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Home , Balsalazide, Cyclopentolate, Delavirdine, Eslicarbazepine acetate, Isradipine

Blue Cross Community CentennialSM 2018 Drug List This document contains information NTENNIALCARE about the drugs we cover in this plan

This formulary is up-to-date through its publication date, July 1, 2018 Blue Cross Community Centennial

What is the Blue Cross Community ––The first column of the chart has the name of the drug. Centennial drug list? Brand name drugs are capitalized (e.g., CIPRO) and generic drugs are listed in lower-case italics The drug list (sometimes called a “formulary”) is a list (e.g., ). showing the drugs that can be covered by your Blue Cross ––The information in the “Necessary actions, restrictions, Community Centennial health plan. The drugs listed will be or limits on use” column tells you if Blue Cross covered as long as you: Community Centennial has any rules for • Have a medical need for them covering your drug. • Fill the medication orders at an in-network pharmacy • The drugs are listed in categories, or groups, based on • Follow the other rules of your Blue Cross Community the type of medical conditions they treat. (For example, Centennial health plan drugs used to treat a condition are listed under Heart and Circulatory Drugs). For more information on how to fill your medication orders, please review your Member Handbook. You may also contact • If you know what your drug is used for, look for the group Blue Cross and Blue Shield of New Mexico (BCBSNM) in the drug list. Then, look under that group for your drug. Member Services at 1-866-689-1523 (TTY/TDD 711). 2. Alphabetical Listing • Look for your drug in the index at the back of this book. What will I pay? • Next to your drug, you will see the page number where In most cases you do not pay for covered drugs. Some you can find coverage information. members will have prescription copays depending on their category of eligibility. What are generic drugs? Can the drug list change? A generic drug is approved by the Food and Drug Administration (FDA) as having the same active ingredient as Yes, it can change for various reasons such as a new, less the brand name drug, but often costs less. expensive generic drug becomes available. You will be told in writing when changes are made to Does the plan cover over-the-counter the drug list. (OTC) drugs? How do I use the drug list? Yes, Blue Cross Community Centennial covers certain OTC drugs with a valid medication order from your health care There are two ways to find your drug in the list provider, and you may get those at no cost. Generic OTC beginning on page 1. drugs are to be prescribed and filled by your pharmacy when 1. Category available. These OTC drugs must be filled at a pharmacy that • The list of covered drugs that begins on page 1 gives you participates in the Blue Cross Community Centennial network information about the drugs covered by Blue Cross and for quantities up to a 30-day supply. Many of the OTC Community Centennial. If you have trouble finding your drugs found on the drug list have an age restriction depending drug in the list, turn to the Index that begins at the back on what type of coverage you have. of this book.

i Drug List

Are there any limits on my coverage? • Step Therapy: In some cases, Blue Cross Community Added conditions or limits on some covered drugs Centennial requires you to first try certain drugs before another drug can be covered. For example if Drug A and may include: Drug B both treat your medical condition, the plan may not • Prior Authorization: You or your provider may need to get cover Drug B unless you try Drug A first. If Drug A does not approval from Blue Cross and Blue Shield of New Mexico work for you, the plan will then cover Drug B. Medications (BCBSNM) before you fill some of your medication orders. that are subject to step therapy are identified in the drug Medications that require prior authorization are identified in list by an “ST” in the “Necessary actions, restrictions, or the drug list by a “PA” in the “Necessary actions, limits on use” column. restrictions, or limits on use” column. If you do not get ––What if my drug is not covered because I have not approval, Blue Cross Community Centennial may not cover met the step therapy? (pay for) the drug. úú Contact BCBSNM Member Services at ––What if my drug requires a prior authorization? 1-866-689-1523 (TTY/TDD 711) and ask how you or úú Contact BCBSNM Member Services at your provider can submit a step therapy 1-866-689-1523 (TTY/TDD 711) and ask how you or exception request. your provider can submit a prior authorization úú You can also talk to your provider to decide if you (exception) request. should first try a different drug on our list that does not úú You can also talk to your provider to decide if you require step therapy. should first try a different drug on our list before you • Equivalent (ME) Dosing: ME dosing is a tool request an exception. used to help prevent members from taking too much pain • Quantity Limits: For certain drugs, Blue Cross Community medication (). This tool allows BCBSNM to calculate Centennial limits the amount of a drug that will be covered the total daily dose of pain medications a member is taking for a period of time (e.g., no more than 60 tablets for 30 no matter which they are prescribed. The current days). Medications that have quantity limits are identified in daily ME limit in New Mexico is 90 mg per day. If you are the drug list by a “QL” in the “Necessary actions, taking a dose above ME90, you will need to get prior restrictions, or limits on use” column. authorization (approval) from BCBSNM for Blue Cross ––What if my drug is not covered because it exceeds Community Centennial to pay for the prescription(s). the quantity limit? Medications that have morphine equivalents are identified úú Contact BCBSNM Member Services at in the drug list by an “ME” in the “Necessary actions, 1-866-689-1523 (TTY/TDD 711) and ask how you or restrictions, or limits on use” column. your provider can submit a quantity limit You can find out if your drug has any other conditions or limits exception request. by looking at the drug list that begins on page 1. úú You can also talk to your provider to decide if you should first try a different drug on our list or different dose of your medication before you request an exception.

ii Blue Cross Community Centennial

What if my drug is not on the drug list? Which drug categories are not covered Contact BCBSNM Member Services at 1-866-689-1523 by the Plan drug list? (TTY/TDD 711) and ask if your drug is covered. If you learn The following drug categories are not covered by your that Blue Cross Community Centennial does not cover your Blue Cross Community Centennial health plan: drug, you have two options: • Anorexia, weight loss, or weight gain drugs • Talk to your provider to decide if you should first try a • Bulk chemicals different drug on our list before you request an exception. • Cosmetic enhancing drugs • Ask Member Services about making an exception to cover your drug. Member Services will tell you how you or your • Diagnostic agents provider can ask for an exception to the drug list. • Drug Efficacy Study Implementation (DESI). These are drugs The date we last updated the list is shown on the that are not shown to be safe and effective. front cover page. • Experimental and investigational drugs • Erectile dysfunction drugs prescribed to treat impotence Specialty Pharmacy (SP) Drugs • Fertility drugs Specialty drugs are certain prescription medications used to • General anesthetic drugs treat complex, chronic conditions like cancer, rheumatoid • Over-the-counter products not otherwise included on the arthritis and multiple sclerosis. Specialty drugs often require plan’s drug list special handling (like refrigeration during shipping) and administration (such as injection or infusion). Specialty • Surgical supply/medical devices pharmacy drugs require prior authorization before a Blue Cross Community Centennial members who have dual prescription may be filled. They can be filled for up to a coverage under both Medicare and Medicaid will find that 30-day supply. They must be filled by a specialty drug supplier most of their medications will be covered by Medicare. that participates in the network for Blue Cross Community However, a limited number of drugs will be covered under Centennial. AllianceRx Walgreens Prime is the preferred Blue Cross Community Centennial. BCBSNM supplier of specialty drugs. Most specialty drugs For Medicare Part B-covered drugs, Blue Cross Community fall under the pharmacy benefit and can be filled by Centennial members who are enrolled in both Medicare and AllianceRx Walgreens Prime. Specialty drugs under the Medicaid may be able to have their coinsurance covered pharmacy benefit that are unavailable from AllianceRx under their Medicaid benefit. However, some drugs are only Walgreens Prime can be obtained from a limited distribution covered under Medicare Part B if a member has a specific pharmacy provider. Limited distribution pharmacy providers medical condition or received a specific medical treatment. are identified by pharmaceutical manufacturers as having the For these drugs, medical history information will need to be highest standards for clinical expertise, patient education, reviewed first in order to cover a member’s coinsurance. service, treatment monitoring and support. For more Members should call Member Services at 1-866-689-1523 information about specialty drugs, contact Member Services (TTY/TDD 711) to have this coverage at 1-866-689-1523 (TTY/TDD 711). determination completed.

iii Drug List

For more Information For more details about drug coverage from your Blue Cross Community Centennial health plan, please review your Member Handbook and other plan materials. If you have any questions, please call BCBSNM Member Services at: 1-866-689-1523 (TTY/TDD 711). We are open 8:00 a.m. until 5:00 p.m. Mountain time, Monday through Friday.

Drug List Language Assistance Interpreter Services We can arrange for someone to help you speak with us in any language. There is no charge for these services. If your health care provider does not speak your language, we can arrange for a translator to help you. Please call Member Services at 1-866-689-1523 (TTY/TDD 711). Hearing and Vision Problems For our members with hearing problems, we offer TTY/TDD service at no charge. The line is open 24 hours a day/seven day a week at 711. Other Languages and Formats You can get this document in Spanish, or speak with someone about this information in other languages at no charge. Call 1-866-689-1523 (TTY/TDD: 711). The call is toll-free. You can also call Member Services, toll-free, to request this information in other alternative formats such as Braille, large print and other forms. Call toll-free: 1-866-689-1523 (TTY/TDD: 711). We are open 8:00 a.m. until 5:00 p.m. Mountain time, Monday through Friday.

iv Blue Cross Community Centennial

ATTENTION: If you speak English, language assistance services, free of charge, are available to you. To ask for auxiliary aids and services or materials in other Call 1-855-710-6984 (TTY: 711). formats and languages at no cost, ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. please call 1-866-689-1523 (TTY/TDD: 711). Llame al 1-855-710-6984 (TTY: 711). Díí baa akó nínízin: Díí saad bee yáníłti’go Diné Bizaad, saad bee áká’ánída’áwo’dę́ę́’, t’áá jiik’eh, éí ná Blue Cross and Blue Shield of New Mexico complies with applicable Federal civil rights laws and does hólǫ, kojį’ hódíílnih 1-855-710-6984 (TTY: 711). not discriminate on the basis of race, color, national origin, age, disability, or sex. Blue Cross and Blue ́ Shield of New Mexico does not exclude people or treat them differently because of race, color, national CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. origin, age, disability, or sex. Gọi số 1-855-710-6984 (TTY: 711).

Blue Cross and Blue Shield of New Mexico: ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur  Provides free aids and services to people with disabilities to communicate effectively with us, Verfügung. Rufnummer: 1-855-710-6984 (TTY: 711). such as: 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-855-710-6984 o Qualified sign language interpreters 。 o Written information in other formats (large print, audio, accessible electronic formats, other (TTY: 711) formats) ﻣﻠﺤﻮظﺔ: إذا ﻛﻨﺖ ﺗﺘﺤﺪث اذﻛﺮ اﻟﻠﻐﺔ، ﻓﺈن ﺧﺪﻣﺎت اﻟﻤﺴﺎﻋﺪة اﻟﻠﻐﻮﯾﺔ ﺗﺘﻮاﻓﺮ ﻟﻚ ﺑﺎﻟﻤﺠﺎن. اﺗﺼﻞ ﺑﺮﻗﻢ  Provides free language services to people whose primary language is not English, such as: 1-855-710-6984 (رﻗﻢ ھﺎﺗﻒ اﻟﺼﻢ واﻟﺒﻜﻢ: ).o Qualified interpreters 711 Information written in other languages o 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. If you need these services, contact Civil Rights Coordinator. 1-855-710-6984 (TTY: 711) 번으로 전화해 주십시오.

If you believe that Blue Cross and Blue Shield of New Mexico has failed to provide these services or PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can nang walang bayad. Tumawag sa 1-855-710-6984 (TTY: 711). file a grievance with: Civil Rights Coordinator, Office of Civil Rights Coordinator, 300 E. Randolph St., 35th floor, Chicago, Illinois 60601, 1-855-664-7270, TTY/TDD: 1-855-661-6965, Fax: 1-855-661-6960, 注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。1-855-710-6984 [email protected]. You can file a grievance in person or by mail, fax, or email. If you （TTY: 711）まで、お電話にてご連絡ください。 need help filing a grievance, Civil Rights Coordinator is available to help you. ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Appelez le 1-855-710-6984 (ATS: 711). Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 1-855-710-6984 (TTY: 711). U.S. Department of Health and Human Services 200 Independence Avenue, SW ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Room 509F, HHH Building Звоните 1-855-710-6984 (телетайп: 711). Washington, D.C. 20201 !यान द': य)द आप ,हदी बोलते ह4 तो आपके िलए मु:त म' भाषा सहायता सेवाएं उपलAध ह4। 1-800-368-1019, 800-537-7697 (TDD) 1-855-710-6984 (TTY: 711) पर कॉल कर'। Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. ھﺠﻮت: رﮔﺎ ھﺐ ﻧﺎﺑﺰ ﯾﺴﺮاف وﮔﺘﻔﮓ ﯾﻢ دﯾﻨﮏ، ﺗﻼﯾﮭﺴﺖ ﯾﻨﺎﺑﺰ ھﺐ ﺗﺮوص ﻧﺎﮔﯿﺎر ﯾﺎرب اﻣﺶ ﻣﮭﺎرف ﯾﻢ دﺷﺎب. اب TTY: 711) 1-855-710-6984) ﺳﺎﻣﺖ دﯾﺮﯾﮕﺐ.

เรียน: ถLาคุณพูดภาษาไทยคุณสามารถใชLบริการช_วยเหลือทางภาษาไดLฟรี โทร 1-855-710-6984 (TTY: 711). v Drug List

ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call 1-855-710-6984 (TTY: 711).

ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-855-710-6984 (TTY: 711).

Díí baa akó nínízin: Díí saad bee yáníłti’go Diné Bizaad, saad bee áká’ánída’áwo’dę́ę́’, t’áá jiik’eh, éí ná hólǫ́, kojį’ hódíílnih 1-855-710-6984 (TTY: 711). CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-855-710-6984 (TTY: 711).

ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-855-710-6984 (TTY: 711).

注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-855-710-6984 (TTY: 711)。

ﻣﻠﺤﻮظﺔ: إذا ﻛﻨﺖ ﺗﺘﺤﺪث اذﻛﺮ اﻟﻠﻐﺔ، ﻓﺈن ﺧﺪﻣﺎت اﻟﻤﺴﺎﻋﺪة اﻟﻠﻐﻮﯾﺔ ﺗﺘﻮاﻓﺮ ﻟﻚ ﺑﺎﻟﻤﺠﺎن. اﺗﺼﻞ ﺑﺮﻗﻢ 1-855-710-6984 (رﻗﻢ ھﺎﺗﻒ اﻟﺼﻢ واﻟﺒﻜﻢ: ).711 ).711

주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-855-710-6984 (TTY: 711) 번으로 전화해 주십시오.

PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-855-710-6984 (TTY: 711).

注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。1-855-710-6984 （TTY: 711）まで、お電話にてご連絡ください。

ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 1-855-710-6984 (ATS: 711).

ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 1-855-710-6984 (TTY: 711).

ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-855-710-6984 (телетайп: 711).

!यान द': य)द आप ,हदी बोलते ह4 तो आपके िलए मु:त म' भाषा सहायता सेवाएं उपलAध ह4। 1-855-710-6984 (TTY: 711) पर कॉल कर'।

ھﺠﻮت: رﮔﺎ ھﺐ ﻧﺎﺑﺰ ﯾﺴﺮاف وﮔﺘﻔﮓ ﯾﻢ دﯾﻨﮏ، ﺗﻼﯾﮭﺴﺖ ﯾﻨﺎﺑﺰ ھﺐ ﺗﺮوص ﻧﺎﮔﯿﺎر ﯾﺎرب اﻣﺶ ﻣﮭﺎرف ﯾﻢ دﺷﺎب. اب TTY: 711) 1-855-710-6984) ﺳﺎﻣﺖ دﯾﺮﯾﮕﺐ.

เรียน: ถLาคุณพูดภาษาไทยคุณสามารถใชLบริการช_วยเหลือทางภาษาไดLฟรี โทร 1-855-710-6984 (TTY: 711). vi 2018

Tier Level Necessary actions, restrictions, or limits on use Name of Drug ANTI-INFECTIVE AGENTS PENICILLINS AMOXICILLIN – amoxicillin (trihydrate) chew tab 125 mg 2 AMOXICILLIN – amoxicillin (trihydrate) chew tab 250 mg 2 amoxicillin (trihydrate) cap 250 mg 1 amoxicillin (trihydrate) cap 500 mg 1 amoxicillin (trihydrate) for susp 125 mg/5ml 1 amoxicillin (trihydrate) for susp 200 mg/5ml 1 amoxicillin (trihydrate) for susp 250 mg/5ml 1 amoxicillin (trihydrate) for susp 400 mg/5ml 1 amoxicillin (trihydrate) tab 875 mg 1 amoxicillin & k clavulanate for susp 200-28.5 mg/5ml 1 amoxicillin & k clavulanate for susp 250-62.5 mg/5ml 1 (Augmentin) amoxicillin & k clavulanate for susp 400-57 mg/5ml 1 amoxicillin & k clavulanate for susp 600-42.9 mg/5ml (Augmentin 1 es-600) amoxicillin & k clavulanate tab 250-125 mg 1 amoxicillin & k clavulanate tab 500-125 mg (Augmentin) 1 amoxicillin & k clavulanate tab 875-125 mg (Augmentin) 1 AMOXICILLIN/CLAVULANATE P – amoxicillin & k clavulanate 2 chew tab 200-28.5 mg AMOXICILLIN/CLAVULANATE P – amoxicillin & k clavulanate 2 chew tab 400-57 mg ampicillin cap 250 mg 1 ampicillin cap 500 mg 1 dicloxacillin cap 250 mg 1 dicloxacillin sodium cap 500 mg 1 penicillin v potassium for soln 125 mg/5ml 1 penicillin v potassium for soln 250 mg/5ml 1 penicillin v potassium tab 250 mg 1 penicillin v potassium tab 500 mg 1 CEPHALOSPORINS cefaclor cap 250 mg 1 cefaclor cap 500 mg 1 cefadroxil cap 500 mg 1

1 = Generic Drugs AL = Age Limit ME90 = Morphine Equivalent ST = Step Therapy 2 = Brand Drugs PA = Prior Authorization QL = Quantity Limits SP = Specialty 90 = 90 days available at mail order 1 2018

Tier Level Necessary actions, restrictions, or limits on use Name of Drug cefadroxil for susp 250 mg/5ml 1 cefadroxil for susp 500 mg/5ml 1 cefadroxil tab 1 gm 1 cefdinir cap 300 mg 1 cefdinir for susp 125 mg/5ml 1 cefdinir for susp 250 mg/5ml 1 cefixime for susp 100 mg/5ml (Suprax) 1 cefixime for susp 200 mg/5ml (Suprax) 1 cefprozil for susp 125 mg/5ml 1 cefprozil for susp 250 mg/5ml 1 cefprozil tab 250 mg 1 cefprozil tab 500 mg 1 cefuroxime axetil tab 250 mg 1 cefuroxime axetil tab 500 mg (Ceftin) 1 cephalexin cap 250 mg (Keflex) 1 cephalexin cap 500 mg (Keflex) 1 cephalexin for susp 125 mg/5ml 1 cephalexin for susp 250 mg/5ml 1 MACROLIDES AZITHROMYCIN – azithromycin powd pack for susp 1 gm 2 azithromycin for susp 100 mg/5ml (Zithromax) 1 azithromycin for susp 200 mg/5ml (Zithromax) 1 azithromycin tab 250 mg (Zithromax) 1 QL (60 tablets/180 days) azithromycin tab 500 mg (Zithromax) 1 QL (60 tablets/180 days) azithromycin tab 600 mg (Zithromax) 1 QL (60 tablets/180 days) for susp 125 mg/5ml 1 clarithromycin for susp 250 mg/5ml (Biaxin) 1 clarithromycin tab 250 mg (Biaxin) 1 clarithromycin tab 500 mg (Biaxin) 1 TETRACYCLINES demeclocycline hcl tab 150 mg 1 demeclocycline hcl tab 300 mg 1 doxycycline hyclate cap 50 mg 1 doxycycline hyclate cap 100 mg (Vibramycin) 1 doxycycline hyclate tab delayed release 50 mg (Doryx) 1 PA

1 = Generic Drugs AL = Age Limit ME90 = Morphine Equivalent ST = Step Therapy 2 = Brand Drugs PA = Prior Authorization QL = Quantity Limits SP = Specialty 90 = 90 days available at mail order 2 2018

Tier Level Necessary actions, restrictions, or limits on use Name of Drug doxycycline hyclate tab 20 mg 1 doxycycline hyclate tab 100 mg 1 doxycycline monohydrate cap 50 mg 1 doxycycline monohydrate cap 100 mg (Monodox) 1 doxycycline monohydrate for susp 25 mg/5ml (Vibramycin) 1 doxycycline monohydrate tab 50 mg (Adoxa) 1 doxycycline monohydrate tab 75 mg (Adoxa) 1 doxycycline monohydrate tab 100 mg (Adoxa pak 1/100) 1 minocycline hcl cap 50 mg (Minocin) 1 minocycline hcl cap 75 mg (Minocin) 1 minocycline hcl cap 100 mg (Minocin) 1 FLUOROQUINOLONES ciprofloxacin for oral susp 250 mg/5ml (5%) (5 gm/100ml) (Cipro) 1 ciprofloxacin for oral susp 500 mg/5ml (10%) (10 gm/100ml) 1 (Cipro) ciprofloxacin hcl tab 250 mg (base equiv) (Cipro) 1 ciprofloxacin hcl tab 500 mg (base equiv) (Cipro) 1 ciprofloxacin hcl tab 750 mg (base equiv) 1 levofloxacin oral soln 25 mg/ml 1 levofloxacin tab 250 mg (Levaquin) 1 levofloxacin tab 500 mg (Levaquin) 1 levofloxacin tab 750 mg (Levaquin) 1 AMINOGLYCOSIDES sulfate tab 500 mg 1 sulfate cap 250 mg 1 TOBRAMYCIN – tobramycin nebu soln 300 mg/5ml 2 SP tobramycin nebu soln 300 mg/5ml (Tobi) 1 SP TUBERCULOSIS ethambutol hcl tab 100 mg (Myambutol) 1 ethambutol hcl tab 400 mg (Myambutol) 1 isoniazid tab 100 mg 1 90 isoniazid tab 300 mg 1 90 PRIFTIN – tab 150 mg 2 pyrazinamide tab 500 mg 1 cap 150 mg (Mycobutin) 1

1 = Generic Drugs AL = Age Limit ME90 = Morphine Equivalent ST = Step Therapy 2 = Brand Drugs PA = Prior Authorization QL = Quantity Limits SP = Specialty 90 = 90 days available at mail order 3 2018

Tier Level Necessary actions, restrictions, or limits on use Name of Drug rifampin cap 150 mg (Rifadin) 1 rifampin cap 300 mg (Rifadin) 1 FUNGAL INFECTIONS fluconazole for susp 10 mg/ml (Diflucan) 1 QL (35 mls/30 days) fluconazole for susp 40 mg/ml (Diflucan) 1 QL (35 mls/30 days) fluconazole tab 50 mg (Diflucan) 1 QL (14 tablets/30 days) fluconazole tab 100 mg (Diflucan) 1 QL (14 tablets/30 days) fluconazole tab 150 mg (Diflucan) 1 QL (14 tablets/30 days) fluconazole tab 200 mg (Diflucan) 1 QL (14 tablets/30 days) flucytosine cap 250 mg (Ancobon) 1 flucytosine cap 500 mg (Ancobon) 1 griseofulvin microsize susp 125 mg/5ml 1 griseofulvin microsize tab 500 mg 1 griseofulvin ultramicrosize tab 125 mg (Gris-peg) 1 griseofulvin ultramicrosize tab 250 mg (Gris-peg) 1 tab 200 mg 1 NOXAFIL – tab delayed release 100 mg 2 PA, 90 NOXAFIL – posaconazole susp 40 mg/ml 2 PA, 90 oral powder 1 nystatin tab 500000 unit 1 terbinafine hcl tab 250 mg (Lamisil) 1 QL (90 tablets/365 days) voriconazole for susp 40 mg/ml (Vfend) 1 PA voriconazole tab 50 mg (Vfend) 1 PA voriconazole tab 200 mg (Vfend) 1 PA VIRAL INFECTIONS Cytomegalovirus valganciclovir hcl for soln 50 mg/ml (base equiv) (Valcyte) 1 90 valganciclovir hcl tab 450 mg (base equivalent) (Valcyte) 1 90 Hepatitis adefovir dipivoxil tab 10 mg (Hepsera) 1 90 BARACLUDE – entecavir oral soln 0.05 mg/ml 2 90 entecavir tab 0.5 mg (Baraclude) 1 90 entecavir tab 1 mg (Baraclude) 1 90 tab 100 mg (hbv) (Epivir hbv) 1 90 MAVYRET – glecaprevir-pibrentasvir tab 100-40 mg 2 PA, SP

1 = Generic Drugs AL = Age Limit ME90 = Morphine Equivalent ST = Step Therapy 2 = Brand Drugs PA = Prior Authorization QL = Quantity Limits SP = Specialty 90 = 90 days available at mail order 4 2018

Tier Level Necessary actions, restrictions, or limits on use Name of Drug ribavirin cap 200 mg (Rebetol) 1 PA, SP ribavirin tab 200 mg (Copegus) 1 PA, SP Herpes acyclovir cap 200 mg (Zovirax) 1 acyclovir susp 200 mg/5ml (Zovirax) 1 acyclovir tab 400 mg (Zovirax) 1 acyclovir tab 800 mg (Zovirax) 1 famciclovir tab 125 mg (Famvir) 1 valacyclovir hcl tab 500 mg (Valtrex) 1 valacyclovir hcl tab 1 gm (Valtrex) 1 HIV/AIDS sulfate soln 20 mg/ml (base equiv) (Ziagen) 1 QL (960 mls/30 days), 90 abacavir sulfate tab 300 mg (base equiv) (Ziagen) 1 QL (60 tablets/30 days), 90 abacavir sulfate-lamivudine tab 600-300 mg (Epzicom) 1 QL (30 tablets/30 days), 90 abacavir sulfate-lamivudine- tab 300-150-300 mg 1 QL (60 tablets/30 days), 90 (Trizivir) APTIVUS – cap 250 mg 2 QL (120 capsules/30 days), 90 APTIVUS – tipranavir oral soln 100 mg/ml 2 QL (380 mls/30 days), 90 sulfate cap 150 mg (base equiv) (Reyataz) 1 QL (30 capsules/30 days), 90 atazanavir sulfate cap 200 mg (base equiv) (Reyataz) 1 QL (60 capsules/30 days), 90 atazanavir sulfate cap 300 mg (base equiv) (Reyataz) 1 QL (30 capsules/30 days), 90 ATRIPLA – --tenofovir df tab 2 QL (30 tablets/30 days), 90 600-200-300 mg COMPLERA – emtricitabine--tenofovir df tab 2 QL (30 tablets/30 days), 90 200-25-300 mg CRIXIVAN – sulfate cap 200 mg 2 QL (270 capsules/30 days), 90 CRIXIVAN – indinavir sulfate cap 400 mg 2 QL (180 capsules/30 days), 90 DESCOVY – emtricitabine- fumarate tab 2 QL (30 tablets/30 days), 90 200-25 mg delayed release capsule 200 mg (Videx ec) 1 QL (30 capsules/30 days), 90 didanosine delayed release capsule 250 mg (Videx ec) 1 QL (30 capsules/30 days), 90 didanosine delayed release capsule 400 mg (Videx ec) 1 QL (30 capsules/30 days), 90 EDURANT – rilpivirine hcl tab 25 mg (base equivalent) 2 QL (30 tablets/30 days), 90 efavirenz cap 50 mg (Sustiva) 1 QL (90 capsules/30 days), 90 efavirenz cap 200 mg (Sustiva) 1 QL (60 capsules/30 days), 90 efavirenz tab 600 mg (Sustiva) 1 QL (30 tablets/30 days), 90

1 = Generic Drugs AL = Age Limit ME90 = Morphine Equivalent ST = Step Therapy 2 = Brand Drugs PA = Prior Authorization QL = Quantity Limits SP = Specialty 90 = 90 days available at mail order 5 2018

Tier Level Necessary actions, restrictions, or limits on use Name of Drug EMTRIVA – emtricitabine caps 200 mg 2 QL (30 capsules/30 days), 90 EMTRIVA – emtricitabine soln 10 mg/ml 2 QL (720 mls/30 days), 90 EVOTAZ – atazanavir sulfate- tab 300-150 mg (base 2 QL (30 tablets/30 days), 90 equiv) calcium tab 700 mg (base equiv) (Lexiva) 1 QL (120 tablets/30 days), 90 FUZEON – for inj 90 mg 2 QL (1 kit/30 days), SP, 90 GENVOYA – elvitegrav-cobic-emtricitab-tenofov af tab 2 QL (30 tablets/30 days), 90 150-150-200-10 mg INTELENCE – tab 25 mg 2 QL (120 tablets/30 days), 90 INTELENCE – etravirine tab 100 mg 2 QL (60 tablets/30 days), 90 INTELENCE – etravirine tab 200 mg 2 QL (60 tablets/30 days), 90 INVIRASE – mesylate cap 200 mg 2 QL (300 capsules/30 days), 90 INVIRASE – saquinavir mesylate tab 500 mg 2 QL (120 tablets/30 days), 90 ISENTRESS – potassium packet for susp 100 mg 2 QL (60 packets/30 days), 90 (base equiv) ISENTRESS – raltegravir potassium tab 400 mg (base equiv) 2 QL (60 tablets/30 days), 90 ISENTRESS – raltegravir potassium chew tab 25 mg (base 2 QL (180 tablets/30 days), 90 equiv) ISENTRESS – raltegravir potassium chew tab 100 mg (base 2 QL (180 tablets/30 days), 90 equiv) ISENTRESS HD – raltegravir potassium tab 600 mg (base equiv) 2 QL (60 tablets/30 days), 90 JULUCA – sodium-rilpivirine hcl tab 50-25 mg (base 2 QL (30 tablets/30 days) eq) KALETRA – - tab 100-25 mg 2 QL (180 tablets/30 days), 90 KALETRA – lopinavir-ritonavir tab 200-50 mg 2 QL (120 tablets/30 days), 90 lamivudine oral soln 10 mg/ml (Epivir) 1 QL (960 mls/30 days), 90 lamivudine tab 150 mg (Epivir) 1 QL (30 tablets/30 days), 90 lamivudine tab 300 mg (Epivir) 1 QL (30 tablets/30 days), 90 lamivudine-zidovudine tab 150-300 mg (Combivir) 1 QL (60 tablets/30 days), 90 LEXIVA – fosamprenavir calcium susp 50 mg/ml (base equiv) 2 QL (1800 mls/30 days) lopinavir-ritonavir soln 400-100 mg/5ml (80-20 mg/ml) (Kaletra) 1 QL (480 mls/30 days), 90 tab er 24hr 100 mg (Viramune xr) 1 QL (90 tablets/30 days), 90 nevirapine tab er 24hr 400 mg (Viramune xr) 1 QL (30 tablets/30 days), 90 nevirapine tab 200 mg (Viramune) 1 QL (60 tablets/30 days), 90 NORVIR – ritonavir cap 100 mg 2 QL (180 capsules/30 days), 90 NORVIR – ritonavir oral soln 80 mg/ml 2 QL (480 mls/30 days), 90 ODEFSEY – emtricitabine-rilpivirine-tenofovir af tab 2 QL (30 tablets/30 days), 90 200-25-25 mg

1 = Generic Drugs AL = Age Limit ME90 = Morphine Equivalent ST = Step Therapy 2 = Brand Drugs PA = Prior Authorization QL = Quantity Limits SP = Specialty 90 = 90 days available at mail order 6 2018

Tier Level Necessary actions, restrictions, or limits on use Name of Drug PREZCOBIX – -cobicistat tab 800-150 mg 2 QL (30 tablets/30 days), 90 PREZISTA – darunavir ethanolate susp 100 mg/ml (base equiv) 2 QL (400 mls/30 days), 90 PREZISTA – darunavir ethanolate tab 75 mg (base equiv) 2 QL (300 tablets/30 days), 90 PREZISTA – darunavir ethanolate tab 150 mg (base equiv) 2 QL (180 tablets/30 days), 90 PREZISTA – darunavir ethanolate tab 600 mg (base equiv) 2 QL (60 tablets/30 days), 90 PREZISTA – darunavir ethanolate tab 800 mg (base equiv) 2 QL (30 tablets/30 days), 90 RESCRIPTOR – delavirdine mesylate tab 100 mg 2 QL (90 tablets/30 days), 90 RESCRIPTOR – delavirdine mesylate tab 200 mg 2 QL (180 tablets/30 days), 90 ritonavir tab 100 mg (Norvir) 1 QL (180 tablets/30 days), 90 SELZENTRY – tab 150 mg 2 QL (60 tablets/30 days), 90 SELZENTRY – maraviroc tab 300 mg 2 QL (120 capsules/30 days), 90 cap 15 mg (Zerit) 1 QL (60 capsules/30 days), 90 stavudine cap 20 mg (Zerit) 1 QL (60 capsules/30 days), 90 stavudine cap 30 mg (Zerit) 1 QL (60 capsules/30 days), 90 stavudine cap 40 mg (Zerit) 1 QL (60 capsules/30 days), 90 STRIBILD – elvitegrav-cobic-emtricitab-tenofovdf tab 2 QL (30 tablets/30 days), 90 150-150-200-300 mg SUSTIVA – efavirenz tab 600 mg 2 QL (30 tablets/30 days), 90 SUSTIVA – efavirenz cap 50 mg 2 QL (90 capsules/30 days), 90 SUSTIVA – efavirenz cap 200 mg 2 QL (60 capsules/30 days), 90 fumarate tab 300 mg (Viread) 1 QL (30 tablets/30 days), 90 TIVICAY – dolutegravir sodium tab 50 mg (base equiv) 2 QL (60 tablets/30 days), 90 TRIUMEQ – abacavir-dolutegravir-lamivudine tab 600-50-300 mg 2 QL (30 tablets/30 days), 90 TRUVADA – emtricitabine-tenofovir disoproxil fumarate tab 2 QL (30 tablets/30 days), 90 100-150 mg TRUVADA – emtricitabine-tenofovir disoproxil fumarate tab 2 QL (30 tablets/30 days), 90 133-200 mg TRUVADA – emtricitabine-tenofovir disoproxil fumarate tab 2 QL (30 tablets/30 days), 90 167-250 mg TRUVADA – emtricitabine-tenofovir disoproxil fumarate tab 2 QL (30 tablets/30 days), 90 200-300 mg TYBOST – cobicistat tab 150 mg 2 QL (30 tablets/30 days), 90 VIDEX – didanosine for soln 2 gm 2 QL (1200 mls/30 days), 90 VIDEX – didanosine for soln 4 gm 2 QL (1200 mls/30 days), 90 VIRACEPT – mesylate tab 250 mg 2 QL (270 tablets/30 days), 90 VIRACEPT – nelfinavir mesylate tab 625 mg 2 QL (120 tablets/30 days), 90 VIRAMUNE – nevirapine susp 50 mg/5ml 2 QL (1200 mls/30 days), 90

1 = Generic Drugs AL = Age Limit ME90 = Morphine Equivalent ST = Step Therapy 2 = Brand Drugs PA = Prior Authorization QL = Quantity Limits SP = Specialty 90 = 90 days available at mail order 7 2018

Tier Level Necessary actions, restrictions, or limits on use Name of Drug VIREAD – tenofovir disoproxil fumarate oral powder 40 mg/gm 2 QL (4 bottles/30 days), 90 VIREAD – tenofovir disoproxil fumarate tab 150 mg 2 QL (30 tablets/30 days), 90 VIREAD – tenofovir disoproxil fumarate tab 200 mg 2 QL (30 tablets/30 days), 90 VIREAD – tenofovir disoproxil fumarate tab 250 mg 2 QL (30 tablets/30 days), 90 VIREAD – tenofovir disoproxil fumarate tab 300 mg 2 QL (30 tablets/30 days), 90 VITEKTA – tab 85 mg 2 QL (30 tablets/30 days), 90 VITEKTA – elvitegravir tab 150 mg 2 QL (30 tablets/30 days), 90 zidovudine cap 100 mg (Retrovir) 1 QL (180 capsules/30 days), 90 zidovudine syrup 10 mg/ml (Retrovir) 1 QL (1920 mls/30 days), 90 zidovudine tab 300 mg 1 QL (60 tablets/30 days), 90 Influenza RELENZA DISKHALER – zanamivir aero powder breath 2 QL (20 disks/120 days) activated 5 mg/blister MALARIA atovaquone-proguanil hcl tab 62.5-25 mg (Malarone) 1 QL (30 tablets/90 days) atovaquone-proguanil hcl tab 250-100 mg (Malarone) 1 QL (30 tablets/90 days) chloroquine phosphate tab 500 mg (Aralen) 1 90 DARAPRIM – pyrimethamine tab 25 mg 2 PA, SP hydroxychloroquine sulfate tab 200 mg (Plaquenil) 1 90 HCL – mefloquine hcl tab 250 mg 2 90 mefloquine hcl tab 250 mg 1 90 PRIMAQUINE PHOSPHATE – primaquine phosphate tab 2 26.3 mg (15 mg base) WORM INFECTIONS ALBENZA – albendazole tab 200 mg 2 BENZNIDAZOLE – benznidazole tab 12.5 mg 2 BENZNIDAZOLE – benznidazole tab 100 mg 2 ivermectin tab 3 mg (Stromectol) 1 praziquantel tab 600 mg (Biltricide) 1 OTHER ANTI-INFECTIVES CAYSTON – aztreonam lysine for inhal soln 75 mg (base 2 PA equivalent) clindamycin hcl cap 75 mg (Cleocin) 1 clindamycin hcl cap 150 mg (Cleocin) 1 clindamycin hcl cap 300 mg (Cleocin) 1

1 = Generic Drugs AL = Age Limit ME90 = Morphine Equivalent ST = Step Therapy 2 = Brand Drugs PA = Prior Authorization QL = Quantity Limits SP = Specialty 90 = 90 days available at mail order 8 2018

Tier Level Necessary actions, restrictions, or limits on use Name of Drug clindamycin palmitate hcl for soln 75 mg/5ml (base equiv) 1 (Cleocin pediatric gr) dapsone tab 25 mg 1 90 dapsone tab 100 mg 1 90 ENGERIX-B – hepatitis b vaccine (recombinant) susp 2 10 mcg/0.5ml ENGERIX-B – hepatitis b vaccine (recombinant) susp 20 mcg/ml 2 ENGERIX-B – hepatitis b vaccine (recombinant) 10 mcg/0.5ml 2 ENGERIX-B – hepatitis b vaccine (recombinant) 20 mcg/ml 2 IMOVAX RABIES (H.D.C.V.) – rabies virus vaccine, hdc inj 2 linezolid for susp 100 mg/5ml (Zyvox) 1 PA, QL (600 mls/180 days) linezolid tab 600 mg (Zyvox) 1 PA, QL (56 tablets/180 days) metronidazole cap 375 mg (Flagyl) 1 metronidazole tab 250 mg (Flagyl) 1 metronidazole tab 500 mg (Flagyl) 1 RABAVERT – rabies vaccine, pcec for inj 2 RECOMBIVAX HB – hepatitis b vaccine (recombinant) susp 2 5 mcg/0.5ml RECOMBIVAX HB – hepatitis b vaccine (recombinant) susp 2 10 mcg/ml RECOMBIVAX HB – hepatitis b vaccine (recombinant) susp 2 40 mcg/ml sulfamethoxazole-trimethoprim susp 200-40 mg/5ml 1 sulfamethoxazole-trimethoprim tab 400-80 mg (Bactrim) 1 sulfamethoxazole-trimethoprim tab 800-160 mg (Bactrim ds) 1 trimethoprim tab 100 mg 1 hcl cap 125 mg (Vancocin hcl) 1 vancomycin hcl cap 250 mg (Vancocin hcl) 1 XIFAXAN – tab 550 mg 2 PA, QL (60 tablets/30 days), 90 ZYVOX – linezolid for susp 100 mg/5ml 2 PA, QL (600 mls/180 days) AFLURIA PF 2017-2018 – influenza virus vaccine split pf susp 2 pref syringe 0.5 ml AFLURIA QUADRIVALENT 2017 – influenza virus vac split 2 quadrivalent susp pref syr 0.5ml AFLURIA QUADRIVALENT 2017 – influenza virus vaccine split 2 quadrivalent im inj AFLURIA 2017-2018 – influenza virus vaccine split im susp 2

1 = Generic Drugs AL = Age Limit ME90 = Morphine Equivalent ST = Step Therapy 2 = Brand Drugs PA = Prior Authorization QL = Quantity Limits SP = Specialty 90 = 90 days available at mail order 9 2018

Tier Level Necessary actions, restrictions, or limits on use Name of Drug FLUARIX QUADRIVALENT 2017 – influenza virus vac split 2 quadrivalent susp pref syr 0.5ml FLUCELVAX QUADRIVALENT 20 – influenza vac tissue-cultured 2 subunit quadrivalent im susp FLULAVAL QUADRIVALENT 201 – influenza virus vac split 2 quadrivalent susp pref syr 0.5ml FLUVIRIN 2017-2018 – influenza vac type a&b surface antigen 2 susp pref syr 0.5 ml FLUVIRIN 2017-2018 – influenza virus vaccine types a & b 2 surface antigen im susp FLUZONE HIGH-DOSE PF 2017 – influenza virus vac split high- 2 dose pf susp pref syr 0.5ml FLUZONE QUADRIVALENT 2015 – influenza virus vac split 2 quadrivalent susp pref syr 0.5ml FLUZONE QUADRIVALENT 2017 – influenza virus vac split 2 quadrivalent susp pref syr 0.5ml FLUZONE QUADRIVALENT 2017 – influenza virus vaccine split 2 quadrivalent im inj SHINGRIX – recombinant adjuvanted for im inj 2 QL (2 vaccines/days) 50 mcg CANCER DRUGS ACTIMMUNE – interferon gamma-1b inj 100 mcg/0.5ml 2 PA, QL (12 vials/28 days), SP, 90 (2000000 unit/0.5ml) AFINITOR – everolimus tab 2.5 mg 2 PA, QL (30 tablets/30 days), SP AFINITOR – everolimus tab 5 mg 2 PA, QL (30 tablets/30 days), SP AFINITOR – everolimus tab 7.5 mg 2 PA, QL (30 tablets/30 days), SP AFINITOR – everolimus tab 10 mg 2 PA, QL (30 tablets/30 days), SP AFINITOR DISPERZ – everolimus tab for oral susp 2 mg 2 PA, QL (60 tablets/30 days), SP AFINITOR DISPERZ – everolimus tab for oral susp 3 mg 2 PA, QL (90 tablets/30 days), SP AFINITOR DISPERZ – everolimus tab for oral susp 5 mg 2 PA, QL (60 tablets/30 days), SP ALECENSA – alectinib hcl cap 150 mg (base equivalent) 2 PA, QL (240 capsules/30 days), SP ALKERAN – melphalan tab 2 mg 2 anastrozole tab 1 mg (Arimidex) 1 90 bexarotene cap 75 mg (Targretin) 1 PA, SP bicalutamide tab 50 mg (Casodex) 1 BOSULIF – bosutinib tab 100 mg 2 PA, QL (120 tablets/30 days), SP BOSULIF – bosutinib tab 500 mg 2 PA, QL (30 tablets/30 days), SP CABOMETYX – cabozantinib s-malate tab 20 mg (base 2 PA, QL (30 tablets/30 days), SP equivalent)

1 = Generic Drugs AL = Age Limit ME90 = Morphine Equivalent ST = Step Therapy 2 = Brand Drugs PA = Prior Authorization QL = Quantity Limits SP = Specialty 90 = 90 days available at mail order 10 2018

Tier Level Necessary actions, restrictions, or limits on use Name of Drug CABOMETYX – cabozantinib s-malate tab 40 mg (base 2 PA, QL (30 tablets/30 days), SP equivalent) CABOMETYX – cabozantinib s-malate tab 60 mg (base 2 PA, QL (30 tablets/30 days), SP equivalent) CALQUENCE – acalabrutinib cap 100 mg 2 PA, QL (60 capsules/30 days) capecitabine tab 150 mg (Xeloda) 1 PA, SP capecitabine tab 500 mg (Xeloda) 1 PA, SP CAPRELSA – vandetanib tab 100 mg 2 PA, QL (60 tablets/30 days), SP CAPRELSA – vandetanib tab 300 mg 2 PA, QL (30 tablets/30 days), SP COMETRIQ – cabozantinib s-malate cap 3 x 20 mg (60 mg dose) 2 PA, QL (1 carton/28 days), SP kit COMETRIQ – cabozantinib s-mal cap 1 x 80 mg & 1 x 20 mg 2 PA, QL (1 carton/28 days), SP (100 dose) kit COMETRIQ – cabozantinib s-mal cap 1 x 80 mg & 3 x 20 mg 2 PA, QL (1 carton/28 days), SP (140 dose) kit COTELLIC – cobimetinib fumarate tab 20 mg (base equivalent) 2 PA, QL (63 tablets/28 days), SP cyclophosphamide cap 25 mg (Cyclophosphamide) 1 cyclophosphamide cap 50 mg (Cyclophosphamide) 1 ELIGARD – leuprolide acetate for subcutaneous inj kit 7.5 mg 2 SP ELIGARD – leuprolide acetate (3 month) for subcutaneous inj kit 2 SP 22.5mg ELIGARD – leuprolide acetate (4 month) for subcutaneous inj kit 2 SP 30 mg ELIGARD – leuprolide acetate (6 month) for subcutaneous inj kit 2 SP 45 mg ERIVEDGE – vismodegib cap 150 mg 2 PA, QL (30 capsules/30 days), SP exemestane tab 25 mg (Aromasin) 1 90 flutamide cap 125 mg 1 GILOTRIF – afatinib dimaleate tab 20 mg (base equivalent) 2 PA, QL (30 tablets/30 days), SP GILOTRIF – afatinib dimaleate tab 30 mg (base equivalent) 2 PA, QL (30 tablets/30 days), SP GILOTRIF – afatinib dimaleate tab 40 mg (base equivalent) 2 PA, QL (30 tablets/30 days), SP HEXALEN – altretamine cap 50 mg 2 PA, SP HYCAMTIN – hcl cap 0.25 mg (base equiv) 2 PA, SP HYCAMTIN – topotecan hcl cap 1 mg (base equiv) 2 PA, SP hydroxyurea cap 500 mg (Hydrea) 1 IBRANCE – palbociclib cap 75 mg 2 PA, QL (21 capsules/28 days), SP IBRANCE – palbociclib cap 100 mg 2 PA, QL (21 capsules/28 days), SP IBRANCE – palbociclib cap 125 mg 2 PA, QL (21 capsules/28 days), SP

1 = Generic Drugs AL = Age Limit ME90 = Morphine Equivalent ST = Step Therapy 2 = Brand Drugs PA = Prior Authorization QL = Quantity Limits SP = Specialty 90 = 90 days available at mail order 11 2018

Tier Level Necessary actions, restrictions, or limits on use Name of Drug ICLUSIG – ponatinib hcl tab 15 mg (base equiv) 2 PA, QL (60 tablets/30 days), SP ICLUSIG – ponatinib hcl tab 45 mg (base equiv) 2 PA, QL (30 tablets/30 days), SP mesylate tab 100 mg (base equivalent) (Gleevec) 1 PA, QL (90 tablets/30), SP imatinib mesylate tab 400 mg (base equivalent) (Gleevec) 1 PA, QL (60 tablets/30 days), SP INLYTA – axitinib tab 1 mg 2 PA, QL (180 tablets/30 days), SP INLYTA – axitinib tab 5 mg 2 PA, QL (120 tablets/30 days), SP JAKAFI – ruxolitinib phosphate tab 5 mg (base equivalent) 2 PA, QL (60 tablets/30 days), SP JAKAFI – ruxolitinib phosphate tab 10 mg (base equivalent) 2 PA, QL (60 tablets/30 days), SP JAKAFI – ruxolitinib phosphate tab 15 mg (base equivalent) 2 PA, QL (60 tablets/30 days), SP JAKAFI – ruxolitinib phosphate tab 20 mg (base equivalent) 2 PA, QL (60 tablets/30 days), SP JAKAFI – ruxolitinib phosphate tab 25 mg (base equivalent) 2 PA, QL (60 tablets/30 days), SP KISQALI FEMARA 600 DOSE – ribociclib tab 200 mg & letrozole 2 PA, QL (91 tablets/28 days) tab 2.5 mg therapy pack LENVIMA 10 MG DAILY DOSE – lenvatinib cap therapy pack 2 PA, QL (30 capsules/30 days), SP 10 mg (10 mg daily dose) LENVIMA 14 MG DAILY DOSE – lenvatinib cap therapy pack 10 2 PA, QL (60 capsules/30 days), SP & 4 mg (14 mg daily dose) LENVIMA 18 MG DAILY DOSE – lenvatinib cap therapy pack 10 2 PA, QL (90 capsules/30 days), SP & 4 (2) mg (18 mg daily dose) LENVIMA 20 MG DAILY DOSE – lenvatinib cap therapy pack 10 2 PA, QL (60 capsules/30 days), SP (2) mg (20 mg daily dose) LENVIMA 24 MG DAILY DOSE – lenvatinib cap therapy pack 10 2 PA, QL (90 capsules/30 days), SP (2) & 4 mg (24 mg daily dose) LENVIMA 8 MG DAILY DOSE – lenvatinib cap therapy pack 4 2 PA, QL (60 capsules/30 days), SP (2) mg (8 mg daily dose) letrozole tab 2.5 mg (Femara) 1 90 LEUCOVORIN CALCIUM – leucovorin calcium tab 10 mg 2 LEUCOVORIN CALCIUM – leucovorin calcium tab 15 mg 2 leucovorin calcium tab 5 mg 1 leucovorin calcium tab 25 mg 1 LEUKERAN – chlorambucil tab 2 mg 2 LONSURF – trifluridine-tipiracil tab 15-6.14 mg 2 PA, QL (100 tablets/28 days), SP LONSURF – trifluridine-tipiracil tab 20-8.19 mg 2 PA, QL (80 tablets/28 days), SP LUPRON DEPOT (1-MONTH) – leuprolide acetate for inj kit 2 PA, SP 3.75 mg LUPRON DEPOT (1-MONTH) – leuprolide acetate for inj kit 2 PA, SP 7.5 mg LUPRON DEPOT (3-MONTH) – leuprolide acetate (3 month) for 2 PA, SP inj kit 11.25 mg

1 = Generic Drugs AL = Age Limit ME90 = Morphine Equivalent ST = Step Therapy 2 = Brand Drugs PA = Prior Authorization QL = Quantity Limits SP = Specialty 90 = 90 days available at mail order 12 2018

Tier Level Necessary actions, restrictions, or limits on use Name of Drug LUPRON DEPOT (3-MONTH) – leuprolide acetate (3 month) for 2 PA, SP inj kit 22.5 mg LUPRON DEPOT (4-MONTH) – leuprolide acetate (4 month) for 2 PA, SP inj kit 30 mg LUPRON DEPOT (6-MONTH) – leuprolide acetate (6 month) for 2 PA, SP inj kit 45 mg LYNPARZA – olaparib cap 50 mg 2 PA, QL (480 capsules/30 days), SP LYNPARZA – olaparib tab 100 mg 2 PA, QL (120 tablets/30 days) LYNPARZA – olaparib tab 150 mg 2 PA, QL (120 tablets/30 days) LYSODREN – mitotane tab 500 mg 2 PA, SP MATULANE – procarbazine hcl cap 50 mg 2 PA, SP megestrol acetate susp 40 mg/ml (Megace oral) 1 megestrol acetate tab 20 mg 1 megestrol acetate tab 40 mg 1 MEKINIST – trametinib dimethyl sulfoxide tab 0.5 mg (base 2 PA, QL (90 tablets/30 days), SP equivalent) MEKINIST – trametinib dimethyl sulfoxide tab 2 mg (base 2 PA, QL (30 tablets/30 days), SP equivalent) mercaptopurine tab 50 mg 1 methotrexate sodium tab 2.5 mg (base equiv) 1 MYLERAN – busulfan tab 2 mg 2 NEXAVAR – sorafenib tosylate tab 200 mg (base equivalent) 2 PA, QL (120 tablets/30 days), SP NINLARO – ixazomib citrate cap 2.3 mg (base equivalent) 2 PA, QL (3 capsules/28 days), SP NINLARO – ixazomib citrate cap 3 mg (base equivalent) 2 PA, QL (3 capsules/28 days), SP NINLARO – ixazomib citrate cap 4 mg (base equivalent) 2 PA, QL (3 capsules/28 days), SP POMALYST – pomalidomide cap 1 mg 2 PA, QL (21 capsules/30 days), SP POMALYST – pomalidomide cap 2 mg 2 PA, QL (21 capsules/30 days), SP POMALYST – pomalidomide cap 3 mg 2 PA, QL (21 capsules/30 days), SP POMALYST – pomalidomide cap 4 mg 2 PA, QL (21 capsules/30 days), SP PURIXAN – mercaptopurine susp 2000 mg/100ml (20 mg/ml) 2 PA, SP RUBRACA – rucaparib camsylate tab 200 mg (base equivalent) 2 PA, QL (120 tablets/30 days) RUBRACA – rucaparib camsylate tab 250 mg (base equivalent) 2 PA, QL (120 tablets/30 days) RUBRACA – rucaparib camsylate tab 300 mg (base equivalent) 2 PA, QL (120 tablets/30 days) SPRYCEL – tab 20 mg 2 PA, QL (90 tablets/30 days), SP SPRYCEL – dasatinib tab 50 mg 2 PA, QL (30 tablets/30 days), SP SPRYCEL – dasatinib tab 70 mg 2 PA, QL (30 tablets/30 days), SP

1 = Generic Drugs AL = Age Limit ME90 = Morphine Equivalent ST = Step Therapy 2 = Brand Drugs PA = Prior Authorization QL = Quantity Limits SP = Specialty 90 = 90 days available at mail order 13 2018

Tier Level Necessary actions, restrictions, or limits on use Name of Drug SPRYCEL – dasatinib tab 80 mg 2 PA, QL (30 tablets/30 days), SP SPRYCEL – dasatinib tab 100 mg 2 PA, QL (30 tablets/30 days), SP SPRYCEL – dasatinib tab 140 mg 2 PA, QL (30 tablets/30 days), SP STIVARGA – regorafenib tab 40 mg 2 PA, QL (90 tablets/30 days), SP SUTENT – sunitinib malate cap 12.5 mg (base equivalent) 2 PA, QL (90 capsules/30 days), SP SUTENT – sunitinib malate cap 25 mg (base equivalent) 2 PA, QL (30 capsules/30 days), SP SUTENT – sunitinib malate cap 37.5 mg (base equivalent) 2 PA, QL (30 capsules/30 days), SP SUTENT – sunitinib malate cap 50 mg (base equivalent) 2 PA, QL (30 capsules/30 days), SP SYLATRON – peginterferon alfa-2b for inj kit 200 mcg 2 PA, SP SYLATRON – peginterferon alfa-2b for inj kit 300 mcg 2 PA, SP SYLATRON – peginterferon alfa-2b for inj kit 600 mcg 2 PA, SP TAFINLAR – dabrafenib mesylate cap 50 mg (base equivalent) 2 PA, QL (120 capsules/30 days), SP TAFINLAR – dabrafenib mesylate cap 75 mg (base equivalent) 2 PA, QL (120 capsules/30 days), SP tamoxifen citrate tab 10 mg (base equivalent) 1 90 tamoxifen citrate tab 20 mg (base equivalent) 1 90 TARCEVA – erlotinib hcl tab 25 mg (base equivalent) 2 PA, QL (60 tablets/30 days), SP TARCEVA – erlotinib hcl tab 100 mg (base equivalent) 2 PA, QL (30 tablets/30 days), SP TARCEVA – erlotinib hcl tab 150 mg (base equivalent) 2 PA, QL (30 tablets/30 days), SP TARGRETIN – bexarotene cap 75 mg 2 PA, SP TASIGNA – nilotinib hcl cap 50 mg (base equivalent) 2 PA, QL (120 capsules/30 days) TASIGNA – nilotinib hcl cap 150 mg (base equivalent) 2 PA, QL (120 capsules/30 days), SP TASIGNA – nilotinib hcl cap 200 mg (base equivalent) 2 PA, QL (120 capsules/30 days), SP temozolomide cap 5 mg (Temodar) 1 PA, SP temozolomide cap 20 mg (Temodar) 1 PA, SP temozolomide cap 100 mg (Temodar) 1 PA, SP temozolomide cap 140 mg (Temodar) 1 PA, SP temozolomide cap 180 mg (Temodar) 1 PA, SP temozolomide cap 250 mg (Temodar) 1 PA, SP tretinoin cap 10 mg 1 PA, SP TYKERB – lapatinib ditosylate tab 250 mg (base equiv) 2 PA, QL (180 tablets/30 days), SP VENCLEXTA – venetoclax tab 10 mg 2 PA, QL (60 tablets/30 days), SP VENCLEXTA – venetoclax tab 50 mg 2 PA, QL (30 tablets/30 days), SP

1 = Generic Drugs AL = Age Limit ME90 = Morphine Equivalent ST = Step Therapy 2 = Brand Drugs PA = Prior Authorization QL = Quantity Limits SP = Specialty 90 = 90 days available at mail order 14 2018

Tier Level Necessary actions, restrictions, or limits on use Name of Drug VENCLEXTA – venetoclax tab 100 mg 2 PA, QL (120 tablets/30 days), SP VENCLEXTA STARTING PACK – venetoclax tab therapy starter 2 PA, QL (1 pack/180 days), SP pack 10 & 50 & 100 mg VERZENIO – abemaciclib tab 50 mg 2 PA, QL (60 tablets/30 days) VERZENIO – abemaciclib tab 100 mg 2 PA, QL (60 tablets/30 days) VERZENIO – abemaciclib tab 150 mg 2 PA, QL (60 tablets/30 days) VERZENIO – abemaciclib tab 200 mg 2 PA, QL (60 tablets/30 days) VOTRIENT – pazopanib hcl tab 200 mg (base equiv) 2 PA, QL (120 tablets/30 days), SP XALKORI – crizotinib cap 200 mg 2 PA, QL (60 capsules/30 days), SP XALKORI – crizotinib cap 250 mg 2 PA, QL (60 capsules/30 days), SP XTANDI – enzalutamide cap 40 mg 2 PA, QL (120 capsules/30 days), SP ZELBORAF – vemurafenib tab 240 mg 2 PA, QL (240 tablets/30 days), SP ZOLINZA – vorinostat cap 100 mg 2 PA, QL (120 capsules/30 days), SP ZYKADIA – ceritinib cap 150 mg 2 PA, QL (150 capsules/30 days), SP ZYTIGA – abiraterone acetate tab 250 mg 2 PA, QL (120 tablets/30 days), SP ZYTIGA – abiraterone acetate tab 500 mg 2 PA, QL (60 tablets/30 days) HORMONES, DIABETES AND RELATED DRUGS delayed release particles cap 3 mg (Entocort ec) 1 CORTISONE ACETATE – cortisone acetate tab 25 mg 2 DEXAMETHASONE – dexamethasone soln 0.5 mg/5ml 2 dexamethasone elixir 0.5 mg/5ml 1 dexamethasone tab 0.5 mg 1 dexamethasone tab 0.75 mg 1 dexamethasone tab 1.5 mg 1 dexamethasone tab 4 mg 1 dexamethasone tab 6 mg 1 fludrocortisone acetate tab 0.1 mg 1 90 hydrocortisone tab 5 mg (Cortef) 1 hydrocortisone tab 10 mg (Cortef) 1 hydrocortisone tab 20 mg (Cortef) 1 methylprednisolone tab therapy pack 4 mg (21) (Medrol dosepak) 1 methylprednisolone tab 4 mg (Medrol) 1

1 = Generic Drugs AL = Age Limit ME90 = Morphine Equivalent ST = Step Therapy 2 = Brand Drugs PA = Prior Authorization QL = Quantity Limits SP = Specialty 90 = 90 days available at mail order 15 2018

Tier Level Necessary actions, restrictions, or limits on use Name of Drug methylprednisolone tab 8 mg (Medrol) 1 methylprednisolone tab 16 mg (Medrol) 1 methylprednisolone tab 32 mg (Medrol) 1 – prednisolone syrup 15 mg/5ml (usp solution 2 equivalent) prednisolone sod phosph oral soln 6.7 mg/5ml (5 mg/5ml base) 1 (Pediapred) prednisolone sod phosphate oral soln 15 mg/5ml (base equiv) 1 prednisolone syrup 15 mg/5ml (usp solution equivalent) 1 – prednisone tab 50 mg 2 PREDNISONE – prednisone oral soln 5 mg/5ml 2 PREDNISONE – prednisone tab therapy pack 5 mg (21) 2 PREDNISONE – prednisone tab therapy pack 5 mg (48) 2 PREDNISONE – prednisone tab therapy pack 10 mg (21) 2 PREDNISONE – prednisone tab therapy pack 10 mg (48) 2 prednisone tab 1 mg 1 prednisone tab 2.5 mg 1 prednisone tab 5 mg 1 prednisone tab 10 mg 1 prednisone tab 20 mg 1 SOLU-CORTEF – hydrocortisone sodium succinate pf for inj 2 100 mg SOLU-CORTEF – hydrocortisone sodium succinate pf for inj 2 250 mg SOLU-CORTEF – hydrocortisone sodium succinate pf for inj 2 500 mg SOLU-CORTEF – hydrocortisone sodium succinate pf for inj 2 1000 mg MALE HORMONES danazol cap 50 mg 1 danazol cap 100 mg 1 danazol cap 200 mg 1 testosterone td gel 25 mg/2.5gm (1%) (Androgel) 1 PA, QL (60 packets/30 days), 90 testosterone td gel 50 mg/5gm (1%) (Androgel) 1 PA, QL (300 grams/30 days), 90 testosterone td gel 12.5 mg/act (1%) (Androgel pump) 1 PA, QL (300 grams/30 days), 90 ESTROGENS

1 = Generic Drugs AL = Age Limit ME90 = Morphine Equivalent ST = Step Therapy 2 = Brand Drugs PA = Prior Authorization QL = Quantity Limits SP = Specialty 90 = 90 days available at mail order 16 2018

Tier Level Necessary actions, restrictions, or limits on use Name of Drug COMBIPATCH – estradiol-norethindrone ace td pttw 2 90 0.05-0.14 mg/day COMBIPATCH – estradiol-norethindrone ace td pttw 2 90 0.05-0.25 mg/day ENJUVIA – estrogens, conjugated synthetic b tab 0.3 mg 2 90 ENJUVIA – estrogens, conjugated synthetic b tab 0.45 mg 2 90 ENJUVIA – estrogens, conjugated synthetic b tab 0.625 mg 2 90 ENJUVIA – estrogens, conjugated synthetic b tab 0.9 mg 2 90 estradiol & norethindrone acetate tab 0.5-0.1 mg (Activella) 1 90 estradiol & norethindrone acetate tab 1-0.5 mg (Activella) 1 90 estradiol tab 0.5 mg (Estrace) 1 90 estradiol tab 1 mg (Estrace) 1 90 estradiol tab 2 mg (Estrace) 1 90 estradiol td patch twice weekly 0.025 mg/24hr (Vivelle-dot) 1 QL (8 patches/28 days), 90 estradiol td patch twice weekly 0.0375 mg/24hr (Vivelle-dot) 1 QL (8 patches/28 days), 90 estradiol td patch twice weekly 0.05 mg/24hr (Vivelle-dot) 1 QL (8 patches/28 days), 90 estradiol td patch twice weekly 0.075 mg/24hr (Vivelle-dot) 1 QL (8 patches/28 days), 90 estradiol td patch twice weekly 0.1 mg/24hr (Vivelle-dot) 1 QL (8 patches/28 days), 90 estradiol td patch weekly 0.025 mg/24hr (Climara) 1 QL (4 patches/28 days), 90 estradiol td patch weekly 0.0375 mg/24hr (37.5 mcg/24hr) 1 QL (4 patches/28 days), 90 (Climara) estradiol td patch weekly 0.05 mg/24hr (Climara) 1 QL (4 patches/28 days), 90 estradiol td patch weekly 0.06 mg/24hr (Climara) 1 QL (4 patches/28 days), 90 estradiol td patch weekly 0.075 mg/24hr (Climara) 1 QL (4 patches/28 days) estradiol td patch weekly 0.1 mg/24hr (Climara) 1 QL (4 patches/28 days), 90 ESTROPIPATE – estropipate tab 3 mg 2 90 norethindrone acetate-ethinyl estradiol tab 0.5 mg-2.5 mcg 1 90 (Femhrt low dose) norethindrone acetate-ethinyl estradiol tab 1 mg-5 mcg 1 90 PROGESTINS medroxyprogesterone acetate tab 2.5 mg (Provera) 1 90 medroxyprogesterone acetate tab 5 mg (Provera) 1 90 medroxyprogesterone acetate tab 10 mg (Provera) 1 90 megestrol acetate susp 625 mg/5ml (Megace es) 1 90 norethindrone acetate tab 5 mg (Aygestin) 1 90 progesterone micronized cap 100 mg (Prometrium) 1 90

1 = Generic Drugs AL = Age Limit ME90 = Morphine Equivalent ST = Step Therapy 2 = Brand Drugs PA = Prior Authorization QL = Quantity Limits SP = Specialty 90 = 90 days available at mail order 17 2018

Tier Level Necessary actions, restrictions, or limits on use Name of Drug progesterone micronized cap 200 mg (Prometrium) 1 90 BIRTH CONTROL ELLA – ulipristal acetate tab 30 mg 2 QL (3 tablets/365 days) KYLEENA – releasing iud 17.5 mcg/day (19.5 mg 2 total) LILETTA – levonorgestrel releasing iud 18.6 mcg/day (52 mg 2 total) MIRENA – levonorgestrel releasing iud 20 mcg/day (52 mg total) 2 90 NEXPLANON – etonogestrel subdermal implant 68 mg 2 90 NUVARING – etonogestrel-ethinyl estradiol va ring 2 QL (1 ring/21 days), 90 0.120-0.015 mg/24hr PARAGARD INTRAUTERINE COP – copper iud 2 90 XULANE – norelgestromin-ethinyl estradiol td ptwk 2 QL (4 patches/28 days), 90 150-35 mcg/24hr ENDOMETRIOSIS LUPANETA PACK – leuprolide (1 mon) inj 3.75 mg & 2 PA, SP norethindrone tab 5 mg kit LUPANETA PACK – leuprolide (3 mon) inj 11.25 mg & 2 PA, SP norethindrone tab 5 mg kit LUPRON DEPOT-PED (1-MONTH – leuprolide acetate for inj 2 PA pediatric kit 7.5 mg LUPRON DEPOT-PED (1-MONTH – leuprolide acetate for inj 2 PA pediatric kit 11.25 mg LUPRON DEPOT-PED (1-MONTH – leuprolide acetate for inj 2 PA pediatric kit 15 mg LUPRON DEPOT-PED (3-MONTH – leuprolide acetate (3 2 PA month) for inj pediatric kit 11.25 mg LUPRON DEPOT-PED (3-MONTH – leuprolide acetate (3 2 PA month) for inj pediatric kit 30 mg SYNAREL – nafarelin acetate nasal soln 2 mg/ml (200 mcg/act) 2 SP (base eq) DIABETES acarbose tab 25 mg (Precose) 1 QL (180 tablets/30 days), 90 acarbose tab 50 mg (Precose) 1 QL (180 tablets/30 days), 90 acarbose tab 100 mg (Precose) 1 QL (90 tablets/30 days), 90 ALOGLIPTIN – alogliptin benzoate tab 6.25 mg (base equiv) 2 QL (30 tablets/30 days), ST, 90 ALOGLIPTIN – alogliptin benzoate tab 12.5 mg (base equiv) 2 QL (30 tablets/30 days), ST, 90 ALOGLIPTIN – alogliptin benzoate tab 25 mg (base equiv) 2 QL (30 tablets/30 days), ST, 90 ALOGLIPTIN/METFORMIN HCL – alogliptin-metformin hcl tab 2 QL (60 tablets/30 days), ST, 90 12.5-500 mg

1 = Generic Drugs AL = Age Limit ME90 = Morphine Equivalent ST = Step Therapy 2 = Brand Drugs PA = Prior Authorization QL = Quantity Limits SP = Specialty 90 = 90 days available at mail order 18 2018

Tier Level Necessary actions, restrictions, or limits on use Name of Drug ALOGLIPTIN/METFORMIN HCL – alogliptin-metformin hcl tab 2 QL (60 tablets/30 days), ST, 90 12.5-1000 mg ALOGLIPTIN/PIOGLITAZONE – alogliptin-pioglitazone tab 2 QL (30 tablets/30 days), ST, 90 12.5-15 mg ALOGLIPTIN/PIOGLITAZONE – alogliptin-pioglitazone tab 2 QL (30 tablets/30 days), ST, 90 12.5-30 mg ALOGLIPTIN/PIOGLITAZONE – alogliptin-pioglitazone tab 2 QL (30 tablets/30 days), ST, 90 12.5-45 mg ALOGLIPTIN/PIOGLITAZONE – alogliptin-pioglitazone tab 2 QL (30 tablets/30 days), ST, 90 25-15 mg ALOGLIPTIN/PIOGLITAZONE – alogliptin-pioglitazone tab 2 QL (30 tablets/30 days), ST, 90 25-30 mg ALOGLIPTIN/PIOGLITAZONE – alogliptin-pioglitazone tab 2 QL (30 tablets/30 days), ST, 90 25-45 mg tab 1 mg (Amaryl) 1 QL (60 tablets/30 days), 90 glimepiride tab 2 mg (Amaryl) 1 QL (60 tablets/30 days), 90 glimepiride tab 4 mg (Amaryl) 1 QL (60 tablets/30 days), 90 tab er 24hr 2.5 mg (Glucotrol xl) 1 QL (60 tablets/30 days), 90 glipizide tab er 24hr 5 mg (Glucotrol xl) 1 QL (90 tablets/30 days), 90 glipizide tab er 24hr 10 mg (Glucotrol xl) 1 QL (60 tablets/30 days), 90 glipizide tab 5 mg (Glucotrol) 1 QL (120 tablets/30 days), 90 glipizide tab 10 mg (Glucotrol) 1 QL (120 tablets/30 days), 90 glipizide-metformin hcl tab 2.5-250 mg 1 QL (120 tablets/30 days), 90 glipizide-metformin hcl tab 2.5-500 mg 1 QL (120 tablets/30 days), 90 glipizide-metformin hcl tab 5-500 mg 1 QL (120 tablets/30 days), 90 GLUCAGON EMERGENCY KIT – glucagon (rdna) for inj kit 1 mg 2 QL (6 pens/365 days) glyburide micronized tab 1.5 mg (Glynase) 1 QL (120 tablets/30 days), 90 glyburide micronized tab 3 mg (Glynase) 1 QL (60 tablets/30 days), 90 glyburide micronized tab 6 mg (Glynase) 1 QL (60 tablets/30 days), 90 glyburide tab 1.25 mg 1 QL (60 tablets/30 days), 90 glyburide tab 2.5 mg 1 QL (60 tablets/30 days), 90 glyburide tab 5 mg 1 QL (120 tablets/30 days), 90 glyburide-metformin tab 1.25-250 mg (Glucovance) 1 QL (120 tablets/30 days), 90 glyburide-metformin tab 2.5-500 mg (Glucovance) 1 QL (120 tablets/30 days), 90 glyburide-metformin tab 5-500 mg (Glucovance) 1 QL (120 tablets/30 days), 90 KORLYM – mifepristone tab 300 mg 2 PA, QL (120 tablets/30 days), SP, 90 metformin hcl tab er 24hr 500 mg (Glucophage xr) 1 QL (120 tablets/30 days), 90

1 = Generic Drugs AL = Age Limit ME90 = Morphine Equivalent ST = Step Therapy 2 = Brand Drugs PA = Prior Authorization QL = Quantity Limits SP = Specialty 90 = 90 days available at mail order 19 2018

Tier Level Necessary actions, restrictions, or limits on use Name of Drug metformin hcl tab er 24hr 750 mg (Glucophage xr) 1 QL (60 tablets/30 days), 90 metformin hcl tab 500 mg (Glucophage) 1 QL (120 tablets/30 days), 90 metformin hcl tab 850 mg (Glucophage) 1 QL (90 tablets/30 days), 90 metformin hcl tab 1000 mg (Glucophage) 1 QL (60 tablets/30 days), 90 miglitol tab 25 mg (Glyset) 1 QL (120 tablets/30 days), 90 miglitol tab 50 mg (Glyset) 1 QL (90 tablets/30 days), 90 miglitol tab 100 mg (Glyset) 1 QL (90 tablets/30 days), 90 tab 60 mg (Starlix) 1 QL (120 tablets/30 days), 90 nateglinide tab 120 mg (Starlix) 1 QL (90 tablets/30 days), 90 pioglitazone hcl tab 15 mg (base equiv) (Actos) 1 QL (30 tablets/30 days), 90 pioglitazone hcl tab 30 mg (base equiv) (Actos) 1 QL (30 tablets/30 days), 90 pioglitazone hcl tab 45 mg (base equiv) (Actos) 1 QL (30 tablets/30 days), 90 VICTOZA – liraglutide soln pen-injector 18 mg/3ml (6 mg/ml) 2 PA, QL (3 pens/30 days), 90 DIABETES - INSULINS Rapid-Acting Insulins ADMELOG – insulin lispro inj 100 unit/ml 2 QL (45 mls/30 days), 90 ADMELOG SOLOSTAR – insulin lispro soln pen-injector 100 2 QL (45 mls/30 days), 90 unit/ml Short-Acting Insulins HUMULIN R – insulin regular (human) inj 100 unit/ml 2 QL (45 mls/30 days), 90 NOVOLIN R – insulin regular (human) inj 100 unit/ml 2 QL (45 mls/30 days), 90 NOVOLIN R RELION – insulin regular (human) inj 100 unit/ml 2 QL (45 mls/30 days), 90 RELION R – insulin regular (human) inj 100 unit/ml 2 QL (45 mls/30 days), 90 Intermediate-Acting Insulins HUMALOG MIX 50/50 – insulin lispro protamine & lispro inj 100 2 QL (45 mls/30 days), 90 unit/ml (50-50) HUMALOG MIX 50/50 KWIKPEN – insulin lispro prot & lispro sus 2 QL (45 mls/30 days), 90 pen-inj 100 unit/ml (50-50) HUMALOG MIX 75/25 – insulin lispro prot & lispro inj 100 unit/ml 2 QL (45 mls/30 days), 90 (75-25) HUMALOG MIX 75/25 KWIKPEN – insulin lispro prot & lispro sus 2 QL (45 mls/30 days), 90 pen-inj 100 unit/ml (75-25) HUMULIN N – insulin nph (human) (isophane) inj 100 unit/ml 2 QL (45 mls/30 days), 90 HUMULIN N KWIKPEN – insulin nph (human) (isophane) susp 2 QL (45 mls/30 days), 90 pen-injector 100 unit/ml HUMULIN 70/30 – insulin nph isophane & regular human inj 100 2 QL (45 mls/30 days), 90 unit/ml (70-30)

1 = Generic Drugs AL = Age Limit ME90 = Morphine Equivalent ST = Step Therapy 2 = Brand Drugs PA = Prior Authorization QL = Quantity Limits SP = Specialty 90 = 90 days available at mail order 20 2018

Tier Level Necessary actions, restrictions, or limits on use Name of Drug HUMULIN 70/30 KWIKPEN – insulin nph & regular susp pen-inj 2 QL (45 mls/30 days), 90 100 unit/ml (70-30) NOVOLIN N – insulin nph (human) (isophane) inj 100 unit/ml 2 QL (45 mls/30 days), 90 NOVOLIN N RELION – insulin nph (human) (isophane) inj 100 2 QL (45 mls/30 days), 90 unit/ml NOVOLIN 70/30 – insulin nph isophane & regular human inj 100 2 QL (45 mls/30 days), 90 unit/ml (70-30) NOVOLIN 70/30 RELION – insulin nph isophane & regular 2 QL (45 mls/30 days), 90 human inj 100 unit/ml (70-30) NOVOLOG MIX 70/30 – insulin aspart prot & aspart (human) inj 2 QL (45 mls/30 days), 90 100 unit/ml (70-30) NOVOLOG MIX 70/30 PREFILL – insulin aspart prot & aspart 2 QL (45 mls/30 days), 90 sus pen-inj 100 unit/ml (70-30) Basal Insulins BASAGLAR KWIKPEN – insulin glargine soln pen-injector 100 2 QL (45 mls/30 days), 90 unit/ml THYROID REGULATION levothyroxine sodium tab 25 mcg (Synthroid) 1 90 levothyroxine sodium tab 50 mcg (Synthroid) 1 90 levothyroxine sodium tab 75 mcg (Synthroid) 1 90 levothyroxine sodium tab 88 mcg (Synthroid) 1 90 levothyroxine sodium tab 100 mcg (Synthroid) 1 90 levothyroxine sodium tab 112 mcg (Synthroid) 1 90 levothyroxine sodium tab 125 mcg (Synthroid) 1 90 levothyroxine sodium tab 137 mcg (Synthroid) 1 90 levothyroxine sodium tab 150 mcg (Synthroid) 1 90 levothyroxine sodium tab 175 mcg (Synthroid) 1 90 levothyroxine sodium tab 200 mcg (Synthroid) 1 90 levothyroxine sodium tab 300 mcg (Synthroid) 1 90 liothyronine sodium tab 5 mcg (Cytomel) 1 90 liothyronine sodium tab 25 mcg (Cytomel) 1 90 liothyronine sodium tab 50 mcg (Cytomel) 1 90 methimazole tab 5 mg (Tapazole) 1 90 methimazole tab 10 mg (Tapazole) 1 90 propylthiouracil tab 50 mg 1 90 thyroid tab 30 mg (1/2 grain) (Armour thyroid) 1 90 thyroid tab 60 mg (1 grain) (Armour thyroid) 1 90

1 = Generic Drugs AL = Age Limit ME90 = Morphine Equivalent ST = Step Therapy 2 = Brand Drugs PA = Prior Authorization QL = Quantity Limits SP = Specialty 90 = 90 days available at mail order 21 2018

Tier Level Necessary actions, restrictions, or limits on use Name of Drug thyroid tab 90 mg (1 1/2 grain) (Armour thyroid) 1 90 GROWTH HORMONE INCRELEX – mecasermin inj 40 mg/4ml (10 mg/ml) 2 PA, SP, 90 OMNITROPE – somatropin for inj 5.8 mg 2 PA, SP, 90 SEROSTIM – somatropin (non-refrigerated) for subcutaneous inj 2 PA, SP, 90 4 mg SEROSTIM – somatropin (non-refrigerated) for subcutaneous inj 2 PA, SP, 90 5 mg SEROSTIM – somatropin (non-refrigerated) for subcutaneous inj 2 PA, SP, 90 6 mg ZORBTIVE – somatropin (non-refrigerated) for subcutaneous inj 2 PA, SP, 90 8.8 mg OTHER HORMONES AND RELATED DRUGS ALENDRONATE SODIUM – alendronate sodium tab 40 mg 2 QL (30 tablets/30 days) alendronate sodium tab 5 mg 1 QL (30 tablets/30 days), 90 alendronate sodium tab 10 mg 1 QL (30 tablets/30 days), 90 alendronate sodium tab 35 mg 1 QL (4 tablets/28 days), 90 alendronate sodium tab 70 mg (Fosamax) 1 QL (4 tablets/28 days), 90 BUPHENYL – sodium phenylbutyrate tab 500 mg 2 PA, SP, 90 cabergoline tab 0.5 mg 1 calcitonin (salmon) nasal soln 200 unit/act (Miacalcin) 1 90 calcitriol cap 0.25 mcg (Rocaltrol) 1 90 calcitriol cap 0.5 mcg (Rocaltrol) 1 90 calcitriol oral soln 1 mcg/ml (Rocaltrol) 1 90 CARBAGLU – carglumic acid tab 200 mg 2 PA, SP, 90 desmopressin acetate nasal spray soln 0.01% (Ddavp) 1 90 desmopressin acetate nasal spray soln 0.01% (refrigerated) 1 90 desmopressin acetate tab 0.1 mg (Ddavp) 1 90 desmopressin acetate tab 0.2 mg (Ddavp) 1 90 ETIDRONATE DISODIUM – etidronate disodium tab 200 mg 2 H.P. ACTHAR – corticotropin inj gel 80 unit/ml 2 PA, SP ibandronate sodium tab 150 mg (base equivalent) (Boniva) 1 QL (1 tablets/30 days), 90 KUVAN – sapropterin dihydrochloride soluble tab 100 mg 2 PA, SP, 90 KUVAN – sapropterin dihydrochloride powder packet 100 mg 2 PA, SP, 90 KUVAN – sapropterin dihydrochloride powder packet 500 mg 2 PA, SP, 90 levocarnitine oral soln 1 gm/10ml (10%) (Carnitor) 1 90

1 = Generic Drugs AL = Age Limit ME90 = Morphine Equivalent ST = Step Therapy 2 = Brand Drugs PA = Prior Authorization QL = Quantity Limits SP = Specialty 90 = 90 days available at mail order 22 2018

Tier Level Necessary actions, restrictions, or limits on use Name of Drug levocarnitine tab 330 mg (Carnitor) 1 90 LUPRON DEPOT-PED (1-MONTH – leuprolide acetate for inj 2 PA pediatric kit 7.5 mg LUPRON DEPOT-PED (1-MONTH – leuprolide acetate for inj 2 PA pediatric kit 11.25 mg LUPRON DEPOT-PED (1-MONTH – leuprolide acetate for inj 2 PA pediatric kit 15 mg methylergonovine maleate tab 0.2 mg 1 NITYR – nitisinone tab 2 mg 2 PA, 90 NITYR – nitisinone tab 5 mg 2 PA, 90 NITYR – nitisinone tab 10 mg 2 PA, 90 raloxifene hcl tab 60 mg (Evista) 1 90 RAVICTI – glycerol phenylbutyrate liquid 1.1 gm/ml 2 PA, SP, 90 risedronate sodium tab delayed release 35 mg (Atelvia) 1 QL (4 tablets/28 days), 90 SAMSCA – tolvaptan tab 15 mg 2 PA, QL (30 tablets/365 days), SP SAMSCA – tolvaptan tab 30 mg 2 PA, QL (60 tablets/365 days), SP SIGNIFOR – pasireotide diaspartate inj 0.3 mg/ml (base equiv) 2 PA, QL (60 mls/30 days), SP, 90 SIGNIFOR – pasireotide diaspartate inj 0.6 mg/ml (base equiv) 2 PA, QL (60 mls/30 days), SP, 90 SIGNIFOR – pasireotide diaspartate inj 0.9 mg/ml (base equiv) 2 PA, QL (60 mls/30 days), SP, 90 SOMAVERT – pegvisomant for inj 10 mg (as protein) 2 PA, QL (30 vials/30 days), SP, 90 SOMAVERT – pegvisomant for inj 15 mg (as protein) 2 PA, QL (30 vials/30 days), SP, 90 SOMAVERT – pegvisomant for inj 20 mg (as protein) 2 PA, QL (30 vials/30 days), SP, 90 SOMAVERT – pegvisomant for inj 25 mg (as protein) 2 PA, QL (30 vials/30 days), SP, 90 SOMAVERT – pegvisomant for inj 30 mg (as protein) 2 PA, QL (30 vials/30 days), SP, 90 STIMATE – desmopressin acetate nasal soln 1.5 mg/ml 2 90 XURIDEN – uridine triacetate oral granules packet 2 gm 2 SP, 90 HEART AND CIRCULATORY DRUGS ANGIOTENSIN CONVERTING ENZYME (ACE) INHIBITORS AND COMBINATI benazepril & tab 5-6.25 mg 1 90 benazepril & hydrochlorothiazide tab 10-12.5 mg (Lotensin hct) 1 90 benazepril & hydrochlorothiazide tab 20-12.5 mg (Lotensin hct) 1 90 benazepril & hydrochlorothiazide tab 20-25 mg (Lotensin hct) 1 90 benazepril hcl tab 5 mg 1 90 benazepril hcl tab 10 mg (Lotensin) 1 90 benazepril hcl tab 20 mg (Lotensin) 1 90 benazepril hcl tab 40 mg (Lotensin) 1 90

1 = Generic Drugs AL = Age Limit ME90 = Morphine Equivalent ST = Step Therapy 2 = Brand Drugs PA = Prior Authorization QL = Quantity Limits SP = Specialty 90 = 90 days available at mail order 23 2018

Tier Level Necessary actions, restrictions, or limits on use Name of Drug captopril tab 12.5 mg 1 90 captopril tab 25 mg 1 90 captopril tab 50 mg 1 90 captopril tab 100 mg 1 90 CAPTOPRIL/HYDROCHLOROTHIA – captopril & 2 90 hydrochlorothiazide tab 25-15 mg CAPTOPRIL/HYDROCHLOROTHIA – captopril & 2 90 hydrochlorothiazide tab 25-25 mg CAPTOPRIL/HYDROCHLOROTHIA – captopril & 2 90 hydrochlorothiazide tab 50-15 mg CAPTOPRIL/HYDROCHLOROTHIA – captopril & 2 90 hydrochlorothiazide tab 50-25 mg enalapril maleate & hydrochlorothiazide tab 5-12.5 mg 1 90 enalapril maleate & hydrochlorothiazide tab 10-25 mg (Vaseretic) 1 90 enalapril maleate tab 2.5 mg (Vasotec) 1 90 enalapril maleate tab 5 mg (Vasotec) 1 90 enalapril maleate tab 10 mg (Vasotec) 1 90 enalapril maleate tab 20 mg (Vasotec) 1 90 fosinopril sodium & hydrochlorothiazide tab 10-12.5 mg 1 90 fosinopril sodium & hydrochlorothiazide tab 20-12.5 mg 1 90 fosinopril sodium tab 10 mg 1 90 fosinopril sodium tab 20 mg 1 90 fosinopril sodium tab 40 mg 1 90 lisinopril & hydrochlorothiazide tab 10-12.5 mg (Zestoretic) 1 90 lisinopril & hydrochlorothiazide tab 20-12.5 mg (Zestoretic) 1 90 lisinopril & hydrochlorothiazide tab 20-25 mg (Zestoretic) 1 90 lisinopril tab 2.5 mg (Zestril) 1 90 lisinopril tab 5 mg (Prinivil) 1 90 lisinopril tab 10 mg (Prinivil) 1 90 lisinopril tab 20 mg (Prinivil) 1 90 lisinopril tab 30 mg (Zestril) 1 90 lisinopril tab 40 mg (Zestril) 1 90 moexipril hcl tab 7.5 mg 1 90 moexipril hcl tab 15 mg 1 90 moexipril-hydrochlorothiazide tab 7.5-12.5 mg 1 90 moexipril-hydrochlorothiazide tab 15-12.5 mg 1 90

1 = Generic Drugs AL = Age Limit ME90 = Morphine Equivalent ST = Step Therapy 2 = Brand Drugs PA = Prior Authorization QL = Quantity Limits SP = Specialty 90 = 90 days available at mail order 24 2018

Tier Level Necessary actions, restrictions, or limits on use Name of Drug moexipril-hydrochlorothiazide tab 15-25 mg 1 90 perindopril erbumine tab 2 mg 1 90 perindopril erbumine tab 4 mg (Aceon) 1 90 perindopril erbumine tab 8 mg (Aceon) 1 90 quinapril hcl tab 5 mg (Accupril) 1 90 quinapril hcl tab 10 mg (Accupril) 1 90 quinapril hcl tab 20 mg (Accupril) 1 90 quinapril hcl tab 40 mg (Accupril) 1 90 quinapril-hydrochlorothiazide tab 10-12.5 mg (Accuretic) 1 90 quinapril-hydrochlorothiazide tab 20-12.5 mg (Accuretic) 1 90 quinapril-hydrochlorothiazide tab 20-25 mg (Accuretic) 1 90 ramipril cap 1.25 mg (Altace) 1 90 ramipril cap 2.5 mg (Altace) 1 90 ramipril cap 5 mg (Altace) 1 90 ramipril cap 10 mg (Altace) 1 90 trandolapril tab 1 mg (Mavik) 1 90 trandolapril tab 2 mg (Mavik) 1 90 trandolapril tab 4 mg 1 90 ANGIOTENSIN II RECEPTOR ANTAGONISTS (ARBS) AND COMBINATIONS irbesartan tab 75 mg (Avapro) 1 QL (30 tablets/30 days), 90 irbesartan tab 150 mg (Avapro) 1 QL (30 tablets/30 days), 90 irbesartan tab 300 mg (Avapro) 1 QL (30 tablets/30 days), 90 irbesartan-hydrochlorothiazide tab 150-12.5 mg (Avalide) 1 QL (30 tablets/30 days), 90 irbesartan-hydrochlorothiazide tab 300-12.5 mg (Avalide) 1 QL (30 tablets/30 days), 90 losartan potassium & hydrochlorothiazide tab 50-12.5 mg 1 QL (30 tablets/30 days), 90 (Hyzaar) losartan potassium & hydrochlorothiazide tab 100-12.5 mg 1 QL (30 tablets/30 days), 90 (Hyzaar) losartan potassium & hydrochlorothiazide tab 100-25 mg 1 QL (30 tablets/30 days), 90 (Hyzaar) losartan potassium tab 25 mg (Cozaar) 1 QL (60 tablets/30 days), 90 losartan potassium tab 50 mg (Cozaar) 1 QL (60 tablets/30 days), 90 losartan potassium tab 100 mg (Cozaar) 1 QL (30 tablets/30 days), 90 olmesartan medoxomil tab 5 mg (Benicar) 1 QL (60 tablets/30 days), 90 olmesartan medoxomil tab 20 mg (Benicar) 1 QL (30 tablets/30 days), 90 olmesartan medoxomil tab 40 mg (Benicar) 1 QL (30 tablets/30 days), 90

1 = Generic Drugs AL = Age Limit ME90 = Morphine Equivalent ST = Step Therapy 2 = Brand Drugs PA = Prior Authorization QL = Quantity Limits SP = Specialty 90 = 90 days available at mail order 25 2018

Tier Level Necessary actions, restrictions, or limits on use Name of Drug olmesartan medoxomil-hydrochlorothiazide tab 20-12.5 mg 1 QL (30 tablets/30 days), 90 (Benicar hct) olmesartan medoxomil-hydrochlorothiazide tab 40-12.5 mg 1 QL (30 tablets/30 days), 90 (Benicar hct) olmesartan medoxomil-hydrochlorothiazide tab 40-25 mg 1 QL (30 tablets/30 days), 90 (Benicar hct) valsartan tab 40 mg (Diovan) 1 QL (60 tablets/30 days), 90 valsartan tab 80 mg (Diovan) 1 QL (60 tablets/30 days), 90 valsartan tab 160 mg (Diovan) 1 QL (60 tablets/30 days), 90 valsartan tab 320 mg (Diovan) 1 QL (30 tablets/30 days), 90 valsartan-hydrochlorothiazide tab 80-12.5 mg (Diovan hct) 1 QL (30 tablets/30 days), 90 valsartan-hydrochlorothiazide tab 160-12.5 mg (Diovan hct) 1 QL (30 tablets/30 days), 90 valsartan-hydrochlorothiazide tab 160-25 mg (Diovan hct) 1 QL (30 tablets/30 days), 90 valsartan-hydrochlorothiazide tab 320-12.5 mg (Diovan hct) 1 QL (30 tablets/30 days), 90 valsartan-hydrochlorothiazide tab 320-25 mg (Diovan hct) 1 QL (30 tablets/30 days), 90 BETA BLOCKERS AND COMBINATIONS acebutolol hcl cap 200 mg (Sectral) 1 90 acebutolol hcl cap 400 mg (Sectral) 1 90 atenolol & chlorthalidone tab 50-25 mg (Tenoretic 50) 1 90 atenolol & chlorthalidone tab 100-25 mg (Tenoretic 100) 1 90 atenolol tab 25 mg (Tenormin) 1 90 atenolol tab 50 mg (Tenormin) 1 90 atenolol tab 100 mg (Tenormin) 1 90 betaxolol hcl tab 10 mg (Kerlone) 1 90 betaxolol hcl tab 20 mg (Kerlone) 1 90 bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg (Ziac) 1 90 bisoprolol & hydrochlorothiazide tab 5-6.25 mg (Ziac) 1 90 bisoprolol & hydrochlorothiazide tab 10-6.25 mg (Ziac) 1 90 bisoprolol fumarate tab 5 mg (Zebeta) 1 90 bisoprolol fumarate tab 10 mg (Zebeta) 1 90 tab 3.125 mg (Coreg) 1 90 carvedilol tab 6.25 mg (Coreg) 1 90 carvedilol tab 12.5 mg (Coreg) 1 90 carvedilol tab 25 mg (Coreg) 1 90 labetalol hcl tab 100 mg 1 90 labetalol hcl tab 200 mg 1 90

1 = Generic Drugs AL = Age Limit ME90 = Morphine Equivalent ST = Step Therapy 2 = Brand Drugs PA = Prior Authorization QL = Quantity Limits SP = Specialty 90 = 90 days available at mail order 26 2018

Tier Level Necessary actions, restrictions, or limits on use Name of Drug labetalol hcl tab 300 mg 1 90 metoprolol & hydrochlorothiazide tab 50-25 mg (Lopressor hct) 1 90 metoprolol & hydrochlorothiazide tab 100-25 mg (Lopressor hct) 1 90 metoprolol & hydrochlorothiazide tab 100-50 mg 1 90 metoprolol succinate tab er 24hr 25 mg (tartrate equiv) (Toprol xl) 1 90 metoprolol succinate tab er 24hr 50 mg (tartrate equiv) (Toprol xl) 1 90 metoprolol succinate tab er 24hr 100 mg (tartrate equiv) (Toprol 1 90 xl) metoprolol succinate tab er 24hr 200 mg (tartrate equiv) (Toprol 1 90 xl) metoprolol tartrate tab 25 mg 1 90 metoprolol tartrate tab 50 mg (Lopressor) 1 90 metoprolol tartrate tab 100 mg (Lopressor) 1 90 METOPROLOL/HYDROCHLOROTHI – metoprolol & 2 90 hydrochlorothiazide tab 100-50 mg nadolol tab 20 mg (Corgard) 1 90 nadolol tab 40 mg (Corgard) 1 90 nadolol tab 80 mg (Corgard) 1 90 pindolol tab 5 mg 1 90 hcl cap er 24hr 60 mg (Inderal la) 1 90 propranolol hcl cap er 24hr 80 mg (Inderal la) 1 90 propranolol hcl cap er 24hr 120 mg (Inderal la) 1 90 propranolol hcl cap er 24hr 160 mg (Inderal la) 1 90 propranolol hcl tab 10 mg 1 90 propranolol hcl tab 20 mg 1 90 propranolol hcl tab 40 mg 1 90 propranolol hcl tab 60 mg 1 90 propranolol hcl tab 80 mg 1 90 PROPRANOLOL/HYDROCHLOROTH – propranolol & 2 90 hydrochlorothiazide tab 40-25 mg PROPRANOLOL/HYDROCHLOROTH – propranolol & 2 90 hydrochlorothiazide tab 80-25 mg BLOCKERS AND COMBINATIONS besylate tab 2.5 mg (base equivalent) (Norvasc) 1 90 amlodipine besylate tab 5 mg (base equivalent) (Norvasc) 1 90 amlodipine besylate tab 10 mg (base equivalent) (Norvasc) 1 90 amlodipine besylate-benazepril hcl cap 2.5-10 mg 1 90

1 = Generic Drugs AL = Age Limit ME90 = Morphine Equivalent ST = Step Therapy 2 = Brand Drugs PA = Prior Authorization QL = Quantity Limits SP = Specialty 90 = 90 days available at mail order 27 2018

Tier Level Necessary actions, restrictions, or limits on use Name of Drug amlodipine besylate-benazepril hcl cap 5-10 mg (Lotrel) 1 90 amlodipine besylate-benazepril hcl cap 5-20 mg (Lotrel) 1 90 amlodipine besylate-benazepril hcl cap 5-40 mg 1 90 amlodipine besylate-benazepril hcl cap 10-20 mg (Lotrel) 1 90 amlodipine besylate-benazepril hcl cap 10-40 mg (Lotrel) 1 90 hcl cap er 12hr 60 mg 1 90 diltiazem hcl cap er 12hr 90 mg 1 90 diltiazem hcl cap er 12hr 120 mg 1 90 diltiazem hcl cap er 24hr 120 mg 1 90 diltiazem hcl cap er 24hr 180 mg 1 90 diltiazem hcl cap er 24hr 240 mg 1 90 diltiazem hcl coated beads cap er 24hr 120 mg (Cardizem cd) 1 90 diltiazem hcl coated beads cap er 24hr 180 mg (Cardizem cd) 1 90 diltiazem hcl coated beads cap er 24hr 240 mg (Cardizem cd) 1 90 diltiazem hcl coated beads cap er 24hr 300 mg 1 90 diltiazem hcl extended release beads cap er 24hr 120 mg 1 90 (Tiazac) diltiazem hcl extended release beads cap er 24hr 180 mg 1 90 (Tiazac) diltiazem hcl extended release beads cap er 24hr 240 mg 1 90 (Tiazac) diltiazem hcl extended release beads cap er 24hr 300 mg 1 90 (Tiazac) diltiazem hcl extended release beads cap er 24hr 360 mg 1 90 (Tiazac) diltiazem hcl extended release beads cap er 24hr 420 mg 1 90 (Tiazac) diltiazem hcl tab 30 mg (Cardizem) 1 90 diltiazem hcl tab 60 mg (Cardizem) 1 90 diltiazem hcl tab 90 mg 1 90 diltiazem hcl tab 120 mg (Cardizem) 1 90 ENTRESTO – sacubitril-valsartan tab 24-26 mg 2 PA, QL (60 tablets/30 days), 90 ENTRESTO – sacubitril-valsartan tab 49-51 mg 2 PA, QL (60 tablets/30 days), 90 ENTRESTO – sacubitril-valsartan tab 97-103 mg 2 PA, QL (60 tablets/30 days), 90 tab er 24hr 2.5 mg 1 90 felodipine tab er 24hr 5 mg 1 90 felodipine tab er 24hr 10 mg 1 90

1 = Generic Drugs AL = Age Limit ME90 = Morphine Equivalent ST = Step Therapy 2 = Brand Drugs PA = Prior Authorization QL = Quantity Limits SP = Specialty 90 = 90 days available at mail order 28 2018

Tier Level Necessary actions, restrictions, or limits on use Name of Drug cap 2.5 mg 1 90 isradipine cap 5 mg 1 90 hcl cap 20 mg 1 90 cap 10 mg (Procardia) 1 90 nifedipine cap 20 mg 1 90 nifedipine tab er 24hr 30 mg (Adalat cc) 1 90 nifedipine tab er 24hr 60 mg (Adalat cc) 1 90 nifedipine tab er 24hr 90 mg (Adalat cc) 1 90 nifedipine tab er 24hr osmotic release 30 mg (Procardia xl) 1 90 nifedipine tab er 24hr osmotic release 60 mg (Procardia xl) 1 90 nifedipine tab er 24hr osmotic release 90 mg (Procardia xl) 1 90 cap 30 mg 1 90 trandolapril- hcl tab er 1-240 mg (Tarka) 1 90 trandolapril-verapamil hcl tab er 2-180 mg (Tarka) 1 90 trandolapril-verapamil hcl tab er 2-240 mg (Tarka) 1 90 trandolapril-verapamil hcl tab er 4-240 mg (Tarka) 1 90 TRANDOLAPRIL/VERAPAMIL HC – trandolapril-verapamil hcl 2 90 tab er 1-240 mg verapamil hcl cap er 24hr 100 mg (Verelan pm) 1 90 verapamil hcl cap er 24hr 120 mg (Verelan) 1 90 verapamil hcl cap er 24hr 180 mg (Verelan) 1 90 verapamil hcl cap er 24hr 200 mg (Verelan pm) 1 90 verapamil hcl cap er 24hr 240 mg (Verelan) 1 90 verapamil hcl cap er 24hr 300 mg (Verelan pm) 1 90 verapamil hcl cap er 24hr 360 mg (Verelan) 1 90 verapamil hcl tab er 120 mg (Calan sr) 1 90 verapamil hcl tab er 180 mg (Calan sr) 1 90 verapamil hcl tab er 240 mg (Calan sr) 1 90 verapamil hcl tab 40 mg 1 90 verapamil hcl tab 80 mg (Calan) 1 90 verapamil hcl tab 120 mg (Calan) 1 90 CHEST PAIN isosorbide mononitrate tab er 24hr 30 mg 1 90 isosorbide mononitrate tab er 24hr 60 mg 1 90 isosorbide mononitrate tab er 24hr 120 mg 1 90

1 = Generic Drugs AL = Age Limit ME90 = Morphine Equivalent ST = Step Therapy 2 = Brand Drugs PA = Prior Authorization QL = Quantity Limits SP = Specialty 90 = 90 days available at mail order 29 2018

Tier Level Necessary actions, restrictions, or limits on use Name of Drug isosorbide mononitrate tab 10 mg 1 90 isosorbide mononitrate tab 20 mg 1 90 cap er 2.5 mg 1 90 nitroglycerin cap er 6.5 mg 1 90 nitroglycerin cap er 9 mg 1 90 nitroglycerin sl tab 0.3 mg (Nitrostat) 1 90 nitroglycerin sl tab 0.4 mg (Nitrostat) 1 90 nitroglycerin sl tab 0.6 mg (Nitrostat) 1 90 nitroglycerin td patch 24hr 0.1 mg/hr (Nitro-dur) 1 90 nitroglycerin td patch 24hr 0.2 mg/hr (Nitro-dur) 1 90 nitroglycerin td patch 24hr 0.4 mg/hr (Nitro-dur) 1 90 nitroglycerin td patch 24hr 0.6 mg/hr (Nitro-dur) 1 90 LOWERING atorvastatin calcium tab 10 mg (base equivalent) (Lipitor) 1 QL (30 tablets/30 days), 90 atorvastatin calcium tab 20 mg (base equivalent) (Lipitor) 1 QL (30 tablets/30 days), 90 atorvastatin calcium tab 40 mg (base equivalent) (Lipitor) 1 QL (30 tablets/30 days), 90 atorvastatin calcium tab 80 mg (base equivalent) (Lipitor) 1 QL (30 tablets/30 days), 90 cholestyramine light powder packets 4 gm 1 90 cholestyramine light powder 4 gm/dose (Questran light) 1 90 cholestyramine powder packets 4 gm (Questran) 1 90 cholestyramine powder 4 gm/dose (Questran) 1 90 fenofibrate cap dr 45 mg (fenofibric acid equiv) (Trilipix) 1 QL (60 tablets/30 days), 90 colestipol hcl granule packets 5 gm (Colestid flavored) 1 90 colestipol hcl granules 5 gm (Colestid flavored) 1 90 colestipol hcl tab 1 gm (Colestid) 1 90 fenofibrate micronized cap 43 mg 1 QL (60 capsules/30 days), 90 fenofibrate micronized cap 67 mg (Lofibra) 1 QL (30 capsules/30 days), 90 fenofibrate micronized cap 134 mg (Lofibra) 1 QL (30 capsules/30 days), 90 fenofibrate micronized cap 200 mg (Lofibra) 1 QL (30 capsules/30 days), 90 fenofibrate tab 48 mg (Tricor) 1 QL (60 tablets/30 days), 90 fenofibrate tab 54 mg (Lofibra) 1 QL (60 tablets/30 days), 90 fenofibrate tab 145 mg (Tricor) 1 QL (30 tablets/30 days), 90 fenofibrate tab 160 mg (Lofibra) 1 QL (30 tablets/30 days), 90 fluvastatin sodium tab er 24 hr 80 mg (Lescol xl) 1 QL (30 tablets/30 days), 90 gemfibrozil tab 600 mg (Lopid) 1 QL (60 tablets/30 days), 90

1 = Generic Drugs AL = Age Limit ME90 = Morphine Equivalent ST = Step Therapy 2 = Brand Drugs PA = Prior Authorization QL = Quantity Limits SP = Specialty 90 = 90 days available at mail order 30 2018

Tier Level Necessary actions, restrictions, or limits on use Name of Drug JUXTAPID – lomitapide mesylate cap 5 mg (base equiv) 2 PA, QL (30 capsules/30 days), SP, 90 JUXTAPID – lomitapide mesylate cap 10 mg (base equiv) 2 PA, QL (30 capsules/30 days), SP, 90 JUXTAPID – lomitapide mesylate cap 20 mg (base equiv) 2 PA, QL (30 capsules/30 days), SP, 90 JUXTAPID – lomitapide mesylate cap 30 mg (base equiv) 2 PA, QL (30 capsules/30 days), SP, 90 JUXTAPID – lomitapide mesylate cap 40 mg (base equiv) 2 PA, QL (30 capsules/30 days), SP, 90 JUXTAPID – lomitapide mesylate cap 60 mg (base equiv) 2 PA, QL (30 capsules/30 days), SP, 90 tab 10 mg 1 QL (60 tablets/30 days), 90 lovastatin tab 20 mg 1 QL (60 tablets/30 days), 90 lovastatin tab 40 mg (Mevacor) 1 QL (60 tablets/30 days), 90 PRALUENT – alirocumab subcutaneous soln pen-injector 75 mg/ 2 PA, QL (2 pens/28 days), SP, 90 ml PRALUENT – alirocumab subcutaneous soln pen-injector 2 PA, QL (2 pens/28 days), SP, 90 150 mg/ml PRALUENT – alirocumab subcutaneous soln prefilled syringe 2 PA, QL (2 syringes/28 75 mg/ml days), SP, 90 PRALUENT – alirocumab subcutaneous soln prefilled syringe 2 PA, QL (2 syringes/28 150 mg/ml days), SP, 90 pravastatin sodium tab 10 mg 1 QL (45 tablets/30 days), 90 pravastatin sodium tab 20 mg (Pravachol) 1 QL (45 tablets/30 days), 90 pravastatin sodium tab 40 mg (Pravachol) 1 QL (45 tablets/30 days), 90 pravastatin sodium tab 80 mg (Pravachol) 1 QL (30 tablets/30 days), 90 REPATHA – evolocumab subcutaneous soln prefilled syringe 2 PA, QL (2 syringes/28 140 mg/ml days), SP, 90 REPATHA PUSHTRONEX SYSTEM – evolocumab 2 PA, QL (1 syringe/30 subcutaneous soln cartridge/infusor 420 mg/3.5ml days), SP, 90 REPATHA SURECLICK – evolocumab subcutaneous soln auto- 2 PA, QL (2 syringes/28 injector 140 mg/ml days), SP, 90 rosuvastatin calcium tab 5 mg (Crestor) 1 QL (30 tablets/30 days), 90 rosuvastatin calcium tab 10 mg (Crestor) 1 QL (30 tablets/30 days), 90 rosuvastatin calcium tab 20 mg (Crestor) 1 QL (30 tablets/30 days), 90 rosuvastatin calcium tab 40 mg (Crestor) 1 QL (30 tablets/30 days), 90 tab 5 mg (Zocor) 1 QL (30 tablets/30 days), 90

1 = Generic Drugs AL = Age Limit ME90 = Morphine Equivalent ST = Step Therapy 2 = Brand Drugs PA = Prior Authorization QL = Quantity Limits SP = Specialty 90 = 90 days available at mail order 31 2018

Tier Level Necessary actions, restrictions, or limits on use Name of Drug simvastatin tab 10 mg (Zocor) 1 QL (30 tablets/30 days), 90 simvastatin tab 20 mg (Zocor) 1 QL (30 tablets/30 days), 90 simvastatin tab 40 mg (Zocor) 1 QL (30 tablets/30 days), 90 simvastatin tab 80 mg (Zocor) 1 QL (30 tablets/30 days), 90 FLUID RETENTION cap er 12hr 500 mg (Diamox) 1 90 acetazolamide tab 250 mg 1 90 & hydrochlorothiazide tab 5-50 mg 1 90 amiloride hcl tab 5 mg 1 90 tab 0.5 mg (Bumex) 1 90 bumetanide tab 1 mg (Bumex) 1 90 bumetanide tab 2 mg (Bumex) 1 90 CHLOROTHIAZIDE – chlorothiazide tab 250 mg 2 90 chlorothiazide tab 500 mg 1 90 chlorthalidone tab 25 mg 1 90 oral soln 10 mg/ml 1 90 furosemide tab 20 mg (Lasix) 1 90 furosemide tab 40 mg (Lasix) 1 90 furosemide tab 80 mg (Lasix) 1 90 hydrochlorothiazide cap 12.5 mg (Microzide) 1 90 hydrochlorothiazide tab 12.5 mg 1 90 hydrochlorothiazide tab 25 mg 1 90 hydrochlorothiazide tab 50 mg 1 90 indapamide tab 1.25 mg 1 90 indapamide tab 2.5 mg 1 90 metolazone tab 2.5 mg 1 90 metolazone tab 5 mg 1 90 metolazone tab 10 mg 1 90 spironolactone & hydrochlorothiazide tab 25-25 mg (Aldactazide) 1 90 spironolactone tab 25 mg (Aldactone) 1 90 spironolactone tab 50 mg (Aldactone) 1 90 spironolactone tab 100 mg (Aldactone) 1 90 torsemide tab 5 mg 1 90 torsemide tab 10 mg (Demadex) 1 90 torsemide tab 20 mg (Demadex) 1 90

1 = Generic Drugs AL = Age Limit ME90 = Morphine Equivalent ST = Step Therapy 2 = Brand Drugs PA = Prior Authorization QL = Quantity Limits SP = Specialty 90 = 90 days available at mail order 32 2018

Tier Level Necessary actions, restrictions, or limits on use Name of Drug torsemide tab 100 mg 1 90 & hydrochlorothiazide cap 37.5-25 mg (Dyazide) 1 90 triamterene & hydrochlorothiazide tab 37.5-25 mg (Maxzide-25) 1 90 triamterene & hydrochlorothiazide tab 75-50 mg (Maxzide) 1 90 HEART RHYTHM hcl tab 200 mg (Cordarone) 1 90 phosphate cap 100 mg (Norpace) 1 90 disopyramide phosphate cap 150 mg (Norpace) 1 90 cap 125 mcg (0.125 mg) (Tikosyn) 1 90 dofetilide cap 250 mcg (0.25 mg) (Tikosyn) 1 90 dofetilide cap 500 mcg (0.5 mg) (Tikosyn) 1 90 acetate tab 50 mg 1 90 flecainide acetate tab 100 mg 1 90 flecainide acetate tab 150 mg 1 90 hcl tab 150 mg 1 90 propafenone hcl tab 225 mg (Rythmol) 1 90 propafenone hcl tab 300 mg 1 90 gluconate tab er 324 mg 1 90 QUINIDINE SULFATE – quinidine sulfate tab 200 mg 2 90 QUINIDINE SULFATE – quinidine sulfate tab 300 mg 2 90 hcl (afib/afl) tab 80 mg (Betapace af) 1 90 sotalol hcl (afib/afl) tab 120 mg (Betapace af) 1 90 sotalol hcl (afib/afl) tab 160 mg (Betapace af) 1 90 sotalol hcl tab 80 mg (Betapace) 1 90 sotalol hcl tab 120 mg (Betapace) 1 90 sotalol hcl tab 160 mg (Betapace) 1 90 sotalol hcl tab 240 mg 1 90 OTHER HEART RELATED DRUGS ADCIRCA – tab 20 mg (pah) 2 PA, QL (60 tablets/30 days), SP, 90 ADEMPAS – riociguat tab 0.5 mg 2 PA, QL (90 tablets/30 days), SP, 90 ADEMPAS – riociguat tab 1 mg 2 PA, QL (90 tablets/30 days), SP, 90

1 = Generic Drugs AL = Age Limit ME90 = Morphine Equivalent ST = Step Therapy 2 = Brand Drugs PA = Prior Authorization QL = Quantity Limits SP = Specialty 90 = 90 days available at mail order 33 2018

Tier Level Necessary actions, restrictions, or limits on use Name of Drug ADEMPAS – riociguat tab 1.5 mg 2 PA, QL (90 tablets/30 days), SP, 90 ADEMPAS – riociguat tab 2 mg 2 PA, QL (90 tablets/30 days), SP, 90 ADEMPAS – riociguat tab 2.5 mg 2 PA, QL (90 tablets/30 days), SP, 90 clonidine hcl tab 0.1 mg (Catapres) 1 90 clonidine hcl tab 0.2 mg (Catapres) 1 90 clonidine hcl tab 0.3 mg (Catapres) 1 90 clonidine hcl td patch weekly 0.1 mg/24hr (Catapres-tts-1) 1 90 clonidine hcl td patch weekly 0.2 mg/24hr (Catapres-tts-2) 1 90 clonidine hcl td patch weekly 0.3 mg/24hr (Catapres-tts-3) 1 90 – digoxin oral soln 0.05 mg/ml 2 90 digoxin tab 125 mcg (0.125 mg) (Lanoxin) 1 90 digoxin tab 250 mcg (0.25 mg) (Lanoxin) 1 90 doxazosin mesylate tab 1 mg (Cardura) 1 QL (30 tablets/30 days), 90 doxazosin mesylate tab 2 mg (Cardura) 1 QL (30 tablets/30 days), 90 doxazosin mesylate tab 4 mg (Cardura) 1 QL (30 tablets/30 days), 90 doxazosin mesylate tab 8 mg (Cardura) 1 QL (60 tablets/30 days), 90 guanfacine hcl tab 1 mg (Tenex) 1 90 guanfacine hcl tab 2 mg (Tenex) 1 90 hydralazine hcl tab 10 mg 1 90 hydralazine hcl tab 25 mg 1 90 hydralazine hcl tab 50 mg 1 90 hydralazine hcl tab 100 mg 1 90 LETAIRIS – ambrisentan tab 5 mg 2 PA, QL (30 tablets/30 days), SP, 90 LETAIRIS – ambrisentan tab 10 mg 2 PA, QL (30 tablets/30 days), SP, 90 methyldopa tab 250 mg 1 90 methyldopa tab 500 mg 1 90 midodrine hcl tab 2.5 mg 1 midodrine hcl tab 5 mg 1 midodrine hcl tab 10 mg 1 tab 2.5 mg 1 90 minoxidil tab 10 mg 1 90

1 = Generic Drugs AL = Age Limit ME90 = Morphine Equivalent ST = Step Therapy 2 = Brand Drugs PA = Prior Authorization QL = Quantity Limits SP = Specialty 90 = 90 days available at mail order 34 2018

Tier Level Necessary actions, restrictions, or limits on use Name of Drug phenoxybenzamine hcl cap 10 mg (Dibenzyline) 1 prazosin hcl cap 1 mg (Minipress) 1 90 prazosin hcl cap 2 mg (Minipress) 1 90 prazosin hcl cap 5 mg (Minipress) 1 90 REVATIO – citrate for suspension 10 mg/ml 2 PA, QL (2 bottles/30 days), SP, 90 terazosin hcl cap 1 mg (base equivalent) 1 QL (30 capsules/30 days), 90 terazosin hcl cap 2 mg (base equivalent) 1 QL (30 capsules/30 days), 90 terazosin hcl cap 5 mg (base equivalent) 1 QL (30 capsules/30 days), 90 terazosin hcl cap 10 mg (base equivalent) 1 QL (60 capsules/30 days), 90 TRACLEER – bosentan tab for oral susp 32 mg 2 PA, QL (120 tablets/30 days) TRACLEER – bosentan tab 62.5 mg 2 PA, QL (60 tablets/30 days), SP, 90 TRACLEER – bosentan tab 125 mg 2 PA, QL (60 tablets/30 days), SP, 90 TYVASO – treprostinil inhalation solution 0.6 mg/ml 2 PA, QL (81.2 mls/28 days), SP, 90 TYVASO REFILL – treprostinil inhalation solution 0.6 mg/ml 2 PA, QL (81.2 mls/28 days), SP, 90 TYVASO STARTER – treprostinil inhalation solution 0.6 mg/ml 2 PA, QL (1 kit/180 days), SP, 90 UPTRAVI – selexipag tab therapy pack 200 mcg (140) & 2 PA, QL (200 800 mcg (60) tablets/180 days), SP UPTRAVI – selexipag tab 200 mcg 2 PA, QL (60 tablets/30 days), SP, 90 UPTRAVI – selexipag tab 400 mcg 2 PA, QL (60 tablets/30 days), SP, 90 UPTRAVI – selexipag tab 600 mcg 2 PA, QL (60 tablets/30 days), SP, 90 UPTRAVI – selexipag tab 800 mcg 2 PA, QL (60 tablets/30 days), SP, 90 UPTRAVI – selexipag tab 1000 mcg 2 PA, QL (60 tablets/30 days), SP, 90 UPTRAVI – selexipag tab 1200 mcg 2 PA, QL (60 tablets/30 days), SP, 90 UPTRAVI – selexipag tab 1400 mcg 2 PA, QL (60 tablets/30 days), SP, 90 UPTRAVI – selexipag tab 1600 mcg 2 PA, QL (60 tablets/30 days), SP, 90 VENTAVIS – iloprost inhalation solution 10 mcg/ml 2 SP, 90 VENTAVIS – iloprost inhalation solution 20 mcg/ml 2 SP, 90

1 = Generic Drugs AL = Age Limit ME90 = Morphine Equivalent ST = Step Therapy 2 = Brand Drugs PA = Prior Authorization QL = Quantity Limits SP = Specialty 90 = 90 days available at mail order 35 2018

Tier Level Necessary actions, restrictions, or limits on use Name of Drug ANAPHYLAXIS EPINEPHRINE – epinephrine solution auto-injector 2 QL (2 pens/1 prescription) 0.15 mg/0.3ml (1:2000) EPINEPHRINE – epinephrine solution auto-injector 0.3 mg/0.3ml 2 QL (2 pens/1 prescription) (1:1000) RESPIRATORY AGENTS maleate soln 4 mg/5ml 1 carbinoxamine maleate tab 4 mg 1 hcl oral soln 1 mg/ml (5 mg/5ml) 1 hcl syrup 2 mg/5ml 1 cyproheptadine hcl tab 4 mg 1 tab 5 mg (Clarinex) 1 hcl cap 50 mg 1 levocetirizine dihydrochloride tab 5 mg (Xyzal) 1 hcl suppos 12.5 mg 1 promethazine hcl suppos 25 mg 1 promethazine hcl syrup 6.25 mg/5ml 1 promethazine hcl tab 12.5 mg 1 promethazine hcl tab 25 mg 1 promethazine hcl tab 50 mg 1 NASAL PRODUCTS azelastine hcl nasal spray 0.1% (137 mcg/spray) 1 QL (2 bottles/30 days) FLUNISOLIDE – flunisolide nasal soln 25 mcg/act (0.025%) 2 QL (3 bottles/30 days) nasal susp 50 mcg/act 1 QL (1 inhaler/30 days) ipratropium nasal soln 0.03% (21 mcg/spray) 1 QL (2 bottles/30 days), 90 nasal soln 0.06% (42 mcg/spray) 1 QL (3 bottles/30 days), 90 triamcinolone acetonide nasal aerosol suspension 55 mcg/act 1 QL (1 bottle/30 days) COUGH/COLD/ALLERGY acetylcysteine inhal soln 10% 1 acetylcysteine inhal soln 20% 1 HYDROCODONE BITARTRATE/CH – pseudoeph-chlorphen w/ 2 ME90 hydrocodone soln 60-4-5 mg/5ml w/ dm-gg liqd 10-15-300 mg/5ml 1 phenylephrine w/ dm-gg liqd 2.5-5-50 mg/ml 1 phenylephrine w/ dm-gg liqd 2.5-7.5-88 mg/ml 1

1 = Generic Drugs AL = Age Limit ME90 = Morphine Equivalent ST = Step Therapy 2 = Brand Drugs PA = Prior Authorization QL = Quantity Limits SP = Specialty 90 = 90 days available at mail order 36 2018

Tier Level Necessary actions, restrictions, or limits on use Name of Drug promethazine w/ syrup 6.25-10 mg/5ml 1 ME90 pseudoeph-chlorphen w/ hydrocodone soln 60-4-5 mg/5ml 1 ME90 (Zutripro) sodium chloride soln nebu 0.9% 1 sodium chloride soln nebu 3% 1 sodium chloride soln nebu 7% (Hyper-sal) 1 sodium chloride soln nebu 10% 1 ASTHMA/COPD ALBUTEROL SULFATE ER – albuterol sulfate tab er 12hr 4 mg 2 90 ALBUTEROL SULFATE ER – albuterol sulfate tab er 12hr 8 mg 2 90 albuterol sulfate soln nebu 0.083% (2.5 mg/3ml) 1 QL (125 containers/30 days), 90 albuterol sulfate soln nebu 0.5% (5 mg/ml) 1 QL (60 mls/30 days), 90 albuterol sulfate soln nebu 0.63 mg/3ml (base equiv) 1 QL (125 containers/30 days), 90 albuterol sulfate soln nebu 1.25 mg/3ml (base equiv) 1 QL (125 containers/30 days), 90 albuterol sulfate syrup 2 mg/5ml 1 90 albuterol sulfate tab er 12hr 4 mg (Vospire er) 1 90 albuterol sulfate tab er 12hr 8 mg (Vospire er) 1 90 albuterol sulfate tab 2 mg 1 90 albuterol sulfate tab 4 mg 1 90 ARNUITY ELLIPTA – fluticasone furoate aerosol powder breath 2 QL (30 blisters/30 days), 90 activ 100 mcg/act ARNUITY ELLIPTA – fluticasone furoate aerosol powder breath 2 QL (30 blisters/30 days), 90 activ 200 mcg/act ATROVENT HFA – ipratropium bromide hfa inhal aerosol 2 QL (2 inhalers/30 days), 90 17 mcg/act budesonide inhalation susp 0.25 mg/2ml (Pulmicort) 1 QL (60 containers/30 days), 90 budesonide inhalation susp 0.5 mg/2ml (Pulmicort) 1 QL (60 containers/30 days), 90 budesonide inhalation susp 1 mg/2ml (Pulmicort) 1 QL (60 mls/30 days), 90 COMBIVENT RESPIMAT – ipratropium-albuterol inhal aerosol 2 QL (2 inhalers/30 days), 90 soln 20-100 mcg/act dyphylline-guaifenesin liqd 100-100 mg/5ml 1 FLOVENT DISKUS – fluticasone propionate aer pow ba 50 mcg/ 2 AL, QL (1 inhaler/30 days), 90 blister FLOVENT DISKUS – fluticasone propionate aer pow ba 2 AL, QL (1 inhaler/30 days), 90 100 mcg/blister FLOVENT DISKUS – fluticasone propionate aer pow ba 2 AL, QL (4 inhalers/30 days), 90 250 mcg/blister

1 = Generic Drugs AL = Age Limit ME90 = Morphine Equivalent ST = Step Therapy 2 = Brand Drugs PA = Prior Authorization QL = Quantity Limits SP = Specialty 90 = 90 days available at mail order 37 2018

Tier Level Necessary actions, restrictions, or limits on use Name of Drug FLOVENT HFA – fluticasone propionate hfa inhal aero 44 mcg/ 2 AL, QL (1 inhaler/30 days), 90 act (50/valve) FLOVENT HFA – fluticasone propionate hfa inhal aer 110 mcg/ 2 AL, QL (1 inhaler/30 days), 90 act (125/valve) FLOVENT HFA – fluticasone propionate hfa inhal aer 220 mcg/ 2 AL, QL (2 inhalers/30 days), 90 act (250/valve) FLUTICASONE PROPIONATE/SA – fluticasone-salmeterol aer 2 QL (1 inhaler/30 days), 90 powder ba 55-14 mcg/act FLUTICASONE PROPIONATE/SA – fluticasone-salmeterol aer 2 QL (1 inhaler/30 days), 90 powder ba 113-14 mcg/act FLUTICASONE PROPIONATE/SA – fluticasone-salmeterol aer 2 QL (1 inhaler/30 days), 90 powder ba 232-14 mcg/act INCRUSE ELLIPTA – umeclidinium br aero powd breath act 2 QL (30 blisters/30 days), 90 62.5 mcg/inh (base eq) ipratropium bromide inhal soln 0.02% 1 QL (125 cartridges/30 days), 90 ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml 1 QL (180 containers/30 days), 90 montelukast sodium chew tab 4 mg (base equiv) (Singulair) 1 QL (30 tablets/30 days), 90 montelukast sodium chew tab 5 mg (base equiv) (Singulair) 1 QL (30 tablets/30 days), 90 montelukast sodium oral granules packet 4 mg (base equiv) 1 QL (30 packets/30 days), 90 (Singulair) montelukast sodium tab 10 mg (base equiv) (Singulair) 1 QL (30 tablets/30 days), 90 NUCALA – mepolizumab for inj 100 mg 2 SP, 90 QVAR – beclomethasone diprop inhal aero soln 40 mcg/act (50/ 2 AL, QL (2 containers/30 days), 90 valve) QVAR – beclomethasone diprop inhal aero soln 80 mcg/act (100/ 2 AL, QL (2 containers/30 days), 90 valve) QVAR REDIHALER – beclomethasone diprop hfa breath act inh 2 AL, QL (1 inhaler/30 days) aer 40 mcg/act QVAR REDIHALER – beclomethasone diprop hfa breath act inh 2 AL, QL (2 inhalers/30 days) aer 80 mcg/act STRIVERDI RESPIMAT – olodaterol hcl inhal aerosol soln 2 QL (1 inhaler/30 days), 90 2.5 mcg/act (base equiv) SYMBICORT – budesonide-formoterol fumarate dihyd aerosol 2 AL, QL (1 inhaler/30 days), 90 80-4.5 mcg/act SYMBICORT – budesonide-formoterol fumarate dihyd aerosol 2 AL, QL (1 inhaler/30 days), 90 160-4.5 mcg/act terbutaline sulfate tab 2.5 mg 1 90 terbutaline sulfate tab 5 mg 1 90 theophylline soln 80 mg/15ml 1 90 theophylline tab er 12hr 100 mg 1 90 theophylline tab er 12hr 200 mg 1 90

1 = Generic Drugs AL = Age Limit ME90 = Morphine Equivalent ST = Step Therapy 2 = Brand Drugs PA = Prior Authorization QL = Quantity Limits SP = Specialty 90 = 90 days available at mail order 38 2018

Tier Level Necessary actions, restrictions, or limits on use Name of Drug theophylline tab er 12hr 300 mg 1 90 theophylline tab er 12hr 450 mg 1 90 theophylline tab er 24hr 400 mg 1 90 theophylline tab er 24hr 600 mg 1 90 VENTOLIN HFA – albuterol sulfate inhal aero 108 mcg/act 2 QL (3 inhalers/30 days), 90 (90mcg base equiv) OTHER RESPIRATORY DRUGS ESBRIET – pirfenidone cap 267 mg 2 PA, QL (180 capsules/30 days), SP, 90 KALYDECO – tab 150 mg 2 PA, QL (60 tablets/30 days), SP, 90 KALYDECO – ivacaftor packet 50 mg 2 PA, QL (60 packets/30 days), SP, 90 KALYDECO – ivacaftor packet 75 mg 2 PA, QL (60 packets/30 days), SP, 90 OFEV – nintedanib esylate cap 100 mg (base equivalent) 2 PA, QL (60 capsules/30 days), SP, 90 OFEV – nintedanib esylate cap 150 mg (base equivalent) 2 PA, QL (60 capsules/30 days), SP, 90 ORKAMBI – lumacaftor-ivacaftor tab 100-125 mg 2 PA, QL (120 tablets/30 days), SP, 90 ORKAMBI – lumacaftor-ivacaftor tab 200-125 mg 2 PA, QL (120 tablets/30 days), SP, 90 PULMOZYME – dornase alfa inhal soln 1 mg/ml 2 PA, SP, 90 GASTROINTESTINAL DRUGS LAXATIVES bisacodyl tab & peg 3350-kcl-sod bicarb-nacl for soln kit 1 lactulose solution 10 gm/15ml 1 90 peg 3350-kcl-sod bicarb-nacl for soln 420 gm (Nulytely/flavor 1 pack) peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm (Golytely) 1 peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240 gm (Colyte- 1 flavor packs) polyethylene glycol 3350 oral packet 1 polyethylene glycol 3350 oral powder 1 ANTIDIARRHEALS w/ tab 2.5-0.025 mg (Lomotil) 1

1 = Generic Drugs AL = Age Limit ME90 = Morphine Equivalent ST = Step Therapy 2 = Brand Drugs PA = Prior Authorization QL = Quantity Limits SP = Specialty 90 = 90 days available at mail order 39 2018

Tier Level Necessary actions, restrictions, or limits on use Name of Drug hcl cap 2 mg 1 ULCER/GERD chlordiazepoxide hcl- cap 5-2.5 mg (Librax) 1 HCL – cimetidine hcl soln 300 mg/5ml 2 90 cimetidine tab 200 mg 1 cimetidine tab 300 mg 1 90 cimetidine tab 400 mg 1 90 cimetidine tab 800 mg 1 90 dicyclomine hcl cap 10 mg (Bentyl) 1 dicyclomine hcl oral soln 10 mg/5ml 1 dicyclomine hcl tab 20 mg (Bentyl) 1 famotidine for susp 40 mg/5ml (Pepcid) 1 90 famotidine tab 20 mg (Pepcid) 1 90 famotidine tab 40 mg (Pepcid) 1 90 glycopyrrolate tab 1 mg (Robinul) 1 glycopyrrolate tab 2 mg (Robinul forte) 1 sulfate elixir 0.125 mg/5ml 1 90 hyoscyamine sulfate soln 0.125 mg/ml 1 90 hyoscyamine sulfate tab disint 0.125 mg (Anaspaz) 1 90 hyoscyamine sulfate tab er 12hr 0.375 mg (Levbid) 1 90 hyoscyamine sulfate tab sl 0.125 mg (Levsin/sl) 1 90 hyoscyamine sulfate tab 0.125 mg (Levsin) 1 90 cap delayed release 15 mg (Prevacid) 1 QL (120 capsules/365 days), 90 lansoprazole cap delayed release 30 mg (Prevacid) 1 QL (120 capsules/365 days), 90 methscopolamine bromide tab 2.5 mg (Pamine) 1 misoprostol tab 100 mcg (Cytotec) 1 90 misoprostol tab 200 mcg (Cytotec) 1 90 nizatidine cap 150 mg 1 90 nizatidine cap 300 mg 1 90 omeprazole cap delayed release 10 mg (Prilosec) 1 QL (120 capsules/365 days), 90 omeprazole cap delayed release 20 mg (Prilosec) 1 QL (120 capsules/365 days), 90 omeprazole cap delayed release 40 mg (Prilosec) 1 QL (120 capsules/365 days), 90 pantoprazole sodium ec tab 20 mg (base equiv) (Protonix) 1 QL (120 packets/365 days), 90 pantoprazole sodium ec tab 40 mg (base equiv) (Protonix) 1 QL (120 packets/365 days), 90 rabeprazole sodium ec tab 20 mg (Aciphex) 1 QL (120 capsules/365 days), 90

1 = Generic Drugs AL = Age Limit ME90 = Morphine Equivalent ST = Step Therapy 2 = Brand Drugs PA = Prior Authorization QL = Quantity Limits SP = Specialty 90 = 90 days available at mail order 40 2018

Tier Level Necessary actions, restrictions, or limits on use Name of Drug hcl syrup 15 mg/ml (75 mg/5ml) 1 90 ranitidine hcl tab 150 mg (Zantac) 1 90 ranitidine hcl tab 300 mg (Zantac) 1 90 sucralfate tab 1 gm (Carafate) 1 90 NAUSEA AND VOMITING hcl tab 12.5 mg 1 meclizine hcl tab 25 mg 1 ondansetron hcl oral soln 4 mg/5ml (Zofran) 1 QL (300 mls/30 days) ondansetron hcl tab 4 mg (Zofran) 1 QL (30 tablets/30 days) ondansetron hcl tab 8 mg (Zofran) 1 QL (30 tablets/30 days) ondansetron hcl tab 24 mg 1 QL (1 /30 days) ondansetron orally disintegrating tab 4 mg (Zofran odt) 1 QL (30 tablets/30 days) ondansetron orally disintegrating tab 8 mg (Zofran odt) 1 QL (30 tablets/30 days) trimethobenzamide hcl cap 300 mg (Tigan) 1 DIGESTIVE ENZYMES CREON – pancrelipase (lip-prot-amyl) dr cap 3000-9500-15000 2 90 unit CREON – pancrelipase (lip-prot-amyl) dr cap 6000-19000-30000 2 90 unit CREON – pancrelipase (lip-prot-amyl) dr cap 2 90 12000-38000-60000 unit CREON – pancrelipase (lip-prot-amyl) dr cap 2 90 24000-76000-120000 unit CREON – pancrelipase (lip-prot-amyl) dr cap 2 90 36000-114000-180000 unit SUCRAID – sacrosidase soln 8500 unit/ml 2 PA, SP, 90 ZENPEP – pancrelipase (lip-prot-amyl) dr cap 2 90 3000-10000-16000 unit ZENPEP – pancrelipase (lip-prot-amyl) dr cap 2 5000-17000-24000 unit ZENPEP – pancrelipase (lip-prot-amyl) dr cap 2 90 5000-17000-27000 unit ZENPEP – pancrelipase (lip-prot-amyl) dr cap 2 10000-32000-42000 unit ZENPEP – pancrelipase (lip-prot-amyl) dr cap 2 90 10000-34000-55000 unit ZENPEP – pancrelipase (lip-prot-amyl) dr cap 2 15000-47000-63000 unit

1 = Generic Drugs AL = Age Limit ME90 = Morphine Equivalent ST = Step Therapy 2 = Brand Drugs PA = Prior Authorization QL = Quantity Limits SP = Specialty 90 = 90 days available at mail order 41 2018

Tier Level Necessary actions, restrictions, or limits on use Name of Drug ZENPEP – pancrelipase (lip-prot-amyl) dr cap 2 90 15000-51000-82000 unit ZENPEP – pancrelipase (lip-prot-amyl) dr cap 2 20000-63000-84000 unit ZENPEP – pancrelipase (lip-prot-amyl) dr cap 2 90 20000-68000-109000 unit ZENPEP – pancrelipase (lip-prot-amyl) dr cap 2 90 25000-85000-136000 unit ZENPEP – pancrelipase (lip-prot-amyl) dr cap 2 25000-79000-105000 unit ZENPEP – pancrelipase (lip-prot-amyl) dr cap 2 40000-126000-168000 unit ZENPEP – pancrelipase (lip-prot-amyl) dr cap 2 90 40000-136000-218000 unit OTHER GASTROINTESTINAL DRUGS alosetron hcl tab 0.5 mg (base equiv) (Lotronex) 1 PA, QL (60 tablets/30 days), 90 alosetron hcl tab 1 mg (base equiv) (Lotronex) 1 PA, QL (60 tablets/30 days), 90 balsalazide disodium cap 750 mg (Colazal) 1 calcium acetate (phosphate binder) cap 667 mg (169 mg ca) 1 90 (Phoslo) calcium acetate (phosphate binder) tab 667 mg (Eliphos) 1 CANASA – mesalamine suppos 1000 mg 2 CHENODAL – chenodiol tab 250 mg 2 PA, SP CHOLBAM – cholic acid cap 50 mg 2 90 CHOLBAM – cholic acid cap 250 mg 2 90 CIMZIA – certolizumab pegol for inj kit 2 x 200 mg 2 PA, QL (2 vials/28 days), SP CIMZIA – certolizumab pegol inj kit 2 x 200 mg/ml 2 PA, QL (2 syringes/28 days), SP, 90 CIMZIA STARTER KIT – certolizumab pegol inj kit 6 x 200 mg/ml 2 PA, QL (1 kit/180 days), SP, 90 GATTEX – teduglutide (rdna) for inj kit 5 mg 2 PA, SP, 90 lactulose (encephalopathy) solution 10 gm/15ml 1 90 MESALAMINE DR – mesalamine tab delayed release 800 mg 2 mesalamine enema 4 gm 1 mesalamine rectal enema 4 gm & cleanser wipe kit (Rowasa) 1 metoclopramide hcl soln 5 mg/5ml (10 mg/10ml) (base equiv) 1 metoclopramide hcl tab 5 mg (base equivalent) (Reglan) 1 metoclopramide hcl tab 10 mg (base equivalent) (Reglan) 1 90 PENTASA – mesalamine cap er 250 mg 2 90

1 = Generic Drugs AL = Age Limit ME90 = Morphine Equivalent ST = Step Therapy 2 = Brand Drugs PA = Prior Authorization QL = Quantity Limits SP = Specialty 90 = 90 days available at mail order 42 2018

Tier Level Necessary actions, restrictions, or limits on use Name of Drug PENTASA – mesalamine cap er 500 mg 2 90 tab delayed release 500 mg (Azulfidine en-tabs) 1 90 sulfasalazine tab 500 mg (Azulfidine) 1 90 ursodiol cap 300 mg (Actigall) 1 90 ursodiol tab 250 mg (Urso 250) 1 90 ursodiol tab 500 mg (Urso forte) 1 90 GENITOURINARY DRUGS URINARY TRACT INFECTIONS nitrofurantoin macrocrystalline cap 25 mg (Macrodantin) 1 nitrofurantoin macrocrystalline cap 50 mg (Macrodantin) 1 nitrofurantoin macrocrystalline cap 100 mg (Macrodantin) 1 nitrofurantoin monohydrate macrocrystalline cap 100 mg 1 (Macrobid) URINARY TRACT SPASMS chloride tab 5 mg (Urecholine) 1 bethanechol chloride tab 10 mg (Urecholine) 1 bethanechol chloride tab 25 mg (Urecholine) 1 bethanechol chloride tab 50 mg (Urecholine) 1 hydrobromide tab er 24hr 7.5 mg (base equiv) 1 QL (30 tablets/30 days), 90 (Enablex) darifenacin hydrobromide tab er 24hr 15 mg (base equiv) 1 QL (30 tablets/30 days), 90 (Enablex) hcl tab 100 mg 1 90 chloride syrup 5 mg/5ml 1 QL (600 mls/30 days), 90 oxybutynin chloride tab er 24hr 5 mg (Ditropan xl) 1 QL (30 tablets/30 days), 90 oxybutynin chloride tab er 24hr 10 mg (Ditropan xl) 1 QL (60 tablets/30 days), 90 oxybutynin chloride tab er 24hr 15 mg (Ditropan xl) 1 QL (60 tablets/30 days), 90 oxybutynin chloride tab 5 mg 1 QL (120 tablets/30 days), 90 tartrate tab 2 mg (Detrol) 1 QL (60 tablets/30 days), 90 cap er 24hr 60 mg 1 QL (30 capsules/30 days), 90 trospium chloride tab 20 mg 1 QL (60 tablets/30 days), 90 VAGINAL PRODUCTS clindamycin phosphate vaginal cream 2% (Cleocin) 1 estradiol vaginal tab 10 mcg (Vagifem) 1 90 metronidazole vaginal gel 0.75% (Metrogel-vaginal) 1 TERCONAZOLE – terconazole vaginal cream 0.8% 2

1 = Generic Drugs AL = Age Limit ME90 = Morphine Equivalent ST = Step Therapy 2 = Brand Drugs PA = Prior Authorization QL = Quantity Limits SP = Specialty 90 = 90 days available at mail order 43 2018

Tier Level Necessary actions, restrictions, or limits on use Name of Drug terconazole vaginal cream 0.4% (Terazol 7) 1 terconazole vaginal cream 0.8% (Terazol 3) 1 terconazole vaginal suppos 80 mg 1 OTHER GENITOURINARY DRUGS irrigation soln 0.25% 1 alfuzosin hcl tab er 24hr 10 mg (Uroxatral) 1 QL (30 tablets/30 days), 90 CYSTAGON – cysteamine bitartrate cap 50 mg 2 PA, SP, 90 CYSTAGON – cysteamine bitartrate cap 150 mg 2 PA, SP, 90 dutasteride cap 0.5 mg (Avodart) 1 QL (30 capsules/30 days), 90 dutasteride-tamsulosin hcl cap 0.5-0.4 mg (Jalyn) 1 QL (30 capsules/30 days), 90 finasteride tab 5 mg (Proscar) 1 QL (30 tablets/30 days), 90 irrigation soln 1.5% 1 neomycin- gu irrigation soln (Neosporin gu irrigan) 1 phenazopyridine hcl tab 100 mg (Pyridium) 1 phenazopyridine hcl tab 200 mg (Pyridium) 1 pot & sod citrates w/ cit ac soln 550-500-334 mg/5ml 1 potassium citrate & citric acid powder pack 3300-1002 mg 1 potassium citrate & citric acid soln 1100-334 mg/5ml 1 potassium citrate tab er 5 meq (540 mg) (Urocit-k 5) 1 potassium citrate tab er 10 meq (1080 mg) (Urocit-k 10) 1 potassium citrate tab er 15 meq (1620 mg) (Urocit-k 15) 1 POTASSIUM CITRATE/SODIUM – pot & sod citrates w/ cit ac 2 soln 550-500-334 mg/5ml PROCYSBI – cysteamine bitartrate cap delayed release 25 mg 2 PA, SP, 90 (base equiv) PROCYSBI – cysteamine bitartrate cap delayed release 75 mg 2 PA, SP, 90 (base equiv) sodium chloride irrigation soln 0.9% 1 sodium citrate & citric acid soln 500-334 mg/5ml (Shohls solution 1 modi) tamsulosin hcl cap 0.4 mg (Flomax) 1 QL (60 capsules/30 days), 90 TRICITRATES – pot & sod citrates w/ cit ac soln 2 550-500-334 mg/5ml CENTRAL NERVOUS SYSTEM DRUGS ANXIETY ALPRAZOLAM INTENSOL – alprazolam conc 1 mg/ml 2 QL (180 mls/30 days) alprazolam tab er 24hr 0.5 mg (Xanax xr) 1 QL (30 tablets/30 days)

1 = Generic Drugs AL = Age Limit ME90 = Morphine Equivalent ST = Step Therapy 2 = Brand Drugs PA = Prior Authorization QL = Quantity Limits SP = Specialty 90 = 90 days available at mail order 44 2018

Tier Level Necessary actions, restrictions, or limits on use Name of Drug alprazolam tab er 24hr 1 mg (Xanax xr) 1 QL (30 tablets/30 days) alprazolam tab er 24hr 2 mg (Xanax xr) 1 QL (90 tablets/30 days) alprazolam tab er 24hr 3 mg (Xanax xr) 1 QL (60 tablets/30 days) alprazolam tab 0.25 mg (Xanax) 1 QL (120 tablets/30 days) alprazolam tab 0.5 mg (Xanax) 1 QL (120 tablets/30 days) alprazolam tab 1 mg (Xanax) 1 QL (120 tablets/30 days) alprazolam tab 2 mg (Xanax) 1 QL (90 tablets/30 days) hcl tab 5 mg 1 buspirone hcl tab 10 mg 1 buspirone hcl tab 15 mg 1 buspirone hcl tab 30 mg 1 chlordiazepoxide hcl cap 5 mg 1 QL (120 capsules/30 days) chlordiazepoxide hcl cap 10 mg 1 QL (120 capsules/30 days) chlordiazepoxide hcl cap 25 mg 1 QL (120 capsules/30 days) dipotassium tab 3.75 mg 1 QL (90 tablets/30 days) clorazepate dipotassium tab 7.5 mg (Tranxene t) 1 QL (90 tablets/30 days) clorazepate dipotassium tab 15 mg 1 QL (120 tablets/30 days) – diazepam im solution auto-inj 10 mg/2ml 2 PA DIAZEPAM – diazepam oral soln 1 mg/ml 2 QL (1200 mls/30 days) diazepam conc 5 mg/ml 1 QL (240 mls/30 days) diazepam tab 2 mg (Valium) 1 QL (120 tablets/30 days) diazepam tab 5 mg (Valium) 1 QL (120 tablets/30 days) diazepam tab 10 mg (Valium) 1 QL (120 tablets/30 days) hcl syrup 10 mg/5ml 1 hydroxyzine hcl tab 10 mg 1 hydroxyzine hcl tab 25 mg 1 hydroxyzine hcl tab 50 mg 1 hydroxyzine pamoate cap 25 mg (Vistaril) 1 hydroxyzine pamoate cap 50 mg (Vistaril) 1 conc 2 mg/ml 1 QL (150 mls/30 days) lorazepam tab 0.5 mg (Ativan) 1 QL (90 tablets/30 days) lorazepam tab 1 mg (Ativan) 1 QL (90 tablets/30 days) lorazepam tab 2 mg (Ativan) 1 QL (150 tablets/30 days) DEPRESSION hcl tab 10 mg 1 90

1 = Generic Drugs AL = Age Limit ME90 = Morphine Equivalent ST = Step Therapy 2 = Brand Drugs PA = Prior Authorization QL = Quantity Limits SP = Specialty 90 = 90 days available at mail order 45 2018

Tier Level Necessary actions, restrictions, or limits on use Name of Drug amitriptyline hcl tab 25 mg (Elavil) 1 90 amitriptyline hcl tab 50 mg 1 90 amitriptyline hcl tab 75 mg 1 90 amitriptyline hcl tab 100 mg 1 90 amitriptyline hcl tab 150 mg 1 90 – amoxapine tab 25 mg 2 PA, 90 AMOXAPINE – amoxapine tab 50 mg 2 PA, 90 AMOXAPINE – amoxapine tab 100 mg 2 PA, 90 AMOXAPINE – amoxapine tab 150 mg 2 PA, 90 APLENZIN – hbr tab er 24hr 174 mg 2 PA, QL (30 tablets/30 days), 90 APLENZIN – bupropion hbr tab er 24hr 348 mg 2 PA, QL (30 tablets/30 days), 90 APLENZIN – bupropion hbr tab er 24hr 522 mg 2 PA, QL (30 tablets/30 days), 90 BRINTELLIX – hbr tab 5 mg (base equiv) 2 QL (30 tablets/30 days), 90 BRINTELLIX – vortioxetine hbr tab 10 mg (base equiv) 2 QL (30 tablets/30 days), 90 BRINTELLIX – vortioxetine hbr tab 20 mg (base equiv) 2 QL (30 tablets/30 days), 90 bupropion hcl tab er 12hr 100 mg (Wellbutrin sr) 1 QL (60 tablets/30 days), 90 bupropion hcl tab er 12hr 150 mg (Wellbutrin sr) 1 QL (60 tablets/30 days), 90 bupropion hcl tab er 12hr 200 mg (Wellbutrin sr) 1 QL (60 tablets/30 days), 90 bupropion hcl tab er 24hr 150 mg (Wellbutrin xl) 1 QL (30 tablets/30 days), 90 bupropion hcl tab er 24hr 300 mg (Wellbutrin xl) 1 QL (30 tablets/30 days), 90 bupropion hcl tab 75 mg 1 QL (60 tablets/30 days), 90 bupropion hcl tab 100 mg 1 QL (120 tablets/30 days), 90 citalopram hydrobromide oral soln 10 mg/5ml 1 QL (600 mls/30 days), 90 citalopram hydrobromide tab 10 mg (base equiv) (Celexa) 1 QL (30 tablets/30 days), 90 citalopram hydrobromide tab 20 mg (base equiv) (Celexa) 1 QL (30 tablets/30 days), 90 citalopram hydrobromide tab 40 mg (base equiv) (Celexa) 1 QL (30 tablets/30 days), 90 hcl tab 10 mg (Norpramin) 1 90 desipramine hcl tab 25 mg (Norpramin) 1 90 desipramine hcl tab 50 mg 1 90 desipramine hcl tab 75 mg 1 90 desipramine hcl tab 100 mg 1 90 desipramine hcl tab 150 mg 1 90 hcl cap 10 mg 1 90 doxepin hcl cap 25 mg 1 90 doxepin hcl cap 50 mg 1 90

1 = Generic Drugs AL = Age Limit ME90 = Morphine Equivalent ST = Step Therapy 2 = Brand Drugs PA = Prior Authorization QL = Quantity Limits SP = Specialty 90 = 90 days available at mail order 46 2018

Tier Level Necessary actions, restrictions, or limits on use Name of Drug doxepin hcl cap 75 mg 1 90 doxepin hcl cap 100 mg 1 90 doxepin hcl cap 150 mg 1 90 doxepin hcl conc 10 mg/ml 1 90 duloxetine hcl enteric coated pellets cap 20 mg (base eq) 1 QL (60 capsules/30 days), 90 (Cymbalta) duloxetine hcl enteric coated pellets cap 30 mg (base eq) 1 QL (90 capsules/30 days), 90 (Cymbalta) duloxetine hcl enteric coated pellets cap 60 mg (base eq) 1 QL (60 capsules/30 days), 90 (Cymbalta) EMSAM – selegiline td patch 24hr 6 mg/24hr 2 PA, 90 EMSAM – selegiline td patch 24hr 9 mg/24hr 2 PA, 90 EMSAM – selegiline td patch 24hr 12 mg/24hr 2 PA, 90 escitalopram oxalate soln 5 mg/5ml (base equiv) (Lexapro) 1 QL (600 mls/30 days), 90 escitalopram oxalate tab 5 mg (base equiv) (Lexapro) 1 QL (30 tablets/30 days), 90 escitalopram oxalate tab 10 mg (base equiv) (Lexapro) 1 QL (30 tablets/30 days), 90 escitalopram oxalate tab 20 mg (base equiv) (Lexapro) 1 QL (30 tablets/30 days), 90 FETZIMA – levomilnacipran hcl cap er 24hr 20 mg (base 2 PA, QL (30 capsules/30 days), 90 equivalent) FETZIMA – levomilnacipran hcl cap er 24hr 40 mg (base 2 PA, QL (30 capsules/30 days), 90 equivalent) FETZIMA – levomilnacipran hcl cap er 24hr 80 mg (base 2 PA, QL (30 capsules/30 days), 90 equivalent) FETZIMA – levomilnacipran hcl cap er 24hr 120 mg (base 2 PA, QL (30 capsules/30 days), 90 equivalent) FETZIMA TITRATION PACK – levomilnacipran hcl cap er 24hr 2 PA, QL (28 tablets/180 days), 90 20 & 40 mg therapy pack hcl cap 10 mg (Prozac) 1 QL (30 capsules/30 days), 90 fluoxetine hcl cap 20 mg (Prozac) 1 QL (120 capsules/30 days), 90 fluoxetine hcl cap 40 mg (Prozac) 1 QL (60 capsules/30 days), 90 fluoxetine hcl solution 20 mg/5ml 1 QL (600 mls/30 days), 90 fluoxetine hcl tab 10 mg 1 QL (30 tablets/30 days), 90 fluoxetine hcl tab 20 mg 1 QL (120 tablets/30 days), 90 fluvoxamine maleate tab 25 mg 1 QL (30 tablets/30 days), 90 fluvoxamine maleate tab 50 mg 1 QL (30 tablets/30 days), 90 fluvoxamine maleate tab 100 mg 1 QL (90 tablets/30 days), 90 FORFIVO XL – bupropion hcl tab er 24hr 450 mg 2 PA, QL (30 tablets/30 days), 90 hcl tab 10 mg (Tofranil) 1 90

1 = Generic Drugs AL = Age Limit ME90 = Morphine Equivalent ST = Step Therapy 2 = Brand Drugs PA = Prior Authorization QL = Quantity Limits SP = Specialty 90 = 90 days available at mail order 47 2018

Tier Level Necessary actions, restrictions, or limits on use Name of Drug imipramine hcl tab 25 mg (Tofranil) 1 90 imipramine hcl tab 50 mg (Tofranil) 1 90 HCL – maprotiline hcl tab 25 mg 2 PA, QL (90 tablets/30 days), 90 MAPROTILINE HCL – maprotiline hcl tab 50 mg 2 PA, QL (90 tablets/30 days), 90 MAPROTILINE HCL – maprotiline hcl tab 75 mg 2 PA, QL (90 tablets/30 days), 90 MARPLAN – isocarboxazid tab 10 mg 2 PA, 90 tab 15 mg (Remeron) 1 QL (30 tablets/30 days), 90 mirtazapine tab 30 mg (Remeron) 1 QL (30 tablets/30 days), 90 mirtazapine tab 45 mg (Remeron) 1 QL (30 tablets/30 days), 90 HCL – nefazodone hcl tab 100 mg 2 PA, 90 NEFAZODONE HCL – nefazodone hcl tab 150 mg 2 PA, 90 NEFAZODONE HCL – nefazodone hcl tab 200 mg 2 PA, 90 hcl cap 10 mg (Pamelor) 1 90 nortriptyline hcl cap 25 mg (Pamelor) 1 90 nortriptyline hcl cap 50 mg (Pamelor) 1 90 nortriptyline hcl cap 75 mg (Pamelor) 1 90 hcl tab 10 mg (Paxil) 1 QL (30 tablets/30 days), 90 paroxetine hcl tab 20 mg (Paxil) 1 QL (30 tablets/30 days), 90 paroxetine hcl tab 30 mg (Paxil) 1 QL (60 tablets/30 days), 90 paroxetine hcl tab 40 mg (Paxil) 1 QL (30 tablets/30 days), 90 PAXIL – paroxetine hcl oral susp 10 mg/5ml (base equiv) 2 PA, QL (900 mls/30 days), 90 PEXEVA – paroxetine mesylate tab 10 mg (base equiv) 2 PA, QL (30 tablets/30 days), 90 PEXEVA – paroxetine mesylate tab 20 mg (base equiv) 2 PA, QL (30 tablets/30 days), 90 PEXEVA – paroxetine mesylate tab 30 mg (base equiv) 2 PA, QL (60 tablets/30 days), 90 PEXEVA – paroxetine mesylate tab 40 mg (base equiv) 2 PA, QL (30 tablets/30 days), 90 sertraline hcl oral concentrate for solution 20 mg/ml (Zoloft) 1 QL (300 mls/30 days), 90 sertraline hcl tab 25 mg (Zoloft) 1 QL (30 tablets/30 days), 90 sertraline hcl tab 50 mg (Zoloft) 1 QL (30 tablets/30 days), 90 sertraline hcl tab 100 mg (Zoloft) 1 QL (60 tablets/30 days), 90 hcl tab 50 mg 1 90 trazodone hcl tab 100 mg 1 90 trazodone hcl tab 150 mg 1 90 venlafaxine hcl cap er 24hr 37.5 mg (base equivalent) (Effexor 1 QL (30 capsules/30 days), 90 xr) venlafaxine hcl cap er 24hr 75 mg (base equivalent) (Effexor xr) 1 QL (90 capsules/30 days), 90

1 = Generic Drugs AL = Age Limit ME90 = Morphine Equivalent ST = Step Therapy 2 = Brand Drugs PA = Prior Authorization QL = Quantity Limits SP = Specialty 90 = 90 days available at mail order 48 2018

Tier Level Necessary actions, restrictions, or limits on use Name of Drug venlafaxine hcl cap er 24hr 150 mg (base equivalent) (Effexor xr) 1 QL (30 capsules/30 days), 90 venlafaxine hcl tab 25 mg 1 QL (90 tablets/30 days), 90 venlafaxine hcl tab 37.5 mg 1 QL (90 tablets/30 days), 90 venlafaxine hcl tab 50 mg 1 QL (90 tablets/30 days), 90 venlafaxine hcl tab 75 mg 1 QL (90 tablets/30 days), 90 venlafaxine hcl tab 100 mg 1 QL (90 tablets/30 days), 90 VIIBRYD – hcl tab 10 mg 2 PA, QL (30 tablets/30 days), 90 VIIBRYD – vilazodone hcl tab 20 mg 2 PA, QL (30 tablets/30 days), 90 VIIBRYD – vilazodone hcl tab 40 mg 2 PA, QL (30 tablets/30 days), 90 VIIBRYD STARTER PACK – vilazodone hcl tab starter kit 10 (7) 2 PA, QL (30 tablets/180 days), 90 & 20 (23) mg PSYCHOTIC AND BIPOLAR DISORDERS ABILIFY MAINTENA – im for er susp prefilled 2 AL, PA, QL (1 vials/28 days) syringe 300 mg ABILIFY MAINTENA – aripiprazole im for er susp prefilled 2 AL, PA, QL (1 vials/28 days) syringe 400 mg ABILIFY MAINTENA – aripiprazole im for extended release susp 2 PA, QL (1 vials/28 days) 300 mg ABILIFY MAINTENA – aripiprazole im for extended release susp 2 PA, QL (1 vials/28 days) 400 mg ADASUVE – aerosol powder breath activated 10 mg 2 PA aripiprazole oral solution 1 mg/ml 1 PA, QL (150 mls/30 days), 90 aripiprazole orally disintegrating tab 15 mg 1 AL, PA, QL (30 tablets/30 days), 90 aripiprazole tab 2 mg (Abilify) 1 AL, PA, QL (30 tablets/30 days), 90 aripiprazole tab 5 mg (Abilify) 1 AL, PA, QL (30 tablets/30 days), 90 aripiprazole tab 10 mg (Abilify) 1 AL, PA, QL (30 tablets/30 days), 90 aripiprazole tab 15 mg (Abilify) 1 AL, PA, QL (30 tablets/30 days), 90 aripiprazole tab 20 mg (Abilify) 1 AL, PA, QL (30 tablets/30 days), 90 aripiprazole tab 30 mg (Abilify) 1 AL, PA, QL (30 tablets/30 days), 90 ARISTADA – im er susp prefilled syr 2 PA, QL (1 syringe/28 days), 90 441 mg/1.6ml

1 = Generic Drugs AL = Age Limit ME90 = Morphine Equivalent ST = Step Therapy 2 = Brand Drugs PA = Prior Authorization QL = Quantity Limits SP = Specialty 90 = 90 days available at mail order 49 2018

Tier Level Necessary actions, restrictions, or limits on use Name of Drug ARISTADA – aripiprazole lauroxil im er susp prefilled syr 2 PA, QL (1 syringe/28 days), 90 662 mg/2.4ml ARISTADA – aripiprazole lauroxil im er susp prefilled syr 2 PA, QL (1 syringe/28 days), 90 882 mg/3.2ml ARISTADA – aripiprazole lauroxil im er susp prefilled syr 2 PA, QL (1 syringe/56 days), 90 1064 mg/3.9ml HCL – chlorpromazine hcl inj 50 mg/2ml 2 PA chlorpromazine hcl tab 10 mg 1 PA, 90 chlorpromazine hcl tab 25 mg 1 PA, 90 chlorpromazine hcl tab 50 mg 1 PA, 90 chlorpromazine hcl tab 100 mg 1 PA, 90 chlorpromazine hcl tab 200 mg 1 PA, 90 orally disintegrating tab 12.5 mg (Fazaclo) 1 AL, PA, QL (60 tablets/30 days) clozapine orally disintegrating tab 25 mg (Fazaclo) 1 AL, PA, QL (60 tablets/30 days) clozapine orally disintegrating tab 100 mg (Fazaclo) 1 AL, PA, QL (60 tablets/30 days) clozapine tab 25 mg (Clozaril) 1 AL, PA, QL (90 tablets/30 days) clozapine tab 50 mg 1 AL, PA, QL (90 tablets/30 days) clozapine tab 100 mg (Clozaril) 1 AL, PA, QL (270 tablets/30 days) clozapine tab 200 mg 1 AL, PA, QL (120 tablets/30 days) EQUETRO – () cap er 12hr 100 mg 2 PA, 90 EQUETRO – carbamazepine (antipsychotic) cap er 12hr 200 mg 2 PA, 90 EQUETRO – carbamazepine (antipsychotic) cap er 12hr 300 mg 2 PA, 90 FANAPT – iloperidone tab 1 mg 2 PA, QL (60 tablets/30 days), 90 FANAPT – iloperidone tab 2 mg 2 PA, QL (60 tablets/30 days), 90 FANAPT – iloperidone tab 4 mg 2 PA, QL (60 tablets/30 days), 90 FANAPT – iloperidone tab 6 mg 2 PA, QL (60 tablets/30 days), 90 FANAPT – iloperidone tab 8 mg 2 PA, QL (60 tablets/30 days), 90 FANAPT – iloperidone tab 10 mg 2 PA, QL (60 tablets/30 days), 90 FANAPT – iloperidone tab 12 mg 2 PA, QL (60 tablets/30 days), 90 FANAPT TITRATION PACK – iloperidone tab 1 mg & 2 mg & 2 PA, QL (8 tablets/180 days) 4 mg & 6 mg titration pak FAZACLO – clozapine orally disintegrating tab 150 mg 2 PA, QL (60 tablets/30 days) FAZACLO – clozapine orally disintegrating tab 200 mg 2 PA, QL (120 tablets/30 days) HCL – fluphenazine hcl elixir 2.5 mg/5ml 2 PA, 90 FLUPHENAZINE HCL – fluphenazine hcl oral conc 5 mg/ml 2 PA, 90 FLUPHENAZINE HCL – fluphenazine hcl inj 2.5 mg/ml 2 PA

1 = Generic Drugs AL = Age Limit ME90 = Morphine Equivalent ST = Step Therapy 2 = Brand Drugs PA = Prior Authorization QL = Quantity Limits SP = Specialty 90 = 90 days available at mail order 50 2018

Tier Level Necessary actions, restrictions, or limits on use Name of Drug fluphenazine hcl tab 1 mg 1 90 fluphenazine hcl tab 2.5 mg 1 90 fluphenazine hcl tab 5 mg 1 90 fluphenazine hcl tab 10 mg 1 90 GEODON – mesylate for inj 20 mg (base equivalent) 2 PA lactate oral conc 2 mg/ml 1 AL, PA, 90 haloperidol tab 0.5 mg 1 AL, PA, 90 haloperidol tab 1 mg 1 AL, PA, 90 haloperidol tab 2 mg 1 AL, PA, 90 haloperidol tab 5 mg 1 AL, PA, 90 haloperidol tab 10 mg 1 AL, PA, 90 haloperidol tab 20 mg 1 AL, PA, 90 INVEGA – paliperidone tab er 24hr 1.5 mg 2 PA, QL (30 tablets/30 days), 90 INVEGA – paliperidone tab er 24hr 3 mg 2 PA, QL (30 tablets/30 days), 90 INVEGA – paliperidone tab er 24hr 6 mg 2 PA, QL (60 tablets/30 days), 90 INVEGA – paliperidone tab er 24hr 9 mg 2 PA, QL (30 tablets/30 days), 90 INVEGA SUSTENNA – paliperidone palmitate im extended- 2 PA, QL (1 kit/28 days) release susp 39 mg/0.25ml INVEGA SUSTENNA – paliperidone palmitate im extended- 2 PA, QL (1 kit/28 days) release susp 78 mg/0.5ml INVEGA SUSTENNA – paliperidone palmitate im extend-release 2 PA, QL (1 kit/28 days) susp 117 mg/0.75ml INVEGA SUSTENNA – paliperidone palmitate im extended- 2 PA, QL (1 kit/28 days) release susp 156 mg/ml INVEGA SUSTENNA – paliperidone palmitate im extended- 2 PA, QL (1 kit/28 days) release susp 234 mg/1.5ml INVEGA TRINZA – paliperidone palmitate im extend-release 2 PA, QL (1 syringe/90 days), 90 susp 273 mg/0.875ml INVEGA TRINZA – paliperidone palmitate im extend-release 2 PA, QL (1 syringe/90 days), 90 susp 410 mg/1.315ml INVEGA TRINZA – paliperidone palmitate im extend-release 2 PA, QL (1 syringe/90 days), 90 susp 546 mg/1.75ml INVEGA TRINZA – paliperidone palmitate im extend-release 2 PA, QL (1 syringe/90 days), 90 susp 819 mg/2.625ml LATUDA – hcl tab 20 mg 2 PA, QL (30 tablets/30 days), 90 LATUDA – lurasidone hcl tab 40 mg 2 PA, QL (30 tablets/30 days), 90 LATUDA – lurasidone hcl tab 60 mg 2 PA, QL (30 tablets/30 days), 90 LATUDA – lurasidone hcl tab 80 mg 2 PA, QL (60 tablets/30 days), 90

1 = Generic Drugs AL = Age Limit ME90 = Morphine Equivalent ST = Step Therapy 2 = Brand Drugs PA = Prior Authorization QL = Quantity Limits SP = Specialty 90 = 90 days available at mail order 51 2018

Tier Level Necessary actions, restrictions, or limits on use Name of Drug LATUDA – lurasidone hcl tab 120 mg 2 PA, QL (30 tablets/30 days), 90 LITHIUM – lithium oral solution 8 meq/5ml 2 PA, 90 lithium carbonate cap 150 mg (Lithium carbonate) 1 90 lithium carbonate cap 300 mg 1 90 lithium carbonate cap 600 mg (Lithium carbonate) 1 90 lithium carbonate tab er 300 mg (Lithobid) 1 90 lithium carbonate tab er 450 mg 1 90 lithium carbonate tab 300 mg 1 90 loxapine succinate cap 5 mg 1 AL, PA, 90 loxapine succinate cap 10 mg 1 AL, PA, 90 loxapine succinate cap 25 mg 1 AL, PA, 90 loxapine succinate cap 50 mg 1 AL, PA, 90 MOLINDONE HYDROCHLORIDE – molindone hcl tab 5 mg 2 90 MOLINDONE HYDROCHLORIDE – molindone hcl tab 10 mg 2 90 MOLINDONE HYDROCHLORIDE – molindone hcl tab 25 mg 2 90 orally disintegrating tab 5 mg (Zyprexa zydis) 1 AL, PA, QL (30 tablets/30 days), 90 olanzapine orally disintegrating tab 10 mg (Zyprexa zydis) 1 AL, PA, QL (30 tablets/30 days), 90 olanzapine orally disintegrating tab 15 mg (Zyprexa zydis) 1 AL, PA, QL (30 tablets/30 days), 90 olanzapine orally disintegrating tab 20 mg (Zyprexa zydis) 1 AL, PA, QL (30 tablets/30 days), 90 olanzapine tab 2.5 mg (Zyprexa) 1 AL, PA, QL (30 tablets/30 days), 90 olanzapine tab 5 mg (Zyprexa) 1 AL, PA, QL (30 tablets/30 days), 90 olanzapine tab 7.5 mg (Zyprexa) 1 AL, PA, QL (30 tablets/30 days), 90 olanzapine tab 10 mg (Zyprexa) 1 AL, PA, QL (30 tablets/30 days), 90 olanzapine tab 15 mg (Zyprexa) 1 AL, PA, QL (30 tablets/30 days), 90 olanzapine tab 20 mg (Zyprexa) 1 AL, PA, QL (30 tablets/30 days), 90 paliperidone tab er 24hr 1.5 mg (Invega) 1 PA, QL (30 tablets/30 days), 90 paliperidone tab er 24hr 3 mg (Invega) 1 PA, QL (30 tablets/30 days), 90

1 = Generic Drugs AL = Age Limit ME90 = Morphine Equivalent ST = Step Therapy 2 = Brand Drugs PA = Prior Authorization QL = Quantity Limits SP = Specialty 90 = 90 days available at mail order 52 2018

Tier Level Necessary actions, restrictions, or limits on use Name of Drug paliperidone tab er 24hr 6 mg (Invega) 1 PA, QL (60 tablets/30 days), 90 paliperidone tab er 24hr 9 mg (Invega) 1 PA, QL (30 tablets/30 days), 90 tab 2 mg 1 AL, PA, 90 perphenazine tab 4 mg 1 AL, PA, 90 perphenazine tab 8 mg 1 AL, PA, 90 perphenazine tab 16 mg 1 AL, PA, 90 fumarate tab er 24hr 400 mg (Seroquel xr) 1 AL, PA, QL (60 tablets/30 days), 90 quetiapine fumarate tab 25 mg (Seroquel) 1 AL, PA, QL (90 tablets/30 days), 90 quetiapine fumarate tab 50 mg (Seroquel) 1 AL, PA, QL (90 tablets/30 days), 90 quetiapine fumarate tab 100 mg (Seroquel) 1 AL, PA, QL (90 tablets/30 days), 90 quetiapine fumarate tab 200 mg (Seroquel) 1 AL, PA, QL (90 tablets/30 days), 90 quetiapine fumarate tab 300 mg (Seroquel) 1 AL, PA, QL (60 tablets/30 days), 90 quetiapine fumarate tab 400 mg (Seroquel) 1 AL, PA, QL (60 tablets/30 days), 90 REXULTI – brexpiprazole tab 0.25 mg 2 PA, QL (30 tablets/30 days), 90 REXULTI – brexpiprazole tab 0.5 mg 2 PA, QL (30 tablets/30 days), 90 REXULTI – brexpiprazole tab 1 mg 2 PA, QL (30 tablets/30 days), 90 REXULTI – brexpiprazole tab 2 mg 2 PA, QL (30 tablets/30 days), 90 REXULTI – brexpiprazole tab 3 mg 2 PA, QL (30 tablets/30 days), 90 REXULTI – brexpiprazole tab 4 mg 2 PA, QL (30 tablets/30 days), 90 RISPERDAL CONSTA – risperidone microspheres for inj 2 PA 12.5 mg RISPERDAL CONSTA – risperidone microspheres for inj 25 mg 2 PA RISPERDAL CONSTA – risperidone microspheres for inj 2 PA 37.5 mg RISPERDAL CONSTA – risperidone microspheres for inj 50 mg 2 PA RISPERIDONE ODT – risperidone orally disintegrating tab 2 AL, PA, QL (60 0.25 mg tablets/30 days), 90 risperidone orally disintegrating tab 0.25 mg 1 AL, PA, QL (60 tablets/30 days), 90 risperidone orally disintegrating tab 0.5 mg (Risperdal m-tab) 1 AL, PA, QL (60 tablets/30 days), 90

1 = Generic Drugs AL = Age Limit ME90 = Morphine Equivalent ST = Step Therapy 2 = Brand Drugs PA = Prior Authorization QL = Quantity Limits SP = Specialty 90 = 90 days available at mail order 53 2018

Tier Level Necessary actions, restrictions, or limits on use Name of Drug risperidone orally disintegrating tab 1 mg (Risperdal m-tab) 1 AL, PA, QL (60 tablets/30 days), 90 risperidone orally disintegrating tab 2 mg (Risperdal m-tab) 1 AL, PA, QL (60 tablets/30 days), 90 risperidone orally disintegrating tab 3 mg (Risperdal m-tab) 1 AL, PA, QL (60 tablets/30 days), 90 risperidone orally disintegrating tab 4 mg (Risperdal m-tab) 1 AL, PA, QL (120 tablets/30 days), 90 risperidone soln 1 mg/ml (Risperdal) 1 AL, PA, QL (480 mls/30 days), 90 risperidone tab 0.25 mg (Risperdal) 1 AL, PA, QL (120 tablets/30 days), 90 risperidone tab 0.5 mg (Risperdal) 1 AL, PA, QL (120 tablets/30 days), 90 risperidone tab 1 mg (Risperdal) 1 AL, PA, QL (120 tablets/30 days), 90 risperidone tab 2 mg (Risperdal) 1 AL, PA, QL (120 tablets/30 days), 90 risperidone tab 3 mg (Risperdal) 1 AL, PA, QL (60 tablets/30 days), 90 risperidone tab 4 mg (Risperdal) 1 AL, PA, QL (120 tablets/30 days), 90 SAPHRIS – maleate sl tab 2.5 mg (base equiv) 2 PA, QL (60 tablets/30 days), 90 SAPHRIS – asenapine maleate sl tab 5 mg (base equiv) 2 PA, QL (60 tablets/30 days), 90 SAPHRIS – asenapine maleate sl tab 10 mg (base equiv) 2 PA, QL (60 tablets/30 days), 90 hcl tab 10 mg 1 AL, PA, 90 thioridazine hcl tab 25 mg 1 AL, PA, 90 thioridazine hcl tab 50 mg 1 AL, PA, 90 thioridazine hcl tab 100 mg 1 AL, PA, 90 thiothixene cap 1 mg 1 AL, PA, 90 thiothixene cap 2 mg 1 AL, PA, 90 thiothixene cap 5 mg 1 AL, PA, 90 thiothixene cap 10 mg 1 AL, PA, 90 hcl tab 1 mg (base equivalent) 1 AL, PA, 90 trifluoperazine hcl tab 2 mg (base equivalent) 1 AL, PA, 90 trifluoperazine hcl tab 5 mg (base equivalent) 1 AL, PA, 90 trifluoperazine hcl tab 10 mg (base equivalent) 1 AL, PA, 90 VERSACLOZ – clozapine susp 50 mg/ml 2 PA, QL (540 mls/30 days)

1 = Generic Drugs AL = Age Limit ME90 = Morphine Equivalent ST = Step Therapy 2 = Brand Drugs PA = Prior Authorization QL = Quantity Limits SP = Specialty 90 = 90 days available at mail order 54 2018

Tier Level Necessary actions, restrictions, or limits on use Name of Drug ziprasidone hcl cap 20 mg (Geodon) 1 AL, PA, QL (60 capsules/30 days), 90 ziprasidone hcl cap 40 mg (Geodon) 1 AL, PA, QL (60 capsules/30 days), 90 ziprasidone hcl cap 60 mg (Geodon) 1 AL, PA, QL (60 capsules/30 days), 90 ziprasidone hcl cap 80 mg (Geodon) 1 AL, PA, QL (60 capsules/30 days), 90 ZYPREXA RELPREVV – olanzapine pamoate for extended rel im 2 PA, QL (2 vials/28 days) susp 210 mg (base eq) ZYPREXA RELPREVV – olanzapine pamoate for extended rel im 2 PA, QL (2 vials/28 days) susp 300 mg (base eq) ZYPREXA RELPREVV – olanzapine pamoate for extended rel im 2 PA, QL (1 vial/28 days) susp 405 mg (base eq) SLEEP AIDS estazolam tab 1 mg 1 QL (30 tablets/30 days) estazolam tab 2 mg 1 QL (30 tablets/30 days) eszopiclone tab 1 mg (Lunesta) 1 QL (30 tablets/30 days) eszopiclone tab 2 mg (Lunesta) 1 QL (30 tablets/30 days) eszopiclone tab 3 mg (Lunesta) 1 QL (30 tablets/30 days) – phenobarbital tab 15 mg 2 90 PHENOBARBITAL – phenobarbital tab 30 mg 2 90 PHENOBARBITAL – phenobarbital tab 60 mg 2 90 PHENOBARBITAL – phenobarbital tab 100 mg 2 90 phenobarbital elixir 20 mg/5ml 1 90 phenobarbital tab 16.2 mg 1 90 phenobarbital tab 32.4 mg 1 90 phenobarbital tab 64.8 mg 1 90 phenobarbital tab 97.2 mg 1 90 QUAZEPAM – quazepam tab 15 mg 2 QL (30 tablets/30 days) cap 15 mg (Restoril) 1 QL (30 capsules/30 days) temazepam cap 30 mg (Restoril) 1 QL (30 capsules/30 days) zaleplon cap 5 mg (Sonata) 1 QL (30 capsules/30 days) zaleplon cap 10 mg (Sonata) 1 QL (30 capsules/30 days) zolpidem tartrate tab 5 mg (Ambien) 1 QL (30 tablets/30 days) zolpidem tartrate tab 10 mg (Ambien) 1 QL (30 tablets/30 days) HYPERACTIVITY/NARCOLEPSY

1 = Generic Drugs AL = Age Limit ME90 = Morphine Equivalent ST = Step Therapy 2 = Brand Drugs PA = Prior Authorization QL = Quantity Limits SP = Specialty 90 = 90 days available at mail order 55 2018

Tier Level Necessary actions, restrictions, or limits on use Name of Drug amphetamine-dextroamphetamine cap er 24hr 5 mg (Adderall xr) 1 PA, QL (30 capsules/30 days), 90 amphetamine-dextroamphetamine cap er 24hr 10 mg (Adderall 1 PA, QL (30 capsules/30 days), 90 xr) amphetamine-dextroamphetamine cap er 24hr 15 mg (Adderall 1 PA, QL (30 capsules/30 days), 90 xr) amphetamine-dextroamphetamine cap er 24hr 20 mg (Adderall 1 PA, QL (30 capsules/30 days), 90 xr) amphetamine-dextroamphetamine cap er 24hr 25 mg (Adderall 1 PA, QL (30 capsules/30 days), 90 xr) amphetamine-dextroamphetamine cap er 24hr 30 mg (Adderall 1 PA, QL (30 capsules/30 days), 90 xr) amphetamine-dextroamphetamine tab 5 mg (Adderall) 1 PA, QL (60 tablets/30 days), 90 amphetamine-dextroamphetamine tab 7.5 mg (Adderall) 1 PA, QL (60 tablets/30 days), 90 amphetamine-dextroamphetamine tab 10 mg (Adderall) 1 PA, QL (60 tablets/30 days), 90 amphetamine-dextroamphetamine tab 12.5 mg (Adderall) 1 PA, QL (60 tablets/30 days), 90 amphetamine-dextroamphetamine tab 15 mg (Adderall) 1 PA, QL (60 tablets/30 days), 90 amphetamine-dextroamphetamine tab 20 mg (Adderall) 1 PA, QL (90 tablets/30 days), 90 amphetamine-dextroamphetamine tab 30 mg (Adderall) 1 PA, QL (60 tablets/30 days), 90 armodafinil tab 50 mg (Nuvigil) 1 PA, QL (30 tablets/30 days), 90 armodafinil tab 150 mg (Nuvigil) 1 PA, QL (30 tablets/30 days), 90 armodafinil tab 250 mg (Nuvigil) 1 PA, QL (30 tablets/30 days), 90 caffeine citrate oral soln 60 mg/3ml (10 mg/ml base equiv) 1 clonidine hcl tab er 12hr 0.1 mg (Kapvay) 1 QL (120 tablets/30 days), 90 dexmethylphenidate hcl cap er 24 hr 5 mg (Focalin xr) 1 PA, QL (30 capsules/30 days), 90 dexmethylphenidate hcl cap er 24 hr 10 mg (Focalin xr) 1 PA, QL (30 capsules/30 days), 90 dexmethylphenidate hcl cap er 24 hr 15 mg (Focalin xr) 1 PA, QL (30 capsules/30 days), 90 dexmethylphenidate hcl cap er 24 hr 20 mg (Focalin xr) 1 PA, QL (30 capsules/30 days), 90 dexmethylphenidate hcl cap er 24 hr 30 mg (Focalin xr) 1 PA, QL (30 capsules/30 days), 90 dexmethylphenidate hcl cap er 24 hr 40 mg (Focalin xr) 1 PA, QL (30 capsules/30 days), 90 dexmethylphenidate hcl tab 2.5 mg (Focalin) 1 PA, QL (60 tablets/30 days), 90 dexmethylphenidate hcl tab 5 mg (Focalin) 1 PA, QL (60 tablets/30 days), 90 dexmethylphenidate hcl tab 10 mg (Focalin) 1 PA, QL (60 tablets/30 days), 90 dextroamphetamine sulfate cap er 24hr 5 mg (Dexedrine) 1 PA, QL (90 capsules/30 days), 90 dextroamphetamine sulfate cap er 24hr 10 mg (Dexedrine) 1 PA, QL (120 capsules/30 days), 90 dextroamphetamine sulfate cap er 24hr 15 mg (Dexedrine) 1 PA, QL (120 capsules/30 days), 90

1 = Generic Drugs AL = Age Limit ME90 = Morphine Equivalent ST = Step Therapy 2 = Brand Drugs PA = Prior Authorization QL = Quantity Limits SP = Specialty 90 = 90 days available at mail order 56 2018

Tier Level Necessary actions, restrictions, or limits on use Name of Drug dextroamphetamine sulfate oral solution 5 mg/5ml (Procentra) 1 PA, QL (1800 ml/30 days), 90 dextroamphetamine sulfate tab 5 mg 1 PA, QL (90 tablets/30 days), 90 dextroamphetamine sulfate tab 10 mg 1 PA, QL (180 tablets/30 days), 90 guanfacine hcl tab er 24hr 1 mg (base equiv) (Intuniv) 1 QL (30 tablets/30 days), 90 guanfacine hcl tab er 24hr 2 mg (base equiv) (Intuniv) 1 QL (30 tablets/30 days), 90 guanfacine hcl tab er 24hr 3 mg (base equiv) (Intuniv) 1 QL (30 tablets/30 days), 90 guanfacine hcl tab er 24hr 4 mg (base equiv) (Intuniv) 1 QL (30 tablets/30 days), 90 methylphenidate hcl cap er 10 mg (cd) 1 PA, QL (30 capsules/30 days), 90 methylphenidate hcl cap er 20 mg (cd) 1 PA, QL (30 capsules/30 days), 90 methylphenidate hcl cap er 30 mg (cd) 1 PA, QL (30 capsules/30 days), 90 methylphenidate hcl cap er 40 mg (cd) 1 PA, QL (30 capsules/30 days), 90 methylphenidate hcl cap er 50 mg (cd) 1 PA, QL (30 capsules/30 days), 90 methylphenidate hcl cap er 60 mg (cd) 1 PA, QL (30 capsules/30 days), 90 methylphenidate hcl cap er 24hr 20 mg (la) (Ritalin la) 1 PA, QL (30 capsules/30 days), 90 methylphenidate hcl cap er 24hr 30 mg (la) (Ritalin la) 1 PA, QL (30 capsules/30 days), 90 methylphenidate hcl cap er 24hr 40 mg (la) (Ritalin la) 1 PA, QL (30 capsules/30 days), 90 methylphenidate hcl chew tab 2.5 mg 1 PA, QL (90 tablets/30 days), 90 methylphenidate hcl chew tab 5 mg 1 PA, QL (90 tablets/30 days), 90 methylphenidate hcl chew tab 10 mg 1 PA, QL (180 tablets/30 days), 90 METHYLPHENIDATE HCL ER – methylphenidate hcl tab er 24hr 2 PA, QL (30 tablets/30 days), 90 18 mg METHYLPHENIDATE HCL ER – methylphenidate hcl tab er 24hr 2 PA, QL (30 tablets/30 days), 90 27 mg METHYLPHENIDATE HCL ER – methylphenidate hcl tab er 24hr 2 PA, QL (60 tablets/30 days), 90 36 mg METHYLPHENIDATE HCL ER – methylphenidate hcl tab er 24hr 2 PA, QL (30 tablets/30 days), 90 54 mg methylphenidate hcl soln 5 mg/5ml (Methylin) 1 PA, QL (450 ml/30 days), 90 methylphenidate hcl soln 10 mg/5ml (Methylin) 1 PA, QL (900 ml/30 days), 90 methylphenidate hcl tab er 10 mg 1 PA, QL (90 tablets/30 days), 90 methylphenidate hcl tab er 20 mg 1 PA, QL (90 tablets/30 days), 90 methylphenidate hcl tab 5 mg (Ritalin) 1 PA, QL (90 tablets/30 days), 90 methylphenidate hcl tab 10 mg (Ritalin) 1 PA, QL (90 tablets/30 days), 90 methylphenidate hcl tab 20 mg (Ritalin) 1 PA, QL (90 tablets/30 days), 90 modafinil tab 100 mg (Provigil) 1 PA, QL (30 tablets/30 days), 90 modafinil tab 200 mg (Provigil) 1 PA, QL (30 tablets/30 days), 90

1 = Generic Drugs AL = Age Limit ME90 = Morphine Equivalent ST = Step Therapy 2 = Brand Drugs PA = Prior Authorization QL = Quantity Limits SP = Specialty 90 = 90 days available at mail order 57 2018

Tier Level Necessary actions, restrictions, or limits on use Name of Drug MULTIPLE SCLEROSIS AUBAGIO – teriflunomide tab 7 mg 2 PA, QL (30 tablets/30 days), SP, 90 AUBAGIO – teriflunomide tab 14 mg 2 PA, QL (30 tablets/30 days), SP, 90 AVONEX – interferon beta-1a im prefilled syringe kit 2 PA, QL (1 kit/28 days), SP, 90 30 mcg/0.5ml AVONEX – interferon beta-1a for im inj kit 30mcg (33mcg(6.6 2 PA, QL (4 vials/28 days), SP, 90 mu)/vial) AVONEX PEN – interferon beta-1a im auto-injector kit 2 PA, QL (1 kit/28 days), SP, 90 30 mcg/0.5ml EXTAVIA – interferon beta-1b for inj kit 0.3 mg 2 PA, QL (14 vials/28 days), SP, 90 glatiramer acetate soln prefilled syringe 20 mg/ml (Glatopa) 1 PA, QL (30 syringes/30 days), SP, 90 glatiramer acetate soln prefilled syringe 40 mg/ml (Copaxone) 1 PA, QL (12 syringes/28 days), SP, 90 OTHER CENTRAL NERVOUS SYSTEM DRUGS acamprosate calcium tab delayed release 333 mg 1 90 bupropion hcl (smoking deterrent) tab er 12hr 150 mg (Zyban) 1 QL (180 days/365 days) CHANTIX – varenicline tartrate tab 0.5 mg (base equiv) 2 QL (180 days/365 days) CHANTIX – varenicline tartrate tab 1 mg (base equiv) 2 QL (180 days/365 days) CHANTIX CONTINUING MONTH – varenicline tartrate tab 1 mg 2 QL (180 days/365 days) (base equiv) CHANTIX STARTING MONTH PA – varenicline tartrate tab 2 QL (180 days/365 days) 0.5 mg x 11 & tab 1 mg x 42 pack CHLORDIAZEPOXIDE/AMITRIPT – chlordiazepoxide- 2 QL (120 tablets/30 days), 90 amitriptyline tab 5-12.5 mg CHLORDIAZEPOXIDE/AMITRIPT – chlordiazepoxide- 2 QL (180 tablets/30 days), 90 amitriptyline tab 10-25 mg disulfiram tab 250 mg (Antabuse) 1 90 disulfiram tab 500 mg (Antabuse) 1 90 donepezil hydrochloride orally disintegrating tab 5 mg 1 QL (30 tablets/30 days), 90 donepezil hydrochloride orally disintegrating tab 10 mg 1 QL (30 tablets/30 days), 90 donepezil hydrochloride tab 5 mg (Aricept) 1 QL (30 tablets/30 days), 90 donepezil hydrochloride tab 10 mg (Aricept) 1 QL (30 tablets/30 days), 90 GALANTAMINE HYDROBROMIDE – galantamine hydrobromide 2 QL (200 mls/30 days), 90 oral soln 4 mg/ml galantamine hydrobromide cap er 24hr 8 mg (Razadyne er) 1 QL (30 capsules/30 days), 90 galantamine hydrobromide cap er 24hr 16 mg (Razadyne er) 1 QL (30 capsules/30 days), 90

1 = Generic Drugs AL = Age Limit ME90 = Morphine Equivalent ST = Step Therapy 2 = Brand Drugs PA = Prior Authorization QL = Quantity Limits SP = Specialty 90 = 90 days available at mail order 58 2018

Tier Level Necessary actions, restrictions, or limits on use Name of Drug galantamine hydrobromide cap er 24hr 24 mg (Razadyne er) 1 QL (30 capsules/30 days), 90 galantamine hydrobromide tab 4 mg (Razadyne) 1 QL (60 tablets/30 days), 90 galantamine hydrobromide tab 8 mg (Razadyne) 1 QL (60 tablets/30 days), 90 galantamine hydrobromide tab 12 mg (Razadyne) 1 QL (60 tablets/30 days), 90 memantine hcl oral solution 2 mg/ml (Namenda) 1 QL (360 mls/30 days), 90 memantine hcl tab 5 mg (Namenda) 1 QL (60 tablets/30 days), 90 memantine hcl tab 10 mg (Namenda) 1 QL (60 tablets/30 days), 90 memantine hcl tab 5 mg (28) & 10 mg (21) titration pak 1 QL (49 tablets/180 days) (Namenda titration pa) NICOTROL INHALER – nicotine inhaler system 10 mg (4 mg 2 QL (180 days/365 days) delivered) NICOTROL NS – nicotine nasal spray 10 mg/ml (0.5 mg/spray) 2 QL (180 days/365 days) PERPHENAZINE/AMITRIPTYLIN – perphenazine-amitriptyline 2 PA, 90 tab 2-10 mg PERPHENAZINE/AMITRIPTYLIN – perphenazine-amitriptyline 2 PA, 90 tab 2-25 mg PERPHENAZINE/AMITRIPTYLIN – perphenazine-amitriptyline 2 PA, 90 tab 4-10 mg PERPHENAZINE/AMITRIPTYLIN – perphenazine-amitriptyline 2 PA, 90 tab 4-25 mg PERPHENAZINE/AMITRIPTYLIN – perphenazine-amitriptyline 2 PA, 90 tab 4-50 mg tab 1 mg (Orap) 1 90 pimozide tab 2 mg (Orap) 1 90 rivastigmine tartrate cap 4.5 mg (Exelon) 1 QL (60 capsules/30 days), 90 PAIN RELIEF DRUGS NON-NARCOTIC DRUGS butalbital-acetaminophen tab 50-325 mg 1 QL (180 tablets/30 days) butalbital-acetaminophen-caffeine cap 50-300-40 mg (Fioricet) 1 QL (180 capsules/30 days) butalbital-acetaminophen-caffeine tab 50-325-40 mg (Esgic) 1 QL (180 tablets/30 days) butalbital--caffeine cap 50-325-40 mg (Fiorinal) 1 QL (180 capsules/30 days) NARCOTIC DRUGS acetaminophen w/ codeine soln 120-12 mg/5ml 1 ME90, QL (2700 mls/30 days) acetaminophen w/ codeine tab 300-15 mg (Tylenol/codeine) 1 ME90, QL (360 tablets/30 days) acetaminophen w/ codeine tab 300-30 mg (Tylenol/codeine #3) 1 ME90, QL (360 tablets/30 days) acetaminophen w/ codeine tab 300-60 mg (Tylenol/codeine #4) 1 ME90, QL (180 tablets/30 days) ACETAMINOPHEN/CAFFEINE/DI – acetaminophen-caffeine- 2 ME90, QL (300 capsules/30 days) dihydrocodeine cap 320.5-30-16 mg

1 = Generic Drugs AL = Age Limit ME90 = Morphine Equivalent ST = Step Therapy 2 = Brand Drugs PA = Prior Authorization QL = Quantity Limits SP = Specialty 90 = 90 days available at mail order 59 2018

Tier Level Necessary actions, restrictions, or limits on use Name of Drug hcl sl tab 2 mg (base equiv) 1 QL (90 tablets/30 days) buprenorphine hcl sl tab 8 mg (base equiv) 1 QL (90 tablets/30 days) buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg (base equiv) 1 QL (90 tablets/30 days) buprenorphine hcl-naloxone hcl sl tab 8-2 mg (base equiv) 1 QL (60 tablets/30 days) butalbital-acetaminophen-caff w/ cod cap 50-325-40-30 mg 1 ME90, QL (180 capsules/30 days) butalbital-aspirin-caff w/ codeine cap 50-325-40-30 mg (Fiorinal/ 1 ME90, QL (180 capsules/30 days) codeine #3) butorphanol tartrate nasal soln 10 mg/ml 1 ME90, QL (2 bottles/30 days) codeine sulfate tab 15 mg (Codeine sulfate) 1 ME90, QL (180 tablets/30 days) codeine sulfate tab 30 mg (Codeine sulfate) 1 ME90, QL (180 tablets/30 days) codeine sulfate tab 60 mg (Codeine sulfate) 1 ME90, QL (180 tablets/30 days) td patch 72hr 12 mcg/hr (Duragesic) 1 ME90, QL (15 patches/30 days) fentanyl td patch 72hr 25 mcg/hr (Duragesic) 1 ME90, QL (15 patches/30 days) fentanyl td patch 72hr 50 mcg/hr (Duragesic) 1 ME90, QL (15 patches/30 days) fentanyl td patch 72hr 75 mcg/hr (Duragesic) 1 ME90, QL (15 patches/30 days) fentanyl td patch 72hr 100 mcg/hr (Duragesic) 1 ME90, QL (15 patches/30 days) hydrocodone-acetaminophen soln 7.5-325 mg/15ml (Hycet) 1 ME90, QL (3600 mls/30 days) hydrocodone-acetaminophen soln 10-325 mg/15ml (Zamicet) 1 ME90, QL (2700 mls/30 days) hydrocodone-acetaminophen tab 2.5-325 mg 1 ME90, QL (360 tablets/30 days) hydrocodone-acetaminophen tab 10-325 mg (Norco) 1 ME90, QL (180 tablets/30 days) hydrocodone-acetaminophen tab 7.5-300 mg (Xodol) 1 ME90, QL (180 tablets/30 days) hydrocodone-acetaminophen tab 5-325 mg (Norco) 1 ME90, QL (360 tablets/30 days) hydrocodone-acetaminophen tab 7.5-325 mg (Norco) 1 ME90, QL (180 tablets/30 days) hydrocodone-acetaminophen tab 10-300 mg (Xodol) 1 ME90, QL (180 tablets/30 days) hydrocodone- tab 5-200 mg (Reprexain) 1 ME90, QL (150 tablets/30 days) hydrocodone-ibuprofen tab 7.5-200 mg 1 ME90, QL (150 tablets/30 days) hydromorphone hcl liqd 1 mg/ml (Dilaudid) 1 ME90, QL (1440 mls/30 days) hydromorphone hcl tab 2 mg (Dilaudid) 1 ME90, QL (180 tablets/30 days) hydromorphone hcl tab 4 mg (Dilaudid) 1 ME90, QL (180 tablets/30 days) hydromorphone hcl tab 8 mg (Dilaudid) 1 ME90, QL (180 tablets/30 days) methadone hcl conc 10 mg/ml (Methadose) 1 ME90, QL (90 mls/30 days) methadone hcl soln 5 mg/5ml (Methadone hcl) 1 ME90, QL (900 mls/30 days) methadone hcl soln 10 mg/5ml (Methadone hcl) 1 ME90, QL (450 mls/30 days) methadone hcl tab for oral susp 40 mg 1 ME90, QL (90 tablets/30 days) methadone hcl tab 5 mg (Dolophine) 1 ME90, QL (90 tablets/30 days)

1 = Generic Drugs AL = Age Limit ME90 = Morphine Equivalent ST = Step Therapy 2 = Brand Drugs PA = Prior Authorization QL = Quantity Limits SP = Specialty 90 = 90 days available at mail order 60 2018

Tier Level Necessary actions, restrictions, or limits on use Name of Drug methadone hcl tab 10 mg (Dolophine) 1 ME90, QL (90 tablets/30 days) MORPHINE SULFATE – morphine sulfate tab 15 mg 2 ME90, QL (240 tablets/30 days) MORPHINE SULFATE – morphine sulfate tab 30 mg 2 ME90, QL (180 tablets/30 days) MORPHINE SULFATE – morphine sulfate suppos 5 mg 2 ME90 MORPHINE SULFATE – morphine sulfate suppos 10 mg 2 ME90 MORPHINE SULFATE – morphine sulfate suppos 20 mg 2 ME90 MORPHINE SULFATE – morphine sulfate suppos 30 mg 2 ME90 morphine sulfate cap er 24hr 100 mg (Kadian) 1 ME90, QL (60 tablets/30 days) MORPHINE SULFATE ER – morphine sulfate beads cap er 24hr 2 ME90, QL (30 capsules/30 days) 60 mg MORPHINE SULFATE ER – morphine sulfate beads cap er 24hr 2 ME90, QL (30 capsules/30 days) 75 mg MORPHINE SULFATE ER – morphine sulfate beads cap er 24hr 2 ME90, QL (30 capsules/30 days) 120 mg morphine sulfate oral soln 10 mg/5ml 1 ME90, QL (2700 mls/30 days) morphine sulfate oral soln 20 mg/5ml 1 ME90, QL (1350 mls/30 days) morphine sulfate oral soln 100 mg/5ml (20 mg/ml) 1 ME90, QL (270 mls/30 days) morphine sulfate tab er 15 mg (Ms contin) 1 ME90, QL (90 tablets/30 days) morphine sulfate tab er 30 mg (Ms contin) 1 ME90, QL (90 tablets/30 days) morphine sulfate tab er 60 mg (Ms contin) 1 ME90, QL (90 tablets/30 days) morphine sulfate tab er 100 mg (Ms contin) 1 ME90, QL (90 tablets/30 days) morphine sulfate tab er 200 mg (Ms contin) 1 ME90, QL (90 tablets/30 days) oxycodone hcl conc 100 mg/5ml (20 mg/ml) 1 ME90, QL (270 mls/30 days) oxycodone hcl soln 5 mg/5ml 1 ME90, QL (5400 mls/30 days) oxycodone hcl tab 5 mg (Roxicodone) 1 ME90, QL (360 tablets/30 days) oxycodone hcl tab 10 mg 1 ME90, QL (180 tablets/30 days) oxycodone hcl tab 15 mg (Roxicodone) 1 ME90, QL (180 tablets/30 days) oxycodone hcl tab 20 mg 1 ME90, QL (180 tablets/30 days) oxycodone hcl tab 30 mg (Roxicodone) 1 ME90, QL (180 tablets/30 days) oxycodone w/ acetaminophen tab 2.5-325 mg (Percocet) 1 ME90, QL (360 tablets/30 days) oxycodone w/ acetaminophen tab 5-325 mg (Percocet) 1 ME90, QL (360 tablets/30 days) oxycodone w/ acetaminophen tab 7.5-325 mg (Percocet) 1 ME90, QL (240 tablets/30 days) oxycodone w/ acetaminophen tab 10-325 mg (Percocet) 1 ME90, QL (180 tablets/30 days) oxycodone-aspirin tab 4.8355-325 mg 1 ME90, QL (360 tablets/30 days) OXYCODONE/ACETAMINOPHEN – oxycodone w/ 2 ME90, QL (1800 mls/30 days) acetaminophen soln 5-325 mg/5ml

1 = Generic Drugs AL = Age Limit ME90 = Morphine Equivalent ST = Step Therapy 2 = Brand Drugs PA = Prior Authorization QL = Quantity Limits SP = Specialty 90 = 90 days available at mail order 61 2018

Tier Level Necessary actions, restrictions, or limits on use Name of Drug OXYCODONE/IBUPROFEN – oxycodone-ibuprofen tab 2 ME90, QL (120 tablets/30 days) 5-400 mg oxymorphone hcl tab er 12hr 5 mg 1 ME90, QL (60 tablets/30 days) oxymorphone hcl tab er 12hr 7.5 mg 1 ME90, QL (60 tablets/30 days) oxymorphone hcl tab er 12hr 10 mg 1 ME90, QL (60 tablets/30 days) oxymorphone hcl tab er 12hr 15 mg 1 ME90, QL (60 tablets/30 days) oxymorphone hcl tab er 12hr 20 mg 1 ME90, QL (60 tablets/30 days) oxymorphone hcl tab er 12hr 30 mg 1 ME90, QL (60 tablets/30 days) oxymorphone hcl tab er 12hr 40 mg 1 ME90, QL (60 tablets/30 days) oxymorphone hcl tab 5 mg (Opana) 1 ME90, QL (180 tablets/30 days) oxymorphone hcl tab 10 mg (Opana) 1 ME90, QL (180 tablets/30 days) SUBOXONE – buprenorphine hcl-naloxone hcl sl film 2-0.5 mg 2 QL (90 films/30 days) (base equiv) SUBOXONE – buprenorphine hcl-naloxone hcl sl film 4-1 mg 2 QL (90 films/30 days) (base equiv) SUBOXONE – buprenorphine hcl-naloxone hcl sl film 8-2 mg 2 QL (90 films/30 days) (base equiv) SUBOXONE – buprenorphine hcl-naloxone hcl sl film 12-3 mg 2 QL (90 films/30 days) (base equiv) hcl tab 50 mg (Ultram) 1 ME90, QL (240 tablets/30 days) tramadol-acetaminophen tab 37.5-325 mg (Ultracet) 1 ME90, QL (240 tablets/30 days) RHEUMATOID AND OSTEOARTHRITIS ARCALYST – rilonacept for inj 220 mg 2 PA, QL (4 vials/28 days), SP, 90 celecoxib cap 50 mg (Celebrex) 1 QL (60 capsules/30 days), ST, 90 celecoxib cap 100 mg (Celebrex) 1 QL (60 capsules/30 days), ST, 90 celecoxib cap 200 mg (Celebrex) 1 QL (60 capsules/30 days), ST, 90 celecoxib cap 400 mg (Celebrex) 1 QL (30 capsules/30 days), ST diclofenac potassium tab 50 mg 1 QL (120 tablets/30 days), 90 diclofenac sodium tab delayed release 50 mg 1 QL (120 tablets/30 days), 90 diclofenac sodium tab delayed release 75 mg 1 QL (60 tablets/30 days), 90 diclofenac sodium tab er 24hr 100 mg 1 QL (60 tablets/30 days), 90 ENBREL – etanercept for subcutaneous inj 25 mg 2 PA, QL (8 vials/28 days), SP, 90 ENBREL – etanercept subcutaneous soln prefilled syringe 2 PA, QL (8 syringes/28 25 mg/0.5ml days), SP, 90 ENBREL – etanercept subcutaneous soln prefilled syringe 2 PA, QL (4 syringes/28 50 mg/ml days), SP, 90

1 = Generic Drugs AL = Age Limit ME90 = Morphine Equivalent ST = Step Therapy 2 = Brand Drugs PA = Prior Authorization QL = Quantity Limits SP = Specialty 90 = 90 days available at mail order 62 2018

Tier Level Necessary actions, restrictions, or limits on use Name of Drug ENBREL SURECLICK – etanercept subcutaneous solution auto- 2 PA, QL (4 syringes/28 injector 50 mg/ml days), SP, 90 flurbiprofen tab 50 mg 1 QL (180 tablets/30 days), 90 flurbiprofen tab 100 mg 1 QL (90 tablets/30 days), 90 HUMIRA – adalimumab prefilled syringe kit 10 mg/0.1ml 2 PA, QL (2 syringes/28 days) HUMIRA – adalimumab prefilled syringe kit 10 mg/0.2ml 2 PA, QL (2 syringes/28 days), SP, 90 HUMIRA – adalimumab prefilled syringe kit 20 mg/0.2ml 2 PA, QL (2 syringes/28 days) HUMIRA – adalimumab prefilled syringe kit 20 mg/0.4ml 2 PA, QL (2 syringes/28 days), SP, 90 HUMIRA – adalimumab prefilled syringe kit 40 mg/0.8ml 2 PA, QL (2 syringes/28 days), SP, 90 HUMIRA – adalimumab prefilled syringe kit 40 mg/0.4ml 2 PA, QL (2 syringes/28 days) HUMIRA PEDIATRIC CROHNS D – adalimumab prefilled syringe 2 PA, QL (3 syringes/180 kit 40 mg/0.8ml days), SP, 90 HUMIRA PEDIATRIC CROHNS D – adalimumab prefilled syringe 2 PA, QL (3 syringes/180 days) kit 80 mg/0.8ml HUMIRA PEDIATRIC CROHNS D – adalimumab prefilled syringe 2 PA, QL (2 syringes/180 days) kit 80 mg/0.8ml & 40 mg/0.4ml HUMIRA PEN – adalimumab pen-injector kit 40 mg/0.8ml 2 PA, QL (2 pens/180 days), SP, 90 HUMIRA PEN – adalimumab pen-injector kit 40 mg/0.4ml 2 PA, QL (2 pens/28 days) HUMIRA PEN-CROHNS DISEASE – adalimumab pen-injector kit 2 PA, QL (6 pens/180 days), SP, 90 40 mg/0.8ml HUMIRA PEN-PSORIASIS STAR – adalimumab pen-injector kit 2 PA, QL (4 pens/28 days), SP, 90 40 mg/0.8ml ibuprofen susp 100 mg/5ml 1 QL (1000 mls/30 days) ibuprofen tab 400 mg 1 QL (120 tablets/30 days), 90 ibuprofen tab 600 mg 1 QL (150 tablets/30 days), 90 ibuprofen tab 800 mg 1 QL (120 tablets/30 days), 90 indomethacin cap er 75 mg 1 QL (60 capsules/30 days), 90 indomethacin cap 25 mg 1 QL (90 capsules/30 days), 90 indomethacin cap 50 mg 1 QL (60 capsules/30 days), 90 KETOPROFEN – ketoprofen cap 50 mg 2 QL (180 capsules/30 days), 90 KETOPROFEN – ketoprofen cap 75 mg 2 QL (120 capsules/30 days), 90 ketoprofen cap 50 mg 1 QL (180 capsules/30 days), 90 ketoprofen cap 75 mg 1 QL (120 capsules/30 days), 90 ketorolac tromethamine tab 10 mg 1 QL (20 tablets/30 days)

1 = Generic Drugs AL = Age Limit ME90 = Morphine Equivalent ST = Step Therapy 2 = Brand Drugs PA = Prior Authorization QL = Quantity Limits SP = Specialty 90 = 90 days available at mail order 63 2018

Tier Level Necessary actions, restrictions, or limits on use Name of Drug KINERET – anakinra subcutaneous soln prefilled syringe 2 PA, QL (30 syringes/30 100 mg/0.67ml days), SP, 90 leflunomide tab 10 mg (Arava) 1 90 leflunomide tab 20 mg (Arava) 1 90 meloxicam tab 7.5 mg (Mobic) 1 QL (60 tablets/30 days), 90 meloxicam tab 15 mg (Mobic) 1 QL (30 tablets/30 days), 90 nabumetone tab 500 mg 1 QL (120 tablets/30 days), 90 nabumetone tab 750 mg 1 QL (60 tablets/30 days), 90 naproxen sodium tab er 24hr 375 mg (base equiv) (Naprelan) 1 QL (120 tablets/30 days), 90 naproxen sodium tab 275 mg 1 QL (150 tablets/30 days), 90 naproxen sodium tab 550 mg (Anaprox ds) 1 QL (90 tablets/30 days), 90 naproxen susp 125 mg/5ml (Naprosyn) 1 QL (900 mls/30 days), 90 naproxen tab ec 375 mg (Ec-naprosyn) 1 QL (120 tablets/30 days), 90 naproxen tab ec 500 mg (Ec-naprosyn) 1 QL (90 tablets/30 days), 90 naproxen tab 250 mg 1 QL (150 tablets/30 days), 90 naproxen tab 375 mg 1 QL (120 tablets/30 days), 90 naproxen tab 500 mg (Naprosyn) 1 QL (90 tablets/30 days), 90 ORENCIA – abatacept subcutaneous soln prefilled syringe 2 PA, QL (4 syringes/28 125 mg/ml days), SP, 90 ORENCIA CLICKJECT – abatacept subcutaneous soln auto- 2 PA, QL (4 syringes/28 injector 125 mg/ml days), SP, 90 piroxicam cap 10 mg (Feldene) 1 QL (60 capsules/30 days), 90 piroxicam cap 20 mg (Feldene) 1 QL (30 capsules/30 days), 90 SIMPONI – golimumab subcutaneous soln auto-injector 2 PA, QL (1 syringe/28 50 mg/0.5ml days), SP, 90 SIMPONI – golimumab subcutaneous soln auto-injector 100 mg/ 2 PA, QL (1 syringe/28 ml days), SP, 90 SIMPONI – golimumab subcutaneous soln prefilled syringe 2 PA, QL (1 syringe/28 50 mg/0.5ml days), SP, 90 SIMPONI – golimumab subcutaneous soln prefilled syringe 2 PA, QL (1 syringe/28 100 mg/ml days), SP, 90 sulindac tab 150 mg 1 QL (60 tablets/30 days), 90 sulindac tab 200 mg 1 QL (60 tablets/30 days), 90 XELJANZ – tofacitinib citrate tab 5 mg (base equivalent) 2 PA, QL (120 tablets/30 days), SP, 90 XELJANZ XR – tofacitinib citrate tab er 24hr 11 mg (base 2 PA, QL (30 tablets/30 equivalent) days), SP, 90

1 = Generic Drugs AL = Age Limit ME90 = Morphine Equivalent ST = Step Therapy 2 = Brand Drugs PA = Prior Authorization QL = Quantity Limits SP = Specialty 90 = 90 days available at mail order 64 2018

Tier Level Necessary actions, restrictions, or limits on use Name of Drug MIGRAINE HEADACHES almotriptan malate tab 6.25 mg (Axert) 1 QL (18 tablets/30 days) almotriptan malate tab 12.5 mg (Axert) 1 QL (18 tablets/30 days) frovatriptan succinate tab 2.5 mg (base equivalent) (Frova) 1 QL (18 tablets/30 days) IMITREX – sumatriptan nasal spray 5 mg/act 2 QL (12 units/30 days) IMITREX – sumatriptan nasal spray 20 mg/act 2 QL (12 units/30 days) rizatriptan benzoate oral disintegrating tab 5 mg (base eq) 1 QL (18 tablets/30 days) (Maxalt-mlt) rizatriptan benzoate oral disintegrating tab 10 mg (base eq) 1 QL (18 tablets/30 days) (Maxalt-mlt) rizatriptan benzoate tab 5 mg (base equivalent) (Maxalt) 1 QL (18 tablets/30 days) rizatriptan benzoate tab 10 mg (base equivalent) (Maxalt) 1 QL (18 tablets/30 days) sumatriptan nasal spray 5 mg/act (Imitrex) 1 QL (12 units/30 days) sumatriptan nasal spray 20 mg/act (Imitrex) 1 QL (12 units/30 days) SUMATRIPTAN SUCCINATE – sumatriptan succinate solution 2 QL (12 doses/30 days) prefilled syringe 6 mg/0.5ml sumatriptan succinate inj 6 mg/0.5ml (Imitrex) 1 QL (12 vials/30 days) sumatriptan succinate solution auto-injector 4 mg/0.5ml (Imitrex 1 QL (12 doses/30 days) statdose sys) sumatriptan succinate solution auto-injector 6 mg/0.5ml (Imitrex 1 QL (12 doses/30 days) statdose sys) sumatriptan succinate solution cartridge 4 mg/0.5ml (Imitrex 1 QL (12 doses/30 days) statdose ref) sumatriptan succinate solution cartridge 6 mg/0.5ml (Imitrex 1 QL (12 doses/30 days) statdose ref) sumatriptan succinate tab 25 mg (Imitrex) 1 QL (18 tablets/30 days) sumatriptan succinate tab 50 mg (Imitrex) 1 QL (18 tablets/30 days) sumatriptan succinate tab 100 mg (Imitrex) 1 QL (18 tablets/30 days) GOUT allopurinol tab 100 mg (Zyloprim) 1 90 allopurinol tab 300 mg (Zyloprim) 1 90 colchicine w/ probenecid tab 0.5-500 mg 1 90 COLCRYS – colchicine tab 0.6 mg 2 probenecid tab 500 mg 1 90 NEUROMUSCULAR DRUGS APTIOM – tab 200 mg 2 90

1 = Generic Drugs AL = Age Limit ME90 = Morphine Equivalent ST = Step Therapy 2 = Brand Drugs PA = Prior Authorization QL = Quantity Limits SP = Specialty 90 = 90 days available at mail order 65 2018

Tier Level Necessary actions, restrictions, or limits on use Name of Drug APTIOM – eslicarbazepine acetate tab 400 mg 2 90 APTIOM – eslicarbazepine acetate tab 600 mg 2 90 APTIOM – eslicarbazepine acetate tab 800 mg 2 90 carbamazepine cap er 12hr 100 mg (Carbatrol) 1 90 carbamazepine cap er 12hr 200 mg (Carbatrol) 1 90 carbamazepine cap er 12hr 300 mg (Carbatrol) 1 90 carbamazepine chew tab 100 mg 1 90 carbamazepine susp 100 mg/5ml (Tegretol) 1 90 carbamazepine tab er 12hr 100 mg (Tegretol-xr) 1 90 carbamazepine tab er 12hr 200 mg (Tegretol-xr) 1 90 carbamazepine tab er 12hr 400 mg (Tegretol-xr) 1 90 carbamazepine tab 200 mg (Tegretol) 1 90 orally disintegrating tab 0.125 mg 1 QL (90 tablets/30 days), 90 clonazepam orally disintegrating tab 0.25 mg 1 QL (90 tablets/30 days), 90 clonazepam orally disintegrating tab 0.5 mg 1 QL (90 tablets/30 days), 90 clonazepam orally disintegrating tab 1 mg 1 QL (90 tablets/30 days), 90 clonazepam orally disintegrating tab 2 mg 1 QL (60 tablets/30 days), 90 clonazepam tab 0.5 mg (Klonopin) 1 QL (90 tablets/30 days), 90 clonazepam tab 1 mg (Klonopin) 1 QL (90 tablets/30 days), 90 clonazepam tab 2 mg (Klonopin) 1 QL (60 tablets/30 days), 90 DIAZEPAM – diazepam rectal gel delivery system 2.5 mg 2 QL (2 packs/30 days) DIAZEPAM – diazepam rectal gel delivery system 10 mg 2 QL (2 packs/30 days) DIAZEPAM – diazepam rectal gel delivery system 20 mg 2 QL (2 packs/30 days) DILANTIN – sodium extended cap 30 mg 2 90 divalproex sodium cap delayed release sprinkle 125 mg 1 90 (Depakote sprinkles) divalproex sodium tab delayed release 125 mg (Depakote) 1 90 divalproex sodium tab delayed release 250 mg (Depakote) 1 90 divalproex sodium tab delayed release 500 mg (Depakote) 1 90 divalproex sodium tab er 24 hr 250 mg (Depakote er) 1 90 divalproex sodium tab er 24 hr 500 mg (Depakote er) 1 90 cap 250 mg (Zarontin) 1 90 ethosuximide soln 250 mg/5ml (Zarontin) 1 90 susp 600 mg/5ml (Felbatol) 1 90 felbamate tab 400 mg (Felbatol) 1 90

1 = Generic Drugs AL = Age Limit ME90 = Morphine Equivalent ST = Step Therapy 2 = Brand Drugs PA = Prior Authorization QL = Quantity Limits SP = Specialty 90 = 90 days available at mail order 66 2018

Tier Level Necessary actions, restrictions, or limits on use Name of Drug felbamate tab 600 mg (Felbatol) 1 90 cap 100 mg (Neurontin) 1 QL (720 capsules/30 days), 90 gabapentin cap 300 mg (Neurontin) 1 QL (240 capsules/30 days), 90 gabapentin cap 400 mg (Neurontin) 1 QL (180 capsules/30 days), 90 gabapentin oral soln 250 mg/5ml (Neurontin) 1 QL (1500 mls/30 days), 90 gabapentin tab 600 mg (Neurontin) 1 QL (120 tablets/30 days), 90 gabapentin tab 800 mg (Neurontin) 1 QL (90 tablets/30 days), 90 LAMICTAL STARTER/NOT TAKI – tab 25 mg (42) & 2 PA 100 mg (7) starter kit LAMICTAL STARTER/TAKING C – lamotrigine tab 25 mg (84) & 2 PA 100 mg (14) starter kit LAMICTAL STARTER/TAKING V – lamotrigine tab 25 mg (35) 2 PA starter kit LAMICTAL XR – lamotrigine tab er 24hr 25 mg (21) & 50 mg (7) 2 PA titration kit LAMICTAL XR – lamotrigine tab er 24hr 25 (14) & 50 mg (14) & 2 PA 100 mg(7) kit LAMICTAL XR – lamotrigine tab er 24hr 50 (14) & 100 mg(14) & 2 PA 200 mg(7) kit lamotrigine tab chewable dispersible 5 mg (Lamictal chewable di) 1 90 lamotrigine tab chewable dispersible 25 mg (Lamictal chewable 1 90 di) lamotrigine tab disint 25 mg (21) & 50 mg (7) titration kit (Lamictal 1 PA odt) lamotrigine tab disint 50 mg (42)- 100 mg(14) titration kit 1 PA (Lamictal odt) lamotrigine tab disint 25 (14) & 50 mg (14) & 100 mg (7) kit 1 PA (Lamictal odt) lamotrigine tab er 24hr 25 mg (Lamictal xr) 1 90 lamotrigine tab er 24hr 50 mg (Lamictal xr) 1 90 lamotrigine tab er 24hr 100 mg (Lamictal xr) 1 90 lamotrigine tab er 24hr 200 mg (Lamictal xr) 1 90 lamotrigine tab er 24hr 250 mg (Lamictal xr) 1 90 lamotrigine tab er 24hr 300 mg (Lamictal xr) 1 90 lamotrigine tab 25 mg (Lamictal) 1 90 lamotrigine tab 100 mg (Lamictal) 1 90 lamotrigine tab 150 mg (Lamictal) 1 90 lamotrigine tab 200 mg (Lamictal) 1 90 oral soln 100 mg/ml (Keppra) 1 90

1 = Generic Drugs AL = Age Limit ME90 = Morphine Equivalent ST = Step Therapy 2 = Brand Drugs PA = Prior Authorization QL = Quantity Limits SP = Specialty 90 = 90 days available at mail order 67 2018

Tier Level Necessary actions, restrictions, or limits on use Name of Drug levetiracetam tab er 24hr 500 mg (Keppra xr) 1 90 levetiracetam tab er 24hr 750 mg (Keppra xr) 1 90 levetiracetam tab 250 mg (Keppra) 1 90 levetiracetam tab 500 mg (Keppra) 1 90 levetiracetam tab 750 mg (Keppra) 1 90 levetiracetam tab 1000 mg (Keppra) 1 90 susp 300 mg/5ml (60 mg/ml) (Trileptal) 1 90 oxcarbazepine tab 150 mg (Trileptal) 1 90 oxcarbazepine tab 300 mg (Trileptal) 1 90 oxcarbazepine tab 600 mg (Trileptal) 1 90 OXTELLAR XR – oxcarbazepine tab er 24hr 150 mg 2 PA, 90 OXTELLAR XR – oxcarbazepine tab er 24hr 300 mg 2 PA, 90 OXTELLAR XR – oxcarbazepine tab er 24hr 600 mg 2 PA, 90 phenytoin chew tab 50 mg (Dilantin infatabs) 1 90 phenytoin sodium extended cap 100 mg (Dilantin) 1 90 phenytoin sodium extended cap 200 mg (Phenytek) 1 90 phenytoin sodium extended cap 300 mg (Phenytek) 1 90 phenytoin susp 125 mg/5ml (Dilantin-125) 1 90 tab 50 mg (Mysoline) 1 90 primidone tab 250 mg (Mysoline) 1 90 SABRIL – tab 500 mg 2 PA, QL (180 tablets/30 days), SP, 90 hcl tab 2 mg (Gabitril) 1 90 tiagabine hcl tab 4 mg (Gabitril) 1 90 sprinkle cap 15 mg (Topamax sprinkle) 1 90 topiramate sprinkle cap 25 mg (Topamax sprinkle) 1 90 topiramate tab 25 mg (Topamax) 1 90 topiramate tab 50 mg (Topamax) 1 90 topiramate tab 100 mg (Topamax) 1 90 topiramate tab 200 mg (Topamax) 1 90 valproic acid cap 250 mg (Depakene) 1 90 vigabatrin powd pack 500 mg (Sabril) 1 PA, QL (180 packets/30 days), SP, 90 cap 25 mg (Zonegran) 1 90 zonisamide cap 50 mg 1 90

1 = Generic Drugs AL = Age Limit ME90 = Morphine Equivalent ST = Step Therapy 2 = Brand Drugs PA = Prior Authorization QL = Quantity Limits SP = Specialty 90 = 90 days available at mail order 68 2018

Tier Level Necessary actions, restrictions, or limits on use Name of Drug zonisamide cap 100 mg (Zonegran) 1 90 PARKINSON'S DISEASE amantadine hcl cap 100 mg 1 90 amantadine hcl syrup 50 mg/5ml 1 90 benztropine mesylate tab 0.5 mg 1 90 benztropine mesylate tab 1 mg 1 90 benztropine mesylate tab 2 mg 1 90 bromocriptine mesylate cap 5 mg (base equivalent) 1 90 bromocriptine mesylate tab 2.5 mg (base equivalent) (Parlodel) 1 90 carbidopa & levodopa orally disintegrating tab 10-100 mg 1 90 carbidopa & levodopa orally disintegrating tab 25-100 mg 1 90 carbidopa & levodopa orally disintegrating tab 25-250 mg 1 90 carbidopa & levodopa tab er 25-100 mg (Sinemet cr) 1 90 carbidopa & levodopa tab er 50-200 mg (Sinemet cr) 1 90 carbidopa & levodopa tab 10-100 mg (Sinemet) 1 90 carbidopa & levodopa tab 25-100 mg (Sinemet) 1 90 carbidopa & levodopa tab 25-250 mg (Sinemet) 1 90 carbidopa tab 25 mg (Lodosyn) 1 90 entacapone tab 200 mg (Comtan) 1 90 pramipexole dihydrochloride tab er 24hr 2.25 mg (Mirapex er) 1 90 pramipexole dihydrochloride tab 0.125 mg (Mirapex) 1 90 pramipexole dihydrochloride tab 0.25 mg (Mirapex) 1 90 pramipexole dihydrochloride tab 0.5 mg (Mirapex) 1 90 pramipexole dihydrochloride tab 0.75 mg (Mirapex) 1 90 pramipexole dihydrochloride tab 1 mg (Mirapex) 1 90 pramipexole dihydrochloride tab 1.5 mg (Mirapex) 1 90 ropinirole hydrochloride tab 0.25 mg (Requip) 1 90 ropinirole hydrochloride tab 0.5 mg (Requip) 1 90 ropinirole hydrochloride tab 1 mg (Requip) 1 90 ropinirole hydrochloride tab 2 mg (Requip) 1 90 ropinirole hydrochloride tab 3 mg (Requip) 1 90 ropinirole hydrochloride tab 4 mg (Requip) 1 90 ropinirole hydrochloride tab 5 mg (Requip) 1 90 selegiline hcl cap 5 mg (Eldepryl) 1 90 selegiline hcl tab 5 mg 1 90

1 = Generic Drugs AL = Age Limit ME90 = Morphine Equivalent ST = Step Therapy 2 = Brand Drugs PA = Prior Authorization QL = Quantity Limits SP = Specialty 90 = 90 days available at mail order 69 2018

Tier Level Necessary actions, restrictions, or limits on use Name of Drug tolcapone tab 100 mg (Tasmar) 1 90 hcl elixir 0.4 mg/ml 1 90 trihexyphenidyl hcl tab 2 mg 1 90 trihexyphenidyl hcl tab 5 mg 1 90 MUSCLE RELAXANTS tab 10 mg 1 90 baclofen tab 20 mg 1 90 carisoprodol tab 250 mg (Soma) 1 – chlorzoxazone tab 500 mg 2 hcl tab 5 mg 1 cyclobenzaprine hcl tab 10 mg 1 dantrolene sodium cap 25 mg (Dantrium) 1 dantrolene sodium cap 50 mg (Dantrium) 1 dantrolene sodium cap 100 mg 1 methocarbamol tab 500 mg (Robaxin) 1 methocarbamol tab 750 mg (Robaxin-750) 1 citrate tab er 12hr 100 mg 1 hcl tab 2 mg (base equivalent) 1 QL (180 tablets/30 days), 90 tizanidine hcl tab 4 mg (base equivalent) (Zanaflex) 1 QL (180 tablets/30 days), 90 OTHER NEUROMUSCULAR DRUGS pyridostigmine bromide tab 60 mg (Mestinon) 1 tab 50 mg (Rilutek) 1 90 SUPPLEMENTS VITAMINS ergocalciferol cap 50000 unit 1 90 MEPHYTON – phytonadione tab 5 mg 2 MULTIVITAMINS b-complex w/ c & folic acid cap 1 mg (Nephrocaps) 1 b-complex w/ c & folic acid tab 1 b-complex w/ c & folic acid tab 1 mg (Nephro-vite rx) 1 b-complex w/ c & folic acid tab 5 mg 1 CLASSIC PRENATAL – prenatal vit w/ fe fumarate-fa tab 2 28-0.8 mg EQL PRENATAL FORMULA – prenatal vit w/ fe fumarate-fa tab 2 28-0.8 mg

1 = Generic Drugs AL = Age Limit ME90 = Morphine Equivalent ST = Step Therapy 2 = Brand Drugs PA = Prior Authorization QL = Quantity Limits SP = Specialty 90 = 90 days available at mail order 70 2018

Tier Level Necessary actions, restrictions, or limits on use Name of Drug FOLBEE PLUS CZ – b-complex w/ c-biotin-minerals & folic acid 2 tab 5 mg GNP PRENATAL – prenatal vit w/ fe fumarate-fa tab 28-0.8 mg 2 GOODSENSE PRENATAL VITAMI – prenatal vit w/ fe fumarate- 2 fa tab 28-0.8 mg HM PRENATAL – prenatal vit w/ fe fumarate-fa tab 28-0.8 mg 2 KP PRENATAL MULTIVITAMINS – prenatal vit w/ fe fumarate-fa 2 tab 28-0.8 mg M-VIT – prenatal vit w/ fe fumarate-fa tab 27-1 mg 2 MULTI PRENATAL – prenatal vit w/ fe fumarate-fa tab 27-0.8 mg 2 multiple vitamins w/ minerals & fa tab 1.25 mg (Corvite) 1 multiple vitamins w/ minerals cap 1 multiple vitamins w/ minerals tab (Strovite forte) 1 NAT-RUL PRENATAL VITAMINS – prenatal vit w/ fe fumarate-fa 2 tab 28-0.8 mg NIVA-PLUS – prenatal vit w/ fe fumarate-fa tab 27-1 mg 2 O-CAL FA – prenatal vit w/ fe fumarate-fa tab 27-1 mg 2 pediatric multiple vitamin w/ minerals & c drops 45 mg/ml 1 pediatric vitamins acd w/ fluoride soln 0.25 mg/ml 1 PNV FOLIC ACID + IRON MUL – prenatal vit w/ fe fumarate-fa 2 tab 27-1 mg PNV PRENATAL PLUS MULTIVI – prenatal vit w/ fe fumarate-fa 2 tab 27-1 mg POLY-VI-FLOR – ped multiple vit w/ fluoride biphasic chew tab 2 0.25 mg POLY-VI-FLOR – ped multiple vit w/ fluoride biphasic chew tab 2 0.5 mg POLY-VI-FLOR – ped multiple vit w/ fluoride biphasic chew tab 2 1 mg PRE-NATAL FORMULA – prenatal multivitamins & minerals w/ 2 iron & fa tab 0.8 mg PRENATAL – prenatal multivitamins & minerals w/iron & fa tab 2 0.8 mg PRENATAL – prenatal vit w/ fe fumarate-fa tab 27-0.8 mg 2 PRENATAL – prenatal vit w/ fe fumarate-fa tab 27-1 mg 2 PRENATAL – prenatal vit w/ fe fumarate-fa tab 28-0.8 mg 2 PRENATAL AND IRON – prenatal multivitamins & minerals w/ 2 iron & fa tab 0.8 mg PRENATAL FORMULA – prenatal vit w/ fe fumarate-fa tab 2 28-0.8 mg

1 = Generic Drugs AL = Age Limit ME90 = Morphine Equivalent ST = Step Therapy 2 = Brand Drugs PA = Prior Authorization QL = Quantity Limits SP = Specialty 90 = 90 days available at mail order 71 2018

Tier Level Necessary actions, restrictions, or limits on use Name of Drug PRENATAL FORTE – prenatal multivitamins & minerals w/iron & 2 fa tab 0.8 mg PRENATAL LOW IRON – prenatal vit w/ fe fumarate-fa tab 2 27-0.8 mg PRENATAL MULTI +DHA – prenatal vit w/ fe fum-fa-omega 3 cap 2 27-0.8-228 mg PRENATAL ONE DAILY – prenatal vit w/ fe fumarate-fa tab 2 27-0.8 mg PRENATAL PLUS – prenatal vit w/ fe fumarate-fa tab 27-1 mg 2 PRENATAL PLUS DHA – prenatal mv & min w/fe carbonyl-fa-dha 2 tab 7-0.4-100 mg prenatal vit w/ fe fumarate-fa tab 28-0.8 mg 1 PRENATAL VITAMIN – prenatal vit w/ fe fumarate-fa tab 2 27-0.8 mg PRENATAL VITAMINS – prenatal vit w/ fe fumarate-fa tab 2 28-0.8 mg PRENATAL 19 – prenatal vit w/ fe fumarate-fa chew tab 29-1 mg 2 PRENATAL 19 – prenatal vit w/ dss-fe fumarate-fa tab 29-1 mg 2 PREPLUS – prenatal vit w/ fe fumarate-fa tab 27-1 mg 2 PX PRENATAL MULTIVITAMINS – prenatal vit w/ fe fumarate-fa 2 tab 28-0.8 mg QC PRENATAL – prenatal vit w/ fe fumarate-fa tab 28-0.8 mg 2 RA PRENATAL – prenatal vit w/ fe fumarate-fa tab 28-0.8 mg 2 RA PRENATAL FORMULA/FOLIC – prenatal vit w/ fe fumarate-fa 2 tab 28-0.8 mg RIGHT STEP PRENATAL – prenatal vit w/ fe fumarate-fa tab 2 27-0.8 mg SE-NATAL 19 – prenatal vit w/ fe fumarate-fa chew tab 29-1 mg 2 SE-NATAL 19 – prenatal vit w/ dss-fe fumarate-fa tab 29-1 mg 2 SM PRENATAL VITAMINS – prenatal vit w/ fe fumarate-fa tab 2 28-0.8 mg speciality vitamin product tab 1 TRI-VIT/FLUORIDE/IRON – pediatric vitamins acd fluoride & fe 2 drops 0.25-10 mg/ml TRICARE – prenatal vit w/ fe fumarate-fa tab 27-1 mg 2 TRINATAL RX 1 – prenatal vit w/ fe fumarate-fa tab 60-1 mg 2 VINATE M – prenatal vit w/ sel-fe fumarate-fa tab 27-1 mg 2 VINATE ONE – prenatal vit w/ fe fumarate-fa tab 60-1 mg 2 VOL-PLUS – prenatal vit w/ fe fumarate-fa tab 27-1 mg 2 MINERALS AND ELECTROLYTES

1 = Generic Drugs AL = Age Limit ME90 = Morphine Equivalent ST = Step Therapy 2 = Brand Drugs PA = Prior Authorization QL = Quantity Limits SP = Specialty 90 = 90 days available at mail order 72 2018

Tier Level Necessary actions, restrictions, or limits on use Name of Drug K-PHOS – potassium phosphate monobasic tab 500 mg 2 90 pot bicarbonate & chloride effer tab 25 meq 1 90 pot phos monobasic w/sod phos di & monobas tab 1 90 155-852-130mg (K-phos neutral) potassium bicarbonate effer tab 25 meq 1 90 potassium chloride cap er 8 meq (Micro-k) 1 90 potassium chloride cap er 10 meq (Micro-k) 1 90 POTASSIUM CHLORIDE ER – potassium chloride tab er 8 meq 2 90 (600 mg) potassium chloride microencapsulated crys er tab 10 meq 1 90 potassium chloride microencapsulated crys er tab 20 meq 1 90 potassium chloride oral soln 10% (20 meq/15ml) 1 90 potassium chloride oral soln 20% (40 meq/15ml) 1 90 potassium chloride tab er 8 meq (600 mg) 1 90 potassium chloride tab er 10 meq (K-tab) 1 90 SODIUM FLUORIDE – sodium fluoride tab 0.5 mg f (from 1.1 mg 2 90 naf) SODIUM FLUORIDE – sodium fluoride tab 1 mg f (from 2.2 mg 2 90 naf) sodium fluoride chew tab 0.25 mg f (from 0.55 mg naf) (Luride) 1 90 sodium fluoride chew tab 0.5 mg f (from 1.1 mg naf) (Luride) 1 90 sodium fluoride chew tab 1 mg f (from 2.2 mg naf) (Luride) 1 90 sodium fluoride soln 0.125 mg/drop f (0.275 mg/drop naf) 1 90 sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml naf) (Luride) 1 90 OTHER SUPPLEMENTS acetylcysteine cap 600 mg 1 amino acids cap 1 folic acid-pyridoxine-cyanocobalamin tab 2.5-25-2 mg 1 BLOOD MODIFYING DRUGS BLOOD MODIFYING DRUGS anagrelide hcl cap 0.5 mg (Agrylin) 1 90 anagrelide hcl cap 1 mg 1 90 ARANESP ALBUMIN FREE – darbepoetin alfa soln prefilled 2 PA, SP syringe 10 mcg/0.4ml ARANESP ALBUMIN FREE – darbepoetin alfa soln prefilled 2 PA, SP syringe 25 mcg/0.42ml

1 = Generic Drugs AL = Age Limit ME90 = Morphine Equivalent ST = Step Therapy 2 = Brand Drugs PA = Prior Authorization QL = Quantity Limits SP = Specialty 90 = 90 days available at mail order 73 2018

Tier Level Necessary actions, restrictions, or limits on use Name of Drug ARANESP ALBUMIN FREE – darbepoetin alfa soln prefilled 2 PA, SP syringe 40 mcg/0.4ml ARANESP ALBUMIN FREE – darbepoetin alfa soln prefilled 2 PA, SP syringe 60 mcg/0.3ml ARANESP ALBUMIN FREE – darbepoetin alfa soln prefilled 2 PA, SP syringe 100 mcg/0.5ml ARANESP ALBUMIN FREE – darbepoetin alfa soln prefilled 2 PA, SP syringe 150 mcg/0.3ml ARANESP ALBUMIN FREE – darbepoetin alfa soln prefilled 2 PA, SP syringe 200 mcg/0.4ml ARANESP ALBUMIN FREE – darbepoetin alfa soln prefilled 2 PA, SP syringe 300 mcg/0.6ml ARANESP ALBUMIN FREE – darbepoetin alfa soln prefilled 2 PA, SP syringe 500 mcg/ml ARANESP ALBUMIN FREE – darbepoetin alfa soln inj 25 mcg/ 2 PA, SP ml ARANESP ALBUMIN FREE – darbepoetin alfa soln inj 40 mcg/ 2 PA, SP ml ARANESP ALBUMIN FREE – darbepoetin alfa soln inj 60 mcg/ 2 PA, SP ml ARANESP ALBUMIN FREE – darbepoetin alfa soln inj 100 mcg/ 2 PA, SP ml ARANESP ALBUMIN FREE – darbepoetin alfa soln inj 200 mcg/ 2 PA, SP ml ARANESP ALBUMIN FREE – darbepoetin alfa soln inj 300 mcg/ 2 PA, SP ml BRILINTA – ticagrelor tab 60 mg 2 PA, QL (60 tablets/30 days), 90 BRILINTA – ticagrelor tab 90 mg 2 PA, QL (60 tablets/30 days), 90 cilostazol tab 50 mg 1 90 cilostazol tab 100 mg 1 90 clopidogrel bisulfate tab 75 mg (base equiv) (Plavix) 1 90 clopidogrel bisulfate tab 300 mg (base equiv) (Plavix) 1 cyanocobalamin inj 1000 mcg/ml 1 dipyridamole tab 25 mg 1 90 dipyridamole tab 50 mg 1 90 dipyridamole tab 75 mg 1 90 ELIQUIS – apixaban tab 2.5 mg 2 PA, QL (60 tablets/30 days), 90 ELIQUIS – apixaban tab 5 mg 2 PA, QL (120 tablets/30 days), 90 ELIQUIS STARTER PACK – apixaban tab 5 mg 2 PA, QL (74 tablets/180 days), 90 enoxaparin sodium inj 30 mg/0.3ml (Lovenox) 1 QL (30 syringes/365 days)

1 = Generic Drugs AL = Age Limit ME90 = Morphine Equivalent ST = Step Therapy 2 = Brand Drugs PA = Prior Authorization QL = Quantity Limits SP = Specialty 90 = 90 days available at mail order 74 2018

Tier Level Necessary actions, restrictions, or limits on use Name of Drug enoxaparin sodium inj 40 mg/0.4ml (Lovenox) 1 QL (30 syringes/365 days) enoxaparin sodium inj 60 mg/0.6ml (Lovenox) 1 QL (30 syringes/365 days) enoxaparin sodium inj 80 mg/0.8ml (Lovenox) 1 QL (30 syringes/365 days) enoxaparin sodium inj 100 mg/ml (Lovenox) 1 QL (30 syringes/365 days) enoxaparin sodium inj 120 mg/0.8ml (Lovenox) 1 QL (30 syringes/365 days) enoxaparin sodium inj 150 mg/ml (Lovenox) 1 QL (30 syringes/365 days) EPOGEN – epoetin alfa inj 2000 unit/ml 2 PA, SP EPOGEN – epoetin alfa inj 3000 unit/ml 2 PA, SP EPOGEN – epoetin alfa inj 4000 unit/ml 2 PA, SP EPOGEN – epoetin alfa inj 10000 unit/ml 2 PA, SP EPOGEN – epoetin alfa inj 20000 unit/ml 2 PA, SP fe fum-iron polysacch complex-fa-b cmplx-c-zn-mn-cu cap 1 (Tandem plus) fe fumarate w/ b12-vit c-fa-ifc cap 110-0.015-75-0.5-240 mg 1 fe fumarate-vit c-vit b12-fa cap 460 (151 fe)-60-0.01-1 mg 1 ferrous fumarate-fa-b complex-c-zn-mg-mn-cu tab 106-1 mg 1 ferrous fumarate-folic acid tab 324-1 mg 1 FIRAZYR – icatibant acetate inj 30 mg/3ml (base equivalent) 2 PA, QL (6 syringes/30 days), SP folic acid tab 1 mg 1 90 folic acid-vitamin b6-vitamin b12 tab 2.2-25-0.5 mg 1 folic acid-vitamin b6-vitamin b12 tab 2.2-25-1 mg (Folgard rx) 1 folic acid-vitamin b6-vitamin b12 tab 2.5-25-1 mg 1 INFED – iron dextran inj 50 mg/ml (elemental iron) 2 IPRIVASK – desirudin for inj 15 mg 2 SP iron combination cap 1 iron polysacch complex-vit b12-fa cap 150-0.025-1 mg 1 iron-docusate-b12-folic acid-c-e-cu-biotin tab 150-1 mg 1 (Hematron-af) iron-folic acid-vit c-vit b6-vit b12-zinc tab 150-1.25 mg (Corvite 1 150) miglustat cap 100 mg (Zavesca) 1 PA, QL (90 capsules/30 days), SP, 90 NEULASTA – pegfilgrastim soln prefilled syringe 6 mg/0.6ml 2 SP NEULASTA ONPRO KIT – pegfilgrastim soln prefilled syringe kit 2 SP 6 mg/0.6ml pentoxifylline tab er 400 mg 1 90 PROCRIT – epoetin alfa inj 2000 unit/ml 2 PA, SP

1 = Generic Drugs AL = Age Limit ME90 = Morphine Equivalent ST = Step Therapy 2 = Brand Drugs PA = Prior Authorization QL = Quantity Limits SP = Specialty 90 = 90 days available at mail order 75 2018

Tier Level Necessary actions, restrictions, or limits on use Name of Drug PROCRIT – epoetin alfa inj 3000 unit/ml 2 PA, SP PROCRIT – epoetin alfa inj 4000 unit/ml 2 PA, SP PROCRIT – epoetin alfa inj 10000 unit/ml 2 PA, SP PROCRIT – epoetin alfa inj 20000 unit/ml 2 PA, SP PROCRIT – epoetin alfa inj 40000 unit/ml 2 PA, SP PROMACTA – eltrombopag olamine tab 12.5 mg (base equiv) 2 PA, QL (30 tablets/30 days), SP, 90 PROMACTA – eltrombopag olamine tab 25 mg (base equiv) 2 PA, QL (30 tablets/30 days), SP, 90 PROMACTA – eltrombopag olamine tab 50 mg (base equiv) 2 PA, QL (60 tablets/30 days), SP, 90 PROMACTA – eltrombopag olamine tab 75 mg (base equiv) 2 PA, QL (60 tablets/30 days), SP, 90 tranexamic acid tab 650 mg (Lysteda) 1 sodium tab 1 mg (Coumadin) 1 90 warfarin sodium tab 2 mg (Coumadin) 1 90 warfarin sodium tab 2.5 mg (Coumadin) 1 90 warfarin sodium tab 3 mg (Coumadin) 1 90 warfarin sodium tab 4 mg (Coumadin) 1 90 warfarin sodium tab 5 mg (Coumadin) 1 90 warfarin sodium tab 6 mg (Coumadin) 1 90 warfarin sodium tab 7.5 mg (Coumadin) 1 90 warfarin sodium tab 10 mg (Coumadin) 1 90 XARELTO – rivaroxaban tab 10 mg 2 QL (35 tablets/365 days), 90 XARELTO – rivaroxaban tab 15 mg 2 PA, QL (60 tablets/30 days), 90 XARELTO – rivaroxaban tab 20 mg 2 PA, QL (30 tablets/30 days), 90 XARELTO STARTER PACK – rivaroxaban tab starter therapy 2 PA, QL (51 tablets/30 days) pack 15 mg & 20 mg TOPICAL PRODUCTS EYE Anti-infectives BACITRACIN – bacitracin ophth oint 500 unit/gm 2 bacitracin-polymyxin b ophth oint 1 ciprofloxacin hcl ophth soln 0.3% (Ciloxan) 1 ophth oint 5 mg/gm 1 gentamicin sulfate ophth oint 0.3% 1

1 = Generic Drugs AL = Age Limit ME90 = Morphine Equivalent ST = Step Therapy 2 = Brand Drugs PA = Prior Authorization QL = Quantity Limits SP = Specialty 90 = 90 days available at mail order 76 2018

Tier Level Necessary actions, restrictions, or limits on use Name of Drug gentamicin sulfate ophth soln 0.3% 1 NATACYN – ophth susp 5% 2 neomycin-bacitrac zn-polymyx 5(3.5)mg-400unt-10000unt op oin 1 neomycin-polymy-gramicid op sol 1.75-10000-0.025mg-unt-mg/ 1 ml (Neosporin) ofloxacin ophth soln 0.3% (Ocuflox) 1 polymyxin b-trimethoprim ophth soln 10000 unit/ml-0.1% 1 (Polytrim) sulfacetamide sodium ophth soln 10% (Bleph-10) 1 tobramycin ophth soln 0.3% (Tobrex) 1 trifluridine ophth soln 1% (Viroptic) 1 Steroids and Combination Products bacitracin-polymyxin-neomycin-hc ophth oint 1% 1 DEXAMETHASONE SODIUM PHOS – dexamethasone sodium 2 phosphate ophth soln 0.1% fluorometholone ophth susp 0.1% (Fml liquifilm) 1 neomycin-polymyxin-dexamethasone ophth oint 0.1% (Maxitrol) 1 neomycin-polymyxin-dexamethasone ophth susp 0.1% (Maxitrol) 1 prednisolone acetate ophth susp 1% (Pred forte) 1 PREDNISOLONE SODIUM PHOSP – prednisolone sodium 2 phosphate ophth soln 1% sulfacetamide sodium-prednisolone ophth soln 10-0.23(0.25)% 1 apraclonidine hcl ophth soln 0.5% (base equivalent) (Iopidine) 1 betaxolol hcl ophth soln 0.5% 1 90 brimonidine tartrate ophth soln 0.2% 1 90 CARTEOLOL HCL – carteolol hcl ophth soln 1% 2 90 carteolol hcl ophth soln 1% 1 90 dorzolamide hcl ophth soln 2% (Trusopt) 1 90 dorzolamide hcl-timolol maleate ophth soln 22.3-6.8 mg/ml 1 90 (Cosopt) latanoprost ophth soln 0.005% (Xalatan) 1 QL (1 bottle/30 days), 90 levobunolol hcl ophth soln 0.5% (Betagan) 1 90 METIPRANOLOL – metipranolol ophth soln 0.3% 2 90 hcl ophth soln 1% (Isopto carpine) 1 90 pilocarpine hcl ophth soln 2% (Isopto carpine) 1 90 pilocarpine hcl ophth soln 4% (Isopto carpine) 1 90

1 = Generic Drugs AL = Age Limit ME90 = Morphine Equivalent ST = Step Therapy 2 = Brand Drugs PA = Prior Authorization QL = Quantity Limits SP = Specialty 90 = 90 days available at mail order 77 2018

Tier Level Necessary actions, restrictions, or limits on use Name of Drug timolol maleate ophth soln 0.25% (Timoptic) 1 90 timolol maleate ophth soln 0.5% (Timoptic) 1 90 Other Eye Products ATROPINE SULFATE – atropine sulfate ophth soln 1% 2 90 ATROPINE SULFATE – atropine sulfate ophth oint 1% 2 90 azelastine hcl ophth soln 0.05% 1 cromolyn sodium ophth soln 4% 1 cyclopentolate hcl ophth soln 0.5% (Cyclogyl) 1 90 cyclopentolate hcl ophth soln 1% (Cyclogyl) 1 90 cyclopentolate hcl ophth soln 2% (Cyclogyl) 1 90 diclofenac sodium ophth soln 0.1% 1 hcl ophth soln 0.05% (Elestat) 1 flurbiprofen sodium ophth soln 0.03% (Ocufen) 1 hbr ophth soln 5% 1 90 ketorolac tromethamine ophth soln 0.4% (Acular ls) 1 ketorolac tromethamine ophth soln 0.5% (Acular) 1 hcl ophth soln 0.1% (base equivalent) (Patanol) 1 phenylephrine hcl ophth soln 2.5% 1 proparacaine hcl ophth soln 0.5% (Alcaine) 1 hcl ophth soln 0.5% 1 EAR acetic acid otic soln 2% 1 hydrocortisone w/ acetic acid otic soln 1-2% 1 neomycin-polymyxin-hc otic soln 1% 1 neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000 unit/ml-1% 1 ofloxacin otic soln 0.3% (Floxin otic) 1 MOUTH AND THROAT (LOCAL) chlorhexidine gluconate soln 0.12% (Peridex) 1 clotrimazole troche 10 mg 1 hcl viscous soln 2% 1 nystatin susp 100000 unit/ml 1 pilocarpine hcl tab 5 mg (Salagen) 1 90 pilocarpine hcl tab 7.5 mg (Salagen) 1 90 PREVIDENT FLUORIDE – sodium fluoride gel 1.1% (0.5% f) 2 90

1 = Generic Drugs AL = Age Limit ME90 = Morphine Equivalent ST = Step Therapy 2 = Brand Drugs PA = Prior Authorization QL = Quantity Limits SP = Specialty 90 = 90 days available at mail order 78 2018

Tier Level Necessary actions, restrictions, or limits on use Name of Drug PREVIDENT 5000 DRY MOUTH – sodium fluoride gel 1.1% 2 90 (0.5% f) sodium fluoride cream 1.1% (Prevident 5000 plus) 1 90 sodium fluoride gel 1.1% (0.5% f) (Prevident fluoride) 1 90 sodium fluoride paste 1.1% (Prevident 5000 boost) 1 90 sodium fluoride rinse 0.2% 1 90 sodium fluoride-potassium nitrate paste 1.1-5% (Prevident 5000 1 sensi) stannous fluoride gel 0.4% 1 THERA-FLUR-N – sodium fluoride gel 1.1% (0.5% f) 2 90 triamcinolone acetonide dental paste 0.1% 1 ANORECTAL AGENTS hydrocortisone enema 100 mg/60ml (Cortenema) 1 hydrocortisone rectal cream 1% (Proctocort) 1 hydrocortisone rectal cream 2.5% (Anusol-hc) 1 SKIN CONDITIONS/PRODUCTS Acne adapalene cream 0.1% (Differin) 1 PA benzoyl peroxide cloth 6% 1 PA benzoyl peroxide-erythromycin gel 5-3% (Benzamycin) 1 PA clindamycin phosph-benzoyl peroxide (refrig) gel 1.2 (1)-5% 1 PA (Duac) clindamycin phosphate gel 1% (Cleocin-t) 1 PA clindamycin phosphate lotion 1% (Cleocin-t) 1 PA clindamycin phosphate soln 1% (Cleocin-t) 1 PA clindamycin phosphate swab 1% (Cleocin-t) 1 PA erythromycin pads 2% 1 PA erythromycin soln 2% 1 PA FINACEA – azelaic acid gel 15% 2 PA isotretinoin cap 10 mg 1 PA isotretinoin cap 20 mg 1 PA isotretinoin cap 30 mg 1 PA isotretinoin cap 40 mg 1 PA metronidazole cream 0.75% (Metrocream) 1 PA metronidazole gel 0.75% 1 PA sulfacetamide sodium lotion 10% (acne) (Klaron) 1 PA

1 = Generic Drugs AL = Age Limit ME90 = Morphine Equivalent ST = Step Therapy 2 = Brand Drugs PA = Prior Authorization QL = Quantity Limits SP = Specialty 90 = 90 days available at mail order 79 2018

Tier Level Necessary actions, restrictions, or limits on use Name of Drug tazarotene cream 0.1% (Tazorac) 1 PA TAZORAC – tazarotene cream 0.05% 2 PA TAZORAC – tazarotene gel 0.05% 2 PA TAZORAC – tazarotene gel 0.1% 2 PA tretinoin cream 0.025% (Retin-a) 1 PA tretinoin cream 0.05% (Retin-a) 1 PA tretinoin cream 0.1% (Retin-a) 1 PA tretinoin gel 0.01% (Retin-a) 1 PA tretinoin gel 0.025% (Retin-a) 1 PA tretinoin gel 0.05% (Atralin) 1 PA Anti-infectives acyclovir oint 5% (Zovirax) 1 ciclopirox olamine cream 0.77% (base equiv) (Loprox) 1 ciclopirox olamine susp 0.77% (base equiv) 1 ciclopirox solution 8% (Penlac Nail Lacquer) 1 PA, QL (6.6 mls/30 days) clotrimazole cream 1% 1 clotrimazole soln 1% 1 clotrimazole w/ cream 1-0.05% (Lotrisone) 1 diclofenac sodium gel 1% (Voltaren) 1 QL (200 grams/30 days) gentamicin sulfate oint 0.1% 1 ketoconazole cream 2% 1 ketoconazole shampoo 2% (Nizoral) 1 mupirocin oint 2% 1 naftifine hcl cream 2% (Naftin) 1 nystatin cream 100000 unit/gm 1 nystatin oint 100000 unit/gm 1 oxiconazole nitrate cream 1% (Oxistat) 1 cream 6% 1 salicylic acid cream 6% & cleanser liqd kit (Salex cream) 1 salicylic acid film forming liquid 27.5% (Virasal) 1 salicylic acid foam 6% (Salvax) 1 salicylic acid gel 6% (Keralyt) 1 salicylic acid lotion 6% 1 salicylic acid lotion 6% & cleanser liqd kit (Salex lotion) 1 salicylic acid shampoo 6% (Salex) 1

1 = Generic Drugs AL = Age Limit ME90 = Morphine Equivalent ST = Step Therapy 2 = Brand Drugs PA = Prior Authorization QL = Quantity Limits SP = Specialty 90 = 90 days available at mail order 80 2018

Tier Level Necessary actions, restrictions, or limits on use Name of Drug silver sulfadiazine cream 1% (Silvadene) 1 Corticosteroids alclometasone dipropionate cream 0.05% (Aclovate) 1 alclometasone dipropionate oint 0.05% 1 AUGMENTED BETAMETHASONE D – betamethasone 2 QL (180 grams/90 days) dipropionate augmented gel 0.05% betamethasone dipropionate augmented cream 0.05% 1 QL (180 grams/90 days) (Diprolene af) betamethasone dipropionate augmented gel 0.05% 1 QL (180 grams/90 days) betamethasone dipropionate augmented lotion 0.05% (Diprolene) 1 QL (180 grams/90 days) betamethasone dipropionate augmented oint 0.05% (Diprolene) 1 QL (180 grams/90 days) betamethasone dipropionate cream 0.05% 1 QL (180 grams/90 days) betamethasone dipropionate lotion 0.05% 1 QL (180 grams/90 days) betamethasone dipropionate oint 0.05% 1 QL (180 grams/90 days) betamethasone valerate cream 0.1% (base equivalent) 1 betamethasone valerate lotion 0.1% (base equivalent) 1 betamethasone valerate oint 0.1% (base equivalent) 1 clobetasol propionate emollient base cream 0.05% (Temovate e) 1 clobetasol propionate soln 0.05% (Temovate) 1 QL (180 grams/90 days) desonide cream 0.05% (Desowen) 1 desonide oint 0.05% 1 desoximetasone cream 0.25% (Topicort) 1 QL (180 grams/90 days) desoximetasone gel 0.05% (Topicort) 1 QL (180 grams/90 days) fluocinolone acetonide cream 0.01% 1 fluocinolone acetonide cream 0.025% (Synalar) 1 fluocinolone acetonide oil 0.01% (scalp oil) (Derma-smoothe/fs 1 sca) fluocinolone acetonide oint 0.025% (Synalar) 1 fluocinolone acetonide soln 0.01% (Synalar) 1 fluocinonide cream 0.05% 1 QL (180 grams/90 days) fluocinonide emulsified base cream 0.05% 1 QL (180 grams/90 days) fluocinonide gel 0.05% 1 QL (180 grams/90 days) fluocinonide oint 0.05% 1 QL (180 grams/90 days) fluocinonide soln 0.05% 1 QL (180 grams/90 days) flurandrenolide cream 0.05% (Cordran) 1 fluticasone propionate cream 0.05% (Cutivate) 1

1 = Generic Drugs AL = Age Limit ME90 = Morphine Equivalent ST = Step Therapy 2 = Brand Drugs PA = Prior Authorization QL = Quantity Limits SP = Specialty 90 = 90 days available at mail order 81 2018

Tier Level Necessary actions, restrictions, or limits on use Name of Drug fluticasone propionate oint 0.005% 1 halobetasol propionate cream 0.05% (Ultravate) 1 QL (180 grams/90 days) halobetasol propionate oint 0.05% (Ultravate) 1 QL (180 grams/90 days) hydrocortisone butyrate oint 0.1% (Locoid) 1 hydrocortisone butyrate soln 0.1% (Locoid) 1 hydrocortisone cream 1% 1 hydrocortisone cream 2.5% 1 hydrocortisone lotion 2% (Ala scalp) 1 hydrocortisone lotion 2.5% 1 hydrocortisone oint 1% 1 hydrocortisone oint 2.5% 1 hydrocortisone valerate cream 0.2% 1 hydrocortisone valerate oint 0.2% (Westcort) 1 mometasone furoate cream 0.1% (Elocon) 1 mometasone furoate oint 0.1% (Elocon) 1 QL (180 grams/90 days) mometasone furoate solution 0.1% (lotion) (Elocon) 1 PREDNICARBATE – prednicarbate cream 0.1% 2 PREDNICARBATE – prednicarbate oint 0.1% 2 prednicarbate cream 0.1% (Dermatop) 1 triamcinolone acetonide aerosol soln 0.147 mg/gm (Kenalog) 1 triamcinolone acetonide cream 0.025% 1 triamcinolone acetonide cream 0.1% 1 triamcinolone acetonide cream 0.5% 1 QL (180 grams/90 days) triamcinolone acetonide lotion 0.025% 1 triamcinolone acetonide lotion 0.1% 1 triamcinolone acetonide oint 0.025% 1 triamcinolone acetonide oint 0.1% 1 Other Skin Products acitretin cap 10 mg (Soriatane) 1 acitretin cap 17.5 mg (Soriatane) 1 acitretin cap 25 mg (Soriatane) 1 calcipotriene cream 0.005% (Dovonex) 1 calcipotriene oint 0.005% 1 calcipotriene soln 0.005% (50 mcg/ml) 1 CEM-UREA – urea soln 45% 2

1 = Generic Drugs AL = Age Limit ME90 = Morphine Equivalent ST = Step Therapy 2 = Brand Drugs PA = Prior Authorization QL = Quantity Limits SP = Specialty 90 = 90 days available at mail order 82 2018

Tier Level Necessary actions, restrictions, or limits on use Name of Drug COSENTYX – secukinumab subcutaneous soln prefilled syringe 2 PA, QL (2 syringes/28 150 mg/ml days), SP, 90 COSENTYX SENSOREADY PEN – secukinumab subcutaneous 2 PA, QL (2 pens/28 days), SP, 90 soln auto-injector 150 mg/ml CUTTER BACKWOODS – diethyltoluamide (deet) aerosol 2 CUTTER SKINSATIONS – diethyltoluamide (deet) liquid 2 fluorouracil cream 5% (Efudex) 1 QL (240 grams/180 days) imiquimod cream 5% (Aldara) 1 QL (48 grams/180 days) lidocaine hcl gel 2% 1 QL (120 grams/30 days) lidocaine hcl soln 4% (Xylocaine) 1 QL (120 grams/30 days) lidocaine patch 5% (Lidoderm) 1 PA, QL (120 patches/30 days) lidocaine- cream 2.5-2.5% 1 QL (30 grams/60 days) methoxsalen rapid cap 10 mg (Oxsoralen ultra) 1 NATRAPEL 12-HOUR TICK & I – picaridin aerosol 2 OFF ACTIVE – diethyltoluamide (deet) aerosol 2 OFF DEEP WOODS – diethyltoluamide (deet) aerosol 2 OFF DEEP WOODS DRY – diethyltoluamide (deet) aerosol 2 OFF SMOOTH & DRY – diethyltoluamide (deet) aerosol 2 permethrin cream 5% (Elimite) 1 podofilox soln 0.5% (Condylox) 1 REPEL SPORTSMEN – diethyltoluamide (deet) aerosol 2 REPEL SPORTSMEN MAX – diethyltoluamide (deet) aerosol 2 SAWYER PREMIUM INSECT REP – picaridin liquid 2 selenium sulfide lotion 2.5% 1 selenium sulfide shampoo 2.25% 1 skin protectants misc - cream 1 STELARA – ustekinumab soln prefilled syringe 45 mg/0.5ml 2 PA, QL (1 syringe/84 days), SP, 90 STELARA – ustekinumab soln prefilled syringe 90 mg/ml 2 PA, QL (1 syringe/56 days), SP, 90 tacrolimus oint 0.03% (Protopic) 1 QL (60 days supply/120 days), ST tacrolimus oint 0.1% (Protopic) 1 QL (60 days supply/120 days), ST MISCELLANEOUS CATEGORIES DIABETIC SUPPLIES BAYER CONTOUR BLOOD GLUCO – blood glucose monitoring 2 devices

1 = Generic Drugs AL = Age Limit ME90 = Morphine Equivalent ST = Step Therapy 2 = Brand Drugs PA = Prior Authorization QL = Quantity Limits SP = Specialty 90 = 90 days available at mail order 83 2018

Tier Level Necessary actions, restrictions, or limits on use Name of Drug CALIBRATION LIQUID - BAYER BREEZE 2, CONTOUR, 2 CONTOUR NEXT KETOSTIX – acetone (urine) test strip 2 TEST STRIPS – BAYER ASCENCIA 2 QL (150 strips/ 30 days), ST, 90 INSULIN SYRINGES - TECHLITE AND TRUEPLUS 2 QL (200 syringes/30 days), 90 INUSLIN PEN NEEDLES - TECHLITE AND TRUEPLUS 2 QL (200 insulin pen needles/30 days), 90 LANCETS - BAYER ASCENCIA 2 QL (200 units/30 days), 90 RESPIRATORY INHALER-ASSIST DEVICES AEROCHAMBER 2 BREATHERITE 2 MISCELLANEOUS DRUGS azathioprine tab 50 mg (Imuran) 1 90 CHEMET – succimer cap 100 mg 2 CUPRIMINE – penicillamine cap 250 mg 2 PA, SP cyclosporine cap 25 mg (Sandimmune) 1 90 cyclosporine cap 100 mg (Sandimmune) 1 90 CYCLOSPORINE MODIFIED – cyclosporine modified cap 50 mg 2 90 cyclosporine modified cap 25 mg (Neoral) 1 90 cyclosporine modified cap 50 mg (Cyclosporine modifie) 1 90 cyclosporine modified cap 100 mg (Neoral) 1 90 cyclosporine modified oral soln 100 mg/ml (Neoral) 1 90 DEPEN TITRATABS – penicillamine tab 250 mg 2 PA, SP EXJADE – deferasirox tab for oral susp 125 mg 2 PA, QL (30 tablets/30 days), SP, 90 EXJADE – deferasirox tab for oral susp 250 mg 2 PA, QL (30 tablets/30 days), SP, 90 EXJADE – deferasirox tab for oral susp 500 mg 2 PA, QL (90 tablets/30 days), SP, 90 FERRIPROX – deferiprone tab 500 mg 2 PA, QL (540 tablets/30 days), SP, 90 FERRIPROX – deferiprone oral soln 100 mg/ml 2 PA, QL (2700 mls/30 days), SP, 90 irrigation solution, physiological 1 lactated ringer's for irrigation 1 – methylene blue inj 1% 2

1 = Generic Drugs AL = Age Limit ME90 = Morphine Equivalent ST = Step Therapy 2 = Brand Drugs PA = Prior Authorization QL = Quantity Limits SP = Specialty 90 = 90 days available at mail order 84 2018

Tier Level Necessary actions, restrictions, or limits on use Name of Drug mycophenolate mofetil cap 250 mg (Cellcept) 1 90 mycophenolate mofetil for oral susp 200 mg/ml (Cellcept) 1 90 mycophenolate mofetil tab 500 mg (Cellcept) 1 90 mycophenolate sodium tab dr 180 mg (mycophenolic acid equiv) 1 90 (Myfortic) mycophenolate sodium tab dr 360 mg (mycophenolic acid equiv) 1 90 (Myfortic) naltrexone hcl tab 50 mg 1 NARCAN – naloxone hcl nasal spray 4 mg/0.1ml 2 NEXAVIR – liver derivative complex inj 25.5 mg/ml 2 REVLIMID – lenalidomide caps 2.5 mg 2 PA, QL (30 capsules/30 days), SP REVLIMID – lenalidomide cap 5 mg 2 PA, QL (30 capsules/30 days), SP REVLIMID – lenalidomide cap 10 mg 2 PA, QL (30 capsules/30 days), SP REVLIMID – lenalidomide cap 15 mg 2 PA, QL (21 capsules/28 days), SP REVLIMID – lenalidomide cap 20 mg 2 PA, QL (21 capsules/28 days), SP REVLIMID – lenalidomide cap 25 mg 2 PA, QL (21 capsules/28 days), SP ringer's solution for irrigation 1 sirolimus tab 0.5 mg (Rapamune) 1 90 sirolimus tab 1 mg (Rapamune) 1 90 sirolimus tab 2 mg (Rapamune) 1 90 sodium polystyrene sulfonate oral susp 15 gm/60ml 1 sodium polystyrene sulfonate powder (Kayexalate) 1 sodium polystyrene sulfonate rectal susp 30 gm/120ml 1 tacrolimus cap 0.5 mg (Prograf) 1 90 tacrolimus cap 1 mg (Prograf) 1 90 tacrolimus cap 5 mg (Prograf) 1 90 THALOMID – thalidomide cap 50 mg 2 PA, QL (30 capsules/30 days), SP, 90 THALOMID – thalidomide cap 100 mg 2 PA, QL (30 capsules/30 days), SP, 90 THALOMID – thalidomide cap 150 mg 2 PA, QL (60 capsules/30 days), SP, 90 THALOMID – thalidomide cap 200 mg 2 PA, QL (60 capsules/30 days), SP, 90 trientine hcl cap 250 mg (Syprine) 1 PA water for irrigation, sterile irrigation soln 1

1 = Generic Drugs AL = Age Limit ME90 = Morphine Equivalent ST = Step Therapy 2 = Brand Drugs PA = Prior Authorization QL = Quantity Limits SP = Specialty 90 = 90 days available at mail order 85 2018

Tier Level Necessary actions, restrictions, or limits on use Name of Drug ZORTRESS – everolimus tab 0.25 mg 2 90 ZORTRESS – everolimus tab 0.5 mg 2 90 ZORTRESS – everolimus tab 0.75 mg 2 90

1 = Generic Drugs AL = Age Limit ME90 = Morphine Equivalent ST = Step Therapy 2 = Brand Drugs PA = Prior Authorization QL = Quantity Limits SP = Specialty 90 = 90 days available at mail order 86 2018

ADEMPAS – riociguat tab 1.5 mg...... 34 INDEX ADEMPAS – riociguat tab 2 mg...... 34 ADEMPAS – riociguat tab 2.5 mg...... 34 A ADMELOG – insulin lispro inj 100 unit/ml...... 20 ADMELOG SOLOSTAR – insulin lispro soln pen-injector abacavir sulfate-lamivudine tab 600-300 mg (Epzicom)..... 5 100 unit/ml...... 20 abacavir sulfate-lamivudine-zidovudine tab 300-150-300 AEROCHAMBER...... 84 mg (Trizivir)...... 5 AFINITOR DISPERZ – everolimus tab for oral susp 2 abacavir sulfate soln 20 mg/ml (base equiv) (Ziagen)...... 5 mg...... 10 abacavir sulfate tab 300 mg (base equiv) (Ziagen)...... 5 AFINITOR DISPERZ – everolimus tab for oral susp 3 ABILIFY MAINTENA – aripiprazole im for er susp prefilled mg...... 10 syringe 300 mg...... 49 AFINITOR DISPERZ – everolimus tab for oral susp 5 ABILIFY MAINTENA – aripiprazole im for er susp prefilled mg...... 10 syringe 400 mg...... 49 AFINITOR – everolimus tab 2.5 mg...... 10 ABILIFY MAINTENA – aripiprazole im for extended AFINITOR – everolimus tab 5 mg...... 10 release susp 300 mg...... 49 AFINITOR – everolimus tab 7.5 mg...... 10 ABILIFY MAINTENA – aripiprazole im for extended AFINITOR – everolimus tab 10 mg...... 10 release susp 400 mg...... 49 AFLURIA 2017-2018 – influenza virus vaccine split im acamprosate calcium tab delayed release 333 mg...... 58 susp...... 9 acarbose tab 25 mg (Precose)...... 18 AFLURIA PF 2017-2018 – influenza virus vaccine split pf acarbose tab 50 mg (Precose)...... 18 susp pref syringe 0.5 ml...... 9 acarbose tab 100 mg (Precose)...... 18 AFLURIA QUADRIVALENT 2017 – influenza virus acebutolol hcl cap 200 mg (Sectral)...... 26 vaccine split quadrivalent im inj...... 9 acebutolol hcl cap 400 mg (Sectral)...... 26 AFLURIA QUADRIVALENT 2017 – influenza virus vac ACETAMINOPHEN/CAFFEINE/DI – acetaminophen- split quadrivalent susp pref syr 0.5ml...... 9 caffeine-dihydrocodeine cap 320.5-30-16 mg...... 59 ALBENZA – albendazole tab 200 mg...... 8 acetaminophen w/ codeine soln 120-12 mg/5ml...... 59 ALBUTEROL SULFATE ER – albuterol sulfate tab er 12hr acetaminophen w/ codeine tab 300-15 mg (Tylenol/ 4 mg...... 37 codeine)...... 59 ALBUTEROL SULFATE ER – albuterol sulfate tab er 12hr acetaminophen w/ codeine tab 300-30 mg (Tylenol/ 8 mg...... 37 codeine #3)...... 59 albuterol sulfate soln nebu 0.083% (2.5 mg/3ml)...... 37 acetaminophen w/ codeine tab 300-60 mg (Tylenol/ albuterol sulfate soln nebu 0.5% (5 mg/ml)...... 37 codeine #4)...... 59 albuterol sulfate soln nebu 0.63 mg/3ml (base equiv)...... 37 acetazolamide cap er 12hr 500 mg (Diamox)...... 32 albuterol sulfate soln nebu 1.25 mg/3ml (base equiv)...... 37 acetazolamide tab 250 mg...... 32 albuterol sulfate syrup 2 mg/5ml...... 37 acetic acid irrigation soln 0.25%...... 44 albuterol sulfate tab er 12hr 4 mg (Vospire er)...... 37 acetic acid otic soln 2%...... 78 albuterol sulfate tab er 12hr 8 mg (Vospire er)...... 37 acetylcysteine cap 600 mg...... 73 albuterol sulfate tab 2 mg...... 37 acetylcysteine inhal soln 10%...... 36 albuterol sulfate tab 4 mg...... 37 acetylcysteine inhal soln 20%...... 36 alclometasone dipropionate cream 0.05% (Aclovate)...... 81 acitretin cap 10 mg (Soriatane)...... 82 alclometasone dipropionate oint 0.05%...... 81 acitretin cap 17.5 mg (Soriatane)...... 82 ALECENSA – alectinib hcl cap 150 mg (base acitretin cap 25 mg (Soriatane)...... 82 equivalent)...... 10 ACTIMMUNE – interferon gamma-1b inj 100 mcg/0.5ml ALENDRONATE SODIUM – alendronate sodium tab 40 (2000000 unit/0.5ml)...... 10 mg...... 22 acyclovir cap 200 mg (Zovirax)...... 5 alendronate sodium tab 5 mg...... 22 acyclovir oint 5% (Zovirax)...... 80 alendronate sodium tab 10 mg...... 22 acyclovir susp 200 mg/5ml (Zovirax)...... 5 alendronate sodium tab 35 mg...... 22 acyclovir tab 400 mg (Zovirax)...... 5 alendronate sodium tab 70 mg (Fosamax)...... 22 acyclovir tab 800 mg (Zovirax)...... 5 alfuzosin hcl tab er 24hr 10 mg (Uroxatral)...... 44 adapalene cream 0.1% (Differin)...... 79 ALKERAN – melphalan tab 2 mg...... 10 ADASUVE – loxapine aerosol powder breath activated 10 allopurinol tab 100 mg (Zyloprim)...... 65 mg...... 49 allopurinol tab 300 mg (Zyloprim)...... 65 ADCIRCA – tadalafil tab 20 mg (pah)...... 33 almotriptan malate tab 6.25 mg (Axert)...... 65 adefovir dipivoxil tab 10 mg (Hepsera)...... 4 almotriptan malate tab 12.5 mg (Axert)...... 65 ADEMPAS – riociguat tab 0.5 mg...... 33 ADEMPAS – riociguat tab 1 mg...... 33

87 2018 ALOGLIPTIN/METFORMIN HCL – alogliptin-metformin amlodipine besylate tab 2.5 mg (base equivalent) hcl tab 12.5-500 mg...... 18 (Norvasc)...... 27 ALOGLIPTIN/METFORMIN HCL – alogliptin-metformin amlodipine besylate tab 5 mg (base equivalent) hcl tab 12.5-1000 mg...... 19 (Norvasc)...... 27 ALOGLIPTIN/PIOGLITAZONE – alogliptin-pioglitazone amlodipine besylate tab 10 mg (base equivalent) tab 12.5-15 mg...... 19 (Norvasc)...... 27 ALOGLIPTIN/PIOGLITAZONE – alogliptin-pioglitazone AMOXAPINE – amoxapine tab 25 mg...... 46 tab 12.5-30 mg...... 19 AMOXAPINE – amoxapine tab 50 mg...... 46 ALOGLIPTIN/PIOGLITAZONE – alogliptin-pioglitazone AMOXAPINE – amoxapine tab 100 mg...... 46 tab 12.5-45 mg...... 19 AMOXAPINE – amoxapine tab 150 mg...... 46 ALOGLIPTIN/PIOGLITAZONE – alogliptin-pioglitazone AMOXICILLIN/CLAVULANATE P – amoxicillin & k tab 25-15 mg...... 19 clavulanate chew tab 200-28.5 mg...... 1 ALOGLIPTIN/PIOGLITAZONE – alogliptin-pioglitazone AMOXICILLIN/CLAVULANATE P – amoxicillin & k tab 25-30 mg...... 19 clavulanate chew tab 400-57 mg...... 1 ALOGLIPTIN/PIOGLITAZONE – alogliptin-pioglitazone amoxicillin & k clavulanate for susp 200-28.5 mg/5ml...... 1 tab 25-45 mg...... 19 amoxicillin & k clavulanate for susp 400-57 mg/5ml...... 1 ALOGLIPTIN – alogliptin benzoate tab 6.25 mg (base amoxicillin & k clavulanate for susp 250-62.5 mg/5ml equiv)...... 18 (Augmentin)...... 1 ALOGLIPTIN – alogliptin benzoate tab 12.5 mg (base amoxicillin & k clavulanate for susp 600-42.9 mg/5ml equiv)...... 18 (Augmentin es-600)...... 1 ALOGLIPTIN – alogliptin benzoate tab 25 mg (base amoxicillin & k clavulanate tab 250-125 mg...... 1 equiv)...... 18 amoxicillin & k clavulanate tab 500-125 mg alosetron hcl tab 0.5 mg (base equiv) (Lotronex)...... 42 (Augmentin)...... 1 alosetron hcl tab 1 mg (base equiv) (Lotronex)...... 42 amoxicillin & k clavulanate tab 875-125 mg ALPRAZOLAM INTENSOL – alprazolam conc 1 mg/ (Augmentin)...... 1 ml...... 44 AMOXICILLIN – amoxicillin (trihydrate) chew tab 125 alprazolam tab er 24hr 0.5 mg (Xanax xr)...... 44 mg...... 1 alprazolam tab er 24hr 1 mg (Xanax xr)...... 45 AMOXICILLIN – amoxicillin (trihydrate) chew tab 250 alprazolam tab er 24hr 2 mg (Xanax xr)...... 45 mg...... 1 alprazolam tab er 24hr 3 mg (Xanax xr)...... 45 amoxicillin (trihydrate) cap 250 mg...... 1 alprazolam tab 0.25 mg (Xanax)...... 45 amoxicillin (trihydrate) cap 500 mg...... 1 alprazolam tab 0.5 mg (Xanax)...... 45 amoxicillin (trihydrate) for susp 125 mg/5ml...... 1 alprazolam tab 1 mg (Xanax)...... 45 amoxicillin (trihydrate) for susp 200 mg/5ml...... 1 alprazolam tab 2 mg (Xanax)...... 45 amoxicillin (trihydrate) for susp 250 mg/5ml...... 1 amantadine hcl cap 100 mg...... 69 amoxicillin (trihydrate) for susp 400 mg/5ml...... 1 amantadine hcl syrup 50 mg/5ml...... 69 amoxicillin (trihydrate) tab 875 mg...... 1 amiloride & hydrochlorothiazide tab 5-50 mg...... 32 amphetamine-dextroamphetamine cap er 24hr 5 mg amiloride hcl tab 5 mg...... 32 (Adderall xr)...... 56 amino acids cap...... 73 amphetamine-dextroamphetamine cap er 24hr 10 mg amiodarone hcl tab 200 mg (Cordarone)...... 33 (Adderall xr)...... 56 amitriptyline hcl tab 10 mg...... 45 amphetamine-dextroamphetamine cap er 24hr 15 mg amitriptyline hcl tab 50 mg...... 46 (Adderall xr)...... 56 amitriptyline hcl tab 75 mg...... 46 amphetamine-dextroamphetamine cap er 24hr 20 mg amitriptyline hcl tab 100 mg...... 46 (Adderall xr)...... 56 amitriptyline hcl tab 150 mg...... 46 amphetamine-dextroamphetamine cap er 24hr 25 mg amitriptyline hcl tab 25 mg (Elavil)...... 46 (Adderall xr)...... 56 amlodipine besylate-benazepril hcl cap 2.5-10 mg...... 27 amphetamine-dextroamphetamine cap er 24hr 30 mg amlodipine besylate-benazepril hcl cap 5-40 mg...... 28 (Adderall xr)...... 56 amlodipine besylate-benazepril hcl cap 5-10 mg amphetamine-dextroamphetamine tab 5 mg (Lotrel)...... 28 (Adderall)...... 56 amlodipine besylate-benazepril hcl cap 5-20 mg amphetamine-dextroamphetamine tab 7.5 mg (Lotrel)...... 28 (Adderall)...... 56 amlodipine besylate-benazepril hcl cap 10-20 mg amphetamine-dextroamphetamine tab 10 mg (Lotrel)...... 28 (Adderall)...... 56 amlodipine besylate-benazepril hcl cap 10-40 mg amphetamine-dextroamphetamine tab 12.5 mg (Lotrel)...... 28 (Adderall)...... 56

88 2018 amphetamine-dextroamphetamine tab 15 mg aripiprazole tab 5 mg (Abilify)...... 49 (Adderall)...... 56 aripiprazole tab 10 mg (Abilify)...... 49 amphetamine-dextroamphetamine tab 20 mg aripiprazole tab 15 mg (Abilify)...... 49 (Adderall)...... 56 aripiprazole tab 20 mg (Abilify)...... 49 amphetamine-dextroamphetamine tab 30 mg aripiprazole tab 30 mg (Abilify)...... 49 (Adderall)...... 56 ARISTADA – aripiprazole lauroxil im er susp prefilled syr ampicillin cap 250 mg...... 1 441 mg/1.6ml...... 49 ampicillin cap 500 mg...... 1 ARISTADA – aripiprazole lauroxil im er susp prefilled syr anagrelide hcl cap 1 mg...... 73 662 mg/2.4ml...... 50 anagrelide hcl cap 0.5 mg (Agrylin)...... 73 ARISTADA – aripiprazole lauroxil im er susp prefilled syr anastrozole tab 1 mg (Arimidex)...... 10 882 mg/3.2ml...... 50 APLENZIN – bupropion hbr tab er 24hr 174 mg...... 46 ARISTADA – aripiprazole lauroxil im er susp prefilled syr APLENZIN – bupropion hbr tab er 24hr 348 mg...... 46 1064 mg/3.9ml...... 50 APLENZIN – bupropion hbr tab er 24hr 522 mg...... 46 armodafinil tab 50 mg (Nuvigil)...... 56 apraclonidine hcl ophth soln 0.5% (base equivalent) armodafinil tab 150 mg (Nuvigil)...... 56 (Iopidine)...... 77 armodafinil tab 250 mg (Nuvigil)...... 56 APTIOM – eslicarbazepine acetate tab 200 mg...... 65 ARNUITY ELLIPTA – fluticasone furoate aerosol powder APTIOM – eslicarbazepine acetate tab 400 mg...... 66 breath activ 100 mcg/act...... 37 APTIOM – eslicarbazepine acetate tab 600 mg...... 66 ARNUITY ELLIPTA – fluticasone furoate aerosol powder APTIOM – eslicarbazepine acetate tab 800 mg...... 66 breath activ 200 mcg/act...... 37 APTIVUS – tipranavir cap 250 mg...... 5 atazanavir sulfate cap 150 mg (base equiv) (Reyataz)...... 5 APTIVUS – tipranavir oral soln 100 mg/ml...... 5 atazanavir sulfate cap 200 mg (base equiv) (Reyataz)...... 5 ARANESP ALBUMIN FREE – darbepoetin alfa soln inj 25 atazanavir sulfate cap 300 mg (base equiv) (Reyataz)...... 5 mcg/ml...... 74 atenolol & chlorthalidone tab 50-25 mg (Tenoretic 50)...... 26 ARANESP ALBUMIN FREE – darbepoetin alfa soln inj 40 atenolol & chlorthalidone tab 100-25 mg (Tenoretic mcg/ml...... 74 100)...... 26 ARANESP ALBUMIN FREE – darbepoetin alfa soln inj 60 atenolol tab 25 mg (Tenormin)...... 26 mcg/ml...... 74 atenolol tab 50 mg (Tenormin)...... 26 ARANESP ALBUMIN FREE – darbepoetin alfa soln inj atenolol tab 100 mg (Tenormin)...... 26 100 mcg/ml...... 74 atorvastatin calcium tab 10 mg (base equivalent) ARANESP ALBUMIN FREE – darbepoetin alfa soln inj (Lipitor)...... 30 200 mcg/ml...... 74 atorvastatin calcium tab 20 mg (base equivalent) ARANESP ALBUMIN FREE – darbepoetin alfa soln inj (Lipitor)...... 30 300 mcg/ml...... 74 atorvastatin calcium tab 40 mg (base equivalent) ARANESP ALBUMIN FREE – darbepoetin alfa soln (Lipitor)...... 30 prefilled syringe 10 mcg/0.4ml...... 73 atorvastatin calcium tab 80 mg (base equivalent) ARANESP ALBUMIN FREE – darbepoetin alfa soln (Lipitor)...... 30 prefilled syringe 25 mcg/0.42ml...... 73 atovaquone-proguanil hcl tab 62.5-25 mg (Malarone)...... 8 ARANESP ALBUMIN FREE – darbepoetin alfa soln atovaquone-proguanil hcl tab 250-100 mg (Malarone)...... 8 prefilled syringe 40 mcg/0.4ml...... 74 ATRIPLA – efavirenz-emtricitabine-tenofovir df tab ARANESP ALBUMIN FREE – darbepoetin alfa soln 600-200-300 mg...... 5 prefilled syringe 60 mcg/0.3ml...... 74 ATROPINE SULFATE – atropine sulfate ophth oint ARANESP ALBUMIN FREE – darbepoetin alfa soln 1%...... 78 prefilled syringe 100 mcg/0.5ml...... 74 ATROPINE SULFATE – atropine sulfate ophth soln ARANESP ALBUMIN FREE – darbepoetin alfa soln 1%...... 78 prefilled syringe 150 mcg/0.3ml...... 74 ATROVENT HFA – ipratropium bromide hfa inhal aerosol ARANESP ALBUMIN FREE – darbepoetin alfa soln 17 mcg/act...... 37 prefilled syringe 200 mcg/0.4ml...... 74 AUBAGIO – teriflunomide tab 7 mg...... 58 ARANESP ALBUMIN FREE – darbepoetin alfa soln AUBAGIO – teriflunomide tab 14 mg...... 58 prefilled syringe 300 mcg/0.6ml...... 74 AUGMENTED BETAMETHASONE D – betamethasone ARANESP ALBUMIN FREE – darbepoetin alfa soln dipropionate augmented gel 0.05%...... 81 prefilled syringe 500 mcg/ml...... 74 AVONEX – interferon beta-1a for im inj kit 30mcg ARCALYST – rilonacept for inj 220 mg...... 62 (33mcg(6.6 mu)/vial)...... 58 aripiprazole orally disintegrating tab 15 mg...... 49 AVONEX – interferon beta-1a im prefilled syringe kit 30 aripiprazole oral solution 1 mg/ml...... 49 mcg/0.5ml...... 58 aripiprazole tab 2 mg (Abilify)...... 49

89 2018

AVONEX PEN – interferon beta-1a im auto-injector kit 30 betamethasone dipropionate lotion 0.05%...... 81 mcg/0.5ml...... 58 betamethasone dipropionate oint 0.05%...... 81 azathioprine tab 50 mg (Imuran)...... 84 betamethasone valerate cream 0.1% (base azelastine hcl nasal spray 0.1% (137 mcg/spray)...... 36 equivalent)...... 81 azelastine hcl ophth soln 0.05%...... 78 betamethasone valerate lotion 0.1% (base AZITHROMYCIN – azithromycin powd pack for susp 1 equivalent)...... 81 gm...... 2 betamethasone valerate oint 0.1% (base equivalent)...... 81 azithromycin for susp 100 mg/5ml (Zithromax)...... 2 betaxolol hcl ophth soln 0.5%...... 77 azithromycin for susp 200 mg/5ml (Zithromax)...... 2 betaxolol hcl tab 10 mg (Kerlone)...... 26 azithromycin tab 250 mg (Zithromax)...... 2 betaxolol hcl tab 20 mg (Kerlone)...... 26 azithromycin tab 500 mg (Zithromax)...... 2 bethanechol chloride tab 5 mg (Urecholine)...... 43 azithromycin tab 600 mg (Zithromax)...... 2 bethanechol chloride tab 10 mg (Urecholine)...... 43 bethanechol chloride tab 25 mg (Urecholine)...... 43 B bethanechol chloride tab 50 mg (Urecholine)...... 43 BACITRACIN – bacitracin ophth oint 500 unit/gm...... 76 bexarotene cap 75 mg (Targretin)...... 10 bacitracin-polymyxin b ophth oint...... 76 bicalutamide tab 50 mg (Casodex)...... 10 bacitracin-polymyxin-neomycin-hc ophth oint 1%...... 77 bisacodyl tab & peg 3350-kcl-sod bicarb-nacl for soln baclofen tab 10 mg...... 70 kit...... 39 baclofen tab 20 mg...... 70 bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg balsalazide disodium cap 750 mg (Colazal)...... 42 (Ziac)...... 26 BARACLUDE – entecavir oral soln 0.05 mg/ml...... 4 bisoprolol & hydrochlorothiazide tab 5-6.25 mg (Ziac)...... 26 BASAGLAR KWIKPEN – insulin glargine soln pen-injector bisoprolol & hydrochlorothiazide tab 10-6.25 mg 100 unit/ml...... 21 (Ziac)...... 26 BAYER CONTOUR BLOOD GLUCO – blood glucose bisoprolol fumarate tab 5 mg (Zebeta)...... 26 monitoring devices...... 83 bisoprolol fumarate tab 10 mg (Zebeta)...... 26 b-complex w/ c & folic acid cap 1 mg (Nephrocaps)...... 70 BOSULIF – bosutinib tab 100 mg...... 10 b-complex w/ c & folic acid tab...... 70 BOSULIF – bosutinib tab 500 mg...... 10 b-complex w/ c & folic acid tab 5 mg...... 70 BREATHERITE...... 84 b-complex w/ c & folic acid tab 1 mg (Nephro-vite rx)...... 70 BRILINTA – ticagrelor tab 60 mg...... 74 benazepril & hydrochlorothiazide tab 5-6.25 mg...... 23 BRILINTA – ticagrelor tab 90 mg...... 74 benazepril & hydrochlorothiazide tab 10-12.5 mg brimonidine tartrate ophth soln 0.2%...... 77 (Lotensin hct)...... 23 BRINTELLIX – vortioxetine hbr tab 5 mg (base equiv)..... 46 benazepril & hydrochlorothiazide tab 20-12.5 mg BRINTELLIX – vortioxetine hbr tab 10 mg (base (Lotensin hct)...... 23 equiv)...... 46 benazepril & hydrochlorothiazide tab 20-25 mg (Lotensin BRINTELLIX – vortioxetine hbr tab 20 mg (base hct)...... 23 equiv)...... 46 benazepril hcl tab 5 mg...... 23 bromocriptine mesylate cap 5 mg (base equivalent)...... 69 benazepril hcl tab 10 mg (Lotensin)...... 23 bromocriptine mesylate tab 2.5 mg (base equivalent) benazepril hcl tab 20 mg (Lotensin)...... 23 (Parlodel)...... 69 benazepril hcl tab 40 mg (Lotensin)...... 23 budesonide delayed release particles cap 3 mg (Entocort BENZNIDAZOLE – benznidazole tab 12.5 mg...... 8 ec)...... 15 BENZNIDAZOLE – benznidazole tab 100 mg...... 8 budesonide inhalation susp 0.25 mg/2ml (Pulmicort)...... 37 benzoyl peroxide cloth 6%...... 79 budesonide inhalation susp 0.5 mg/2ml (Pulmicort)...... 37 benzoyl peroxide-erythromycin gel 5-3% budesonide inhalation susp 1 mg/2ml (Pulmicort)...... 37 (Benzamycin)...... 79 bumetanide tab 0.5 mg (Bumex)...... 32 benztropine mesylate tab 0.5 mg...... 69 bumetanide tab 1 mg (Bumex)...... 32 benztropine mesylate tab 1 mg...... 69 bumetanide tab 2 mg (Bumex)...... 32 benztropine mesylate tab 2 mg...... 69 BUPHENYL – sodium phenylbutyrate tab 500 mg...... 22 betamethasone dipropionate augmented cream 0.05% buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg (base (Diprolene af)...... 81 equiv)...... 60 betamethasone dipropionate augmented gel 0.05%...... 81 buprenorphine hcl-naloxone hcl sl tab 8-2 mg (base betamethasone dipropionate augmented lotion 0.05% equiv)...... 60 (Diprolene)...... 81 buprenorphine hcl sl tab 2 mg (base equiv)...... 60 betamethasone dipropionate augmented oint 0.05% buprenorphine hcl sl tab 8 mg (base equiv)...... 60 (Diprolene)...... 81 bupropion hcl (smoking deterrent) tab er 12hr 150 mg betamethasone dipropionate cream 0.05%...... 81 (Zyban)...... 58

90 2018 bupropion hcl tab er 12hr 100 mg (Wellbutrin sr)...... 46 CAPTOPRIL/HYDROCHLOROTHIA – captopril & bupropion hcl tab er 12hr 150 mg (Wellbutrin sr)...... 46 hydrochlorothiazide tab 50-15 mg...... 24 bupropion hcl tab er 12hr 200 mg (Wellbutrin sr)...... 46 CAPTOPRIL/HYDROCHLOROTHIA – captopril & bupropion hcl tab er 24hr 150 mg (Wellbutrin xl)...... 46 hydrochlorothiazide tab 50-25 mg...... 24 bupropion hcl tab er 24hr 300 mg (Wellbutrin xl)...... 46 captopril tab 12.5 mg...... 24 bupropion hcl tab 75 mg...... 46 captopril tab 25 mg...... 24 bupropion hcl tab 100 mg...... 46 captopril tab 50 mg...... 24 buspirone hcl tab 5 mg...... 45 captopril tab 100 mg...... 24 buspirone hcl tab 10 mg...... 45 CARBAGLU – carglumic acid tab 200 mg...... 22 buspirone hcl tab 15 mg...... 45 carbamazepine cap er 12hr 100 mg (Carbatrol)...... 66 buspirone hcl tab 30 mg...... 45 carbamazepine cap er 12hr 200 mg (Carbatrol)...... 66 butalbital-acetaminophen-caffeine cap 50-300-40 mg carbamazepine cap er 12hr 300 mg (Carbatrol)...... 66 (Fioricet)...... 59 carbamazepine chew tab 100 mg...... 66 butalbital-acetaminophen-caffeine tab 50-325-40 mg carbamazepine susp 100 mg/5ml (Tegretol)...... 66 (Esgic)...... 59 carbamazepine tab er 12hr 100 mg (Tegretol-xr)...... 66 butalbital-acetaminophen-caff w/ cod cap 50-325-40-30 carbamazepine tab er 12hr 200 mg (Tegretol-xr)...... 66 mg...... 60 carbamazepine tab er 12hr 400 mg (Tegretol-xr)...... 66 butalbital-acetaminophen tab 50-325 mg...... 59 carbamazepine tab 200 mg (Tegretol)...... 66 butalbital-aspirin-caffeine cap 50-325-40 mg (Fiorinal).....59 carbidopa & levodopa orally disintegrating tab 10-100 butalbital-aspirin-caff w/ codeine cap 50-325-40-30 mg mg...... 69 (Fiorinal/codeine #3)...... 60 carbidopa & levodopa orally disintegrating tab 25-100 butorphanol tartrate nasal soln 10 mg/ml...... 60 mg...... 69 carbidopa & levodopa orally disintegrating tab 25-250 C mg...... 69 cabergoline tab 0.5 mg...... 22 carbidopa & levodopa tab er 25-100 mg (Sinemet cr)...... 69 CABOMETYX – cabozantinib s-malate tab 20 mg (base carbidopa & levodopa tab er 50-200 mg (Sinemet cr)...... 69 equivalent)...... 10 carbidopa & levodopa tab 10-100 mg (Sinemet)...... 69 CABOMETYX – cabozantinib s-malate tab 40 mg (base carbidopa & levodopa tab 25-100 mg (Sinemet)...... 69 equivalent)...... 11 carbidopa & levodopa tab 25-250 mg (Sinemet)...... 69 CABOMETYX – cabozantinib s-malate tab 60 mg (base carbidopa tab 25 mg (Lodosyn)...... 69 equivalent)...... 11 carbinoxamine maleate soln 4 mg/5ml...... 36 caffeine citrate oral soln 60 mg/3ml (10 mg/ml base carbinoxamine maleate tab 4 mg...... 36 equiv)...... 56 carisoprodol tab 250 mg (Soma)...... 70 calcipotriene cream 0.005% (Dovonex)...... 82 CARTEOLOL HCL – carteolol hcl ophth soln 1%...... 77 calcipotriene oint 0.005%...... 82 carteolol hcl ophth soln 1%...... 77 calcipotriene soln 0.005% (50 mcg/ml)...... 82 carvedilol tab 3.125 mg (Coreg)...... 26 calcitonin (salmon) nasal soln 200 unit/act (Miacalcin)..... 22 carvedilol tab 6.25 mg (Coreg)...... 26 calcitriol cap 0.25 mcg (Rocaltrol)...... 22 carvedilol tab 12.5 mg (Coreg)...... 26 calcitriol cap 0.5 mcg (Rocaltrol)...... 22 carvedilol tab 25 mg (Coreg)...... 26 calcitriol oral soln 1 mcg/ml (Rocaltrol)...... 22 CAYSTON – aztreonam lysine for inhal soln 75 mg (base calcium acetate (phosphate binder) cap 667 mg (169 mg equivalent)...... 8 ca) (Phoslo)...... 42 cefaclor cap 250 mg...... 1 calcium acetate (phosphate binder) tab 667 mg cefaclor cap 500 mg...... 1 (Eliphos)...... 42 cefadroxil cap 500 mg...... 1 CALIBRATION LIQUID - BAYER BREEZE 2, CONTOUR, cefadroxil for susp 250 mg/5ml...... 2 CONTOUR NEXT...... 84 cefadroxil for susp 500 mg/5ml...... 2 CALQUENCE – acalabrutinib cap 100 mg...... 11 cefadroxil tab 1 gm...... 2 CANASA – mesalamine suppos 1000 mg...... 42 cefdinir cap 300 mg...... 2 capecitabine tab 150 mg (Xeloda)...... 11 cefdinir for susp 125 mg/5ml...... 2 capecitabine tab 500 mg (Xeloda)...... 11 cefdinir for susp 250 mg/5ml...... 2 CAPRELSA – vandetanib tab 100 mg...... 11 cefixime for susp 100 mg/5ml (Suprax)...... 2 CAPRELSA – vandetanib tab 300 mg...... 11 cefixime for susp 200 mg/5ml (Suprax)...... 2 CAPTOPRIL/HYDROCHLOROTHIA – captopril & cefprozil for susp 125 mg/5ml...... 2 hydrochlorothiazide tab 25-15 mg...... 24 cefprozil for susp 250 mg/5ml...... 2 CAPTOPRIL/HYDROCHLOROTHIA – captopril & cefprozil tab 250 mg...... 2 hydrochlorothiazide tab 25-25 mg...... 24 cefprozil tab 500 mg...... 2

91 2018 cefuroxime axetil tab 250 mg...... 2 cilostazol tab 50 mg...... 74 cefuroxime axetil tab 500 mg (Ceftin)...... 2 cilostazol tab 100 mg...... 74 celecoxib cap 50 mg (Celebrex)...... 62 CIMETIDINE HCL – cimetidine hcl soln 300 mg/5ml...... 40 celecoxib cap 100 mg (Celebrex)...... 62 cimetidine tab 200 mg...... 40 celecoxib cap 200 mg (Celebrex)...... 62 cimetidine tab 300 mg...... 40 celecoxib cap 400 mg (Celebrex)...... 62 cimetidine tab 400 mg...... 40 CEM-UREA – urea soln 45%...... 82 cimetidine tab 800 mg...... 40 cephalexin cap 250 mg (Keflex)...... 2 CIMZIA – certolizumab pegol for inj kit 2 x 200 mg...... 42 cephalexin cap 500 mg (Keflex)...... 2 CIMZIA – certolizumab pegol inj kit 2 x 200 mg/ml...... 42 cephalexin for susp 125 mg/5ml...... 2 CIMZIA STARTER KIT – certolizumab pegol inj kit 6 x 200 cephalexin for susp 250 mg/5ml...... 2 mg/ml...... 42 cetirizine hcl oral soln 1 mg/ml (5 mg/5ml)...... 36 ciprofloxacin for oral susp 250 mg/5ml (5%) (5 gm/100ml) CHANTIX CONTINUING MONTH – varenicline tartrate (Cipro)...... 3 tab 1 mg (base equiv)...... 58 ciprofloxacin for oral susp 500 mg/5ml (10%) (10 CHANTIX STARTING MONTH PA – varenicline tartrate gm/100ml) (Cipro)...... 3 tab 0.5 mg x 11 & tab 1 mg x 42 pack...... 58 ciprofloxacin hcl ophth soln 0.3% (Ciloxan)...... 76 CHANTIX – varenicline tartrate tab 0.5 mg (base ciprofloxacin hcl tab 750 mg (base equiv)...... 3 equiv)...... 58 ciprofloxacin hcl tab 250 mg (base equiv) (Cipro)...... 3 CHANTIX – varenicline tartrate tab 1 mg (base equiv)..... 58 ciprofloxacin hcl tab 500 mg (base equiv) (Cipro)...... 3 CHEMET – succimer cap 100 mg...... 84 citalopram hydrobromide oral soln 10 mg/5ml...... 46 CHENODAL – chenodiol tab 250 mg...... 42 citalopram hydrobromide tab 10 mg (base equiv) CHLORDIAZEPOXIDE/AMITRIPT – chlordiazepoxide- (Celexa)...... 46 amitriptyline tab 5-12.5 mg...... 58 citalopram hydrobromide tab 20 mg (base equiv) CHLORDIAZEPOXIDE/AMITRIPT – chlordiazepoxide- (Celexa)...... 46 amitriptyline tab 10-25 mg...... 58 citalopram hydrobromide tab 40 mg (base equiv) chlordiazepoxide hcl cap 5 mg...... 45 (Celexa)...... 46 chlordiazepoxide hcl cap 10 mg...... 45 clarithromycin for susp 125 mg/5ml...... 2 chlordiazepoxide hcl cap 25 mg...... 45 clarithromycin for susp 250 mg/5ml (Biaxin)...... 2 chlordiazepoxide hcl-clidinium bromide cap 5-2.5 mg clarithromycin tab 250 mg (Biaxin)...... 2 (Librax)...... 40 clarithromycin tab 500 mg (Biaxin)...... 2 chlorhexidine gluconate soln 0.12% (Peridex)...... 78 CLASSIC PRENATAL – prenatal vit w/ fe fumarate-fa tab chloroquine phosphate tab 500 mg (Aralen)...... 8 28-0.8 mg...... 70 CHLOROTHIAZIDE – chlorothiazide tab 250 mg...... 32 clindamycin hcl cap 75 mg (Cleocin)...... 8 chlorothiazide tab 500 mg...... 32 clindamycin hcl cap 150 mg (Cleocin)...... 8 CHLORPROMAZINE HCL – chlorpromazine hcl inj 50 clindamycin hcl cap 300 mg (Cleocin)...... 8 mg/2ml...... 50 clindamycin palmitate hcl for soln 75 mg/5ml (base equiv) chlorpromazine hcl tab 10 mg...... 50 (Cleocin pediatric gr)...... 9 chlorpromazine hcl tab 25 mg...... 50 clindamycin phosphate gel 1% (Cleocin-t)...... 79 chlorpromazine hcl tab 50 mg...... 50 clindamycin phosphate lotion 1% (Cleocin-t)...... 79 chlorpromazine hcl tab 100 mg...... 50 clindamycin phosphate soln 1% (Cleocin-t)...... 79 chlorpromazine hcl tab 200 mg...... 50 clindamycin phosphate swab 1% (Cleocin-t)...... 79 chlorthalidone tab 25 mg...... 32 clindamycin phosphate vaginal cream 2% (Cleocin)...... 43 CHLORZOXAZONE – chlorzoxazone tab 500 mg...... 70 clindamycin phosph-benzoyl peroxide (refrig) gel 1.2 CHOLBAM – cholic acid cap 50 mg...... 42 (1)-5% (Duac)...... 79 CHOLBAM – cholic acid cap 250 mg...... 42 clobetasol propionate emollient base cream 0.05% cholestyramine light powder 4 gm/dose (Questran (Temovate e)...... 81 light)...... 30 clobetasol propionate soln 0.05% (Temovate)...... 81 cholestyramine light powder packets 4 gm...... 30 clonazepam orally disintegrating tab 0.125 mg...... 66 cholestyramine powder 4 gm/dose (Questran)...... 30 clonazepam orally disintegrating tab 0.25 mg...... 66 cholestyramine powder packets 4 gm (Questran)...... 30 clonazepam orally disintegrating tab 0.5 mg...... 66 choline fenofibrate cap dr 45 mg (fenofibric acid equiv) clonazepam orally disintegrating tab 1 mg...... 66 (Trilipix)...... 30 clonazepam orally disintegrating tab 2 mg...... 66 ciclopirox olamine cream 0.77% (base equiv) clonazepam tab 0.5 mg (Klonopin)...... 66 (Loprox)...... 80 clonazepam tab 1 mg (Klonopin)...... 66 ciclopirox olamine susp 0.77% (base equiv)...... 80 clonazepam tab 2 mg (Klonopin)...... 66 ciclopirox solution 8% (Penlac Nail Lacquer)...... 80 clonidine hcl tab er 12hr 0.1 mg (Kapvay)...... 56

92 2018 clonidine hcl tab 0.1 mg (Catapres)...... 34 COTELLIC – cobimetinib fumarate tab 20 mg (base clonidine hcl tab 0.2 mg (Catapres)...... 34 equivalent)...... 11 clonidine hcl tab 0.3 mg (Catapres)...... 34 CREON – pancrelipase (lip-prot-amyl) dr cap clonidine hcl td patch weekly 0.1 mg/24hr (Catapres- 3000-9500-15000 unit...... 41 tts-1)...... 34 CREON – pancrelipase (lip-prot-amyl) dr cap clonidine hcl td patch weekly 0.2 mg/24hr (Catapres- 6000-19000-30000 unit...... 41 tts-2)...... 34 CREON – pancrelipase (lip-prot-amyl) dr cap clonidine hcl td patch weekly 0.3 mg/24hr (Catapres- 12000-38000-60000 unit...... 41 tts-3)...... 34 CREON – pancrelipase (lip-prot-amyl) dr cap clopidogrel bisulfate tab 75 mg (base equiv) (Plavix)...... 74 24000-76000-120000 unit...... 41 clopidogrel bisulfate tab 300 mg (base equiv) (Plavix)...... 74 CREON – pancrelipase (lip-prot-amyl) dr cap clorazepate dipotassium tab 3.75 mg...... 45 36000-114000-180000 unit...... 41 clorazepate dipotassium tab 15 mg...... 45 CRIXIVAN – indinavir sulfate cap 200 mg...... 5 clorazepate dipotassium tab 7.5 mg (Tranxene t)...... 45 CRIXIVAN – indinavir sulfate cap 400 mg...... 5 clotrimazole cream 1%...... 80 cromolyn sodium ophth soln 4%...... 78 clotrimazole soln 1%...... 80 CUPRIMINE – penicillamine cap 250 mg...... 84 clotrimazole troche 10 mg...... 78 CUTTER BACKWOODS – diethyltoluamide (deet) clotrimazole w/ betamethasone cream 1-0.05% aerosol...... 83 (Lotrisone)...... 80 CUTTER SKINSATIONS – diethyltoluamide (deet) clozapine orally disintegrating tab 12.5 mg (Fazaclo)...... 50 liquid...... 83 clozapine orally disintegrating tab 25 mg (Fazaclo)...... 50 cyanocobalamin inj 1000 mcg/ml...... 74 clozapine orally disintegrating tab 100 mg (Fazaclo)...... 50 cyclobenzaprine hcl tab 5 mg...... 70 clozapine tab 50 mg...... 50 cyclobenzaprine hcl tab 10 mg...... 70 clozapine tab 200 mg...... 50 cyclopentolate hcl ophth soln 0.5% (Cyclogyl)...... 78 clozapine tab 25 mg (Clozaril)...... 50 cyclopentolate hcl ophth soln 1% (Cyclogyl)...... 78 clozapine tab 100 mg (Clozaril)...... 50 cyclopentolate hcl ophth soln 2% (Cyclogyl)...... 78 codeine sulfate tab 15 mg (Codeine sulfate)...... 60 cyclophosphamide cap 25 mg (Cyclophosphamide)...... 11 codeine sulfate tab 30 mg (Codeine sulfate)...... 60 cyclophosphamide cap 50 mg (Cyclophosphamide)...... 11 codeine sulfate tab 60 mg (Codeine sulfate)...... 60 cyclosporine cap 25 mg (Sandimmune)...... 84 colchicine w/ probenecid tab 0.5-500 mg...... 65 cyclosporine cap 100 mg (Sandimmune)...... 84 COLCRYS – colchicine tab 0.6 mg...... 65 cyclosporine modified cap 50 mg (Cyclosporine colestipol hcl granule packets 5 gm (Colestid modifie)...... 84 flavored)...... 30 cyclosporine modified cap 25 mg (Neoral)...... 84 colestipol hcl granules 5 gm (Colestid flavored)...... 30 cyclosporine modified cap 100 mg (Neoral)...... 84 colestipol hcl tab 1 gm (Colestid)...... 30 CYCLOSPORINE MODIFIED – cyclosporine modified cap COMBIPATCH – estradiol-norethindrone ace td pttw 50 mg...... 84 0.05-0.14 mg/day...... 17 cyclosporine modified oral soln 100 mg/ml (Neoral)...... 84 COMBIPATCH – estradiol-norethindrone ace td pttw cyproheptadine hcl syrup 2 mg/5ml...... 36 0.05-0.25 mg/day...... 17 cyproheptadine hcl tab 4 mg...... 36 COMBIVENT RESPIMAT – ipratropium-albuterol inhal CYSTAGON – cysteamine bitartrate cap 50 mg...... 44 aerosol soln 20-100 mcg/act...... 37 CYSTAGON – cysteamine bitartrate cap 150 mg...... 44 COMETRIQ – cabozantinib s-malate cap 3 x 20 mg (60 D mg dose) kit...... 11 COMETRIQ – cabozantinib s-mal cap 1 x 80 mg & 1 x 20 danazol cap 50 mg...... 16 mg (100 dose) kit...... 11 danazol cap 100 mg...... 16 COMETRIQ – cabozantinib s-mal cap 1 x 80 mg & 3 x 20 danazol cap 200 mg...... 16 mg (140 dose) kit...... 11 dantrolene sodium cap 100 mg...... 70 COMPLERA – emtricitabine-rilpivirine-tenofovir df tab dantrolene sodium cap 25 mg (Dantrium)...... 70 200-25-300 mg...... 5 dantrolene sodium cap 50 mg (Dantrium)...... 70 CORTISONE ACETATE – cortisone acetate tab 25 dapsone tab 25 mg...... 9 mg...... 15 dapsone tab 100 mg...... 9 COSENTYX – secukinumab subcutaneous soln prefilled DARAPRIM – pyrimethamine tab 25 mg...... 8 syringe 150 mg/ml...... 83 darifenacin hydrobromide tab er 24hr 7.5 mg (base equiv) COSENTYX SENSOREADY PEN – secukinumab (Enablex)...... 43 subcutaneous soln auto-injector 150 mg/ml...... 83 darifenacin hydrobromide tab er 24hr 15 mg (base equiv) (Enablex)...... 43

93 2018

demeclocycline hcl tab 150 mg...... 2 dextroamphetamine sulfate tab 10 mg...... 57 demeclocycline hcl tab 300 mg...... 2 diazepam conc 5 mg/ml...... 45 DEPEN TITRATABS – penicillamine tab 250 mg...... 84 DIAZEPAM – diazepam im solution auto-inj 10 DESCOVY – emtricitabine-tenofovir alafenamide fumarate mg/2ml...... 45 tab 200-25 mg...... 5 DIAZEPAM – diazepam oral soln 1 mg/ml...... 45 desipramine hcl tab 50 mg...... 46 DIAZEPAM – diazepam rectal gel delivery system 2.5 desipramine hcl tab 75 mg...... 46 mg...... 66 desipramine hcl tab 100 mg...... 46 DIAZEPAM – diazepam rectal gel delivery system 10 desipramine hcl tab 150 mg...... 46 mg...... 66 desipramine hcl tab 10 mg (Norpramin)...... 46 DIAZEPAM – diazepam rectal gel delivery system 20 desipramine hcl tab 25 mg (Norpramin)...... 46 mg...... 66 desloratadine tab 5 mg (Clarinex)...... 36 diazepam tab 2 mg (Valium)...... 45 desmopressin acetate nasal spray soln 0.01% diazepam tab 5 mg (Valium)...... 45 (Ddavp)...... 22 diazepam tab 10 mg (Valium)...... 45 desmopressin acetate nasal spray soln 0.01% diclofenac potassium tab 50 mg...... 62 (refrigerated)...... 22 diclofenac sodium gel 1% (Voltaren)...... 80 desmopressin acetate tab 0.1 mg (Ddavp)...... 22 diclofenac sodium ophth soln 0.1%...... 78 desmopressin acetate tab 0.2 mg (Ddavp)...... 22 diclofenac sodium tab delayed release 50 mg...... 62 desonide cream 0.05% (Desowen)...... 81 diclofenac sodium tab delayed release 75 mg...... 62 desonide oint 0.05%...... 81 diclofenac sodium tab er 24hr 100 mg...... 62 desoximetasone cream 0.25% (Topicort)...... 81 dicloxacillin sodium cap 250 mg...... 1 desoximetasone gel 0.05% (Topicort)...... 81 dicloxacillin sodium cap 500 mg...... 1 DEXAMETHASONE – dexamethasone soln 0.5 dicyclomine hcl cap 10 mg (Bentyl)...... 40 mg/5ml...... 15 dicyclomine hcl oral soln 10 mg/5ml...... 40 dexamethasone elixir 0.5 mg/5ml...... 15 dicyclomine hcl tab 20 mg (Bentyl)...... 40 DEXAMETHASONE SODIUM PHOS – dexamethasone didanosine delayed release capsule 200 mg (Videx ec).....5 sodium phosphate ophth soln 0.1%...... 77 didanosine delayed release capsule 250 mg (Videx ec).....5 dexamethasone tab 0.5 mg...... 15 didanosine delayed release capsule 400 mg (Videx ec).....5 dexamethasone tab 0.75 mg...... 15 DIGOXIN – digoxin oral soln 0.05 mg/ml...... 34 dexamethasone tab 1.5 mg...... 15 digoxin tab 125 mcg (0.125 mg) (Lanoxin)...... 34 dexamethasone tab 4 mg...... 15 digoxin tab 250 mcg (0.25 mg) (Lanoxin)...... 34 dexamethasone tab 6 mg...... 15 DILANTIN – phenytoin sodium extended cap 30 mg...... 66 dexmethylphenidate hcl cap er 24 hr 5 mg (Focalin diltiazem hcl cap er 12hr 60 mg...... 28 xr)...... 56 diltiazem hcl cap er 12hr 90 mg...... 28 dexmethylphenidate hcl cap er 24 hr 10 mg (Focalin diltiazem hcl cap er 12hr 120 mg...... 28 xr)...... 56 diltiazem hcl cap er 24hr 120 mg...... 28 dexmethylphenidate hcl cap er 24 hr 15 mg (Focalin diltiazem hcl cap er 24hr 180 mg...... 28 xr)...... 56 diltiazem hcl cap er 24hr 240 mg...... 28 dexmethylphenidate hcl cap er 24 hr 20 mg (Focalin diltiazem hcl coated beads cap er 24hr 300 mg...... 28 xr)...... 56 diltiazem hcl coated beads cap er 24hr 120 mg (Cardizem dexmethylphenidate hcl cap er 24 hr 30 mg (Focalin cd)...... 28 xr)...... 56 diltiazem hcl coated beads cap er 24hr 180 mg (Cardizem dexmethylphenidate hcl cap er 24 hr 40 mg (Focalin cd)...... 28 xr)...... 56 diltiazem hcl coated beads cap er 24hr 240 mg (Cardizem dexmethylphenidate hcl tab 2.5 mg (Focalin)...... 56 cd)...... 28 dexmethylphenidate hcl tab 5 mg (Focalin)...... 56 diltiazem hcl extended release beads cap er 24hr 120 mg dexmethylphenidate hcl tab 10 mg (Focalin)...... 56 (Tiazac)...... 28 dextroamphetamine sulfate cap er 24hr 5 mg diltiazem hcl extended release beads cap er 24hr 180 mg (Dexedrine)...... 56 (Tiazac)...... 28 dextroamphetamine sulfate cap er 24hr 10 mg diltiazem hcl extended release beads cap er 24hr 240 mg (Dexedrine)...... 56 (Tiazac)...... 28 dextroamphetamine sulfate cap er 24hr 15 mg diltiazem hcl extended release beads cap er 24hr 300 mg (Dexedrine)...... 56 (Tiazac)...... 28 dextroamphetamine sulfate oral solution 5 mg/5ml diltiazem hcl extended release beads cap er 24hr 360 mg (Procentra)...... 57 (Tiazac)...... 28 dextroamphetamine sulfate tab 5 mg...... 57

94 2018 diltiazem hcl extended release beads cap er 24hr 420 mg doxycycline monohydrate tab 50 mg (Adoxa)...... 3 (Tiazac)...... 28 doxycycline monohydrate tab 75 mg (Adoxa)...... 3 diltiazem hcl tab 90 mg...... 28 doxycycline monohydrate tab 100 mg (Adoxa pak diltiazem hcl tab 30 mg (Cardizem)...... 28 1/100)...... 3 diltiazem hcl tab 60 mg (Cardizem)...... 28 duloxetine hcl enteric coated pellets cap 20 mg (base eq) diltiazem hcl tab 120 mg (Cardizem)...... 28 (Cymbalta)...... 47 diphenhydramine hcl cap 50 mg...... 36 duloxetine hcl enteric coated pellets cap 30 mg (base eq) diphenoxylate w/ atropine tab 2.5-0.025 mg (Lomotil)...... 39 (Cymbalta)...... 47 dipyridamole tab 25 mg...... 74 duloxetine hcl enteric coated pellets cap 60 mg (base eq) dipyridamole tab 50 mg...... 74 (Cymbalta)...... 47 dipyridamole tab 75 mg...... 74 dutasteride cap 0.5 mg (Avodart)...... 44 disopyramide phosphate cap 100 mg (Norpace)...... 33 dutasteride-tamsulosin hcl cap 0.5-0.4 mg (Jalyn)...... 44 disopyramide phosphate cap 150 mg (Norpace)...... 33 dyphylline-guaifenesin liqd 100-100 mg/5ml...... 37 disulfiram tab 250 mg (Antabuse)...... 58 E disulfiram tab 500 mg (Antabuse)...... 58 divalproex sodium cap delayed release sprinkle 125 mg EDURANT – rilpivirine hcl tab 25 mg (base equivalent)..... 5 (Depakote sprinkles)...... 66 efavirenz cap 50 mg (Sustiva)...... 5 divalproex sodium tab delayed release 125 mg efavirenz cap 200 mg (Sustiva)...... 5 (Depakote)...... 66 efavirenz tab 600 mg (Sustiva)...... 5 divalproex sodium tab delayed release 250 mg ELIGARD – leuprolide acetate for subcutaneous inj kit 7.5 (Depakote)...... 66 mg...... 11 divalproex sodium tab delayed release 500 mg ELIGARD – leuprolide acetate (3 month) for (Depakote)...... 66 subcutaneous inj kit 22.5mg...... 11 divalproex sodium tab er 24 hr 250 mg (Depakote er)...... 66 ELIGARD – leuprolide acetate (4 month) for divalproex sodium tab er 24 hr 500 mg (Depakote er)...... 66 subcutaneous inj kit 30 mg...... 11 dofetilide cap 125 mcg (0.125 mg) (Tikosyn)...... 33 ELIGARD – leuprolide acetate (6 month) for dofetilide cap 250 mcg (0.25 mg) (Tikosyn)...... 33 subcutaneous inj kit 45 mg...... 11 dofetilide cap 500 mcg (0.5 mg) (Tikosyn)...... 33 ELIQUIS – apixaban tab 2.5 mg...... 74 donepezil hydrochloride orally disintegrating tab 5 mg..... 58 ELIQUIS – apixaban tab 5 mg...... 74 donepezil hydrochloride orally disintegrating tab 10 ELIQUIS STARTER PACK – apixaban tab 5 mg...... 74 mg...... 58 ELLA – ulipristal acetate tab 30 mg...... 18 donepezil hydrochloride tab 5 mg (Aricept)...... 58 EMSAM – selegiline td patch 24hr 6 mg/24hr...... 47 donepezil hydrochloride tab 10 mg (Aricept)...... 58 EMSAM – selegiline td patch 24hr 9 mg/24hr...... 47 dorzolamide hcl ophth soln 2% (Trusopt)...... 77 EMSAM – selegiline td patch 24hr 12 mg/24hr...... 47 dorzolamide hcl-timolol maleate ophth soln 22.3-6.8 mg/ EMTRIVA – emtricitabine caps 200 mg...... 6 ml (Cosopt)...... 77 EMTRIVA – emtricitabine soln 10 mg/ml...... 6 doxazosin mesylate tab 1 mg (Cardura)...... 34 enalapril maleate & hydrochlorothiazide tab 5-12.5 doxazosin mesylate tab 2 mg (Cardura)...... 34 mg...... 24 doxazosin mesylate tab 4 mg (Cardura)...... 34 enalapril maleate & hydrochlorothiazide tab 10-25 mg doxazosin mesylate tab 8 mg (Cardura)...... 34 (Vaseretic)...... 24 doxepin hcl cap 10 mg...... 46 enalapril maleate tab 2.5 mg (Vasotec)...... 24 doxepin hcl cap 25 mg...... 46 enalapril maleate tab 5 mg (Vasotec)...... 24 doxepin hcl cap 50 mg...... 46 enalapril maleate tab 10 mg (Vasotec)...... 24 doxepin hcl cap 75 mg...... 47 enalapril maleate tab 20 mg (Vasotec)...... 24 doxepin hcl cap 100 mg...... 47 ENBREL – etanercept for subcutaneous inj 25 mg...... 62 doxepin hcl cap 150 mg...... 47 ENBREL – etanercept subcutaneous soln prefilled syringe doxepin hcl conc 10 mg/ml...... 47 25 mg/0.5ml...... 62 doxycycline hyclate cap 50 mg...... 2 ENBREL – etanercept subcutaneous soln prefilled syringe doxycycline hyclate cap 100 mg (Vibramycin)...... 2 50 mg/ml...... 62 doxycycline hyclate tab delayed release 50 mg (Doryx)..... 2 ENBREL SURECLICK – etanercept subcutaneous doxycycline hyclate tab 20 mg...... 3 solution auto-injector 50 mg/ml...... 63 doxycycline hyclate tab 100 mg...... 3 ENGERIX-B – hepatitis b vaccine (recombinant) 10 doxycycline monohydrate cap 50 mg...... 3 mcg/0.5ml...... 9 doxycycline monohydrate cap 100 mg (Monodox)...... 3 ENGERIX-B – hepatitis b vaccine (recombinant) 20 mcg/ doxycycline monohydrate for susp 25 mg/5ml ml...... 9 (Vibramycin)...... 3

95 2018

ENGERIX-B – hepatitis b vaccine (recombinant) susp 10 estazolam tab 1 mg...... 55 mcg/0.5ml...... 9 estazolam tab 2 mg...... 55 ENGERIX-B – hepatitis b vaccine (recombinant) susp 20 estradiol & norethindrone acetate tab 0.5-0.1 mg mcg/ml...... 9 (Activella)...... 17 ENJUVIA – estrogens, conjugated synthetic b tab 0.3 estradiol & norethindrone acetate tab 1-0.5 mg mg...... 17 (Activella)...... 17 ENJUVIA – estrogens, conjugated synthetic b tab 0.45 estradiol tab 0.5 mg (Estrace)...... 17 mg...... 17 estradiol tab 1 mg (Estrace)...... 17 ENJUVIA – estrogens, conjugated synthetic b tab 0.625 estradiol tab 2 mg (Estrace)...... 17 mg...... 17 estradiol td patch twice weekly 0.025 mg/24hr (Vivelle- ENJUVIA – estrogens, conjugated synthetic b tab 0.9 dot)...... 17 mg...... 17 estradiol td patch twice weekly 0.0375 mg/24hr (Vivelle- enoxaparin sodium inj 30 mg/0.3ml (Lovenox)...... 74 dot)...... 17 enoxaparin sodium inj 40 mg/0.4ml (Lovenox)...... 75 estradiol td patch twice weekly 0.05 mg/24hr (Vivelle- enoxaparin sodium inj 60 mg/0.6ml (Lovenox)...... 75 dot)...... 17 enoxaparin sodium inj 80 mg/0.8ml (Lovenox)...... 75 estradiol td patch twice weekly 0.075 mg/24hr (Vivelle- enoxaparin sodium inj 100 mg/ml (Lovenox)...... 75 dot)...... 17 enoxaparin sodium inj 120 mg/0.8ml (Lovenox)...... 75 estradiol td patch twice weekly 0.1 mg/24hr (Vivelle- enoxaparin sodium inj 150 mg/ml (Lovenox)...... 75 dot)...... 17 entacapone tab 200 mg (Comtan)...... 69 estradiol td patch weekly 0.025 mg/24hr (Climara)...... 17 entecavir tab 0.5 mg (Baraclude)...... 4 estradiol td patch weekly 0.05 mg/24hr (Climara)...... 17 entecavir tab 1 mg (Baraclude)...... 4 estradiol td patch weekly 0.06 mg/24hr (Climara)...... 17 ENTRESTO – sacubitril-valsartan tab 24-26 mg...... 28 estradiol td patch weekly 0.075 mg/24hr (Climara)...... 17 ENTRESTO – sacubitril-valsartan tab 49-51 mg...... 28 estradiol td patch weekly 0.1 mg/24hr (Climara)...... 17 ENTRESTO – sacubitril-valsartan tab 97-103 mg...... 28 estradiol td patch weekly 0.0375 mg/24hr (37.5 mcg/24hr) epinastine hcl ophth soln 0.05% (Elestat)...... 78 (Climara)...... 17 EPINEPHRINE – epinephrine solution auto-injector 0.15 estradiol vaginal tab 10 mcg (Vagifem)...... 43 mg/0.3ml (1:2000)...... 36 ESTROPIPATE – estropipate tab 3 mg...... 17 EPINEPHRINE – epinephrine solution auto-injector 0.3 eszopiclone tab 1 mg (Lunesta)...... 55 mg/0.3ml (1:1000)...... 36 eszopiclone tab 2 mg (Lunesta)...... 55 EPOGEN – epoetin alfa inj 2000 unit/ml...... 75 eszopiclone tab 3 mg (Lunesta)...... 55 EPOGEN – epoetin alfa inj 3000 unit/ml...... 75 ethambutol hcl tab 100 mg (Myambutol)...... 3 EPOGEN – epoetin alfa inj 4000 unit/ml...... 75 ethambutol hcl tab 400 mg (Myambutol)...... 3 EPOGEN – epoetin alfa inj 10000 unit/ml...... 75 ethosuximide cap 250 mg (Zarontin)...... 66 EPOGEN – epoetin alfa inj 20000 unit/ml...... 75 ethosuximide soln 250 mg/5ml (Zarontin)...... 66 EQL PRENATAL FORMULA – prenatal vit w/ fe fumarate- ETIDRONATE DISODIUM – etidronate disodium tab 200 fa tab 28-0.8 mg...... 70 mg...... 22 EQUETRO – carbamazepine (antipsychotic) cap er 12hr EVOTAZ – atazanavir sulfate-cobicistat tab 300-150 mg 100 mg...... 50 (base equiv)...... 6 EQUETRO – carbamazepine (antipsychotic) cap er 12hr exemestane tab 25 mg (Aromasin)...... 11 200 mg...... 50 EXJADE – deferasirox tab for oral susp 125 mg...... 84 EQUETRO – carbamazepine (antipsychotic) cap er 12hr EXJADE – deferasirox tab for oral susp 250 mg...... 84 300 mg...... 50 EXJADE – deferasirox tab for oral susp 500 mg...... 84 ergocalciferol cap 50000 unit...... 70 EXTAVIA – interferon beta-1b for inj kit 0.3 mg...... 58 ERIVEDGE – vismodegib cap 150 mg...... 11 F erythromycin ophth oint 5 mg/gm...... 76 erythromycin pads 2%...... 79 famciclovir tab 125 mg (Famvir)...... 5 erythromycin soln 2%...... 79 famotidine for susp 40 mg/5ml (Pepcid)...... 40 ESBRIET – pirfenidone cap 267 mg...... 39 famotidine tab 20 mg (Pepcid)...... 40 escitalopram oxalate soln 5 mg/5ml (base equiv) famotidine tab 40 mg (Pepcid)...... 40 (Lexapro)...... 47 FANAPT – iloperidone tab 1 mg...... 50 escitalopram oxalate tab 5 mg (base equiv) (Lexapro)..... 47 FANAPT – iloperidone tab 2 mg...... 50 escitalopram oxalate tab 10 mg (base equiv) FANAPT – iloperidone tab 4 mg...... 50 (Lexapro)...... 47 FANAPT – iloperidone tab 6 mg...... 50 escitalopram oxalate tab 20 mg (base equiv) FANAPT – iloperidone tab 8 mg...... 50 (Lexapro)...... 47 FANAPT – iloperidone tab 10 mg...... 50

96 2018

FANAPT – iloperidone tab 12 mg...... 50 FLOVENT DISKUS – fluticasone propionate aer pow ba FANAPT TITRATION PACK – iloperidone tab 1 mg & 2 50 mcg/blister...... 37 mg & 4 mg & 6 mg titration pak...... 50 FLOVENT DISKUS – fluticasone propionate aer pow ba FAZACLO – clozapine orally disintegrating tab 150 100 mcg/blister...... 37 mg...... 50 FLOVENT DISKUS – fluticasone propionate aer pow ba FAZACLO – clozapine orally disintegrating tab 200 250 mcg/blister...... 37 mg...... 50 FLOVENT HFA – fluticasone propionate hfa inhal aer 110 fe fumarate-vit c-vit b12-fa cap 460 (151 fe)-60-0.01-1 mcg/act (125/valve)...... 38 mg...... 75 FLOVENT HFA – fluticasone propionate hfa inhal aer 220 fe fumarate w/ b12-vit c-fa-ifc cap 110-0.015-75-0.5-240 mcg/act (250/valve)...... 38 mg...... 75 FLOVENT HFA – fluticasone propionate hfa inhal aero 44 fe fum-iron polysacch complex-fa-b cmplx-c-zn-mn-cu cap mcg/act (50/valve)...... 38 (Tandem plus)...... 75 FLUARIX QUADRIVALENT 2017 – influenza virus vac felbamate susp 600 mg/5ml (Felbatol)...... 66 split quadrivalent susp pref syr 0.5ml...... 10 felbamate tab 400 mg (Felbatol)...... 66 FLUCELVAX QUADRIVALENT 20 – influenza vac tissue- felbamate tab 600 mg (Felbatol)...... 67 cultured subunit quadrivalent im susp...... 10 felodipine tab er 24hr 2.5 mg...... 28 fluconazole for susp 10 mg/ml (Diflucan)...... 4 felodipine tab er 24hr 5 mg...... 28 fluconazole for susp 40 mg/ml (Diflucan)...... 4 felodipine tab er 24hr 10 mg...... 28 fluconazole tab 50 mg (Diflucan)...... 4 fenofibrate micronized cap 43 mg...... 30 fluconazole tab 100 mg (Diflucan)...... 4 fenofibrate micronized cap 67 mg (Lofibra)...... 30 fluconazole tab 150 mg (Diflucan)...... 4 fenofibrate micronized cap 134 mg (Lofibra)...... 30 fluconazole tab 200 mg (Diflucan)...... 4 fenofibrate micronized cap 200 mg (Lofibra)...... 30 flucytosine cap 250 mg (Ancobon)...... 4 fenofibrate tab 54 mg (Lofibra)...... 30 flucytosine cap 500 mg (Ancobon)...... 4 fenofibrate tab 160 mg (Lofibra)...... 30 fludrocortisone acetate tab 0.1 mg...... 15 fenofibrate tab 48 mg (Tricor)...... 30 FLULAVAL QUADRIVALENT 201 – influenza virus vac fenofibrate tab 145 mg (Tricor)...... 30 split quadrivalent susp pref syr 0.5ml...... 10 fentanyl td patch 72hr 12 mcg/hr (Duragesic)...... 60 FLUNISOLIDE – flunisolide nasal soln 25 mcg/act fentanyl td patch 72hr 25 mcg/hr (Duragesic)...... 60 (0.025%)...... 36 fentanyl td patch 72hr 50 mcg/hr (Duragesic)...... 60 fluocinolone acetonide cream 0.01%...... 81 fentanyl td patch 72hr 75 mcg/hr (Duragesic)...... 60 fluocinolone acetonide cream 0.025% (Synalar)...... 81 fentanyl td patch 72hr 100 mcg/hr (Duragesic)...... 60 fluocinolone acetonide oil 0.01% (scalp oil) (Derma- FERRIPROX – deferiprone oral soln 100 mg/ml...... 84 smoothe/fs sca)...... 81 FERRIPROX – deferiprone tab 500 mg...... 84 fluocinolone acetonide oint 0.025% (Synalar)...... 81 ferrous fumarate-fa-b complex-c-zn-mg-mn-cu tab 106-1 fluocinolone acetonide soln 0.01% (Synalar)...... 81 mg...... 75 fluocinonide cream 0.05%...... 81 ferrous fumarate-folic acid tab 324-1 mg...... 75 fluocinonide emulsified base cream 0.05%...... 81 FETZIMA – levomilnacipran hcl cap er 24hr 20 mg (base fluocinonide gel 0.05%...... 81 equivalent)...... 47 fluocinonide oint 0.05%...... 81 FETZIMA – levomilnacipran hcl cap er 24hr 40 mg (base fluocinonide soln 0.05%...... 81 equivalent)...... 47 fluorometholone ophth susp 0.1% (Fml liquifilm)...... 77 FETZIMA – levomilnacipran hcl cap er 24hr 80 mg (base fluorouracil cream 5% (Efudex)...... 83 equivalent)...... 47 fluoxetine hcl cap 10 mg (Prozac)...... 47 FETZIMA – levomilnacipran hcl cap er 24hr 120 mg (base fluoxetine hcl cap 20 mg (Prozac)...... 47 equivalent)...... 47 fluoxetine hcl cap 40 mg (Prozac)...... 47 FETZIMA TITRATION PACK – levomilnacipran hcl cap er fluoxetine hcl solution 20 mg/5ml...... 47 24hr 20 & 40 mg therapy pack...... 47 fluoxetine hcl tab 10 mg...... 47 FINACEA – azelaic acid gel 15%...... 79 fluoxetine hcl tab 20 mg...... 47 finasteride tab 5 mg (Proscar)...... 44 FLUPHENAZINE HCL – fluphenazine hcl elixir 2.5 FIRAZYR – icatibant acetate inj 30 mg/3ml (base mg/5ml...... 50 equivalent)...... 75 FLUPHENAZINE HCL – fluphenazine hcl inj 2.5 mg/ flavoxate hcl tab 100 mg...... 43 ml...... 50 flecainide acetate tab 50 mg...... 33 FLUPHENAZINE HCL – fluphenazine hcl oral conc 5 mg/ flecainide acetate tab 100 mg...... 33 ml...... 50 flecainide acetate tab 150 mg...... 33 fluphenazine hcl tab 1 mg...... 51 fluphenazine hcl tab 2.5 mg...... 51

97 2018 fluphenazine hcl tab 5 mg...... 51 FUZEON – enfuvirtide for inj 90 mg...... 6 fluphenazine hcl tab 10 mg...... 51 G flurandrenolide cream 0.05% (Cordran)...... 81 flurbiprofen sodium ophth soln 0.03% (Ocufen)...... 78 gabapentin cap 100 mg (Neurontin)...... 67 flurbiprofen tab 50 mg...... 63 gabapentin cap 300 mg (Neurontin)...... 67 flurbiprofen tab 100 mg...... 63 gabapentin cap 400 mg (Neurontin)...... 67 flutamide cap 125 mg...... 11 gabapentin oral soln 250 mg/5ml (Neurontin)...... 67 FLUTICASONE PROPIONATE/SA – fluticasone- gabapentin tab 600 mg (Neurontin)...... 67 salmeterol aer powder ba 55-14 mcg/act...... 38 gabapentin tab 800 mg (Neurontin)...... 67 FLUTICASONE PROPIONATE/SA – fluticasone- galantamine hydrobromide cap er 24hr 8 mg (Razadyne salmeterol aer powder ba 113-14 mcg/act...... 38 er)...... 58 FLUTICASONE PROPIONATE/SA – fluticasone- galantamine hydrobromide cap er 24hr 16 mg (Razadyne salmeterol aer powder ba 232-14 mcg/act...... 38 er)...... 58 fluticasone propionate cream 0.05% (Cutivate)...... 81 galantamine hydrobromide cap er 24hr 24 mg (Razadyne fluticasone propionate nasal susp 50 mcg/act...... 36 er)...... 59 fluticasone propionate oint 0.005%...... 82 GALANTAMINE HYDROBROMIDE – galantamine fluvastatin sodium tab er 24 hr 80 mg (Lescol xl)...... 30 hydrobromide oral soln 4 mg/ml...... 58 FLUVIRIN 2017-2018 – influenza vac type a&b surface galantamine hydrobromide tab 4 mg (Razadyne)...... 59 antigen susp pref syr 0.5 ml...... 10 galantamine hydrobromide tab 8 mg (Razadyne)...... 59 FLUVIRIN 2017-2018 – influenza virus vaccine types a & galantamine hydrobromide tab 12 mg (Razadyne)...... 59 b surface antigen im susp...... 10 GATTEX – teduglutide (rdna) for inj kit 5 mg...... 42 fluvoxamine maleate tab 25 mg...... 47 gemfibrozil tab 600 mg (Lopid)...... 30 fluvoxamine maleate tab 50 mg...... 47 gentamicin sulfate oint 0.1%...... 80 fluvoxamine maleate tab 100 mg...... 47 gentamicin sulfate ophth oint 0.3%...... 76 FLUZONE HIGH-DOSE PF 2017 – influenza virus vac gentamicin sulfate ophth soln 0.3%...... 77 split high-dose pf susp pref syr 0.5ml...... 10 GENVOYA – elvitegrav-cobic-emtricitab-tenofov af tab FLUZONE QUADRIVALENT 2017 – influenza virus 150-150-200-10 mg...... 6 vaccine split quadrivalent im inj...... 10 GEODON – ziprasidone mesylate for inj 20 mg (base FLUZONE QUADRIVALENT 2015 – influenza virus vac equivalent)...... 51 split quadrivalent susp pref syr 0.5ml...... 10 GILOTRIF – afatinib dimaleate tab 20 mg (base FLUZONE QUADRIVALENT 2017 – influenza virus vac equivalent)...... 11 split quadrivalent susp pref syr 0.5ml...... 10 GILOTRIF – afatinib dimaleate tab 30 mg (base FOLBEE PLUS CZ – b-complex w/ c-biotin-minerals & equivalent)...... 11 folic acid tab 5 mg...... 71 GILOTRIF – afatinib dimaleate tab 40 mg (base folic acid-pyridoxine-cyanocobalamin tab 2.5-25-2 mg..... 73 equivalent)...... 11 folic acid tab 1 mg...... 75 glatiramer acetate soln prefilled syringe 40 mg/ml folic acid-vitamin b6-vitamin b12 tab 2.2-25-0.5 mg...... 75 (Copaxone)...... 58 folic acid-vitamin b6-vitamin b12 tab 2.5-25-1 mg...... 75 glatiramer acetate soln prefilled syringe 20 mg/ml folic acid-vitamin b6-vitamin b12 tab 2.2-25-1 mg (Folgard (Glatopa)...... 58 rx)...... 75 glimepiride tab 1 mg (Amaryl)...... 19 FORFIVO XL – bupropion hcl tab er 24hr 450 mg...... 47 glimepiride tab 2 mg (Amaryl)...... 19 fosamprenavir calcium tab 700 mg (base equiv) glimepiride tab 4 mg (Amaryl)...... 19 (Lexiva)...... 6 glipizide-metformin hcl tab 2.5-250 mg...... 19 fosinopril sodium & hydrochlorothiazide tab 10-12.5 glipizide-metformin hcl tab 2.5-500 mg...... 19 mg...... 24 glipizide-metformin hcl tab 5-500 mg...... 19 fosinopril sodium & hydrochlorothiazide tab 20-12.5 glipizide tab er 24hr 2.5 mg (Glucotrol xl)...... 19 mg...... 24 glipizide tab er 24hr 5 mg (Glucotrol xl)...... 19 fosinopril sodium tab 10 mg...... 24 glipizide tab er 24hr 10 mg (Glucotrol xl)...... 19 fosinopril sodium tab 20 mg...... 24 glipizide tab 5 mg (Glucotrol)...... 19 fosinopril sodium tab 40 mg...... 24 glipizide tab 10 mg (Glucotrol)...... 19 frovatriptan succinate tab 2.5 mg (base equivalent) GLUCAGON EMERGENCY KIT – glucagon (rdna) for inj (Frova)...... 65 kit 1 mg...... 19 furosemide oral soln 10 mg/ml...... 32 glyburide-metformin tab 1.25-250 mg (Glucovance)...... 19 furosemide tab 20 mg (Lasix)...... 32 glyburide-metformin tab 2.5-500 mg (Glucovance)...... 19 furosemide tab 40 mg (Lasix)...... 32 glyburide-metformin tab 5-500 mg (Glucovance)...... 19 furosemide tab 80 mg (Lasix)...... 32 glyburide micronized tab 1.5 mg (Glynase)...... 19

98 2018 glyburide micronized tab 3 mg (Glynase)...... 19 HUMIRA – adalimumab prefilled syringe kit 40 glyburide micronized tab 6 mg (Glynase)...... 19 mg/0.4ml...... 63 glyburide tab 1.25 mg...... 19 HUMIRA PEDIATRIC CROHNS D – adalimumab prefilled glyburide tab 2.5 mg...... 19 syringe kit 40 mg/0.8ml...... 63 glyburide tab 5 mg...... 19 HUMIRA PEDIATRIC CROHNS D – adalimumab prefilled glycine irrigation soln 1.5%...... 44 syringe kit 80 mg/0.8ml...... 63 glycopyrrolate tab 1 mg (Robinul)...... 40 HUMIRA PEDIATRIC CROHNS D – adalimumab prefilled glycopyrrolate tab 2 mg (Robinul forte)...... 40 syringe kit 80 mg/0.8ml & 40 mg/0.4ml...... 63 GNP PRENATAL – prenatal vit w/ fe fumarate-fa tab HUMIRA PEN – adalimumab pen-injector kit 40 28-0.8 mg...... 71 mg/0.8ml...... 63 GOODSENSE PRENATAL VITAMI – prenatal vit w/ fe HUMIRA PEN – adalimumab pen-injector kit 40 fumarate-fa tab 28-0.8 mg...... 71 mg/0.4ml...... 63 griseofulvin microsize susp 125 mg/5ml...... 4 HUMIRA PEN-CROHNS DISEASE – adalimumab pen- griseofulvin microsize tab 500 mg...... 4 injector kit 40 mg/0.8ml...... 63 griseofulvin ultramicrosize tab 125 mg (Gris-peg)...... 4 HUMIRA PEN-PSORIASIS STAR – adalimumab pen- griseofulvin ultramicrosize tab 250 mg (Gris-peg)...... 4 injector kit 40 mg/0.8ml...... 63 guanfacine hcl tab er 24hr 1 mg (base equiv) (Intuniv).....57 HUMULIN 70/30 – insulin nph isophane & regular human guanfacine hcl tab er 24hr 2 mg (base equiv) (Intuniv).....57 inj 100 unit/ml (70-30)...... 20 guanfacine hcl tab er 24hr 3 mg (base equiv) (Intuniv).....57 HUMULIN 70/30 KWIKPEN – insulin nph & regular susp guanfacine hcl tab er 24hr 4 mg (base equiv) (Intuniv).....57 pen-inj 100 unit/ml (70-30)...... 21 guanfacine hcl tab 1 mg (Tenex)...... 34 HUMULIN N – insulin nph (human) (isophane) inj 100 guanfacine hcl tab 2 mg (Tenex)...... 34 unit/ml...... 20 HUMULIN N KWIKPEN – insulin nph (human) (isophane) H susp pen-injector 100 unit/ml...... 20 halobetasol propionate cream 0.05% (Ultravate)...... 82 HUMULIN R – insulin regular (human) inj 100 unit/ml...... 20 halobetasol propionate oint 0.05% (Ultravate)...... 82 HYCAMTIN – topotecan hcl cap 0.25 mg (base haloperidol lactate oral conc 2 mg/ml...... 51 equiv)...... 11 haloperidol tab 0.5 mg...... 51 HYCAMTIN – topotecan hcl cap 1 mg (base equiv)...... 11 haloperidol tab 1 mg...... 51 hydralazine hcl tab 10 mg...... 34 haloperidol tab 2 mg...... 51 hydralazine hcl tab 25 mg...... 34 haloperidol tab 5 mg...... 51 hydralazine hcl tab 50 mg...... 34 haloperidol tab 10 mg...... 51 hydralazine hcl tab 100 mg...... 34 haloperidol tab 20 mg...... 51 hydrochlorothiazide cap 12.5 mg (Microzide)...... 32 HEXALEN – altretamine cap 50 mg...... 11 hydrochlorothiazide tab 12.5 mg...... 32 HM PRENATAL – prenatal vit w/ fe fumarate-fa tab 28-0.8 hydrochlorothiazide tab 25 mg...... 32 mg...... 71 hydrochlorothiazide tab 50 mg...... 32 homatropine hbr ophth soln 5%...... 78 hydrocodone-acetaminophen soln 7.5-325 mg/15ml H.P. ACTHAR – corticotropin inj gel 80 unit/ml...... 22 (Hycet)...... 60 HUMALOG MIX 75/25 – insulin lispro prot & lispro inj 100 hydrocodone-acetaminophen soln 10-325 mg/15ml unit/ml (75-25)...... 20 (Zamicet)...... 60 HUMALOG MIX 50/50 – insulin lispro protamine & lispro hydrocodone-acetaminophen tab 2.5-325 mg...... 60 inj 100 unit/ml (50-50)...... 20 hydrocodone-acetaminophen tab 7.5-325 mg (Norco)..... 60 HUMALOG MIX 50/50 KWIKPEN – insulin lispro prot & hydrocodone-acetaminophen tab 5-325 mg (Norco)...... 60 lispro sus pen-inj 100 unit/ml (50-50)...... 20 hydrocodone-acetaminophen tab 10-325 mg (Norco)...... 60 HUMALOG MIX 75/25 KWIKPEN – insulin lispro prot & hydrocodone-acetaminophen tab 7.5-300 mg (Xodol)...... 60 lispro sus pen-inj 100 unit/ml (75-25)...... 20 hydrocodone-acetaminophen tab 10-300 mg (Xodol)...... 60 HUMIRA – adalimumab prefilled syringe kit 10 HYDROCODONE BITARTRATE/CH – pseudoeph- mg/0.1ml...... 63 chlorphen w/ hydrocodone soln 60-4-5 mg/5ml...... 36 HUMIRA – adalimumab prefilled syringe kit 10 hydrocodone-ibuprofen tab 7.5-200 mg...... 60 mg/0.2ml...... 63 hydrocodone-ibuprofen tab 5-200 mg (Reprexain)...... 60 HUMIRA – adalimumab prefilled syringe kit 20 hydrocortisone butyrate oint 0.1% (Locoid)...... 82 mg/0.2ml...... 63 hydrocortisone butyrate soln 0.1% (Locoid)...... 82 HUMIRA – adalimumab prefilled syringe kit 20 hydrocortisone cream 1%...... 82 mg/0.4ml...... 63 hydrocortisone cream 2.5%...... 82 HUMIRA – adalimumab prefilled syringe kit 40 hydrocortisone enema 100 mg/60ml (Cortenema)...... 79 mg/0.8ml...... 63 hydrocortisone lotion 2.5%...... 82

99 2018 hydrocortisone lotion 2% (Ala scalp)...... 82 INCRUSE ELLIPTA – umeclidinium br aero powd breath hydrocortisone oint 1%...... 82 act 62.5 mcg/inh (base eq)...... 38 hydrocortisone oint 2.5%...... 82 indapamide tab 1.25 mg...... 32 hydrocortisone rectal cream 2.5% (Anusol-hc)...... 79 indapamide tab 2.5 mg...... 32 hydrocortisone rectal cream 1% (Proctocort)...... 79 indomethacin cap er 75 mg...... 63 hydrocortisone tab 5 mg (Cortef)...... 15 indomethacin cap 25 mg...... 63 hydrocortisone tab 10 mg (Cortef)...... 15 indomethacin cap 50 mg...... 63 hydrocortisone tab 20 mg (Cortef)...... 15 INFED – iron dextran inj 50 mg/ml (elemental iron)...... 75 hydrocortisone valerate cream 0.2%...... 82 INLYTA – axitinib tab 1 mg...... 12 hydrocortisone valerate oint 0.2% (Westcort)...... 82 INLYTA – axitinib tab 5 mg...... 12 hydrocortisone w/ acetic acid otic soln 1-2%...... 78 INTELENCE – etravirine tab 25 mg...... 6 hydromorphone hcl liqd 1 mg/ml (Dilaudid)...... 60 INTELENCE – etravirine tab 100 mg...... 6 hydromorphone hcl tab 2 mg (Dilaudid)...... 60 INTELENCE – etravirine tab 200 mg...... 6 hydromorphone hcl tab 4 mg (Dilaudid)...... 60 INVEGA – paliperidone tab er 24hr 1.5 mg...... 51 hydromorphone hcl tab 8 mg (Dilaudid)...... 60 INVEGA – paliperidone tab er 24hr 3 mg...... 51 hydroxychloroquine sulfate tab 200 mg (Plaquenil)...... 8 INVEGA – paliperidone tab er 24hr 6 mg...... 51 hydroxyurea cap 500 mg (Hydrea)...... 11 INVEGA – paliperidone tab er 24hr 9 mg...... 51 hydroxyzine hcl syrup 10 mg/5ml...... 45 INVEGA SUSTENNA – paliperidone palmitate im hydroxyzine hcl tab 10 mg...... 45 extended-release susp 39 mg/0.25ml...... 51 hydroxyzine hcl tab 25 mg...... 45 INVEGA SUSTENNA – paliperidone palmitate im hydroxyzine hcl tab 50 mg...... 45 extended-release susp 78 mg/0.5ml...... 51 hydroxyzine pamoate cap 25 mg (Vistaril)...... 45 INVEGA SUSTENNA – paliperidone palmitate im hydroxyzine pamoate cap 50 mg (Vistaril)...... 45 extended-release susp 156 mg/ml...... 51 hyoscyamine sulfate elixir 0.125 mg/5ml...... 40 INVEGA SUSTENNA – paliperidone palmitate im hyoscyamine sulfate soln 0.125 mg/ml...... 40 extended-release susp 234 mg/1.5ml...... 51 hyoscyamine sulfate tab disint 0.125 mg (Anaspaz)...... 40 INVEGA SUSTENNA – paliperidone palmitate im extend- hyoscyamine sulfate tab er 12hr 0.375 mg (Levbid)...... 40 release susp 117 mg/0.75ml...... 51 hyoscyamine sulfate tab 0.125 mg (Levsin)...... 40 INVEGA TRINZA – paliperidone palmitate im extend- hyoscyamine sulfate tab sl 0.125 mg (Levsin/sl)...... 40 release susp 273 mg/0.875ml...... 51 INVEGA TRINZA – paliperidone palmitate im extend- I release susp 410 mg/1.315ml...... 51 ibandronate sodium tab 150 mg (base equivalent) INVEGA TRINZA – paliperidone palmitate im extend- (Boniva)...... 22 release susp 546 mg/1.75ml...... 51 IBRANCE – palbociclib cap 75 mg...... 11 INVEGA TRINZA – paliperidone palmitate im extend- IBRANCE – palbociclib cap 100 mg...... 11 release susp 819 mg/2.625ml...... 51 IBRANCE – palbociclib cap 125 mg...... 11 INVIRASE – saquinavir mesylate cap 200 mg...... 6 ibuprofen susp 100 mg/5ml...... 63 INVIRASE – saquinavir mesylate tab 500 mg...... 6 ibuprofen tab 400 mg...... 63 ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml...... 38 ibuprofen tab 600 mg...... 63 ipratropium bromide inhal soln 0.02%...... 38 ibuprofen tab 800 mg...... 63 ipratropium bromide nasal soln 0.03% (21 mcg/spray).....36 ICLUSIG – ponatinib hcl tab 15 mg (base equiv)...... 12 ipratropium bromide nasal soln 0.06% (42 mcg/spray).....36 ICLUSIG – ponatinib hcl tab 45 mg (base equiv)...... 12 IPRIVASK – desirudin for inj 15 mg...... 75 imatinib mesylate tab 100 mg (base equivalent) irbesartan-hydrochlorothiazide tab 150-12.5 mg (Gleevec)...... 12 (Avalide)...... 25 imatinib mesylate tab 400 mg (base equivalent) irbesartan-hydrochlorothiazide tab 300-12.5 mg (Gleevec)...... 12 (Avalide)...... 25 imipramine hcl tab 10 mg (Tofranil)...... 47 irbesartan tab 75 mg (Avapro)...... 25 imipramine hcl tab 25 mg (Tofranil)...... 48 irbesartan tab 150 mg (Avapro)...... 25 imipramine hcl tab 50 mg (Tofranil)...... 48 irbesartan tab 300 mg (Avapro)...... 25 imiquimod cream 5% (Aldara)...... 83 iron combination cap...... 75 IMITREX – sumatriptan nasal spray 5 mg/act...... 65 iron-docusate-b12-folic acid-c-e-cu-biotin tab 150-1 mg IMITREX – sumatriptan nasal spray 20 mg/act...... 65 (Hematron-af)...... 75 IMOVAX RABIES (H.D.C.V.) – rabies virus vaccine, hdc iron-folic acid-vit c-vit b6-vit b12-zinc tab 150-1.25 mg inj...... 9 (Corvite 150)...... 75 INCRELEX – mecasermin inj 40 mg/4ml (10 mg/ml)...... 22 iron polysacch complex-vit b12-fa cap 150-0.025-1 mg...... 75

100 2018 irrigation solution, physiological...... 84 KALYDECO – ivacaftor packet 75 mg...... 39 ISENTRESS HD – raltegravir potassium tab 600 mg KALYDECO – ivacaftor tab 150 mg...... 39 (base equiv)...... 6 ketoconazole cream 2%...... 80 ISENTRESS – raltegravir potassium chew tab 25 mg ketoconazole shampoo 2% (Nizoral)...... 80 (base equiv)...... 6 ketoconazole tab 200 mg...... 4 ISENTRESS – raltegravir potassium chew tab 100 mg ketoprofen cap 50 mg...... 63 (base equiv)...... 6 ketoprofen cap 75 mg...... 63 ISENTRESS – raltegravir potassium packet for susp 100 KETOPROFEN – ketoprofen cap 50 mg...... 63 mg (base equiv)...... 6 KETOPROFEN – ketoprofen cap 75 mg...... 63 ISENTRESS – raltegravir potassium tab 400 mg (base ketorolac tromethamine ophth soln 0.5% (Acular)...... 78 equiv)...... 6 ketorolac tromethamine ophth soln 0.4% (Acular ls)...... 78 isoniazid tab 100 mg...... 3 ketorolac tromethamine tab 10 mg...... 63 isoniazid tab 300 mg...... 3 KETOSTIX – acetone (urine) test strip...... 84 isosorbide mononitrate tab er 24hr 30 mg...... 29 KINERET – anakinra subcutaneous soln prefilled syringe isosorbide mononitrate tab er 24hr 60 mg...... 29 100 mg/0.67ml...... 64 isosorbide mononitrate tab er 24hr 120 mg...... 29 KISQALI FEMARA 600 DOSE – ribociclib tab 200 mg & isosorbide mononitrate tab 10 mg...... 30 letrozole tab 2.5 mg therapy pack...... 12 isosorbide mononitrate tab 20 mg...... 30 KORLYM – mifepristone tab 300 mg...... 19 isotretinoin cap 10 mg...... 79 K-PHOS – potassium phosphate monobasic tab 500 isotretinoin cap 20 mg...... 79 mg...... 73 isotretinoin cap 30 mg...... 79 KP PRENATAL MULTIVITAMINS – prenatal vit w/ fe isotretinoin cap 40 mg...... 79 fumarate-fa tab 28-0.8 mg...... 71 isradipine cap 2.5 mg...... 29 KUVAN – sapropterin dihydrochloride powder packet 100 isradipine cap 5 mg...... 29 mg...... 22 ivermectin tab 3 mg (Stromectol)...... 8 KUVAN – sapropterin dihydrochloride powder packet 500 mg...... 22 J KUVAN – sapropterin dihydrochloride soluble tab 100 JAKAFI – ruxolitinib phosphate tab 5 mg (base mg...... 22 equivalent)...... 12 KYLEENA – levonorgestrel releasing iud 17.5 mcg/day JAKAFI – ruxolitinib phosphate tab 10 mg (base (19.5 mg total)...... 18 equivalent)...... 12 JAKAFI – ruxolitinib phosphate tab 15 mg (base L equivalent)...... 12 labetalol hcl tab 100 mg...... 26 JAKAFI – ruxolitinib phosphate tab 20 mg (base labetalol hcl tab 200 mg...... 26 equivalent)...... 12 labetalol hcl tab 300 mg...... 27 JAKAFI – ruxolitinib phosphate tab 25 mg (base lactated ringer's for irrigation...... 84 equivalent)...... 12 lactulose (encephalopathy) solution 10 gm/15ml...... 42 JULUCA – dolutegravir sodium-rilpivirine hcl tab 50-25 mg lactulose solution 10 gm/15ml...... 39 (base eq)...... 6 LAMICTAL STARTER/NOT TAKI – lamotrigine tab 25 mg JUXTAPID – lomitapide mesylate cap 5 mg (base (42) & 100 mg (7) starter kit...... 67 equiv)...... 31 LAMICTAL STARTER/TAKING C – lamotrigine tab 25 mg JUXTAPID – lomitapide mesylate cap 10 mg (base (84) & 100 mg (14) starter kit...... 67 equiv)...... 31 LAMICTAL STARTER/TAKING V – lamotrigine tab 25 mg JUXTAPID – lomitapide mesylate cap 20 mg (base (35) starter kit...... 67 equiv)...... 31 LAMICTAL XR – lamotrigine tab er 24hr 25 (14) & 50 mg JUXTAPID – lomitapide mesylate cap 30 mg (base (14) & 100 mg(7) kit...... 67 equiv)...... 31 LAMICTAL XR – lamotrigine tab er 24hr 50 (14) & 100 JUXTAPID – lomitapide mesylate cap 40 mg (base mg(14) & 200 mg(7) kit...... 67 equiv)...... 31 LAMICTAL XR – lamotrigine tab er 24hr 25 mg (21) & 50 JUXTAPID – lomitapide mesylate cap 60 mg (base mg (7) titration kit...... 67 equiv)...... 31 lamivudine oral soln 10 mg/ml (Epivir)...... 6 lamivudine tab 150 mg (Epivir)...... 6 K lamivudine tab 300 mg (Epivir)...... 6 KALETRA – lopinavir-ritonavir tab 100-25 mg...... 6 lamivudine tab 100 mg (hbv) (Epivir hbv)...... 4 KALETRA – lopinavir-ritonavir tab 200-50 mg...... 6 lamivudine-zidovudine tab 150-300 mg (Combivir)...... 6 KALYDECO – ivacaftor packet 50 mg...... 39

101 2018 lamotrigine tab chewable dispersible 5 mg (Lamictal levetiracetam tab 250 mg (Keppra)...... 68 chewable di)...... 67 levetiracetam tab 500 mg (Keppra)...... 68 lamotrigine tab chewable dispersible 25 mg (Lamictal levetiracetam tab 750 mg (Keppra)...... 68 chewable di)...... 67 levetiracetam tab 1000 mg (Keppra)...... 68 lamotrigine tab disint 25 (14) & 50 mg (14) & 100 mg (7) levobunolol hcl ophth soln 0.5% (Betagan)...... 77 kit (Lamictal odt)...... 67 levocarnitine oral soln 1 gm/10ml (10%) (Carnitor)...... 22 lamotrigine tab disint 25 mg (21) & 50 mg (7) titration kit levocarnitine tab 330 mg (Carnitor)...... 23 (Lamictal odt)...... 67 levocetirizine dihydrochloride tab 5 mg (Xyzal)...... 36 lamotrigine tab disint 50 mg (42)- 100 mg(14) titration kit levofloxacin oral soln 25 mg/ml...... 3 (Lamictal odt)...... 67 levofloxacin tab 250 mg (Levaquin)...... 3 lamotrigine tab er 24hr 25 mg (Lamictal xr)...... 67 levofloxacin tab 500 mg (Levaquin)...... 3 lamotrigine tab er 24hr 50 mg (Lamictal xr)...... 67 levofloxacin tab 750 mg (Levaquin)...... 3 lamotrigine tab er 24hr 100 mg (Lamictal xr)...... 67 levothyroxine sodium tab 25 mcg (Synthroid)...... 21 lamotrigine tab er 24hr 200 mg (Lamictal xr)...... 67 levothyroxine sodium tab 50 mcg (Synthroid)...... 21 lamotrigine tab er 24hr 250 mg (Lamictal xr)...... 67 levothyroxine sodium tab 75 mcg (Synthroid)...... 21 lamotrigine tab er 24hr 300 mg (Lamictal xr)...... 67 levothyroxine sodium tab 88 mcg (Synthroid)...... 21 lamotrigine tab 25 mg (Lamictal)...... 67 levothyroxine sodium tab 100 mcg (Synthroid)...... 21 lamotrigine tab 100 mg (Lamictal)...... 67 levothyroxine sodium tab 112 mcg (Synthroid)...... 21 lamotrigine tab 150 mg (Lamictal)...... 67 levothyroxine sodium tab 125 mcg (Synthroid)...... 21 lamotrigine tab 200 mg (Lamictal)...... 67 levothyroxine sodium tab 137 mcg (Synthroid)...... 21 LANCETS - BAYER ASCENCIA...... 84 levothyroxine sodium tab 150 mcg (Synthroid)...... 21 lansoprazole cap delayed release 15 mg (Prevacid)...... 40 levothyroxine sodium tab 175 mcg (Synthroid)...... 21 lansoprazole cap delayed release 30 mg (Prevacid)...... 40 levothyroxine sodium tab 200 mcg (Synthroid)...... 21 latanoprost ophth soln 0.005% (Xalatan)...... 77 levothyroxine sodium tab 300 mcg (Synthroid)...... 21 LATUDA – lurasidone hcl tab 20 mg...... 51 LEXIVA – fosamprenavir calcium susp 50 mg/ml (base LATUDA – lurasidone hcl tab 40 mg...... 51 equiv)...... 6 LATUDA – lurasidone hcl tab 60 mg...... 51 lidocaine hcl gel 2%...... 83 LATUDA – lurasidone hcl tab 80 mg...... 51 lidocaine hcl soln 4% (Xylocaine)...... 83 LATUDA – lurasidone hcl tab 120 mg...... 52 lidocaine hcl viscous soln 2%...... 78 leflunomide tab 10 mg (Arava)...... 64 lidocaine patch 5% (Lidoderm)...... 83 leflunomide tab 20 mg (Arava)...... 64 lidocaine-prilocaine cream 2.5-2.5%...... 83 LENVIMA 14 MG DAILY DOSE – lenvatinib cap therapy LILETTA – levonorgestrel releasing iud 18.6 mcg/day (52 pack 10 & 4 mg (14 mg daily dose)...... 12 mg total)...... 18 LENVIMA 18 MG DAILY DOSE – lenvatinib cap therapy linezolid for susp 100 mg/5ml (Zyvox)...... 9 pack 10 & 4 (2) mg (18 mg daily dose)...... 12 linezolid tab 600 mg (Zyvox)...... 9 LENVIMA 24 MG DAILY DOSE – lenvatinib cap therapy liothyronine sodium tab 5 mcg (Cytomel)...... 21 pack 10 (2) & 4 mg (24 mg daily dose)...... 12 liothyronine sodium tab 25 mcg (Cytomel)...... 21 LENVIMA 10 MG DAILY DOSE – lenvatinib cap therapy liothyronine sodium tab 50 mcg (Cytomel)...... 21 pack 10 mg (10 mg daily dose)...... 12 lisinopril & hydrochlorothiazide tab 10-12.5 mg LENVIMA 20 MG DAILY DOSE – lenvatinib cap therapy (Zestoretic)...... 24 pack 10 (2) mg (20 mg daily dose)...... 12 lisinopril & hydrochlorothiazide tab 20-12.5 mg LENVIMA 8 MG DAILY DOSE – lenvatinib cap therapy (Zestoretic)...... 24 pack 4 (2) mg (8 mg daily dose)...... 12 lisinopril & hydrochlorothiazide tab 20-25 mg LETAIRIS – ambrisentan tab 5 mg...... 34 (Zestoretic)...... 24 LETAIRIS – ambrisentan tab 10 mg...... 34 lisinopril tab 5 mg (Prinivil)...... 24 letrozole tab 2.5 mg (Femara)...... 12 lisinopril tab 10 mg (Prinivil)...... 24 LEUCOVORIN CALCIUM – leucovorin calcium tab 10 lisinopril tab 20 mg (Prinivil)...... 24 mg...... 12 lisinopril tab 2.5 mg (Zestril)...... 24 LEUCOVORIN CALCIUM – leucovorin calcium tab 15 lisinopril tab 30 mg (Zestril)...... 24 mg...... 12 lisinopril tab 40 mg (Zestril)...... 24 leucovorin calcium tab 5 mg...... 12 lithium carbonate cap 300 mg...... 52 leucovorin calcium tab 25 mg...... 12 lithium carbonate cap 150 mg (Lithium carbonate)...... 52 LEUKERAN – chlorambucil tab 2 mg...... 12 lithium carbonate cap 600 mg (Lithium carbonate)...... 52 levetiracetam oral soln 100 mg/ml (Keppra)...... 67 lithium carbonate tab er 450 mg...... 52 levetiracetam tab er 24hr 500 mg (Keppra xr)...... 68 lithium carbonate tab er 300 mg (Lithobid)...... 52 levetiracetam tab er 24hr 750 mg (Keppra xr)...... 68 lithium carbonate tab 300 mg...... 52

102 2018

LITHIUM – lithium oral solution 8 meq/5ml...... 52 M LONSURF – trifluridine-tipiracil tab 15-6.14 mg...... 12 LONSURF – trifluridine-tipiracil tab 20-8.19 mg...... 12 MAPROTILINE HCL – maprotiline hcl tab 25 mg...... 48 loperamide hcl cap 2 mg...... 40 MAPROTILINE HCL – maprotiline hcl tab 50 mg...... 48 lopinavir-ritonavir soln 400-100 mg/5ml (80-20 mg/ml) MAPROTILINE HCL – maprotiline hcl tab 75 mg...... 48 (Kaletra)...... 6 MARPLAN – isocarboxazid tab 10 mg...... 48 lorazepam conc 2 mg/ml...... 45 MATULANE – procarbazine hcl cap 50 mg...... 13 lorazepam tab 0.5 mg (Ativan)...... 45 MAVYRET – glecaprevir-pibrentasvir tab 100-40 mg...... 4 lorazepam tab 1 mg (Ativan)...... 45 meclizine hcl tab 12.5 mg...... 41 lorazepam tab 2 mg (Ativan)...... 45 meclizine hcl tab 25 mg...... 41 losartan potassium & hydrochlorothiazide tab 50-12.5 mg medroxyprogesterone acetate tab 2.5 mg (Provera)...... 17 (Hyzaar)...... 25 medroxyprogesterone acetate tab 5 mg (Provera)...... 17 losartan potassium & hydrochlorothiazide tab 100-12.5 medroxyprogesterone acetate tab 10 mg (Provera)...... 17 mg (Hyzaar)...... 25 MEFLOQUINE HCL – mefloquine hcl tab 250 mg...... 8 losartan potassium & hydrochlorothiazide tab 100-25 mg mefloquine hcl tab 250 mg...... 8 (Hyzaar)...... 25 megestrol acetate susp 625 mg/5ml (Megace es)...... 17 losartan potassium tab 25 mg (Cozaar)...... 25 megestrol acetate susp 40 mg/ml (Megace oral)...... 13 losartan potassium tab 50 mg (Cozaar)...... 25 megestrol acetate tab 20 mg...... 13 losartan potassium tab 100 mg (Cozaar)...... 25 megestrol acetate tab 40 mg...... 13 lovastatin tab 10 mg...... 31 MEKINIST – trametinib dimethyl sulfoxide tab 0.5 mg lovastatin tab 20 mg...... 31 (base equivalent)...... 13 lovastatin tab 40 mg (Mevacor)...... 31 MEKINIST – trametinib dimethyl sulfoxide tab 2 mg (base loxapine succinate cap 5 mg...... 52 equivalent)...... 13 loxapine succinate cap 10 mg...... 52 meloxicam tab 7.5 mg (Mobic)...... 64 loxapine succinate cap 25 mg...... 52 meloxicam tab 15 mg (Mobic)...... 64 loxapine succinate cap 50 mg...... 52 memantine hcl oral solution 2 mg/ml (Namenda)...... 59 LUPANETA PACK – leuprolide (1 mon) inj 3.75 mg & memantine hcl tab 5 mg (28) & 10 mg (21) titration pak norethindrone tab 5 mg kit...... 18 (Namenda titration pa)...... 59 LUPANETA PACK – leuprolide (3 mon) inj 11.25 mg & memantine hcl tab 5 mg (Namenda)...... 59 norethindrone tab 5 mg kit...... 18 memantine hcl tab 10 mg (Namenda)...... 59 LUPRON DEPOT (1-MONTH) – leuprolide acetate for inj MEPHYTON – phytonadione tab 5 mg...... 70 kit 3.75 mg...... 12 mercaptopurine tab 50 mg...... 13 LUPRON DEPOT (1-MONTH) – leuprolide acetate for inj MESALAMINE DR – mesalamine tab delayed release 800 kit 7.5 mg...... 12 mg...... 42 LUPRON DEPOT (3-MONTH) – leuprolide acetate (3 mesalamine enema 4 gm...... 42 month) for inj kit 11.25 mg...... 12 mesalamine rectal enema 4 gm & cleanser wipe kit LUPRON DEPOT (3-MONTH) – leuprolide acetate (3 (Rowasa)...... 42 month) for inj kit 22.5 mg...... 13 metformin hcl tab er 24hr 500 mg (Glucophage xr)...... 19 LUPRON DEPOT (4-MONTH) – leuprolide acetate (4 metformin hcl tab er 24hr 750 mg (Glucophage xr)...... 20 month) for inj kit 30 mg...... 13 metformin hcl tab 500 mg (Glucophage)...... 20 LUPRON DEPOT (6-MONTH) – leuprolide acetate (6 metformin hcl tab 850 mg (Glucophage)...... 20 month) for inj kit 45 mg...... 13 metformin hcl tab 1000 mg (Glucophage)...... 20 LUPRON DEPOT-PED (1-MONTH – leuprolide acetate methadone hcl conc 10 mg/ml (Methadose)...... 60 for inj pediatric kit 7.5 mg...... 18,23 methadone hcl soln 5 mg/5ml (Methadone hcl)...... 60 LUPRON DEPOT-PED (1-MONTH – leuprolide acetate methadone hcl soln 10 mg/5ml (Methadone hcl)...... 60 for inj pediatric kit 11.25 mg...... 18,23 methadone hcl tab for oral susp 40 mg...... 60 LUPRON DEPOT-PED (1-MONTH – leuprolide acetate methadone hcl tab 5 mg (Dolophine)...... 60 for inj pediatric kit 15 mg...... 18,23 methadone hcl tab 10 mg (Dolophine)...... 61 LUPRON DEPOT-PED (3-MONTH – leuprolide acetate (3 methimazole tab 5 mg (Tapazole)...... 21 month) for inj pediatric kit 11.25 mg...... 18 methimazole tab 10 mg (Tapazole)...... 21 LUPRON DEPOT-PED (3-MONTH – leuprolide acetate (3 methocarbamol tab 750 mg (Robaxin-750)...... 70 month) for inj pediatric kit 30 mg...... 18 methocarbamol tab 500 mg (Robaxin)...... 70 LYNPARZA – olaparib cap 50 mg...... 13 methotrexate sodium tab 2.5 mg (base equiv)...... 13 LYNPARZA – olaparib tab 100 mg...... 13 methoxsalen rapid cap 10 mg (Oxsoralen ultra)...... 83 LYNPARZA – olaparib tab 150 mg...... 13 methscopolamine bromide tab 2.5 mg (Pamine)...... 40 LYSODREN – mitotane tab 500 mg...... 13 methyldopa tab 250 mg...... 34

103 2018

methyldopa tab 500 mg...... 34 metoprolol succinate tab er 24hr 25 mg (tartrate equiv) METHYLENE BLUE – methylene blue inj 1%...... 84 (Toprol xl)...... 27 methylergonovine maleate tab 0.2 mg...... 23 metoprolol succinate tab er 24hr 50 mg (tartrate equiv) methylphenidate hcl cap er 24hr 20 mg (la) (Ritalin (Toprol xl)...... 27 la)...... 57 metoprolol succinate tab er 24hr 100 mg (tartrate equiv) methylphenidate hcl cap er 24hr 30 mg (la) (Ritalin (Toprol xl)...... 27 la)...... 57 metoprolol succinate tab er 24hr 200 mg (tartrate equiv) methylphenidate hcl cap er 24hr 40 mg (la) (Ritalin (Toprol xl)...... 27 la)...... 57 metoprolol tartrate tab 25 mg...... 27 methylphenidate hcl cap er 10 mg (cd)...... 57 metoprolol tartrate tab 50 mg (Lopressor)...... 27 methylphenidate hcl cap er 20 mg (cd)...... 57 metoprolol tartrate tab 100 mg (Lopressor)...... 27 methylphenidate hcl cap er 30 mg (cd)...... 57 metronidazole cap 375 mg (Flagyl)...... 9 methylphenidate hcl cap er 40 mg (cd)...... 57 metronidazole cream 0.75% (Metrocream)...... 79 methylphenidate hcl cap er 50 mg (cd)...... 57 metronidazole gel 0.75%...... 79 methylphenidate hcl cap er 60 mg (cd)...... 57 metronidazole tab 250 mg (Flagyl)...... 9 methylphenidate hcl chew tab 2.5 mg...... 57 metronidazole tab 500 mg (Flagyl)...... 9 methylphenidate hcl chew tab 5 mg...... 57 metronidazole vaginal gel 0.75% (Metrogel-vaginal)...... 43 methylphenidate hcl chew tab 10 mg...... 57 midodrine hcl tab 2.5 mg...... 34 METHYLPHENIDATE HCL ER – methylphenidate hcl tab midodrine hcl tab 5 mg...... 34 er 24hr 18 mg...... 57 midodrine hcl tab 10 mg...... 34 METHYLPHENIDATE HCL ER – methylphenidate hcl tab miglitol tab 25 mg (Glyset)...... 20 er 24hr 27 mg...... 57 miglitol tab 50 mg (Glyset)...... 20 METHYLPHENIDATE HCL ER – methylphenidate hcl tab miglitol tab 100 mg (Glyset)...... 20 er 24hr 36 mg...... 57 miglustat cap 100 mg (Zavesca)...... 75 METHYLPHENIDATE HCL ER – methylphenidate hcl tab minocycline hcl cap 50 mg (Minocin)...... 3 er 24hr 54 mg...... 57 minocycline hcl cap 75 mg (Minocin)...... 3 methylphenidate hcl soln 5 mg/5ml (Methylin)...... 57 minocycline hcl cap 100 mg (Minocin)...... 3 methylphenidate hcl soln 10 mg/5ml (Methylin)...... 57 minoxidil tab 2.5 mg...... 34 methylphenidate hcl tab er 10 mg...... 57 minoxidil tab 10 mg...... 34 methylphenidate hcl tab er 20 mg...... 57 MIRENA – levonorgestrel releasing iud 20 mcg/day (52 methylphenidate hcl tab 5 mg (Ritalin)...... 57 mg total)...... 18 methylphenidate hcl tab 10 mg (Ritalin)...... 57 mirtazapine tab 15 mg (Remeron)...... 48 methylphenidate hcl tab 20 mg (Ritalin)...... 57 mirtazapine tab 30 mg (Remeron)...... 48 methylprednisolone tab 4 mg (Medrol)...... 15 mirtazapine tab 45 mg (Remeron)...... 48 methylprednisolone tab 8 mg (Medrol)...... 16 misoprostol tab 100 mcg (Cytotec)...... 40 methylprednisolone tab 16 mg (Medrol)...... 16 misoprostol tab 200 mcg (Cytotec)...... 40 methylprednisolone tab 32 mg (Medrol)...... 16 modafinil tab 100 mg (Provigil)...... 57 methylprednisolone tab therapy pack 4 mg (21) (Medrol modafinil tab 200 mg (Provigil)...... 57 dosepak)...... 15 moexipril hcl tab 7.5 mg...... 24 METIPRANOLOL – metipranolol ophth soln 0.3%...... 77 moexipril hcl tab 15 mg...... 24 metoclopramide hcl soln 5 mg/5ml (10 mg/10ml) (base moexipril-hydrochlorothiazide tab 7.5-12.5 mg...... 24 equiv)...... 42 moexipril-hydrochlorothiazide tab 15-12.5 mg...... 24 metoclopramide hcl tab 5 mg (base equivalent) moexipril-hydrochlorothiazide tab 15-25 mg...... 25 (Reglan)...... 42 MOLINDONE HYDROCHLORIDE – molindone hcl tab 5 metoclopramide hcl tab 10 mg (base equivalent) mg...... 52 (Reglan)...... 42 MOLINDONE HYDROCHLORIDE – molindone hcl tab 10 metolazone tab 2.5 mg...... 32 mg...... 52 metolazone tab 5 mg...... 32 MOLINDONE HYDROCHLORIDE – molindone hcl tab 25 metolazone tab 10 mg...... 32 mg...... 52 METOPROLOL/HYDROCHLOROTHI – metoprolol & mometasone furoate cream 0.1% (Elocon)...... 82 hydrochlorothiazide tab 100-50 mg...... 27 mometasone furoate oint 0.1% (Elocon)...... 82 metoprolol & hydrochlorothiazide tab 100-50 mg...... 27 mometasone furoate solution 0.1% (lotion) (Elocon)...... 82 metoprolol & hydrochlorothiazide tab 50-25 mg montelukast sodium chew tab 4 mg (base equiv) (Lopressor hct)...... 27 (Singulair)...... 38 metoprolol & hydrochlorothiazide tab 100-25 mg montelukast sodium chew tab 5 mg (base equiv) (Lopressor hct)...... 27 (Singulair)...... 38

104 2018 montelukast sodium oral granules packet 4 mg (base naproxen sodium tab er 24hr 375 mg (base equiv) equiv) (Singulair)...... 38 (Naprelan)...... 64 montelukast sodium tab 10 mg (base equiv) naproxen sodium tab 275 mg...... 64 (Singulair)...... 38 naproxen sodium tab 550 mg (Anaprox ds)...... 64 morphine sulfate cap er 24hr 100 mg (Kadian)...... 61 naproxen susp 125 mg/5ml (Naprosyn)...... 64 MORPHINE SULFATE ER – morphine sulfate beads cap naproxen tab ec 375 mg (Ec-naprosyn)...... 64 er 24hr 60 mg...... 61 naproxen tab ec 500 mg (Ec-naprosyn)...... 64 MORPHINE SULFATE ER – morphine sulfate beads cap naproxen tab 250 mg...... 64 er 24hr 75 mg...... 61 naproxen tab 375 mg...... 64 MORPHINE SULFATE ER – morphine sulfate beads cap naproxen tab 500 mg (Naprosyn)...... 64 er 24hr 120 mg...... 61 NARCAN – naloxone hcl nasal spray 4 mg/0.1ml...... 85 MORPHINE SULFATE – morphine sulfate suppos 5 NATACYN – natamycin ophth susp 5%...... 77 mg...... 61 nateglinide tab 60 mg (Starlix)...... 20 MORPHINE SULFATE – morphine sulfate suppos 10 nateglinide tab 120 mg (Starlix)...... 20 mg...... 61 NATRAPEL 12-HOUR TICK & I – picaridin aerosol...... 83 MORPHINE SULFATE – morphine sulfate suppos 20 NAT-RUL PRENATAL VITAMINS – prenatal vit w/ fe mg...... 61 fumarate-fa tab 28-0.8 mg...... 71 MORPHINE SULFATE – morphine sulfate suppos 30 NEFAZODONE HCL – nefazodone hcl tab 100 mg...... 48 mg...... 61 NEFAZODONE HCL – nefazodone hcl tab 150 mg...... 48 MORPHINE SULFATE – morphine sulfate tab 15 mg...... 61 NEFAZODONE HCL – nefazodone hcl tab 200 mg...... 48 MORPHINE SULFATE – morphine sulfate tab 30 mg...... 61 neomycin-bacitrac zn-polymyx 5(3.5)mg-400unt-10000unt morphine sulfate oral soln 10 mg/5ml...... 61 op oin...... 77 morphine sulfate oral soln 20 mg/5ml...... 61 neomycin-polymy-gramicid op sol 1.75-10000-0.025mg- morphine sulfate oral soln 100 mg/5ml (20 mg/ml)...... 61 unt-mg/ml (Neosporin)...... 77 morphine sulfate tab er 15 mg (Ms contin)...... 61 neomycin-polymyxin b gu irrigation soln (Neosporin gu morphine sulfate tab er 30 mg (Ms contin)...... 61 irrigan)...... 44 morphine sulfate tab er 60 mg (Ms contin)...... 61 neomycin-polymyxin-dexamethasone ophth oint 0.1% morphine sulfate tab er 100 mg (Ms contin)...... 61 (Maxitrol)...... 77 morphine sulfate tab er 200 mg (Ms contin)...... 61 neomycin-polymyxin-dexamethasone ophth susp 0.1% multiple vitamins w/ minerals & fa tab 1.25 mg (Maxitrol)...... 77 (Corvite)...... 71 neomycin-polymyxin-hc otic soln 1%...... 78 multiple vitamins w/ minerals cap...... 71 neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000 unit/ multiple vitamins w/ minerals tab (Strovite forte)...... 71 ml-1%...... 78 MULTI PRENATAL – prenatal vit w/ fe fumarate-fa tab neomycin sulfate tab 500 mg...... 3 27-0.8 mg...... 71 NEULASTA ONPRO KIT – pegfilgrastim soln prefilled mupirocin oint 2%...... 80 syringe kit 6 mg/0.6ml...... 75 M-VIT – prenatal vit w/ fe fumarate-fa tab 27-1 mg...... 71 NEULASTA – pegfilgrastim soln prefilled syringe 6 mycophenolate mofetil cap 250 mg (Cellcept)...... 85 mg/0.6ml...... 75 mycophenolate mofetil for oral susp 200 mg/ml nevirapine tab er 24hr 100 mg (Viramune xr)...... 6 (Cellcept)...... 85 nevirapine tab er 24hr 400 mg (Viramune xr)...... 6 mycophenolate mofetil tab 500 mg (Cellcept)...... 85 nevirapine tab 200 mg (Viramune)...... 6 mycophenolate sodium tab dr 180 mg (mycophenolic acid NEXAVAR – sorafenib tosylate tab 200 mg (base equiv) (Myfortic)...... 85 equivalent)...... 13 mycophenolate sodium tab dr 360 mg (mycophenolic acid NEXAVIR – liver derivative complex inj 25.5 mg/ml...... 85 equiv) (Myfortic)...... 85 NEXPLANON – etonogestrel subdermal implant 68 MYLERAN – busulfan tab 2 mg...... 13 mg...... 18 nicardipine hcl cap 20 mg...... 29 N NICOTROL INHALER – nicotine inhaler system 10 mg (4 nabumetone tab 500 mg...... 64 mg delivered)...... 59 nabumetone tab 750 mg...... 64 NICOTROL NS – nicotine nasal spray 10 mg/ml (0.5 mg/ nadolol tab 20 mg (Corgard)...... 27 spray)...... 59 nadolol tab 40 mg (Corgard)...... 27 nifedipine cap 20 mg...... 29 nadolol tab 80 mg (Corgard)...... 27 nifedipine cap 10 mg (Procardia)...... 29 naftifine hcl cream 2% (Naftin)...... 80 nifedipine tab er 24hr 30 mg (Adalat cc)...... 29 naltrexone hcl tab 50 mg...... 85 nifedipine tab er 24hr 60 mg (Adalat cc)...... 29 nifedipine tab er 24hr 90 mg (Adalat cc)...... 29

105 2018 nifedipine tab er 24hr osmotic release 30 mg (Procardia NOVOLIN N RELION – insulin nph (human) (isophane) inj xl)...... 29 100 unit/ml...... 21 nifedipine tab er 24hr osmotic release 60 mg (Procardia NOVOLIN R – insulin regular (human) inj 100 unit/ml...... 20 xl)...... 29 NOVOLIN R RELION – insulin regular (human) inj 100 nifedipine tab er 24hr osmotic release 90 mg (Procardia unit/ml...... 20 xl)...... 29 NOVOLOG MIX 70/30 – insulin aspart prot & aspart nimodipine cap 30 mg...... 29 (human) inj 100 unit/ml (70-30)...... 21 NINLARO – ixazomib citrate cap 2.3 mg (base NOVOLOG MIX 70/30 PREFILL – insulin aspart prot & equivalent)...... 13 aspart sus pen-inj 100 unit/ml (70-30)...... 21 NINLARO – ixazomib citrate cap 3 mg (base NOXAFIL – posaconazole susp 40 mg/ml...... 4 equivalent)...... 13 NOXAFIL – posaconazole tab delayed release 100 mg..... 4 NINLARO – ixazomib citrate cap 4 mg (base NUCALA – mepolizumab for inj 100 mg...... 38 equivalent)...... 13 NUVARING – etonogestrel-ethinyl estradiol va ring nitrofurantoin macrocrystalline cap 25 mg 0.120-0.015 mg/24hr...... 18 (Macrodantin)...... 43 nystatin cream 100000 unit/gm...... 80 nitrofurantoin macrocrystalline cap 50 mg nystatin oint 100000 unit/gm...... 80 (Macrodantin)...... 43 nystatin oral powder...... 4 nitrofurantoin macrocrystalline cap 100 mg nystatin susp 100000 unit/ml...... 78 (Macrodantin)...... 43 nystatin tab 500000 unit...... 4 nitrofurantoin monohydrate macrocrystalline cap 100 mg O (Macrobid)...... 43 nitroglycerin cap er 2.5 mg...... 30 O-CAL FA – prenatal vit w/ fe fumarate-fa tab 27-1 nitroglycerin cap er 6.5 mg...... 30 mg...... 71 nitroglycerin cap er 9 mg...... 30 ODEFSEY – emtricitabine-rilpivirine-tenofovir af tab nitroglycerin sl tab 0.3 mg (Nitrostat)...... 30 200-25-25 mg...... 6 nitroglycerin sl tab 0.4 mg (Nitrostat)...... 30 OFEV – nintedanib esylate cap 100 mg (base nitroglycerin sl tab 0.6 mg (Nitrostat)...... 30 equivalent)...... 39 nitroglycerin td patch 24hr 0.1 mg/hr (Nitro-dur)...... 30 OFEV – nintedanib esylate cap 150 mg (base nitroglycerin td patch 24hr 0.2 mg/hr (Nitro-dur)...... 30 equivalent)...... 39 nitroglycerin td patch 24hr 0.4 mg/hr (Nitro-dur)...... 30 OFF ACTIVE – diethyltoluamide (deet) aerosol...... 83 nitroglycerin td patch 24hr 0.6 mg/hr (Nitro-dur)...... 30 OFF DEEP WOODS – diethyltoluamide (deet) NITYR – nitisinone tab 2 mg...... 23 aerosol...... 83 NITYR – nitisinone tab 5 mg...... 23 OFF DEEP WOODS DRY – diethyltoluamide (deet) NITYR – nitisinone tab 10 mg...... 23 aerosol...... 83 NIVA-PLUS – prenatal vit w/ fe fumarate-fa tab 27-1 OFF SMOOTH & DRY – diethyltoluamide (deet) mg...... 71 aerosol...... 83 nizatidine cap 150 mg...... 40 ofloxacin ophth soln 0.3% (Ocuflox)...... 77 nizatidine cap 300 mg...... 40 ofloxacin otic soln 0.3% (Floxin otic)...... 78 norethindrone acetate-ethinyl estradiol tab 1 mg-5 olanzapine orally disintegrating tab 5 mg (Zyprexa mcg...... 17 zydis)...... 52 norethindrone acetate-ethinyl estradiol tab 0.5 mg-2.5 olanzapine orally disintegrating tab 10 mg (Zyprexa mcg (Femhrt low dose)...... 17 zydis)...... 52 norethindrone acetate tab 5 mg (Aygestin)...... 17 olanzapine orally disintegrating tab 15 mg (Zyprexa nortriptyline hcl cap 10 mg (Pamelor)...... 48 zydis)...... 52 nortriptyline hcl cap 25 mg (Pamelor)...... 48 olanzapine orally disintegrating tab 20 mg (Zyprexa nortriptyline hcl cap 50 mg (Pamelor)...... 48 zydis)...... 52 nortriptyline hcl cap 75 mg (Pamelor)...... 48 olanzapine tab 2.5 mg (Zyprexa)...... 52 NORVIR – ritonavir cap 100 mg...... 6 olanzapine tab 5 mg (Zyprexa)...... 52 NORVIR – ritonavir oral soln 80 mg/ml...... 6 olanzapine tab 7.5 mg (Zyprexa)...... 52 NOVOLIN 70/30 – insulin nph isophane & regular human olanzapine tab 10 mg (Zyprexa)...... 52 inj 100 unit/ml (70-30)...... 21 olanzapine tab 15 mg (Zyprexa)...... 52 NOVOLIN 70/30 RELION – insulin nph isophane & olanzapine tab 20 mg (Zyprexa)...... 52 regular human inj 100 unit/ml (70-30)...... 21 olmesartan medoxomil-hydrochlorothiazide tab 20-12.5 NOVOLIN N – insulin nph (human) (isophane) inj 100 unit/ mg (Benicar hct)...... 26 ml...... 21 olmesartan medoxomil-hydrochlorothiazide tab 40-12.5 mg (Benicar hct)...... 26

106 2018 olmesartan medoxomil-hydrochlorothiazide tab 40-25 mg oxycodone w/ acetaminophen tab 7.5-325 mg (Benicar hct)...... 26 (Percocet)...... 61 olmesartan medoxomil tab 5 mg (Benicar)...... 25 oxycodone w/ acetaminophen tab 10-325 mg olmesartan medoxomil tab 20 mg (Benicar)...... 25 (Percocet)...... 61 olmesartan medoxomil tab 40 mg (Benicar)...... 25 oxymorphone hcl tab er 12hr 5 mg...... 62 olopatadine hcl ophth soln 0.1% (base equivalent) oxymorphone hcl tab er 12hr 7.5 mg...... 62 (Patanol)...... 78 oxymorphone hcl tab er 12hr 10 mg...... 62 omeprazole cap delayed release 10 mg (Prilosec)...... 40 oxymorphone hcl tab er 12hr 15 mg...... 62 omeprazole cap delayed release 20 mg (Prilosec)...... 40 oxymorphone hcl tab er 12hr 20 mg...... 62 omeprazole cap delayed release 40 mg (Prilosec)...... 40 oxymorphone hcl tab er 12hr 30 mg...... 62 OMNITROPE – somatropin for inj 5.8 mg...... 22 oxymorphone hcl tab er 12hr 40 mg...... 62 ondansetron hcl oral soln 4 mg/5ml (Zofran)...... 41 oxymorphone hcl tab 5 mg (Opana)...... 62 ondansetron hcl tab 24 mg...... 41 oxymorphone hcl tab 10 mg (Opana)...... 62 ondansetron hcl tab 4 mg (Zofran)...... 41 P ondansetron hcl tab 8 mg (Zofran)...... 41 ondansetron orally disintegrating tab 4 mg (Zofran paliperidone tab er 24hr 1.5 mg (Invega)...... 52 odt)...... 41 paliperidone tab er 24hr 3 mg (Invega)...... 52 ondansetron orally disintegrating tab 8 mg (Zofran paliperidone tab er 24hr 6 mg (Invega)...... 53 odt)...... 41 paliperidone tab er 24hr 9 mg (Invega)...... 53 ORENCIA – abatacept subcutaneous soln prefilled pantoprazole sodium ec tab 20 mg (base equiv) syringe 125 mg/ml...... 64 (Protonix)...... 40 ORENCIA CLICKJECT – abatacept subcutaneous soln pantoprazole sodium ec tab 40 mg (base equiv) auto-injector 125 mg/ml...... 64 (Protonix)...... 40 ORKAMBI – lumacaftor-ivacaftor tab 100-125 mg...... 39 PARAGARD INTRAUTERINE COP – copper iud...... 18 ORKAMBI – lumacaftor-ivacaftor tab 200-125 mg...... 39 paromomycin sulfate cap 250 mg...... 3 orphenadrine citrate tab er 12hr 100 mg...... 70 paroxetine hcl tab 10 mg (Paxil)...... 48 oxcarbazepine susp 300 mg/5ml (60 mg/ml) paroxetine hcl tab 20 mg (Paxil)...... 48 (Trileptal)...... 68 paroxetine hcl tab 30 mg (Paxil)...... 48 oxcarbazepine tab 150 mg (Trileptal)...... 68 paroxetine hcl tab 40 mg (Paxil)...... 48 oxcarbazepine tab 300 mg (Trileptal)...... 68 PAXIL – paroxetine hcl oral susp 10 mg/5ml (base oxcarbazepine tab 600 mg (Trileptal)...... 68 equiv)...... 48 oxiconazole nitrate cream 1% (Oxistat)...... 80 pediatric multiple vitamin w/ minerals & c drops 45 mg/ OXTELLAR XR – oxcarbazepine tab er 24hr 150 mg...... 68 ml...... 71 OXTELLAR XR – oxcarbazepine tab er 24hr 300 mg...... 68 pediatric vitamins acd w/ fluoride soln 0.25 mg/ml...... 71 OXTELLAR XR – oxcarbazepine tab er 24hr 600 mg...... 68 peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240 gm oxybutynin chloride syrup 5 mg/5ml...... 43 (Colyte-flavor packs)...... 39 oxybutynin chloride tab er 24hr 5 mg (Ditropan xl)...... 43 peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm oxybutynin chloride tab er 24hr 10 mg (Ditropan xl)...... 43 (Golytely)...... 39 oxybutynin chloride tab er 24hr 15 mg (Ditropan xl)...... 43 peg 3350-kcl-sod bicarb-nacl for soln 420 gm (Nulytely/ oxybutynin chloride tab 5 mg...... 43 flavor pack)...... 39 OXYCODONE/ACETAMINOPHEN – oxycodone w/ penicillin v potassium for soln 125 mg/5ml...... 1 acetaminophen soln 5-325 mg/5ml...... 61 penicillin v potassium for soln 250 mg/5ml...... 1 OXYCODONE/IBUPROFEN – oxycodone-ibuprofen tab penicillin v potassium tab 250 mg...... 1 5-400 mg...... 62 penicillin v potassium tab 500 mg...... 1 oxycodone-aspirin tab 4.8355-325 mg...... 61 PENTASA – mesalamine cap er 250 mg...... 42 oxycodone hcl conc 100 mg/5ml (20 mg/ml)...... 61 PENTASA – mesalamine cap er 500 mg...... 43 oxycodone hcl soln 5 mg/5ml...... 61 pentoxifylline tab er 400 mg...... 75 oxycodone hcl tab 10 mg...... 61 perindopril erbumine tab 2 mg...... 25 oxycodone hcl tab 20 mg...... 61 perindopril erbumine tab 4 mg (Aceon)...... 25 oxycodone hcl tab 5 mg (Roxicodone)...... 61 perindopril erbumine tab 8 mg (Aceon)...... 25 oxycodone hcl tab 15 mg (Roxicodone)...... 61 permethrin cream 5% (Elimite)...... 83 oxycodone hcl tab 30 mg (Roxicodone)...... 61 PERPHENAZINE/AMITRIPTYLIN – perphenazine- oxycodone w/ acetaminophen tab 2.5-325 mg amitriptyline tab 2-10 mg...... 59 (Percocet)...... 61 PERPHENAZINE/AMITRIPTYLIN – perphenazine- oxycodone w/ acetaminophen tab 5-325 mg amitriptyline tab 2-25 mg...... 59 (Percocet)...... 61

107 2018

PERPHENAZINE/AMITRIPTYLIN – perphenazine- podofilox soln 0.5% (Condylox)...... 83 amitriptyline tab 4-10 mg...... 59 polyethylene glycol 3350 oral packet...... 39 PERPHENAZINE/AMITRIPTYLIN – perphenazine- polyethylene glycol 3350 oral powder...... 39 amitriptyline tab 4-25 mg...... 59 polymyxin b-trimethoprim ophth soln 10000 unit/ml-0.1% PERPHENAZINE/AMITRIPTYLIN – perphenazine- (Polytrim)...... 77 amitriptyline tab 4-50 mg...... 59 POLY-VI-FLOR – ped multiple vit w/ fluoride biphasic perphenazine tab 2 mg...... 53 chew tab 0.25 mg...... 71 perphenazine tab 4 mg...... 53 POLY-VI-FLOR – ped multiple vit w/ fluoride biphasic perphenazine tab 8 mg...... 53 chew tab 0.5 mg...... 71 perphenazine tab 16 mg...... 53 POLY-VI-FLOR – ped multiple vit w/ fluoride biphasic PEXEVA – paroxetine mesylate tab 10 mg (base chew tab 1 mg...... 71 equiv)...... 48 POMALYST – pomalidomide cap 1 mg...... 13 PEXEVA – paroxetine mesylate tab 20 mg (base POMALYST – pomalidomide cap 2 mg...... 13 equiv)...... 48 POMALYST – pomalidomide cap 3 mg...... 13 PEXEVA – paroxetine mesylate tab 30 mg (base POMALYST – pomalidomide cap 4 mg...... 13 equiv)...... 48 pot & sod citrates w/ cit ac soln 550-500-334 mg/5ml...... 44 PEXEVA – paroxetine mesylate tab 40 mg (base potassium bicarbonate effer tab 25 meq...... 73 equiv)...... 48 potassium chloride cap er 8 meq (Micro-k)...... 73 phenazopyridine hcl tab 100 mg (Pyridium)...... 44 potassium chloride cap er 10 meq (Micro-k)...... 73 phenazopyridine hcl tab 200 mg (Pyridium)...... 44 POTASSIUM CHLORIDE ER – potassium chloride tab er phenobarbital elixir 20 mg/5ml...... 55 8 meq (600 mg)...... 73 PHENOBARBITAL – phenobarbital tab 15 mg...... 55 potassium chloride microencapsulated crys er tab 10 PHENOBARBITAL – phenobarbital tab 30 mg...... 55 meq...... 73 PHENOBARBITAL – phenobarbital tab 60 mg...... 55 potassium chloride microencapsulated crys er tab 20 PHENOBARBITAL – phenobarbital tab 100 mg...... 55 meq...... 73 phenobarbital tab 16.2 mg...... 55 potassium chloride oral soln 10% (20 meq/15ml)...... 73 phenobarbital tab 32.4 mg...... 55 potassium chloride oral soln 20% (40 meq/15ml)...... 73 phenobarbital tab 64.8 mg...... 55 potassium chloride tab er 10 meq (K-tab)...... 73 phenobarbital tab 97.2 mg...... 55 potassium chloride tab er 8 meq (600 mg)...... 73 phenoxybenzamine hcl cap 10 mg (Dibenzyline)...... 35 POTASSIUM CITRATE/SODIUM – pot & sod citrates w/ phenylephrine hcl ophth soln 2.5%...... 78 cit ac soln 550-500-334 mg/5ml...... 44 phenylephrine w/ dm-gg liqd 10-15-300 mg/5ml...... 36 potassium citrate & citric acid powder pack 3300-1002 phenylephrine w/ dm-gg liqd 2.5-5-50 mg/ml...... 36 mg...... 44 phenylephrine w/ dm-gg liqd 2.5-7.5-88 mg/ml...... 36 potassium citrate & citric acid soln 1100-334 mg/5ml...... 44 phenytoin chew tab 50 mg (Dilantin infatabs)...... 68 potassium citrate tab er 5 meq (540 mg) (Urocit-k 5)...... 44 phenytoin sodium extended cap 100 mg (Dilantin)...... 68 potassium citrate tab er 10 meq (1080 mg) (Urocit-k phenytoin sodium extended cap 200 mg (Phenytek)...... 68 10)...... 44 phenytoin sodium extended cap 300 mg (Phenytek)...... 68 potassium citrate tab er 15 meq (1620 mg) (Urocit-k phenytoin susp 125 mg/5ml (Dilantin-125)...... 68 15)...... 44 pilocarpine hcl ophth soln 1% (Isopto carpine)...... 77 pot bicarbonate & chloride effer tab 25 meq...... 73 pilocarpine hcl ophth soln 2% (Isopto carpine)...... 77 pot phos monobasic w/sod phos di & monobas tab pilocarpine hcl ophth soln 4% (Isopto carpine)...... 77 155-852-130mg (K-phos neutral)...... 73 pilocarpine hcl tab 5 mg (Salagen)...... 78 PRALUENT – alirocumab subcutaneous soln pen-injector pilocarpine hcl tab 7.5 mg (Salagen)...... 78 75 mg/ml...... 31 pimozide tab 1 mg (Orap)...... 59 PRALUENT – alirocumab subcutaneous soln pen-injector pimozide tab 2 mg (Orap)...... 59 150 mg/ml...... 31 pindolol tab 5 mg...... 27 PRALUENT – alirocumab subcutaneous soln prefilled pioglitazone hcl tab 15 mg (base equiv) (Actos)...... 20 syringe 75 mg/ml...... 31 pioglitazone hcl tab 30 mg (base equiv) (Actos)...... 20 PRALUENT – alirocumab subcutaneous soln prefilled pioglitazone hcl tab 45 mg (base equiv) (Actos)...... 20 syringe 150 mg/ml...... 31 piroxicam cap 10 mg (Feldene)...... 64 pramipexole dihydrochloride tab er 24hr 2.25 mg (Mirapex piroxicam cap 20 mg (Feldene)...... 64 er)...... 69 PNV FOLIC ACID + IRON MUL – prenatal vit w/ fe pramipexole dihydrochloride tab 0.125 mg (Mirapex)...... 69 fumarate-fa tab 27-1 mg...... 71 pramipexole dihydrochloride tab 0.25 mg (Mirapex)...... 69 PNV PRENATAL PLUS MULTIVI – prenatal vit w/ fe pramipexole dihydrochloride tab 0.5 mg (Mirapex)...... 69 fumarate-fa tab 27-1 mg...... 71 pramipexole dihydrochloride tab 0.75 mg (Mirapex)...... 69

108 2018 pramipexole dihydrochloride tab 1 mg (Mirapex)...... 69 PRENATAL PLUS – prenatal vit w/ fe fumarate-fa tab 27-1 pramipexole dihydrochloride tab 1.5 mg (Mirapex)...... 69 mg...... 72 pravastatin sodium tab 10 mg...... 31 PRENATAL – prenatal multivitamins & minerals w/iron & pravastatin sodium tab 20 mg (Pravachol)...... 31 fa tab 0.8 mg...... 71 pravastatin sodium tab 40 mg (Pravachol)...... 31 PRENATAL 19 – prenatal vit w/ dss-fe fumarate-fa tab pravastatin sodium tab 80 mg (Pravachol)...... 31 29-1 mg...... 72 praziquantel tab 600 mg (Biltricide)...... 8 PRENATAL 19 – prenatal vit w/ fe fumarate-fa chew tab prazosin hcl cap 1 mg (Minipress)...... 35 29-1 mg...... 72 prazosin hcl cap 2 mg (Minipress)...... 35 PRENATAL – prenatal vit w/ fe fumarate-fa tab 27-0.8 prazosin hcl cap 5 mg (Minipress)...... 35 mg...... 71 prednicarbate cream 0.1% (Dermatop)...... 82 PRENATAL – prenatal vit w/ fe fumarate-fa tab 27-1 PREDNICARBATE – prednicarbate cream 0.1%...... 82 mg...... 71 PREDNICARBATE – prednicarbate oint 0.1%...... 82 PRENATAL – prenatal vit w/ fe fumarate-fa tab 28-0.8 prednisolone acetate ophth susp 1% (Pred forte)...... 77 mg...... 71 PREDNISOLONE – prednisolone syrup 15 mg/5ml (usp PRENATAL VITAMIN – prenatal vit w/ fe fumarate-fa tab solution equivalent)...... 16 27-0.8 mg...... 72 PREDNISOLONE SODIUM PHOSP – prednisolone PRENATAL VITAMINS – prenatal vit w/ fe fumarate-fa tab sodium phosphate ophth soln 1%...... 77 28-0.8 mg...... 72 prednisolone sod phosphate oral soln 15 mg/5ml (base prenatal vit w/ fe fumarate-fa tab 28-0.8 mg...... 72 equiv)...... 16 PREPLUS – prenatal vit w/ fe fumarate-fa tab 27-1 prednisolone sod phosph oral soln 6.7 mg/5ml (5 mg/5ml mg...... 72 base) (Pediapred)...... 16 PREVIDENT 5000 DRY MOUTH – sodium fluoride gel prednisolone syrup 15 mg/5ml (usp solution 1.1% (0.5% f)...... 79 equivalent)...... 16 PREVIDENT FLUORIDE – sodium fluoride gel 1.1% PREDNISONE – prednisone oral soln 5 mg/5ml...... 16 (0.5% f)...... 78 PREDNISONE – prednisone tab 50 mg...... 16 PREZCOBIX – darunavir-cobicistat tab 800-150 mg...... 7 PREDNISONE – prednisone tab therapy pack 5 mg PREZISTA – darunavir ethanolate susp 100 mg/ml (base (21)...... 16 equiv)...... 7 PREDNISONE – prednisone tab therapy pack 5 mg PREZISTA – darunavir ethanolate tab 75 mg (base (48)...... 16 equiv)...... 7 PREDNISONE – prednisone tab therapy pack 10 mg PREZISTA – darunavir ethanolate tab 150 mg (base (21)...... 16 equiv)...... 7 PREDNISONE – prednisone tab therapy pack 10 mg PREZISTA – darunavir ethanolate tab 600 mg (base (48)...... 16 equiv)...... 7 prednisone tab 1 mg...... 16 PREZISTA – darunavir ethanolate tab 800 mg (base prednisone tab 2.5 mg...... 16 equiv)...... 7 prednisone tab 5 mg...... 16 PRIFTIN – rifapentine tab 150 mg...... 3 prednisone tab 10 mg...... 16 PRIMAQUINE PHOSPHATE – primaquine phosphate tab prednisone tab 20 mg...... 16 26.3 mg (15 mg base)...... 8 PRENATAL AND IRON – prenatal multivitamins & primidone tab 50 mg (Mysoline)...... 68 minerals w/iron & fa tab 0.8 mg...... 71 primidone tab 250 mg (Mysoline)...... 68 PRE-NATAL FORMULA – prenatal multivitamins & probenecid tab 500 mg...... 65 minerals w/iron & fa tab 0.8 mg...... 71 PROCRIT – epoetin alfa inj 2000 unit/ml...... 75 PRENATAL FORMULA – prenatal vit w/ fe fumarate-fa tab PROCRIT – epoetin alfa inj 3000 unit/ml...... 76 28-0.8 mg...... 71 PROCRIT – epoetin alfa inj 4000 unit/ml...... 76 PRENATAL FORTE – prenatal multivitamins & minerals PROCRIT – epoetin alfa inj 10000 unit/ml...... 76 w/iron & fa tab 0.8 mg...... 72 PROCRIT – epoetin alfa inj 20000 unit/ml...... 76 PRENATAL LOW IRON – prenatal vit w/ fe fumarate-fa PROCRIT – epoetin alfa inj 40000 unit/ml...... 76 tab 27-0.8 mg...... 72 PROCYSBI – cysteamine bitartrate cap delayed release PRENATAL MULTI +DHA – prenatal vit w/ fe fum-fa- 25 mg (base equiv)...... 44 omega 3 cap 27-0.8-228 mg...... 72 PROCYSBI – cysteamine bitartrate cap delayed release PRENATAL ONE DAILY – prenatal vit w/ fe fumarate-fa 75 mg (base equiv)...... 44 tab 27-0.8 mg...... 72 progesterone micronized cap 100 mg (Prometrium)...... 17 PRENATAL PLUS DHA – prenatal mv & min w/fe progesterone micronized cap 200 mg (Prometrium)...... 18 carbonyl-fa-dha tab 7-0.4-100 mg...... 72 PROMACTA – eltrombopag olamine tab 12.5 mg (base equiv)...... 76

109 2018 PROMACTA – eltrombopag olamine tab 25 mg (base quinapril-hydrochlorothiazide tab 10-12.5 mg equiv)...... 76 (Accuretic)...... 25 PROMACTA – eltrombopag olamine tab 50 mg (base quinapril-hydrochlorothiazide tab 20-12.5 mg equiv)...... 76 (Accuretic)...... 25 PROMACTA – eltrombopag olamine tab 75 mg (base quinapril-hydrochlorothiazide tab 20-25 mg equiv)...... 76 (Accuretic)...... 25 promethazine hcl suppos 12.5 mg...... 36 quinidine gluconate tab er 324 mg...... 33 promethazine hcl suppos 25 mg...... 36 QUINIDINE SULFATE – quinidine sulfate tab 200 mg...... 33 promethazine hcl syrup 6.25 mg/5ml...... 36 QUINIDINE SULFATE – quinidine sulfate tab 300 mg...... 33 promethazine hcl tab 12.5 mg...... 36 QVAR – beclomethasone diprop inhal aero soln 40 mcg/ promethazine hcl tab 25 mg...... 36 act (50/valve)...... 38 promethazine hcl tab 50 mg...... 36 QVAR – beclomethasone diprop inhal aero soln 80 mcg/ promethazine w/ codeine syrup 6.25-10 mg/5ml...... 37 act (100/valve)...... 38 propafenone hcl tab 150 mg...... 33 QVAR REDIHALER – beclomethasone diprop hfa breath propafenone hcl tab 300 mg...... 33 act inh aer 40 mcg/act...... 38 propafenone hcl tab 225 mg (Rythmol)...... 33 QVAR REDIHALER – beclomethasone diprop hfa breath proparacaine hcl ophth soln 0.5% (Alcaine)...... 78 act inh aer 80 mcg/act...... 38 PROPRANOLOL/HYDROCHLOROTH – propranolol & R hydrochlorothiazide tab 40-25 mg...... 27 PROPRANOLOL/HYDROCHLOROTH – propranolol & RABAVERT – rabies vaccine, pcec for inj...... 9 hydrochlorothiazide tab 80-25 mg...... 27 rabeprazole sodium ec tab 20 mg (Aciphex)...... 40 propranolol hcl cap er 24hr 60 mg (Inderal la)...... 27 raloxifene hcl tab 60 mg (Evista)...... 23 propranolol hcl cap er 24hr 80 mg (Inderal la)...... 27 ramipril cap 1.25 mg (Altace)...... 25 propranolol hcl cap er 24hr 120 mg (Inderal la)...... 27 ramipril cap 2.5 mg (Altace)...... 25 propranolol hcl cap er 24hr 160 mg (Inderal la)...... 27 ramipril cap 5 mg (Altace)...... 25 propranolol hcl tab 10 mg...... 27 ramipril cap 10 mg (Altace)...... 25 propranolol hcl tab 20 mg...... 27 ranitidine hcl syrup 15 mg/ml (75 mg/5ml)...... 41 propranolol hcl tab 40 mg...... 27 ranitidine hcl tab 150 mg (Zantac)...... 41 propranolol hcl tab 60 mg...... 27 ranitidine hcl tab 300 mg (Zantac)...... 41 propranolol hcl tab 80 mg...... 27 RA PRENATAL FORMULA/FOLIC – prenatal vit w/ fe propylthiouracil tab 50 mg...... 21 fumarate-fa tab 28-0.8 mg...... 72 pseudoeph-chlorphen w/ hydrocodone soln 60-4-5 RA PRENATAL – prenatal vit w/ fe fumarate-fa tab 28-0.8 mg/5ml (Zutripro)...... 37 mg...... 72 PULMOZYME – dornase alfa inhal soln 1 mg/ml...... 39 RAVICTI – glycerol phenylbutyrate liquid 1.1 gm/ml...... 23 PURIXAN – mercaptopurine susp 2000 mg/100ml (20 mg/ RECOMBIVAX HB – hepatitis b vaccine (recombinant) ml)...... 13 susp 5 mcg/0.5ml...... 9 PX PRENATAL MULTIVITAMINS – prenatal vit w/ fe RECOMBIVAX HB – hepatitis b vaccine (recombinant) fumarate-fa tab 28-0.8 mg...... 72 susp 10 mcg/ml...... 9 pyrazinamide tab 500 mg...... 3 RECOMBIVAX HB – hepatitis b vaccine (recombinant) pyridostigmine bromide tab 60 mg (Mestinon)...... 70 susp 40 mcg/ml...... 9 RELENZA DISKHALER – zanamivir aero powder breath Q activated 5 mg/blister...... 8 QC PRENATAL – prenatal vit w/ fe fumarate-fa tab 28-0.8 RELION R – insulin regular (human) inj 100 unit/ml...... 20 mg...... 72 REPATHA – evolocumab subcutaneous soln prefilled QUAZEPAM – quazepam tab 15 mg...... 55 syringe 140 mg/ml...... 31 quetiapine fumarate tab er 24hr 400 mg (Seroquel xr)..... 53 REPATHA PUSHTRONEX SYSTEM – evolocumab quetiapine fumarate tab 25 mg (Seroquel)...... 53 subcutaneous soln cartridge/infusor 420 mg/3.5ml...... 31 quetiapine fumarate tab 50 mg (Seroquel)...... 53 REPATHA SURECLICK – evolocumab subcutaneous soln quetiapine fumarate tab 100 mg (Seroquel)...... 53 auto-injector 140 mg/ml...... 31 quetiapine fumarate tab 200 mg (Seroquel)...... 53 REPEL SPORTSMEN – diethyltoluamide (deet) quetiapine fumarate tab 300 mg (Seroquel)...... 53 aerosol...... 83 quetiapine fumarate tab 400 mg (Seroquel)...... 53 REPEL SPORTSMEN MAX – diethyltoluamide (deet) quinapril hcl tab 5 mg (Accupril)...... 25 aerosol...... 83 quinapril hcl tab 10 mg (Accupril)...... 25 RESCRIPTOR – delavirdine mesylate tab 100 mg...... 7 quinapril hcl tab 20 mg (Accupril)...... 25 RESCRIPTOR – delavirdine mesylate tab 200 mg...... 7 quinapril hcl tab 40 mg (Accupril)...... 25 REVATIO – sildenafil citrate for suspension 10 mg/ml...... 35

110 2018

REVLIMID – lenalidomide cap 5 mg...... 85 rizatriptan benzoate oral disintegrating tab 10 mg (base REVLIMID – lenalidomide cap 10 mg...... 85 eq) (Maxalt-mlt)...... 65 REVLIMID – lenalidomide cap 15 mg...... 85 rizatriptan benzoate tab 5 mg (base equivalent) REVLIMID – lenalidomide cap 20 mg...... 85 (Maxalt)...... 65 REVLIMID – lenalidomide cap 25 mg...... 85 rizatriptan benzoate tab 10 mg (base equivalent) REVLIMID – lenalidomide caps 2.5 mg...... 85 (Maxalt)...... 65 REXULTI – brexpiprazole tab 0.25 mg...... 53 ropinirole hydrochloride tab 0.25 mg (Requip)...... 69 REXULTI – brexpiprazole tab 0.5 mg...... 53 ropinirole hydrochloride tab 0.5 mg (Requip)...... 69 REXULTI – brexpiprazole tab 1 mg...... 53 ropinirole hydrochloride tab 1 mg (Requip)...... 69 REXULTI – brexpiprazole tab 2 mg...... 53 ropinirole hydrochloride tab 2 mg (Requip)...... 69 REXULTI – brexpiprazole tab 3 mg...... 53 ropinirole hydrochloride tab 3 mg (Requip)...... 69 REXULTI – brexpiprazole tab 4 mg...... 53 ropinirole hydrochloride tab 4 mg (Requip)...... 69 ribavirin cap 200 mg (Rebetol)...... 5 ropinirole hydrochloride tab 5 mg (Requip)...... 69 ribavirin tab 200 mg (Copegus)...... 5 rosuvastatin calcium tab 5 mg (Crestor)...... 31 rifabutin cap 150 mg (Mycobutin)...... 3 rosuvastatin calcium tab 10 mg (Crestor)...... 31 rifampin cap 150 mg (Rifadin)...... 4 rosuvastatin calcium tab 20 mg (Crestor)...... 31 rifampin cap 300 mg (Rifadin)...... 4 rosuvastatin calcium tab 40 mg (Crestor)...... 31 RIGHT STEP PRENATAL – prenatal vit w/ fe fumarate-fa RUBRACA – rucaparib camsylate tab 200 mg (base tab 27-0.8 mg...... 72 equivalent)...... 13 riluzole tab 50 mg (Rilutek)...... 70 RUBRACA – rucaparib camsylate tab 250 mg (base ringer's solution for irrigation...... 85 equivalent)...... 13 risedronate sodium tab delayed release 35 mg RUBRACA – rucaparib camsylate tab 300 mg (base (Atelvia)...... 23 equivalent)...... 13 RISPERDAL CONSTA – risperidone microspheres for inj S 12.5 mg...... 53 RISPERDAL CONSTA – risperidone microspheres for inj SABRIL – vigabatrin tab 500 mg...... 68 25 mg...... 53 salicylic acid cream 6%...... 80 RISPERDAL CONSTA – risperidone microspheres for inj salicylic acid cream 6% & cleanser liqd kit (Salex 37.5 mg...... 53 cream)...... 80 RISPERDAL CONSTA – risperidone microspheres for inj salicylic acid film forming liquid 27.5% (Virasal)...... 80 50 mg...... 53 salicylic acid foam 6% (Salvax)...... 80 RISPERIDONE ODT – risperidone orally disintegrating salicylic acid gel 6% (Keralyt)...... 80 tab 0.25 mg...... 53 salicylic acid lotion 6%...... 80 risperidone orally disintegrating tab 0.25 mg...... 53 salicylic acid lotion 6% & cleanser liqd kit (Salex risperidone orally disintegrating tab 0.5 mg (Risperdal m- lotion)...... 80 tab)...... 53 salicylic acid shampoo 6% (Salex)...... 80 risperidone orally disintegrating tab 1 mg (Risperdal m- SAMSCA – tolvaptan tab 15 mg...... 23 tab)...... 54 SAMSCA – tolvaptan tab 30 mg...... 23 risperidone orally disintegrating tab 2 mg (Risperdal m- SAPHRIS – asenapine maleate sl tab 2.5 mg (base tab)...... 54 equiv)...... 54 risperidone orally disintegrating tab 3 mg (Risperdal m- SAPHRIS – asenapine maleate sl tab 5 mg (base tab)...... 54 equiv)...... 54 risperidone orally disintegrating tab 4 mg (Risperdal m- SAPHRIS – asenapine maleate sl tab 10 mg (base tab)...... 54 equiv)...... 54 risperidone soln 1 mg/ml (Risperdal)...... 54 SAWYER PREMIUM INSECT REP – picaridin liquid...... 83 risperidone tab 0.25 mg (Risperdal)...... 54 selegiline hcl cap 5 mg (Eldepryl)...... 69 risperidone tab 0.5 mg (Risperdal)...... 54 selegiline hcl tab 5 mg...... 69 risperidone tab 1 mg (Risperdal)...... 54 selenium sulfide lotion 2.5%...... 83 risperidone tab 2 mg (Risperdal)...... 54 selenium sulfide shampoo 2.25%...... 83 risperidone tab 3 mg (Risperdal)...... 54 SELZENTRY – maraviroc tab 150 mg...... 7 risperidone tab 4 mg (Risperdal)...... 54 SELZENTRY – maraviroc tab 300 mg...... 7 ritonavir tab 100 mg (Norvir)...... 7 SE-NATAL 19 – prenatal vit w/ dss-fe fumarate-fa tab 29-1 rivastigmine tartrate cap 4.5 mg (Exelon)...... 59 mg...... 72 rizatriptan benzoate oral disintegrating tab 5 mg (base eq) SE-NATAL 19 – prenatal vit w/ fe fumarate-fa chew tab (Maxalt-mlt)...... 65 29-1 mg...... 72

111 2018 SEROSTIM – somatropin (non-refrigerated) for sodium fluoride-potassium nitrate paste 1.1-5% (Prevident subcutaneous inj 4 mg...... 22 5000 sensi)...... 79 SEROSTIM – somatropin (non-refrigerated) for sodium fluoride rinse 0.2%...... 79 subcutaneous inj 5 mg...... 22 SODIUM FLUORIDE – sodium fluoride tab 0.5 mg f (from SEROSTIM – somatropin (non-refrigerated) for 1.1 mg naf)...... 73 subcutaneous inj 6 mg...... 22 SODIUM FLUORIDE – sodium fluoride tab 1 mg f (from sertraline hcl oral concentrate for solution 20 mg/ml 2.2 mg naf)...... 73 (Zoloft)...... 48 sodium fluoride soln 0.125 mg/drop f (0.275 mg/drop sertraline hcl tab 25 mg (Zoloft)...... 48 naf)...... 73 sertraline hcl tab 50 mg (Zoloft)...... 48 sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml naf) sertraline hcl tab 100 mg (Zoloft)...... 48 (Luride)...... 73 SHINGRIX – zoster vaccine recombinant adjuvanted for sodium polystyrene sulfonate oral susp 15 gm/60ml...... 85 im inj 50 mcg...... 10 sodium polystyrene sulfonate powder (Kayexalate)...... 85 SIGNIFOR – pasireotide diaspartate inj 0.3 mg/ml (base sodium polystyrene sulfonate rectal susp 30 equiv)...... 23 gm/120ml...... 85 SIGNIFOR – pasireotide diaspartate inj 0.6 mg/ml (base SOLU-CORTEF – hydrocortisone sodium succinate pf for equiv)...... 23 inj 100 mg...... 16 SIGNIFOR – pasireotide diaspartate inj 0.9 mg/ml (base SOLU-CORTEF – hydrocortisone sodium succinate pf for equiv)...... 23 inj 250 mg...... 16 silver sulfadiazine cream 1% (Silvadene)...... 81 SOLU-CORTEF – hydrocortisone sodium succinate pf for SIMPONI – golimumab subcutaneous soln auto-injector inj 500 mg...... 16 50 mg/0.5ml...... 64 SOLU-CORTEF – hydrocortisone sodium succinate pf for SIMPONI – golimumab subcutaneous soln auto-injector inj 1000 mg...... 16 100 mg/ml...... 64 SOMAVERT – pegvisomant for inj 10 mg (as protein)...... 23 SIMPONI – golimumab subcutaneous soln prefilled SOMAVERT – pegvisomant for inj 15 mg (as protein)...... 23 syringe 50 mg/0.5ml...... 64 SOMAVERT – pegvisomant for inj 20 mg (as protein)...... 23 SIMPONI – golimumab subcutaneous soln prefilled SOMAVERT – pegvisomant for inj 25 mg (as protein)...... 23 syringe 100 mg/ml...... 64 SOMAVERT – pegvisomant for inj 30 mg (as protein)...... 23 simvastatin tab 5 mg (Zocor)...... 31 sotalol hcl (afib/afl) tab 80 mg (Betapace af)...... 33 simvastatin tab 10 mg (Zocor)...... 32 sotalol hcl (afib/afl) tab 120 mg (Betapace af)...... 33 simvastatin tab 20 mg (Zocor)...... 32 sotalol hcl (afib/afl) tab 160 mg (Betapace af)...... 33 simvastatin tab 40 mg (Zocor)...... 32 sotalol hcl tab 240 mg...... 33 simvastatin tab 80 mg (Zocor)...... 32 sotalol hcl tab 80 mg (Betapace)...... 33 sirolimus tab 0.5 mg (Rapamune)...... 85 sotalol hcl tab 120 mg (Betapace)...... 33 sirolimus tab 1 mg (Rapamune)...... 85 sotalol hcl tab 160 mg (Betapace)...... 33 sirolimus tab 2 mg (Rapamune)...... 85 speciality vitamin product tab...... 72 skin protectants misc - cream...... 83 spironolactone & hydrochlorothiazide tab 25-25 mg SM PRENATAL VITAMINS – prenatal vit w/ fe fumarate-fa (Aldactazide)...... 32 tab 28-0.8 mg...... 72 spironolactone tab 25 mg (Aldactone)...... 32 sodium chloride irrigation soln 0.9%...... 44 spironolactone tab 50 mg (Aldactone)...... 32 sodium chloride soln nebu 0.9%...... 37 spironolactone tab 100 mg (Aldactone)...... 32 sodium chloride soln nebu 3%...... 37 SPRYCEL – dasatinib tab 20 mg...... 13 sodium chloride soln nebu 10%...... 37 SPRYCEL – dasatinib tab 50 mg...... 13 sodium chloride soln nebu 7% (Hyper-sal)...... 37 SPRYCEL – dasatinib tab 70 mg...... 13 sodium citrate & citric acid soln 500-334 mg/5ml (Shohls SPRYCEL – dasatinib tab 80 mg...... 14 solution modi)...... 44 SPRYCEL – dasatinib tab 100 mg...... 14 sodium fluoride chew tab 0.25 mg f (from 0.55 mg naf) SPRYCEL – dasatinib tab 140 mg...... 14 (Luride)...... 73 stannous fluoride gel 0.4%...... 79 sodium fluoride chew tab 0.5 mg f (from 1.1 mg naf) stavudine cap 15 mg (Zerit)...... 7 (Luride)...... 73 stavudine cap 20 mg (Zerit)...... 7 sodium fluoride chew tab 1 mg f (from 2.2 mg naf) stavudine cap 30 mg (Zerit)...... 7 (Luride)...... 73 stavudine cap 40 mg (Zerit)...... 7 sodium fluoride cream 1.1% (Prevident 5000 plus)...... 79 STELARA – ustekinumab soln prefilled syringe 45 sodium fluoride gel 1.1% (0.5% f) (Prevident fluoride)...... 79 mg/0.5ml...... 83 sodium fluoride paste 1.1% (Prevident 5000 boost)...... 79 STELARA – ustekinumab soln prefilled syringe 90 mg/ ml...... 83

112 2018 STIMATE – desmopressin acetate nasal soln 1.5 mg/ SUTENT – sunitinib malate cap 50 mg (base ml...... 23 equivalent)...... 14 STIVARGA – regorafenib tab 40 mg...... 14 SYLATRON – peginterferon alfa-2b for inj kit 200 mcg.....14 STRIBILD – elvitegrav-cobic-emtricitab-tenofovdf tab SYLATRON – peginterferon alfa-2b for inj kit 300 mcg.....14 150-150-200-300 mg...... 7 SYLATRON – peginterferon alfa-2b for inj kit 600 mcg.....14 STRIVERDI RESPIMAT – olodaterol hcl inhal aerosol soln SYMBICORT – budesonide-formoterol fumarate dihyd 2.5 mcg/act (base equiv)...... 38 aerosol 80-4.5 mcg/act...... 38 SUBOXONE – buprenorphine hcl-naloxone hcl sl film SYMBICORT – budesonide-formoterol fumarate dihyd 2-0.5 mg (base equiv)...... 62 aerosol 160-4.5 mcg/act...... 38 SUBOXONE – buprenorphine hcl-naloxone hcl sl film 4-1 SYNAREL – nafarelin acetate nasal soln 2 mg/ml (200 mg (base equiv)...... 62 mcg/act) (base eq)...... 18 SUBOXONE – buprenorphine hcl-naloxone hcl sl film 8-2 T mg (base equiv)...... 62 SUBOXONE – buprenorphine hcl-naloxone hcl sl film tacrolimus cap 0.5 mg (Prograf)...... 85 12-3 mg (base equiv)...... 62 tacrolimus cap 1 mg (Prograf)...... 85 SUCRAID – sacrosidase soln 8500 unit/ml...... 41 tacrolimus cap 5 mg (Prograf)...... 85 sucralfate tab 1 gm (Carafate)...... 41 tacrolimus oint 0.03% (Protopic)...... 83 sulfacetamide sodium lotion 10% (acne) (Klaron)...... 79 tacrolimus oint 0.1% (Protopic)...... 83 sulfacetamide sodium ophth soln 10% (Bleph-10)...... 77 TAFINLAR – dabrafenib mesylate cap 50 mg (base sulfacetamide sodium-prednisolone ophth soln equivalent)...... 14 10-0.23(0.25)%...... 77 TAFINLAR – dabrafenib mesylate cap 75 mg (base sulfamethoxazole-trimethoprim susp 200-40 mg/5ml...... 9 equivalent)...... 14 sulfamethoxazole-trimethoprim tab 400-80 mg tamoxifen citrate tab 10 mg (base equivalent)...... 14 (Bactrim)...... 9 tamoxifen citrate tab 20 mg (base equivalent)...... 14 sulfamethoxazole-trimethoprim tab 800-160 mg (Bactrim tamsulosin hcl cap 0.4 mg (Flomax)...... 44 ds)...... 9 TARCEVA – erlotinib hcl tab 25 mg (base equivalent)...... 14 sulfasalazine tab delayed release 500 mg (Azulfidine en- TARCEVA – erlotinib hcl tab 100 mg (base tabs)...... 43 equivalent)...... 14 sulfasalazine tab 500 mg (Azulfidine)...... 43 TARCEVA – erlotinib hcl tab 150 mg (base sulindac tab 150 mg...... 64 equivalent)...... 14 sulindac tab 200 mg...... 64 TARGRETIN – bexarotene cap 75 mg...... 14 sumatriptan nasal spray 5 mg/act (Imitrex)...... 65 TASIGNA – nilotinib hcl cap 50 mg (base equivalent)...... 14 sumatriptan nasal spray 20 mg/act (Imitrex)...... 65 TASIGNA – nilotinib hcl cap 150 mg (base sumatriptan succinate inj 6 mg/0.5ml (Imitrex)...... 65 equivalent)...... 14 sumatriptan succinate solution auto-injector 4 mg/0.5ml TASIGNA – nilotinib hcl cap 200 mg (base (Imitrex statdose sys)...... 65 equivalent)...... 14 sumatriptan succinate solution auto-injector 6 mg/0.5ml tazarotene cream 0.1% (Tazorac)...... 80 (Imitrex statdose sys)...... 65 TAZORAC – tazarotene cream 0.05%...... 80 sumatriptan succinate solution cartridge 4 mg/0.5ml TAZORAC – tazarotene gel 0.05%...... 80 (Imitrex statdose ref)...... 65 TAZORAC – tazarotene gel 0.1%...... 80 sumatriptan succinate solution cartridge 6 mg/0.5ml TECHLITE PEN NEEDLES 29G...... 84 (Imitrex statdose ref)...... 65 temazepam cap 15 mg (Restoril)...... 55 SUMATRIPTAN SUCCINATE – sumatriptan succinate temazepam cap 30 mg (Restoril)...... 55 solution prefilled syringe 6 mg/0.5ml...... 65 temozolomide cap 5 mg (Temodar)...... 14 sumatriptan succinate tab 25 mg (Imitrex)...... 65 temozolomide cap 20 mg (Temodar)...... 14 sumatriptan succinate tab 50 mg (Imitrex)...... 65 temozolomide cap 100 mg (Temodar)...... 14 sumatriptan succinate tab 100 mg (Imitrex)...... 65 temozolomide cap 140 mg (Temodar)...... 14 SUSTIVA – efavirenz cap 50 mg...... 7 temozolomide cap 180 mg (Temodar)...... 14 SUSTIVA – efavirenz cap 200 mg...... 7 temozolomide cap 250 mg (Temodar)...... 14 SUSTIVA – efavirenz tab 600 mg...... 7 tenofovir disoproxil fumarate tab 300 mg (Viread)...... 7 SUTENT – sunitinib malate cap 12.5 mg (base terazosin hcl cap 1 mg (base equivalent)...... 35 equivalent)...... 14 terazosin hcl cap 2 mg (base equivalent)...... 35 SUTENT – sunitinib malate cap 25 mg (base terazosin hcl cap 5 mg (base equivalent)...... 35 equivalent)...... 14 terazosin hcl cap 10 mg (base equivalent)...... 35 SUTENT – sunitinib malate cap 37.5 mg (base terbinafine hcl tab 250 mg (Lamisil)...... 4 equivalent)...... 14 terbutaline sulfate tab 2.5 mg...... 38

113 2018 terbutaline sulfate tab 5 mg...... 38 TRACLEER – bosentan tab for oral susp 32 mg...... 35 TERCONAZOLE – terconazole vaginal cream 0.8%...... 43 TRACLEER – bosentan tab 62.5 mg...... 35 terconazole vaginal cream 0.4% (Terazol 7)...... 44 TRACLEER – bosentan tab 125 mg...... 35 terconazole vaginal cream 0.8% (Terazol 3)...... 44 tramadol-acetaminophen tab 37.5-325 mg (Ultracet)...... 62 terconazole vaginal suppos 80 mg...... 44 tramadol hcl tab 50 mg (Ultram)...... 62 testosterone td gel 12.5 mg/act (1%) (Androgel TRANDOLAPRIL/VERAPAMIL HC – trandolapril- pump)...... 16 verapamil hcl tab er 1-240 mg...... 29 testosterone td gel 25 mg/2.5gm (1%) (Androgel)...... 16 trandolapril tab 4 mg...... 25 testosterone td gel 50 mg/5gm (1%) (Androgel)...... 16 trandolapril tab 1 mg (Mavik)...... 25 TEST STRIPS – BAYER ASCENCIA...... 84 trandolapril tab 2 mg (Mavik)...... 25 tetracaine hcl ophth soln 0.5%...... 78 trandolapril-verapamil hcl tab er 1-240 mg (Tarka)...... 29 THALOMID – thalidomide cap 50 mg...... 85 trandolapril-verapamil hcl tab er 2-180 mg (Tarka)...... 29 THALOMID – thalidomide cap 100 mg...... 85 trandolapril-verapamil hcl tab er 2-240 mg (Tarka)...... 29 THALOMID – thalidomide cap 150 mg...... 85 trandolapril-verapamil hcl tab er 4-240 mg (Tarka)...... 29 THALOMID – thalidomide cap 200 mg...... 85 tranexamic acid tab 650 mg (Lysteda)...... 76 theophylline soln 80 mg/15ml...... 38 trazodone hcl tab 50 mg...... 48 theophylline tab er 12hr 100 mg...... 38 trazodone hcl tab 100 mg...... 48 theophylline tab er 12hr 200 mg...... 38 trazodone hcl tab 150 mg...... 48 theophylline tab er 12hr 300 mg...... 39 tretinoin cap 10 mg...... 14 theophylline tab er 12hr 450 mg...... 39 tretinoin cream 0.025% (Retin-a)...... 80 theophylline tab er 24hr 400 mg...... 39 tretinoin cream 0.05% (Retin-a)...... 80 theophylline tab er 24hr 600 mg...... 39 tretinoin cream 0.1% (Retin-a)...... 80 THERA-FLUR-N – sodium fluoride gel 1.1% (0.5% f)...... 79 tretinoin gel 0.05% (Atralin)...... 80 thioridazine hcl tab 10 mg...... 54 tretinoin gel 0.01% (Retin-a)...... 80 thioridazine hcl tab 25 mg...... 54 tretinoin gel 0.025% (Retin-a)...... 80 thioridazine hcl tab 50 mg...... 54 triamcinolone acetonide aerosol soln 0.147 mg/gm thioridazine hcl tab 100 mg...... 54 (Kenalog)...... 82 thiothixene cap 1 mg...... 54 triamcinolone acetonide cream 0.025%...... 82 thiothixene cap 2 mg...... 54 triamcinolone acetonide cream 0.1%...... 82 thiothixene cap 5 mg...... 54 triamcinolone acetonide cream 0.5%...... 82 thiothixene cap 10 mg...... 54 triamcinolone acetonide dental paste 0.1%...... 79 thyroid tab 30 mg (1/2 grain) (Armour thyroid)...... 21 triamcinolone acetonide lotion 0.025%...... 82 thyroid tab 90 mg (1 1/2 grain) (Armour thyroid)...... 22 triamcinolone acetonide lotion 0.1%...... 82 thyroid tab 60 mg (1 grain) (Armour thyroid)...... 21 triamcinolone acetonide nasal aerosol suspension 55 tiagabine hcl tab 2 mg (Gabitril)...... 68 mcg/act...... 36 tiagabine hcl tab 4 mg (Gabitril)...... 68 triamcinolone acetonide oint 0.025%...... 82 timolol maleate ophth soln 0.25% (Timoptic)...... 78 triamcinolone acetonide oint 0.1%...... 82 timolol maleate ophth soln 0.5% (Timoptic)...... 78 triamterene & hydrochlorothiazide cap 37.5-25 mg TIVICAY – dolutegravir sodium tab 50 mg (base equiv)..... 7 (Dyazide)...... 33 tizanidine hcl tab 2 mg (base equivalent)...... 70 triamterene & hydrochlorothiazide tab 37.5-25 mg tizanidine hcl tab 4 mg (base equivalent) (Zanaflex)...... 70 (Maxzide-25)...... 33 tobramycin nebu soln 300 mg/5ml (Tobi)...... 3 triamterene & hydrochlorothiazide tab 75-50 mg tobramycin ophth soln 0.3% (Tobrex)...... 77 (Maxzide)...... 33 TOBRAMYCIN – tobramycin nebu soln 300 mg/5ml...... 3 TRICARE – prenatal vit w/ fe fumarate-fa tab 27-1 mg.....72 tolcapone tab 100 mg (Tasmar)...... 70 TRICITRATES – pot & sod citrates w/ cit ac soln tolterodine tartrate tab 2 mg (Detrol)...... 43 550-500-334 mg/5ml...... 44 topiramate sprinkle cap 15 mg (Topamax sprinkle)...... 68 trientine hcl cap 250 mg (Syprine)...... 85 topiramate sprinkle cap 25 mg (Topamax sprinkle)...... 68 trifluoperazine hcl tab 1 mg (base equivalent)...... 54 topiramate tab 25 mg (Topamax)...... 68 trifluoperazine hcl tab 2 mg (base equivalent)...... 54 topiramate tab 50 mg (Topamax)...... 68 trifluoperazine hcl tab 5 mg (base equivalent)...... 54 topiramate tab 100 mg (Topamax)...... 68 trifluoperazine hcl tab 10 mg (base equivalent)...... 54 topiramate tab 200 mg (Topamax)...... 68 trifluridine ophth soln 1% (Viroptic)...... 77 torsemide tab 5 mg...... 32 trihexyphenidyl hcl elixir 0.4 mg/ml...... 70 torsemide tab 100 mg...... 33 trihexyphenidyl hcl tab 2 mg...... 70 torsemide tab 10 mg (Demadex)...... 32 trihexyphenidyl hcl tab 5 mg...... 70 torsemide tab 20 mg (Demadex)...... 32 trimethobenzamide hcl cap 300 mg (Tigan)...... 41

114 2018 trimethoprim tab 100 mg...... 9 valsartan-hydrochlorothiazide tab 320-12.5 mg (Diovan TRINATAL RX 1 – prenatal vit w/ fe fumarate-fa tab 60-1 hct)...... 26 mg...... 72 valsartan-hydrochlorothiazide tab 320-25 mg (Diovan TRIUMEQ – abacavir-dolutegravir-lamivudine tab hct)...... 26 600-50-300 mg...... 7 valsartan tab 40 mg (Diovan)...... 26 TRI-VIT/FLUORIDE/IRON – pediatric vitamins acd valsartan tab 80 mg (Diovan)...... 26 fluoride & fe drops 0.25-10 mg/ml...... 72 valsartan tab 160 mg (Diovan)...... 26 trospium chloride cap er 24hr 60 mg...... 43 valsartan tab 320 mg (Diovan)...... 26 trospium chloride tab 20 mg...... 43 vancomycin hcl cap 125 mg (Vancocin hcl)...... 9 TRUEPLUS INSULIN SYRINGE/...... 84 vancomycin hcl cap 250 mg (Vancocin hcl)...... 9 TRUVADA – emtricitabine-tenofovir disoproxil fumarate VENCLEXTA STARTING PACK – venetoclax tab therapy tab 100-150 mg...... 7 starter pack 10 & 50 & 100 mg...... 15 TRUVADA – emtricitabine-tenofovir disoproxil fumarate VENCLEXTA – venetoclax tab 10 mg...... 14 tab 133-200 mg...... 7 VENCLEXTA – venetoclax tab 50 mg...... 14 TRUVADA – emtricitabine-tenofovir disoproxil fumarate VENCLEXTA – venetoclax tab 100 mg...... 15 tab 167-250 mg...... 7 venlafaxine hcl cap er 24hr 37.5 mg (base equivalent) TRUVADA – emtricitabine-tenofovir disoproxil fumarate (Effexor xr)...... 48 tab 200-300 mg...... 7 venlafaxine hcl cap er 24hr 75 mg (base equivalent) TYBOST – cobicistat tab 150 mg...... 7 (Effexor xr)...... 48 TYKERB – lapatinib ditosylate tab 250 mg (base venlafaxine hcl cap er 24hr 150 mg (base equivalent) equiv)...... 14 (Effexor xr)...... 49 TYVASO REFILL – treprostinil inhalation solution 0.6 mg/ venlafaxine hcl tab 25 mg...... 49 ml...... 35 venlafaxine hcl tab 37.5 mg...... 49 TYVASO STARTER – treprostinil inhalation solution 0.6 venlafaxine hcl tab 50 mg...... 49 mg/ml...... 35 venlafaxine hcl tab 75 mg...... 49 TYVASO – treprostinil inhalation solution 0.6 mg/ml...... 35 venlafaxine hcl tab 100 mg...... 49 VENTAVIS – iloprost inhalation solution 10 mcg/ml...... 35 U VENTAVIS – iloprost inhalation solution 20 mcg/ml...... 35 UPTRAVI – selexipag tab 200 mcg...... 35 VENTOLIN HFA – albuterol sulfate inhal aero 108 mcg/act UPTRAVI – selexipag tab 400 mcg...... 35 (90mcg base equiv)...... 39 UPTRAVI – selexipag tab 600 mcg...... 35 verapamil hcl cap er 24hr 120 mg (Verelan)...... 29 UPTRAVI – selexipag tab 800 mcg...... 35 verapamil hcl cap er 24hr 180 mg (Verelan)...... 29 UPTRAVI – selexipag tab 1000 mcg...... 35 verapamil hcl cap er 24hr 240 mg (Verelan)...... 29 UPTRAVI – selexipag tab 1200 mcg...... 35 verapamil hcl cap er 24hr 360 mg (Verelan)...... 29 UPTRAVI – selexipag tab 1400 mcg...... 35 verapamil hcl cap er 24hr 100 mg (Verelan pm)...... 29 UPTRAVI – selexipag tab 1600 mcg...... 35 verapamil hcl cap er 24hr 200 mg (Verelan pm)...... 29 UPTRAVI – selexipag tab therapy pack 200 mcg (140) & verapamil hcl cap er 24hr 300 mg (Verelan pm)...... 29 800 mcg (60)...... 35 verapamil hcl tab er 120 mg (Calan sr)...... 29 ursodiol cap 300 mg (Actigall)...... 43 verapamil hcl tab er 180 mg (Calan sr)...... 29 ursodiol tab 250 mg (Urso 250)...... 43 verapamil hcl tab er 240 mg (Calan sr)...... 29 ursodiol tab 500 mg (Urso forte)...... 43 verapamil hcl tab 40 mg...... 29 V verapamil hcl tab 80 mg (Calan)...... 29 verapamil hcl tab 120 mg (Calan)...... 29 valacyclovir hcl tab 1 gm (Valtrex)...... 5 VERSACLOZ – clozapine susp 50 mg/ml...... 54 valacyclovir hcl tab 500 mg (Valtrex)...... 5 VERZENIO – abemaciclib tab 50 mg...... 15 valganciclovir hcl for soln 50 mg/ml (base equiv) VERZENIO – abemaciclib tab 100 mg...... 15 (Valcyte)...... 4 VERZENIO – abemaciclib tab 150 mg...... 15 valganciclovir hcl tab 450 mg (base equivalent) VERZENIO – abemaciclib tab 200 mg...... 15 (Valcyte)...... 4 VICTOZA – liraglutide soln pen-injector 18 mg/3ml (6 mg/ valproic acid cap 250 mg (Depakene)...... 68 ml)...... 20 valsartan-hydrochlorothiazide tab 80-12.5 mg (Diovan VIDEX – didanosine for soln 2 gm...... 7 hct)...... 26 VIDEX – didanosine for soln 4 gm...... 7 valsartan-hydrochlorothiazide tab 160-12.5 mg (Diovan vigabatrin powd pack 500 mg (Sabril)...... 68 hct)...... 26 VIIBRYD STARTER PACK – vilazodone hcl tab starter kit valsartan-hydrochlorothiazide tab 160-25 mg (Diovan 10 (7) & 20 (23) mg...... 49 hct)...... 26 VIIBRYD – vilazodone hcl tab 10 mg...... 49

115 2018

VIIBRYD – vilazodone hcl tab 20 mg...... 49 Y VIIBRYD – vilazodone hcl tab 40 mg...... 49 VINATE M – prenatal vit w/ sel-fe fumarate-fa tab 27-1 Z mg...... 72 VINATE ONE – prenatal vit w/ fe fumarate-fa tab 60-1 zaleplon cap 5 mg (Sonata)...... 55 mg...... 72 zaleplon cap 10 mg (Sonata)...... 55 VIRACEPT – nelfinavir mesylate tab 250 mg...... 7 ZELBORAF – vemurafenib tab 240 mg...... 15 VIRACEPT – nelfinavir mesylate tab 625 mg...... 7 ZENPEP – pancrelipase (lip-prot-amyl) dr cap VIRAMUNE – nevirapine susp 50 mg/5ml...... 7 3000-10000-16000 unit...... 41 VIREAD – tenofovir disoproxil fumarate oral powder 40 ZENPEP – pancrelipase (lip-prot-amyl) dr cap mg/gm...... 8 5000-17000-24000 unit...... 41 VIREAD – tenofovir disoproxil fumarate tab 150 mg...... 8 ZENPEP – pancrelipase (lip-prot-amyl) dr cap VIREAD – tenofovir disoproxil fumarate tab 200 mg...... 8 5000-17000-27000 unit...... 41 VIREAD – tenofovir disoproxil fumarate tab 250 mg...... 8 ZENPEP – pancrelipase (lip-prot-amyl) dr cap VIREAD – tenofovir disoproxil fumarate tab 300 mg...... 8 10000-32000-42000 unit...... 41 VITEKTA – elvitegravir tab 85 mg...... 8 ZENPEP – pancrelipase (lip-prot-amyl) dr cap VITEKTA – elvitegravir tab 150 mg...... 8 10000-34000-55000 unit...... 41 VOL-PLUS – prenatal vit w/ fe fumarate-fa tab 27-1 ZENPEP – pancrelipase (lip-prot-amyl) dr cap mg...... 72 15000-47000-63000 unit...... 41 voriconazole for susp 40 mg/ml (Vfend)...... 4 ZENPEP – pancrelipase (lip-prot-amyl) dr cap voriconazole tab 50 mg (Vfend)...... 4 15000-51000-82000 unit...... 42 voriconazole tab 200 mg (Vfend)...... 4 ZENPEP – pancrelipase (lip-prot-amyl) dr cap VOTRIENT – pazopanib hcl tab 200 mg (base equiv)...... 15 20000-63000-84000 unit...... 42 ZENPEP – pancrelipase (lip-prot-amyl) dr cap W 20000-68000-109000 unit...... 42 warfarin sodium tab 1 mg (Coumadin)...... 76 ZENPEP – pancrelipase (lip-prot-amyl) dr cap warfarin sodium tab 2 mg (Coumadin)...... 76 25000-85000-136000 unit...... 42 warfarin sodium tab 2.5 mg (Coumadin)...... 76 ZENPEP – pancrelipase (lip-prot-amyl) dr cap warfarin sodium tab 3 mg (Coumadin)...... 76 25000-79000-105000 unit...... 42 warfarin sodium tab 4 mg (Coumadin)...... 76 ZENPEP – pancrelipase (lip-prot-amyl) dr cap warfarin sodium tab 5 mg (Coumadin)...... 76 40000-126000-168000 unit...... 42 warfarin sodium tab 6 mg (Coumadin)...... 76 ZENPEP – pancrelipase (lip-prot-amyl) dr cap warfarin sodium tab 7.5 mg (Coumadin)...... 76 40000-136000-218000 unit...... 42 warfarin sodium tab 10 mg (Coumadin)...... 76 zidovudine cap 100 mg (Retrovir)...... 8 water for irrigation, sterile irrigation soln...... 85 zidovudine syrup 10 mg/ml (Retrovir)...... 8 zidovudine tab 300 mg...... 8 X ziprasidone hcl cap 20 mg (Geodon)...... 55 XALKORI – crizotinib cap 200 mg...... 15 ziprasidone hcl cap 40 mg (Geodon)...... 55 XALKORI – crizotinib cap 250 mg...... 15 ziprasidone hcl cap 60 mg (Geodon)...... 55 XARELTO – rivaroxaban tab 10 mg...... 76 ziprasidone hcl cap 80 mg (Geodon)...... 55 XARELTO – rivaroxaban tab 15 mg...... 76 ZOLINZA – vorinostat cap 100 mg...... 15 XARELTO – rivaroxaban tab 20 mg...... 76 zolpidem tartrate tab 5 mg (Ambien)...... 55 XARELTO STARTER PACK – rivaroxaban tab starter zolpidem tartrate tab 10 mg (Ambien)...... 55 therapy pack 15 mg & 20 mg...... 76 zonisamide cap 50 mg...... 68 XELJANZ – tofacitinib citrate tab 5 mg (base zonisamide cap 25 mg (Zonegran)...... 68 equivalent)...... 64 zonisamide cap 100 mg (Zonegran)...... 69 XELJANZ XR – tofacitinib citrate tab er 24hr 11 mg (base ZORBTIVE – somatropin (non-refrigerated) for equivalent)...... 64 subcutaneous inj 8.8 mg...... 22 XIFAXAN – rifaximin tab 550 mg...... 9 ZORTRESS – everolimus tab 0.25 mg...... 86 XTANDI – enzalutamide cap 40 mg...... 15 ZORTRESS – everolimus tab 0.5 mg...... 86 XULANE – norelgestromin-ethinyl estradiol td ptwk ZORTRESS – everolimus tab 0.75 mg...... 86 150-35 mcg/24hr...... 18 ZYKADIA – ceritinib cap 150 mg...... 15 XURIDEN – uridine triacetate oral granules packet 2 ZYPREXA RELPREVV – olanzapine pamoate for gm...... 23 extended rel im susp 210 mg (base eq)...... 55 ZYPREXA RELPREVV – olanzapine pamoate for extended rel im susp 300 mg (base eq)...... 55

116 2018 ZYPREXA RELPREVV – olanzapine pamoate for extended rel im susp 405 mg (base eq)...... 55 ZYTIGA – abiraterone acetate tab 250 mg...... 15 ZYTIGA – abiraterone acetate tab 500 mg...... 15 ZYVOX – linezolid for susp 100 mg/5ml...... 9

117 Such services are funded in part with the State of New Mexico. Blue Cross and Blue Shield of New Mexico, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association 479328.0718