) celecoxib cap 100 mg ST (Must have recently been on 30 days supply of NSAID or GI protectant OR be taking a drug that could cause adverse GI events) celecoxib cap 200 mg ST (Must have recently been on 30 days supply of NSAID or GI protectant OR be taking a drug that could cause adverse GI events) celecoxib cap 400 mg ST (Must have recently been on 30 days supply of NSAID or GI protectant OR be taking a drug that could cause adverse GI events) GOUT allopurinol tab 100 mg allopurinol tab 300 mg colchicine tab 0.6 mg QL (30 per month) probenecid tab 500 mg NON-OPIOID ANALGESICS acetaminophen cap 500 mg OTC acetaminophen chew tab 80 mg OTC acetaminophen chew tab 160 mg OTC acetaminophen disintegrating tab 80 mg OTC acetaminophen disintegrating tab 160 mg OTC acetaminophen elixir 160 mg/5ml OTC acetaminophen liquid 160 mg/5ml OTC acetaminophen liquid 167 mg/5ml OTC acetaminophen soln 160 mg/5ml OTC acetaminophen suppos 120 mg OTC acetaminophen suppos 325 mg OTC acetaminophen suppos 650 mg OTC acetaminophen susp 80 mg/0.8ml OTC acetaminophen susp 160 mg/5ml OTC acetaminophen tab 325 mg OTC acetaminophen tab 500 mg OTC acetaminophen tab er 650 mg OTC

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 3 Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit Drug Name Requirements/Limits butalbital-acetaminophen-caffeine cap 50-325-40 QL (60 per month) mg butalbital-acetaminophen-caffeine tab 50-325-40 QL (60 per month) mg butalbital-aspirin-caffeine cap 50-325-40 mg QL (60 per month) FEVERALL INF SUP 80MG OTC FEVERALL SUP 325MG OTC NSAIDS diclofenac potassium tab 50 mg diclofenac sodium tab delayed release 25 mg diclofenac sodium tab delayed release 50 mg diclofenac sodium tab delayed release 75 mg diclofenac sodium tab er 24hr 100 mg diflunisal tab 500 mg etodolac cap 200 mg etodolac cap 300 mg etodolac tab 400 mg etodolac tab 500 mg etodolac tab er 24hr 400 mg etodolac tab er 24hr 500 mg etodolac tab er 24hr 600 mg flurbiprofen tab 50 mg flurbiprofen tab 100 mg ibuprofen cap 200 mg OTC ibuprofen chew tab 100 mg OTC ibuprofen susp 40 mg/ml OTC ibuprofen susp 100 mg/5ml ibuprofen susp 100 mg/5ml OTC ibuprofen tab 100 mg OTC ibuprofen tab 200 mg OTC ibuprofen tab 400 mg ibuprofen tab 600 mg ibuprofen tab 800 mg ketorolac tromethamine tab 10 mg QL (20 per month) meloxicam tab 7.5 mg meloxicam tab 15 mg nabumetone tab 500 mg nabumetone tab 750 mg naproxen sodium cap 220 mg OTC naproxen sodium tab 220 mg OTC naproxen sodium tab 275 mg naproxen sodium tab 550 mg naproxen susp 125 mg/5ml naproxen tab 250 mg

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 4 Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit Drug Name Requirements/Limits naproxen tab 375 mg naproxen tab 500 mg naproxen tab ec 375 mg naproxen tab ec 500 mg oxaprozin tab 600 mg sulindac tab 150 mg sulindac tab 200 mg NSAIDS, TOPICAL diclofenac sodium gel 1% QL (500 grams per month) OPIOID ANALGESICS acetaminophen w/ codeine soln 120-12 mg/5ml QL (5000 mL per month) acetaminophen w/ codeine tab 300-15 mg QL (400 per month) acetaminophen w/ codeine tab 300-30 mg QL (400 per month) acetaminophen w/ codeine tab 300-60 mg QL (400 per month) fentanyl td patch 72hr 12 mcg/hr QL (20 per month) fentanyl td patch 72hr 25 mcg/hr QL (20 per month) fentanyl td patch 72hr 50 mcg/hr QL (20 per month) fentanyl td patch 72hr 75 mcg/hr QL (20 per month) fentanyl td patch 72hr 100 mcg/hr QL (20 per month) hydrocodone-acetaminophen soln 7.5-325 QL (5540 mL per month) mg/15ml hydrocodone-acetaminophen tab 5-325 mg QL (375 per month) hydrocodone-acetaminophen tab 7.5-325 mg QL (375 per month) hydrocodone-acetaminophen tab 10-325 mg QL (375 per month) hydromorphone hcl tab 2 mg QL (180 per month) hydromorphone hcl tab 4 mg QL (180 per month) hydromorphone hcl tab 8 mg QL (180 per month) methadone hcl tab 5 mg methadone hcl tab 10 mg morphine sulfate oral soln 10 mg/5ml QL (900 mL per month) morphine sulfate oral soln 20 mg/5ml QL (900 mL per month) morphine sulfate oral soln 100 mg/5ml (20 mg/ml) QL (180 mL per month) morphine sulfate tab 15 mg QL (180 per month) morphine sulfate tab 30 mg QL (180 per month) morphine sulfate tab er 15 mg QL (120 per month) morphine sulfate tab er 30 mg QL (120 per month) morphine sulfate tab er 60 mg QL (120 per month) morphine sulfate tab er 100 mg QL (60 per month) morphine sulfate tab er 200 mg QL (60 per month) oxycodone hcl cap 5 mg QL (180 per month) oxycodone hcl conc 100 mg/5ml (20 mg/ml) QL (180 mL per month) oxycodone hcl soln 5 mg/5ml QL (180 mL per month) oxycodone hcl tab 5 mg QL (180 per month) oxycodone hcl tab 10 mg QL (180 per month)

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 5 Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit Drug Name Requirements/Limits oxycodone hcl tab 15 mg QL (180 per month) oxycodone hcl tab 20 mg QL (180 per month) oxycodone hcl tab 30 mg QL (180 per month) oxycodone w/ acetaminophen tab 2.5-325 mg QL (375 per month) oxycodone w/ acetaminophen tab 5-325 mg QL (375 per month) oxycodone w/ acetaminophen tab 7.5-325 mg QL (375 per month) oxycodone w/ acetaminophen tab 10-325 mg QL (375 per month) oxycodone-aspirin tab 4.8355-325 mg QL (308 per month) tramadol hcl tab 50 mg QL (240 per month) tramadol hcl tab er 24hr 100 mg QL (30 per month) tramadol hcl tab er 24hr 200 mg QL (30 per month) tramadol hcl tab er 24hr 300 mg QL (30 per month) tramadol hcl tab er 24hr biphasic release 300 mg QL (30 per month) tramadol-acetaminophen tab 37.5-325 mg QL (240 per month) ANTI-INFECTIVES AMINOGLYCOSIDES neomycin sulfate tab 500 mg ANTIBACTERIALS, CEPHALOSPORINS, First Generation cefadroxil cap 500 mg cefadroxil for susp 250 mg/5ml cefadroxil for susp 500 mg/5ml cefadroxil tab 1 gm cephalexin cap 250 mg cephalexin cap 500 mg cephalexin cap 750 mg cephalexin for susp 125 mg/5ml cephalexin for susp 250 mg/5ml cephalexin tab 250 mg cephalexin tab 500 mg ANTIBACTERIALS, CEPHALOSPORINS, Second Generation cefprozil for susp 125 mg/5ml cefprozil for susp 250 mg/5ml cefprozil tab 250 mg cefprozil tab 500 mg cefuroxime axetil tab 250 mg cefuroxime axetil tab 500 mg ANTIBACTERIALS, CEPHALOSPORINS, Third Generation cefdinir cap 300 mg cefdinir for susp 125 mg/5ml cefdinir for susp 250 mg/5ml ANTIBACTERIALS, ERYTHROMYCINS/MACROLIDES azithromycin for susp 100 mg/5ml azithromycin for susp 200 mg/5ml

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 6 Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit Drug Name Requirements/Limits azithromycin powd pack for susp 1 gm azithromycin tab 250 mg azithromycin tab 500 mg azithromycin tab 600 mg clarithromycin for susp 125 mg/5ml clarithromycin for susp 250 mg/5ml clarithromycin tab 250 mg clarithromycin tab 500 mg clarithromycin tab er 24hr 500 mg erythromycin ethylsuccinate for susp 200 mg/5ml erythromycin ethylsuccinate tab 400 mg erythromycin stearate tab 250 mg erythromycin tab 250 mg erythromycin tab 500 mg erythromycin tab delayed release 250 mg erythromycin tab delayed release 333 mg erythromycin tab delayed release 500 mg erythromycin w/ delayed release particles cap 250 mg ANTIBACTERIALS, FLUOROQUINOLONES ciprofloxacin hcl tab 100 mg (base equiv) ciprofloxacin hcl tab 250 mg (base equiv) ciprofloxacin hcl tab 500 mg (base equiv) ciprofloxacin hcl tab 750 mg (base equiv) levofloxacin oral soln 25 mg/ml levofloxacin tab 250 mg levofloxacin tab 500 mg levofloxacin tab 750 mg ANTIBACTERIALS, PENICILLINS amoxicillin & k clavulanate chew tab 200-28.5 mg amoxicillin & k clavulanate chew tab 400-57 mg amoxicillin & k clavulanate for susp 200-28.5 mg/5ml amoxicillin & k clavulanate for susp 250-62.5 mg/5ml amoxicillin & k clavulanate for susp 400-57 mg/5ml amoxicillin & k clavulanate for susp 600-42.9 mg/5ml amoxicillin & k clavulanate tab 250-125 mg amoxicillin & k clavulanate tab 500-125 mg amoxicillin & k clavulanate tab 875-125 mg amoxicillin (trihydrate) cap 250 mg amoxicillin (trihydrate) cap 500 mg

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 7 Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit Drug Name Requirements/Limits amoxicillin (trihydrate) chew tab 125 mg amoxicillin (trihydrate) chew tab 250 mg amoxicillin (trihydrate) for susp 125 mg/5ml amoxicillin (trihydrate) for susp 200 mg/5ml amoxicillin (trihydrate) for susp 250 mg/5ml amoxicillin (trihydrate) for susp 400 mg/5ml amoxicillin (trihydrate) tab 500 mg amoxicillin (trihydrate) tab 875 mg ampicillin cap 500 mg AUGMENTIN SUS 125/5ML dicloxacillin sodium cap 250 mg dicloxacillin sodium cap 500 mg penicillin v potassium for soln 125 mg/5ml penicillin v potassium for soln 250 mg/5ml penicillin v potassium tab 250 mg penicillin v potassium tab 500 mg ANTIBACTERIALS, SULFONAMIDES SULFADIAZINE TAB 500MG sulfamethoxazole-trimethoprim susp 200-40 mg/5ml sulfamethoxazole-trimethoprim tab 400-80 mg sulfamethoxazole-trimethoprim tab 800-160 mg ANTIBACTERIALS, TETRACYCLINES demeclocycline hcl tab 150 mg demeclocycline hcl tab 300 mg doxycycline hyclate cap 50 mg doxycycline hyclate cap 100 mg doxycycline hyclate tab 20 mg doxycycline hyclate tab 100 mg doxycycline monohydrate for susp 25 mg/5ml minocycline hcl cap 50 mg minocycline hcl cap 75 mg minocycline hcl cap 100 mg tetracycline hcl cap 250 mg tetracycline hcl cap 500 mg ANTIFUNGALS clotrimazole troche 10 mg fluconazole for susp 10 mg/ml fluconazole for susp 40 mg/ml fluconazole tab 50 mg fluconazole tab 100 mg fluconazole tab 150 mg fluconazole tab 200 mg

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 8 Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit Drug Name Requirements/Limits griseofulvin microsize susp 125 mg/5ml griseofulvin ultramicrosize tab 125 mg griseofulvin ultramicrosize tab 250 mg itraconazole cap 100 mg PA nystatin oral powder nystatin susp 100000 unit/ml nystatin tab 500000 unit terbinafine hcl tab 250 mg QL (1 tab per day; 90 days per year) voriconazole for susp 40 mg/ml PA voriconazole tab 50 mg PA voriconazole tab 200 mg PA ANTIMALARIALS atovaquone-proguanil hcl tab 62.5-25 mg QL (23 per 6 months) atovaquone-proguanil hcl tab 250-100 mg QL (23 per 6 months) chloroquine phosphate tab 250 mg QL (8 per 6 months) chloroquine phosphate tab 500 mg QL (8 per 6 months) mefloquine hcl tab 250 mg QL (8 per 6 months) ANTIRETROVIRALS, ANTIRETROVIRAL ADJUVANTS TYBOST TAB 150MG SP ANTIRETROVIRALS, ANTIRETROVIRAL COMBINATIONS abacavir sulfate-lamivudine tab 600-300 mg SP abacavir sulfate-lamivudine-zidovudine tab 300- SP 150-300 mg ATRIPLA TAB SP BIKTARVY TAB SP CIMDUO TAB 300-300 SP COMBIVIR TAB 150-300 SP; + COMPLERA TAB SP DESCOVY TAB 200/25 SP EPZICOM TAB 600-300 SP; + EVOTAZ TAB 300-150 SP GENVOYA TAB SP lamivudine-zidovudine tab 150-300 mg SP ODEFSEY TAB SP PREZCOBIX TAB 800-150 SP STRIBILD TAB SP SYMFI LO TAB SP SYMFI TAB SP SYMTUZA TAB SP TRIUMEQ TAB SP TRIZIVIR TAB SP; + TRUVADA TAB 100-150 SP

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 9 Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit Drug Name Requirements/Limits TRUVADA TAB 133-200 SP TRUVADA TAB 167-250 SP TRUVADA TAB 200-300 SP ANTIRETROVIRALS, CHEMOKINE RECEPTOR ANTAGONISTS SELZENTRY SOL 20MG/ML SP SELZENTRY TAB 25MG SP SELZENTRY TAB 75MG SP SELZENTRY TAB 150MG SP SELZENTRY TAB 300MG SP ANTIRETROVIRALS, FUSION INHIBITORS FUZEON INJ 90MG SP ANTIRETROVIRALS, INTEGRASE INHIBITORS ISENTRESS CHW 25MG SP ISENTRESS CHW 100MG SP ISENTRESS HD TAB 600MG SP ISENTRESS POW 100MG SP ISENTRESS TAB 400MG SP TIVICAY TAB 10MG SP TIVICAY TAB 25MG SP TIVICAY TAB 50MG SP ANTIRETROVIRALS, NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS EDURANT TAB 25MG SP efavirenz cap 50 mg SP efavirenz cap 200 mg SP efavirenz tab 600 mg SP INTELENCE TAB 25MG SP INTELENCE TAB 100MG SP INTELENCE TAB 200MG SP nevirapine susp 50 mg/5ml SP nevirapine tab 200 mg SP nevirapine tab er 24hr 100 mg SP nevirapine tab er 24hr 400 mg SP RESCRIPTOR TAB 200MG SP SUSTIVA CAP 50MG SP; + SUSTIVA CAP 200MG SP; + SUSTIVA TAB 600MG SP; + VIRAMUNE SUS 50MG/5ML SP; + VIRAMUNE TAB 200MG SP; + VIRAMUNE XR TAB 400MG SP; + ANTIRETROVIRALS, NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS abacavir sulfate soln 20 mg/ml (base equiv) SP

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 10 Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit Drug Name Requirements/Limits abacavir sulfate tab 300 mg (base equiv) SP didanosine delayed release capsule 200 mg SP didanosine delayed release capsule 250 mg SP didanosine delayed release capsule 400 mg SP EMTRIVA CAP 200MG SP EMTRIVA SOL 10MG/ML SP EPIVIR SOL 10MG/ML SP; + EPIVIR TAB 150MG SP; + EPIVIR TAB 300MG SP; + lamivudine oral soln 10 mg/ml SP lamivudine tab 150 mg SP lamivudine tab 300 mg SP RETROVIR CAP 100MG SP; + RETROVIR SYP 50MG/5ML SP; + stavudine cap 15 mg SP stavudine cap 20 mg SP stavudine cap 30 mg SP stavudine cap 40 mg SP VIDEX EC CAP 125MG SP VIDEX EC CAP 200MG SP; + VIDEX EC CAP 250MG SP; + VIDEX EC CAP 400MG SP; + VIDEX SOL 2GM SP ZIAGEN SOL 20MG/ML SP; + ZIAGEN TAB 300MG SP; + zidovudine cap 100 mg SP zidovudine syrup 10 mg/ml SP zidovudine tab 300 mg SP ANTIRETROVIRALS, NUCLEOTIDE REVERSE TRANSCRIPTASE INHIBITORS tenofovir disoproxil fumarate tab 300 mg SP VIREAD POW 40MG/GM SP VIREAD TAB 150MG SP VIREAD TAB 200MG SP VIREAD TAB 250MG SP VIREAD TAB 300MG SP; + ANTIRETROVIRALS, PROTEASE INHIBITORS APTIVUS CAP 250MG SP APTIVUS SOL SP atazanavir sulfate cap 150 mg (base equiv) SP atazanavir sulfate cap 200 mg (base equiv) SP atazanavir sulfate cap 300 mg (base equiv) SP CRIXIVAN CAP 200MG SP

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 11 Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit Drug Name Requirements/Limits CRIXIVAN CAP 400MG SP fosamprenavir calcium tab 700 mg (base equiv) SP INVIRASE TAB 500MG SP KALETRA SOL SP; + KALETRA TAB 100-25MG SP KALETRA TAB 200-50MG SP LEXIVA SUS 50MG/ML SP LEXIVA TAB 700MG SP; + lopinavir-ritonavir soln 400-100 mg/5ml (80-20 SP mg/ml) NORVIR POW 100MG SP NORVIR SOL 80MG/ML SP NORVIR TAB 100MG SP; + PREZISTA SUS 100MG/ML SP PREZISTA TAB 75MG SP PREZISTA TAB 150MG SP PREZISTA TAB 600MG SP PREZISTA TAB 800MG SP REYATAZ CAP 150MG SP; + REYATAZ CAP 200MG SP; + REYATAZ CAP 300MG SP; + REYATAZ POW 50MG SP ritonavir tab 100 mg SP VIRACEPT TAB 250MG SP VIRACEPT TAB 625MG SP ANTITUBERCULAR AGENTS ethambutol hcl tab 100 mg ethambutol hcl tab 400 mg isoniazid syrup 50 mg/5ml AL (covered for ages 18 and under; refer to Dept of Health if > 18 years old) isoniazid tab 100 mg AL (covered for ages 18 and under; refer to Dept of Health if > 18 years old) isoniazid tab 300 mg AL (covered for ages 18 and under; refer to Dept of Health if > 18 years old) pyrazinamide tab 500 mg rifampin cap 150 mg rifampin cap 300 mg ANTIVIRALS, CYTOMEGALOVIRUS AGENTS valganciclovir hcl for soln 50 mg/ml (base equiv) valganciclovir hcl tab 450 mg (base equivalent)

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 12 Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit Drug Name Requirements/Limits ANTIVIRALS, HEPATITIS AGENTS, Hepatitis B adefovir dipivoxil tab 10 mg BARACLUDE SOL .05MG/ML entecavir tab 0.5 mg entecavir tab 1 mg lamivudine tab 100 mg (hbv) ANTIVIRALS, HEPATITIS AGENTS, Hepatitis C MAVYRET TAB 100-40MG SP, PA; for genotypes 1, 2, 3, 4, 5, 6 REBETOL SOL 40MG/ML SP, PA RIBAPAK PAK 800/DAY SP, PA RIBAPAK PAK 1200/DAY SP, PA RIBAPAK TAB 600/DAY SP, PA RIBAPAK TAB 1000/DAY SP, PA ribasphere cap 200mg SP, PA ribasphere tab 200mg SP, PA RIBASPHERE TAB 400MG SP, PA ribasphere tab 600mg SP, PA ribavirin cap 200 mg SP, PA ribavirin tab 200 mg SP, PA ANTIVIRALS, HERPES AGENTS acyclovir cap 200 mg acyclovir susp 200 mg/5ml acyclovir tab 400 mg acyclovir tab 800 mg famciclovir tab 125 mg famciclovir tab 250 mg famciclovir tab 500 mg valacyclovir hcl tab 1 gm valacyclovir hcl tab 500 mg ANTIVIRALS, INFLUENZA AGENTS oseltamivir phosphate cap 30 mg (base equiv) QL (56 caps per 6 months) oseltamivir phosphate cap 45 mg (base equiv) QL (28 caps per 6 months) oseltamivir phosphate cap 75 mg (base equiv) QL (28 caps per 6 months) oseltamivir phosphate for susp 6 mg/ml (base QL (360 mL per 6 months) equiv) MISCELLANEOUS atovaquone susp 750 mg/5ml clindamycin hcl cap 150 mg clindamycin hcl cap 300 mg clindamycin palmitate hcl for soln 75 mg/5ml (base equiv) dapsone tab 25 mg

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 13 Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit Drug Name Requirements/Limits dapsone tab 100 mg DARAPRIM TAB 25MG EMVERM CHW 100MG QL (12 tabs per 365 days) ivermectin tab 3 mg linezolid for susp 100 mg/5ml PA linezolid tab 600 mg PA metronidazole cap 375 mg metronidazole tab 250 mg metronidazole tab 500 mg nitrofurantoin macrocrystalline cap 25 mg nitrofurantoin macrocrystalline cap 50 mg nitrofurantoin macrocrystalline cap 100 mg nitrofurantoin monohydrate macrocrystalline cap 100 mg nitrofurantoin susp 25 mg/5ml PINWORM TAB MEDICINE OTC pyrantel pamoate susp 144 mg/ml (50 mg/ml base OTC equiv) rifabutin cap 150 mg trimethoprim tab 100 mg vancomycin hcl cap 125 mg (base equivalent) QL (80 caps per 10 days) vancomycin hcl cap 250 mg (base equivalent) QL (80 caps per 10 days) ANTINEOPLASTIC AGENTS ALKYLATING AGENTS cyclophosphamide cap 25 mg cyclophosphamide cap 50 mg GLEOSTINE CAP 10MG GLEOSTINE CAP 40MG GLEOSTINE CAP 100MG LEUKERAN TAB 2MG melphalan tab 2 mg MYLERAN TAB 2MG temozolomide cap 5 mg SP, PA temozolomide cap 20 mg SP, PA temozolomide cap 100 mg SP, PA temozolomide cap 140 mg SP, PA temozolomide cap 180 mg SP, PA temozolomide cap 250 mg SP, PA ANTIMETABOLITES capecitabine tab 150 mg SP, PA capecitabine tab 500 mg SP, PA mercaptopurine tab 50 mg methotrexate sodium tab 2.5 mg (base equiv)

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 14 Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit Drug Name Requirements/Limits HORMONAL ANTINEOPLASTICS, ANTIANDROGENS abiraterone acetate tab 250 mg SP, PA bicalutamide tab 50 mg flutamide cap 125 mg HORMONAL ANTINEOPLASTICS, ANTIESTROGENS tamoxifen citrate tab 10 mg (base equivalent) tamoxifen citrate tab 20 mg (base equivalent) toremifene citrate tab 60 mg (base equivalent) HORMONAL ANTINEOPLASTICS, AROMATASE INHIBITORS anastrozole tab 1 mg exemestane tab 25 mg letrozole tab 2.5 mg HORMONAL ANTINEOPLASTICS, PROGESTINS megestrol acetate tab 20 mg megestrol acetate tab 40 mg IMMUNOMODULATORS REVLIMID CAP 2.5MG SP, PA REVLIMID CAP 5MG SP, PA REVLIMID CAP 10MG SP, PA REVLIMID CAP 15MG SP, PA REVLIMID CAP 20MG SP, PA REVLIMID CAP 25MG SP, PA KINASE INHIBITORS AFINITOR TAB 2.5MG SP, PA AFINITOR TAB 5MG SP, PA AFINITOR TAB 7.5MG SP, PA AFINITOR TAB 10MG SP, PA ALECENSA CAP 150MG SP, PA CABOMETYX TAB 20MG SP, QL (30 per month), PA CABOMETYX TAB 40MG SP, QL (30 per month), PA CABOMETYX TAB 60MG SP, QL (30 per month), PA CALQUENCE CAP 100MG SP, PA CAPRELSA TAB 100MG SP, PA CAPRELSA TAB 300MG SP, PA COMETRIQ KIT 60MG SP, PA COMETRIQ KIT 100MG SP, PA COMETRIQ KIT 140MG SP, PA erlotinib hcl tab 25 mg (base equivalent) SP, PA erlotinib hcl tab 100 mg (base equivalent) SP, PA erlotinib hcl tab 150 mg (base equivalent) SP, PA GILOTRIF TAB 20MG SP, PA GILOTRIF TAB 30MG SP, PA GILOTRIF TAB 40MG SP, PA

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 15 Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit Drug Name Requirements/Limits IBRANCE CAP 75MG SP, PA IBRANCE CAP 100MG SP, PA IBRANCE CAP 125MG SP, PA IMBRUVICA CAP 70MG SP, PA IMBRUVICA CAP 140MG SP, PA IMBRUVICA TAB 140MG SP, PA IMBRUVICA TAB 280MG SP, PA IMBRUVICA TAB 420MG SP, PA IMBRUVICA TAB 560MG SP, PA INLYTA TAB 1MG SP, PA INLYTA TAB 5MG SP, PA JAKAFI TAB 5MG SP, PA JAKAFI TAB 10MG SP, PA JAKAFI TAB 15MG SP, PA JAKAFI TAB 20MG SP, PA JAKAFI TAB 25MG SP, PA LENVIMA CAP 4MG SP, PA LENVIMA CAP 8 MG SP, PA LENVIMA CAP 10 MG SP, PA LENVIMA CAP 12MG SP, PA LENVIMA CAP 14 MG SP, PA LENVIMA CAP 18 MG SP, PA LENVIMA CAP 20 MG SP, PA LENVIMA CAP 24 MG SP, PA LORBRENA TAB 25MG SP, PA LORBRENA TAB 100MG SP, PA MEKINIST TAB 0.5MG SP, PA MEKINIST TAB 2MG SP, PA NEXAVAR TAB 200MG SP, PA RYDAPT CAP 25MG SP, PA STIVARGA TAB 40MG SP, PA SUTENT CAP 12.5MG SP, PA SUTENT CAP 25MG SP, PA SUTENT CAP 37.5MG SP, PA SUTENT CAP 50MG SP, PA TAFINLAR CAP 50MG SP, PA TAFINLAR CAP 75MG SP, PA TYKERB TAB 250MG SP, PA VITRAKVI CAP 25MG SP, PA VITRAKVI CAP 100MG SP, PA VITRAKVI SOL 20MG/ML SP, PA VOTRIENT TAB 200MG SP, PA ZELBORAF TAB 240MG SP, PA ZYDELIG TAB 100MG SP, PA

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 16 Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit Drug Name Requirements/Limits ZYDELIG TAB 150MG SP, PA ZYKADIA CAP 150MG SP, PA KINASE INHIBITORS FOR CML imatinib mesylate tab 100 mg (base equivalent) SP, PA imatinib mesylate tab 400 mg (base equivalent) SP, PA MISCELLANEOUS bexarotene cap 75 mg SP, PA ERIVEDGE CAP 150MG SP, PA etoposide cap 50 mg FARYDAK CAP 10MG SP, PA FARYDAK CAP 15MG SP, PA FARYDAK CAP 20MG SP, PA hydroxyurea cap 500 mg IDHIFA TAB 50MG SP, PA IDHIFA TAB 100MG SP, PA leucovorin calcium tab 5 mg leucovorin calcium tab 10 mg leucovorin calcium tab 15 mg leucovorin calcium tab 25 mg LYNPARZA TAB 100MG SP, PA LYNPARZA TAB 150MG SP, PA LYSODREN TAB 500MG MATULANE CAP 50MG RUBRACA TAB 200MG SP, PA RUBRACA TAB 250MG SP, PA RUBRACA TAB 300MG SP, PA tretinoin cap 10 mg VENCLEXTA TAB 10MG SP, PA VENCLEXTA TAB 50MG SP, PA VENCLEXTA TAB 100MG SP, PA VENCLEXTA TAB START PK SP, PA VISTOGARD PAK 10GM ZEJULA CAP 100MG SP, PA ZOLINZA CAP 100MG SP, PA CARDIOVASCULAR ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS amlodipine besylate-benazepril hcl cap 2.5-10 mg amlodipine besylate-benazepril hcl cap 5-10 mg amlodipine besylate-benazepril hcl cap 5-20 mg amlodipine besylate-benazepril hcl cap 5-40 mg amlodipine besylate-benazepril hcl cap 10-20 mg amlodipine besylate-benazepril hcl cap 10-40 mg

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 17 Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit Drug Name Requirements/Limits ACE INHIBITOR/DIURETIC COMBINATIONS benazepril & hydrochlorothiazide tab 5-6.25 mg benazepril & hydrochlorothiazide tab 10-12.5 mg benazepril & hydrochlorothiazide tab 20-12.5 mg benazepril & hydrochlorothiazide tab 20-25 mg captopril & hydrochlorothiazide tab 25-15 mg captopril & hydrochlorothiazide tab 25-25 mg captopril & hydrochlorothiazide tab 50-15 mg captopril & hydrochlorothiazide tab 50-25 mg enalapril maleate & hydrochlorothiazide tab 5-12.5 mg enalapril maleate & hydrochlorothiazide tab 10-25 mg fosinopril sodium & hydrochlorothiazide tab 10- 12.5 mg fosinopril sodium & hydrochlorothiazide tab 20- 12.5 mg lisinopril & hydrochlorothiazide tab 10-12.5 mg lisinopril & hydrochlorothiazide tab 20-12.5 mg lisinopril & hydrochlorothiazide tab 20-25 mg quinapril-hydrochlorothiazide tab 10-12.5 mg quinapril-hydrochlorothiazide tab 20-12.5 mg quinapril-hydrochlorothiazide tab 20-25 mg ACE INHIBITORS benazepril hcl tab 5 mg benazepril hcl tab 10 mg benazepril hcl tab 20 mg benazepril hcl tab 40 mg captopril tab 12.5 mg captopril tab 25 mg captopril tab 50 mg captopril tab 100 mg enalapril maleate tab 2.5 mg enalapril maleate tab 5 mg enalapril maleate tab 10 mg enalapril maleate tab 20 mg fosinopril sodium tab 10 mg fosinopril sodium tab 20 mg fosinopril sodium tab 40 mg lisinopril tab 2.5 mg lisinopril tab 5 mg lisinopril tab 10 mg lisinopril tab 20 mg lisinopril tab 30 mg

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 18 Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit Drug Name Requirements/Limits lisinopril tab 40 mg quinapril hcl tab 5 mg quinapril hcl tab 10 mg quinapril hcl tab 20 mg quinapril hcl tab 40 mg ramipril cap 1.25 mg ramipril cap 2.5 mg ramipril cap 5 mg ramipril cap 10 mg trandolapril tab 1 mg trandolapril tab 2 mg trandolapril tab 4 mg ADRENOLYTICS, CENTRAL clonidine hcl tab 0.1 mg clonidine hcl tab 0.2 mg clonidine hcl tab 0.3 mg clonidine td patch weekly 0.1 mg/24hr clonidine td patch weekly 0.2 mg/24hr clonidine td patch weekly 0.3 mg/24hr guanfacine hcl tab 1 mg guanfacine hcl tab 2 mg methyldopa tab 250 mg methyldopa tab 500 mg ALDOSTERONE RECEPTOR ANTAGONISTS eplerenone tab 25 mg eplerenone tab 50 mg spironolactone tab 25 mg spironolactone tab 50 mg spironolactone tab 100 mg ALPHA BLOCKERS doxazosin mesylate tab 1 mg doxazosin mesylate tab 2 mg doxazosin mesylate tab 4 mg doxazosin mesylate tab 8 mg prazosin hcl cap 1 mg prazosin hcl cap 2 mg prazosin hcl cap 5 mg terazosin hcl cap 1 mg (base equivalent) terazosin hcl cap 2 mg (base equivalent) terazosin hcl cap 5 mg (base equivalent) terazosin hcl cap 10 mg (base equivalent)

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 19 Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit Drug Name Requirements/Limits ANGIOTENSIN II RECEPTOR ANTAGONIST/DIURETIC COMBINATIONS irbesartan-hydrochlorothiazide tab 150-12.5 mg irbesartan-hydrochlorothiazide tab 300-12.5 mg losartan potassium & hydrochlorothiazide tab 50- 12.5 mg losartan potassium & hydrochlorothiazide tab 100- 12.5 mg losartan potassium & hydrochlorothiazide tab 100- 25 mg valsartan-hydrochlorothiazide tab 80-12.5 mg valsartan-hydrochlorothiazide tab 160-12.5 mg valsartan-hydrochlorothiazide tab 160-25 mg valsartan-hydrochlorothiazide tab 320-12.5 mg valsartan-hydrochlorothiazide tab 320-25 mg ANGIOTENSIN II RECEPTOR ANTAGONISTS irbesartan tab 75 mg irbesartan tab 150 mg irbesartan tab 300 mg losartan potassium tab 25 mg losartan potassium tab 50 mg losartan potassium tab 100 mg valsartan tab 40 mg valsartan tab 80 mg valsartan tab 160 mg valsartan tab 320 mg ANTIARRHYTHMICS amiodarone hcl tab 100 mg amiodarone hcl tab 200 mg amiodarone hcl tab 400 mg BETAPACE AF TAB 80MG + BETAPACE AF TAB 120MG + BETAPACE AF TAB 160MG + BETAPACE TAB 80MG + BETAPACE TAB 120MG + BETAPACE TAB 160MG + disopyramide phosphate cap 100 mg disopyramide phosphate cap 150 mg dofetilide cap 125 mcg (0.125 mg) SP, PA dofetilide cap 250 mcg (0.25 mg) SP, PA dofetilide cap 500 mcg (0.5 mg) SP, PA flecainide acetate tab 50 mg flecainide acetate tab 100 mg flecainide acetate tab 150 mg

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 20 Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit Drug Name Requirements/Limits MULTAQ TAB 400MG NORPACE CAP 100MG + NORPACE CAP 100MG CR NORPACE CAP 150MG + NORPACE CAP 150MG CR propafenone hcl cap er 12hr 225 mg propafenone hcl cap er 12hr 325 mg propafenone hcl cap er 12hr 425 mg propafenone hcl tab 150 mg propafenone hcl tab 225 mg propafenone hcl tab 300 mg RYTHMOL SR CAP 225MG + RYTHMOL SR CAP 325MG + RYTHMOL SR CAP 425MG + sotalol hcl (afib/afl) tab 80 mg sotalol hcl (afib/afl) tab 120 mg sotalol hcl (afib/afl) tab 160 mg sotalol hcl tab 80 mg sotalol hcl tab 120 mg sotalol hcl tab 160 mg sotalol hcl tab 240 mg TIKOSYN CAP 125MCG SP, PA; + TIKOSYN CAP 250MCG SP, PA; + TIKOSYN CAP 500MCG SP, PA; + ANTILIPEMICS, BILE ACID RESINS cholestyramine light powder 4 gm/dose cholestyramine light powder packets 4 gm cholestyramine powder 4 gm/dose cholestyramine powder packets 4 gm colestipol hcl granule packets 5 gm colestipol hcl granules 5 gm colestipol hcl tab 1 gm ANTILIPEMICS, CHOLESTEROL ABSORPTION INHIBITORS ezetimibe tab 10 mg QL (30 per month) ANTILIPEMICS, FIBRATES fenofibrate micronized cap 67 mg fenofibrate micronized cap 134 mg fenofibrate micronized cap 200 mg fenofibrate tab 48 mg fenofibrate tab 54 mg fenofibrate tab 145 mg fenofibrate tab 160 mg gemfibrozil tab 600 mg

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 21 Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit Drug Name Requirements/Limits ANTILIPEMICS, HMG-COA REDUCTASE INHIBITORS/COMBINATIONS atorvastatin calcium tab 10 mg (base equivalent) QL (30 per month) atorvastatin calcium tab 20 mg (base equivalent) QL (30 per month) atorvastatin calcium tab 40 mg (base equivalent) QL (30 per month) atorvastatin calcium tab 80 mg (base equivalent) QL (30 per month) lovastatin tab 10 mg QL (30 per month) lovastatin tab 20 mg QL (30 per month) lovastatin tab 40 mg QL (30 per month) pravastatin sodium tab 10 mg QL (30 per month) pravastatin sodium tab 20 mg QL (30 per month) pravastatin sodium tab 40 mg QL (30 per month) pravastatin sodium tab 80 mg QL (30 per month) simvastatin tab 5 mg QL (30 per month) simvastatin tab 10 mg QL (30 per month) simvastatin tab 20 mg QL (30 per month) simvastatin tab 40 mg QL (30 per month) simvastatin tab 80 mg QL (30 per month) ANTILIPEMICS, NIACINS niacin tab er 500 mg (antihyperlipidemic) niacin tab er 750 mg (antihyperlipidemic) niacin tab er 1000 mg (antihyperlipidemic) BETA-BLOCKER/DIURETIC COMBINATIONS atenolol & chlorthalidone tab 50-25 mg atenolol & chlorthalidone tab 100-25 mg bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg bisoprolol & hydrochlorothiazide tab 5-6.25 mg bisoprolol & hydrochlorothiazide tab 10-6.25 mg metoprolol & hydrochlorothiazide tab 50-25 mg metoprolol & hydrochlorothiazide tab 100-25 mg metoprolol & hydrochlorothiazide tab 100-50 mg BETA-BLOCKERS atenolol tab 25 mg atenolol tab 50 mg atenolol tab 100 mg bisoprolol fumarate tab 5 mg bisoprolol fumarate tab 10 mg carvedilol tab 3.125 mg carvedilol tab 6.25 mg carvedilol tab 12.5 mg carvedilol tab 25 mg labetalol hcl tab 100 mg labetalol hcl tab 200 mg

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 22 Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit Drug Name Requirements/Limits labetalol hcl tab 300 mg metoprolol succinate tab er 24hr 25 mg (tartrate equiv) metoprolol succinate tab er 24hr 50 mg (tartrate equiv) metoprolol succinate tab er 24hr 100 mg (tartrate equiv) metoprolol succinate tab er 24hr 200 mg (tartrate equiv) metoprolol tartrate tab 25 mg metoprolol tartrate tab 50 mg metoprolol tartrate tab 100 mg nadolol tab 20 mg nadolol tab 40 mg nadolol tab 80 mg pindolol tab 5 mg pindolol tab 10 mg propranolol hcl cap er 24hr 60 mg propranolol hcl cap er 24hr 80 mg propranolol hcl cap er 24hr 120 mg propranolol hcl cap er 24hr 160 mg propranolol hcl oral soln 20 mg/5ml propranolol hcl oral soln 40 mg/5ml propranolol hcl tab 10 mg propranolol hcl tab 20 mg propranolol hcl tab 40 mg propranolol hcl tab 60 mg propranolol hcl tab 80 mg timolol maleate tab 5 mg timolol maleate tab 10 mg timolol maleate tab 20 mg CALCIUM CHANNEL BLOCKERS, DIHYDROPYRIDINES amlodipine besylate tab 2.5 mg (base equivalent) amlodipine besylate tab 5 mg (base equivalent) amlodipine besylate tab 10 mg (base equivalent) felodipine tab er 24hr 2.5 mg felodipine tab er 24hr 5 mg felodipine tab er 24hr 10 mg nifedipine tab er 24hr 30 mg nifedipine tab er 24hr 60 mg nifedipine tab er 24hr 90 mg nifedipine tab er 24hr osmotic release 30 mg nifedipine tab er 24hr osmotic release 60 mg nifedipine tab er 24hr osmotic release 90 mg

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 23 Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit Drug Name Requirements/Limits CALCIUM CHANNEL BLOCKERS, NON-DIHYDROPYRIDINES diltiazem hcl cap er 12hr 60 mg diltiazem hcl cap er 12hr 90 mg diltiazem hcl cap er 12hr 120 mg diltiazem hcl cap er 24hr 120 mg diltiazem hcl cap er 24hr 180 mg diltiazem hcl cap er 24hr 240 mg diltiazem hcl coated beads cap er 24hr 120 mg diltiazem hcl coated beads cap er 24hr 180 mg diltiazem hcl coated beads cap er 24hr 240 mg diltiazem hcl coated beads cap er 24hr 300 mg diltiazem hcl coated beads cap er 24hr 360 mg diltiazem hcl coated beads tab er 24hr 180 mg diltiazem hcl coated beads tab er 24hr 240 mg diltiazem hcl coated beads tab er 24hr 300 mg diltiazem hcl coated beads tab er 24hr 360 mg diltiazem hcl coated beads tab er 24hr 420 mg diltiazem hcl extended release beads cap er 24hr 120 mg diltiazem hcl extended release beads cap er 24hr 180 mg diltiazem hcl extended release beads cap er 24hr 240 mg diltiazem hcl extended release beads cap er 24hr 300 mg diltiazem hcl extended release beads cap er 24hr 360 mg diltiazem hcl extended release beads cap er 24hr 420 mg diltiazem hcl tab 30 mg diltiazem hcl tab 60 mg diltiazem hcl tab 90 mg diltiazem hcl tab 120 mg verapamil hcl tab er 120 mg verapamil hcl tab er 180 mg verapamil hcl tab er 240 mg DIGITALIS GLYCOSIDES digoxin oral soln 0.05 mg/ml digoxin tab 125 mcg (0.125 mg) digoxin tab 250 mcg (0.25 mg) LANOXIN TAB 0.0625MG LANOXIN TAB 0.1875MG DIURETICS, CARBONIC ANHYDRASE INHIBITORS acetazolamide cap er 12hr 500 mg

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 24 Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit Drug Name Requirements/Limits acetazolamide tab 125 mg acetazolamide tab 250 mg methazolamide tab 25 mg methazolamide tab 50 mg DIURETICS, DIURETIC COMBINATIONS ALDACTAZIDE TAB 50/50 amiloride & hydrochlorothiazide tab 5-50 mg spironolactone & hydrochlorothiazide tab 25-25 mg triamterene & hydrochlorothiazide cap 37.5-25 mg triamterene & hydrochlorothiazide tab 37.5-25 mg triamterene & hydrochlorothiazide tab 75-50 mg DIURETICS, LOOP DIURETICS bumetanide tab 0.5 mg bumetanide tab 1 mg bumetanide tab 2 mg furosemide oral soln 10 mg/ml furosemide tab 20 mg furosemide tab 40 mg furosemide tab 80 mg torsemide tab 5 mg torsemide tab 10 mg torsemide tab 20 mg torsemide tab 100 mg DIURETICS, POTASSIUM-SPARING DIURETICS amiloride hcl tab 5 mg DIURETICS, THIAZIDES AND THIAZIDE-LIKE DIURETICS chlorthalidone tab 25 mg chlorthalidone tab 50 mg hydrochlorothiazide cap 12.5 mg hydrochlorothiazide tab 12.5 mg hydrochlorothiazide tab 25 mg hydrochlorothiazide tab 50 mg indapamide tab 1.25 mg indapamide tab 2.5 mg metolazone tab 2.5 mg metolazone tab 5 mg metolazone tab 10 mg HEART FAILURE CORLANOR TAB 5MG CORLANOR TAB 7.5MG ENTRESTO TAB 24-26MG ENTRESTO TAB 49-51MG ENTRESTO TAB 97-103MG

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 25 Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit Drug Name Requirements/Limits MISCELLANEOUS hydralazine hcl tab 10 mg hydralazine hcl tab 25 mg hydralazine hcl tab 50 mg hydralazine hcl tab 100 mg NITRATES, ORAL ISORDIL TAB 40MG isosorbide dinitrate tab 5 mg isosorbide dinitrate tab 10 mg isosorbide dinitrate tab 20 mg isosorbide dinitrate tab 30 mg isosorbide dinitrate tab er 40 mg isosorbide mononitrate tab 10 mg isosorbide mononitrate tab 20 mg isosorbide mononitrate tab er 24hr 30 mg isosorbide mononitrate tab er 24hr 60 mg isosorbide mononitrate tab er 24hr 120 mg nitroglycerin cap er 2.5 mg nitroglycerin cap er 6.5 mg nitroglycerin cap er 9 mg NITRATES, SUBLINGUAL/TRANSLINGUAL nitroglycerin sl tab 0.3 mg nitroglycerin sl tab 0.4 mg nitroglycerin sl tab 0.6 mg NITRATES, TRANSDERMAL NITRO-BID OIN 2% NITRO-DUR DIS 0.3MG/HR NITRO-DUR DIS 0.8MG/HR nitroglycerin td patch 24hr 0.1 mg/hr nitroglycerin td patch 24hr 0.2 mg/hr nitroglycerin td patch 24hr 0.4 mg/hr nitroglycerin td patch 24hr 0.6 mg/hr PULMONARY ARTERIAL HYPERTENSION, ENDOTHELIN RECEPTOR ANTAGONISTS ambrisentan tab 5 mg SP, PA ambrisentan tab 10 mg SP, PA bosentan tab 62.5 mg SP, PA bosentan tab 125 mg SP, PA OPSUMIT TAB 10MG SP, PA TRACLEER TAB 32MG SP, PA

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 26 Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit Drug Name Requirements/Limits PULMONARY ARTERIAL HYPERTENSION, PHOSPHODIESTERASE INHIBITORS sildenafil citrate for suspension 10 mg/ml SP, QL (90 mL per month), PA sildenafil citrate tab 20 mg SP, PA PULMONARY ARTERIAL HYPERTENSION, PROSTACYCLIN RECEPTOR AGONISTS UPTRAVI TAB 200/800 SP, PA UPTRAVI TAB 200MCG SP, PA UPTRAVI TAB 400MCG SP, PA UPTRAVI TAB 600MCG SP, PA UPTRAVI TAB 800MCG SP, PA UPTRAVI TAB 1000MCG SP, PA UPTRAVI TAB 1200MCG SP, PA UPTRAVI TAB 1400MCG SP, PA UPTRAVI TAB 1600MCG SP, PA PULMONARY ARTERIAL HYPERTENSION, PROSTAGLANDIN VASODILATORS ORENITRAM TAB 0.25MG SP, PA ORENITRAM TAB 0.125MG SP, PA ORENITRAM TAB 1MG SP, PA ORENITRAM TAB 2.5MG SP, PA ORENITRAM TAB 5MG SP, PA TYVASO REFIL SOL 0.6MG/ML SP, PA TYVASO SOL 0.6MG/ML SP, PA TYVASO START SOL 0.6MG/ML SP, PA VASOPRESSORS midodrine hcl tab 2.5 mg midodrine hcl tab 5 mg midodrine hcl tab 10 mg CENTRAL NERVOUS SYSTEM ANTIANXIETY, BENZODIAZEPINES ALPRAZOLAM CON 1 MG/ML alprazolam orally disintegrating tab 0.5 mg alprazolam orally disintegrating tab 0.25 mg alprazolam orally disintegrating tab 1 mg alprazolam orally disintegrating tab 2 mg alprazolam tab 0.5 mg alprazolam tab 0.25 mg alprazolam tab 1 mg alprazolam tab 2 mg alprazolam tab er 24hr 0.5 mg alprazolam tab er 24hr 1 mg

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 27 Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit Drug Name Requirements/Limits alprazolam tab er 24hr 2 mg alprazolam tab er 24hr 3 mg ATIVAN INJ 2MG/ML + ATIVAN INJ 4MG/ML + ATIVAN TAB 0.5MG + ATIVAN TAB 1MG + ATIVAN TAB 2MG + chlordiazepoxide hcl cap 5 mg chlordiazepoxide hcl cap 10 mg chlordiazepoxide hcl cap 25 mg clonazepam orally disintegrating tab 0.5 mg clonazepam orally disintegrating tab 0.25 mg clonazepam orally disintegrating tab 0.125 mg clonazepam orally disintegrating tab 1 mg clonazepam orally disintegrating tab 2 mg clonazepam tab 0.5 mg clonazepam tab 1 mg clonazepam tab 2 mg clorazepate dipotassium tab 3.75 mg clorazepate dipotassium tab 7.5 mg clorazepate dipotassium tab 15 mg diazepam conc 5 mg/ml diazepam inj 5 mg/ml DIAZEPAM INJ 10MG/2ML diazepam oral soln 1 mg/ml diazepam tab 2 mg diazepam tab 5 mg diazepam tab 10 mg KLONOPIN TAB 0.5MG + KLONOPIN TAB 1MG + KLONOPIN TAB 2MG + lorazepam conc 2 mg/ml lorazepam inj 2 mg/ml lorazepam inj 4 mg/ml lorazepam tab 0.5 mg lorazepam tab 1 mg lorazepam tab 2 mg oxazepam cap 10 mg oxazepam cap 15 mg oxazepam cap 30 mg TRANXENE T TAB 7.5MG + VALIUM TAB 2MG + VALIUM TAB 5MG + VALIUM TAB 10MG +

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 28 Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit Drug Name Requirements/Limits XANAX TAB 0.5MG + XANAX TAB 0.25MG + XANAX TAB 1MG + XANAX TAB 2MG + XANAX XR TAB 0.5MG + XANAX XR TAB 1MG + XANAX XR TAB 2MG + XANAX XR TAB 3MG + ANTIANXIETY, MISCELLANEOUS ANAFRANIL CAP 25MG + ANAFRANIL CAP 50MG + ANAFRANIL CAP 75MG + buspirone hcl tab 5 mg buspirone hcl tab 7.5 mg buspirone hcl tab 10 mg buspirone hcl tab 15 mg buspirone hcl tab 30 mg clomipramine hcl cap 25 mg clomipramine hcl cap 50 mg clomipramine hcl cap 75 mg fluvoxamine maleate cap er 24hr 100 mg fluvoxamine maleate cap er 24hr 150 mg fluvoxamine maleate tab 25 mg fluvoxamine maleate tab 50 mg fluvoxamine maleate tab 100 mg meprobamate tab 200 mg meprobamate tab 400 mg ANTICONVULSANTS APTIOM TAB 200MG APTIOM TAB 400MG APTIOM TAB 600MG APTIOM TAB 800MG BANZEL SUS 40MG/ML BANZEL TAB 200MG BANZEL TAB 400MG BRIVIACT SOL 10MG/ML BRIVIACT TAB 10MG BRIVIACT TAB 25MG BRIVIACT TAB 50MG BRIVIACT TAB 75MG BRIVIACT TAB 100MG carbamazepine cap er 12hr 100 mg carbamazepine cap er 12hr 200 mg

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 29 Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit Drug Name Requirements/Limits carbamazepine cap er 12hr 300 mg carbamazepine chew tab 100 mg carbamazepine susp 100 mg/5ml carbamazepine tab 200 mg carbamazepine tab er 12hr 100 mg carbamazepine tab er 12hr 200 mg carbamazepine tab er 12hr 400 mg CARBATROL CAP 100MG + CARBATROL CAP 200MG + CARBATROL CAP 300MG + CELONTIN CAP 300MG clobazam suspension 2.5 mg/ml clobazam tab 10 mg clobazam tab 20 mg DEPAKENE CAP 250MG + DEPAKENE SOL 250/5ML + DEPAKOTE ER TAB 250MG + DEPAKOTE ER TAB 500MG + DEPAKOTE SPR CAP 125MG + DEPAKOTE TAB 125MG DR + DEPAKOTE TAB 250MG DR + DEPAKOTE TAB 500MG DR + DIASTAT ACDL GEL 5-10MG + DIASTAT ACDL GEL 12.5-20 + DIASTAT PED GEL 2.5M GEL + diazepam rectal gel delivery system 2.5 mg diazepam rectal gel delivery system 10 mg diazepam rectal gel delivery system 20 mg DILANTIN CAP 30MG DILANTIN CAP 100MG + DILANTIN CHW 50MG + DILANTIN-125 SUS 125/5ML + divalproex sodium cap delayed release sprinkle 125 mg divalproex sodium tab delayed release 125 mg divalproex sodium tab delayed release 250 mg divalproex sodium tab delayed release 500 mg divalproex sodium tab er 24 hr 250 mg divalproex sodium tab er 24 hr 500 mg epitol tab 200mg ethosuximide cap 250 mg ethosuximide soln 250 mg/5ml FANATREX SUS 25MG/ML felbamate susp 600 mg/5ml

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 30 Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit Drug Name Requirements/Limits felbamate tab 400 mg felbamate tab 600 mg FELBATOL SUS 600/5ML + FELBATOL TAB 400MG + FELBATOL TAB 600MG + FYCOMPA SUS 0.5MG/ML FYCOMPA TAB 2MG FYCOMPA TAB 4MG FYCOMPA TAB 6MG FYCOMPA TAB 8MG FYCOMPA TAB 10MG FYCOMPA TAB 12MG gabapentin cap 100 mg QL (1080 per month) gabapentin cap 300 mg QL (360 per month) gabapentin cap 400 mg QL (270 per month) gabapentin oral soln 250 mg/5ml QL (2100 mL per month) gabapentin tab 600 mg QL (180 per month) gabapentin tab 800 mg QL (120 per month) GABITRIL TAB 2MG + GABITRIL TAB 4MG + GABITRIL TAB 12MG + GABITRIL TAB 16MG + KEPPRA SOL 100MG/ML + KEPPRA TAB 250MG + KEPPRA TAB 500MG + KEPPRA TAB 750MG + KEPPRA TAB 1000MG + KEPPRA XR TAB 500MG + KEPPRA XR TAB 750MG + LAMICTAL CHW 5MG + LAMICTAL CHW 25MG + LAMICTAL KIT START 35 + LAMICTAL KIT START 49 + LAMICTAL KIT START 98 + LAMICTAL ODT KIT LAMICTAL ODT TAB 25MG + LAMICTAL ODT TAB 50MG + LAMICTAL ODT TAB 100MG + LAMICTAL ODT TAB 200MG + LAMICTAL TAB 25MG + LAMICTAL TAB 100MG + LAMICTAL TAB 150MG + LAMICTAL TAB 200MG + LAMICTAL XR KIT

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 31 Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit Drug Name Requirements/Limits LAMICTAL XR TAB 25MG + LAMICTAL XR TAB 50MG + LAMICTAL XR TAB 100MG + LAMICTAL XR TAB 200MG + LAMICTAL XR TAB 250MG + LAMICTAL XR TAB 300MG + lamotrigine orally disintegrating tab 25 mg lamotrigine orally disintegrating tab 50 mg lamotrigine orally disintegrating tab 100 mg lamotrigine orally disintegrating tab 200 mg lamotrigine tab 25 mg lamotrigine tab 25 mg (35) starter kit lamotrigine tab 25 mg (42) & 100 mg (7) starter kit lamotrigine tab 25 mg (84) & 100 mg (14) starter kit lamotrigine tab 100 mg lamotrigine tab 150 mg lamotrigine tab 200 mg lamotrigine tab chewable dispersible 5 mg lamotrigine tab chewable dispersible 25 mg lamotrigine tab er 24hr 25 mg lamotrigine tab er 24hr 50 mg lamotrigine tab er 24hr 100 mg lamotrigine tab er 24hr 200 mg lamotrigine tab er 24hr 250 mg lamotrigine tab er 24hr 300 mg levetiracetam oral soln 100 mg/ml levetiracetam tab 250 mg levetiracetam tab 500 mg levetiracetam tab 750 mg levetiracetam tab 1000 mg levetiracetam tab er 24hr 500 mg levetiracetam tab er 24hr 750 mg MYSOLINE TAB 50MG + MYSOLINE TAB 250MG + NEURONTIN CAP 100MG QL (1080 per month); + NEURONTIN CAP 300MG QL (360 per month); + NEURONTIN CAP 400MG QL (270 per month); + NEURONTIN SOL 250/5ML QL (2100 mL per month); + NEURONTIN TAB 600MG QL (180 per month); + NEURONTIN TAB 800MG QL (120 per month); + ONFI SUS 2.5MG/ML + ONFI TAB 10MG +

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 32 Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit Drug Name Requirements/Limits ONFI TAB 20MG + oxcarbazepine susp 300 mg/5ml (60 mg/ml) oxcarbazepine tab 150 mg oxcarbazepine tab 300 mg oxcarbazepine tab 600 mg OXTELLAR XR TAB 150MG OXTELLAR XR TAB 300MG OXTELLAR XR TAB 600MG PEGANONE TAB 250MG phenobarbital elixir 20 mg/5ml phenobarbital tab 15 mg phenobarbital tab 16.2 mg phenobarbital tab 30 mg phenobarbital tab 32.4 mg phenobarbital tab 60 mg phenobarbital tab 64.8 mg phenobarbital tab 97.2 mg phenobarbital tab 100 mg PHENYTEK CAP 200MG + PHENYTEK CAP 300MG + phenytoin chew tab 50 mg phenytoin sodium extended cap 100 mg phenytoin sodium extended cap 200 mg phenytoin sodium extended cap 300 mg phenytoin susp 125 mg/5ml pregabalin cap 25 mg QL (120 per month) pregabalin cap 50 mg QL (120 per month) pregabalin cap 75 mg QL (120 per month) pregabalin cap 100 mg QL (120 per month) pregabalin cap 150 mg QL (120 per month) pregabalin cap 200 mg QL (90 per month) pregabalin cap 225 mg QL (60 per month) pregabalin cap 300 mg QL (60 per month) pregabalin soln 20 mg/ml QL (900 mL per month) primidone tab 50 mg primidone tab 250 mg SABRIL POW 500MG SP, PA; + SABRIL TAB 500MG SP, PA; + TEGRETOL SUS 100/5ML + TEGRETOL TAB 200MG + TEGRETOL-XR TAB 100MG + TEGRETOL-XR TAB 200MG + TEGRETOL-XR TAB 400MG + tiagabine hcl tab 2 mg

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 33 Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit Drug Name Requirements/Limits tiagabine hcl tab 4 mg tiagabine hcl tab 12 mg tiagabine hcl tab 16 mg TOPAMAX SPR CAP 15MG + TOPAMAX SPR CAP 25MG + TOPAMAX TAB 25MG + TOPAMAX TAB 50MG + TOPAMAX TAB 100MG + TOPAMAX TAB 200MG + topiramate cap er 24hr sprinkle 25 mg topiramate cap er 24hr sprinkle 50 mg topiramate cap er 24hr sprinkle 100 mg topiramate cap er 24hr sprinkle 150 mg topiramate cap er 24hr sprinkle 200 mg topiramate sprinkle cap 15 mg topiramate sprinkle cap 25 mg topiramate tab 25 mg topiramate tab 50 mg topiramate tab 100 mg topiramate tab 200 mg TRILEPTAL SUS 300MG/5M + TRILEPTAL TAB 150MG + TRILEPTAL TAB 300MG + TRILEPTAL TAB 600MG + TROKENDI XR CAP 25MG TROKENDI XR CAP 50MG TROKENDI XR CAP 100MG TROKENDI XR CAP 200MG valproate sodium oral soln 250 mg/5ml (base equiv) valproic acid cap 250 mg vigabatrin powd pack 500 mg SP, PA vigabatrin tab 500 mg SP, PA VIMPAT SOL 10MG/ML VIMPAT TAB 50MG VIMPAT TAB 100MG VIMPAT TAB 150MG VIMPAT TAB 200MG ZARONTIN CAP 250MG + ZARONTIN SOL 250/5ML + ZONEGRAN CAP 25MG + ZONEGRAN CAP 100MG + zonisamide cap 25 mg zonisamide cap 50 mg

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 34 Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit Drug Name Requirements/Limits zonisamide cap 100 mg ANTIDEMENTIA donepezil hydrochloride orally disintegrating tab 5 mg donepezil hydrochloride orally disintegrating tab 10 mg donepezil hydrochloride tab 5 mg donepezil hydrochloride tab 10 mg donepezil hydrochloride tab 23 mg galantamine hydrobromide cap er 24hr 8 mg galantamine hydrobromide cap er 24hr 16 mg galantamine hydrobromide cap er 24hr 24 mg galantamine hydrobromide oral soln 4 mg/ml galantamine hydrobromide tab 4 mg galantamine hydrobromide tab 8 mg galantamine hydrobromide tab 12 mg memantine hcl oral solution 2 mg/ml PA only applies to members less than 30 years of age memantine hcl tab 5 mg PA only applies to members less than 30 years of age memantine hcl tab 5 mg (28) & 10 mg (21) PA only applies to members titration pak less than 30 years of age memantine hcl tab 10 mg PA only applies to members less than 30 years of age rivastigmine tartrate cap 1.5 mg (base equivalent) PA rivastigmine tartrate cap 3 mg (base equivalent) PA rivastigmine tartrate cap 4.5 mg (base equivalent) PA rivastigmine tartrate cap 6 mg (base equivalent) PA rivastigmine td patch 24hr 4.6 mg/24hr PA rivastigmine td patch 24hr 9.5 mg/24hr PA rivastigmine td patch 24hr 13.3 mg/24hr PA ANTIDEPRESSANTS, MISCELLANEOUS APLENZIN TAB 174MG APLENZIN TAB 348MG APLENZIN TAB 522MG bupropion hcl tab 75 mg bupropion hcl tab 100 mg bupropion hcl tab er 12hr 100 mg bupropion hcl tab er 12hr 150 mg bupropion hcl tab er 12hr 200 mg bupropion hcl tab er 24hr 150 mg bupropion hcl tab er 24hr 300 mg bupropion hcl tab er 24hr 450 mg chlordiazepoxide-amitriptyline tab 5-12.5 mg

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 35 Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit Drug Name Requirements/Limits chlordiazepoxide-amitriptyline tab 10-25 mg FORFIVO XL TAB 450MG + maprotiline hcl tab 25 mg maprotiline hcl tab 50 mg maprotiline hcl tab 75 mg mirtazapine orally disintegrating tab 15 mg mirtazapine orally disintegrating tab 30 mg mirtazapine orally disintegrating tab 45 mg mirtazapine tab 7.5 mg mirtazapine tab 15 mg mirtazapine tab 30 mg mirtazapine tab 45 mg nefazodone hcl tab 50 mg nefazodone hcl tab 100 mg nefazodone hcl tab 150 mg nefazodone hcl tab 200 mg nefazodone hcl tab 250 mg REMERON SLTB TAB 15MG + REMERON SLTB TAB 30MG + REMERON SLTB TAB 45MG + REMERON TAB 15MG + REMERON TAB 30MG + trazodone hcl tab 50 mg trazodone hcl tab 100 mg trazodone hcl tab 150 mg trazodone hcl tab 300 mg WELLBUTRIN TAB 100MG SR + WELLBUTRIN TAB 150MG SR + WELLBUTRIN TAB 200MG SR + WELLBUTRIN TAB XL 150MG + WELLBUTRIN TAB XL 300MG + ANTIDEPRESSANTS, MONOAMINE OXIDASE INHIBITORS (MAOIs) EMSAM DIS 6MG/24HR EMSAM DIS 9MG/24HR EMSAM DIS 12MG/24H MARPLAN TAB 10MG NARDIL TAB 15MG + PARNATE TAB 10MG + phenelzine sulfate tab 15 mg tranylcypromine sulfate tab 10 mg ANTIDEPRESSANTS, SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIs) CELEXA TAB 10MG +

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 36 Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit Drug Name Requirements/Limits CELEXA TAB 20MG + CELEXA TAB 40MG + citalopram hydrobromide oral soln 10 mg/5ml citalopram hydrobromide tab 10 mg (base equiv) citalopram hydrobromide tab 20 mg (base equiv) citalopram hydrobromide tab 40 mg (base equiv) escitalopram oxalate soln 5 mg/5ml (base equiv) escitalopram oxalate tab 5 mg (base equiv) escitalopram oxalate tab 10 mg (base equiv) escitalopram oxalate tab 20 mg (base equiv) fluoxetine hcl (pmdd) cap 10 mg fluoxetine hcl (pmdd) cap 20 mg fluoxetine hcl (pmdd) tab 10 mg fluoxetine hcl (pmdd) tab 20 mg fluoxetine hcl cap 10 mg fluoxetine hcl cap 20 mg fluoxetine hcl cap 40 mg fluoxetine hcl cap delayed release 90 mg fluoxetine hcl solution 20 mg/5ml fluoxetine hcl tab 10 mg fluoxetine hcl tab 20 mg fluoxetine hcl tab 60 mg FLUOXETINE TAB 60MG + LEXAPRO TAB 5MG + LEXAPRO TAB 10MG + LEXAPRO TAB 20MG + paroxetine hcl tab 10 mg paroxetine hcl tab 20 mg paroxetine hcl tab 30 mg paroxetine hcl tab 40 mg paroxetine hcl tab er 24hr 12.5 mg paroxetine hcl tab er 24hr 25 mg paroxetine hcl tab er 24hr 37.5 mg PAXIL CR TAB 12.5MG + PAXIL CR TAB 25MG + PAXIL CR TAB 37.5MG + PAXIL SUS 10MG/5ML PAXIL TAB 10MG + PAXIL TAB 20MG + PAXIL TAB 30MG + PAXIL TAB 40MG + PEXEVA TAB 10MG PEXEVA TAB 20MG PEXEVA TAB 30MG

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 37 Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit Drug Name Requirements/Limits PEXEVA TAB 40MG PROZAC CAP 10MG + PROZAC CAP 20MG + PROZAC CAP 40MG + SARAFEM TAB 10MG + SARAFEM TAB 20MG + sertraline hcl oral concentrate for solution 20 mg/ml sertraline hcl tab 25 mg sertraline hcl tab 50 mg sertraline hcl tab 100 mg TRINTELLIX TAB 5MG TRINTELLIX TAB 10MG TRINTELLIX TAB 20MG VIIBRYD KIT STARTER VIIBRYD TAB 10MG VIIBRYD TAB 20MG VIIBRYD TAB 40MG ZOLOFT TAB 25MG + ZOLOFT TAB 50MG + ZOLOFT TAB 100MG + ANTIDEPRESSANTS, SEROTONIN NOREPINEPHRINE REUPTAKE INHIBITORS (SNRIs) CYMBALTA CAP 20MG + CYMBALTA CAP 30MG + CYMBALTA CAP 60MG + DESVENLAFAX TAB 50MG ER DESVENLAFAX TAB 100MG ER desvenlafaxine succinate tab er 24hr 25 mg (base equiv) desvenlafaxine succinate tab er 24hr 50 mg (base equiv) desvenlafaxine succinate tab er 24hr 100 mg (base equiv) desvenlafaxine tab er 24hr 50 mg desvenlafaxine tab er 24hr 100 mg duloxetine hcl enteric coated pellets cap 20 mg (base eq) duloxetine hcl enteric coated pellets cap 30 mg (base eq) duloxetine hcl enteric coated pellets cap 40 mg (base eq) duloxetine hcl enteric coated pellets cap 60 mg (base eq)

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 38 Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit Drug Name Requirements/Limits EFFEXOR XR CAP 37.5MG + EFFEXOR XR CAP 75MG + EFFEXOR XR CAP 150MG + FETZIMA CAP 20MG FETZIMA CAP 40MG FETZIMA CAP 80MG FETZIMA CAP 120MG FETZIMA CAP TITRATIO KHEDEZLA TAB 50MG ER + KHEDEZLA TAB 100MG ER + PRISTIQ TAB 25MG + PRISTIQ TAB 50MG + PRISTIQ TAB 100MG + venlafaxine hcl cap er 24hr 37.5 mg (base equivalent) venlafaxine hcl cap er 24hr 75 mg (base equivalent) venlafaxine hcl cap er 24hr 150 mg (base equivalent) venlafaxine hcl tab 25 mg (base equivalent) venlafaxine hcl tab 37.5 mg (base equivalent) venlafaxine hcl tab 50 mg (base equivalent) venlafaxine hcl tab 75 mg (base equivalent) venlafaxine hcl tab 100 mg (base equivalent) venlafaxine hcl tab er 24hr 37.5 mg (base equivalent) venlafaxine hcl tab er 24hr 75 mg (base equivalent) venlafaxine hcl tab er 24hr 150 mg (base equivalent) venlafaxine hcl tab er 24hr 225 mg (base equivalent) ANTIDEPRESSANTS, TRICYCLIC ANTIDEPRESSANTS (TCAs) amitriptyline hcl tab 10 mg amitriptyline hcl tab 25 mg amitriptyline hcl tab 50 mg amitriptyline hcl tab 75 mg amitriptyline hcl tab 100 mg amitriptyline hcl tab 150 mg amoxapine tab 25 mg amoxapine tab 50 mg amoxapine tab 100 mg amoxapine tab 150 mg desipramine hcl tab 10 mg

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 39 Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit Drug Name Requirements/Limits desipramine hcl tab 25 mg desipramine hcl tab 50 mg desipramine hcl tab 75 mg desipramine hcl tab 100 mg desipramine hcl tab 150 mg doxepin hcl cap 10 mg doxepin hcl cap 25 mg doxepin hcl cap 50 mg doxepin hcl cap 75 mg doxepin hcl cap 100 mg doxepin hcl cap 150 mg doxepin hcl conc 10 mg/ml imipramine hcl tab 10 mg imipramine hcl tab 25 mg imipramine hcl tab 50 mg imipramine pamoate cap 75 mg imipramine pamoate cap 100 mg imipramine pamoate cap 125 mg imipramine pamoate cap 150 mg NORPRAMIN TAB 10MG + NORPRAMIN TAB 25MG + nortriptyline hcl cap 10 mg nortriptyline hcl cap 25 mg nortriptyline hcl cap 50 mg nortriptyline hcl cap 75 mg nortriptyline hcl soln 10 mg/5ml PAMELOR CAP 10MG + PAMELOR CAP 25MG + PAMELOR CAP 50MG + PAMELOR CAP 75MG + protriptyline hcl tab 5 mg protriptyline hcl tab 10 mg SURMONTIL CAP 25MG + SURMONTIL CAP 50MG + SURMONTIL CAP 100MG + TOFRANIL TAB 10MG + TOFRANIL TAB 25MG + TOFRANIL TAB 50MG + trimipramine maleate cap 25 mg trimipramine maleate cap 50 mg trimipramine maleate cap 100 mg ANTIPARKINSONIAN AGENTS amantadine hcl cap 100 mg amantadine hcl syrup 50 mg/5ml

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 40 Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit Drug Name Requirements/Limits amantadine hcl tab 100 mg benztropine mesylate tab 0.5 mg benztropine mesylate tab 1 mg benztropine mesylate tab 2 mg bromocriptine mesylate cap 5 mg (base equivalent) bromocriptine mesylate tab 2.5 mg (base equivalent) carbidopa & levodopa orally disintegrating tab 10- 100 mg carbidopa & levodopa orally disintegrating tab 25- 100 mg carbidopa & levodopa orally disintegrating tab 25- 250 mg carbidopa & levodopa tab 10-100 mg carbidopa & levodopa tab 25-100 mg carbidopa & levodopa tab 25-250 mg carbidopa & levodopa tab er 25-100 mg carbidopa & levodopa tab er 50-200 mg carbidopa-levodopa-entacapone tabs 12.5-50-200 mg carbidopa-levodopa-entacapone tabs 18.75-75- 200 mg carbidopa-levodopa-entacapone tabs 25-100-200 mg carbidopa-levodopa-entacapone tabs 31.25-125- 200 mg carbidopa-levodopa-entacapone tabs 37.5-150- 200 mg carbidopa-levodopa-entacapone tabs 50-200-200 mg entacapone tab 200 mg pramipexole dihydrochloride tab 0.5 mg pramipexole dihydrochloride tab 0.25 mg pramipexole dihydrochloride tab 0.75 mg pramipexole dihydrochloride tab 0.125 mg pramipexole dihydrochloride tab 1 mg pramipexole dihydrochloride tab 1.5 mg ropinirole hydrochloride tab 0.5 mg ropinirole hydrochloride tab 0.25 mg ropinirole hydrochloride tab 1 mg ropinirole hydrochloride tab 2 mg ropinirole hydrochloride tab 3 mg ropinirole hydrochloride tab 4 mg ropinirole hydrochloride tab 5 mg

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 41 Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit Drug Name Requirements/Limits selegiline hcl cap 5 mg selegiline hcl tab 5 mg trihexyphenidyl hcl elixir 0.4 mg/ml trihexyphenidyl hcl tab 2 mg trihexyphenidyl hcl tab 5 mg ANTIPSYCHOTICS, ATYPICALS ABILIFY MAIN INJ 300MG ABILIFY MAIN INJ 400MG ABILIFY TAB 2MG + ABILIFY TAB 5MG + ABILIFY TAB 10MG + ABILIFY TAB 15MG + ABILIFY TAB 20MG + ABILIFY TAB 30MG + aripiprazole oral solution 1 mg/ml aripiprazole orally disintegrating tab 10 mg aripiprazole orally disintegrating tab 15 mg aripiprazole tab 2 mg aripiprazole tab 5 mg aripiprazole tab 10 mg aripiprazole tab 15 mg aripiprazole tab 20 mg aripiprazole tab 30 mg ARISTADA INJ 441MG/1. ARISTADA INJ 662MG/2 ARISTADA INJ 882MG/3 ARISTADA INJ 1064MG ARISTADA INJ INITIO clozapine orally disintegrating tab 12.5 mg clozapine orally disintegrating tab 25 mg clozapine orally disintegrating tab 100 mg clozapine orally disintegrating tab 150 mg clozapine orally disintegrating tab 200 mg clozapine tab 25 mg clozapine tab 50 mg clozapine tab 100 mg clozapine tab 200 mg CLOZARIL TAB 25MG + CLOZARIL TAB 100MG + FANAPT PAK FANAPT TAB 1MG FANAPT TAB 2MG FANAPT TAB 4MG FANAPT TAB 6MG

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 42 Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit Drug Name Requirements/Limits FANAPT TAB 8MG FANAPT TAB 10MG FANAPT TAB 12MG FAZACLO TAB 12.5 ODT + FAZACLO TAB 25MG ODT + FAZACLO TAB 100 ODT + FAZACLO TAB 150 ODT + FAZACLO TAB 200 ODT + GEODON CAP 20MG + GEODON CAP 40MG + GEODON CAP 60MG + GEODON CAP 80MG + GEODON INJ 20MG INVEGA SUST INJ 39/0.25 INVEGA SUST INJ 78/0.5ML INVEGA SUST INJ 117/0.75 INVEGA SUST INJ 156MG/ML INVEGA SUST INJ 234/1.5 INVEGA TAB 1.5MG + INVEGA TAB 3MG + INVEGA TAB 6MG + INVEGA TAB 9MG + INVEGA TRINZ INJ 273MG INVEGA TRINZ INJ 410MG INVEGA TRINZ INJ 546MG INVEGA TRINZ INJ 819MG LATUDA TAB 20MG LATUDA TAB 40MG LATUDA TAB 60MG LATUDA TAB 80MG LATUDA TAB 120MG olanzapine for im inj 10 mg olanzapine orally disintegrating tab 5 mg olanzapine orally disintegrating tab 10 mg olanzapine orally disintegrating tab 15 mg olanzapine orally disintegrating tab 20 mg olanzapine tab 2.5 mg olanzapine tab 5 mg olanzapine tab 7.5 mg olanzapine tab 10 mg olanzapine tab 15 mg olanzapine tab 20 mg olanzapine-fluoxetine hcl cap 3-25 mg olanzapine-fluoxetine hcl cap 6-25 mg

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 43 Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit Drug Name Requirements/Limits olanzapine-fluoxetine hcl cap 6-50 mg olanzapine-fluoxetine hcl cap 12-25 mg olanzapine-fluoxetine hcl cap 12-50 mg paliperidone tab er 24hr 1.5 mg paliperidone tab er 24hr 3 mg paliperidone tab er 24hr 6 mg paliperidone tab er 24hr 9 mg quetiapine fumarate tab 25 mg quetiapine fumarate tab 50 mg quetiapine fumarate tab 100 mg quetiapine fumarate tab 200 mg quetiapine fumarate tab 300 mg quetiapine fumarate tab 400 mg quetiapine fumarate tab er 24hr 50 mg quetiapine fumarate tab er 24hr 150 mg quetiapine fumarate tab er 24hr 200 mg quetiapine fumarate tab er 24hr 300 mg quetiapine fumarate tab er 24hr 400 mg REXULTI TAB 0.5MG REXULTI TAB 0.25MG REXULTI TAB 1MG REXULTI TAB 2MG REXULTI TAB 3MG REXULTI TAB 4MG RISPERDAL INJ 12.5MG RISPERDAL INJ 25MG RISPERDAL INJ 37.5MG RISPERDAL INJ 50MG RISPERDAL SOL 1MG/ML + RISPERDAL TAB 0.5MG + RISPERDAL TAB 0.25MG + RISPERDAL TAB 1MG + RISPERDAL TAB 2MG + RISPERDAL TAB 3MG + RISPERDAL TAB 4MG + risperidone orally disintegrating tab 0.5 mg risperidone orally disintegrating tab 0.25 mg risperidone orally disintegrating tab 1 mg risperidone orally disintegrating tab 2 mg risperidone orally disintegrating tab 3 mg risperidone orally disintegrating tab 4 mg risperidone soln 1 mg/ml risperidone tab 0.5 mg risperidone tab 0.25 mg

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 44 Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit Drug Name Requirements/Limits risperidone tab 1 mg risperidone tab 2 mg risperidone tab 3 mg risperidone tab 4 mg SAPHRIS SUB 2.5MG SAPHRIS SUB 5MG SAPHRIS SUB 10MG SEROQUEL TAB 25MG + SEROQUEL TAB 50MG + SEROQUEL TAB 100MG + SEROQUEL TAB 200MG + SEROQUEL TAB 300MG + SEROQUEL TAB 400MG + SEROQUEL XR TAB 50MG + SEROQUEL XR TAB 150MG + SEROQUEL XR TAB 200MG + SEROQUEL XR TAB 300MG + SEROQUEL XR TAB 400MG + VERSACLOZ SUS 50MG/ML VRAYLAR CAP 1.5-3MG VRAYLAR CAP 1.5MG VRAYLAR CAP 3MG VRAYLAR CAP 4.5MG VRAYLAR CAP 6MG ziprasidone hcl cap 20 mg ziprasidone hcl cap 40 mg ziprasidone hcl cap 60 mg ziprasidone hcl cap 80 mg ZYPREXA INJ 10MG + ZYPREXA RELP INJ 210MG ZYPREXA RELP INJ 300MG ZYPREXA RELP INJ 405MG ZYPREXA TAB 2.5MG + ZYPREXA TAB 5MG + ZYPREXA TAB 7.5MG + ZYPREXA TAB 10MG + ZYPREXA TAB 15MG + ZYPREXA TAB 20MG + ZYPREXA ZYDI TAB 5MG + ZYPREXA ZYDI TAB 10MG + ZYPREXA ZYDI TAB 15MG + ZYPREXA ZYDI TAB 20MG + ANTIPSYCHOTICS, MISCELLANEOUS ADASUVE INH 10MG

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 45 Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit Drug Name Requirements/Limits CHLORPROMAZ INJ 25MG/ML CHLORPROMAZ INJ 50MG/2ML chlorpromazine hcl tab 10 mg chlorpromazine hcl tab 25 mg chlorpromazine hcl tab 50 mg chlorpromazine hcl tab 100 mg chlorpromazine hcl tab 200 mg fluphenazine decanoate inj 25 mg/ml fluphenazine hcl elixir 2.5 mg/5ml fluphenazine hcl inj 2.5 mg/ml fluphenazine hcl oral conc 5 mg/ml fluphenazine hcl tab 1 mg fluphenazine hcl tab 2.5 mg fluphenazine hcl tab 5 mg fluphenazine hcl tab 10 mg haloperidol decanoate im soln 50 mg/ml haloperidol decanoate im soln 100 mg/ml haloperidol lactate inj 5 mg/ml haloperidol lactate oral conc 2 mg/ml haloperidol tab 0.5 mg haloperidol tab 1 mg haloperidol tab 2 mg haloperidol tab 5 mg haloperidol tab 10 mg haloperidol tab 20 mg loxapine succinate cap 5 mg loxapine succinate cap 10 mg loxapine succinate cap 25 mg loxapine succinate cap 50 mg NUPLAZID CAP 34MG SP NUPLAZID TAB 10MG SP perphenazine tab 2 mg perphenazine tab 4 mg perphenazine tab 8 mg perphenazine tab 16 mg perphenazine-amitriptyline tab 2-10 mg perphenazine-amitriptyline tab 2-25 mg perphenazine-amitriptyline tab 4-10 mg perphenazine-amitriptyline tab 4-25 mg perphenazine-amitriptyline tab 4-50 mg thioridazine hcl tab 10 mg thioridazine hcl tab 25 mg thioridazine hcl tab 50 mg thioridazine hcl tab 100 mg

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 46 Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit Drug Name Requirements/Limits thiothixene cap 1 mg thiothixene cap 2 mg thiothixene cap 5 mg thiothixene cap 10 mg trifluoperazine hcl tab 1 mg (base equivalent) trifluoperazine hcl tab 2 mg (base equivalent) trifluoperazine hcl tab 5 mg (base equivalent) trifluoperazine hcl tab 10 mg (base equivalent) ATTENTION DEFICIT HYPERACTIVITY DISORDER amphetamine-dextroamphetamine cap er 24hr 5 QL (360 per month) mg amphetamine-dextroamphetamine cap er 24hr 10 QL (180 per month) mg amphetamine-dextroamphetamine cap er 24hr 15 QL (120 per month) mg amphetamine-dextroamphetamine cap er 24hr 20 QL (90 per month) mg amphetamine-dextroamphetamine cap er 24hr 25 QL (60 per month) mg amphetamine-dextroamphetamine cap er 24hr 30 QL (60 per month) mg amphetamine-dextroamphetamine tab 5 mg QL (360 per month) amphetamine-dextroamphetamine tab 7.5 mg QL (240 per month) amphetamine-dextroamphetamine tab 10 mg QL (180 per month) amphetamine-dextroamphetamine tab 12.5 mg QL (135 per month) amphetamine-dextroamphetamine tab 15 mg QL (120 per month) amphetamine-dextroamphetamine tab 20 mg QL (90 per month) amphetamine-dextroamphetamine tab 30 mg QL (60 per month) atomoxetine hcl cap 10 mg (base equiv) QL (120 per month); ST (Must have recently been on 30 days of generic immediate-release ADHD drug, methylphenidate cap cr (cd), amphetamine- dextroamphetamine cap sr 24hr OR dextroamphetamine sulfate cap sr 24hr)

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 47 Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit Drug Name Requirements/Limits atomoxetine hcl cap 18 mg (base equiv) QL (120 per month); ST (Must have recently been on 30 days of generic immediate-release ADHD drug, methylphenidate cap cr (cd), amphetamine- dextroamphetamine cap sr 24hr OR dextroamphetamine sulfate cap sr 24hr) atomoxetine hcl cap 25 mg (base equiv) QL (120 per month); ST (Must have recently been on 30 days of generic immediate-release ADHD drug, methylphenidate cap cr (cd), amphetamine- dextroamphetamine cap sr 24hr OR dextroamphetamine sulfate cap sr 24hr) atomoxetine hcl cap 40 mg (base equiv) QL (60 per month); ST (Must have recently been on 30 days of generic immediate-release ADHD drug, methylphenidate cap cr (cd), amphetamine- dextroamphetamine cap sr 24hr OR dextroamphetamine sulfate cap sr 24hr) atomoxetine hcl cap 60 mg (base equiv) QL (30 per month); ST (Must have recently been on 30 days of generic immediate-release ADHD drug, methylphenidate cap cr (cd), amphetamine- dextroamphetamine cap sr 24hr OR dextroamphetamine sulfate cap sr 24hr)

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 48 Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit Drug Name Requirements/Limits atomoxetine hcl cap 80 mg (base equiv) QL (30 per month); ST (Must have recently been on 30 days of generic immediate-release ADHD drug, methylphenidate cap cr (cd), amphetamine- dextroamphetamine cap sr 24hr OR dextroamphetamine sulfate cap sr 24hr) atomoxetine hcl cap 100 mg (base equiv) QL (30 per month); ST (Must have recently been on 30 days of generic immediate-release ADHD drug, methylphenidate cap cr (cd), amphetamine- dextroamphetamine cap sr 24hr OR dextroamphetamine sulfate cap sr 24hr) dexmethylphenidate hcl tab 2.5 mg QL (600 per month) dexmethylphenidate hcl tab 5 mg QL (300 per month) dexmethylphenidate hcl tab 10 mg QL (150 per month) dextroamphetamine sulfate cap er 24hr 5 mg QL (360 per month) dextroamphetamine sulfate cap er 24hr 10 mg QL (180 per month) dextroamphetamine sulfate cap er 24hr 15 mg QL (120 per month) dextroamphetamine sulfate tab 5 mg QL (360 per month) dextroamphetamine sulfate tab 10 mg QL (180 per month) metadate tab 20mg er QL (150 per month); ST (Must have recently been on 30 days of generic immediate-release ADHD drug, methylphenidate cap cr (cd), amphetamine- dextroamphetamine cap sr 24hr OR dextroamphetamine sulfate cap sr 24hr) methylphenidate hcl cap er 10 mg (cd) QL (300 per month) methylphenidate hcl cap er 20 mg (cd) QL (150 per month)

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 49 Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit Drug Name Requirements/Limits methylphenidate hcl cap er 24hr 20 mg (la) QL (150 per month); ST (Must have recently been on 30 days of generic immediate-release ADHD drug, methylphenidate cap cr (cd), amphetamine- dextroamphetamine cap sr 24hr OR dextroamphetamine sulfate cap sr 24hr) methylphenidate hcl cap er 24hr 30 mg (la) QL (90 per month); ST (Must have recently been on 30 days of generic immediate-release ADHD drug, methylphenidate cap cr (cd), amphetamine- dextroamphetamine cap sr 24hr OR dextroamphetamine sulfate cap sr 24hr) methylphenidate hcl cap er 24hr 40 mg (la) QL (60 per month); ST (Must have recently been on 30 days of generic immediate-release ADHD drug, methylphenidate cap cr (cd), amphetamine- dextroamphetamine cap sr 24hr OR dextroamphetamine sulfate cap sr 24hr) methylphenidate hcl cap er 30 mg (cd) QL (90 per month) methylphenidate hcl cap er 40 mg (cd) QL (60 per month) methylphenidate hcl cap er 50 mg (cd) QL (60 per month) methylphenidate hcl cap er 60 mg (cd) QL (30 per month) methylphenidate hcl soln 5 mg/5ml QL (3000 mL per month) methylphenidate hcl soln 10 mg/5ml QL (1500 mL per month) methylphenidate hcl tab 5 mg QL (600 per month) methylphenidate hcl tab 10 mg QL (300 per month) methylphenidate hcl tab 20 mg QL (150 per month)

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 50 Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit Drug Name Requirements/Limits methylphenidate hcl tab er 10 mg QL (300 per month); ST (Must have recently been on 30 days of generic immediate-release ADHD drug, methylphenidate cap cr (cd), amphetamine- dextroamphetamine cap sr 24hr OR dextroamphetamine sulfate cap sr 24hr) methylphenidate hcl tab er 20 mg QL (150 per month); ST (Must have recently been on 30 days of generic immediate-release ADHD drug, methylphenidate cap cr (cd), amphetamine- dextroamphetamine cap sr 24hr OR dextroamphetamine sulfate cap sr 24hr) methylphenidate hcl tab er 24hr 18 mg QL (180 per month); ST (Must have recently been on 30 days of generic immediate-release ADHD drug, methylphenidate cap cr (cd), amphetamine- dextroamphetamine cap sr 24hr OR dextroamphetamine sulfate cap sr 24hr) methylphenidate hcl tab er 24hr 27 mg QL (120 per month); ST (Must have recently been on 30 days of generic immediate-release ADHD drug, methylphenidate cap cr (cd), amphetamine- dextroamphetamine cap sr 24hr OR dextroamphetamine sulfate cap sr 24hr)

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 51 Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit Drug Name Requirements/Limits methylphenidate hcl tab er 24hr 36 mg QL (90 per month); ST (Must have recently been on 30 days of generic immediate-release ADHD drug, methylphenidate cap cr (cd), amphetamine- dextroamphetamine cap sr 24hr OR dextroamphetamine sulfate cap sr 24hr) methylphenidate hcl tab er 24hr 54 mg QL (60 per month); ST (Must have recently been on 30 days of generic immediate-release ADHD drug, methylphenidate cap cr (cd), amphetamine- dextroamphetamine cap sr 24hr OR dextroamphetamine sulfate cap sr 24hr) methylphenidate hcl tab er osmotic release (osm) QL (180 per month); ST 18 mg (Must have recently been on 30 days of generic immediate-release ADHD drug, methylphenidate cap cr (cd), amphetamine- dextroamphetamine cap sr 24hr OR dextroamphetamine sulfate cap sr 24hr) methylphenidate hcl tab er osmotic release (osm) QL (120 per month); ST 27 mg (Must have recently been on 30 days of generic immediate-release ADHD drug, methylphenidate cap cr (cd), amphetamine- dextroamphetamine cap sr 24hr OR dextroamphetamine sulfate cap sr 24hr)

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 52 Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit Drug Name Requirements/Limits methylphenidate hcl tab er osmotic release (osm) QL (90 per month); ST 36 mg (Must have recently been on 30 days of generic immediate-release ADHD drug, methylphenidate cap cr (cd), amphetamine- dextroamphetamine cap sr 24hr OR dextroamphetamine sulfate cap sr 24hr) methylphenidate hcl tab er osmotic release (osm) QL (60 per month); ST 54 mg (Must have recently been on 30 days of generic immediate-release ADHD drug, methylphenidate cap cr (cd), amphetamine- dextroamphetamine cap sr 24hr OR dextroamphetamine sulfate cap sr 24hr) FIBROMYALGIA SAVELLA MIS TITR PAK PA SAVELLA TAB 12.5MG PA SAVELLA TAB 25MG PA SAVELLA TAB 50MG PA SAVELLA TAB 100MG PA HUNTINGTON'S DISEASE AGENTS AUSTEDO TAB 6MG SP, PA AUSTEDO TAB 9MG SP, PA AUSTEDO TAB 12MG SP, PA tetrabenazine tab 12.5 mg SP, PA tetrabenazine tab 25 mg SP, PA HYPNOTICS, BENZODIAZEPINES temazepam cap 7.5 mg QL (15 per month) temazepam cap 15 mg QL (15 per month) temazepam cap 22.5 mg QL (15 per month) temazepam cap 30 mg QL (15 per month) HYPNOTICS, NON-BENZODIAZEPINES diphenhydramine hcl (sleep) cap 50 mg OTC diphenhydramine hcl (sleep) tab 25 mg OTC diphenhydramine hcl (sleep) tab 50 mg OTC doxylamine succinate (sleep) tab 25 mg OTC zolpidem tartrate tab 5 mg QL (30 per month) zolpidem tartrate tab 10 mg QL (30 per month) zolpidem tartrate tab er 6.25 mg QL (30 per month)

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 53 Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit Drug Name Requirements/Limits zolpidem tartrate tab er 12.5 mg QL (30 per month) MIGRAINE, ERGOTAMINE DERIVATIVES ergotamine w/ caffeine tab 1-100 mg MIGRAINE, SELECTIVE SEROTONIN AGONISTS naratriptan hcl tab 1 mg (base equiv) QL (12 per month); ST (Must have recently been on 9 days of sumatriptan) naratriptan hcl tab 1 mg (base equiv) QL (12 per month); ST (Must have recently been on 9 days supply of sumatriptan) naratriptan hcl tab 2.5 mg (base equiv) QL (12 per month); ST (Must have recently been on 9 days of sumatriptan) naratriptan hcl tab 2.5 mg (base equiv) QL (12 per month); ST (Must have recently been on 9 days supply of sumatriptan) rizatriptan benzoate oral disintegrating tab 5 mg QL (18 per month); ST (base eq) (Must have recently been on 9 days supply of sumatriptan) rizatriptan benzoate oral disintegrating tab 10 mg QL (18 per month); ST (base eq) (Must have recently been on 9 days supply of sumatriptan) rizatriptan benzoate tab 5 mg (base equivalent) QL (18 per month); ST (Must have recently been on 9 days supply of sumatriptan) rizatriptan benzoate tab 10 mg (base equivalent) QL (18 per month); ST (Must have recently been on 9 days supply of sumatriptan) sumatriptan nasal spray 5 mg/act QL (24 per month) sumatriptan nasal spray 20 mg/act QL (24 per month) sumatriptan succinate inj 6 mg/0.5ml QL (6 per month) sumatriptan succinate solution auto-injector 4 QL (6 per month) mg/0.5ml sumatriptan succinate solution auto-injector 6 QL (6 per month) mg/0.5ml sumatriptan succinate solution cartridge 4 QL (6 per month) mg/0.5ml sumatriptan succinate solution cartridge 6 QL (6 per month) mg/0.5ml sumatriptan succinate tab 25 mg QL (12 per month)

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 54 Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit Drug Name Requirements/Limits sumatriptan succinate tab 50 mg QL (12 per month) sumatriptan succinate tab 100 mg QL (12 per month) zolmitriptan orally disintegrating tab 2.5 mg QL (12 per month); ST (Must have recently been on 9 days supply of sumatriptan) zolmitriptan orally disintegrating tab 5 mg QL (12 per month); ST (Must have recently been on 9 days supply of sumatriptan) zolmitriptan tab 2.5 mg QL (12 per month); ST (Must have recently been on 9 days supply of sumatriptan) zolmitriptan tab 5 mg QL (12 per month); ST (Must have recently been on 9 days supply of sumatriptan) MISCELLANEOUS riluzole tab 50 mg MOOD STABILIZERS EQUETRO CAP 100MG EQUETRO CAP 200MG EQUETRO CAP 300MG lithium carbonate cap 150 mg lithium carbonate cap 300 mg lithium carbonate cap 600 mg lithium carbonate tab 300 mg lithium carbonate tab er 300 mg lithium carbonate tab er 450 mg LITHIUM SOL 8MEQ/5ML LITHOBID TAB 300MG CR + MULTIPLE SCLEROSIS AUBAGIO TAB 7MG SP, PA AUBAGIO TAB 14MG SP, PA AVONEX KIT 30MCG SP AVONEX PEN KIT 30MCG SP AVONEX PREFL KIT 30MCG SP BETASERON INJ 0.3MG SP COPAXONE INJ 40MG/ML SP; + dalfampridine tab er 12hr 10 mg SP, PA EXTAVIA INJ 0.3MG SP GILENYA CAP 0.5MG SP, PA glatiramer acetate soln prefilled syringe 20 mg/ml SP

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 55 Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit Drug Name Requirements/Limits glatiramer acetate soln prefilled syringe 40 mg/ml SP REBIF INJ 22/0.5 SP REBIF INJ 44/0.5 SP REBIF REBIDO INJ 22/0.5 SP REBIF REBIDO INJ 44/0.5 SP REBIF REBIDO INJ TITRATN SP REBIF TITRTN INJ PACK SP TECFIDERA CAP 120MG SP, PA TECFIDERA CAP 240MG SP, PA TECFIDERA MIS STARTER SP, PA MUSCULOSKELETAL THERAPY AGENTS baclofen tab 10 mg baclofen tab 20 mg carisoprodol tab 250 mg QL (120 per month) carisoprodol tab 350 mg QL (120 per month) chlorzoxazone tab 500 mg cyclobenzaprine hcl tab 5 mg cyclobenzaprine hcl tab 10 mg dantrolene sodium cap 25 mg dantrolene sodium cap 50 mg dantrolene sodium cap 100 mg methocarbamol tab 500 mg methocarbamol tab 750 mg orphenadrine citrate tab er 12hr 100 mg tizanidine hcl tab 2 mg (base equivalent) tizanidine hcl tab 4 mg (base equivalent) MYASTHENIA GRAVIS pyridostigmine bromide syrup 60 mg/5ml pyridostigmine bromide tab 60 mg pyridostigmine bromide tab er 180 mg NARCOLEPSY armodafinil tab 50 mg PA armodafinil tab 150 mg PA armodafinil tab 200 mg PA armodafinil tab 250 mg PA modafinil tab 100 mg PA modafinil tab 200 mg PA PSYCHOTHERAPEUTIC-MISCELLANEOUS, ALCOHOL DETERRENTS acamprosate calcium tab delayed release 333 mg PA disulfiram tab 250 mg disulfiram tab 500 mg PSYCHOTHERAPEUTIC-MISCELLANEOUS, OPIOID ANTAGONISTS naltrexone hcl tab 50 mg

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 56 Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit Drug Name Requirements/Limits NARCAN SPR QL (2 cartons (4 nasal sprays) per 180 days) PSYCHOTHERAPEUTIC-MISCELLANEOUS, PARTIAL OPIOID AGONIST/OPIOID ANTAGONIST COMBINATIONS buprenorphine hcl-naloxone hcl sl film 2-0.5 mg (base equiv) buprenorphine hcl-naloxone hcl sl film 4-1 mg (base equiv) buprenorphine hcl-naloxone hcl sl film 8-2 mg (base equiv) buprenorphine hcl-naloxone hcl sl film 12-3 mg (base equiv) buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg (base equiv) buprenorphine hcl-naloxone hcl sl tab 8-2 mg (base equiv) ZUBSOLV SUB 0.7-0.18 ZUBSOLV SUB 1.4-0.36 ZUBSOLV SUB 2.9-0.71 ZUBSOLV SUB 5.7-1.4 ZUBSOLV SUB 8.6-2.1 ZUBSOLV SUB 11.4-2.9 PSYCHOTHERAPEUTIC-MISCELLANEOUS, PARTIAL OPIOID AGONISTS buprenorphine hcl sl tab 2 mg (base equiv) buprenorphine hcl sl tab 8 mg (base equiv) PSYCHOTHERAPEUTIC-MISCELLANEOUS, PSEUDOBULBAR AFFECT AGENTS NUEDEXTA CAP 20-10MG PA PSYCHOTHERAPEUTIC-MISCELLANEOUS, SMOKING DETERRENTS bupropion hcl (smoking deterrent) tab er 12hr 150 QL (Max 180 days per mg year); AL (covered for ages 18 and over) CHANTIX PAK 0.5& 1MG QL (Max 180 days per year); AL (covered for ages 18 and over) CHANTIX PAK 1MG QL (Max 180 days per year); AL (covered for ages 18 and over) CHANTIX TAB 0.5MG QL (Max 180 days per year); AL (covered for ages 18 and over) CHANTIX TAB 1MG QL (Max 180 days per year); AL (covered for ages 18 and over)

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 57 Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit Drug Name Requirements/Limits nicotine polacrilex gum 2 mg OTC, QL (Max 180 days per year); AL (covered for ages 18 and over) nicotine polacrilex gum 4 mg OTC, QL (Max 180 days per year); AL (covered for ages 18 and over) nicotine td patch 24hr 7 mg/24hr OTC, QL (Max 180 days per year); AL (covered for ages 18 and over) nicotine td patch 24hr 14 mg/24hr OTC, QL (Max 180 days per year); AL (covered for ages 18 and over) nicotine td patch 24hr 21 mg/24hr OTC, QL (Max 180 days per year); AL (covered for ages 18 and over) ENDOCRINE AND METABOLIC ANDROGENS danazol cap 50 mg danazol cap 100 mg danazol cap 200 mg testosterone td gel 10mg/act (2%) PA; Males only testosterone td gel 25 mg/2.5gm (1%) PA ANTIDIABETICS, ALPHA-GLUCOSIDASE INHIBITORS acarbose tab 25 mg acarbose tab 50 mg acarbose tab 100 mg ANTIDIABETICS, BIGUANIDE/SULFONYLUREA COMBINATIONS glipizide-metformin hcl tab 2.5-250 mg glipizide-metformin hcl tab 2.5-500 mg glipizide-metformin hcl tab 5-500 mg glyburide-metformin tab 1.25-250 mg glyburide-metformin tab 2.5-500 mg glyburide-metformin tab 5-500 mg ANTIDIABETICS, BIGUANIDES metformin hcl tab 500 mg metformin hcl tab 850 mg metformin hcl tab 1000 mg metformin hcl tab er 24hr 500 mg metformin hcl tab er 24hr 750 mg ANTIDIABETICS, DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITOR/BIGUANIDE COMBINATIONS JANUMET TAB 50-500MG ST (Must try metformin, sulfonylurea, or insulin sensitizer)

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 58 Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit Drug Name Requirements/Limits JANUMET TAB 50-1000 ST (Must try metformin, sulfonylurea, or insulin sensitizer) JANUMET XR TAB 50-500MG ST (Must try metformin, sulfonylurea, or insulin sensitizer) JANUMET XR TAB 50-1000 ST (Must try metformin, sulfonylurea, or insulin sensitizer) JANUMET XR TAB 100-1000 ST (Must try metformin, sulfonylurea, or insulin sensitizer) ANTIDIABETICS, DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS JANUVIA TAB 25MG ST (Must try metformin, sulfonylurea, or insulin sensitizer) JANUVIA TAB 50MG ST (Must try metformin, sulfonylurea, or insulin sensitizer) JANUVIA TAB 100MG ST (Must try metformin, sulfonylurea, or insulin sensitizer) ANTIDIABETICS, INCRETIN MIMETIC AGENT/INSULIN COMBINATIONS SOLIQUA INJ 100/33 ST (Must try metformin AND long-acting insulin or another mono incretin mimetic agent) ANTIDIABETICS, INCRETIN MIMETIC AGENTS OZEMPIC INJ 2/1.5ML ST (Must have been on 30 days of metformin) TRULICITY INJ 0.75/0.5 ST (Must have been on 30 days of metformin) TRULICITY INJ 1.5/0.5 ST (Must have been on 30 days of metformin) VICTOZA INJ 18MG/3ML ST (Must have been on 30 days of metformin) ANTIDIABETICS, INSULIN SENSITIZER/BIGUANIDE COMBINATIONS pioglitazone hcl-metformin hcl tab 15-500 mg pioglitazone hcl-metformin hcl tab 15-850 mg ANTIDIABETICS, INSULIN SENSITIZER/SULFONYLUREA COMBINATIONS pioglitazone hcl-glimepiride tab 30-2 mg pioglitazone hcl-glimepiride tab 30-4 mg

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 59 Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit Drug Name Requirements/Limits ANTIDIABETICS, INSULIN SENSITIZERS pioglitazone hcl tab 15 mg (base equiv) pioglitazone hcl tab 30 mg (base equiv) pioglitazone hcl tab 45 mg (base equiv) ANTIDIABETICS, INSULINS APIDRA INJ SOLOSTAR APIDRA INJ U-100 BASAGLAR INJ 100UNIT FIASP FLEX INJ TOUCH FIASP INJ 100/ML HUMALOG INJ 100/ML HUMALOG JR INJ 100/ML HUMALOG KWIK INJ 100/ML HUMALOG MIX INJ 50/50 HUMALOG MIX INJ 50/50KWP HUMALOG MIX INJ 75/25KWP HUMALOG MIX SUS 75/25 HUMULIN INJ 70/30 OTC HUMULIN INJ 70/30KWP OTC HUMULIN N INJ U-100 OTC HUMULIN N INJ U-100KWP OTC HUMULIN R INJ U-100 OTC HUMULIN R INJ U-500 NOVOLIN70/30 INJ RELION OTC NOVOLIN INJ 70/30 OTC NOVOLIN INJ FLEXPEN OTC NOVOLIN N INJ RELION OTC NOVOLIN N INJ U-100 OTC NOVOLIN R INJ RELION OTC NOVOLIN R INJ U-100 OTC NOVOLOG INJ 100/ML NOVOLOG INJ FLEXPEN NOVOLOG INJ PENFILL NOVOLOG MIX INJ 70/30 NOVOLOG MIX INJ FLEXPEN ANTIDIABETICS, MEGLITINIDES nateglinide tab 60 mg nateglinide tab 120 mg repaglinide tab 0.5 mg repaglinide tab 1 mg repaglinide tab 2 mg

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 60 Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit Drug Name Requirements/Limits ANTIDIABETICS, SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITOR/BIGUANIDE COMBINATIONS INVOKAMET TAB 50-500MG ST (Must try metformin, sulfonylurea, or insulin sensitizer) INVOKAMET TAB 50-1000 ST (Must try metformin, sulfonylurea, or insulin sensitizer) INVOKAMET TAB 150-500 ST (Must try metformin, sulfonylurea, or insulin sensitizer) INVOKAMET TAB 150-1000 ST (Must try metformin, sulfonylurea, or insulin sensitizer) INVOKAMET XR TAB 50-500MG ST (Must try metformin, sulfonylurea, or insulin sensitizer) INVOKAMET XR TAB 50-1000 ST (Must try metformin, sulfonylurea, or insulin sensitizer) INVOKAMET XR TAB 150-500 ST (Must try metformin, sulfonylurea, or insulin sensitizer) INVOKAMET XR TAB 150-1000 ST (Must try metformin, sulfonylurea, or insulin sensitizer) ANTIDIABETICS, SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITORS INVOKANA TAB 100MG ST (Must try metformin, sulfonylurea, or insulin sensitizer) INVOKANA TAB 300MG ST (Must try metformin, sulfonylurea, or insulin sensitizer) ANTIDIABETICS, SULFONYLUREAS glimepiride tab 1 mg glimepiride tab 2 mg glimepiride tab 4 mg glipizide tab 5 mg glipizide tab 10 mg glipizide tab er 24hr 2.5 mg glipizide tab er 24hr 5 mg glipizide tab er 24hr 10 mg glyburide micronized tab 1.5 mg glyburide micronized tab 3 mg

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 61 Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit Drug Name Requirements/Limits glyburide micronized tab 6 mg glyburide tab 1.25 mg glyburide tab 2.5 mg glyburide tab 5 mg ANTIDIABETICS, SUPPLIES ALCOHOL SWAB PAD OTC, QL (400 per month) BD INSULIN SYRINGE 0.3/30G OTC BD INSULIN SYRINGE 0.3/31G OTC BD INSULIN SYRINGE 0.5/30G OTC BD INSULIN SYRINGE 0.5/31G OTC BD INSULIN SYRINGE 1ML/30G OTC BD INSULIN SYRINGE 1ML/31G OTC BD PEN NEEDL MIS 29GX12.7 OTC BD PEN NEEDL MIS 31GX5MM OTC BD PEN NEEDL MIS 31GX8MM OTC BD PEN NEEDL MIS 32GX4MM OTC BD PEN NEEDL MIS 32GX6MM OTC BD U-500 MIS 31GX6MM OTC FREESTYLE TES OTC FREESTYLE TES INSULINX OTC FREESTYLE TES LITE OTC KETO-DIASTIX TES OTC, QL (100 per month) LANCETS MIS OTC PRECISION TES XTRA OTC CALCIUM RECEPTOR ANTAGONISTS SENSIPAR TAB 30MG SP, PA SENSIPAR TAB 60MG SP, PA SENSIPAR TAB 90MG SP, PA CALCIUM REGULATORS, BISPHOSPHONATES alendronate sodium tab 5 mg alendronate sodium tab 10 mg alendronate sodium tab 35 mg alendronate sodium tab 40 mg alendronate sodium tab 70 mg CALCIUM REGULATORS, CALCITONINS calcitonin (salmon) nasal soln 200 unit/act CALCIUM REGULATORS, PARATHYROID HORMONES FORTEO SOL 600/2.4 SP, PA CARNITINE DEFICIENCY AGENTS levocarnitine oral soln 1 gm/10ml (10%) levocarnitine tab 330 mg

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 62 Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit Drug Name Requirements/Limits CONTRACEPTIVES, BIPHASIC desogest-eth estrad & eth estrad tab 0.15- Females only 0.02/0.01 mg(21/5) CONTRACEPTIVES, EMERGENCY CONTRACEPTION ELLA TAB 30MG QL (2 per year); Females only levonorgestrel tab 1.5 mg OTC, QL (2 per year); Females only CONTRACEPTIVES, INJECTABLE medroxyprogesterone acetate im susp 150 mg/ml QL (1 mL per 3 months); Females only medroxyprogesterone acetate im susp prefilled syr QL (1 mL per 3 months); 150 mg/ml Females only CONTRACEPTIVES, MISCELLANEOUS CONDOMS MIS OTC, QL (24 per month); Males only DIAPHRAGM QL (1 per year) ENCARE SUP 100MG OTC GYNOL II GEL 3% OTC nonoxynol-9 gel 4% OTC SHUR-SEAL GEL 2% OTC VCF VAGINAL AER CONTRACP OTC VCF VAGINAL MIS CONTRACP OTC CONTRACEPTIVES, MONOPHASIC, 20 mcg Estrogen drospirenone-ethinyl estradiol tab 3-0.02 mg Females only levonorgestrel & ethinyl estradiol tab 0.1 mg-20 Females only mcg norethindrone ace & ethinyl estradiol tab 1 mg-20 Females only mcg norethindrone ace & ethinyl estradiol-fe tab 1 mg- Females only 20 mcg CONTRACEPTIVES, MONOPHASIC, 30 mcg Estrogen desogestrel & ethinyl estradiol tab 0.15 mg-30 Females only mcg drospirenone-ethinyl estradiol tab 3-0.03 mg Females only levonorgestrel & ethinyl estradiol tab 0.15 mg-30 Females only mcg norethindrone ace & ethinyl estradiol tab 1.5 mg- Females only 30 mcg norethindrone ace & ethinyl estradiol-fe tab 1.5 Females only mg-30 mcg norgestrel & ethinyl estradiol tab 0.3 mg-30 mcg Females only

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 63 Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit Drug Name Requirements/Limits CONTRACEPTIVES, MONOPHASIC, 35 mcg Estrogen ethynodiol diacetate & ethinyl estradiol tab 1 mg- Females only 35 mcg norethindrone & ethinyl estradiol tab 0.4 mg-35 Females only mcg norethindrone & ethinyl estradiol tab 0.5 mg-35 Females only mcg norethindrone & ethinyl estradiol tab 1 mg-35 mcg Females only norgestimate & ethinyl estradiol tab 0.25 mg-35 Females only mcg CONTRACEPTIVES, MONOPHASIC, 50 mcg Estrogen ethynodiol diacetate & ethinyl estradiol tab 1 mg- Females only 50 mcg norgestrel & ethinyl estradiol tab 0.5 mg-50 mcg Females only CONTRACEPTIVES, PROGESTIN ONLY norethindrone tab 0.35 mg Females only CONTRACEPTIVES, TRANSDERMAL norelgestromin-ethinyl estradiol td ptwk 150-35 Females only mcg/24hr CONTRACEPTIVES, TRIPHASIC desogest-ethin est tab 0.1-0.025/0.125- Females only 0.025/0.15-0.025mg-mg levonorgestrel-eth estra tab 0.05-30/0.075- Females only 40/0.125-30mg-mcg norethindrone-eth estradiol tab 0.5-35/0.75-35/1- Females only 35 mg-mcg norethindrone-eth estradiol tab 0.5-35/1-35/0.5- Females only 35 mg-mcg norgestimate-eth estrad tab 0.18-25/0.215- Females only 25/0.25-25 mg-mcg norgestimate-eth estrad tab 0.18-35/0.215- Females only 35/0.25-35 mg-mcg CONTRACEPTIVES, VAGINAL NUVARING MIS Females only ENDOMETRIOSIS danazol cap 50 mg danazol cap 100 mg danazol cap 200 mg SYNAREL SOL 2MG/ML ESTROGEN/PROGESTIN, ORAL estradiol & norethindrone acetate tab 0.5-0.1 mg Females only estradiol & norethindrone acetate tab 1-0.5 mg Females only norethindrone acetate-ethinyl estradiol tab 0.5 Females only mg-2.5 mcg

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 64 Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit Drug Name Requirements/Limits norethindrone acetate-ethinyl estradiol tab 1 mg-5 Females only mcg ESTROGEN/PROGESTIN, TRANSDERMAL COMBIPATCH DIS .05/.14 Females only COMBIPATCH DIS .05/.25 Females only ESTROGENS, ORAL estradiol tab 0.5 mg Females only estradiol tab 1 mg Females only estradiol tab 2 mg Females only ESTROGENS, TRANSDERMAL estradiol td patch weekly 0.1 mg/24hr Females only estradiol td patch weekly 0.05 mg/24hr Females only estradiol td patch weekly 0.06 mg/24hr Females only estradiol td patch weekly 0.025 mg/24hr Females only estradiol td patch weekly 0.075 mg/24hr Females only estradiol td patch weekly 0.0375 mg/24hr (37.5 Females only mcg/24hr) ESTROGENS, VAGINAL estradiol vaginal tab 10 mcg PREMARIN VAG CRE 0.625MG GAUCHER DISEASE CERDELGA CAP 84MG SP, PA GLUCOCORTICOIDS dexamethasone elixir 0.5 mg/5ml dexamethasone soln 0.5 mg/5ml dexamethasone tab 0.5 mg dexamethasone tab 0.75 mg dexamethasone tab 1 mg dexamethasone tab 1.5 mg dexamethasone tab 2 mg dexamethasone tab 4 mg dexamethasone tab 6 mg hydrocortisone tab 5 mg hydrocortisone tab 10 mg hydrocortisone tab 20 mg MEDROL TAB 2MG methylprednisolone tab 4 mg methylprednisolone tab 8 mg methylprednisolone tab 16 mg methylprednisolone tab 32 mg methylprednisolone tab therapy pack 4 mg (21) prednisolone sod phos orally disintegr tab 10 mg (base eq)

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 65 Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit Drug Name Requirements/Limits prednisolone sod phos orally disintegr tab 15 mg (base eq) prednisolone sod phos orally disintegr tab 30 mg (base eq) prednisolone sod phosph oral soln 6.7 mg/5ml (5 mg/5ml base) prednisolone sod phosphate oral soln 15 mg/5ml (base equiv) prednisolone syrup 15 mg/5ml (usp solution equivalent) prednisone oral soln 5 mg/5ml prednisone tab 1 mg prednisone tab 2.5 mg prednisone tab 5 mg prednisone tab 10 mg prednisone tab 20 mg prednisone tab 50 mg prednisone tab therapy pack 5 mg (21) prednisone tab therapy pack 5 mg (48) prednisone tab therapy pack 10 mg (21) prednisone tab therapy pack 10 mg (48) GLUCOSE ELEVATING AGENTS GLUCAGEN INJ HYPOKIT QL (2 inj per month) GLUCAGON KIT 1MG QL (2 inj per month) HEREDITARY TYROSINEMIA TYPE 1 AGENTS NITYR TAB 2MG SP, PA NITYR TAB 5MG SP, PA NITYR TAB 10MG SP, PA HUMAN GROWTH HORMONES GENOTROPIN INJ 0.2MG SP, PA GENOTROPIN INJ 0.4MG SP, PA GENOTROPIN INJ 0.6MG SP, PA GENOTROPIN INJ 0.8MG SP, PA GENOTROPIN INJ 1.2MG SP, PA GENOTROPIN INJ 1.4MG SP, PA GENOTROPIN INJ 1.6MG SP, PA GENOTROPIN INJ 1.8MG SP, PA GENOTROPIN INJ 1MG SP, PA GENOTROPIN INJ 2MG SP, PA GENOTROPIN INJ 5MG SP, PA GENOTROPIN INJ 12MG SP, PA HUMATROPE INJ 5MG SP, PA HUMATROPE INJ 6MG SP, PA HUMATROPE INJ 12MG SP, PA

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 66 Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit Drug Name Requirements/Limits HUMATROPE INJ 24MG SP, PA NORDITROPIN INJ 5/1.5ML SP, PA NORDITROPIN INJ 10/1.5ML SP, PA NORDITROPIN INJ 15/1.5ML SP, PA NORDITROPIN INJ 30/3ML SP, PA NUTROPIN AQ INJ 10MG/2ML SP, PA NUTROPIN AQ INJ 20MG/2ML SP, PA NUTROPIN AQ INJ NUSPIN 5 SP, PA OMNITROPE INJ 5.8MG SP, PA OMNITROPE INJ 5/1.5ML SP, PA OMNITROPE INJ 10/1.5ML SP, PA SAIZEN INJ 5MG SP, PA SAIZEN INJ 8.8MG SP, PA SAIZENPREP INJ 8.8MG SP, PA SEROSTIM INJ 4MG SP, PA SEROSTIM INJ 5MG SP, PA SEROSTIM INJ 6MG SP, PA ZOMACTON INJ 5MG SP, PA ZOMACTON INJ 10MG SP, PA ZORBTIVE INJ 8.8MG SP, PA HYPERPARATHYROID TREATMENT, VITAMIN D ANALOGS calcitriol cap 0.5 mcg calcitriol cap 0.25 mcg calcitriol oral soln 1 mcg/ml doxercalciferol cap 0.5 mcg doxercalciferol cap 1 mcg doxercalciferol cap 2.5 mcg paricalcitol cap 1 mcg paricalcitol cap 2 mcg paricalcitol cap 4 mcg MINERALOCORTICOIDS fludrocortisone acetate tab 0.1 mg MISCELLANEOUS cabergoline tab 0.5 mg CYSTAGON CAP 50MG SP, PA CYSTAGON CAP 150MG SP, PA PHENYLKETONURIA TREATMENT AGENTS KUVAN POW 100MG SP, PA KUVAN TAB 100MG SP, PA PHOSPHATE BINDER AGENTS calcium acetate (phosphate binder) cap 667 mg (169 mg ca)

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 67 Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit Drug Name Requirements/Limits sevelamer carbonate packet 0.8 gm ST (Must try calcium acetate (generic PHOSLO)) sevelamer carbonate packet 2.4 gm ST (Must try calcium acetate (generic PHOSLO)) sevelamer carbonate tab 800 mg ST (Must try calcium acetate (generic PHOSLO)) POTASSIUM-REMOVING AGENTS sodium polystyrene sulfonate oral susp 15 gm/60ml sodium polystyrene sulfonate rectal susp 30 gm/120ml PROGESTINS, ORAL medroxyprogesterone acetate tab 2.5 mg medroxyprogesterone acetate tab 5 mg medroxyprogesterone acetate tab 10 mg megestrol acetate susp 40 mg/ml norethindrone acetate tab 5 mg progesterone micronized cap 100 mg progesterone micronized cap 200 mg PROGESTINS, VAGINAL CRINONE GEL 4% VAG PA CRINONE GEL 8% VAG PA SELECTIVE ESTROGEN RECEPTOR MODULATORS OSPHENA TAB 60MG PA raloxifene hcl tab 60 mg THYROID AGENTS, ANTITHYROID AGENTS methimazole tab 5 mg methimazole tab 10 mg propylthiouracil tab 50 mg SSKI SOL 1GM/ML THYROID AGENTS, THYROID SUPPLEMENTS CYTOMEL TAB 5MCG + CYTOMEL TAB 25MCG + CYTOMEL TAB 50MCG + levothyroxine sodium tab 25 mcg levothyroxine sodium tab 50 mcg levothyroxine sodium tab 75 mcg levothyroxine sodium tab 88 mcg levothyroxine sodium tab 100 mcg levothyroxine sodium tab 112 mcg levothyroxine sodium tab 125 mcg levothyroxine sodium tab 137 mcg levothyroxine sodium tab 150 mcg

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 68 Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit Drug Name Requirements/Limits levothyroxine sodium tab 175 mcg levothyroxine sodium tab 200 mcg levothyroxine sodium tab 300 mcg liothyronine sodium tab 5 mcg liothyronine sodium tab 25 mcg liothyronine sodium tab 50 mcg SYNTHROID TAB 25MCG + SYNTHROID TAB 50MCG + SYNTHROID TAB 75MCG + SYNTHROID TAB 88MCG + SYNTHROID TAB 100MCG + SYNTHROID TAB 112MCG + SYNTHROID TAB 125MCG + SYNTHROID TAB 137MCG + SYNTHROID TAB 150MCG + SYNTHROID TAB 175MCG + SYNTHROID TAB 200MCG + SYNTHROID TAB 300MCG + UREA CYCLE DISORDERS sodium phenylbutyrate oral powder 3 SP, PA gm/teaspoonful sodium phenylbutyrate tab 500 mg SP, PA VASOPRESSIN RECEPTOR ANTAGONISTS SAMSCA TAB 15MG SP, PA SAMSCA TAB 30MG SP, PA VASOPRESSINS DDAVP SOL 0.01% PA desmopressin acetate nasal spray soln 0.01% PA desmopressin acetate nasal spray soln 0.01% PA (refrigerated) desmopressin acetate tab 0.1 mg PA desmopressin acetate tab 0.2 mg PA GASTROINTESTINAL ANTACIDS alum & mag hydroxide-simethicone chew tab 200- OTC 200-25 mg alum & mag hydroxide-simethicone susp 200-200- OTC 20 mg/5ml alum & mag hydroxide-simethicone susp 400-400- OTC 40 mg/5ml aluminum hydroxide-magnesium carbonate chew OTC tab 160-105 mg aluminum hydroxide-magnesium carbonate susp OTC 95-358 mg/15ml

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 69 Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit Drug Name Requirements/Limits aluminum hydroxide-magnesium carbonate susp OTC 508-475 mg/10ml aluminum hydroxide-magnesium trisilicate chew OTC tab 80-20 mg ANTACID CHW 1177MG OTC CALCIUM CARB TAB 648MG OTC calcium carbonate (antacid) chew tab 400 mg OTC calcium carbonate (antacid) chew tab 420 mg OTC calcium carbonate (antacid) chew tab 500 mg OTC calcium carbonate (antacid) chew tab 750 mg OTC calcium carbonate (antacid) chew tab 1000 mg OTC calcium carbonate (antacid) susp 1250 mg/5ml OTC calcium carbonate-mag hydroxide chew tab 550- OTC 110 mg calcium carbonate-mag hydroxide susp 400-135 OTC mg/5ml MAALOX CHW 600MG OTC TUMS CHW DEL CHW 1177MG OTC ANTIDIARRHEALS bismuth subsalicylate chew tab 262 mg OTC bismuth subsalicylate susp 262 mg/15ml OTC bismuth subsalicylate susp 525 mg/15ml OTC bismuth subsalicylate tab 262 mg OTC diphenoxylate w/ atropine liq 2.5-0.025 mg/5ml diphenoxylate w/ atropine tab 2.5-0.025 mg loperamide hcl cap 2 mg loperamide hcl cap 2 mg OTC loperamide hcl liq 1 mg/5ml (0.2 mg/ml) OTC loperamide hcl tab 2 mg OTC ANTIEMETICS aprepitant capsule 40 mg QL (6 caps per 6 months), PA aprepitant capsule 80 mg QL (16 caps per 21 days), PA aprepitant capsule 125 mg QL (4 caps per 21 days), PA aprepitant capsule therapy pack 80 & 125 mg QL (4 packs per 21 days) dronabinol cap 2.5 mg QL (60 per month) dronabinol cap 5 mg QL (60 per month) dronabinol cap 10 mg QL (60 per month) EMEND SOL 150MG QL (12 kits per 21 days), PA granisetron hcl tab 1 mg QL (6 per 15 days) meclizine hcl chew tab 25 mg OTC meclizine hcl tab 12.5 mg meclizine hcl tab 12.5 mg OTC

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 70 Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit Drug Name Requirements/Limits meclizine hcl tab 25 mg meclizine hcl tab 25 mg OTC metoclopramide hcl soln 5 mg/5ml (10 mg/10ml) (base equiv) metoclopramide hcl tab 5 mg (base equivalent) metoclopramide hcl tab 10 mg (base equivalent) ondansetron hcl oral soln 4 mg/5ml QL (100 mL per 15 days) ondansetron hcl tab 4 mg QL (12 per 15 days) ondansetron hcl tab 8 mg QL (12 per 15 days) ondansetron hcl tab 24 mg QL (1 per 15 days) ondansetron orally disintegrating tab 4 mg QL (12 per 15 days) ondansetron orally disintegrating tab 8 mg QL (12 per 15 days) prochlorperazine maleate tab 5 mg (base equivalent) prochlorperazine maleate tab 10 mg (base equivalent) prochlorperazine suppos 25 mg promethazine hcl suppos 12.5 mg promethazine hcl suppos 25 mg promethazine hcl suppos 50 mg promethazine hcl syrup 6.25 mg/5ml promethazine hcl tab 12.5 mg promethazine hcl tab 25 mg promethazine hcl tab 50 mg trimethobenzamide hcl cap 300 mg ANTISPASMODICS chlordiazepoxide hcl-clidinium bromide cap 5-2.5 mg dicyclomine hcl cap 10 mg dicyclomine hcl oral soln 10 mg/5ml dicyclomine hcl tab 20 mg glycopyrrolate tab 1 mg glycopyrrolate tab 2 mg hyoscyamine sulfate elixir 0.125 mg/5ml hyoscyamine sulfate sl tab 0.125 mg hyoscyamine sulfate soln 0.125 mg/ml hyoscyamine sulfate tab 0.125 mg hyoscyamine sulfate tab disint 0.125 mg hyoscyamine sulfate tab er 12hr 0.375 mg CHOLELITHOLYTICS ursodiol cap 300 mg ursodiol tab 250 mg ursodiol tab 500 mg

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 71 Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit Drug Name Requirements/Limits H2-RECEPTOR ANTAGONISTS cimetidine hcl soln 300 mg/5ml cimetidine tab 200 mg cimetidine tab 200 mg OTC cimetidine tab 300 mg cimetidine tab 400 mg cimetidine tab 800 mg famotidine for susp 40 mg/5ml famotidine tab 10 mg OTC famotidine tab 20 mg famotidine tab 20 mg OTC famotidine tab 40 mg nizatidine cap 150 mg nizatidine cap 300 mg nizatidine oral soln 15 mg/ml ranitidine hcl cap 150 mg ranitidine hcl cap 300 mg ranitidine hcl syrup 15 mg/ml (75 mg/5ml) ranitidine hcl tab 75 mg OTC ranitidine hcl tab 150 mg ranitidine hcl tab 150 mg OTC ranitidine hcl tab 300 mg INFLAMMATORY BOWEL DISEASE, ORAL AGENTS APRISO CAP 0.375GM ST (Must have recently been on 30 days of sulfasalazine) balsalazide disodium cap 750 mg budesonide delayed release particles cap 3 mg sulfasalazine tab 500 mg sulfasalazine tab delayed release 500 mg INFLAMMATORY BOWEL DISEASE, RECTAL AGENTS hydrocortisone enema 100 mg/60ml mesalamine enema 4 gm mesalamine rectal enema 4 gm & cleanser wipe kit IRRITABLE BOWEL SYNDROME WITH CONSTIPATION/CHRONIC IDIOPATHIC CONSTIPATION LINZESS CAP 72MCG LINZESS CAP 145MCG LINZESS CAP 290MCG TRULANCE TAB 3MG LAXATIVES/STOOL SOFTENERS bisacodyl suppos 10 mg OTC bisacodyl tab delayed release 5 mg OTC docusate calcium cap 240 mg OTC

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 72 Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit Drug Name Requirements/Limits docusate sodium cap 50 mg OTC docusate sodium cap 100 mg OTC docusate sodium cap 250 mg OTC docusate sodium liquid 150 mg/15ml OTC docusate sodium syrup 60 mg/15ml OTC docusate sodium tab 100 mg OTC lactulose solution 10 gm/15ml PEDIA-LAX LIQ 50MG OTC peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240 gm peg 3350-kcl-sod bicarb-nacl for soln 420 gm polyethylene glycol 3350 oral packet OTC polyethylene glycol 3350 oral powder OTC sennosides chew tab 15 mg OTC sennosides syrup 8.8 mg/5ml OTC sennosides tab 8.6 mg OTC sennosides tab 15 mg OTC sennosides tab 17.2 mg OTC sennosides tab 25 mg OTC sennosides-docusate sodium tab 8.6-50 mg OTC MISCELLANEOUS CUVPOSA SOL 1MG/5ML AL (covered for ages 3-16) GAS-X CHILD MIS 40MG OTC lactulose (encephalopathy) solution 10 gm/15ml simethicone cap 125 mg OTC simethicone cap 180 mg OTC simethicone chew tab 80 mg OTC simethicone chew tab 125 mg OTC simethicone liquid 40 mg/0.6ml OTC simethicone susp 40 mg/0.6ml OTC sucralfate tab 1 gm OPIOID-INDUCED CONSTIPATION MOVANTIK TAB 12.5MG MOVANTIK TAB 25MG PANCREATIC ENZYMES CREON CAP 3000UNIT CREON CAP 6000UNIT CREON CAP 12000UNT CREON CAP 24000UNT CREON CAP 36000UNT VIOKACE TAB 10440

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 73 Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit Drug Name Requirements/Limits VIOKACE TAB 20880 ZENPEP CAP 3000UNIT ZENPEP CAP 5000UNIT ZENPEP CAP 10000UNT ZENPEP CAP 15000UNT ZENPEP CAP 20000UNT ZENPEP CAP 25000 ZENPEP CAP 25000UNT ZENPEP CAP 40000 ZENPEP CAP 40000UNT PROSTAGLANDINS misoprostol tab 100 mcg misoprostol tab 200 mcg PROTON PUMP INHIBITORS esomeprazole magnesium cap delayed release 20 QL (30 per month) mg (base eq) lansoprazole cap delayed release 15 mg OTC, QL (30 per month) NEXIUM 24HR TAB 20MG OTC, QL (30 per month) NEXIUM GRA 2.5MG DR QL (30 per month); AL (Covered for ages less than 1 only) NEXIUM GRA 5MG DR QL (30 per month); AL (Covered for ages less than 1 only) NEXIUM GRA 10MG DR QL (30 per month); AL (Covered for ages less than 1 only) omeprazole cap delayed release 10 mg QL (30 per month) omeprazole cap delayed release 20 mg QL (30 per month) omeprazole cap delayed release 40 mg QL (30 per month) omeprazole magnesium cap dr 20.6 mg (20 mg OTC, QL (30 per month) base equiv) OMEPRAZOLE TAB 20MG OTC omeprazole-sodium bicarbonate cap 20-1100 mg QL (30 per month) pantoprazole sodium ec tab 20 mg (base equiv) QL (30 per month) pantoprazole sodium ec tab 40 mg (base equiv) QL (30 per month) PRILOSEC OTC TAB 20MG OTC SALIVA STIMULANTS pilocarpine hcl tab 5 mg pilocarpine hcl tab 7.5 mg STEROIDS, RECTAL hydrocortisone rectal cream 1% hydrocortisone rectal cream 2.5%

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 74 Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit Drug Name Requirements/Limits GENITOURINARY BENIGN PROSTATIC HYPERPLASIA alfuzosin hcl tab er 24hr 10 mg finasteride tab 5 mg tamsulosin hcl cap 0.4 mg MISCELLANEOUS acetic acid vaginal solution OTC bethanechol chloride tab 5 mg bethanechol chloride tab 10 mg bethanechol chloride tab 25 mg bethanechol chloride tab 50 mg ELMIRON CAP 100MG K-PHOS TAB K-PHOS TAB NO 2 phenazopyridine hcl tab 100 mg phenazopyridine hcl tab 200 mg potassium citrate & citric acid powder pack 3300- 1002 mg potassium citrate & citric acid soln 1100-334 mg/5ml potassium citrate tab er 5 meq (540 mg) potassium citrate tab er 10 meq (1080 mg) potassium citrate tab er 15 meq (1620 mg) URINARY ANTISPASMODICS oxybutynin chloride syrup 5 mg/5ml oxybutynin chloride tab 5 mg oxybutynin chloride tab er 24hr 5 mg oxybutynin chloride tab er 24hr 10 mg oxybutynin chloride tab er 24hr 15 mg tolterodine tartrate tab 1 mg tolterodine tartrate tab 2 mg trospium chloride cap er 24hr 60 mg trospium chloride tab 20 mg VAGINAL ANTI-INFECTIVES clindamycin phosphate vaginal cream 2% clotrimazole vaginal cream 1% OTC clotrimazole vaginal cream 2% OTC metronidazole vaginal gel 0.75% miconazole nitrate vaginal app 200 mg & 2% OTC cream 9 gm kit miconazole nitrate vaginal cream 2% OTC miconazole nitrate vaginal cream 4% (200 OTC mg/5gm)

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 75 Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit Drug Name Requirements/Limits miconazole nitrate vaginal supp 200 mg & 2% OTC cream 9 gm kit miconazole nitrate vaginal supp 1200 mg & 2% OTC cream kit miconazole nitrate vaginal suppos 100 mg OTC miconazole nitrate vaginal suppos 200 mg MONISTAT 3 KIT COMBO PK OTC MONISTAT 7 KIT COMPLETE OTC terconazole vaginal cream 0.4% terconazole vaginal cream 0.8% terconazole vaginal suppos 80 mg HEMATOLOGIC ANTICOAGULANTS, ORAL COUMADIN TAB 1MG + COUMADIN TAB 2.5MG + COUMADIN TAB 2MG + COUMADIN TAB 3MG + COUMADIN TAB 4MG + COUMADIN TAB 5MG + COUMADIN TAB 6MG + COUMADIN TAB 7.5MG + COUMADIN TAB 10MG + ELIQUIS TAB 2.5MG ELIQUIS TAB 5MG warfarin sodium tab 1 mg warfarin sodium tab 2 mg warfarin sodium tab 2.5 mg warfarin sodium tab 3 mg warfarin sodium tab 4 mg warfarin sodium tab 5 mg warfarin sodium tab 6 mg warfarin sodium tab 7.5 mg warfarin sodium tab 10 mg XARELTO STAR TAB 15/20MG XARELTO TAB 2.5MG XARELTO TAB 10MG XARELTO TAB 15MG XARELTO TAB 20MG HEMOSTATICS, SYSTEMIC AMICAR SOL 0.25/ML aminocaproic acid tab 500 mg aminocaproic acid tab 1000 mg

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 76 Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit Drug Name Requirements/Limits MISCELLANEOUS CHEMET CAP 100MG cilostazol tab 50 mg cilostazol tab 100 mg ENDARI POW 5GM SP, PA pentoxifylline tab er 400 mg PLATELET AGGREGATION INHIBITORS aspirin chew tab 81 mg OTC aspirin tab 325 mg OTC aspirin tab 500 mg OTC aspirin tab delayed release 81 mg OTC aspirin tab delayed release 325 mg OTC aspirin tab delayed release 500 mg OTC BRILINTA TAB 60MG BRILINTA TAB 90MG clopidogrel bisulfate tab 75 mg (base equiv) clopidogrel bisulfate tab 300 mg (base equiv) dipyridamole tab 25 mg dipyridamole tab 50 mg dipyridamole tab 75 mg prasugrel hcl tab 5 mg (base equiv) prasugrel hcl tab 10 mg (base equiv) ZONTIVITY TAB 2.08MG PLATELET SYNTHESIS INHIBITOR anagrelide hcl cap 0.5 mg anagrelide hcl cap 1 mg THROMBOCYTOPENIA AGENTS MULPLETA TAB 3MG SP, PA PROMACTA TAB 12.5MG SP, PA PROMACTA TAB 25MG SP, PA PROMACTA TAB 50MG SP, PA PROMACTA TAB 75MG SP, PA IMMUNOLOGIC AGENTS AUTOIMMUNE AGENTS ENBREL INJ 25/0.5ML SP, PA ENBREL INJ 25MG SP, PA ENBREL INJ 50MG/ML SP, PA ENBREL MINI INJ 50MG/ML SP, PA ENBREL SRCLK INJ 50MG/ML SP, PA HUMIRA INJ 10/0.1ML SP, PA HUMIRA INJ 10MG/0.2 SP, PA HUMIRA INJ 20/0.2ML SP, PA HUMIRA INJ 40/0.4ML SP, PA

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 77 Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit Drug Name Requirements/Limits HUMIRA KIT 20MG/0.4 SP, PA HUMIRA KIT 40MG/0.8 SP, PA HUMIRA PEDIA INJ CROHNS SP, PA HUMIRA PEN INJ 40/0.4ML SP, PA HUMIRA PEN INJ 40MG/0.8 SP, PA HUMIRA PEN INJ CD/UC/HS SP, PA HUMIRA PEN INJ PS/UV SP, PA HUMIRA PEN KIT CD/UC/HS SP, PA HUMIRA PEN KIT PS/UV SP, PA XELJANZ TAB 5MG SP, PA XELJANZ TAB 10MG SP, PA XELJANZ XR TAB 11MG SP, PA DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDs) hydroxychloroquine sulfate tab 200 mg leflunomide tab 10 mg leflunomide tab 20 mg IMMUNOMODULATORS, INTERFERONS PEGASYS INJ SP, PA PEGASYS INJ 180MCG/M SP, PA PEGASYS INJ PROCLICK SP, PA PEGINTRON KIT 50MCG SP, PA IMMUNOSUPPRESSANTS, ANTIMETABOLITES AZASAN TAB 75 MG + AZASAN TAB 100MG azathioprine tab 50 mg CELLCEPT CAP 250MG + CELLCEPT SUS 200MG/ML + CELLCEPT TAB 500MG + IMURAN TAB 50MG + mycophenolate mofetil cap 250 mg mycophenolate mofetil for oral susp 200 mg/ml mycophenolate mofetil tab 500 mg mycophenolate sodium tab dr 180 mg (mycophenolic acid equiv) mycophenolate sodium tab dr 360 mg (mycophenolic acid equiv) MYFORTIC TAB 180MG + MYFORTIC TAB 360MG + IMMUNOSUPPRESSANTS, CALCINEURIN INHIBITORS ASTAGRAF XL CAP 0.5MG ASTAGRAF XL CAP 1MG ASTAGRAF XL CAP 5MG cyclosporine cap 25 mg

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 78 Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit Drug Name Requirements/Limits cyclosporine cap 100 mg cyclosporine modified cap 25 mg cyclosporine modified cap 50 mg cyclosporine modified cap 100 mg cyclosporine modified oral soln 100 mg/ml ENVARSUS XR TAB 0.75MG ENVARSUS XR TAB 1MG ENVARSUS XR TAB 4MG gengraf cap 25mg gengraf cap 100mg gengraf sol 100mg/ml NEORAL CAP 25MG + NEORAL CAP 100MG + NEORAL SOL 100MG/ML + PROGRAF CAP 0.5MG + PROGRAF CAP 1MG + PROGRAF CAP 5MG + SANDIMMUNE CAP 25MG + SANDIMMUNE CAP 100MG + SANDIMMUNE SOL 100MG/ML tacrolimus cap 0.5 mg tacrolimus cap 1 mg tacrolimus cap 5 mg IMMUNOSUPPRESSANTS, RAPAMYCIN DERIVATIVE RAPAMUNE SOL 1MG/ML + RAPAMUNE TAB 0.5MG + RAPAMUNE TAB 1MG + RAPAMUNE TAB 2MG + sirolimus oral soln 1 mg/ml sirolimus tab 0.5 mg sirolimus tab 1 mg sirolimus tab 2 mg ZORTRESS TAB 0.5MG ZORTRESS TAB 0.25MG ZORTRESS TAB 0.75MG VACCINES ADACEL INJ AL (covered for ages 19 and over) BOOSTRIX INJ AL (covered for ages 19 and over) DAPTACEL INJ AL (covered for ages 19 and over) DIP/TET PED INJ 25-5LFU AL (covered for ages 19 and over)

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 79 Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit Drug Name Requirements/Limits ENGERIX-B INJ 10/0.5ML QL (3 vaccines per lifetime); AL (covered for ages 19 and over) ENGERIX-B INJ 20MCG/ML QL (3 vaccines per lifetime); AL (covered for ages 19 and over) GARDASIL 9 INJ QL (3 vaccines per lifetime); AL (covered for ages 19-45) HAVRIX INJ 720UNIT QL (2 vaccines per lifetime); AL (covered for ages 19 and over) HAVRIX INJ 1440UNIT QL (2 vaccines per lifetime); AL (covered for ages 19 and over) INFANRIX INJ AL (covered for ages 19 and over) M-M-R II INJ AL (covered for ages 19 and over) MENACTRA INJ AL (covered for ages 19 and over) MENVEO INJ AL (covered for ages 19 and over) PNEUMOVAX 23 INJ 25/0.5 AL (covered for ages 19 and over) RECOMBIVA HB INJ 5MCG/0.5 QL (3 vaccines per lifetime); AL (covered for ages 19 and over) RECOMBIVA HB INJ 10MCG/ML QL (3 vaccines per lifetime); AL (covered for ages 19 and over) RECOMBIVA-HB INJ 40MCG/ML QL (3 vaccines per lifetime); AL (covered for ages 19 and over) TDVAX INJ 2-2 LF AL (covered for ages 19 and over) TENIVAC INJ 5-2LF AL (covered for ages 19 and over) TWINRIX INJ QL (3 vaccines per lifetime); AL (covered for ages 19 and over) VAQTA INJ 25/0.5ML QL (2 vaccines per lifetime); AL (covered for ages 19 and over) VAQTA INJ 50UNT/ML QL (2 vaccines per lifetime); AL (covered for ages 19 and over)

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 80 Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit Drug Name Requirements/Limits VARIVAX INJ AL (covered for ages 19 and over) ZOSTAVAX INJ AL (covered for ages 60 and over) MISCELLANEOUS DIAGNOSTIC AGENTS CHEMSTRIP 2 TES GP OTC, QL (100 per month) CHEMSTRIP 5 TES OB OTC, QL (100 per month) CHEMSTRIP 7 TES OTC, QL (100 per month) CHEMSTRIP 9 TES STRIPS OTC, QL (100 per month) CHEMSTRIP 10 TES MD OTC, QL (100 per month) CHEMSTRIP TES -10 SG OTC, QL (100 per month) COMBISTIX TES OTC, QL (100 per month) HEMA-COMBIST TES OTC, QL (100 per month) LABSTIX TES OTC, QL (100 per month) MULTISTIX 5 TES OTC, QL (100 per month) MULTISTIX 7 TES OTC, QL (100 per month) MULTISTIX 8 TES SG OTC, QL (100 per month) MULTISTIX 9 TES OTC, QL (100 per month) MULTISTIX 9 TES SG OTC, QL (100 per month) MULTISTIX 10 TES SG OTC, QL (100 per month) MULTISTIX TES OTC, QL (100 per month) URISTIX 4 TES OTC, QL (100 per month) URISTIX TES OTC, QL (100 per month) MEDICAL SUPPLIES bandages: adhesive; elastic; gauze OTC NUTRITIONAL / SUPPLEMENTS ELECTROLYTES, MISCELLANEOUS oral electrolyte solution OTC ELECTROLYTES, POTASSIUM potassium bicarbonate effer tab 25 meq potassium chloride cap er 8 meq potassium chloride cap er 10 meq potassium chloride microencapsulated crys er tab 10 meq potassium chloride microencapsulated crys er tab 20 meq potassium chloride oral soln 10% (20 meq/15ml) potassium chloride oral soln 20% (40 meq/15ml) potassium chloride tab er 8 meq (600 mg) potassium chloride tab er 10 meq potassium chloride tab er 20 meq (1500 mg)

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 81 Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit Drug Name Requirements/Limits VITAMINS AND MINERALS, CALCIUM SUPPLEMENTS calcium carbonate tab 600 mg OTC calcium carbonate tab 1250 mg (500 mg OTC elemental ca) calcium carbonate tab 1500 mg (600 mg OTC elemental ca) calcium carbonate-cholecalciferol cap 600 mg-500 OTC unit calcium carbonate-cholecalciferol chew tab 500 OTC mg-400 unit calcium carbonate-cholecalciferol chew tab 500 OTC mg-600 unit calcium carbonate-cholecalciferol tab 250 mg-125 OTC unit calcium carbonate-cholecalciferol tab 500 mg-125 OTC unit calcium carbonate-cholecalciferol tab 500 mg-200 OTC unit calcium carbonate-cholecalciferol tab 500 mg-400 OTC unit calcium carbonate-cholecalciferol tab 600 mg-200 OTC unit calcium carbonate-cholecalciferol tab 600 mg-400 OTC unit calcium carbonate-cholecalciferol tab 600 mg-800 OTC unit calcium carbonate-vitamin d cap 600 mg-200 unit OTC calcium carbonate-vitamin d chew tab 600 mg-400 OTC unit calcium carbonate-vitamin d tab 250 mg-125 unit OTC calcium carbonate-vitamin d tab 500 mg-125 unit OTC calcium carbonate-vitamin d tab 500 mg-200 unit OTC calcium carbonate-vitamin d tab 500 mg-400 unit OTC calcium carbonate-vitamin d tab 600 mg-125 unit OTC calcium carbonate-vitamin d tab 600 mg-200 unit OTC calcium carbonate-vitamin d tab 600 mg-400 unit OTC calcium citrate tab 950 mg (200 mg elemental ca) OTC calcium citrate-vitamin d tab 200 mg-250 unit OTC (elemental ca) calcium citrate-vitamin d tab 250 mg-200 unit OTC (elemental ca) calcium citrate-vitamin d tab 315 mg-200 unit OTC (elemental ca) calcium citrate-vitamin d tab 315 mg-250 unit OTC (elemental ca) calcium tab 500 mg OTC

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 82 Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit Drug Name Requirements/Limits calcium tab 600 mg OTC calcium w/ magnesium tab 250-125 mg OTC calcium w/ magnesium tab 333-167 mg OTC calcium w/ magnesium tab 500-250 mg OTC calcium w/ vitamin d & k chew tab 500 mg-100 OTC unit-40 mcg calcium w/ vitamin d & k chew tab 500 mg-200 OTC unit-40 mcg calcium w/ vitamin d tab 600 mg-200 unit OTC calcium-mag-vit c-vit d cap 185 mg-28 mg-2.5 OTC mg-200 unit calcium-magnesium-zinc tab 333-133-5 mg OTC calcium-magnesium-zinc tab 333-133-8.3 mg OTC oyster shell calcium tab 500 mg OTC VITAMINS AND MINERALS, FOLIC ACID/COMBINATIONS folic acid tab 1 mg folic acid tab 1 mg OTC folic acid tab 400 mcg OTC folic acid tab 800 mcg OTC folic acid-vitamin b6-vitamin b12 tab 0.8-10-0.115 OTC mg folic acid-vitamin b6-vitamin b12 tab 2.2-25-0.5 mg folic acid-vitamin b6-vitamin b12 tab 2.2-25-1 mg folic acid-vitamin b6-vitamin b12 tab 2.5-25-1 mg VITAMINS AND MINERALS, IRON/COMBINATIONS fe bisglyc-vit c-vit b12-folic acid cap 28-60-0.008- OTC 0.4 mg fe fum-iron polysacch complex-fa-b cmplx-c-zn- mn-cu cap fe fumarate w/ b12-vit c-fa-ifc cap 110-0.015-75- 0.5-240 mg fe fumarate-vit c-vit b12-fa cap 460 (151 fe)-60- 0.01-1 mg ferrous fumarate tab 324 mg (106 mg elemental OTC fe) ferrous fumarate-fa-b complex-c-zn-mg-mn-cu tab 106-1 mg ferrous fumarate-folic acid tab 324-1 mg ferrous gluconate tab 240 mg (27 mg elemental OTC fe) ferrous gluconate tab 324 mg (37.5 mg elemental OTC iron) ferrous sulfate dried tab 200 mg (65 mg elemental OTC fe)

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 83 Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit Drug Name Requirements/Limits ferrous sulfate dried tab er 45 mg (fe equivalent) OTC ferrous sulfate dried tab er 160 mg (50 mg fe OTC equivalent) ferrous sulfate elixir 220 mg/5ml (44 mg/5ml OTC elemental fe) ferrous sulfate soln 75 mg/ml (15 mg/ml OTC elemental fe) ferrous sulfate tab 27 mg (elemental fe) OTC ferrous sulfate tab 134 mg (27 mg elemental fe) OTC ferrous sulfate tab 325 mg (65 mg elemental fe) OTC ferrous sulfate tab ec 325 mg (65 mg fe OTC equivalent) ferrous sulfate tab er 47.5 mg (elemental fe) OTC ferrous sulfate tab er 50 mg (elemental fe) OTC ferrous sulfate tab er 142 mg (45 mg fe OTC equivalent) iron combination cap iron combination cap OTC iron polysacch complex-vit b12-fa cap 150-0.025-1 mg iron polysacch complex-vit b12-fa cap 150-0.025-1 OTC mg iron-docusate-b12-folic acid-c-e-cu-biotin tab 150- 1 mg iron-docusate-b12-folic acid-c-e-cu-biotin tab 150- OTC 1 mg iron-folic acid-vit c-vit b6-vit b12-zinc tab 150- 1.25 mg iron-vit c-vit b12-folic acid tab 100-250-0.025-1 OTC mg iron-vitamin c tab 100-250 mg OTC polysaccharide iron complex cap 150 mg (iron OTC equivalent) VITAMINS AND MINERALS, MISCELLANEOUS b-complex vitamin cap OTC b-complex vitamin sublingual liquid OTC b-complex vitamin tab OTC b-complex vitamin tab er OTC b-complex w/ c & calcium tab OTC b-complex w/ c & e + zn tab OTC b-complex w/ c & folic acid cap 1 mg b-complex w/ c & folic acid tab b-complex w/ c & folic acid tab OTC b-complex w/ c & folic acid tab 0.8 mg OTC b-complex w/ c & folic acid tab 1 mg

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 84 Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit Drug Name Requirements/Limits b-complex w/ c & folic acid tab 1 mg OTC b-complex w/ c & folic acid tab 5 mg b-complex w/ c cap OTC b-complex w/ c tab OTC b-complex w/ c tab er OTC b-complex w/ c-biotin-minerals & folic acid tab 5 mg b-complex w/ folic acid cap OTC b-complex w/ folic acid tab OTC b-complex w/ folic acid tab er OTC b-complex w/ iron tab OTC b-complex w/ minerals liq OTC b-complex w/biotin & folic acid tab OTC b-complex w/biotin & folic acid tab er OTC bioflavonoid products tab OTC bioflavonoid products tab er OTC brewers yeast tab OTC calcium ascorbate tab 500 mg OTC calcium pantothenate tab 500 mg OTC cholecalciferol cap 400 unit OTC cholecalciferol cap 1000 unit OTC cholecalciferol cap 2000 unit OTC cholecalciferol cap 5000 unit OTC cholecalciferol cap 10000 unit OTC cholecalciferol cap 50000 unit OTC cholecalciferol chew tab 400 unit OTC cholecalciferol chew tab 1000 unit OTC cholecalciferol chew tab 2000 unit OTC cholecalciferol chew tab 5000 unit OTC cholecalciferol drops 400 unit/0.03ml (per drop) OTC cholecalciferol drops 2000 unit/0.03ml (per drop) OTC cholecalciferol drops 5000 unit/ml (1000 OTC unit/0.2ml) cholecalciferol oral liquid 400 unit/ml OTC cholecalciferol tab 400 unit OTC cholecalciferol tab 1000 unit OTC cholecalciferol tab 2000 unit OTC cholecalciferol tab 5000 unit OTC cholecalciferol tab 50000 unit OTC cod liver oil cap OTC cyanocobalamin inj 1000 mcg/ml ergocalciferol cap 50000 unit ergocalciferol soln 8000 unit/ml OTC iron w/ vitamin liq OTC

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 85 Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit Drug Name Requirements/Limits iron w/ vitamin tab OTC multiple vitamin cap OTC; AL (covered for ages 20 and under) multiple vitamin tab OTC; AL (covered for ages 20 and under) multiple vitamins w/ calcium tab OTC; AL (covered for ages 20 and under) multiple vitamins w/ iron tab OTC; AL (covered for ages 20 and under) multiple vitamins w/ minerals & fa tab 1.25 mg AL (covered for ages 20 and under) multiple vitamins w/ minerals cap AL (covered for ages 20 and under) multiple vitamins w/ minerals cap OTC; AL (covered for ages 20 and under) multiple vitamins w/ minerals chew tab OTC; AL (covered for ages 20 and under) multiple vitamins w/ minerals effer tab OTC; AL (covered for ages 20 and under) multiple vitamins w/ minerals liquid OTC; AL (covered for ages 20 and under) multiple vitamins w/ minerals tab AL (covered for ages 20 and under) multiple vitamins w/ minerals tab OTC; AL (covered for ages 20 and under) multiple vitamins w/ minerals tab er OTC; AL (covered for ages 20 and under) NASCOBAL SPR 500MCG niacin cap er 250 mg OTC niacin cap er 500 mg OTC niacin tab 50 mg OTC niacin tab 100 mg OTC niacin tab 250 mg OTC niacin tab 500 mg OTC niacin tab er 250 mg OTC niacin tab er 500 mg OTC niacin tab er 750 mg OTC niacin w/ inositol cap 400-100 mg OTC niacinamide tab 100 mg OTC niacinamide tab 500 mg OTC omega-3 fatty acids - oral liquid OTC omega-3 fatty acids cap 300 mg OTC omega-3 fatty acids cap 435 mg OTC omega-3 fatty acids cap 500 mg OTC omega-3 fatty acids cap 1000 mg OTC

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 86 Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit Drug Name Requirements/Limits omega-3 fatty acids cap 1200 mg OTC omega-3 fatty acids chew tab 113.5 mg OTC pantothenic acid tab 500 mg OTC pediatric multiple vitamin liq OTC; AL (covered for ages 20 and under) pediatric multiple vitamin w/ c & fa chew tab OTC; AL (covered for ages 20 and under) pediatric multiple vitamin w/ c soln 35 mg/ml OTC; AL (covered for ages 20 and under) pediatric multiple vitamin w/ extra c & fa chew tab OTC; AL (covered for ages 20 and under) pediatric multiple vitamin w/ minerals & c chew OTC; AL (covered for ages tab 20 and under) pediatric multiple vitamin w/ minerals & c chew OTC; AL (covered for ages tab 60 mg 20 and under) pediatric multiple vitamin w/ minerals & c drops 45 AL (covered for ages 20 and mg/ml under) pediatric multiple vitamin w/ minerals & c drops 45 OTC; AL (covered for ages mg/ml 20 and under) pediatric multiple vitamins w/ fl-fe drops 0.25-6 AL (covered for ages 20 and mg/ml under) pediatric multiple vitamins w/ fl-fe drops 0.25-10 AL (covered for ages 20 and mg/ml under) pediatric multiple vitamins w/ fluoride chew tab AL (covered for ages 20 and 0.5 mg under) pediatric multiple vitamins w/ fluoride chew tab AL (covered for ages 20 and 0.25 mg under) pediatric multiple vitamins w/ fluoride chew tab 1 AL (covered for ages 20 and mg under) pediatric multiple vitamins w/ fluoride soln 0.5 AL (covered for ages 20 and mg/ml under) pediatric multiple vitamins w/ fluoride soln 0.25 AL (covered for ages 20 and mg/ml under) pediatric multiple vitamins w/ iron chew tab 15 mg OTC; AL (covered for ages 20 and under) pediatric multiple vitamins w/ iron drops 10 mg/ml OTC; AL (covered for ages 20 and under) pediatric vitamins acd w/ fluoride soln 0.5 mg/ml AL (covered for ages 20 and under) pediatric vitamins acd w/ fluoride soln 0.25 mg/ml AL (covered for ages 20 and under) pediatric vitamins adc drops 1500 unit-400 unit-35 OTC; AL (covered for ages mg/ml 20 and under) phytonadione tab 5 mg pyridoxine hcl tab 25 mg OTC pyridoxine hcl tab 50 mg OTC

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 87 Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit Drug Name Requirements/Limits pyridoxine hcl tab 100 mg OTC pyridoxine hcl tab 250 mg OTC pyridoxine hcl tab 500 mg OTC pyridoxine hcl tab er 200 mg OTC riboflavin tab 25 mg OTC riboflavin tab 50 mg OTC riboflavin tab 100 mg OTC sodium fluoride chew tab 0.5 mg f (from 1.1 mg naf) sodium fluoride chew tab 0.25 mg f (from 0.55 mg naf) sodium fluoride chew tab 1 mg f (from 2.2 mg naf) sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml naf) sodium fluoride soln 0.25 mg/drop f (from 0.55 mg/drop naf) sodium fluoride soln 0.125 mg/drop f (0.275 mg/drop naf) sodium fluoride tab 0.5 mg f (from 1.1 mg naf) sodium fluoride tab 1 mg f (from 2.2 mg naf) thiamine hcl tab 50 mg OTC thiamine hcl tab 100 mg OTC thiamine hcl tab 250 mg OTC thiamine mononitrate tab 100 mg OTC vitamin e cap 400 unit OTC vitamin mixture cap OTC vitamin mixture tab OTC vitamins a & d cap OTC vitamins a & d tab OTC vitamins a & d w/ c chew tab OTC vitamins c & e cap OTC vitamins w/ lipotropics cap OTC vitamins w/ lipotropics tab OTC vitamins w/ lipotropics tab er OTC VITAMINS AND MINERALS, PRENATAL VITAMINS CITRANATAL CAP HARMONY CITRANATAL CAP MEDLEY CITRANATAL MIS CITRANATAL MIS 90 DHA CITRANATAL MIS B-CALM CITRANATAL PAK ASSURE CITRANATAL PAK DHA CITRANATAL TAB BLOOM CITRANATAL TAB RX

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 88 Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit Drug Name Requirements/Limits PRENAISSANCE CAP PLUS prenatal vit w/ dss-fe fumarate-fa tab 29-1 mg prenatal vit w/ dss-iron carbonyl-fa tab 90-1 mg prenatal vit w/ fe fumarate-fa chew tab 29-1 mg prenatal vit w/ iron carbonyl-fa tab 29-1 mg RESPIRATORY ANAPHYLAXIS TREATMENT AGENTS epinephrine solution auto-injector 0.3 mg/0.3ml QL (8 per year) (1:1000) epinephrine solution auto-injector 0.15 mg/0.15ml QL (8 per year) (1:1000) EPIPEN 2-PAK INJ 0.3MG QL (8 per year) EPIPEN-JR INJ 0.15MG QL (8 per year) ANTICHOLINERGIC/BETA AGONIST COMBINATIONS, LONG ACTING STIOLTO AER 2.5-2.5 QL (1 inhaler per month) ANTICHOLINERGIC/BETA AGONIST COMBINATIONS, SHORT ACTING COMBIVENT AER 20-100 QL (2 inhalers per month) ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml QL (540 mL per month) ANTICHOLINERGICS INCRUSE ELPT INH 62.5MCG QL (1 inhaler per month) ipratropium bromide inhal soln 0.02% QL (313 mL per month) ANTIHISTAMINE/DECONGESTANT COMBINATIONS brompheniramine & pseudoephedrine elixir 1-15 OTC mg/5ml cetirizine-pseudoephedrine tab er 12hr 5-120 mg OTC fexofenadine-pseudoephedrine tab er 12hr 60-120 OTC mg fexofenadine-pseudoephedrine tab er 24hr 180- OTC 240 mg loratadine & pseudoephedrine tab er 12hr 5-120 OTC mg loratadine & pseudoephedrine tab er 24hr 10-240 OTC mg promethazine & phenylephrine syrup 6.25-5 mg/5ml ANTIHISTAMINES, LOW SEDATING cetirizine hcl cap 10 mg OTC cetirizine hcl chew tab 5 mg OTC; AL (covered for ages less than 12 years of age) cetirizine hcl chew tab 10 mg OTC; AL (covered for ages less than 12 years of age) cetirizine hcl oral soln 1 mg/ml (5 mg/5ml) cetirizine hcl oral soln 1 mg/ml (5 mg/5ml) OTC

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 89 Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit Drug Name Requirements/Limits cetirizine hcl tab 5 mg OTC cetirizine hcl tab 10 mg OTC ZYRTEC ALLGY TAB 10MG OTC ZYRTEC CHILD TAB 10MG OTC ANTIHISTAMINES, NONSEDATING ALLEGRA ALRG TAB 30MG OTC CLARITIN RDT TAB 5MG OTC fexofenadine hcl susp 30 mg/5ml (6 mg/ml) OTC fexofenadine hcl tab 60 mg OTC fexofenadine hcl tab 180 mg OTC loratadine cap 10 mg OTC loratadine chew tab 5 mg OTC loratadine rapidly-disintegrating tab 10 mg OTC loratadine syrup 5 mg/5ml OTC loratadine tab 10 mg OTC ANTIHISTAMINES, SEDATING chlorpheniramine maleate syrup 2 mg/5ml OTC chlorpheniramine maleate tab 4 mg OTC chlorpheniramine maleate tab er 12 mg OTC clemastine fumarate tab 1.34 mg (1 mg base OTC equiv) clemastine fumarate tab 2.68 mg cyproheptadine hcl syrup 2 mg/5ml cyproheptadine hcl tab 4 mg diphenhydramine hcl cap 25 mg OTC diphenhydramine hcl cap 50 mg OTC diphenhydramine hcl chew tab 12.5 mg OTC diphenhydramine hcl elixir 12.5 mg/5ml diphenhydramine hcl elixir 12.5 mg/5ml OTC diphenhydramine hcl liquid 12.5 mg/5ml OTC diphenhydramine hcl syrup 12.5 mg/5ml OTC diphenhydramine hcl tab 25 mg OTC diphenhydramine hcl tab disint 12.5 mg OTC hydroxyzine hcl syrup 10 mg/5ml hydroxyzine hcl tab 10 mg hydroxyzine hcl tab 25 mg hydroxyzine hcl tab 50 mg hydroxyzine pamoate cap 25 mg hydroxyzine pamoate cap 50 mg hydroxyzine pamoate cap 100 mg VISTARIL CAP 25MG + VISTARIL CAP 50MG +

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 90 Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit Drug Name Requirements/Limits ANTITUSSIVE COMBINATIONS, NON-OPIOID dextromethorphan-guaifenesin liquid 5-100 OTC mg/5ml dextromethorphan-guaifenesin liquid 10-100 OTC mg/5ml dextromethorphan-guaifenesin liquid 10-200 OTC mg/5ml dextromethorphan-guaifenesin liquid 20-300 OTC mg/5ml dextromethorphan-guaifenesin liquid 30-200 OTC mg/5ml dextromethorphan-guaifenesin syrup 10-100 OTC mg/5ml dextromethorphan-guaifenesin tab er 12hr 30-600 OTC mg dextromethorphan-guaifenesin tab er 12hr 60- OTC 1200 mg MUCINEX CGH GRA 5-100MG OTC promethazine-dm syrup 6.25-15 mg/5ml pseudoephed-bromphen-dm syrup 30-2-10 mg/5ml pseudoephed-bromphen-dm syrup 30-2-10 OTC mg/5ml pseudoephedrine w/ dm-gg liquid 30-10-100 OTC mg/5ml ANTITUSSIVE COMBINATIONS, OPIOID guaifenesin-codeine soln 100-6.3 mg/5ml OTC guaifenesin-codeine soln 100-10 mg/5ml OTC hydrocodone w/ homatropine syrup 5-1.5 mg/5ml hydrocodone w/ homatropine tab 5-1.5 mg promethazine w/ codeine syrup 6.25-10 mg/5ml promethazine-phenylephrine-codeine syrup 6.25- 5-10 mg/5ml pseudoephedrine w/ cod-gg soln 30-10-100 OTC mg/5ml ANTITUSSIVES benzonatate cap 100 mg benzonatate cap 200 mg BETA AGONISTS, INHALANTS, Long Acting: Hand-held Active Inhalation STRIVERDI AER 2.5MCG QL (1 inhaler per month) BETA AGONISTS, INHALANTS, Short Acting albuterol sulfate inhal aero 108 mcg/act (90mcg QL (18g - 2 inhalers per base equiv) month)

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 91 Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit Drug Name Requirements/Limits albuterol sulfate soln nebu 0.5% (5 mg/ml) albuterol sulfate soln nebu 0.63 mg/3ml (base equiv) albuterol sulfate soln nebu 0.083% (2.5 mg/3ml) albuterol sulfate soln nebu 1.25 mg/3ml (base equiv) PROAIR RESPI AER QL (2 inhalers per month) VENTOLIN HFA AER QL (18g - 2 inhalers per month) VENTOLIN HFA AER QL (3.7g - 6 inhalers per month) VENTOLIN HFA AER QL (8g - 4 inhalers per month) BETA AGONISTS, ORAL AGENTS albuterol sulfate syrup 2 mg/5ml albuterol sulfate tab 2 mg albuterol sulfate tab 4 mg albuterol sulfate tab er 12hr 4 mg albuterol sulfate tab er 12hr 8 mg terbutaline sulfate tab 2.5 mg terbutaline sulfate tab 5 mg CYSTIC FIBROSIS BETHKIS NEB 300/4ML SP, PA KALYDECO PAK 50MG SP, PA KALYDECO PAK 75MG SP, PA KALYDECO TAB 150MG SP, PA ORKAMBI GRA 100-125 SP, PA ORKAMBI GRA 150-188 SP, PA ORKAMBI TAB 100-125 SP, PA ORKAMBI TAB 200-125 SP, PA PULMOZYME SOL 1MG/ML SP, PA SYMDEKO TAB 100-150 SP, PA tobramycin nebu soln 300 mg/5ml SP, PA DECONGESTANT/EXPECTORANT COMBINATIONS pseudoephedrine-guaifenesin tab er 12hr 60-600 OTC mg pseudoephedrine-guaifenesin tab er 12hr 120- OTC 1200 mg DECONGESTANTS pseudoephedrine hcl liq 15 mg/5ml OTC pseudoephedrine hcl tab 30 mg OTC pseudoephedrine hcl tab 60 mg OTC pseudoephedrine hcl tab er 12hr 120 mg OTC, QL (60 per month) SUDAFED 24HR TAB 240MG OTC, QL (30 per month)

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 92 Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit Drug Name Requirements/Limits EXPECTORANTS guaifenesin liquid 100 mg/5ml OTC guaifenesin syrup 100 mg/5ml OTC guaifenesin tab 200 mg OTC guaifenesin tab 400 mg OTC guaifenesin tab er 12hr 600 mg OTC guaifenesin tab er 12hr 1200 mg OTC MUCINEX/KIDS GRA 100MG OTC YODEFAN-NF LIQ 200-5ML OTC LEUKOTRIENE MODULATORS montelukast sodium chew tab 4 mg (base equiv) montelukast sodium chew tab 5 mg (base equiv) montelukast sodium oral granules packet 4 mg (base equiv) montelukast sodium tab 10 mg (base equiv) MAST CELL STABILIZERS cromolyn sodium nasal aerosol soln 5.2 mg/act OTC (4%) cromolyn sodium soln nebu 20 mg/2ml QL (240 mL per month) MEDICAL SUPPLIES AERCHMBR PLS MIS LRG MASK QL (2 per year) AERCHMBR PLS MIS MED MASK QL (2 per year) AERCHMBR PLS MIS SM MASK QL (2 per year) AERCHMBR Z- MIS STAT PLS QL (2 per year) AEROCHAMBER MIS CHAMBER QL (2 per year) AEROCHAMBER MIS FLOSIGNA QL (2 per year) AEROCHAMBER MIS MV QL (2 per year) AEROCHAMBER MIS PLUS QL (2 per year) MASK VORTEX/ MIS BABY DUC OTC, QL (2 per year) MASK VORTEX/ MIS DUCK OTC, QL (2 per year) MASK VORTEX/ MIS FROG OTC, QL (2 per year) MASK VORTEX/ MIS LADY BUG OTC, QL (2 per year) NEBULIZER MIS OTC PEDIATRIC SM MIS MASK OTC VAPORIZER OTC VORTEX VALVE MIS CHAMBER QL (2 per year) VORTEX/MASK MIS CHILDS QL (2 per year) VORTEX/MASK MIS TODDLER QL (2 per year) MISCELLANEOUS AYR NASAL DRO 0.65% OTC CVS NASAL SPR MIST OTC ipratropium bromide nasal soln 0.03% (21 mcg/spray)

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 93 Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit Drug Name Requirements/Limits ipratropium bromide nasal soln 0.06% (42 mcg/spray) RHINARIS SPR 0.2% OTC saline nasal spray 0.65% OTC SIMPLY SALIN AER 0.9% OTC sodium chloride aero soln 0.9% OTC sodium chloride soln nebu 0.9% sodium chloride soln nebu 3% sodium chloride soln nebu 7% sodium chloride soln nebu 10% NASAL ANTIHISTAMINES azelastine hcl nasal spray 0.1% (137 mcg/spray) QL (2 bottles per month) azelastine hcl nasal spray 0.15% (205.5 QL (2 bottles per month) mcg/spray) NASAL STEROIDS budesonide nasal susp 32 mcg/act OTC, QL (1 bottle per month) flunisolide nasal soln 25 mcg/act (0.025%) QL (2 bottles per month) fluticasone propionate nasal susp 50 mcg/act QL (1 bottle per month) fluticasone propionate nasal susp 50 mcg/act OTC, QL (1 bottle per month) triamcinolone acetonide nasal aerosol suspension OTC, QL (1 bottle per 55 mcg/act month) PULMONARY FIBROSIS AGENTS OFEV CAP 100MG SP, PA OFEV CAP 150MG SP, PA SEVERE ASTHMA AGENTS XOLAIR INJ 75/0.5 SP, PA XOLAIR INJ 150MG/ML SP, PA XOLAIR SOL 150MG SP, PA STEROID INHALANTS ARNUITY ELPT INH 50MCG QL (1 inhaler per month) ARNUITY ELPT INH 100MCG QL (1 inhaler per month) ARNUITY ELPT INH 200MCG QL (1 inhaler per month) budesonide inhalation susp 0.5 mg/2ml QL (120 mL per month) budesonide inhalation susp 0.25 mg/2ml QL (120 mL per month) budesonide inhalation susp 1 mg/2ml QL (60 mL per month) FLOVENT DISK AER 50MCG QL (3 inhalers per month) FLOVENT DISK AER 100MCG QL (4 inhalers per month) FLOVENT DISK AER 250MCG QL (3 inhalers per month) FLOVENT HFA AER 44MCG QL (2 inhalers per month) FLOVENT HFA AER 110MCG QL (2 inhalers per month) FLOVENT HFA AER 220MCG QL (2 inhalers per month) QVAR REDIHA AER 80MCG QL (2 inhalers per month)

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 94 Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit Drug Name Requirements/Limits QVAR REDIHAL AER 40MCG QL (2 inhalers per month) STEROID/BETA AGONIST COMBINATIONS ADVAIR HFA AER 45/21 QL (1 inhaler per month) ADVAIR HFA AER 115/21 QL (1 inhaler per month) ADVAIR HFA AER 230/21 QL (1 inhaler per month) DULERA AER 100-5MCG QL (1 inhaler per month) DULERA AER 200-5MCG QL (1 inhaler per month) fluticasone-salmeterol aer powder ba 100-50 QL (1 inhaler per month) mcg/dose fluticasone-salmeterol aer powder ba 250-50 QL (1 inhaler per month) mcg/dose fluticasone-salmeterol aer powder ba 500-50 QL (1 inhaler per month) mcg/dose XANTHINES ELIXOPHYLLIN ELX 80/15ML THEO-24 CAP 100MG CR THEO-24 CAP 200MG CR THEO-24 CAP 300MG CR THEO-24 CAP 400MG ER theophylline soln 80 mg/15ml theophylline tab er 12hr 100 mg theophylline tab er 12hr 200 mg theophylline tab er 12hr 300 mg theophylline tab er 12hr 450 mg theophylline tab er 24hr 400 mg theophylline tab er 24hr 600 mg TOPICAL DERMATOLOGY, ACNE, Oral claravis cap 10mg PA claravis cap 20mg PA claravis cap 30mg PA claravis cap 40mg PA myorisan cap 10mg PA myorisan cap 20mg PA myorisan cap 30mg PA myorisan cap 40mg PA zenatane cap 10mg PA zenatane cap 20mg PA zenatane cap 30mg PA zenatane cap 40mg PA DERMATOLOGY, ACNE, Topical BENZOYL PER GEL 2.5% OTC benzoyl peroxide cream 2.5% OTC

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 95 Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit Drug Name Requirements/Limits benzoyl peroxide cream 10% OTC benzoyl peroxide gel 5% OTC benzoyl peroxide gel 10% OTC benzoyl peroxide liq 2.5% benzoyl peroxide liq 4% OTC benzoyl peroxide liq 5% OTC benzoyl peroxide liq 5.25% benzoyl peroxide liq 5.25% OTC benzoyl peroxide liq 6% OTC benzoyl peroxide liq 7% benzoyl peroxide liq 10% OTC benzoyl peroxide-erythromycin gel 5-3% clindamycin phosphate gel 1% clindamycin phosphate lotion 1% clindamycin phosphate soln 1% erythromycin gel 2% erythromycin soln 2% sulfacetamide sodium lotion 10% (acne) tretinoin cream 0.1% ST (Members 35 years and older must have recently been on 30 days of a topical formulary alternative) tretinoin cream 0.05% ST (Members 35 years and older must have recently been on 30 days of a topical formulary alternative) tretinoin cream 0.025% ST (Members 35 years and older must have recently been on 30 days of a topical formulary alternative) tretinoin gel 0.01% ST (Members 35 years and older must have recently been on 30 days of a topical formulary alternative) tretinoin gel 0.025% ST (Members 35 years and older must have recently been on 30 days of a topical formulary alternative) DERMATOLOGY, ACTINIC KERATOSIS fluorouracil cream 5% TOLAK CRE 4% DERMATOLOGY, ANTIBIOTICS bacitracin oint 500 unit/gm OTC bacitracin zinc oint 500 unit/gm OTC bacitracin-polymyxin b oint OTC

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 96 Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit Drug Name Requirements/Limits gentamicin sulfate cream 0.1% gentamicin sulfate oint 0.1% mupirocin calcium cream 2% mupirocin oint 2% neomycin-bacitracin-polymyxin oint OTC silver sulfadiazine cream 1% DERMATOLOGY, ANTIFUNGALS ciclopirox gel 0.77% ciclopirox olamine cream 0.77% (base equiv) ciclopirox olamine susp 0.77% (base equiv) ciclopirox shampoo 1% clotrimazole cream 1% clotrimazole cream 1% OTC clotrimazole soln 1% clotrimazole soln 1% OTC ketoconazole cream 2% ketoconazole shampoo 2% miconazole nitrate cream 2% OTC miconazole nitrate ointment 2% OTC miconazole nitrate powder 2% OTC nystatin cream 100000 unit/gm nystatin oint 100000 unit/gm nystatin topical powder 100000 unit/gm tolnaftate aerosol pow 1% OTC tolnaftate cream 1% OTC tolnaftate soln 1% OTC DERMATOLOGY, ANTIPSORIATICS, Topical calcipotriene oint 0.005% calcipotriene soln 0.005% (50 mcg/ml) DERMATOLOGY, ANTISEBORRHEICS selenium sulfide lotion 1% OTC selenium sulfide lotion 2.5% DERMATOLOGY, ANTISEPTICS/DISINFECTANTS IV PREP WIPE PAD OTC MICROCLENS PAD WIPES OTC povidone-iodine oint 10% OTC povidone-iodine soln 7.5% OTC povidone-iodine soln 10% OTC UNI-SOLVE PAD WIPES OTC

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 97 Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit Drug Name Requirements/Limits DERMATOLOGY, ATOPIC DERMATITIS, Topical tacrolimus oint 0.1% ST (Must have recently been on a generic steroid); AL (Must be 16 years of age and older) tacrolimus oint 0.03% ST (Must have recently been on a generic steroid); AL (Must be 2 years of age and older) DERMATOLOGY, CORTICOSTEROID COMBINATIONS hydrocortisone-aloe vera cream 1% OTC DERMATOLOGY, CORTICOSTEROIDS, High Potency betamethasone dipropionate augmented cream QL (120 grams per month) 0.05% betamethasone dipropionate augmented lotion QL (120 mL per month) 0.05% betamethasone dipropionate cream 0.05% QL (120 grams per month) betamethasone dipropionate lotion 0.05% QL (120 mL per month) betamethasone dipropionate oint 0.05% QL (120 grams per month) desoximetasone cream 0.25% QL (120 grams per month) desoximetasone gel 0.05% QL (120 grams per month) desoximetasone oint 0.25% QL (120 grams per month) diflorasone diacetate cream 0.05% QL (120 grams per month) fluocinonide cream 0.05% QL (120 grams per month) fluocinonide gel 0.05% QL (120 grams per month) fluocinonide oint 0.05% QL (120 grams per month) fluocinonide soln 0.05% triamcinolone acetonide cream 0.5% QL (120 grams per month) triamcinolone acetonide oint 0.5% QL (120 grams per month) DERMATOLOGY, CORTICOSTEROIDS, Low Potency alclometasone dipropionate cream 0.05% QL (120 grams per month) alclometasone dipropionate oint 0.05% QL (120 grams per month) desonide cream 0.05% QL (120 grams per month) desonide lotion 0.05% QL (120 mL per month) desonide oint 0.05% QL (120 grams per month) fluocinolone acetonide soln 0.01% hydrocortisone acetate cream 1% OTC hydrocortisone cream 0.5% OTC hydrocortisone cream 1% hydrocortisone cream 1% OTC hydrocortisone cream 2.5% QL (120 grams per month) hydrocortisone gel 1% OTC hydrocortisone lotion 1% OTC hydrocortisone lotion 2.5% QL (120 mL per month)

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 98 Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit Drug Name Requirements/Limits hydrocortisone oint 0.5% OTC hydrocortisone oint 1% hydrocortisone oint 1% OTC hydrocortisone oint 2.5% QL (120 grams per month) hydrocortisone soln 1% OTC DERMATOLOGY, CORTICOSTEROIDS, Medium Potency betamethasone valerate cream 0.1% (base QL (120 grams per month) equivalent) betamethasone valerate lotion 0.1% (base QL (120 mL per month) equivalent) betamethasone valerate oint 0.1% (base equivalent) desoximetasone cream 0.05% QL (120 grams per month) fluocinolone acetonide cream 0.025% QL (120 grams per month) fluocinolone acetonide oint 0.025% QL (120 grams per month) fluticasone propionate cream 0.05% QL (120 grams per month) fluticasone propionate oint 0.005% QL (120 grams per month) hydrocortisone butyrate cream 0.1% QL (120 grams per month) hydrocortisone butyrate oint 0.1% QL (120 grams per month) hydrocortisone butyrate soln 0.1% hydrocortisone valerate cream 0.2% QL (120 grams per month) hydrocortisone valerate oint 0.2% QL (120 grams per month) mometasone furoate cream 0.1% QL (120 grams per month) mometasone furoate oint 0.1% QL (120 grams per month) mometasone furoate solution 0.1% (lotion) triamcinolone acetonide cream 0.1% QL (120 grams per month) triamcinolone acetonide cream 0.025% QL (120 grams per month) triamcinolone acetonide lotion 0.1% QL (120 mL per month) triamcinolone acetonide lotion 0.025% QL (120 mL per month) triamcinolone acetonide oint 0.1% QL (120 grams per month) triamcinolone acetonide oint 0.025% QL (120 grams per month) DERMATOLOGY, CORTICOSTEROIDS, Very High Potency betamethasone dipropionate augmented gel QL (120 grams per month) 0.05% betamethasone dipropionate augmented oint QL (120 grams per month) 0.05% clobetasol propionate cream 0.05% QL (120 grams per month) clobetasol propionate foam 0.05% clobetasol propionate gel 0.05% QL (120 grams per month) clobetasol propionate oint 0.05% QL (120 grams per month) clobetasol propionate soln 0.05% diflorasone diacetate oint 0.05% QL (120 grams per month) halobetasol propionate cream 0.05% QL (120 grams per month) halobetasol propionate oint 0.05% QL (120 grams per month)

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 99 Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit Drug Name Requirements/Limits DERMATOLOGY, EMOLLIENTS lactic acid (ammonium lactate) cream 12% lactic acid (ammonium lactate) cream 12% OTC lactic acid (ammonium lactate) lotion 12% lactic acid (ammonium lactate) lotion 12% OTC DERMATOLOGY, INSECT REPELLENTS CUTTER BACKW AER 25% OTC, QL (2 per 30 days); Females aged 14-45 years old only NATRAPEL 12H SPR 20% OTC, QL (2 per 30 days); Females aged 14-45 years old only OFF DEEP WDS AER 25% OTC, QL (2 per 30 days); Females aged 14-45 years old only REPEL SPORTS AER 25% OTC, QL (2 per 30 days); Females aged 14-45 years old only SAWYER REPEL SPR 20% OTC, QL (2 per 30 days); Females aged 14-45 years old only DERMATOLOGY, LOCAL ANALGESICS ARTH PAIN CRE 0.075% OTC, QL (120 grams per month) capsaicin cream 0.1% OTC, QL (120 grams per month) capsaicin cream 0.025% OTC, QL (120 grams per month) CAPSAICIN LIQ 0.15% OTC, QL (30 grams per month) CAPZASIN GEL RELIEF OTC, QL (42.5 grams per month) CAPZASIN LIQ 0.15% OTC, QL (30 grams per month) CAPZASIN-P CRE 0.035% OTC, QL (120 grams per month) CASTIVA LOT OTC, QL (120 grams per month) lidocaine hcl soln 4% lidocaine patch 4% OTC, QL (30 patches per month) lidocaine patch 5% PA ZOSTRIX NAT CRE 0.033% OTC, QL (120 grams per month)

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 100 Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit Drug Name Requirements/Limits DERMATOLOGY, LOCAL ANESTHETICS lidocaine-prilocaine cream 2.5-2.5% QL (30 grams per month) lidocaine-prilocaine cream kit 2.5-2.5% DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE CALAMINE LOT OTC CALAMINE LOT 8-8% OTC docosanol cream 10% OTC imiquimod cream 5% podofilox soln 0.5% SM CALAMINE LOT OTC DERMATOLOGY, ROSACEA metronidazole cream 0.75% metronidazole gel 0.75% metronidazole gel 1% ST (Must have recently been on 60 days of metronidazole 0.075%) metronidazole lotion 0.75% DERMATOLOGY, SCABICIDES AND PEDICULICIDES malathion lotion 0.5% ST (Must have recently been on 14 days of permethrin) NIX CREM RIN LIQ 1% OTC permethrin aerosol 0.5% OTC permethrin cream 5% permethrin creme rinse 1% OTC permethrin lotion 1% OTC RID AER OTC spinosad susp 0.9% ST (Must have recently been on 14 days of permethrin) MOUTH/THROAT/DENTAL AGENTS, MISCELLANEOUS chlorhexidine gluconate soln 0.12% lidocaine hcl viscous soln 2% sodium fluoride cream 1.1% sodium fluoride gel 1.1% (0.5% f) sodium fluoride paste 1.1% sodium fluoride rinse 0.2% triamcinolone acetonide dental paste 0.1% OPHTHALMIC, ANTI-INFECTIVE/ANTI-INFLAMMATORY COMBINATIONS bacitracin-polymyxin-neomycin-hc ophth oint 1% neomycin-polymyxin-dexamethasone ophth oint 0.1% neomycin-polymyxin-dexamethasone ophth susp 0.1%

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 101 Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit Drug Name Requirements/Limits neomycin-polymyxin-hc ophth susp sulfacetamide sodium-prednisolone ophth soln 10- 0.23(0.25)% OPHTHALMIC, ANTI-INFECTIVES bacitracin ophth oint 500 unit/gm bacitracin-polymyxin b ophth oint ciprofloxacin hcl ophth soln 0.3% (base equivalent) erythromycin ophth oint 5 mg/gm gentamicin sulfate ophth oint 0.3% gentamicin sulfate ophth soln 0.3% levofloxacin ophth soln 0.5% neomycin-bacitrac zn-polymyx 5(3.5)mg-400unt- 10000unt op oin neomycin-polymy-gramicid op sol 1.75-10000- 0.025mg-unt-mg/ml ofloxacin ophth soln 0.3% polymyxin b-trimethoprim ophth soln 10000 unit/ml-0.1% sulfacetamide sodium ophth soln 10% tobramycin ophth soln 0.3% OPHTHALMIC, ANTI-INFLAMMATORY, Nonsteroidal diclofenac sodium ophth soln 0.1% ketorolac tromethamine ophth soln 0.4% ketorolac tromethamine ophth soln 0.5% OPHTHALMIC, ANTI-INFLAMMATORY, Steroidal dexamethasone sodium phosphate ophth soln 0.1% fluorometholone ophth susp 0.1% LOTEMAX GEL 0.5% PRED SOD PHO SOL 1% OP prednisolone acetate ophth susp 1% OPHTHALMIC, ANTIALLERGICS azelastine hcl ophth soln 0.05% cromolyn sodium ophth soln 4% ketotifen fumarate ophth soln 0.025% (base OTC equiv) OPHTHALMIC, ANTIFUNGALS NATACYN SUS 5% OP OPHTHALMIC, ANTIVIRALS trifluridine ophth soln 1% OPHTHALMIC, ARTIFICIAL TEARS/LUBRICANTS artificial tear ophth ointment OTC

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 102 Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit Drug Name Requirements/Limits artificial tear ophth solution OTC carboxymethylcellulose sodium (pf) ophth gel 1% OTC carboxymethylcellulose sodium (pf) ophth soln OTC 0.5% carboxymethylcellulose sodium ophth gel 1% OTC carboxymethylcellulose sodium ophth soln 0.5% OTC carboxymethylcellulose sodium ophth soln 0.25% OTC carboxymethylcellulose-glycerin ophth soln 0.5- OTC 0.9% carboxymethylcellulose-hypromellose gel 0.25- OTC 0.3% dextran 70-hypromellose (pf) ophth soln 0.1-0.3% OTC dextran 70-hypromellose ophth soln 0.1-0.3% OTC GENTEAL GEL 0.3% OTC GENTEAL MILD DRO 0.2% OTC glycerin-hypromellose-peg 400 ophth soln 0.2-0.2-OTC 1% HYPOTEARS SOL 1-1% OTC hypromellose ophth soln 0.3% OTC hypromellose ophth soln 0.4% OTC polyethylene glycol-propylene glycol ophth soln OTC 0.4-0.3% polyethylene glycol-propylene glycol pf op soln OTC 0.4-0.3% polyvinyl alcohol ophth soln 1.4% OTC polyvinyl alcohol-povidone (pf) ophth soln 1.4- OTC 0.6% polyvinyl alcohol-povidone ophth soln 5-6 mg/ml OTC (0.5-0.6%) propylene glycol ophth soln 0.6% OTC propylene glycol-glycerin ophth soln 1-0.3% OTC REFRESH OPTI DRO 0.5-0.9% OTC REFRESH SOL OPTIVE OTC SYSTANE GEL 0.3% OTC THERATEARS SOL OP OTC white petrolatum-mineral oil ophth ointment OTC OPHTHALMIC, BETA-BLOCKERS, Nonselective levobunolol hcl ophth soln 0.5% timolol maleate ophth gel forming soln 0.5% timolol maleate ophth gel forming soln 0.25% timolol maleate ophth soln 0.5% timolol maleate ophth soln 0.25% OPHTHALMIC, BETA-BLOCKERS, Selective betaxolol hcl ophth soln 0.5%

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 103 Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit Drug Name Requirements/Limits OPHTHALMIC, CARBONIC ANHYDRASE INHIBITOR/BETA-BLOCKER COMBINATIONS dorzolamide hcl-timolol maleate ophth soln 22.3- 6.8 mg/ml OPHTHALMIC, CARBONIC ANHYDRASE INHIBITORS dorzolamide hcl ophth soln 2% OPHTHALMIC, DRY EYE DISEASE XIIDRA DRO 5% OPHTHALMIC, MYDRIATICS ATROPINE SUL SOL 1% OP CYCLOMYDRIL SOL OP OPHTHALMIC, PROSTAGLANDINS latanoprost ophth soln 0.005% OPHTHALMIC, SYMPATHOMIMETICS brimonidine tartrate ophth soln 0.2% brimonidine tartrate ophth soln 0.15% OTIC, ANTI-INFECTIVE/ANTI-INFLAMMATORY COMBINATIONS CIPRODEX SUS 0.3-0.1% neomycin-polymyxin-hc otic soln 1% neomycin-polymyxin-hc otic susp 3.5 mg/ml- 10000 unit/ml-1% OTIC, ANTI-INFECTIVES acetic acid otic soln 2% ofloxacin otic soln 0.3%

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 104 Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit Index A mg ...... 5 abacavir sulfate soln 20 mg/ml (base acetaminophen w/ codeine tab 300-60 equiv) ...... 10 mg ...... 5 abacavir sulfate tab 300 mg (base equiv) acetazolamide cap er 12hr 500 mg .... 24 ...... 11 acetazolamide tab 125 mg ...... 25 abacavir sulfate-lamivudine tab 600-300 acetazolamide tab 250 mg ...... 25 mg ...... 9 acetic acid otic soln 2% ...... 104 abacavir sulfate-lamivudine-zidovudine acetic acid vaginal solution ...... 75 tab 300-150-300 mg ...... 9 acyclovir cap 200 mg ...... 13 ABILIFY MAIN INJ 300MG ...... 42 acyclovir susp 200 mg/5ml ...... 13 ABILIFY MAIN INJ 400MG ...... 42 acyclovir tab 400 mg ...... 13 ABILIFY TAB 10MG ...... 42 acyclovir tab 800 mg ...... 13 ABILIFY TAB 15MG ...... 42 ADACEL INJ ...... 79 ABILIFY TAB 20MG ...... 42 ADASUVE INH 10MG ...... 45 ABILIFY TAB 2MG ...... 42 adefovir dipivoxil tab 10 mg ...... 13 ABILIFY TAB 30MG ...... 42 ADVAIR HFA AER 115/21 ...... 95 ABILIFY TAB 5MG ...... 42 ADVAIR HFA AER 230/21 ...... 95 abiraterone acetate tab 250 mg ...... 15 ADVAIR HFA AER 45/21 ...... 95 acamprosate calcium tab delayed release AERCHMBR PLS MIS LRG MASK ...... 93 333 mg ...... 56 AERCHMBR PLS MIS MED MASK ...... 93 acarbose tab 100 mg ...... 58 AERCHMBR PLS MIS SM MASK ...... 93 acarbose tab 25 mg ...... 58 AERCHMBR Z- MIS STAT PLS ...... 93 acarbose tab 50 mg ...... 58 AEROCHAMBER MIS CHAMBER ...... 93 acetaminophen cap 500 mg ...... 3 AEROCHAMBER MIS FLOSIGNA ...... 93 acetaminophen chew tab 160 mg ...... 3 AEROCHAMBER MIS MV ...... 93 acetaminophen chew tab 80 mg ...... 3 AEROCHAMBER MIS PLUS ...... 93 acetaminophen disintegrating tab 160 AFINITOR TAB 10MG ...... 15 mg ...... 3 AFINITOR TAB 2.5MG ...... 15 acetaminophen disintegrating tab 80 mg AFINITOR TAB 5MG ...... 15 ...... 3 AFINITOR TAB 7.5MG ...... 15 acetaminophen elixir 160 mg/5ml ...... 3 albuterol sulfate inhal aero 108 mcg/act acetaminophen liquid 160 mg/5ml ...... 3 (90mcg base equiv) ...... 91 acetaminophen liquid 167 mg/5ml ...... 3 albuterol sulfate soln nebu 0.083% (2.5 acetaminophen soln 160 mg/5ml ...... 3 mg/3ml)...... 92 acetaminophen suppos 120 mg ...... 3 albuterol sulfate soln nebu 0.5% (5 acetaminophen suppos 325 mg ...... 3 mg/ml) ...... 92 acetaminophen suppos 650 mg ...... 3 albuterol sulfate soln nebu 0.63 mg/3ml acetaminophen susp 160 mg/5ml ...... 3 (base equiv) ...... 92 acetaminophen susp 80 mg/0.8ml ...... 3 albuterol sulfate soln nebu 1.25 mg/3ml acetaminophen tab 325 mg ...... 3 (base equiv) ...... 92 acetaminophen tab 500 mg ...... 3 albuterol sulfate syrup 2 mg/5ml ...... 92 acetaminophen tab er 650 mg ...... 3 albuterol sulfate tab 2 mg ...... 92 acetaminophen w/ codeine soln 120-12 albuterol sulfate tab 4 mg ...... 92 mg/5ml ...... 5 albuterol sulfate tab er 12hr 4 mg ...... 92 acetaminophen w/ codeine tab 300-15 albuterol sulfate tab er 12hr 8 mg ...... 92 mg ...... 5 alclometasone dipropionate cream 0.05% acetaminophen w/ codeine tab 300-30 ...... 98 105 alclometasone dipropionate oint 0.05% ambrisentan tab 10 mg ...... 26 ...... 98 ambrisentan tab 5 mg ...... 26 ALCOHOL SWAB PAD ...... 62 AMICAR SOL 0.25/ML ...... 76 ALDACTAZIDE TAB 50/50 ...... 25 amiloride & hydrochlorothiazide tab 5-50 ALECENSA CAP 150MG ...... 15 mg ...... 25 alendronate sodium tab 10 mg ...... 62 amiloride hcl tab 5 mg ...... 25 alendronate sodium tab 35 mg ...... 62 aminocaproic acid tab 1000 mg ...... 76 alendronate sodium tab 40 mg ...... 62 aminocaproic acid tab 500 mg ...... 76 alendronate sodium tab 5 mg ...... 62 amiodarone hcl tab 100 mg ...... 20 alendronate sodium tab 70 mg ...... 62 amiodarone hcl tab 200 mg ...... 20 alfuzosin hcl tab er 24hr 10 mg ...... 75 amiodarone hcl tab 400 mg ...... 20 ALLEGRA ALRG TAB 30MG ...... 90 amitriptyline hcl tab 10 mg ...... 39 allopurinol tab 100 mg ...... 3 amitriptyline hcl tab 100 mg ...... 39 allopurinol tab 300 mg ...... 3 amitriptyline hcl tab 150 mg ...... 39 ALPRAZOLAM CON 1 MG/ML ...... 27 amitriptyline hcl tab 25 mg ...... 39 alprazolam orally disintegrating tab 0.25 amitriptyline hcl tab 50 mg ...... 39 mg ...... 27 amitriptyline hcl tab 75 mg ...... 39 alprazolam orally disintegrating tab 0.5 amlodipine besylate tab 10 mg (base mg ...... 27 equivalent) ...... 23 alprazolam orally disintegrating tab 1 mg amlodipine besylate tab 2.5 mg (base ...... 27 equivalent) ...... 23 alprazolam orally disintegrating tab 2 mg amlodipine besylate tab 5 mg (base ...... 27 equivalent) ...... 23 alprazolam tab 0.25 mg ...... 27 amlodipine besylate-benazepril hcl cap alprazolam tab 0.5 mg ...... 27 10-20 mg ...... 17 alprazolam tab 1 mg ...... 27 amlodipine besylate-benazepril hcl cap alprazolam tab 2 mg ...... 27 10-40 mg ...... 17 alprazolam tab er 24hr 0.5 mg ...... 27 amlodipine besylate-benazepril hcl cap alprazolam tab er 24hr 1 mg ...... 27 2.5-10 mg ...... 17 alprazolam tab er 24hr 2 mg ...... 28 amlodipine besylate-benazepril hcl cap 5- alprazolam tab er 24hr 3 mg ...... 28 10 mg ...... 17 alum & mag hydroxide-simethicone chew amlodipine besylate-benazepril hcl cap 5- tab 200-200-25 mg ...... 69 20 mg ...... 17 alum & mag hydroxide-simethicone susp amlodipine besylate-benazepril hcl cap 5- 200-200-20 mg/5ml ...... 69 40 mg ...... 17 alum & mag hydroxide-simethicone susp amoxapine tab 100 mg ...... 39 400-400-40 mg/5ml ...... 69 amoxapine tab 150 mg ...... 39 aluminum hydroxide-magnesium amoxapine tab 25 mg ...... 39 carbonate chew tab 160-105 mg ...... 69 amoxapine tab 50 mg ...... 39 aluminum hydroxide-magnesium amoxicillin & k clavulanate chew tab 200- carbonate susp 508-475 mg/10ml ...... 70 28.5 mg ...... 7 aluminum hydroxide-magnesium amoxicillin & k clavulanate chew tab 400- carbonate susp 95-358 mg/15ml ...... 69 57 mg ...... 7 aluminum hydroxide-magnesium amoxicillin & k clavulanate for susp 200- trisilicate chew tab 80-20 mg ...... 70 28.5 mg/5ml ...... 7 amantadine hcl cap 100 mg ...... 40 amoxicillin & k clavulanate for susp 250- amantadine hcl syrup 50 mg/5ml ...... 40 62.5 mg/5ml ...... 7 amantadine hcl tab 100 mg ...... 41 amoxicillin & k clavulanate for susp 400- 106 57 mg/5ml ...... 7 mg ...... 47 amoxicillin & k clavulanate for susp 600- amphetamine-dextroamphetamine tab 42.9 mg/5ml ...... 7 7.5 mg ...... 47 amoxicillin & k clavulanate tab 250-125 ampicillin cap 500 mg ...... 8 mg ...... 7 ANAFRANIL CAP 25MG ...... 29 amoxicillin & k clavulanate tab 500-125 ANAFRANIL CAP 50MG ...... 29 mg ...... 7 ANAFRANIL CAP 75MG ...... 29 amoxicillin & k clavulanate tab 875-125 anagrelide hcl cap 0.5 mg ...... 77 mg ...... 7 anagrelide hcl cap 1 mg ...... 77 amoxicillin (trihydrate) cap 250 mg ..... 7 anastrozole tab 1 mg ...... 15 amoxicillin (trihydrate) cap 500 mg ..... 7 ANTACID CHW 1177MG ...... 70 amoxicillin (trihydrate) chew tab 125 mg APIDRA INJ SOLOSTAR ...... 60 ...... 8 APIDRA INJ U-100 ...... 60 amoxicillin (trihydrate) chew tab 250 mg APLENZIN TAB 174MG ...... 35 ...... 8 APLENZIN TAB 348MG ...... 35 amoxicillin (trihydrate) for susp 125 APLENZIN TAB 522MG ...... 35 mg/5ml ...... 8 aprepitant capsule 125 mg ...... 70 amoxicillin (trihydrate) for susp 200 aprepitant capsule 40 mg ...... 70 mg/5ml ...... 8 aprepitant capsule 80 mg ...... 70 amoxicillin (trihydrate) for susp 250 aprepitant capsule therapy pack 80 & mg/5ml ...... 8 125 mg ...... 70 amoxicillin (trihydrate) for susp 400 APRISO CAP 0.375GM ...... 72 mg/5ml ...... 8 APTIOM TAB 200MG ...... 29 amoxicillin (trihydrate) tab 500 mg ...... 8 APTIOM TAB 400MG ...... 29 amoxicillin (trihydrate) tab 875 mg ...... 8 APTIOM TAB 600MG ...... 29 amphetamine-dextroamphetamine cap er APTIOM TAB 800MG ...... 29 24hr 10 mg ...... 47 APTIVUS CAP 250MG ...... 11 amphetamine-dextroamphetamine cap er APTIVUS SOL ...... 11 24hr 15 mg ...... 47 aripiprazole oral solution 1 mg/ml ...... 42 amphetamine-dextroamphetamine cap er aripiprazole orally disintegrating tab 10 24hr 20 mg ...... 47 mg ...... 42 amphetamine-dextroamphetamine cap er aripiprazole orally disintegrating tab 15 24hr 25 mg ...... 47 mg ...... 42 amphetamine-dextroamphetamine cap er aripiprazole tab 10 mg ...... 42 24hr 30 mg ...... 47 aripiprazole tab 15 mg ...... 42 amphetamine-dextroamphetamine cap er aripiprazole tab 2 mg ...... 42 24hr 5 mg ...... 47 aripiprazole tab 20 mg ...... 42 amphetamine-dextroamphetamine tab aripiprazole tab 30 mg ...... 42 10 mg ...... 47 aripiprazole tab 5 mg ...... 42 amphetamine-dextroamphetamine tab ARISTADA INJ 1064MG ...... 42 12.5 mg ...... 47 ARISTADA INJ 441MG/1...... 42 amphetamine-dextroamphetamine tab ARISTADA INJ 662MG/2 ...... 42 15 mg ...... 47 ARISTADA INJ 882MG/3 ...... 42 amphetamine-dextroamphetamine tab ARISTADA INJ INITIO ...... 42 20 mg ...... 47 armodafinil tab 150 mg ...... 56 amphetamine-dextroamphetamine tab armodafinil tab 200 mg ...... 56 30 mg ...... 47 armodafinil tab 250 mg ...... 56 amphetamine-dextroamphetamine tab 5 armodafinil tab 50 mg ...... 56 107 ARNUITY ELPT INH 100MCG ...... 94 equivalent) ...... 22 ARNUITY ELPT INH 200MCG ...... 94 atorvastatin calcium tab 20 mg (base ARNUITY ELPT INH 50MCG ...... 94 equivalent) ...... 22 ARTH PAIN CRE 0.075% ...... 100 atorvastatin calcium tab 40 mg (base artificial tear ophth ointment ...... 102 equivalent) ...... 22 artificial tear ophth solution ...... 103 atorvastatin calcium tab 80 mg (base aspirin chew tab 81 mg ...... 77 equivalent) ...... 22 aspirin tab 325 mg ...... 77 atovaquone susp 750 mg/5ml ...... 13 aspirin tab 500 mg ...... 77 atovaquone-proguanil hcl tab 250-100 aspirin tab delayed release 325 mg ..... 77 mg ...... 9 aspirin tab delayed release 500 mg ..... 77 atovaquone-proguanil hcl tab 62.5-25 aspirin tab delayed release 81 mg ...... 77 mg ...... 9 ASTAGRAF XL CAP 0.5MG ...... 78 ATRIPLA TAB ...... 9 ASTAGRAF XL CAP 1MG ...... 78 ATROPINE SUL SOL 1% OP ...... 104 ASTAGRAF XL CAP 5MG ...... 78 AUBAGIO TAB 14MG ...... 55 atazanavir sulfate cap 150 mg (base AUBAGIO TAB 7MG ...... 55 equiv) ...... 11 AUGMENTIN SUS 125/5ML ...... 8 atazanavir sulfate cap 200 mg (base AUSTEDO TAB 12MG ...... 53 equiv) ...... 11 AUSTEDO TAB 6MG ...... 53 atazanavir sulfate cap 300 mg (base AUSTEDO TAB 9MG ...... 53 equiv) ...... 11 AVONEX KIT 30MCG ...... 55 atenolol & chlorthalidone tab 100-25 mg AVONEX PEN KIT 30MCG ...... 55 ...... 22 AVONEX PREFL KIT 30MCG ...... 55 atenolol & chlorthalidone tab 50-25 mg AYR NASAL DRO 0.65% ...... 93 ...... 22 AZASAN TAB 100MG ...... 78 atenolol tab 100 mg ...... 22 AZASAN TAB 75 MG ...... 78 atenolol tab 25 mg ...... 22 azathioprine tab 50 mg ...... 78 atenolol tab 50 mg ...... 22 azelastine hcl nasal spray 0.1% (137 ATIVAN INJ 2MG/ML ...... 28 mcg/spray) ...... 94 ATIVAN INJ 4MG/ML ...... 28 azelastine hcl nasal spray 0.15% (205.5 ATIVAN TAB 0.5MG ...... 28 mcg/spray) ...... 94 ATIVAN TAB 1MG ...... 28 azelastine hcl ophth soln 0.05% ...... 102 ATIVAN TAB 2MG ...... 28 azithromycin for susp 100 mg/5ml ...... 6 atomoxetine hcl cap 10 mg (base equiv) azithromycin for susp 200 mg/5ml ...... 6 ...... 47 azithromycin powd pack for susp 1 gm . 7 atomoxetine hcl cap 100 mg (base azithromycin tab 250 mg ...... 7 equiv) ...... 49 azithromycin tab 500 mg ...... 7 atomoxetine hcl cap 18 mg (base equiv) azithromycin tab 600 mg ...... 7 ...... 48 B atomoxetine hcl cap 25 mg (base equiv) bacitracin oint 500 unit/gm ...... 96 ...... 48 bacitracin ophth oint 500 unit/gm ..... 102 atomoxetine hcl cap 40 mg (base equiv) bacitracin zinc oint 500 unit/gm ...... 96 ...... 48 bacitracin-polymyxin b oint ...... 96 atomoxetine hcl cap 60 mg (base equiv) bacitracin-polymyxin b ophth oint ..... 102 ...... 48 bacitracin-polymyxin-neomycin-hc ophth atomoxetine hcl cap 80 mg (base equiv) oint 1% ...... 101 ...... 49 baclofen tab 10 mg ...... 56 atorvastatin calcium tab 10 mg (base baclofen tab 20 mg ...... 56 108 balsalazide disodium cap 750 mg ...... 72 25 mg ...... 18 bandages: adhesive; elastic; gauze .... 81 benazepril & hydrochlorothiazide tab 5- BANZEL SUS 40MG/ML ...... 29 6.25 mg ...... 18 BANZEL TAB 200MG ...... 29 benazepril hcl tab 10 mg ...... 18 BANZEL TAB 400MG ...... 29 benazepril hcl tab 20 mg ...... 18 BARACLUDE SOL .05MG/ML ...... 13 benazepril hcl tab 40 mg ...... 18 BASAGLAR INJ 100UNIT ...... 60 benazepril hcl tab 5 mg ...... 18 b-complex vitamin cap ...... 84 benzonatate cap 100 mg ...... 91 b-complex vitamin sublingual liquid .... 84 benzonatate cap 200 mg ...... 91 b-complex vitamin tab ...... 84 BENZOYL PER GEL 2.5% ...... 95 b-complex vitamin tab er...... 84 benzoyl peroxide cream 10% ...... 96 b-complex w/ c & calcium tab ...... 84 benzoyl peroxide cream 2.5% ...... 95 b-complex w/ c & e + zn tab ...... 84 benzoyl peroxide gel 10% ...... 96 b-complex w/ c & folic acid cap 1 mg .. 84 benzoyl peroxide gel 5% ...... 96 b-complex w/ c & folic acid tab ...... 84 benzoyl peroxide liq 10% ...... 96 b-complex w/ c & folic acid tab 0.8 mg 84 benzoyl peroxide liq 2.5% ...... 96 b-complex w/ c & folic acid tab 1 mg .. 84, benzoyl peroxide liq 4% ...... 96 85 benzoyl peroxide liq 5% ...... 96 b-complex w/ c & folic acid tab 5 mg ... 85 benzoyl peroxide liq 5.25% ...... 96 b-complex w/ c cap ...... 85 benzoyl peroxide liq 6% ...... 96 b-complex w/ c tab ...... 85 benzoyl peroxide liq 7% ...... 96 b-complex w/ c tab er ...... 85 benzoyl peroxide-erythromycin gel 5-3% b-complex w/ c-biotin-minerals & folic ...... 96 acid tab 5 mg ...... 85 benztropine mesylate tab 0.5 mg ...... 41 b-complex w/ folic acid cap ...... 85 benztropine mesylate tab 1 mg ...... 41 b-complex w/ folic acid tab ...... 85 benztropine mesylate tab 2 mg ...... 41 b-complex w/ folic acid tab er ...... 85 betamethasone dipropionate augmented b-complex w/ iron tab ...... 85 cream 0.05% ...... 98 b-complex w/ minerals liq...... 85 betamethasone dipropionate augmented b-complex w/biotin & folic acid tab ..... 85 gel 0.05% ...... 99 b-complex w/biotin & folic acid tab er .. 85 betamethasone dipropionate augmented BD INSULIN SYRINGE 0.3/30G ...... 62 lotion 0.05% ...... 98 BD INSULIN SYRINGE 0.3/31G ...... 62 betamethasone dipropionate augmented BD INSULIN SYRINGE 0.5/30G ...... 62 oint 0.05% ...... 99 BD INSULIN SYRINGE 0.5/31G ...... 62 betamethasone dipropionate cream BD INSULIN SYRINGE 1ML/30G ...... 62 0.05% ...... 98 BD INSULIN SYRINGE 1ML/31G ...... 62 betamethasone dipropionate lotion BD PEN NEEDL MIS 29GX12.7 ...... 62 0.05% ...... 98 BD PEN NEEDL MIS 31GX5MM ...... 62 betamethasone dipropionate oint 0.05% BD PEN NEEDL MIS 31GX8MM ...... 62 ...... 98 BD PEN NEEDL MIS 32GX4MM ...... 62 betamethasone valerate cream 0.1% BD PEN NEEDL MIS 32GX6MM ...... 62 (base equivalent) ...... 99 BD U-500 MIS 31GX6MM ...... 62 betamethasone valerate lotion 0.1% benazepril & hydrochlorothiazide tab 10- (base equivalent) ...... 99 12.5 mg ...... 18 betamethasone valerate oint 0.1% (base benazepril & hydrochlorothiazide tab 20- equivalent) ...... 99 12.5 mg ...... 18 BETAPACE AF TAB 120MG ...... 20 benazepril & hydrochlorothiazide tab 20- BETAPACE AF TAB 160MG ...... 20 109 BETAPACE AF TAB 80MG ...... 20 bromocriptine mesylate cap 5 mg (base BETAPACE TAB 120MG ...... 20 equivalent) ...... 41 BETAPACE TAB 160MG ...... 20 bromocriptine mesylate tab 2.5 mg (base BETAPACE TAB 80MG ...... 20 equivalent) ...... 41 BETASERON INJ 0.3MG ...... 55 brompheniramine & pseudoephedrine betaxolol hcl ophth soln 0.5% ...... 103 elixir 1-15 mg/5ml ...... 89 bethanechol chloride tab 10 mg ...... 75 budesonide delayed release particles cap bethanechol chloride tab 25 mg ...... 75 3 mg ...... 72 bethanechol chloride tab 5 mg ...... 75 budesonide inhalation susp 0.25 mg/2ml bethanechol chloride tab 50 mg ...... 75 ...... 94 BETHKIS NEB 300/4ML ...... 92 budesonide inhalation susp 0.5 mg/2ml bexarotene cap 75 mg ...... 17 ...... 94 bicalutamide tab 50 mg ...... 15 budesonide inhalation susp 1 mg/2ml . 94 BIKTARVY TAB ...... 9 budesonide nasal susp 32 mcg/act ..... 94 bioflavonoid products tab ...... 85 bumetanide tab 0.5 mg ...... 25 bioflavonoid products tab er ...... 85 bumetanide tab 1 mg ...... 25 bisacodyl suppos 10 mg ...... 72 bumetanide tab 2 mg ...... 25 bisacodyl tab delayed release 5 mg ..... 72 buprenorphine hcl sl tab 2 mg (base bismuth subsalicylate chew tab 262 mg equiv) ...... 57 ...... 70 buprenorphine hcl sl tab 8 mg (base bismuth subsalicylate susp 262 mg/15ml equiv) ...... 57 ...... 70 buprenorphine hcl-naloxone hcl sl film bismuth subsalicylate susp 525 mg/15ml 12-3 mg (base equiv) ...... 57 ...... 70 buprenorphine hcl-naloxone hcl sl film 2- bismuth subsalicylate tab 262 mg ...... 70 0.5 mg (base equiv) ...... 57 bisoprolol & hydrochlorothiazide tab 10- buprenorphine hcl-naloxone hcl sl film 4- 6.25 mg ...... 22 1 mg (base equiv) ...... 57 bisoprolol & hydrochlorothiazide tab 2.5- buprenorphine hcl-naloxone hcl sl film 8- 6.25 mg ...... 22 2 mg (base equiv) ...... 57 bisoprolol & hydrochlorothiazide tab 5- buprenorphine hcl-naloxone hcl sl tab 2- 6.25 mg ...... 22 0.5 mg (base equiv) ...... 57 bisoprolol fumarate tab 10 mg ...... 22 buprenorphine hcl-naloxone hcl sl tab 8- bisoprolol fumarate tab 5 mg ...... 22 2 mg (base equiv) ...... 57 BOOSTRIX INJ ...... 79 bupropion hcl (smoking deterrent) tab er bosentan tab 125 mg ...... 26 12hr 150 mg ...... 57 bosentan tab 62.5 mg ...... 26 bupropion hcl tab 100 mg ...... 35 brewers yeast tab ...... 85 bupropion hcl tab 75 mg ...... 35 BRILINTA TAB 60MG ...... 77 bupropion hcl tab er 12hr 100 mg ...... 35 BRILINTA TAB 90MG ...... 77 bupropion hcl tab er 12hr 150 mg ...... 35 brimonidine tartrate ophth soln 0.15% bupropion hcl tab er 12hr 200 mg ...... 35 ...... 104 bupropion hcl tab er 24hr 150 mg ...... 35 brimonidine tartrate ophth soln 0.2% 104 bupropion hcl tab er 24hr 300 mg ...... 35 BRIVIACT SOL 10MG/ML ...... 29 bupropion hcl tab er 24hr 450 mg ...... 35 BRIVIACT TAB 100MG ...... 29 buspirone hcl tab 10 mg ...... 29 BRIVIACT TAB 10MG ...... 29 buspirone hcl tab 15 mg ...... 29 BRIVIACT TAB 25MG ...... 29 buspirone hcl tab 30 mg ...... 29 BRIVIACT TAB 50MG ...... 29 buspirone hcl tab 5 mg ...... 29 BRIVIACT TAB 75MG ...... 29 buspirone hcl tab 7.5 mg ...... 29 110 butalbital-acetaminophen-caffeine cap calcium carbonate-cholecalciferol tab 250 50-325-40 mg ...... 4 mg-125 unit ...... 82 butalbital-acetaminophen-caffeine tab calcium carbonate-cholecalciferol tab 500 50-325-40 mg ...... 4 mg-125 unit ...... 82 butalbital-aspirin-caffeine cap 50-325-40 calcium carbonate-cholecalciferol tab 500 mg ...... 4 mg-200 unit ...... 82 C calcium carbonate-cholecalciferol tab 500 cabergoline tab 0.5 mg ...... 67 mg-400 unit ...... 82 CABOMETYX TAB 20MG ...... 15 calcium carbonate-cholecalciferol tab 600 CABOMETYX TAB 40MG ...... 15 mg-200 unit ...... 82 CABOMETYX TAB 60MG ...... 15 calcium carbonate-cholecalciferol tab 600 CALAMINE LOT ...... 101 mg-400 unit ...... 82 CALAMINE LOT 8-8% ...... 101 calcium carbonate-cholecalciferol tab 600 calcipotriene oint 0.005% ...... 97 mg-800 unit ...... 82 calcipotriene soln 0.005% (50 mcg/ml) calcium carbonate-mag hydroxide chew ...... 97 tab 550-110 mg ...... 70 calcitonin (salmon) nasal soln 200 calcium carbonate-mag hydroxide susp unit/act ...... 62 400-135 mg/5ml ...... 70 calcitriol cap 0.25 mcg ...... 67 calcium carbonate-vitamin d cap 600 calcitriol cap 0.5 mcg ...... 67 mg-200 unit ...... 82 calcitriol oral soln 1 mcg/ml ...... 67 calcium carbonate-vitamin d chew tab calcium acetate (phosphate binder) cap 600 mg-400 unit ...... 82 667 mg (169 mg ca) ...... 67 calcium carbonate-vitamin d tab 250 mg- calcium ascorbate tab 500 mg ...... 85 125 unit ...... 82 CALCIUM CARB TAB 648MG ...... 70 calcium carbonate-vitamin d tab 500 mg- calcium carbonate (antacid) chew tab 125 unit ...... 82 1000 mg ...... 70 calcium carbonate-vitamin d tab 500 mg- calcium carbonate (antacid) chew tab 200 unit ...... 82 400 mg ...... 70 calcium carbonate-vitamin d tab 500 mg- calcium carbonate (antacid) chew tab 400 unit ...... 82 420 mg ...... 70 calcium carbonate-vitamin d tab 600 mg- calcium carbonate (antacid) chew tab 125 unit ...... 82 500 mg ...... 70 calcium carbonate-vitamin d tab 600 mg- calcium carbonate (antacid) chew tab 200 unit ...... 82 750 mg ...... 70 calcium carbonate-vitamin d tab 600 mg- calcium carbonate (antacid) susp 1250 400 unit ...... 82 mg/5ml ...... 70 calcium citrate tab 950 mg (200 mg calcium carbonate tab 1250 mg (500 mg elemental ca) ...... 82 elemental ca) ...... 82 calcium citrate-vitamin d tab 200 mg- calcium carbonate tab 1500 mg (600 mg 250 unit (elemental ca) ...... 82 elemental ca) ...... 82 calcium citrate-vitamin d tab 250 mg- calcium carbonate tab 600 mg ...... 82 200 unit (elemental ca) ...... 82 calcium carbonate-cholecalciferol cap calcium citrate-vitamin d tab 315 mg- 600 mg-500 unit ...... 82 200 unit (elemental ca) ...... 82 calcium carbonate-cholecalciferol chew calcium citrate-vitamin d tab 315 mg- tab 500 mg-400 unit ...... 82 250 unit (elemental ca) ...... 82 calcium carbonate-cholecalciferol chew calcium pantothenate tab 500 mg ...... 85 tab 500 mg-600 unit ...... 82 calcium tab 500 mg ...... 82 111 calcium tab 600 mg ...... 83 carbamazepine tab er 12hr 100 mg .... 30 calcium w/ magnesium tab 250-125 mg carbamazepine tab er 12hr 200 mg .... 30 ...... 83 carbamazepine tab er 12hr 400 mg .... 30 calcium w/ magnesium tab 333-167 mg CARBATROL CAP 100MG ...... 30 ...... 83 CARBATROL CAP 200MG ...... 30 calcium w/ magnesium tab 500-250 mg CARBATROL CAP 300MG ...... 30 ...... 83 carbidopa & levodopa orally calcium w/ vitamin d & k chew tab 500 disintegrating tab 10-100 mg ...... 41 mg-100 unit-40 mcg ...... 83 carbidopa & levodopa orally calcium w/ vitamin d & k chew tab 500 disintegrating tab 25-100 mg ...... 41 mg-200 unit-40 mcg ...... 83 carbidopa & levodopa orally calcium w/ vitamin d tab 600 mg-200 disintegrating tab 25-250 mg ...... 41 unit ...... 83 carbidopa & levodopa tab 10-100 mg . 41 calcium-magnesium-zinc tab 333-133-5 carbidopa & levodopa tab 25-100 mg . 41 mg ...... 83 carbidopa & levodopa tab 25-250 mg . 41 calcium-magnesium-zinc tab 333-133- carbidopa & levodopa tab er 25-100 mg 8.3 mg ...... 83 ...... 41 calcium-mag-vit c-vit d cap 185 mg-28 carbidopa & levodopa tab er 50-200 mg mg-2.5 mg-200 unit ...... 83 ...... 41 CALQUENCE CAP 100MG ...... 15 carbidopa-levodopa-entacapone tabs capecitabine tab 150 mg ...... 14 12.5-50-200 mg ...... 41 capecitabine tab 500 mg ...... 14 carbidopa-levodopa-entacapone tabs CAPRELSA TAB 100MG ...... 15 18.75-75-200 mg ...... 41 CAPRELSA TAB 300MG ...... 15 carbidopa-levodopa-entacapone tabs 25- capsaicin cream 0.025% ...... 100 100-200 mg ...... 41 capsaicin cream 0.1% ...... 100 carbidopa-levodopa-entacapone tabs CAPSAICIN LIQ 0.15% ...... 100 31.25-125-200 mg ...... 41 captopril & hydrochlorothiazide tab 25-15 carbidopa-levodopa-entacapone tabs mg ...... 18 37.5-150-200 mg ...... 41 captopril & hydrochlorothiazide tab 25-25 carbidopa-levodopa-entacapone tabs 50- mg ...... 18 200-200 mg ...... 41 captopril & hydrochlorothiazide tab 50-15 carboxymethylcellulose sodium (pf) mg ...... 18 ophth gel 1% ...... 103 captopril & hydrochlorothiazide tab 50-25 carboxymethylcellulose sodium (pf) mg ...... 18 ophth soln 0.5% ...... 103 captopril tab 100 mg ...... 18 carboxymethylcellulose sodium ophth gel captopril tab 12.5 mg ...... 18 1% ...... 103 captopril tab 25 mg ...... 18 carboxymethylcellulose sodium ophth captopril tab 50 mg ...... 18 soln 0.25% ...... 103 CAPZASIN GEL RELIEF ...... 100 carboxymethylcellulose sodium ophth CAPZASIN LIQ 0.15% ...... 100 soln 0.5% ...... 103 CAPZASIN-P CRE 0.035% ...... 100 carboxymethylcellulose-glycerin ophth carbamazepine cap er 12hr 100 mg .... 29 soln 0.5-0.9% ...... 103 carbamazepine cap er 12hr 200 mg .... 29 carboxymethylcellulose-hypromellose gel carbamazepine cap er 12hr 300 mg .... 30 0.25-0.3% ...... 103 carbamazepine chew tab 100 mg ...... 30 carisoprodol tab 250 mg ...... 56 carbamazepine susp 100 mg/5ml ...... 30 carisoprodol tab 350 mg ...... 56 carbamazepine tab 200 mg ...... 30 carvedilol tab 12.5 mg ...... 22 112 carvedilol tab 25 mg ...... 22 CHANTIX TAB 1MG ...... 57 carvedilol tab 3.125 mg ...... 22 CHEMET CAP 100MG ...... 77 carvedilol tab 6.25 mg ...... 22 CHEMSTRIP 10 TES MD ...... 81 CASTIVA LOT ...... 100 CHEMSTRIP 2 TES GP ...... 81 cefadroxil cap 500 mg ...... 6 CHEMSTRIP 5 TES OB ...... 81 cefadroxil for susp 250 mg/5ml ...... 6 CHEMSTRIP 7 TES ...... 81 cefadroxil for susp 500 mg/5ml ...... 6 CHEMSTRIP 9 TES STRIPS ...... 81 cefadroxil tab 1 gm ...... 6 CHEMSTRIP TES -10 SG ...... 81 cefdinir cap 300 mg ...... 6 chlordiazepoxide hcl cap 10 mg ...... 28 cefdinir for susp 125 mg/5ml ...... 6 chlordiazepoxide hcl cap 25 mg ...... 28 cefdinir for susp 250 mg/5ml ...... 6 chlordiazepoxide hcl cap 5 mg ...... 28 cefprozil for susp 125 mg/5ml ...... 6 chlordiazepoxide hcl-clidinium bromide cefprozil for susp 250 mg/5ml ...... 6 cap 5-2.5 mg ...... 71 cefprozil tab 250 mg ...... 6 chlordiazepoxide-amitriptyline tab 10-25 cefprozil tab 500 mg ...... 6 mg ...... 36 cefuroxime axetil tab 250 mg ...... 6 chlordiazepoxide-amitriptyline tab 5-12.5 cefuroxime axetil tab 500 mg ...... 6 mg ...... 35 celecoxib cap 100 mg ...... 3 chlorhexidine gluconate soln 0.12% .. 101 celecoxib cap 200 mg ...... 3 chloroquine phosphate tab 250 mg ...... 9 celecoxib cap 400 mg ...... 3 chloroquine phosphate tab 500 mg ...... 9 celecoxib cap 50 mg ...... 3 chlorpheniramine maleate syrup 2 CELEXA TAB 10MG ...... 36 mg/5ml ...... 90 CELEXA TAB 20MG ...... 37 chlorpheniramine maleate tab 4 mg ... 90 CELEXA TAB 40MG ...... 37 chlorpheniramine maleate tab er 12 mg CELLCEPT CAP 250MG ...... 78 ...... 90 CELLCEPT SUS 200MG/ML ...... 78 CHLORPROMAZ INJ 25MG/ML ...... 46 CELLCEPT TAB 500MG ...... 78 CHLORPROMAZ INJ 50MG/2ML ...... 46 CELONTIN CAP 300MG ...... 30 chlorpromazine hcl tab 10 mg ...... 46 cephalexin cap 250 mg ...... 6 chlorpromazine hcl tab 100 mg ...... 46 cephalexin cap 500 mg ...... 6 chlorpromazine hcl tab 200 mg ...... 46 cephalexin cap 750 mg ...... 6 chlorpromazine hcl tab 25 mg ...... 46 cephalexin for susp 125 mg/5ml ...... 6 chlorpromazine hcl tab 50 mg ...... 46 cephalexin for susp 250 mg/5ml ...... 6 chlorthalidone tab 25 mg ...... 25 cephalexin tab 250 mg ...... 6 chlorthalidone tab 50 mg ...... 25 cephalexin tab 500 mg ...... 6 chlorzoxazone tab 500 mg ...... 56 CERDELGA CAP 84MG ...... 65 cholecalciferol cap 1000 unit ...... 85 cetirizine hcl cap 10 mg ...... 89 cholecalciferol cap 10000 unit ...... 85 cetirizine hcl chew tab 10 mg ...... 89 cholecalciferol cap 2000 unit ...... 85 cetirizine hcl chew tab 5 mg ...... 89 cholecalciferol cap 400 unit ...... 85 cetirizine hcl oral soln 1 mg/ml (5 cholecalciferol cap 5000 unit ...... 85 mg/5ml) ...... 89 cholecalciferol cap 50000 unit ...... 85 cetirizine hcl tab 10 mg ...... 90 cholecalciferol chew tab 1000 unit ...... 85 cetirizine hcl tab 5 mg ...... 90 cholecalciferol chew tab 2000 unit ...... 85 cetirizine-pseudoephedrine tab er 12hr cholecalciferol chew tab 400 unit ...... 85 5-120 mg ...... 89 cholecalciferol chew tab 5000 unit ...... 85 CHANTIX PAK 0.5& 1MG ...... 57 cholecalciferol drops 2000 unit/0.03ml CHANTIX PAK 1MG ...... 57 (per drop) ...... 85 CHANTIX TAB 0.5MG ...... 57 cholecalciferol drops 400 unit/0.03ml 113 (per drop) ...... 85 CITRANATAL CAP HARMONY ...... 88 cholecalciferol drops 5000 unit/ml (1000 CITRANATAL CAP MEDLEY ...... 88 unit/0.2ml) ...... 85 CITRANATAL MIS ...... 88 cholecalciferol oral liquid 400 unit/ml .. 85 CITRANATAL MIS 90 DHA ...... 88 cholecalciferol tab 1000 unit ...... 85 CITRANATAL MIS B-CALM ...... 88 cholecalciferol tab 2000 unit ...... 85 CITRANATAL PAK ASSURE ...... 88 cholecalciferol tab 400 unit ...... 85 CITRANATAL PAK DHA ...... 88 cholecalciferol tab 5000 unit ...... 85 CITRANATAL TAB BLOOM ...... 88 cholecalciferol tab 50000 unit ...... 85 CITRANATAL TAB RX ...... 88 cholestyramine light powder 4 gm/dose claravis cap 10mg ...... 95 ...... 21 claravis cap 20mg ...... 95 cholestyramine light powder packets 4 claravis cap 30mg ...... 95 gm ...... 21 claravis cap 40mg ...... 95 cholestyramine powder 4 gm/dose ...... 21 clarithromycin for susp 125 mg/5ml ..... 7 cholestyramine powder packets 4 gm .. 21 clarithromycin for susp 250 mg/5ml ..... 7 ciclopirox gel 0.77% ...... 97 clarithromycin tab 250 mg ...... 7 ciclopirox olamine cream 0.77% (base clarithromycin tab 500 mg ...... 7 equiv) ...... 97 clarithromycin tab er 24hr 500 mg ...... 7 ciclopirox olamine susp 0.77% (base CLARITIN RDT TAB 5MG ...... 90 equiv) ...... 97 clemastine fumarate tab 1.34 mg (1 mg ciclopirox shampoo 1% ...... 97 base equiv) ...... 90 cilostazol tab 100 mg ...... 77 clemastine fumarate tab 2.68 mg ...... 90 cilostazol tab 50 mg ...... 77 clindamycin hcl cap 150 mg ...... 13 CIMDUO TAB 300-300 ...... 9 clindamycin hcl cap 300 mg ...... 13 cimetidine hcl soln 300 mg/5ml ...... 72 clindamycin palmitate hcl for soln 75 cimetidine tab 200 mg ...... 72 mg/5ml (base equiv) ...... 13 cimetidine tab 300 mg ...... 72 clindamycin phosphate gel 1% ...... 96 cimetidine tab 400 mg ...... 72 clindamycin phosphate lotion 1% ...... 96 cimetidine tab 800 mg ...... 72 clindamycin phosphate soln 1% ...... 96 CIPRODEX SUS 0.3-0.1% ...... 104 clindamycin phosphate vaginal cream 2% ciprofloxacin hcl ophth soln 0.3% (base ...... 75 equivalent) ...... 102 clobazam suspension 2.5 mg/ml ...... 30 ciprofloxacin hcl tab 100 mg (base equiv) clobazam tab 10 mg ...... 30 ...... 7 clobazam tab 20 mg ...... 30 ciprofloxacin hcl tab 250 mg (base equiv) clobetasol propionate cream 0.05% ... 99 ...... 7 clobetasol propionate foam 0.05% ..... 99 ciprofloxacin hcl tab 500 mg (base equiv) clobetasol propionate gel 0.05% ...... 99 ...... 7 clobetasol propionate oint 0.05% ...... 99 ciprofloxacin hcl tab 750 mg (base equiv) clobetasol propionate soln 0.05% ...... 99 ...... 7 clomipramine hcl cap 25 mg ...... 29 citalopram hydrobromide oral soln 10 clomipramine hcl cap 50 mg ...... 29 mg/5ml ...... 37 clomipramine hcl cap 75 mg ...... 29 citalopram hydrobromide tab 10 mg clonazepam orally disintegrating tab (base equiv) ...... 37 0.125 mg ...... 28 citalopram hydrobromide tab 20 mg clonazepam orally disintegrating tab 0.25 (base equiv) ...... 37 mg ...... 28 citalopram hydrobromide tab 40 mg clonazepam orally disintegrating tab 0.5 (base equiv) ...... 37 mg ...... 28 114 clonazepam orally disintegrating tab 1 COMBISTIX TES ...... 81 mg ...... 28 COMBIVENT AER 20-100 ...... 89 clonazepam orally disintegrating tab 2 COMBIVIR TAB 150-300 ...... 9 mg ...... 28 COMETRIQ KIT 100MG ...... 15 clonazepam tab 0.5 mg ...... 28 COMETRIQ KIT 140MG ...... 15 clonazepam tab 1 mg ...... 28 COMETRIQ KIT 60MG ...... 15 clonazepam tab 2 mg ...... 28 COMPLERA TAB ...... 9 clonidine hcl tab 0.1 mg ...... 19 CONDOMS MIS ...... 63 clonidine hcl tab 0.2 mg ...... 19 COPAXONE INJ 40MG/ML ...... 55 clonidine hcl tab 0.3 mg ...... 19 CORLANOR TAB 5MG...... 25 clonidine td patch weekly 0.1 mg/24hr 19 CORLANOR TAB 7.5MG ...... 25 clonidine td patch weekly 0.2 mg/24hr 19 COUMADIN TAB 10MG ...... 76 clonidine td patch weekly 0.3 mg/24hr 19 COUMADIN TAB 1MG ...... 76 clopidogrel bisulfate tab 300 mg (base COUMADIN TAB 2.5MG ...... 76 equiv) ...... 77 COUMADIN TAB 2MG ...... 76 clopidogrel bisulfate tab 75 mg (base COUMADIN TAB 3MG ...... 76 equiv) ...... 77 COUMADIN TAB 4MG ...... 76 clorazepate dipotassium tab 15 mg ..... 28 COUMADIN TAB 5MG ...... 76 clorazepate dipotassium tab 3.75 mg .. 28 COUMADIN TAB 6MG ...... 76 clorazepate dipotassium tab 7.5 mg .... 28 COUMADIN TAB 7.5MG ...... 76 clotrimazole cream 1% ...... 97 CREON CAP 12000UNT ...... 73 clotrimazole soln 1% ...... 97 CREON CAP 24000UNT ...... 73 clotrimazole troche 10 mg ...... 8 CREON CAP 3000UNIT ...... 73 clotrimazole vaginal cream 1% ...... 75 CREON CAP 36000UNT ...... 73 clotrimazole vaginal cream 2% ...... 75 CREON CAP 6000UNIT ...... 73 clozapine orally disintegrating tab 100 CRINONE GEL 4% VAG ...... 68 mg ...... 42 CRINONE GEL 8% VAG ...... 68 clozapine orally disintegrating tab 12.5 CRIXIVAN CAP 200MG ...... 11 mg ...... 42 CRIXIVAN CAP 400MG ...... 12 clozapine orally disintegrating tab 150 cromolyn sodium nasal aerosol soln 5.2 mg ...... 42 mg/act (4%) ...... 93 clozapine orally disintegrating tab 200 cromolyn sodium ophth soln 4% ...... 102 mg ...... 42 cromolyn sodium soln nebu 20 mg/2ml clozapine orally disintegrating tab 25 mg ...... 93 ...... 42 CUTTER BACKW AER 25% ...... 100 clozapine tab 100 mg ...... 42 CUVPOSA SOL 1MG/5ML ...... 73 clozapine tab 200 mg ...... 42 CVS NASAL SPR MIST ...... 93 clozapine tab 25 mg ...... 42 cyanocobalamin inj 1000 mcg/ml ...... 85 clozapine tab 50 mg ...... 42 cyclobenzaprine hcl tab 10 mg ...... 56 CLOZARIL TAB 100MG ...... 42 cyclobenzaprine hcl tab 5 mg ...... 56 CLOZARIL TAB 25MG ...... 42 CYCLOMYDRIL SOL OP ...... 104 cod liver oil cap ...... 85 cyclophosphamide cap 25 mg ...... 14 colchicine tab 0.6 mg ...... 3 cyclophosphamide cap 50 mg ...... 14 colestipol hcl granule packets 5 gm ..... 21 cyclosporine cap 100 mg ...... 79 colestipol hcl granules 5 gm ...... 21 cyclosporine cap 25 mg ...... 78 colestipol hcl tab 1 gm ...... 21 cyclosporine modified cap 100 mg ..... 79 COMBIPATCH DIS .05/.14 ...... 65 cyclosporine modified cap 25 mg ...... 79 COMBIPATCH DIS .05/.25 ...... 65 cyclosporine modified cap 50 mg ...... 79 115 cyclosporine modified oral soln 100 desogest-eth estrad & eth estrad tab mg/ml ...... 79 0.15-0.02/0.01 mg(21/5) ...... 63 CYMBALTA CAP 20MG ...... 38 desogest-ethin est tab 0.1-0.025/0.125- CYMBALTA CAP 30MG ...... 38 0.025/0.15-0.025mg-mg ...... 64 CYMBALTA CAP 60MG ...... 38 desogestrel & ethinyl estradiol tab 0.15 cyproheptadine hcl syrup 2 mg/5ml .... 90 mg-30 mcg ...... 63 cyproheptadine hcl tab 4 mg ...... 90 desonide cream 0.05% ...... 98 CYSTAGON CAP 150MG ...... 67 desonide lotion 0.05% ...... 98 CYSTAGON CAP 50MG ...... 67 desonide oint 0.05% ...... 98 CYTOMEL TAB 25MCG ...... 68 desoximetasone cream 0.05% ...... 99 CYTOMEL TAB 50MCG ...... 68 desoximetasone cream 0.25% ...... 98 CYTOMEL TAB 5MCG ...... 68 desoximetasone gel 0.05% ...... 98 D desoximetasone oint 0.25% ...... 98 dalfampridine tab er 12hr 10 mg ...... 55 DESVENLAFAX TAB 100MG ER ...... 38 danazol cap 100 mg ...... 58, 64 DESVENLAFAX TAB 50MG ER ...... 38 danazol cap 200 mg ...... 58, 64 desvenlafaxine succinate tab er 24hr 100 danazol cap 50 mg ...... 58, 64 mg (base equiv) ...... 38 dantrolene sodium cap 100 mg ...... 56 desvenlafaxine succinate tab er 24hr 25 dantrolene sodium cap 25 mg ...... 56 mg (base equiv) ...... 38 dantrolene sodium cap 50 mg ...... 56 desvenlafaxine succinate tab er 24hr 50 dapsone tab 100 mg ...... 14 mg (base equiv) ...... 38 dapsone tab 25 mg ...... 13 desvenlafaxine tab er 24hr 100 mg .... 38 DAPTACEL INJ ...... 79 desvenlafaxine tab er 24hr 50 mg ...... 38 DARAPRIM TAB 25MG ...... 14 dexamethasone elixir 0.5 mg/5ml ...... 65 DDAVP SOL 0.01% ...... 69 dexamethasone sodium phosphate ophth demeclocycline hcl tab 150 mg ...... 8 soln 0.1% ...... 102 demeclocycline hcl tab 300 mg ...... 8 dexamethasone soln 0.5 mg/5ml ...... 65 DEPAKENE CAP 250MG ...... 30 dexamethasone tab 0.5 mg ...... 65 DEPAKENE SOL 250/5ML ...... 30 dexamethasone tab 0.75 mg ...... 65 DEPAKOTE ER TAB 250MG ...... 30 dexamethasone tab 1 mg ...... 65 DEPAKOTE ER TAB 500MG ...... 30 dexamethasone tab 1.5 mg ...... 65 DEPAKOTE SPR CAP 125MG ...... 30 dexamethasone tab 2 mg ...... 65 DEPAKOTE TAB 125MG DR ...... 30 dexamethasone tab 4 mg ...... 65 DEPAKOTE TAB 250MG DR ...... 30 dexamethasone tab 6 mg ...... 65 DEPAKOTE TAB 500MG DR ...... 30 dexmethylphenidate hcl tab 10 mg .... 49 DESCOVY TAB 200/25 ...... 9 dexmethylphenidate hcl tab 2.5 mg ... 49 desipramine hcl tab 10 mg ...... 39 dexmethylphenidate hcl tab 5 mg ...... 49 desipramine hcl tab 100 mg ...... 40 dextran 70-hypromellose (pf) ophth soln desipramine hcl tab 150 mg ...... 40 0.1-0.3% ...... 103 desipramine hcl tab 25 mg ...... 40 dextran 70-hypromellose ophth soln 0.1- desipramine hcl tab 50 mg ...... 40 0.3% ...... 103 desipramine hcl tab 75 mg ...... 40 dextroamphetamine sulfate cap er 24hr desmopressin acetate nasal spray soln 10 mg ...... 49 0.01% ...... 69 dextroamphetamine sulfate cap er 24hr desmopressin acetate nasal spray soln 15 mg ...... 49 0.01% (refrigerated) ...... 69 dextroamphetamine sulfate cap er 24hr 5 desmopressin acetate tab 0.1 mg ...... 69 mg ...... 49 desmopressin acetate tab 0.2 mg ...... 69 dextroamphetamine sulfate tab 10 mg 49 116 dextroamphetamine sulfate tab 5 mg .. 49 dicyclomine hcl tab 20 mg ...... 71 dextromethorphan-guaifenesin liquid 10- didanosine delayed release capsule 200 100 mg/5ml ...... 91 mg ...... 11 dextromethorphan-guaifenesin liquid 10- didanosine delayed release capsule 250 200 mg/5ml ...... 91 mg ...... 11 dextromethorphan-guaifenesin liquid 20- didanosine delayed release capsule 400 300 mg/5ml ...... 91 mg ...... 11 dextromethorphan-guaifenesin liquid 30- diflorasone diacetate cream 0.05% .... 98 200 mg/5ml ...... 91 diflorasone diacetate oint 0.05% ...... 99 dextromethorphan-guaifenesin liquid 5- diflunisal tab 500 mg ...... 4 100 mg/5ml ...... 91 digoxin oral soln 0.05 mg/ml ...... 24 dextromethorphan-guaifenesin syrup 10- digoxin tab 125 mcg (0.125 mg)...... 24 100 mg/5ml ...... 91 digoxin tab 250 mcg (0.25 mg) ...... 24 dextromethorphan-guaifenesin tab er DILANTIN CAP 100MG ...... 30 12hr 30-600 mg ...... 91 DILANTIN CAP 30MG ...... 30 dextromethorphan-guaifenesin tab er DILANTIN CHW 50MG ...... 30 12hr 60-1200 mg ...... 91 DILANTIN-125 SUS 125/5ML ...... 30 DIAPHRAGM ...... 63 diltiazem hcl cap er 12hr 120 mg ...... 24 DIASTAT ACDL GEL 12.5-20 ...... 30 diltiazem hcl cap er 12hr 60 mg ...... 24 DIASTAT ACDL GEL 5-10MG ...... 30 diltiazem hcl cap er 12hr 90 mg ...... 24 DIASTAT PED GEL 2.5M GEL ...... 30 diltiazem hcl cap er 24hr 120 mg ...... 24 diazepam conc 5 mg/ml ...... 28 diltiazem hcl cap er 24hr 180 mg ...... 24 DIAZEPAM INJ 10MG/2ML ...... 28 diltiazem hcl cap er 24hr 240 mg ...... 24 diazepam inj 5 mg/ml ...... 28 diltiazem hcl coated beads cap er 24hr diazepam oral soln 1 mg/ml ...... 28 120 mg ...... 24 diazepam rectal gel delivery system 10 diltiazem hcl coated beads cap er 24hr mg ...... 30 180 mg ...... 24 diazepam rectal gel delivery system 2.5 diltiazem hcl coated beads cap er 24hr mg ...... 30 240 mg ...... 24 diazepam rectal gel delivery system 20 diltiazem hcl coated beads cap er 24hr mg ...... 30 300 mg ...... 24 diazepam tab 10 mg ...... 28 diltiazem hcl coated beads cap er 24hr diazepam tab 2 mg ...... 28 360 mg ...... 24 diazepam tab 5 mg ...... 28 diltiazem hcl coated beads tab er 24hr diclofenac potassium tab 50 mg ...... 4 180 mg ...... 24 diclofenac sodium gel 1% ...... 5 diltiazem hcl coated beads tab er 24hr diclofenac sodium ophth soln 0.1% ... 102 240 mg ...... 24 diclofenac sodium tab delayed release 25 diltiazem hcl coated beads tab er 24hr mg ...... 4 300 mg ...... 24 diclofenac sodium tab delayed release 50 diltiazem hcl coated beads tab er 24hr mg ...... 4 360 mg ...... 24 diclofenac sodium tab delayed release 75 diltiazem hcl coated beads tab er 24hr mg ...... 4 420 mg ...... 24 diclofenac sodium tab er 24hr 100 mg .. 4 diltiazem hcl extended release beads cap dicloxacillin sodium cap 250 mg ...... 8 er 24hr 120 mg ...... 24 dicloxacillin sodium cap 500 mg ...... 8 diltiazem hcl extended release beads cap dicyclomine hcl cap 10 mg ...... 71 er 24hr 180 mg ...... 24 dicyclomine hcl oral soln 10 mg/5ml ... 71 diltiazem hcl extended release beads cap 117 er 24hr 240 mg ...... 24 divalproex sodium tab delayed release diltiazem hcl extended release beads cap 500 mg ...... 30 er 24hr 300 mg ...... 24 divalproex sodium tab er 24 hr 250 mg diltiazem hcl extended release beads cap ...... 30 er 24hr 360 mg ...... 24 divalproex sodium tab er 24 hr 500 mg diltiazem hcl extended release beads cap ...... 30 er 24hr 420 mg ...... 24 docosanol cream 10% ...... 101 diltiazem hcl tab 120 mg ...... 24 docusate calcium cap 240 mg ...... 72 diltiazem hcl tab 30 mg ...... 24 docusate sodium cap 100 mg ...... 73 diltiazem hcl tab 60 mg ...... 24 docusate sodium cap 250 mg ...... 73 diltiazem hcl tab 90 mg ...... 24 docusate sodium cap 50 mg ...... 73 DIP/TET PED INJ 25-5LFU ...... 79 docusate sodium liquid 150 mg/15ml . 73 diphenhydramine hcl (sleep) cap 50 mg docusate sodium syrup 60 mg/15ml ... 73 ...... 53 docusate sodium tab 100 mg ...... 73 diphenhydramine hcl (sleep) tab 25 mg dofetilide cap 125 mcg (0.125 mg) .... 20 ...... 53 dofetilide cap 250 mcg (0.25 mg) ...... 20 diphenhydramine hcl (sleep) tab 50 mg dofetilide cap 500 mcg (0.5 mg) ...... 20 ...... 53 donepezil hydrochloride orally diphenhydramine hcl cap 25 mg ...... 90 disintegrating tab 10 mg ...... 35 diphenhydramine hcl cap 50 mg ...... 90 donepezil hydrochloride orally diphenhydramine hcl chew tab 12.5 mg disintegrating tab 5 mg ...... 35 ...... 90 donepezil hydrochloride tab 10 mg ..... 35 diphenhydramine hcl elixir 12.5 mg/5ml donepezil hydrochloride tab 23 mg ..... 35 ...... 90 donepezil hydrochloride tab 5 mg ...... 35 diphenhydramine hcl liquid 12.5 mg/5ml dorzolamide hcl ophth soln 2% ...... 104 ...... 90 dorzolamide hcl-timolol maleate ophth diphenhydramine hcl syrup 12.5 mg/5ml soln 22.3-6.8 mg/ml ...... 104 ...... 90 doxazosin mesylate tab 1 mg ...... 19 diphenhydramine hcl tab 25 mg ...... 90 doxazosin mesylate tab 2 mg ...... 19 diphenhydramine hcl tab disint 12.5 mg doxazosin mesylate tab 4 mg ...... 19 ...... 90 doxazosin mesylate tab 8 mg ...... 19 diphenoxylate w/ atropine liq 2.5-0.025 doxepin hcl cap 10 mg ...... 40 mg/5ml ...... 70 doxepin hcl cap 100 mg ...... 40 diphenoxylate w/ atropine tab 2.5-0.025 doxepin hcl cap 150 mg ...... 40 mg ...... 70 doxepin hcl cap 25 mg ...... 40 dipyridamole tab 25 mg ...... 77 doxepin hcl cap 50 mg ...... 40 dipyridamole tab 50 mg ...... 77 doxepin hcl cap 75 mg ...... 40 dipyridamole tab 75 mg ...... 77 doxepin hcl conc 10 mg/ml ...... 40 disopyramide phosphate cap 100 mg .. 20 doxercalciferol cap 0.5 mcg ...... 67 disopyramide phosphate cap 150 mg .. 20 doxercalciferol cap 1 mcg ...... 67 disulfiram tab 250 mg ...... 56 doxercalciferol cap 2.5 mcg ...... 67 disulfiram tab 500 mg ...... 56 doxycycline hyclate cap 100 mg ...... 8 divalproex sodium cap delayed release doxycycline hyclate cap 50 mg ...... 8 sprinkle 125 mg ...... 30 doxycycline hyclate tab 100 mg ...... 8 divalproex sodium tab delayed release doxycycline hyclate tab 20 mg ...... 8 125 mg ...... 30 doxycycline monohydrate for susp 25 divalproex sodium tab delayed release mg/5ml ...... 8 250 mg ...... 30 doxylamine succinate (sleep) tab 25 mg 118 ...... 53 ENBREL INJ 50MG/ML ...... 77 dronabinol cap 10 mg ...... 70 ENBREL MINI INJ 50MG/ML ...... 77 dronabinol cap 2.5 mg ...... 70 ENBREL SRCLK INJ 50MG/ML ...... 77 dronabinol cap 5 mg ...... 70 ENCARE SUP 100MG ...... 63 drospirenone-ethinyl estradiol tab 3-0.02 ENDARI POW 5GM ...... 77 mg ...... 63 ENGERIX-B INJ 10/0.5ML ...... 80 drospirenone-ethinyl estradiol tab 3-0.03 ENGERIX-B INJ 20MCG/ML ...... 80 mg ...... 63 entacapone tab 200 mg ...... 41 DULERA AER 100-5MCG ...... 95 entecavir tab 0.5 mg ...... 13 DULERA AER 200-5MCG ...... 95 entecavir tab 1 mg ...... 13 duloxetine hcl enteric coated pellets cap ENTRESTO TAB 24-26MG ...... 25 20 mg (base eq) ...... 38 ENTRESTO TAB 49-51MG ...... 25 duloxetine hcl enteric coated pellets cap ENTRESTO TAB 97-103MG ...... 25 30 mg (base eq) ...... 38 ENVARSUS XR TAB 0.75MG ...... 79 duloxetine hcl enteric coated pellets cap ENVARSUS XR TAB 1MG ...... 79 40 mg (base eq) ...... 38 ENVARSUS XR TAB 4MG ...... 79 duloxetine hcl enteric coated pellets cap epinephrine solution auto-injector 0.15 60 mg (base eq) ...... 38 mg/0.15ml (1:1000) ...... 89 E epinephrine solution auto-injector 0.3 EDURANT TAB 25MG ...... 10 mg/0.3ml (1:1000) ...... 89 efavirenz cap 200 mg ...... 10 EPIPEN 2-PAK INJ 0.3MG ...... 89 efavirenz cap 50 mg ...... 10 EPIPEN-JR INJ 0.15MG ...... 89 efavirenz tab 600 mg ...... 10 epitol tab 200mg ...... 30 EFFEXOR XR CAP 150MG ...... 39 EPIVIR SOL 10MG/ML ...... 11 EFFEXOR XR CAP 37.5MG ...... 39 EPIVIR TAB 150MG ...... 11 EFFEXOR XR CAP 75MG ...... 39 EPIVIR TAB 300MG ...... 11 ELIQUIS TAB 2.5MG ...... 76 eplerenone tab 25 mg ...... 19 ELIQUIS TAB 5MG ...... 76 eplerenone tab 50 mg ...... 19 ELIXOPHYLLIN ELX 80/15ML ...... 95 EPZICOM TAB 600-300 ...... 9 ELLA TAB 30MG ...... 63 EQUETRO CAP 100MG ...... 55 ELMIRON CAP 100MG ...... 75 EQUETRO CAP 200MG ...... 55 EMEND SOL 150MG ...... 70 EQUETRO CAP 300MG ...... 55 EMSAM DIS 12MG/24H ...... 36 ergocalciferol cap 50000 unit ...... 85 EMSAM DIS 6MG/24HR ...... 36 ergocalciferol soln 8000 unit/ml ...... 85 EMSAM DIS 9MG/24HR ...... 36 ergotamine w/ caffeine tab 1-100 mg . 54 EMTRIVA CAP 200MG ...... 11 ERIVEDGE CAP 150MG ...... 17 EMTRIVA SOL 10MG/ML ...... 11 erlotinib hcl tab 100 mg (base EMVERM CHW 100MG ...... 14 equivalent) ...... 15 enalapril maleate & hydrochlorothiazide erlotinib hcl tab 150 mg (base tab 10-25 mg ...... 18 equivalent) ...... 15 enalapril maleate & hydrochlorothiazide erlotinib hcl tab 25 mg (base equivalent) tab 5-12.5 mg ...... 18 ...... 15 enalapril maleate tab 10 mg ...... 18 erythromycin ethylsuccinate for susp 200 enalapril maleate tab 2.5 mg ...... 18 mg/5ml ...... 7 enalapril maleate tab 20 mg ...... 18 erythromycin ethylsuccinate tab 400 mg enalapril maleate tab 5 mg ...... 18 ...... 7 ENBREL INJ 25/0.5ML ...... 77 erythromycin gel 2% ...... 96 ENBREL INJ 25MG ...... 77 erythromycin ophth oint 5 mg/gm ..... 102 119 erythromycin soln 2% ...... 96 tab 1 mg-50 mcg ...... 64 erythromycin stearate tab 250 mg ...... 7 etodolac cap 200 mg ...... 4 erythromycin tab 250 mg ...... 7 etodolac cap 300 mg ...... 4 erythromycin tab 500 mg ...... 7 etodolac tab 400 mg ...... 4 erythromycin tab delayed release 250 etodolac tab 500 mg ...... 4 mg ...... 7 etodolac tab er 24hr 400 mg ...... 4 erythromycin tab delayed release 333 etodolac tab er 24hr 500 mg ...... 4 mg ...... 7 etodolac tab er 24hr 600 mg ...... 4 erythromycin tab delayed release 500 etoposide cap 50 mg ...... 17 mg ...... 7 EVOTAZ TAB 300-150 ...... 9 erythromycin w/ delayed release exemestane tab 25 mg ...... 15 particles cap 250 mg ...... 7 EXTAVIA INJ 0.3MG ...... 55 escitalopram oxalate soln 5 mg/5ml ezetimibe tab 10 mg ...... 21 (base equiv) ...... 37 F escitalopram oxalate tab 10 mg (base famciclovir tab 125 mg ...... 13 equiv) ...... 37 famciclovir tab 250 mg ...... 13 escitalopram oxalate tab 20 mg (base famciclovir tab 500 mg ...... 13 equiv) ...... 37 famotidine for susp 40 mg/5ml ...... 72 escitalopram oxalate tab 5 mg (base famotidine tab 10 mg ...... 72 equiv) ...... 37 famotidine tab 20 mg ...... 72 esomeprazole magnesium cap delayed famotidine tab 40 mg ...... 72 release 20 mg (base eq) ...... 74 FANAPT PAK ...... 42 estradiol & norethindrone acetate tab FANAPT TAB 10MG ...... 43 0.5-0.1 mg ...... 64 FANAPT TAB 12MG ...... 43 estradiol & norethindrone acetate tab 1- FANAPT TAB 1MG ...... 42 0.5 mg ...... 64 FANAPT TAB 2MG ...... 42 estradiol tab 0.5 mg ...... 65 FANAPT TAB 4MG ...... 42 estradiol tab 1 mg ...... 65 FANAPT TAB 6MG ...... 42 estradiol tab 2 mg ...... 65 FANAPT TAB 8MG ...... 43 estradiol td patch weekly 0.025 mg/24hr FANATREX SUS 25MG/ML ...... 30 ...... 65 FARYDAK CAP 10MG ...... 17 estradiol td patch weekly 0.0375 FARYDAK CAP 15MG ...... 17 mg/24hr (37.5 mcg/24hr) ...... 65 FARYDAK CAP 20MG ...... 17 estradiol td patch weekly 0.05 mg/24hr FAZACLO TAB 100 ODT ...... 43 ...... 65 FAZACLO TAB 12.5 ODT ...... 43 estradiol td patch weekly 0.06 mg/24hr FAZACLO TAB 150 ODT ...... 43 ...... 65 FAZACLO TAB 200 ODT ...... 43 estradiol td patch weekly 0.075 mg/24hr FAZACLO TAB 25MG ODT ...... 43 ...... 65 fe bisglyc-vit c-vit b12-folic acid cap 28- estradiol td patch weekly 0.1 mg/24hr 65 60-0.008-0.4 mg ...... 83 estradiol vaginal tab 10 mcg ...... 65 fe fumarate w/ b12-vit c-fa-ifc cap 110- ethambutol hcl tab 100 mg ...... 12 0.015-75-0.5-240 mg ...... 83 ethambutol hcl tab 400 mg ...... 12 fe fumarate-vit c-vit b12-fa cap 460 (151 ethosuximide cap 250 mg ...... 30 fe)-60-0.01-1 mg ...... 83 ethosuximide soln 250 mg/5ml ...... 30 fe fum-iron polysacch complex-fa-b ethynodiol diacetate & ethinyl estradiol cmplx-c-zn-mn-cu cap ...... 83 tab 1 mg-35 mcg ...... 64 felbamate susp 600 mg/5ml ...... 30 ethynodiol diacetate & ethinyl estradiol felbamate tab 400 mg ...... 31 120 felbamate tab 600 mg ...... 31 equivalent) ...... 84 FELBATOL SUS 600/5ML ...... 31 ferrous sulfate tab er 47.5 mg (elemental FELBATOL TAB 400MG ...... 31 fe) ...... 84 FELBATOL TAB 600MG ...... 31 ferrous sulfate tab er 50 mg (elemental felodipine tab er 24hr 10 mg ...... 23 fe) ...... 84 felodipine tab er 24hr 2.5 mg ...... 23 FETZIMA CAP 120MG ...... 39 felodipine tab er 24hr 5 mg ...... 23 FETZIMA CAP 20MG ...... 39 fenofibrate micronized cap 134 mg ..... 21 FETZIMA CAP 40MG ...... 39 fenofibrate micronized cap 200 mg ..... 21 FETZIMA CAP 80MG ...... 39 fenofibrate micronized cap 67 mg ...... 21 FETZIMA CAP TITRATIO ...... 39 fenofibrate tab 145 mg ...... 21 FEVERALL INF SUP 80MG ...... 4 fenofibrate tab 160 mg ...... 21 FEVERALL SUP 325MG ...... 4 fenofibrate tab 48 mg ...... 21 fexofenadine hcl susp 30 mg/5ml (6 fenofibrate tab 54 mg ...... 21 mg/ml) ...... 90 fentanyl td patch 72hr 100 mcg/hr ...... 5 fexofenadine hcl tab 180 mg ...... 90 fentanyl td patch 72hr 12 mcg/hr ...... 5 fexofenadine hcl tab 60 mg ...... 90 fentanyl td patch 72hr 25 mcg/hr ...... 5 fexofenadine-pseudoephedrine tab er fentanyl td patch 72hr 50 mcg/hr ...... 5 12hr 60-120 mg ...... 89 fentanyl td patch 72hr 75 mcg/hr ...... 5 fexofenadine-pseudoephedrine tab er ferrous fumarate tab 324 mg (106 mg 24hr 180-240 mg ...... 89 elemental fe) ...... 83 FIASP FLEX INJ TOUCH ...... 60 ferrous fumarate-fa-b complex-c-zn-mg- FIASP INJ 100/ML ...... 60 mn-cu tab 106-1 mg ...... 83 finasteride tab 5 mg ...... 75 ferrous fumarate-folic acid tab 324-1 mg flecainide acetate tab 100 mg ...... 20 ...... 83 flecainide acetate tab 150 mg ...... 20 ferrous gluconate tab 240 mg (27 mg flecainide acetate tab 50 mg ...... 20 elemental fe) ...... 83 FLOVENT DISK AER 100MCG ...... 94 ferrous gluconate tab 324 mg (37.5 mg FLOVENT DISK AER 250MCG ...... 94 elemental iron) ...... 83 FLOVENT DISK AER 50MCG ...... 94 ferrous sulfate dried tab 200 mg (65 mg FLOVENT HFA AER 110MCG ...... 94 elemental fe) ...... 83 FLOVENT HFA AER 220MCG ...... 94 ferrous sulfate dried tab er 160 mg (50 FLOVENT HFA AER 44MCG ...... 94 mg fe equivalent) ...... 84 fluconazole for susp 10 mg/ml ...... 8 ferrous sulfate dried tab er 45 mg (fe fluconazole for susp 40 mg/ml ...... 8 equivalent) ...... 84 fluconazole tab 100 mg ...... 8 ferrous sulfate elixir 220 mg/5ml (44 fluconazole tab 150 mg ...... 8 mg/5ml elemental fe) ...... 84 fluconazole tab 200 mg ...... 8 ferrous sulfate soln 75 mg/ml (15 mg/ml fluconazole tab 50 mg ...... 8 elemental fe) ...... 84 fludrocortisone acetate tab 0.1 mg ..... 67 ferrous sulfate tab 134 mg (27 mg flunisolide nasal soln 25 mcg/act elemental fe) ...... 84 (0.025%) ...... 94 ferrous sulfate tab 27 mg (elemental fe) fluocinolone acetonide cream 0.025% 99 ...... 84 fluocinolone acetonide oint 0.025% .... 99 ferrous sulfate tab 325 mg (65 mg fluocinolone acetonide soln 0.01% ..... 98 elemental fe) ...... 84 fluocinonide cream 0.05% ...... 98 ferrous sulfate tab ec 325 mg (65 mg fe fluocinonide gel 0.05% ...... 98 equivalent) ...... 84 fluocinonide oint 0.05% ...... 98 ferrous sulfate tab er 142 mg (45 mg fe fluocinonide soln 0.05% ...... 98 121 fluorometholone ophth susp 0.1% .... 102 0.8-10-0.115 mg ...... 83 fluorouracil cream 5% ...... 96 folic acid-vitamin b6-vitamin b12 tab fluoxetine hcl (pmdd) cap 10 mg ...... 37 2.2-25-0.5 mg ...... 83 fluoxetine hcl (pmdd) cap 20 mg ...... 37 folic acid-vitamin b6-vitamin b12 tab fluoxetine hcl (pmdd) tab 10 mg ...... 37 2.2-25-1 mg ...... 83 fluoxetine hcl (pmdd) tab 20 mg ...... 37 folic acid-vitamin b6-vitamin b12 tab fluoxetine hcl cap 10 mg ...... 37 2.5-25-1 mg ...... 83 fluoxetine hcl cap 20 mg ...... 37 FORFIVO XL TAB 450MG ...... 36 fluoxetine hcl cap 40 mg ...... 37 FORTEO SOL 600/2.4 ...... 62 fluoxetine hcl cap delayed release 90 mg fosamprenavir calcium tab 700 mg (base ...... 37 equiv) ...... 12 fluoxetine hcl solution 20 mg/5ml ...... 37 fosinopril sodium & hydrochlorothiazide fluoxetine hcl tab 10 mg ...... 37 tab 10-12.5 mg ...... 18 fluoxetine hcl tab 20 mg ...... 37 fosinopril sodium & hydrochlorothiazide fluoxetine hcl tab 60 mg ...... 37 tab 20-12.5 mg ...... 18 FLUOXETINE TAB 60MG...... 37 fosinopril sodium tab 10 mg ...... 18 fluphenazine decanoate inj 25 mg/ml .. 46 fosinopril sodium tab 20 mg ...... 18 fluphenazine hcl elixir 2.5 mg/5ml ...... 46 fosinopril sodium tab 40 mg ...... 18 fluphenazine hcl inj 2.5 mg/ml ...... 46 FREESTYLE TES ...... 62 fluphenazine hcl oral conc 5 mg/ml ..... 46 FREESTYLE TES INSULINX ...... 62 fluphenazine hcl tab 1 mg ...... 46 FREESTYLE TES LITE ...... 62 fluphenazine hcl tab 10 mg ...... 46 furosemide oral soln 10 mg/ml ...... 25 fluphenazine hcl tab 2.5 mg ...... 46 furosemide tab 20 mg ...... 25 fluphenazine hcl tab 5 mg ...... 46 furosemide tab 40 mg ...... 25 flurbiprofen tab 100 mg ...... 4 furosemide tab 80 mg ...... 25 flurbiprofen tab 50 mg ...... 4 FUZEON INJ 90MG ...... 10 flutamide cap 125 mg ...... 15 FYCOMPA SUS 0.5MG/ML ...... 31 fluticasone propionate cream 0.05% ... 99 FYCOMPA TAB 10MG ...... 31 fluticasone propionate nasal susp 50 FYCOMPA TAB 12MG ...... 31 mcg/act ...... 94 FYCOMPA TAB 2MG ...... 31 fluticasone propionate oint 0.005% ..... 99 FYCOMPA TAB 4MG ...... 31 fluticasone-salmeterol aer powder ba FYCOMPA TAB 6MG ...... 31 100-50 mcg/dose ...... 95 FYCOMPA TAB 8MG ...... 31 fluticasone-salmeterol aer powder ba G 250-50 mcg/dose ...... 95 gabapentin cap 100 mg ...... 31 fluticasone-salmeterol aer powder ba gabapentin cap 300 mg ...... 31 500-50 mcg/dose ...... 95 gabapentin cap 400 mg ...... 31 fluvoxamine maleate cap er 24hr 100 mg gabapentin oral soln 250 mg/5ml ...... 31 ...... 29 gabapentin tab 600 mg ...... 31 fluvoxamine maleate cap er 24hr 150 mg gabapentin tab 800 mg ...... 31 ...... 29 GABITRIL TAB 12MG ...... 31 fluvoxamine maleate tab 100 mg ...... 29 GABITRIL TAB 16MG ...... 31 fluvoxamine maleate tab 25 mg ...... 29 GABITRIL TAB 2MG ...... 31 fluvoxamine maleate tab 50 mg ...... 29 GABITRIL TAB 4MG ...... 31 folic acid tab 1 mg ...... 83 galantamine hydrobromide cap er 24hr folic acid tab 400 mcg ...... 83 16 mg ...... 35 folic acid tab 800 mcg ...... 83 galantamine hydrobromide cap er 24hr folic acid-vitamin b6-vitamin b12 tab 24 mg ...... 35 122 galantamine hydrobromide cap er 24hr 8 glimepiride tab 1 mg ...... 61 mg ...... 35 glimepiride tab 2 mg ...... 61 galantamine hydrobromide oral soln 4 glimepiride tab 4 mg ...... 61 mg/ml ...... 35 glipizide tab 10 mg ...... 61 galantamine hydrobromide tab 12 mg . 35 glipizide tab 5 mg ...... 61 galantamine hydrobromide tab 4 mg ... 35 glipizide tab er 24hr 10 mg ...... 61 galantamine hydrobromide tab 8 mg ... 35 glipizide tab er 24hr 2.5 mg ...... 61 GARDASIL 9 INJ ...... 80 glipizide tab er 24hr 5 mg ...... 61 GAS-X CHILD MIS 40MG ...... 73 glipizide-metformin hcl tab 2.5-250 mg gemfibrozil tab 600 mg ...... 21 ...... 58 gengraf cap 100mg ...... 79 glipizide-metformin hcl tab 2.5-500 mg gengraf cap 25mg ...... 79 ...... 58 gengraf sol 100mg/ml ...... 79 glipizide-metformin hcl tab 5-500 mg . 58 GENOTROPIN INJ 0.2MG ...... 66 GLUCAGEN INJ HYPOKIT...... 66 GENOTROPIN INJ 0.4MG ...... 66 GLUCAGON KIT 1MG ...... 66 GENOTROPIN INJ 0.6MG ...... 66 glyburide micronized tab 1.5 mg ...... 61 GENOTROPIN INJ 0.8MG ...... 66 glyburide micronized tab 3 mg ...... 61 GENOTROPIN INJ 1.2MG ...... 66 glyburide micronized tab 6 mg ...... 62 GENOTROPIN INJ 1.4MG ...... 66 glyburide tab 1.25 mg ...... 62 GENOTROPIN INJ 1.6MG ...... 66 glyburide tab 2.5 mg ...... 62 GENOTROPIN INJ 1.8MG ...... 66 glyburide tab 5 mg ...... 62 GENOTROPIN INJ 12MG ...... 66 glyburide-metformin tab 1.25-250 mg 58 GENOTROPIN INJ 1MG ...... 66 glyburide-metformin tab 2.5-500 mg .. 58 GENOTROPIN INJ 2MG ...... 66 glyburide-metformin tab 5-500 mg .... 58 GENOTROPIN INJ 5MG ...... 66 glycerin-hypromellose-peg 400 ophth gentamicin sulfate cream 0.1% ...... 97 soln 0.2-0.2-1% ...... 103 gentamicin sulfate oint 0.1% ...... 97 glycopyrrolate tab 1 mg...... 71 gentamicin sulfate ophth oint 0.3%... 102 glycopyrrolate tab 2 mg...... 71 gentamicin sulfate ophth soln 0.3% .. 102 granisetron hcl tab 1 mg...... 70 GENTEAL GEL 0.3% ...... 103 griseofulvin microsize susp 125 mg/5ml 9 GENTEAL MILD DRO 0.2% ...... 103 griseofulvin ultramicrosize tab 125 mg . 9 GENVOYA TAB ...... 9 griseofulvin ultramicrosize tab 250 mg . 9 GEODON CAP 20MG ...... 43 guaifenesin liquid 100 mg/5ml ...... 93 GEODON CAP 40MG ...... 43 guaifenesin syrup 100 mg/5ml ...... 93 GEODON CAP 60MG ...... 43 guaifenesin tab 200 mg ...... 93 GEODON CAP 80MG ...... 43 guaifenesin tab 400 mg ...... 93 GEODON INJ 20MG ...... 43 guaifenesin tab er 12hr 1200 mg ...... 93 GILENYA CAP 0.5MG ...... 55 guaifenesin tab er 12hr 600 mg ...... 93 GILOTRIF TAB 20MG ...... 15 guaifenesin-codeine soln 100-10 mg/5ml GILOTRIF TAB 30MG ...... 15 ...... 91 GILOTRIF TAB 40MG ...... 15 guaifenesin-codeine soln 100-6.3 glatiramer acetate soln prefilled syringe mg/5ml ...... 91 20 mg/ml ...... 55 guanfacine hcl tab 1 mg ...... 19 glatiramer acetate soln prefilled syringe guanfacine hcl tab 2 mg ...... 19 40 mg/ml ...... 56 GYNOL II GEL 3% ...... 63 GLEOSTINE CAP 100MG ...... 14 H GLEOSTINE CAP 10MG ...... 14 halobetasol propionate cream 0.05% . 99 GLEOSTINE CAP 40MG ...... 14 halobetasol propionate oint 0.05% ..... 99 123 haloperidol decanoate im soln 100 mg/ml hydralazine hcl tab 50 mg ...... 26 ...... 46 hydrochlorothiazide cap 12.5 mg ...... 25 haloperidol decanoate im soln 50 mg/ml hydrochlorothiazide tab 12.5 mg ...... 25 ...... 46 hydrochlorothiazide tab 25 mg ...... 25 haloperidol lactate inj 5 mg/ml ...... 46 hydrochlorothiazide tab 50 mg ...... 25 haloperidol lactate oral conc 2 mg/ml .. 46 hydrocodone w/ homatropine syrup 5- haloperidol tab 0.5 mg ...... 46 1.5 mg/5ml ...... 91 haloperidol tab 1 mg ...... 46 hydrocodone w/ homatropine tab 5-1.5 haloperidol tab 10 mg ...... 46 mg ...... 91 haloperidol tab 2 mg ...... 46 hydrocodone-acetaminophen soln 7.5- haloperidol tab 20 mg ...... 46 325 mg/15ml ...... 5 haloperidol tab 5 mg ...... 46 hydrocodone-acetaminophen tab 10-325 HAVRIX INJ 1440UNIT ...... 80 mg ...... 5 HAVRIX INJ 720UNIT ...... 80 hydrocodone-acetaminophen tab 5-325 HEMA-COMBIST TES ...... 81 mg ...... 5 HUMALOG INJ 100/ML ...... 60 hydrocodone-acetaminophen tab 7.5-325 HUMALOG JR INJ 100/ML ...... 60 mg ...... 5 HUMALOG KWIK INJ 100/ML ...... 60 hydrocortisone acetate cream 1% ...... 98 HUMALOG MIX INJ 50/50 ...... 60 hydrocortisone butyrate cream 0.1% .. 99 HUMALOG MIX INJ 50/50KWP ...... 60 hydrocortisone butyrate oint 0.1% ..... 99 HUMALOG MIX INJ 75/25KWP ...... 60 hydrocortisone butyrate soln 0.1% ..... 99 HUMALOG MIX SUS 75/25 ...... 60 hydrocortisone cream 0.5% ...... 98 HUMATROPE INJ 12MG ...... 66 hydrocortisone cream 1% ...... 98 HUMATROPE INJ 24MG ...... 67 hydrocortisone cream 2.5% ...... 98 HUMATROPE INJ 5MG ...... 66 hydrocortisone enema 100 mg/60ml .. 72 HUMATROPE INJ 6MG ...... 66 hydrocortisone gel 1% ...... 98 HUMIRA INJ 10/0.1ML ...... 77 hydrocortisone lotion 1% ...... 98 HUMIRA INJ 10MG/0.2 ...... 77 hydrocortisone lotion 2.5% ...... 98 HUMIRA INJ 20/0.2ML ...... 77 hydrocortisone oint 0.5% ...... 99 HUMIRA INJ 40/0.4ML ...... 77 hydrocortisone oint 1% ...... 99 HUMIRA KIT 20MG/0.4 ...... 78 hydrocortisone oint 2.5% ...... 99 HUMIRA KIT 40MG/0.8 ...... 78 hydrocortisone rectal cream 1% ...... 74 HUMIRA PEDIA INJ CROHNS ...... 78 hydrocortisone rectal cream 2.5% ...... 74 HUMIRA PEN INJ 40/0.4ML ...... 78 hydrocortisone soln 1% ...... 99 HUMIRA PEN INJ 40MG/0.8 ...... 78 hydrocortisone tab 10 mg ...... 65 HUMIRA PEN INJ CD/UC/HS ...... 78 hydrocortisone tab 20 mg ...... 65 HUMIRA PEN INJ PS/UV ...... 78 hydrocortisone tab 5 mg ...... 65 HUMIRA PEN KIT CD/UC/HS ...... 78 hydrocortisone valerate cream 0.2% .. 99 HUMIRA PEN KIT PS/UV ...... 78 hydrocortisone valerate oint 0.2% ..... 99 HUMULIN INJ 70/30 ...... 60 hydrocortisone-aloe vera cream 1% ... 98 HUMULIN INJ 70/30KWP ...... 60 hydromorphone hcl tab 2 mg ...... 5 HUMULIN N INJ U-100 ...... 60 hydromorphone hcl tab 4 mg ...... 5 HUMULIN N INJ U-100KWP ...... 60 hydromorphone hcl tab 8 mg ...... 5 HUMULIN R INJ U-100 ...... 60 hydroxychloroquine sulfate tab 200 mg HUMULIN R INJ U-500 ...... 60 ...... 78 hydralazine hcl tab 10 mg ...... 26 hydroxyurea cap 500 mg ...... 17 hydralazine hcl tab 100 mg ...... 26 hydroxyzine hcl syrup 10 mg/5ml ...... 90 hydralazine hcl tab 25 mg ...... 26 hydroxyzine hcl tab 10 mg ...... 90 124 hydroxyzine hcl tab 25 mg ...... 90 imipramine pamoate cap 75 mg ...... 40 hydroxyzine hcl tab 50 mg ...... 90 imiquimod cream 5% ...... 101 hydroxyzine pamoate cap 100 mg ...... 90 IMURAN TAB 50MG ...... 78 hydroxyzine pamoate cap 25 mg ...... 90 INCRUSE ELPT INH 62.5MCG ...... 89 hydroxyzine pamoate cap 50 mg ...... 90 indapamide tab 1.25 mg ...... 25 hyoscyamine sulfate elixir 0.125 mg/5ml indapamide tab 2.5 mg ...... 25 ...... 71 INFANRIX INJ ...... 80 hyoscyamine sulfate sl tab 0.125 mg .. 71 INLYTA TAB 1MG ...... 16 hyoscyamine sulfate soln 0.125 mg/ml 71 INLYTA TAB 5MG ...... 16 hyoscyamine sulfate tab 0.125 mg ...... 71 INTELENCE TAB 100MG ...... 10 hyoscyamine sulfate tab disint 0.125 mg INTELENCE TAB 200MG ...... 10 ...... 71 INTELENCE TAB 25MG ...... 10 hyoscyamine sulfate tab er 12hr 0.375 INVEGA SUST INJ 117/0.75 ...... 43 mg ...... 71 INVEGA SUST INJ 156MG/ML ...... 43 HYPOTEARS SOL 1-1%...... 103 INVEGA SUST INJ 234/1.5 ...... 43 hypromellose ophth soln 0.3% ...... 103 INVEGA SUST INJ 39/0.25 ...... 43 hypromellose ophth soln 0.4% ...... 103 INVEGA SUST INJ 78/0.5ML ...... 43 I INVEGA TAB 1.5MG ...... 43 IBRANCE CAP 100MG ...... 16 INVEGA TAB 3MG ...... 43 IBRANCE CAP 125MG ...... 16 INVEGA TAB 6MG ...... 43 IBRANCE CAP 75MG...... 16 INVEGA TAB 9MG ...... 43 ibuprofen cap 200 mg ...... 4 INVEGA TRINZ INJ 273MG ...... 43 ibuprofen chew tab 100 mg ...... 4 INVEGA TRINZ INJ 410MG ...... 43 ibuprofen susp 100 mg/5ml ...... 4 INVEGA TRINZ INJ 546MG ...... 43 ibuprofen susp 40 mg/ml ...... 4 INVEGA TRINZ INJ 819MG ...... 43 ibuprofen tab 100 mg ...... 4 INVIRASE TAB 500MG ...... 12 ibuprofen tab 200 mg ...... 4 INVOKAMET TAB 150-1000 ...... 61 ibuprofen tab 400 mg ...... 4 INVOKAMET TAB 150-500 ...... 61 ibuprofen tab 600 mg ...... 4 INVOKAMET TAB 50-1000 ...... 61 ibuprofen tab 800 mg ...... 4 INVOKAMET TAB 50-500MG ...... 61 IDHIFA TAB 100MG ...... 17 INVOKAMET XR TAB 150-1000 ...... 61 IDHIFA TAB 50MG ...... 17 INVOKAMET XR TAB 150-500 ...... 61 imatinib mesylate tab 100 mg (base INVOKAMET XR TAB 50-1000 ...... 61 equivalent) ...... 17 INVOKAMET XR TAB 50-500MG ...... 61 imatinib mesylate tab 400 mg (base INVOKANA TAB 100MG ...... 61 equivalent) ...... 17 INVOKANA TAB 300MG ...... 61 IMBRUVICA CAP 140MG ...... 16 ipratropium bromide inhal soln 0.02% 89 IMBRUVICA CAP 70MG ...... 16 ipratropium bromide nasal soln 0.03% IMBRUVICA TAB 140MG ...... 16 (21 mcg/spray) ...... 93 IMBRUVICA TAB 280MG ...... 16 ipratropium bromide nasal soln 0.06% IMBRUVICA TAB 420MG ...... 16 (42 mcg/spray) ...... 94 IMBRUVICA TAB 560MG ...... 16 ipratropium-albuterol nebu soln 0.5- imipramine hcl tab 10 mg ...... 40 2.5(3) mg/3ml ...... 89 imipramine hcl tab 25 mg ...... 40 irbesartan tab 150 mg ...... 20 imipramine hcl tab 50 mg ...... 40 irbesartan tab 300 mg ...... 20 imipramine pamoate cap 100 mg ...... 40 irbesartan tab 75 mg ...... 20 imipramine pamoate cap 125 mg ...... 40 irbesartan-hydrochlorothiazide tab 150- imipramine pamoate cap 150 mg ...... 40 12.5 mg ...... 20 125 irbesartan-hydrochlorothiazide tab 300- JANUMET XR TAB 50-1000 ...... 59 12.5 mg ...... 20 JANUMET XR TAB 50-500MG ...... 59 iron combination cap ...... 84 JANUVIA TAB 100MG ...... 59 iron polysacch complex-vit b12-fa cap JANUVIA TAB 25MG ...... 59 150-0.025-1 mg ...... 84 JANUVIA TAB 50MG ...... 59 iron w/ vitamin liq ...... 85 K iron w/ vitamin tab ...... 86 KALETRA SOL ...... 12 iron-docusate-b12-folic acid-c-e-cu-biotin KALETRA TAB 100-25MG ...... 12 tab 150-1 mg ...... 84 KALETRA TAB 200-50MG ...... 12 iron-folic acid-vit c-vit b6-vit b12-zinc KALYDECO PAK 50MG ...... 92 tab 150-1.25 mg ...... 84 KALYDECO PAK 75MG ...... 92 iron-vit c-vit b12-folic acid tab 100-250- KALYDECO TAB 150MG ...... 92 0.025-1 mg ...... 84 KEPPRA SOL 100MG/ML ...... 31 iron-vitamin c tab 100-250 mg ...... 84 KEPPRA TAB 1000MG ...... 31 ISENTRESS CHW 100MG ...... 10 KEPPRA TAB 250MG ...... 31 ISENTRESS CHW 25MG ...... 10 KEPPRA TAB 500MG ...... 31 ISENTRESS HD TAB 600MG ...... 10 KEPPRA TAB 750MG ...... 31 ISENTRESS POW 100MG ...... 10 KEPPRA XR TAB 500MG ...... 31 ISENTRESS TAB 400MG ...... 10 KEPPRA XR TAB 750MG ...... 31 isoniazid syrup 50 mg/5ml ...... 12 ketoconazole cream 2% ...... 97 isoniazid tab 100 mg...... 12 ketoconazole shampoo 2% ...... 97 isoniazid tab 300 mg...... 12 KETO-DIASTIX TES ...... 62 ISORDIL TAB 40MG ...... 26 ketorolac tromethamine ophth soln 0.4% isosorbide dinitrate tab 10 mg ...... 26 ...... 102 isosorbide dinitrate tab 20 mg ...... 26 ketorolac tromethamine ophth soln 0.5% isosorbide dinitrate tab 30 mg ...... 26 ...... 102 isosorbide dinitrate tab 5 mg ...... 26 ketorolac tromethamine tab 10 mg ...... 4 isosorbide dinitrate tab er 40 mg ...... 26 ketotifen fumarate ophth soln 0.025% isosorbide mononitrate tab 10 mg ...... 26 (base equiv) ...... 102 isosorbide mononitrate tab 20 mg ...... 26 KHEDEZLA TAB 100MG ER ...... 39 isosorbide mononitrate tab er 24hr 120 KHEDEZLA TAB 50MG ER ...... 39 mg ...... 26 KLONOPIN TAB 0.5MG ...... 28 isosorbide mononitrate tab er 24hr 30 KLONOPIN TAB 1MG ...... 28 mg ...... 26 KLONOPIN TAB 2MG ...... 28 isosorbide mononitrate tab er 24hr 60 K-PHOS TAB ...... 75 mg ...... 26 K-PHOS TAB NO 2 ...... 75 itraconazole cap 100 mg ...... 9 KUVAN POW 100MG ...... 67 IV PREP WIPE PAD ...... 97 KUVAN TAB 100MG ...... 67 ivermectin tab 3 mg ...... 14 L J labetalol hcl tab 100 mg ...... 22 JAKAFI TAB 10MG ...... 16 labetalol hcl tab 200 mg ...... 22 JAKAFI TAB 15MG ...... 16 labetalol hcl tab 300 mg ...... 23 JAKAFI TAB 20MG ...... 16 LABSTIX TES ...... 81 JAKAFI TAB 25MG ...... 16 lactic acid (ammonium lactate) cream JAKAFI TAB 5MG ...... 16 12% ...... 100 JANUMET TAB 50-1000 ...... 59 lactic acid (ammonium lactate) lotion JANUMET TAB 50-500MG ...... 58 12% ...... 100 JANUMET XR TAB 100-1000 ...... 59 lactulose (encephalopathy) solution 10 126 gm/15ml ...... 73 mg ...... 32 lactulose solution 10 gm/15ml ...... 73 lamotrigine tab er 24hr 100 mg ...... 32 LAMICTAL CHW 25MG ...... 31 lamotrigine tab er 24hr 200 mg ...... 32 LAMICTAL CHW 5MG ...... 31 lamotrigine tab er 24hr 25 mg ...... 32 LAMICTAL KIT START 35 ...... 31 lamotrigine tab er 24hr 250 mg ...... 32 LAMICTAL KIT START 49 ...... 31 lamotrigine tab er 24hr 300 mg ...... 32 LAMICTAL KIT START 98 ...... 31 lamotrigine tab er 24hr 50 mg ...... 32 LAMICTAL ODT KIT ...... 31 LANCETS MIS ...... 62 LAMICTAL ODT TAB 100MG ...... 31 LANOXIN TAB 0.0625MG ...... 24 LAMICTAL ODT TAB 200MG ...... 31 LANOXIN TAB 0.1875MG ...... 24 LAMICTAL ODT TAB 25MG ...... 31 lansoprazole cap delayed release 15 mg LAMICTAL ODT TAB 50MG ...... 31 ...... 74 LAMICTAL TAB 100MG ...... 31 latanoprost ophth soln 0.005% ...... 104 LAMICTAL TAB 150MG ...... 31 LATUDA TAB 120MG ...... 43 LAMICTAL TAB 200MG ...... 31 LATUDA TAB 20MG ...... 43 LAMICTAL TAB 25MG ...... 31 LATUDA TAB 40MG ...... 43 LAMICTAL XR KIT ...... 31 LATUDA TAB 60MG ...... 43 LAMICTAL XR TAB 100MG ...... 32 LATUDA TAB 80MG ...... 43 LAMICTAL XR TAB 200MG ...... 32 leflunomide tab 10 mg ...... 78 LAMICTAL XR TAB 250MG ...... 32 leflunomide tab 20 mg ...... 78 LAMICTAL XR TAB 25MG ...... 32 LENVIMA CAP 10 MG ...... 16 LAMICTAL XR TAB 300MG ...... 32 LENVIMA CAP 12MG ...... 16 LAMICTAL XR TAB 50MG ...... 32 LENVIMA CAP 14 MG ...... 16 lamivudine oral soln 10 mg/ml ...... 11 LENVIMA CAP 18 MG ...... 16 lamivudine tab 100 mg (hbv) ...... 13 LENVIMA CAP 20 MG ...... 16 lamivudine tab 150 mg ...... 11 LENVIMA CAP 24 MG ...... 16 lamivudine tab 300 mg ...... 11 LENVIMA CAP 4MG ...... 16 lamivudine-zidovudine tab 150-300 mg 9 LENVIMA CAP 8 MG...... 16 lamotrigine orally disintegrating tab 100 letrozole tab 2.5 mg ...... 15 mg ...... 32 leucovorin calcium tab 10 mg ...... 17 lamotrigine orally disintegrating tab 200 leucovorin calcium tab 15 mg ...... 17 mg ...... 32 leucovorin calcium tab 25 mg ...... 17 lamotrigine orally disintegrating tab 25 leucovorin calcium tab 5 mg ...... 17 mg ...... 32 LEUKERAN TAB 2MG ...... 14 lamotrigine orally disintegrating tab 50 levetiracetam oral soln 100 mg/ml ..... 32 mg ...... 32 levetiracetam tab 1000 mg ...... 32 lamotrigine tab 100 mg ...... 32 levetiracetam tab 250 mg ...... 32 lamotrigine tab 150 mg ...... 32 levetiracetam tab 500 mg ...... 32 lamotrigine tab 200 mg ...... 32 levetiracetam tab 750 mg ...... 32 lamotrigine tab 25 mg ...... 32 levetiracetam tab er 24hr 500 mg ...... 32 lamotrigine tab 25 mg (35) starter kit . 32 levetiracetam tab er 24hr 750 mg ...... 32 lamotrigine tab 25 mg (42) & 100 mg (7) levobunolol hcl ophth soln 0.5% ...... 103 starter kit ...... 32 levocarnitine oral soln 1 gm/10ml (10%) lamotrigine tab 25 mg (84) & 100 mg ...... 62 (14) starter kit ...... 32 levocarnitine tab 330 mg ...... 62 lamotrigine tab chewable dispersible 25 levofloxacin ophth soln 0.5% ...... 102 mg ...... 32 levofloxacin oral soln 25 mg/ml ...... 7 lamotrigine tab chewable dispersible 5 levofloxacin tab 250 mg ...... 7 127 levofloxacin tab 500 mg ...... 7 lisinopril tab 2.5 mg ...... 18 levofloxacin tab 750 mg ...... 7 lisinopril tab 20 mg ...... 18 levonorgestrel & ethinyl estradiol tab 0.1 lisinopril tab 30 mg ...... 18 mg-20 mcg ...... 63 lisinopril tab 40 mg ...... 19 levonorgestrel & ethinyl estradiol tab lisinopril tab 5 mg ...... 18 0.15 mg-30 mcg ...... 63 lithium carbonate cap 150 mg ...... 55 levonorgestrel tab 1.5 mg ...... 63 lithium carbonate cap 300 mg ...... 55 levonorgestrel-eth estra tab 0.05- lithium carbonate cap 600 mg ...... 55 30/0.075-40/0.125-30mg-mcg ...... 64 lithium carbonate tab 300 mg ...... 55 levothyroxine sodium tab 100 mcg ..... 68 lithium carbonate tab er 300 mg ...... 55 levothyroxine sodium tab 112 mcg ..... 68 lithium carbonate tab er 450 mg ...... 55 levothyroxine sodium tab 125 mcg ..... 68 LITHIUM SOL 8MEQ/5ML ...... 55 levothyroxine sodium tab 137 mcg ..... 68 LITHOBID TAB 300MG CR ...... 55 levothyroxine sodium tab 150 mcg ..... 68 loperamide hcl cap 2 mg ...... 70 levothyroxine sodium tab 175 mcg ..... 69 loperamide hcl liq 1 mg/5ml (0.2 mg/ml) levothyroxine sodium tab 200 mcg ..... 69 ...... 70 levothyroxine sodium tab 25 mcg ...... 68 loperamide hcl tab 2 mg ...... 70 levothyroxine sodium tab 300 mcg ..... 69 lopinavir-ritonavir soln 400-100 mg/5ml levothyroxine sodium tab 50 mcg ...... 68 (80-20 mg/ml) ...... 12 levothyroxine sodium tab 75 mcg ...... 68 loratadine & pseudoephedrine tab er levothyroxine sodium tab 88 mcg ...... 68 12hr 5-120 mg ...... 89 LEXAPRO TAB 10MG ...... 37 loratadine & pseudoephedrine tab er LEXAPRO TAB 20MG ...... 37 24hr 10-240 mg ...... 89 LEXAPRO TAB 5MG ...... 37 loratadine cap 10 mg ...... 90 LEXIVA SUS 50MG/ML ...... 12 loratadine chew tab 5 mg ...... 90 LEXIVA TAB 700MG ...... 12 loratadine rapidly-disintegrating tab 10 lidocaine hcl soln 4% ...... 100 mg ...... 90 lidocaine hcl viscous soln 2% ...... 101 loratadine syrup 5 mg/5ml ...... 90 lidocaine patch 4% ...... 100 loratadine tab 10 mg ...... 90 lidocaine patch 5% ...... 100 lorazepam conc 2 mg/ml ...... 28 lidocaine-prilocaine cream 2.5-2.5% . 101 lorazepam inj 2 mg/ml ...... 28 lidocaine-prilocaine cream kit 2.5-2.5% lorazepam inj 4 mg/ml ...... 28 ...... 101 lorazepam tab 0.5 mg ...... 28 linezolid for susp 100 mg/5ml ...... 14 lorazepam tab 1 mg ...... 28 linezolid tab 600 mg ...... 14 lorazepam tab 2 mg ...... 28 LINZESS CAP 145MCG ...... 72 LORBRENA TAB 100MG ...... 16 LINZESS CAP 290MCG ...... 72 LORBRENA TAB 25MG ...... 16 LINZESS CAP 72MCG ...... 72 losartan potassium & hydrochlorothiazide liothyronine sodium tab 25 mcg ...... 69 tab 100-12.5 mg ...... 20 liothyronine sodium tab 5 mcg ...... 69 losartan potassium & hydrochlorothiazide liothyronine sodium tab 50 mcg ...... 69 tab 100-25 mg ...... 20 lisinopril & hydrochlorothiazide tab 10- losartan potassium & hydrochlorothiazide 12.5 mg ...... 18 tab 50-12.5 mg ...... 20 lisinopril & hydrochlorothiazide tab 20- losartan potassium tab 100 mg ...... 20 12.5 mg ...... 18 losartan potassium tab 25 mg ...... 20 lisinopril & hydrochlorothiazide tab 20-25 losartan potassium tab 50 mg ...... 20 mg ...... 18 LOTEMAX GEL 0.5% ...... 102 lisinopril tab 10 mg ...... 18 lovastatin tab 10 mg ...... 22 128 lovastatin tab 20 mg ...... 22 memantine hcl tab 5 mg (28) & 10 mg lovastatin tab 40 mg ...... 22 (21) titration pak ...... 35 loxapine succinate cap 10 mg ...... 46 MENACTRA INJ ...... 80 loxapine succinate cap 25 mg ...... 46 MENVEO INJ ...... 80 loxapine succinate cap 5 mg ...... 46 meprobamate tab 200 mg ...... 29 loxapine succinate cap 50 mg ...... 46 meprobamate tab 400 mg ...... 29 LYNPARZA TAB 100MG ...... 17 mercaptopurine tab 50 mg ...... 14 LYNPARZA TAB 150MG ...... 17 mesalamine enema 4 gm ...... 72 LYSODREN TAB 500MG ...... 17 mesalamine rectal enema 4 gm & M cleanser wipe kit ...... 72 MAALOX CHW 600MG ...... 70 metadate tab 20mg er ...... 49 malathion lotion 0.5% ...... 101 metformin hcl tab 1000 mg ...... 58 maprotiline hcl tab 25 mg ...... 36 metformin hcl tab 500 mg ...... 58 maprotiline hcl tab 50 mg ...... 36 metformin hcl tab 850 mg ...... 58 maprotiline hcl tab 75 mg ...... 36 metformin hcl tab er 24hr 500 mg ..... 58 MARPLAN TAB 10MG ...... 36 metformin hcl tab er 24hr 750 mg ..... 58 MASK VORTEX/ MIS BABY DUC ...... 93 methadone hcl tab 10 mg ...... 5 MASK VORTEX/ MIS DUCK ...... 93 methadone hcl tab 5 mg ...... 5 MASK VORTEX/ MIS FROG ...... 93 methazolamide tab 25 mg ...... 25 MASK VORTEX/ MIS LADY BUG ...... 93 methazolamide tab 50 mg ...... 25 MATULANE CAP 50MG ...... 17 methimazole tab 10 mg ...... 68 MAVYRET TAB 100-40MG ...... 13 methimazole tab 5 mg ...... 68 meclizine hcl chew tab 25 mg ...... 70 methocarbamol tab 500 mg ...... 56 meclizine hcl tab 12.5 mg ...... 70 methocarbamol tab 750 mg ...... 56 meclizine hcl tab 25 mg ...... 71 methotrexate sodium tab 2.5 mg (base MEDROL TAB 2MG ...... 65 equiv) ...... 14 medroxyprogesterone acetate im susp methyldopa tab 250 mg ...... 19 150 mg/ml ...... 63 methyldopa tab 500 mg ...... 19 medroxyprogesterone acetate im susp methylphenidate hcl cap er 10 mg (cd) 49 prefilled syr 150 mg/ml ...... 63 methylphenidate hcl cap er 20 mg (cd) 49 medroxyprogesterone acetate tab 10 mg methylphenidate hcl cap er 24hr 20 mg ...... 68 (la) ...... 50 medroxyprogesterone acetate tab 2.5 methylphenidate hcl cap er 24hr 30 mg mg ...... 68 (la) ...... 50 medroxyprogesterone acetate tab 5 mg methylphenidate hcl cap er 24hr 40 mg ...... 68 (la) ...... 50 mefloquine hcl tab 250 mg ...... 9 methylphenidate hcl cap er 30 mg (cd) 50 megestrol acetate susp 40 mg/ml ...... 68 methylphenidate hcl cap er 40 mg (cd) 50 megestrol acetate tab 20 mg ...... 15 methylphenidate hcl cap er 50 mg (cd) 50 megestrol acetate tab 40 mg ...... 15 methylphenidate hcl cap er 60 mg (cd) 50 MEKINIST TAB 0.5MG ...... 16 methylphenidate hcl soln 10 mg/5ml .. 50 MEKINIST TAB 2MG ...... 16 methylphenidate hcl soln 5 mg/5ml .... 50 meloxicam tab 15 mg ...... 4 methylphenidate hcl tab 10 mg ...... 50 meloxicam tab 7.5 mg ...... 4 methylphenidate hcl tab 20 mg ...... 50 melphalan tab 2 mg ...... 14 methylphenidate hcl tab 5 mg ...... 50 memantine hcl oral solution 2 mg/ml .. 35 methylphenidate hcl tab er 10 mg ...... 51 memantine hcl tab 10 mg ...... 35 methylphenidate hcl tab er 20 mg ...... 51 memantine hcl tab 5 mg ...... 35 methylphenidate hcl tab er 24hr 18 mg 129 ...... 51 metronidazole cream 0.75% ...... 101 methylphenidate hcl tab er 24hr 27 mg metronidazole gel 0.75% ...... 101 ...... 51 metronidazole gel 1% ...... 101 methylphenidate hcl tab er 24hr 36 mg metronidazole lotion 0.75% ...... 101 ...... 52 metronidazole tab 250 mg ...... 14 methylphenidate hcl tab er 24hr 54 mg metronidazole tab 500 mg ...... 14 ...... 52 metronidazole vaginal gel 0.75% ...... 75 methylphenidate hcl tab er osmotic miconazole nitrate cream 2% ...... 97 release (osm) 18 mg ...... 52 miconazole nitrate ointment 2% ...... 97 methylphenidate hcl tab er osmotic miconazole nitrate powder 2% ...... 97 release (osm) 27 mg ...... 52 miconazole nitrate vaginal app 200 mg & methylphenidate hcl tab er osmotic 2% cream 9 gm kit ...... 75 release (osm) 36 mg ...... 53 miconazole nitrate vaginal cream 2% . 75 methylphenidate hcl tab er osmotic miconazole nitrate vaginal cream 4% release (osm) 54 mg ...... 53 (200 mg/5gm) ...... 75 methylprednisolone tab 16 mg ...... 65 miconazole nitrate vaginal supp 1200 mg methylprednisolone tab 32 mg ...... 65 & 2% cream kit ...... 76 methylprednisolone tab 4 mg ...... 65 miconazole nitrate vaginal supp 200 mg methylprednisolone tab 8 mg ...... 65 & 2% cream 9 gm kit ...... 76 methylprednisolone tab therapy pack 4 miconazole nitrate vaginal suppos 100 mg (21) ...... 65 mg ...... 76 metoclopramide hcl soln 5 mg/5ml (10 miconazole nitrate vaginal suppos 200 mg/10ml) (base equiv) ...... 71 mg ...... 76 metoclopramide hcl tab 10 mg (base MICROCLENS PAD WIPES ...... 97 equivalent) ...... 71 midodrine hcl tab 10 mg ...... 27 metoclopramide hcl tab 5 mg (base midodrine hcl tab 2.5 mg ...... 27 equivalent) ...... 71 midodrine hcl tab 5 mg ...... 27 metolazone tab 10 mg ...... 25 minocycline hcl cap 100 mg ...... 8 metolazone tab 2.5 mg ...... 25 minocycline hcl cap 50 mg ...... 8 metolazone tab 5 mg ...... 25 minocycline hcl cap 75 mg ...... 8 metoprolol & hydrochlorothiazide tab mirtazapine orally disintegrating tab 15 100-25 mg ...... 22 mg ...... 36 metoprolol & hydrochlorothiazide tab mirtazapine orally disintegrating tab 30 100-50 mg ...... 22 mg ...... 36 metoprolol & hydrochlorothiazide tab 50- mirtazapine orally disintegrating tab 45 25 mg ...... 22 mg ...... 36 metoprolol succinate tab er 24hr 100 mg mirtazapine tab 15 mg ...... 36 (tartrate equiv) ...... 23 mirtazapine tab 30 mg ...... 36 metoprolol succinate tab er 24hr 200 mg mirtazapine tab 45 mg ...... 36 (tartrate equiv) ...... 23 mirtazapine tab 7.5 mg ...... 36 metoprolol succinate tab er 24hr 25 mg misoprostol tab 100 mcg ...... 74 (tartrate equiv) ...... 23 misoprostol tab 200 mcg ...... 74 metoprolol succinate tab er 24hr 50 mg M-M-R II INJ ...... 80 (tartrate equiv) ...... 23 modafinil tab 100 mg ...... 56 metoprolol tartrate tab 100 mg ...... 23 modafinil tab 200 mg ...... 56 metoprolol tartrate tab 25 mg ...... 23 mometasone furoate cream 0.1% ...... 99 metoprolol tartrate tab 50 mg ...... 23 mometasone furoate oint 0.1% ...... 99 metronidazole cap 375 mg ...... 14 mometasone furoate solution 0.1% 130 (lotion) ...... 99 mupirocin calcium cream 2% ...... 97 MONISTAT 3 KIT COMBO PK ...... 76 mupirocin oint 2% ...... 97 MONISTAT 7 KIT COMPLETE ...... 76 mycophenolate mofetil cap 250 mg .... 78 montelukast sodium chew tab 4 mg mycophenolate mofetil for oral susp 200 (base equiv) ...... 93 mg/ml ...... 78 montelukast sodium chew tab 5 mg mycophenolate mofetil tab 500 mg .... 78 (base equiv) ...... 93 mycophenolate sodium tab dr 180 mg montelukast sodium oral granules packet (mycophenolic acid equiv) ...... 78 4 mg (base equiv) ...... 93 mycophenolate sodium tab dr 360 mg montelukast sodium tab 10 mg (base (mycophenolic acid equiv) ...... 78 equiv) ...... 93 MYFORTIC TAB 180MG ...... 78 morphine sulfate oral soln 10 mg/5ml .. 5 MYFORTIC TAB 360MG ...... 78 morphine sulfate oral soln 100 mg/5ml MYLERAN TAB 2MG ...... 14 (20 mg/ml) ...... 5 myorisan cap 10mg ...... 95 morphine sulfate oral soln 20 mg/5ml .. 5 myorisan cap 20mg ...... 95 morphine sulfate tab 15 mg ...... 5 myorisan cap 30mg ...... 95 morphine sulfate tab 30 mg ...... 5 myorisan cap 40mg ...... 95 morphine sulfate tab er 100 mg ...... 5 MYSOLINE TAB 250MG ...... 32 morphine sulfate tab er 15 mg ...... 5 MYSOLINE TAB 50MG ...... 32 morphine sulfate tab er 200 mg ...... 5 N morphine sulfate tab er 30 mg ...... 5 nabumetone tab 500 mg ...... 4 morphine sulfate tab er 60 mg ...... 5 nabumetone tab 750 mg ...... 4 MOVANTIK TAB 12.5MG ...... 73 nadolol tab 20 mg ...... 23 MOVANTIK TAB 25MG ...... 73 nadolol tab 40 mg ...... 23 MUCINEX CGH GRA 5-100MG ...... 91 nadolol tab 80 mg ...... 23 MUCINEX/KIDS GRA 100MG ...... 93 naltrexone hcl tab 50 mg ...... 56 MULPLETA TAB 3MG ...... 77 naproxen sodium cap 220 mg ...... 4 MULTAQ TAB 400MG ...... 21 naproxen sodium tab 220 mg ...... 4 multiple vitamin cap ...... 86 naproxen sodium tab 275 mg ...... 4 multiple vitamin tab ...... 86 naproxen sodium tab 550 mg ...... 4 multiple vitamins w/ calcium tab ...... 86 naproxen susp 125 mg/5ml ...... 4 multiple vitamins w/ iron tab ...... 86 naproxen tab 250 mg ...... 4 multiple vitamins w/ minerals & fa tab naproxen tab 375 mg ...... 5 1.25 mg ...... 86 naproxen tab 500 mg ...... 5 multiple vitamins w/ minerals cap ...... 86 naproxen tab ec 375 mg ...... 5 multiple vitamins w/ minerals chew tab naproxen tab ec 500 mg ...... 5 ...... 86 naratriptan hcl tab 1 mg (base equiv) . 54 multiple vitamins w/ minerals effer tab 86 naratriptan hcl tab 2.5 mg (base equiv) multiple vitamins w/ minerals liquid .... 86 ...... 54 multiple vitamins w/ minerals tab ...... 86 NARCAN SPR ...... 57 multiple vitamins w/ minerals tab er ... 86 NARDIL TAB 15MG ...... 36 MULTISTIX 10 TES SG ...... 81 NASCOBAL SPR 500MCG ...... 86 MULTISTIX 5 TES ...... 81 NATACYN SUS 5% OP ...... 102 MULTISTIX 7 TES ...... 81 nateglinide tab 120 mg ...... 60 MULTISTIX 8 TES SG ...... 81 nateglinide tab 60 mg ...... 60 MULTISTIX 9 TES ...... 81 NATRAPEL 12H SPR 20% ...... 100 MULTISTIX 9 TES SG ...... 81 NEBULIZER MIS ...... 93 MULTISTIX TES ...... 81 nefazodone hcl tab 100 mg ...... 36 131 nefazodone hcl tab 150 mg ...... 36 niacin tab er 750 mg ...... 86 nefazodone hcl tab 200 mg ...... 36 niacin tab er 750 mg (antihyperlipidemic) nefazodone hcl tab 250 mg ...... 36 ...... 22 nefazodone hcl tab 50 mg ...... 36 niacin w/ inositol cap 400-100 mg ...... 86 neomycin sulfate tab 500 mg ...... 6 niacinamide tab 100 mg ...... 86 neomycin-bacitrac zn-polymyx niacinamide tab 500 mg ...... 86 5(3.5)mg-400unt-10000unt op oin ... 102 nicotine polacrilex gum 2 mg ...... 58 neomycin-bacitracin-polymyxin oint .... 97 nicotine polacrilex gum 4 mg ...... 58 neomycin-polymy-gramicid op sol 1.75- nicotine td patch 24hr 14 mg/24hr ..... 58 10000-0.025mg-unt-mg/ml ...... 102 nicotine td patch 24hr 21 mg/24hr ..... 58 neomycin-polymyxin-dexamethasone nicotine td patch 24hr 7 mg/24hr ...... 58 ophth oint 0.1% ...... 101 nifedipine tab er 24hr 30 mg ...... 23 neomycin-polymyxin-dexamethasone nifedipine tab er 24hr 60 mg ...... 23 ophth susp 0.1% ...... 101 nifedipine tab er 24hr 90 mg ...... 23 neomycin-polymyxin-hc ophth susp .. 102 nifedipine tab er 24hr osmotic release 30 neomycin-polymyxin-hc otic soln 1% 104 mg ...... 23 neomycin-polymyxin-hc otic susp 3.5 nifedipine tab er 24hr osmotic release 60 mg/ml-10000 unit/ml-1% ...... 104 mg ...... 23 NEORAL CAP 100MG ...... 79 nifedipine tab er 24hr osmotic release 90 NEORAL CAP 25MG ...... 79 mg ...... 23 NEORAL SOL 100MG/ML ...... 79 NITRO-BID OIN 2% ...... 26 NEURONTIN CAP 100MG ...... 32 NITRO-DUR DIS 0.3MG/HR ...... 26 NEURONTIN CAP 300MG ...... 32 NITRO-DUR DIS 0.8MG/HR ...... 26 NEURONTIN CAP 400MG ...... 32 nitrofurantoin macrocrystalline cap 100 NEURONTIN SOL 250/5ML ...... 32 mg ...... 14 NEURONTIN TAB 600MG ...... 32 nitrofurantoin macrocrystalline cap 25 NEURONTIN TAB 800MG ...... 32 mg ...... 14 nevirapine susp 50 mg/5ml ...... 10 nitrofurantoin macrocrystalline cap 50 nevirapine tab 200 mg ...... 10 mg ...... 14 nevirapine tab er 24hr 100 mg ...... 10 nitrofurantoin monohydrate nevirapine tab er 24hr 400 mg ...... 10 macrocrystalline cap 100 mg ...... 14 NEXAVAR TAB 200MG ...... 16 nitrofurantoin susp 25 mg/5ml ...... 14 NEXIUM 24HR TAB 20MG ...... 74 nitroglycerin cap er 2.5 mg ...... 26 NEXIUM GRA 10MG DR ...... 74 nitroglycerin cap er 6.5 mg ...... 26 NEXIUM GRA 2.5MG DR ...... 74 nitroglycerin cap er 9 mg ...... 26 NEXIUM GRA 5MG DR ...... 74 nitroglycerin sl tab 0.3 mg ...... 26 niacin cap er 250 mg ...... 86 nitroglycerin sl tab 0.4 mg ...... 26 niacin cap er 500 mg ...... 86 nitroglycerin sl tab 0.6 mg ...... 26 niacin tab 100 mg ...... 86 nitroglycerin td patch 24hr 0.1 mg/hr . 26 niacin tab 250 mg ...... 86 nitroglycerin td patch 24hr 0.2 mg/hr . 26 niacin tab 50 mg ...... 86 nitroglycerin td patch 24hr 0.4 mg/hr . 26 niacin tab 500 mg ...... 86 nitroglycerin td patch 24hr 0.6 mg/hr . 26 niacin tab er 1000 mg NITYR TAB 10MG ...... 66 (antihyperlipidemic) ...... 22 NITYR TAB 2MG...... 66 niacin tab er 250 mg ...... 86 NITYR TAB 5MG...... 66 niacin tab er 500 mg ...... 86 NIX CREM RIN LIQ 1% ...... 101 niacin tab er 500 mg (antihyperlipidemic) nizatidine cap 150 mg ...... 72 ...... 22 nizatidine cap 300 mg ...... 72 132 nizatidine oral soln 15 mg/ml ...... 72 nortriptyline hcl cap 10 mg ...... 40 nonoxynol-9 gel 4% ...... 63 nortriptyline hcl cap 25 mg ...... 40 NORDITROPIN INJ 10/1.5ML ...... 67 nortriptyline hcl cap 50 mg ...... 40 NORDITROPIN INJ 15/1.5ML ...... 67 nortriptyline hcl cap 75 mg ...... 40 NORDITROPIN INJ 30/3ML ...... 67 nortriptyline hcl soln 10 mg/5ml ...... 40 NORDITROPIN INJ 5/1.5ML ...... 67 NORVIR POW 100MG ...... 12 norelgestromin-ethinyl estradiol td ptwk NORVIR SOL 80MG/ML ...... 12 150-35 mcg/24hr ...... 64 NORVIR TAB 100MG ...... 12 norethindrone & ethinyl estradiol tab 0.4 NOVOLIN INJ 70/30 ...... 60 mg-35 mcg ...... 64 NOVOLIN INJ FLEXPEN ...... 60 norethindrone & ethinyl estradiol tab 0.5 NOVOLIN N INJ RELION ...... 60 mg-35 mcg ...... 64 NOVOLIN N INJ U-100 ...... 60 norethindrone & ethinyl estradiol tab 1 NOVOLIN R INJ RELION ...... 60 mg-35 mcg ...... 64 NOVOLIN R INJ U-100 ...... 60 norethindrone ace & ethinyl estradiol tab NOVOLIN70/30 INJ RELION ...... 60 1 mg-20 mcg ...... 63 NOVOLOG INJ 100/ML ...... 60 norethindrone ace & ethinyl estradiol tab NOVOLOG INJ FLEXPEN ...... 60 1.5 mg-30 mcg ...... 63 NOVOLOG INJ PENFILL ...... 60 norethindrone ace & ethinyl estradiol-fe NOVOLOG MIX INJ 70/30 ...... 60 tab 1 mg-20 mcg ...... 63 NOVOLOG MIX INJ FLEXPEN ...... 60 norethindrone ace & ethinyl estradiol-fe NUEDEXTA CAP 20-10MG ...... 57 tab 1.5 mg-30 mcg ...... 63 NUPLAZID CAP 34MG ...... 46 norethindrone acetate tab 5 mg ...... 68 NUPLAZID TAB 10MG ...... 46 norethindrone acetate-ethinyl estradiol NUTROPIN AQ INJ 10MG/2ML ...... 67 tab 0.5 mg-2.5 mcg ...... 64 NUTROPIN AQ INJ 20MG/2ML ...... 67 norethindrone acetate-ethinyl estradiol NUTROPIN AQ INJ NUSPIN 5 ...... 67 tab 1 mg-5 mcg ...... 65 NUVARING MIS ...... 64 norethindrone tab 0.35 mg ...... 64 nystatin cream 100000 unit/gm ...... 97 norethindrone-eth estradiol tab 0.5- nystatin oint 100000 unit/gm ...... 97 35/0.75-35/1-35 mg-mcg ...... 64 nystatin oral powder ...... 9 norethindrone-eth estradiol tab 0.5- nystatin susp 100000 unit/ml ...... 9 35/1-35/0.5-35 mg-mcg ...... 64 nystatin tab 500000 unit ...... 9 norgestimate & ethinyl estradiol tab 0.25 nystatin topical powder 100000 unit/gm mg-35 mcg ...... 64 ...... 97 norgestimate-eth estrad tab 0.18- O 25/0.215-25/0.25-25 mg-mcg ...... 64 ODEFSEY TAB ...... 9 norgestimate-eth estrad tab 0.18- OFEV CAP 100MG ...... 94 35/0.215-35/0.25-35 mg-mcg ...... 64 OFEV CAP 150MG ...... 94 norgestrel & ethinyl estradiol tab 0.3 mg- OFF DEEP WDS AER 25%...... 100 30 mcg ...... 63 ofloxacin ophth soln 0.3% ...... 102 norgestrel & ethinyl estradiol tab 0.5 mg- ofloxacin otic soln 0.3% ...... 104 50 mcg ...... 64 olanzapine for im inj 10 mg ...... 43 NORPACE CAP 100MG ...... 21 olanzapine orally disintegrating tab 10 NORPACE CAP 100MG CR ...... 21 mg ...... 43 NORPACE CAP 150MG ...... 21 olanzapine orally disintegrating tab 15 NORPACE CAP 150MG CR ...... 21 mg ...... 43 NORPRAMIN TAB 10MG ...... 40 olanzapine orally disintegrating tab 20 NORPRAMIN TAB 25MG ...... 40 mg ...... 43 133 olanzapine orally disintegrating tab 5 mg ORENITRAM TAB 0.25MG ...... 27 ...... 43 ORENITRAM TAB 1MG ...... 27 olanzapine tab 10 mg ...... 43 ORENITRAM TAB 2.5MG ...... 27 olanzapine tab 15 mg ...... 43 ORENITRAM TAB 5MG ...... 27 olanzapine tab 2.5 mg ...... 43 ORKAMBI GRA 100-125 ...... 92 olanzapine tab 20 mg ...... 43 ORKAMBI GRA 150-188 ...... 92 olanzapine tab 5 mg ...... 43 ORKAMBI TAB 100-125 ...... 92 olanzapine tab 7.5 mg ...... 43 ORKAMBI TAB 200-125 ...... 92 olanzapine-fluoxetine hcl cap 12-25 mg orphenadrine citrate tab er 12hr 100 mg ...... 44 ...... 56 olanzapine-fluoxetine hcl cap 12-50 mg oseltamivir phosphate cap 30 mg (base ...... 44 equiv) ...... 13 olanzapine-fluoxetine hcl cap 3-25 mg 43 oseltamivir phosphate cap 45 mg (base olanzapine-fluoxetine hcl cap 6-25 mg 43 equiv) ...... 13 olanzapine-fluoxetine hcl cap 6-50 mg 44 oseltamivir phosphate cap 75 mg (base omega-3 fatty acids - oral liquid ...... 86 equiv) ...... 13 omega-3 fatty acids cap 1000 mg ...... 86 oseltamivir phosphate for susp 6 mg/ml omega-3 fatty acids cap 1200 mg ...... 87 (base equiv) ...... 13 omega-3 fatty acids cap 300 mg ...... 86 OSPHENA TAB 60MG ...... 68 omega-3 fatty acids cap 435 mg ...... 86 oxaprozin tab 600 mg ...... 5 omega-3 fatty acids cap 500 mg ...... 86 oxazepam cap 10 mg ...... 28 omega-3 fatty acids chew tab 113.5 mg oxazepam cap 15 mg ...... 28 ...... 87 oxazepam cap 30 mg ...... 28 omeprazole cap delayed release 10 mg74 oxcarbazepine susp 300 mg/5ml (60 omeprazole cap delayed release 20 mg74 mg/ml) ...... 33 omeprazole cap delayed release 40 mg74 oxcarbazepine tab 150 mg ...... 33 omeprazole magnesium cap dr 20.6 mg oxcarbazepine tab 300 mg ...... 33 (20 mg base equiv) ...... 74 oxcarbazepine tab 600 mg ...... 33 OMEPRAZOLE TAB 20MG ...... 74 OXTELLAR XR TAB 150MG ...... 33 omeprazole-sodium bicarbonate cap 20- OXTELLAR XR TAB 300MG ...... 33 1100 mg ...... 74 OXTELLAR XR TAB 600MG ...... 33 OMNITROPE INJ 10/1.5ML ...... 67 oxybutynin chloride syrup 5 mg/5ml .. 75 OMNITROPE INJ 5.8MG ...... 67 oxybutynin chloride tab 5 mg ...... 75 OMNITROPE INJ 5/1.5ML ...... 67 oxybutynin chloride tab er 24hr 10 mg 75 ondansetron hcl oral soln 4 mg/5ml .... 71 oxybutynin chloride tab er 24hr 15 mg 75 ondansetron hcl tab 24 mg ...... 71 oxybutynin chloride tab er 24hr 5 mg . 75 ondansetron hcl tab 4 mg ...... 71 oxycodone hcl cap 5 mg ...... 5 ondansetron hcl tab 8 mg ...... 71 oxycodone hcl conc 100 mg/5ml (20 ondansetron orally disintegrating tab 4 mg/ml) ...... 5 mg ...... 71 oxycodone hcl soln 5 mg/5ml ...... 5 ondansetron orally disintegrating tab 8 oxycodone hcl tab 10 mg ...... 5 mg ...... 71 oxycodone hcl tab 15 mg ...... 6 ONFI SUS 2.5MG/ML ...... 32 oxycodone hcl tab 20 mg ...... 6 ONFI TAB 10MG ...... 32 oxycodone hcl tab 30 mg ...... 6 ONFI TAB 20MG ...... 33 oxycodone hcl tab 5 mg ...... 5 OPSUMIT TAB 10MG ...... 26 oxycodone w/ acetaminophen tab 10-325 oral electrolyte solution ...... 81 mg ...... 6 ORENITRAM TAB 0.125MG ...... 27 oxycodone w/ acetaminophen tab 2.5- 134 325 mg ...... 6 chew tab ...... 87 oxycodone w/ acetaminophen tab 5-325 pediatric multiple vitamin w/ minerals & mg ...... 6 c chew tab ...... 87 oxycodone w/ acetaminophen tab 7.5- pediatric multiple vitamin w/ minerals & 325 mg ...... 6 c chew tab 60 mg ...... 87 oxycodone-aspirin tab 4.8355-325 mg . 6 pediatric multiple vitamin w/ minerals & oyster shell calcium tab 500 mg ...... 83 c drops 45 mg/ml ...... 87 OZEMPIC INJ 2/1.5ML ...... 59 pediatric multiple vitamins w/ fl-fe drops P 0.25-10 mg/ml ...... 87 paliperidone tab er 24hr 1.5 mg ...... 44 pediatric multiple vitamins w/ fl-fe drops paliperidone tab er 24hr 3 mg ...... 44 0.25-6 mg/ml ...... 87 paliperidone tab er 24hr 6 mg ...... 44 pediatric multiple vitamins w/ fluoride paliperidone tab er 24hr 9 mg ...... 44 chew tab 0.25 mg ...... 87 PAMELOR CAP 10MG ...... 40 pediatric multiple vitamins w/ fluoride PAMELOR CAP 25MG ...... 40 chew tab 0.5 mg ...... 87 PAMELOR CAP 50MG ...... 40 pediatric multiple vitamins w/ fluoride PAMELOR CAP 75MG ...... 40 chew tab 1 mg ...... 87 pantoprazole sodium ec tab 20 mg (base pediatric multiple vitamins w/ fluoride equiv) ...... 74 soln 0.25 mg/ml ...... 87 pantoprazole sodium ec tab 40 mg (base pediatric multiple vitamins w/ fluoride equiv) ...... 74 soln 0.5 mg/ml...... 87 pantothenic acid tab 500 mg ...... 87 pediatric multiple vitamins w/ iron chew paricalcitol cap 1 mcg ...... 67 tab 15 mg ...... 87 paricalcitol cap 2 mcg ...... 67 pediatric multiple vitamins w/ iron drops paricalcitol cap 4 mcg ...... 67 10 mg/ml ...... 87 PARNATE TAB 10MG ...... 36 PEDIATRIC SM MIS MASK ...... 93 paroxetine hcl tab 10 mg ...... 37 pediatric vitamins acd w/ fluoride soln paroxetine hcl tab 20 mg ...... 37 0.25 mg/ml ...... 87 paroxetine hcl tab 30 mg ...... 37 pediatric vitamins acd w/ fluoride soln paroxetine hcl tab 40 mg ...... 37 0.5 mg/ml ...... 87 paroxetine hcl tab er 24hr 12.5 mg ..... 37 pediatric vitamins adc drops 1500 unit- paroxetine hcl tab er 24hr 25 mg...... 37 400 unit-35 mg/ml ...... 87 paroxetine hcl tab er 24hr 37.5 mg ..... 37 peg 3350-kcl-na bicarb-nacl-na sulfate PAXIL CR TAB 12.5MG ...... 37 for soln 236 gm ...... 73 PAXIL CR TAB 25MG ...... 37 peg 3350-kcl-na bicarb-nacl-na sulfate PAXIL CR TAB 37.5MG ...... 37 for soln 240 gm ...... 73 PAXIL SUS 10MG/5ML ...... 37 peg 3350-kcl-sod bicarb-nacl for soln PAXIL TAB 10MG ...... 37 420 gm ...... 73 PAXIL TAB 20MG ...... 37 PEGANONE TAB 250MG ...... 33 PAXIL TAB 30MG ...... 37 PEGASYS INJ ...... 78 PAXIL TAB 40MG ...... 37 PEGASYS INJ 180MCG/M ...... 78 PEDIA-LAX LIQ 50MG ...... 73 PEGASYS INJ PROCLICK ...... 78 pediatric multiple vitamin liq ...... 87 PEGINTRON KIT 50MCG ...... 78 pediatric multiple vitamin w/ c & fa chew penicillin v potassium for soln 125 tab ...... 87 mg/5ml ...... 8 pediatric multiple vitamin w/ c soln 35 penicillin v potassium for soln 250 mg/ml ...... 87 mg/5ml ...... 8 pediatric multiple vitamin w/ extra c & fa penicillin v potassium tab 250 mg ...... 8 135 penicillin v potassium tab 500 mg ...... 8 pilocarpine hcl tab 7.5 mg ...... 74 pentoxifylline tab er 400 mg ...... 77 pindolol tab 10 mg ...... 23 permethrin aerosol 0.5% ...... 101 pindolol tab 5 mg ...... 23 permethrin cream 5% ...... 101 PINWORM TAB MEDICINE ...... 14 permethrin creme rinse 1% ...... 101 pioglitazone hcl tab 15 mg (base equiv) permethrin lotion 1% ...... 101 ...... 60 perphenazine tab 16 mg ...... 46 pioglitazone hcl tab 30 mg (base equiv) perphenazine tab 2 mg ...... 46 ...... 60 perphenazine tab 4 mg ...... 46 pioglitazone hcl tab 45 mg (base equiv) perphenazine tab 8 mg ...... 46 ...... 60 perphenazine-amitriptyline tab 2-10 mg pioglitazone hcl-glimepiride tab 30-2 mg ...... 46 ...... 59 perphenazine-amitriptyline tab 2-25 mg pioglitazone hcl-glimepiride tab 30-4 mg ...... 46 ...... 59 perphenazine-amitriptyline tab 4-10 mg pioglitazone hcl-metformin hcl tab 15- ...... 46 500 mg ...... 59 perphenazine-amitriptyline tab 4-25 mg pioglitazone hcl-metformin hcl tab 15- ...... 46 850 mg ...... 59 perphenazine-amitriptyline tab 4-50 mg PNEUMOVAX 23 INJ 25/0.5 ...... 80 ...... 46 podofilox soln 0.5% ...... 101 PEXEVA TAB 10MG ...... 37 polyethylene glycol 3350 oral packet .. 73 PEXEVA TAB 20MG ...... 37 polyethylene glycol 3350 oral powder . 73 PEXEVA TAB 30MG ...... 37 polyethylene glycol-propylene glycol PEXEVA TAB 40MG ...... 38 ophth soln 0.4-0.3% ...... 103 phenazopyridine hcl tab 100 mg ...... 75 polyethylene glycol-propylene glycol pf phenazopyridine hcl tab 200 mg ...... 75 op soln 0.4-0.3% ...... 103 phenelzine sulfate tab 15 mg ...... 36 polymyxin b-trimethoprim ophth soln phenobarbital elixir 20 mg/5ml ...... 33 10000 unit/ml-0.1% ...... 102 phenobarbital tab 100 mg ...... 33 polysaccharide iron complex cap 150 mg phenobarbital tab 15 mg ...... 33 (iron equivalent) ...... 84 phenobarbital tab 16.2 mg ...... 33 polyvinyl alcohol ophth soln 1.4% ..... 103 phenobarbital tab 30 mg ...... 33 polyvinyl alcohol-povidone (pf) ophth phenobarbital tab 32.4 mg ...... 33 soln 1.4-0.6% ...... 103 phenobarbital tab 60 mg ...... 33 polyvinyl alcohol-povidone ophth soln 5- phenobarbital tab 64.8 mg ...... 33 6 mg/ml (0.5-0.6%) ...... 103 phenobarbital tab 97.2 mg ...... 33 potassium bicarbonate effer tab 25 meq PHENYTEK CAP 200MG ...... 33 ...... 81 PHENYTEK CAP 300MG ...... 33 potassium chloride cap er 10 meq ...... 81 phenytoin chew tab 50 mg ...... 33 potassium chloride cap er 8 meq ...... 81 phenytoin sodium extended cap 100 mg potassium chloride microencapsulated ...... 33 crys er tab 10 meq ...... 81 phenytoin sodium extended cap 200 mg potassium chloride microencapsulated ...... 33 crys er tab 20 meq ...... 81 phenytoin sodium extended cap 300 mg potassium chloride oral soln 10% (20 ...... 33 meq/15ml) ...... 81 phenytoin susp 125 mg/5ml ...... 33 potassium chloride oral soln 20% (40 phytonadione tab 5 mg ...... 87 meq/15ml) ...... 81 pilocarpine hcl tab 5 mg ...... 74 potassium chloride tab er 10 meq ...... 81 136 potassium chloride tab er 20 meq (1500 prednisolone sod phosphate oral soln 15 mg) ...... 81 mg/5ml (base equiv) ...... 66 potassium chloride tab er 8 meq (600 prednisolone syrup 15 mg/5ml (usp mg) ...... 81 solution equivalent) ...... 66 potassium citrate & citric acid powder prednisone oral soln 5 mg/5ml ...... 66 pack 3300-1002 mg ...... 75 prednisone tab 1 mg ...... 66 potassium citrate & citric acid soln 1100- prednisone tab 10 mg ...... 66 334 mg/5ml ...... 75 prednisone tab 2.5 mg ...... 66 potassium citrate tab er 10 meq (1080 prednisone tab 20 mg ...... 66 mg) ...... 75 prednisone tab 5 mg ...... 66 potassium citrate tab er 15 meq (1620 prednisone tab 50 mg ...... 66 mg) ...... 75 prednisone tab therapy pack 10 mg (21) potassium citrate tab er 5 meq (540 mg) ...... 66 ...... 75 prednisone tab therapy pack 10 mg (48) povidone-iodine oint 10% ...... 97 ...... 66 povidone-iodine soln 10% ...... 97 prednisone tab therapy pack 5 mg (21) povidone-iodine soln 7.5% ...... 97 ...... 66 pramipexole dihydrochloride tab 0.125 prednisone tab therapy pack 5 mg (48) mg ...... 41 ...... 66 pramipexole dihydrochloride tab 0.25 mg pregabalin cap 100 mg ...... 33 ...... 41 pregabalin cap 150 mg ...... 33 pramipexole dihydrochloride tab 0.5 mg pregabalin cap 200 mg ...... 33 ...... 41 pregabalin cap 225 mg ...... 33 pramipexole dihydrochloride tab 0.75 mg pregabalin cap 25 mg ...... 33 ...... 41 pregabalin cap 300 mg ...... 33 pramipexole dihydrochloride tab 1 mg . 41 pregabalin cap 50 mg ...... 33 pramipexole dihydrochloride tab 1.5 mg pregabalin cap 75 mg ...... 33 ...... 41 pregabalin soln 20 mg/ml ...... 33 prasugrel hcl tab 10 mg (base equiv) .. 77 PREMARIN VAG CRE 0.625MG ...... 65 prasugrel hcl tab 5 mg (base equiv) .... 77 PRENAISSANCE CAP PLUS ...... 89 pravastatin sodium tab 10 mg ...... 22 prenatal vit w/ dss-fe fumarate-fa tab pravastatin sodium tab 20 mg ...... 22 29-1 mg ...... 89 pravastatin sodium tab 40 mg ...... 22 prenatal vit w/ dss-iron carbonyl-fa tab pravastatin sodium tab 80 mg ...... 22 90-1 mg ...... 89 prazosin hcl cap 1 mg ...... 19 prenatal vit w/ fe fumarate-fa chew tab prazosin hcl cap 2 mg ...... 19 29-1 mg ...... 89 prazosin hcl cap 5 mg ...... 19 prenatal vit w/ iron carbonyl-fa tab 29-1 PRECISION TES XTRA ...... 62 mg ...... 89 PRED SOD PHO SOL 1% OP ...... 102 PREZCOBIX TAB 800-150 ...... 9 prednisolone acetate ophth susp 1% . 102 PREZISTA SUS 100MG/ML ...... 12 prednisolone sod phos orally disintegr PREZISTA TAB 150MG ...... 12 tab 10 mg (base eq) ...... 65 PREZISTA TAB 600MG ...... 12 prednisolone sod phos orally disintegr PREZISTA TAB 75MG ...... 12 tab 15 mg (base eq) ...... 66 PREZISTA TAB 800MG ...... 12 prednisolone sod phos orally disintegr PRILOSEC OTC TAB 20MG ...... 74 tab 30 mg (base eq) ...... 66 primidone tab 250 mg ...... 33 prednisolone sod phosph oral soln 6.7 primidone tab 50 mg ...... 33 mg/5ml (5 mg/5ml base) ...... 66 PRISTIQ TAB 100MG ...... 39 137 PRISTIQ TAB 25MG ...... 39 propranolol hcl tab 60 mg ...... 23 PRISTIQ TAB 50MG ...... 39 propranolol hcl tab 80 mg ...... 23 PROAIR RESPI AER ...... 92 propylene glycol ophth soln 0.6% ..... 103 probenecid tab 500 mg ...... 3 propylene glycol-glycerin ophth soln 1- prochlorperazine maleate tab 10 mg 0.3% ...... 103 (base equivalent) ...... 71 propylthiouracil tab 50 mg ...... 68 prochlorperazine maleate tab 5 mg (base protriptyline hcl tab 10 mg ...... 40 equivalent) ...... 71 protriptyline hcl tab 5 mg ...... 40 prochlorperazine suppos 25 mg ...... 71 PROZAC CAP 10MG ...... 38 progesterone micronized cap 100 mg .. 68 PROZAC CAP 20MG ...... 38 progesterone micronized cap 200 mg .. 68 PROZAC CAP 40MG ...... 38 PROGRAF CAP 0.5MG ...... 79 pseudoephed-bromphen-dm syrup 30-2- PROGRAF CAP 1MG ...... 79 10 mg/5ml ...... 91 PROGRAF CAP 5MG ...... 79 pseudoephedrine hcl liq 15 mg/5ml .... 92 PROMACTA TAB 12.5MG ...... 77 pseudoephedrine hcl tab 30 mg ...... 92 PROMACTA TAB 25MG ...... 77 pseudoephedrine hcl tab 60 mg ...... 92 PROMACTA TAB 50MG ...... 77 pseudoephedrine hcl tab er 12hr 120 mg PROMACTA TAB 75MG ...... 77 ...... 92 promethazine & phenylephrine syrup pseudoephedrine w/ cod-gg soln 30-10- 6.25-5 mg/5ml ...... 89 100 mg/5ml ...... 91 promethazine hcl suppos 12.5 mg ...... 71 pseudoephedrine w/ dm-gg liquid 30-10- promethazine hcl suppos 25 mg ...... 71 100 mg/5ml ...... 91 promethazine hcl suppos 50 mg ...... 71 pseudoephedrine-guaifenesin tab er 12hr promethazine hcl syrup 6.25 mg/5ml .. 71 120-1200 mg ...... 92 promethazine hcl tab 12.5 mg ...... 71 pseudoephedrine-guaifenesin tab er 12hr promethazine hcl tab 25 mg ...... 71 60-600 mg ...... 92 promethazine hcl tab 50 mg ...... 71 PULMOZYME SOL 1MG/ML ...... 92 promethazine w/ codeine syrup 6.25-10 pyrantel pamoate susp 144 mg/ml (50 mg/5ml ...... 91 mg/ml base equiv) ...... 14 promethazine-dm syrup 6.25-15 mg/5ml pyrazinamide tab 500 mg ...... 12 ...... 91 pyridostigmine bromide syrup 60 mg/5ml promethazine-phenylephrine-codeine ...... 56 syrup 6.25-5-10 mg/5ml ...... 91 pyridostigmine bromide tab 60 mg ..... 56 propafenone hcl cap er 12hr 225 mg ... 21 pyridostigmine bromide tab er 180 mg 56 propafenone hcl cap er 12hr 325 mg ... 21 pyridoxine hcl tab 100 mg ...... 88 propafenone hcl cap er 12hr 425 mg ... 21 pyridoxine hcl tab 25 mg ...... 87 propafenone hcl tab 150 mg ...... 21 pyridoxine hcl tab 250 mg ...... 88 propafenone hcl tab 225 mg ...... 21 pyridoxine hcl tab 50 mg ...... 87 propafenone hcl tab 300 mg ...... 21 pyridoxine hcl tab 500 mg ...... 88 propranolol hcl cap er 24hr 120 mg .... 23 pyridoxine hcl tab er 200 mg ...... 88 propranolol hcl cap er 24hr 160 mg .... 23 Q propranolol hcl cap er 24hr 60 mg ...... 23 quetiapine fumarate tab 100 mg ...... 44 propranolol hcl cap er 24hr 80 mg ...... 23 quetiapine fumarate tab 200 mg ...... 44 propranolol hcl oral soln 20 mg/5ml .... 23 quetiapine fumarate tab 25 mg ...... 44 propranolol hcl oral soln 40 mg/5ml .... 23 quetiapine fumarate tab 300 mg ...... 44 propranolol hcl tab 10 mg ...... 23 quetiapine fumarate tab 400 mg ...... 44 propranolol hcl tab 20 mg ...... 23 quetiapine fumarate tab 50 mg ...... 44 propranolol hcl tab 40 mg ...... 23 quetiapine fumarate tab er 24hr 150 mg 138 ...... 44 REFRESH OPTI DRO 0.5-0.9% ...... 103 quetiapine fumarate tab er 24hr 200 mg REFRESH SOL OPTIVE ...... 103 ...... 44 REMERON SLTB TAB 15MG ...... 36 quetiapine fumarate tab er 24hr 300 mg REMERON SLTB TAB 30MG ...... 36 ...... 44 REMERON SLTB TAB 45MG ...... 36 quetiapine fumarate tab er 24hr 400 mg REMERON TAB 15MG ...... 36 ...... 44 REMERON TAB 30MG ...... 36 quetiapine fumarate tab er 24hr 50 mg repaglinide tab 0.5 mg ...... 60 ...... 44 repaglinide tab 1 mg ...... 60 quinapril hcl tab 10 mg ...... 19 repaglinide tab 2 mg ...... 60 quinapril hcl tab 20 mg ...... 19 REPEL SPORTS AER 25% ...... 100 quinapril hcl tab 40 mg ...... 19 RESCRIPTOR TAB 200MG ...... 10 quinapril hcl tab 5 mg ...... 19 RETROVIR CAP 100MG ...... 11 quinapril-hydrochlorothiazide tab 10-12.5 RETROVIR SYP 50MG/5ML ...... 11 mg ...... 18 REVLIMID CAP 10MG ...... 15 quinapril-hydrochlorothiazide tab 20-12.5 REVLIMID CAP 15MG ...... 15 mg ...... 18 REVLIMID CAP 2.5MG ...... 15 quinapril-hydrochlorothiazide tab 20-25 REVLIMID CAP 20MG ...... 15 mg ...... 18 REVLIMID CAP 25MG ...... 15 QVAR REDIHA AER 80MCG ...... 94 REVLIMID CAP 5MG ...... 15 QVAR REDIHAL AER 40MCG ...... 95 REXULTI TAB 0.25MG ...... 44 R REXULTI TAB 0.5MG ...... 44 raloxifene hcl tab 60 mg ...... 68 REXULTI TAB 1MG ...... 44 ramipril cap 1.25 mg ...... 19 REXULTI TAB 2MG ...... 44 ramipril cap 10 mg ...... 19 REXULTI TAB 3MG ...... 44 ramipril cap 2.5 mg ...... 19 REXULTI TAB 4MG ...... 44 ramipril cap 5 mg ...... 19 REYATAZ CAP 150MG ...... 12 ranitidine hcl cap 150 mg ...... 72 REYATAZ CAP 200MG ...... 12 ranitidine hcl cap 300 mg ...... 72 REYATAZ CAP 300MG ...... 12 ranitidine hcl syrup 15 mg/ml (75 REYATAZ POW 50MG ...... 12 mg/5ml) ...... 72 RHINARIS SPR 0.2% ...... 94 ranitidine hcl tab 150 mg ...... 72 RIBAPAK PAK 1200/DAY ...... 13 ranitidine hcl tab 300 mg ...... 72 RIBAPAK PAK 800/DAY ...... 13 ranitidine hcl tab 75 mg ...... 72 RIBAPAK TAB 1000/DAY ...... 13 RAPAMUNE SOL 1MG/ML ...... 79 RIBAPAK TAB 600/DAY ...... 13 RAPAMUNE TAB 0.5MG ...... 79 ribasphere cap 200mg ...... 13 RAPAMUNE TAB 1MG ...... 79 ribasphere tab 200mg ...... 13 RAPAMUNE TAB 2MG ...... 79 RIBASPHERE TAB 400MG ...... 13 REBETOL SOL 40MG/ML ...... 13 ribasphere tab 600mg ...... 13 REBIF INJ 22/0.5 ...... 56 ribavirin cap 200 mg ...... 13 REBIF INJ 44/0.5 ...... 56 ribavirin tab 200 mg ...... 13 REBIF REBIDO INJ 22/0.5 ...... 56 riboflavin tab 100 mg ...... 88 REBIF REBIDO INJ 44/0.5 ...... 56 riboflavin tab 25 mg ...... 88 REBIF REBIDO INJ TITRATN ...... 56 riboflavin tab 50 mg ...... 88 REBIF TITRTN INJ PACK ...... 56 RID AER ...... 101 RECOMBIVA HB INJ 10MCG/ML ...... 80 rifabutin cap 150 mg ...... 14 RECOMBIVA HB INJ 5MCG/0.5 ...... 80 rifampin cap 150 mg ...... 12 RECOMBIVA-HB INJ 40MCG/ML ...... 80 rifampin cap 300 mg ...... 12 139 riluzole tab 50 mg ...... 55 rizatriptan benzoate oral disintegrating RISPERDAL INJ 12.5MG ...... 44 tab 5 mg (base eq) ...... 54 RISPERDAL INJ 25MG ...... 44 rizatriptan benzoate tab 10 mg (base RISPERDAL INJ 37.5MG ...... 44 equivalent) ...... 54 RISPERDAL INJ 50MG ...... 44 rizatriptan benzoate tab 5 mg (base RISPERDAL SOL 1MG/ML ...... 44 equivalent) ...... 54 RISPERDAL TAB 0.25MG ...... 44 ropinirole hydrochloride tab 0.25 mg .. 41 RISPERDAL TAB 0.5MG ...... 44 ropinirole hydrochloride tab 0.5 mg .... 41 RISPERDAL TAB 1MG ...... 44 ropinirole hydrochloride tab 1 mg ...... 41 RISPERDAL TAB 2MG ...... 44 ropinirole hydrochloride tab 2 mg ...... 41 RISPERDAL TAB 3MG ...... 44 ropinirole hydrochloride tab 3 mg ...... 41 RISPERDAL TAB 4MG ...... 44 ropinirole hydrochloride tab 4 mg ...... 41 risperidone orally disintegrating tab 0.25 ropinirole hydrochloride tab 5 mg ...... 41 mg ...... 44 RUBRACA TAB 200MG ...... 17 risperidone orally disintegrating tab 0.5 RUBRACA TAB 250MG ...... 17 mg ...... 44 RUBRACA TAB 300MG ...... 17 risperidone orally disintegrating tab 1 mg RYDAPT CAP 25MG ...... 16 ...... 44 RYTHMOL SR CAP 225MG ...... 21 risperidone orally disintegrating tab 2 mg RYTHMOL SR CAP 325MG ...... 21 ...... 44 RYTHMOL SR CAP 425MG ...... 21 risperidone orally disintegrating tab 3 mg S ...... 44 SABRIL POW 500MG ...... 33 risperidone orally disintegrating tab 4 mg SABRIL TAB 500MG ...... 33 ...... 44 SAIZEN INJ 5MG ...... 67 risperidone soln 1 mg/ml ...... 44 SAIZEN INJ 8.8MG ...... 67 risperidone tab 0.25 mg ...... 44 SAIZENPREP INJ 8.8MG ...... 67 risperidone tab 0.5 mg ...... 44 saline nasal spray 0.65% ...... 94 risperidone tab 1 mg ...... 45 SAMSCA TAB 15MG ...... 69 risperidone tab 2 mg ...... 45 SAMSCA TAB 30MG ...... 69 risperidone tab 3 mg ...... 45 SANDIMMUNE CAP 100MG ...... 79 risperidone tab 4 mg ...... 45 SANDIMMUNE CAP 25MG ...... 79 ritonavir tab 100 mg ...... 12 SANDIMMUNE SOL 100MG/ML ...... 79 rivastigmine tartrate cap 1.5 mg (base SAPHRIS SUB 10MG ...... 45 equivalent) ...... 35 SAPHRIS SUB 2.5MG ...... 45 rivastigmine tartrate cap 3 mg (base SAPHRIS SUB 5MG ...... 45 equivalent) ...... 35 SARAFEM TAB 10MG ...... 38 rivastigmine tartrate cap 4.5 mg (base SARAFEM TAB 20MG ...... 38 equivalent) ...... 35 SAVELLA MIS TITR PAK ...... 53 rivastigmine tartrate cap 6 mg (base SAVELLA TAB 100MG ...... 53 equivalent) ...... 35 SAVELLA TAB 12.5MG ...... 53 rivastigmine td patch 24hr 13.3 mg/24hr SAVELLA TAB 25MG ...... 53 ...... 35 SAVELLA TAB 50MG ...... 53 rivastigmine td patch 24hr 4.6 mg/24hr SAWYER REPEL SPR 20% ...... 100 ...... 35 selegiline hcl cap 5 mg ...... 42 rivastigmine td patch 24hr 9.5 mg/24hr selegiline hcl tab 5 mg ...... 42 ...... 35 selenium sulfide lotion 1% ...... 97 rizatriptan benzoate oral disintegrating selenium sulfide lotion 2.5% ...... 97 tab 10 mg (base eq) ...... 54 SELZENTRY SOL 20MG/ML ...... 10 140 SELZENTRY TAB 150MG ...... 10 SIMPLY SALIN AER 0.9% ...... 94 SELZENTRY TAB 25MG ...... 10 simvastatin tab 10 mg ...... 22 SELZENTRY TAB 300MG ...... 10 simvastatin tab 20 mg ...... 22 SELZENTRY TAB 75MG ...... 10 simvastatin tab 40 mg ...... 22 sennosides chew tab 15 mg ...... 73 simvastatin tab 5 mg ...... 22 sennosides syrup 8.8 mg/5ml ...... 73 simvastatin tab 80 mg ...... 22 sennosides tab 15 mg ...... 73 sirolimus oral soln 1 mg/ml ...... 79 sennosides tab 17.2 mg ...... 73 sirolimus tab 0.5 mg ...... 79 sennosides tab 25 mg ...... 73 sirolimus tab 1 mg ...... 79 sennosides tab 8.6 mg ...... 73 sirolimus tab 2 mg ...... 79 sennosides-docusate sodium tab 8.6-50 SM CALAMINE LOT ...... 101 mg ...... 73 sodium chloride aero soln 0.9% ...... 94 SENSIPAR TAB 30MG ...... 62 sodium chloride soln nebu 0.9% ...... 94 SENSIPAR TAB 60MG ...... 62 sodium chloride soln nebu 10% ...... 94 SENSIPAR TAB 90MG ...... 62 sodium chloride soln nebu 3% ...... 94 SEROQUEL TAB 100MG ...... 45 sodium chloride soln nebu 7% ...... 94 SEROQUEL TAB 200MG ...... 45 sodium fluoride chew tab 0.25 mg f SEROQUEL TAB 25MG ...... 45 (from 0.55 mg naf) ...... 88 SEROQUEL TAB 300MG ...... 45 sodium fluoride chew tab 0.5 mg f (from SEROQUEL TAB 400MG ...... 45 1.1 mg naf) ...... 88 SEROQUEL TAB 50MG ...... 45 sodium fluoride chew tab 1 mg f (from SEROQUEL XR TAB 150MG ...... 45 2.2 mg naf) ...... 88 SEROQUEL XR TAB 200MG ...... 45 sodium fluoride cream 1.1% ...... 101 SEROQUEL XR TAB 300MG ...... 45 sodium fluoride gel 1.1% (0.5% f) .... 101 SEROQUEL XR TAB 400MG ...... 45 sodium fluoride paste 1.1% ...... 101 SEROQUEL XR TAB 50MG ...... 45 sodium fluoride rinse 0.2% ...... 101 SEROSTIM INJ 4MG ...... 67 sodium fluoride soln 0.125 mg/drop f SEROSTIM INJ 5MG ...... 67 (0.275 mg/drop naf) ...... 88 SEROSTIM INJ 6MG ...... 67 sodium fluoride soln 0.25 mg/drop f sertraline hcl oral concentrate for (from 0.55 mg/drop naf) ...... 88 solution 20 mg/ml ...... 38 sodium fluoride soln 0.5 mg/ml f (from sertraline hcl tab 100 mg...... 38 1.1 mg/ml naf) ...... 88 sertraline hcl tab 25 mg ...... 38 sodium fluoride tab 0.5 mg f (from 1.1 sertraline hcl tab 50 mg ...... 38 mg naf) ...... 88 sevelamer carbonate packet 0.8 gm .... 68 sodium fluoride tab 1 mg f (from 2.2 mg sevelamer carbonate packet 2.4 gm .... 68 naf) ...... 88 sevelamer carbonate tab 800 mg ...... 68 sodium phenylbutyrate oral powder 3 SHUR-SEAL GEL 2% ...... 63 gm/teaspoonful ...... 69 sildenafil citrate for suspension 10 mg/ml sodium phenylbutyrate tab 500 mg .... 69 ...... 27 sodium polystyrene sulfonate oral susp sildenafil citrate tab 20 mg ...... 27 15 gm/60ml ...... 68 silver sulfadiazine cream 1% ...... 97 sodium polystyrene sulfonate rectal susp simethicone cap 125 mg ...... 73 30 gm/120ml ...... 68 simethicone cap 180 mg ...... 73 SOLIQUA INJ 100/33 ...... 59 simethicone chew tab 125 mg ...... 73 sotalol hcl (afib/afl) tab 120 mg ...... 21 simethicone chew tab 80 mg ...... 73 sotalol hcl (afib/afl) tab 160 mg ...... 21 simethicone liquid 40 mg/0.6ml ...... 73 sotalol hcl (afib/afl) tab 80 mg ...... 21 simethicone susp 40 mg/0.6ml ...... 73 sotalol hcl tab 120 mg ...... 21 141 sotalol hcl tab 160 mg...... 21 6 mg/0.5ml ...... 54 sotalol hcl tab 240 mg...... 21 sumatriptan succinate tab 100 mg ..... 55 sotalol hcl tab 80 mg ...... 21 sumatriptan succinate tab 25 mg ...... 54 spinosad susp 0.9% ...... 101 sumatriptan succinate tab 50 mg ...... 55 spironolactone & hydrochlorothiazide tab SURMONTIL CAP 100MG ...... 40 25-25 mg ...... 25 SURMONTIL CAP 25MG ...... 40 spironolactone tab 100 mg ...... 19 SURMONTIL CAP 50MG ...... 40 spironolactone tab 25 mg ...... 19 SUSTIVA CAP 200MG ...... 10 spironolactone tab 50 mg ...... 19 SUSTIVA CAP 50MG ...... 10 SSKI SOL 1GM/ML ...... 68 SUSTIVA TAB 600MG ...... 10 stavudine cap 15 mg ...... 11 SUTENT CAP 12.5MG ...... 16 stavudine cap 20 mg ...... 11 SUTENT CAP 25MG ...... 16 stavudine cap 30 mg ...... 11 SUTENT CAP 37.5MG ...... 16 stavudine cap 40 mg ...... 11 SUTENT CAP 50MG ...... 16 STIOLTO AER 2.5-2.5 ...... 89 SYMDEKO TAB 100-150 ...... 92 STIVARGA TAB 40MG ...... 16 SYMFI LO TAB ...... 9 STRIBILD TAB ...... 9 SYMFI TAB ...... 9 STRIVERDI AER 2.5MCG ...... 91 SYMTUZA TAB ...... 9 sucralfate tab 1 gm ...... 73 SYNAREL SOL 2MG/ML ...... 64 SUDAFED 24HR TAB 240MG ...... 92 SYNTHROID TAB 100MCG ...... 69 sulfacetamide sodium lotion 10% (acne) SYNTHROID TAB 112MCG ...... 69 ...... 96 SYNTHROID TAB 125MCG ...... 69 sulfacetamide sodium ophth soln 10% SYNTHROID TAB 137MCG ...... 69 ...... 102 SYNTHROID TAB 150MCG ...... 69 sulfacetamide sodium-prednisolone SYNTHROID TAB 175MCG ...... 69 ophth soln 10-0.23(0.25)% ...... 102 SYNTHROID TAB 200MCG ...... 69 SULFADIAZINE TAB 500MG ...... 8 SYNTHROID TAB 25MCG ...... 69 sulfamethoxazole-trimethoprim susp SYNTHROID TAB 300MCG ...... 69 200-40 mg/5ml ...... 8 SYNTHROID TAB 50MCG ...... 69 sulfamethoxazole-trimethoprim tab 400- SYNTHROID TAB 75MCG ...... 69 80 mg ...... 8 SYNTHROID TAB 88MCG ...... 69 sulfamethoxazole-trimethoprim tab 800- SYSTANE GEL 0.3% ...... 103 160 mg ...... 8 T sulfasalazine tab 500 mg ...... 72 tacrolimus cap 0.5 mg ...... 79 sulfasalazine tab delayed release 500 mg tacrolimus cap 1 mg ...... 79 ...... 72 tacrolimus cap 5 mg ...... 79 sulindac tab 150 mg ...... 5 tacrolimus oint 0.03% ...... 98 sulindac tab 200 mg ...... 5 tacrolimus oint 0.1% ...... 98 sumatriptan nasal spray 20 mg/act ..... 54 TAFINLAR CAP 50MG ...... 16 sumatriptan nasal spray 5 mg/act ...... 54 TAFINLAR CAP 75MG ...... 16 sumatriptan succinate inj 6 mg/0.5ml . 54 tamoxifen citrate tab 10 mg (base sumatriptan succinate solution auto- equivalent) ...... 15 injector 4 mg/0.5ml ...... 54 tamoxifen citrate tab 20 mg (base sumatriptan succinate solution auto- equivalent) ...... 15 injector 6 mg/0.5ml ...... 54 tamsulosin hcl cap 0.4 mg ...... 75 sumatriptan succinate solution cartridge TDVAX INJ 2-2 LF ...... 80 4 mg/0.5ml ...... 54 TECFIDERA CAP 120MG ...... 56 sumatriptan succinate solution cartridge TECFIDERA CAP 240MG ...... 56 142 TECFIDERA MIS STARTER ...... 56 theophylline tab er 24hr 400 mg ...... 95 TEGRETOL SUS 100/5ML ...... 33 theophylline tab er 24hr 600 mg ...... 95 TEGRETOL TAB 200MG ...... 33 THERATEARS SOL OP ...... 103 TEGRETOL-XR TAB 100MG ...... 33 thiamine hcl tab 100 mg ...... 88 TEGRETOL-XR TAB 200MG ...... 33 thiamine hcl tab 250 mg ...... 88 TEGRETOL-XR TAB 400MG ...... 33 thiamine hcl tab 50 mg ...... 88 temazepam cap 15 mg ...... 53 thiamine mononitrate tab 100 mg ...... 88 temazepam cap 22.5 mg ...... 53 thioridazine hcl tab 10 mg ...... 46 temazepam cap 30 mg ...... 53 thioridazine hcl tab 100 mg ...... 46 temazepam cap 7.5 mg ...... 53 thioridazine hcl tab 25 mg ...... 46 temozolomide cap 100 mg ...... 14 thioridazine hcl tab 50 mg ...... 46 temozolomide cap 140 mg ...... 14 thiothixene cap 1 mg ...... 47 temozolomide cap 180 mg ...... 14 thiothixene cap 10 mg ...... 47 temozolomide cap 20 mg ...... 14 thiothixene cap 2 mg ...... 47 temozolomide cap 250 mg ...... 14 thiothixene cap 5 mg ...... 47 temozolomide cap 5 mg ...... 14 tiagabine hcl tab 12 mg ...... 34 TENIVAC INJ 5-2LF ...... 80 tiagabine hcl tab 16 mg ...... 34 tenofovir disoproxil fumarate tab 300 mg tiagabine hcl tab 2 mg ...... 33 ...... 11 tiagabine hcl tab 4 mg ...... 34 terazosin hcl cap 1 mg (base equivalent) TIKOSYN CAP 125MCG ...... 21 ...... 19 TIKOSYN CAP 250MCG ...... 21 terazosin hcl cap 10 mg (base TIKOSYN CAP 500MCG ...... 21 equivalent) ...... 19 timolol maleate ophth gel forming soln terazosin hcl cap 2 mg (base equivalent) 0.25% ...... 103 ...... 19 timolol maleate ophth gel forming soln terazosin hcl cap 5 mg (base equivalent) 0.5% ...... 103 ...... 19 timolol maleate ophth soln 0.25% ..... 103 terbinafine hcl tab 250 mg ...... 9 timolol maleate ophth soln 0.5% ...... 103 terbutaline sulfate tab 2.5 mg ...... 92 timolol maleate tab 10 mg ...... 23 terbutaline sulfate tab 5 mg ...... 92 timolol maleate tab 20 mg ...... 23 terconazole vaginal cream 0.4% ...... 76 timolol maleate tab 5 mg ...... 23 terconazole vaginal cream 0.8% ...... 76 TIVICAY TAB 10MG ...... 10 terconazole vaginal suppos 80 mg ...... 76 TIVICAY TAB 25MG ...... 10 testosterone td gel 10mg/act (2%) ..... 58 TIVICAY TAB 50MG ...... 10 testosterone td gel 25 mg/2.5gm (1%)58 tizanidine hcl tab 2 mg (base equivalent) tetrabenazine tab 12.5 mg ...... 53 ...... 56 tetrabenazine tab 25 mg ...... 53 tizanidine hcl tab 4 mg (base equivalent) tetracycline hcl cap 250 mg ...... 8 ...... 56 tetracycline hcl cap 500 mg ...... 8 tobramycin nebu soln 300 mg/5ml ..... 92 THEO-24 CAP 100MG CR ...... 95 tobramycin ophth soln 0.3% ...... 102 THEO-24 CAP 200MG CR ...... 95 TOFRANIL TAB 10MG ...... 40 THEO-24 CAP 300MG CR ...... 95 TOFRANIL TAB 25MG ...... 40 THEO-24 CAP 400MG ER ...... 95 TOFRANIL TAB 50MG ...... 40 theophylline soln 80 mg/15ml ...... 95 TOLAK CRE 4% ...... 96 theophylline tab er 12hr 100 mg ...... 95 tolnaftate aerosol pow 1% ...... 97 theophylline tab er 12hr 200 mg ...... 95 tolnaftate cream 1% ...... 97 theophylline tab er 12hr 300 mg ...... 95 tolnaftate soln 1% ...... 97 theophylline tab er 12hr 450 mg ...... 95 tolterodine tartrate tab 1 mg ...... 75 143 tolterodine tartrate tab 2 mg ...... 75 tretinoin cream 0.1% ...... 96 TOPAMAX SPR CAP 15MG ...... 34 tretinoin gel 0.01% ...... 96 TOPAMAX SPR CAP 25MG ...... 34 tretinoin gel 0.025% ...... 96 TOPAMAX TAB 100MG ...... 34 triamcinolone acetonide cream 0.025% TOPAMAX TAB 200MG ...... 34 ...... 99 TOPAMAX TAB 25MG ...... 34 triamcinolone acetonide cream 0.1% .. 99 TOPAMAX TAB 50MG ...... 34 triamcinolone acetonide cream 0.5% .. 98 topiramate cap er 24hr sprinkle 100 mg triamcinolone acetonide dental paste ...... 34 0.1% ...... 101 topiramate cap er 24hr sprinkle 150 mg triamcinolone acetonide lotion 0.025% 99 ...... 34 triamcinolone acetonide lotion 0.1% ... 99 topiramate cap er 24hr sprinkle 200 mg triamcinolone acetonide nasal aerosol ...... 34 suspension 55 mcg/act ...... 94 topiramate cap er 24hr sprinkle 25 mg 34 triamcinolone acetonide oint 0.025% .. 99 topiramate cap er 24hr sprinkle 50 mg 34 triamcinolone acetonide oint 0.1% ..... 99 topiramate sprinkle cap 15 mg ...... 34 triamcinolone acetonide oint 0.5% ..... 98 topiramate sprinkle cap 25 mg ...... 34 triamterene & hydrochlorothiazide cap topiramate tab 100 mg ...... 34 37.5-25 mg ...... 25 topiramate tab 200 mg ...... 34 triamterene & hydrochlorothiazide tab topiramate tab 25 mg ...... 34 37.5-25 mg ...... 25 topiramate tab 50 mg ...... 34 triamterene & hydrochlorothiazide tab toremifene citrate tab 60 mg (base 75-50 mg ...... 25 equivalent) ...... 15 trifluoperazine hcl tab 1 mg (base torsemide tab 10 mg ...... 25 equivalent) ...... 47 torsemide tab 100 mg ...... 25 trifluoperazine hcl tab 10 mg (base torsemide tab 20 mg ...... 25 equivalent) ...... 47 torsemide tab 5 mg ...... 25 trifluoperazine hcl tab 2 mg (base TRACLEER TAB 32MG ...... 26 equivalent) ...... 47 tramadol hcl tab 50 mg ...... 6 trifluoperazine hcl tab 5 mg (base tramadol hcl tab er 24hr 100 mg ...... 6 equivalent) ...... 47 tramadol hcl tab er 24hr 200 mg ...... 6 trifluridine ophth soln 1% ...... 102 tramadol hcl tab er 24hr 300 mg ...... 6 trihexyphenidyl hcl elixir 0.4 mg/ml ... 42 tramadol hcl tab er 24hr biphasic release trihexyphenidyl hcl tab 2 mg ...... 42 300 mg ...... 6 trihexyphenidyl hcl tab 5 mg ...... 42 tramadol-acetaminophen tab 37.5-325 TRILEPTAL SUS 300MG/5M ...... 34 mg ...... 6 TRILEPTAL TAB 150MG ...... 34 trandolapril tab 1 mg ...... 19 TRILEPTAL TAB 300MG ...... 34 trandolapril tab 2 mg ...... 19 TRILEPTAL TAB 600MG ...... 34 trandolapril tab 4 mg ...... 19 trimethobenzamide hcl cap 300 mg .... 71 TRANXENE T TAB 7.5MG ...... 28 trimethoprim tab 100 mg ...... 14 tranylcypromine sulfate tab 10 mg ...... 36 trimipramine maleate cap 100 mg ...... 40 trazodone hcl tab 100 mg ...... 36 trimipramine maleate cap 25 mg ...... 40 trazodone hcl tab 150 mg ...... 36 trimipramine maleate cap 50 mg ...... 40 trazodone hcl tab 300 mg ...... 36 TRINTELLIX TAB 10MG ...... 38 trazodone hcl tab 50 mg ...... 36 TRINTELLIX TAB 20MG ...... 38 tretinoin cap 10 mg ...... 17 TRINTELLIX TAB 5MG ...... 38 tretinoin cream 0.025% ...... 96 TRIUMEQ TAB ...... 9 tretinoin cream 0.05% ...... 96 TRIZIVIR TAB ...... 9 144 TROKENDI XR CAP 100MG ...... 34 valproic acid cap 250 mg ...... 34 TROKENDI XR CAP 200MG ...... 34 valsartan tab 160 mg ...... 20 TROKENDI XR CAP 25MG ...... 34 valsartan tab 320 mg ...... 20 TROKENDI XR CAP 50MG ...... 34 valsartan tab 40 mg ...... 20 trospium chloride cap er 24hr 60 mg ... 75 valsartan tab 80 mg ...... 20 trospium chloride tab 20 mg ...... 75 valsartan-hydrochlorothiazide tab 160- TRULANCE TAB 3MG ...... 72 12.5 mg ...... 20 TRULICITY INJ 0.75/0.5 ...... 59 valsartan-hydrochlorothiazide tab 160-25 TRULICITY INJ 1.5/0.5 ...... 59 mg ...... 20 TRUVADA TAB 100-150 ...... 9 valsartan-hydrochlorothiazide tab 320- TRUVADA TAB 133-200 ...... 10 12.5 mg ...... 20 TRUVADA TAB 167-250 ...... 10 valsartan-hydrochlorothiazide tab 320-25 TRUVADA TAB 200-300 ...... 10 mg ...... 20 TUMS CHW DEL CHW 1177MG ...... 70 valsartan-hydrochlorothiazide tab 80- TWINRIX INJ ...... 80 12.5 mg ...... 20 TYBOST TAB 150MG ...... 9 vancomycin hcl cap 125 mg (base TYKERB TAB 250MG ...... 16 equivalent) ...... 14 TYVASO REFIL SOL 0.6MG/ML ...... 27 vancomycin hcl cap 250 mg (base TYVASO SOL 0.6MG/ML ...... 27 equivalent) ...... 14 TYVASO START SOL 0.6MG/ML ...... 27 VAPORIZER ...... 93 U VAQTA INJ 25/0.5ML ...... 80 UNI-SOLVE PAD WIPES ...... 97 VAQTA INJ 50UNT/ML ...... 80 UPTRAVI TAB 1000MCG ...... 27 VARIVAX INJ ...... 81 UPTRAVI TAB 1200MCG ...... 27 VCF VAGINAL AER CONTRACP ...... 63 UPTRAVI TAB 1400MCG ...... 27 VCF VAGINAL MIS CONTRACP ...... 63 UPTRAVI TAB 1600MCG ...... 27 VENCLEXTA TAB 100MG ...... 17 UPTRAVI TAB 200/800 ...... 27 VENCLEXTA TAB 10MG ...... 17 UPTRAVI TAB 200MCG ...... 27 VENCLEXTA TAB 50MG ...... 17 UPTRAVI TAB 400MCG ...... 27 VENCLEXTA TAB START PK ...... 17 UPTRAVI TAB 600MCG ...... 27 venlafaxine hcl cap er 24hr 150 mg UPTRAVI TAB 800MCG ...... 27 (base equivalent) ...... 39 URISTIX 4 TES ...... 81 venlafaxine hcl cap er 24hr 37.5 mg URISTIX TES ...... 81 (base equivalent) ...... 39 ursodiol cap 300 mg ...... 71 venlafaxine hcl cap er 24hr 75 mg (base ursodiol tab 250 mg ...... 71 equivalent) ...... 39 ursodiol tab 500 mg ...... 71 venlafaxine hcl tab 100 mg (base V equivalent) ...... 39 valacyclovir hcl tab 1 gm ...... 13 venlafaxine hcl tab 25 mg (base valacyclovir hcl tab 500 mg ...... 13 equivalent) ...... 39 valganciclovir hcl for soln 50 mg/ml venlafaxine hcl tab 37.5 mg (base (base equiv) ...... 12 equivalent) ...... 39 valganciclovir hcl tab 450 mg (base venlafaxine hcl tab 50 mg (base equivalent) ...... 12 equivalent) ...... 39 VALIUM TAB 10MG ...... 28 venlafaxine hcl tab 75 mg (base VALIUM TAB 2MG ...... 28 equivalent) ...... 39 VALIUM TAB 5MG ...... 28 venlafaxine hcl tab er 24hr 150 mg (base valproate sodium oral soln 250 mg/5ml equivalent) ...... 39 (base equiv) ...... 34 venlafaxine hcl tab er 24hr 225 mg (base 145 equivalent) ...... 39 vitamins c & e cap ...... 88 venlafaxine hcl tab er 24hr 37.5 mg vitamins w/ lipotropics cap ...... 88 (base equivalent) ...... 39 vitamins w/ lipotropics tab ...... 88 venlafaxine hcl tab er 24hr 75 mg (base vitamins w/ lipotropics tab er ...... 88 equivalent) ...... 39 VITRAKVI CAP 100MG ...... 16 VENTOLIN HFA AER ...... 92 VITRAKVI CAP 25MG ...... 16 verapamil hcl tab er 120 mg ...... 24 VITRAKVI SOL 20MG/ML ...... 16 verapamil hcl tab er 180 mg ...... 24 voriconazole for susp 40 mg/ml ...... 9 verapamil hcl tab er 240 mg ...... 24 voriconazole tab 200 mg ...... 9 VERSACLOZ SUS 50MG/ML ...... 45 voriconazole tab 50 mg ...... 9 VICTOZA INJ 18MG/3ML ...... 59 VORTEX VALVE MIS CHAMBER ...... 93 VIDEX EC CAP 125MG ...... 11 VORTEX/MASK MIS CHILDS ...... 93 VIDEX EC CAP 200MG ...... 11 VORTEX/MASK MIS TODDLER ...... 93 VIDEX EC CAP 250MG ...... 11 VOTRIENT TAB 200MG ...... 16 VIDEX EC CAP 400MG ...... 11 VRAYLAR CAP 1.5-3MG ...... 45 VIDEX SOL 2GM ...... 11 VRAYLAR CAP 1.5MG ...... 45 vigabatrin powd pack 500 mg ...... 34 VRAYLAR CAP 3MG ...... 45 vigabatrin tab 500 mg ...... 34 VRAYLAR CAP 4.5MG ...... 45 VIIBRYD KIT STARTER ...... 38 VRAYLAR CAP 6MG ...... 45 VIIBRYD TAB 10MG ...... 38 W VIIBRYD TAB 20MG ...... 38 warfarin sodium tab 1 mg ...... 76 VIIBRYD TAB 40MG ...... 38 warfarin sodium tab 10 mg ...... 76 VIMPAT SOL 10MG/ML ...... 34 warfarin sodium tab 2 mg ...... 76 VIMPAT TAB 100MG ...... 34 warfarin sodium tab 2.5 mg ...... 76 VIMPAT TAB 150MG ...... 34 warfarin sodium tab 3 mg ...... 76 VIMPAT TAB 200MG ...... 34 warfarin sodium tab 4 mg ...... 76 VIMPAT TAB 50MG ...... 34 warfarin sodium tab 5 mg ...... 76 VIOKACE TAB 10440 ...... 73 warfarin sodium tab 6 mg ...... 76 VIOKACE TAB 20880 ...... 74 warfarin sodium tab 7.5 mg ...... 76 VIRACEPT TAB 250MG ...... 12 WELLBUTRIN TAB 100MG SR ...... 36 VIRACEPT TAB 625MG ...... 12 WELLBUTRIN TAB 150MG SR ...... 36 VIRAMUNE SUS 50MG/5ML ...... 10 WELLBUTRIN TAB 200MG SR ...... 36 VIRAMUNE TAB 200MG ...... 10 WELLBUTRIN TAB XL 150MG ...... 36 VIRAMUNE XR TAB 400MG ...... 10 WELLBUTRIN TAB XL 300MG ...... 36 VIREAD POW 40MG/GM ...... 11 white petrolatum-mineral oil ophth VIREAD TAB 150MG ...... 11 ointment ...... 103 VIREAD TAB 200MG ...... 11 X VIREAD TAB 250MG ...... 11 XANAX TAB 0.25MG ...... 29 VIREAD TAB 300MG ...... 11 XANAX TAB 0.5MG ...... 29 VISTARIL CAP 25MG ...... 90 XANAX TAB 1MG ...... 29 VISTARIL CAP 50MG ...... 90 XANAX TAB 2MG ...... 29 VISTOGARD PAK 10GM ...... 17 XANAX XR TAB 0.5MG ...... 29 vitamin e cap 400 unit ...... 88 XANAX XR TAB 1MG ...... 29 vitamin mixture cap ...... 88 XANAX XR TAB 2MG ...... 29 vitamin mixture tab ...... 88 XANAX XR TAB 3MG ...... 29 vitamins a & d cap ...... 88 XARELTO STAR TAB 15/20MG ...... 76 vitamins a & d tab ...... 88 XARELTO TAB 10MG ...... 76 vitamins a & d w/ c chew tab ...... 88 XARELTO TAB 15MG ...... 76 146 XARELTO TAB 2.5MG ...... 76 ZOLOFT TAB 25MG ...... 38 XARELTO TAB 20MG ...... 76 ZOLOFT TAB 50MG ...... 38 XELJANZ TAB 10MG ...... 78 zolpidem tartrate tab 10 mg ...... 53 XELJANZ TAB 5MG ...... 78 zolpidem tartrate tab 5 mg ...... 53 XELJANZ XR TAB 11MG ...... 78 zolpidem tartrate tab er 12.5 mg ...... 54 XIIDRA DRO 5% ...... 104 zolpidem tartrate tab er 6.25 mg ...... 53 XOLAIR INJ 150MG/ML ...... 94 ZOMACTON INJ 10MG ...... 67 XOLAIR INJ 75/0.5 ...... 94 ZOMACTON INJ 5MG ...... 67 XOLAIR SOL 150MG ...... 94 ZONEGRAN CAP 100MG ...... 34 Y ZONEGRAN CAP 25MG ...... 34 YODEFAN-NF LIQ 200-5ML ...... 93 zonisamide cap 100 mg ...... 35 Z zonisamide cap 25 mg ...... 34 ZARONTIN CAP 250MG ...... 34 zonisamide cap 50 mg ...... 34 ZARONTIN SOL 250/5ML ...... 34 ZONTIVITY TAB 2.08MG ...... 77 ZEJULA CAP 100MG ...... 17 ZORBTIVE INJ 8.8MG ...... 67 ZELBORAF TAB 240MG ...... 16 ZORTRESS TAB 0.25MG ...... 79 zenatane cap 10mg ...... 95 ZORTRESS TAB 0.5MG ...... 79 zenatane cap 20mg ...... 95 ZORTRESS TAB 0.75MG ...... 79 zenatane cap 30mg ...... 95 ZOSTAVAX INJ ...... 81 zenatane cap 40mg ...... 95 ZOSTRIX NAT CRE 0.033% ...... 100 ZENPEP CAP 10000UNT ...... 74 ZUBSOLV SUB 0.7-0.18 ...... 57 ZENPEP CAP 15000UNT ...... 74 ZUBSOLV SUB 1.4-0.36 ...... 57 ZENPEP CAP 20000UNT ...... 74 ZUBSOLV SUB 11.4-2.9 ...... 57 ZENPEP CAP 25000 ...... 74 ZUBSOLV SUB 2.9-0.71 ...... 57 ZENPEP CAP 25000UNT ...... 74 ZUBSOLV SUB 5.7-1.4 ...... 57 ZENPEP CAP 3000UNIT ...... 74 ZUBSOLV SUB 8.6-2.1 ...... 57 ZENPEP CAP 40000 ...... 74 ZYDELIG TAB 100MG ...... 16 ZENPEP CAP 40000UNT ...... 74 ZYDELIG TAB 150MG ...... 17 ZENPEP CAP 5000UNIT ...... 74 ZYKADIA CAP 150MG ...... 17 ZIAGEN SOL 20MG/ML ...... 11 ZYPREXA INJ 10MG ...... 45 ZIAGEN TAB 300MG ...... 11 ZYPREXA RELP INJ 210MG ...... 45 zidovudine cap 100 mg ...... 11 ZYPREXA RELP INJ 300MG ...... 45 zidovudine syrup 10 mg/ml ...... 11 ZYPREXA RELP INJ 405MG ...... 45 zidovudine tab 300 mg ...... 11 ZYPREXA TAB 10MG ...... 45 ziprasidone hcl cap 20 mg ...... 45 ZYPREXA TAB 15MG ...... 45 ziprasidone hcl cap 40 mg ...... 45 ZYPREXA TAB 2.5MG ...... 45 ziprasidone hcl cap 60 mg ...... 45 ZYPREXA TAB 20MG ...... 45 ziprasidone hcl cap 80 mg ...... 45 ZYPREXA TAB 5MG ...... 45 ZOLINZA CAP 100MG ...... 17 ZYPREXA TAB 7.5MG ...... 45 zolmitriptan orally disintegrating tab 2.5 ZYPREXA ZYDI TAB 10MG ...... 45 mg ...... 55 ZYPREXA ZYDI TAB 15MG ...... 45 zolmitriptan orally disintegrating tab 5 ZYPREXA ZYDI TAB 20MG ...... 45 mg ...... 55 ZYPREXA ZYDI TAB 5MG ...... 45 zolmitriptan tab 2.5 mg ...... 55 ZYRTEC ALLGY TAB 10MG ...... 90 zolmitriptan tab 5 mg ...... 55 ZYRTEC CHILD TAB 10MG ...... 90 ZOLOFT TAB 100MG ...... 38

147