CDPHP Commercial Clinical Formulary-1 2021

NON-DISCRIMINATION/MULTI-LANGUAGE INTERPRETER SERVICES: APPLIES TO MEMBERS/ENROLLEES ONLY Discrimination is Against the Law Capital District Physicians’ Health Plan, Inc. (CDPHP®) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. CDPHP does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

CDPHP: • Provides free aids and services to people with disabilities to communicate effectively with us, such as: o Qualified sign language interpreters o Written information in other formats (large print, audio, accessible electronic formats, other formats) • Provides free language services to people whose primary language is not English, such as: o Qualified interpreters o Information written in other languages

If you need these services, contact the CDPHP Civil Rights Coordinator.

If you believe that CDPHP has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: CDPHP Civil Rights Coordinator, 500 Patroon Creek Blvd., Albany, NY 12206, 1-844-391-4803 (TTY/TDD: 711), Fax (518) 641-3401. You can file a grievance by mail, fax, or electronically at https://www.cdphp.com/customer-support/email-cdphp. If you need help filing a grievance, the CDPHP Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, 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: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20211, 1-800-868-1019 (TDD 1-800-537-7697).

Multi-language Interpreter Services ATTENTION: If you speak a non-English language, language assistance services, free of charge, are available to you. Call the number on your member ID card (TTY: 711). ATENCIÓN: Si habla otro idioma que no es el inglés, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al número que figura en su tarjeta de identificación de miembro (TTY: 711). 注意：如果您使用的語言不是英語，您可以免費獲得語言援助服務。請致電您會員ID卡上的電話（聽力障礙電傳：711）。

ВНИМАНИЕ: Если вы говорите на иностранном языке, вы можете воспользоваться бесплатными услугами перевода. Позвоните по номеру на вашей ID карточке участника (Телетайп: 711). ATANSYON: Si ou pale yon lang ki pa Angle, wap jwenn sèvis asistans lang gratis disponib pou ou. Rele nimewo ki sou kat ID manm ou a (TTY: 711).

주의: 영어 이외의 언어를 사용하는 경우 무료로 언어 지원 서비스를 받을 수 있습니다. 귀하의 회원 ID 카드에 있는 번호로 전화하십시오(TTY: 711). ATTENZIONE: Se non parla inglese né una lingua anglofona, sono disponibili servizi gratuiti di assistenza linguistica. Chiami il numero presente sulla scheda ID dei membri (TTY: 711). אויפמערקזאם: אויב איר רעדט , זענען פארהאן פאר אייך שפראך הילף סערוויסעס פריי פון אפצאל. רופט דעם נומער אויף אייער מעמבער ID קארטל )TTY:711(

মন োন োগ দি ঃ আপদ দি ইংনেজি বদির্ভ তু ক ো র্োষোয় থো বনে , আপ োে ি য দব ো খেচোয় র্োষো সিোয়তো উপের্য েনয়নে। আপ োে সিসয আইদি োনিুে ম্বনে ে 쇁 (TTY: 711)। UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer na Twojej członkowskiej karcie ID (TTY: 711). تنبيه: إذا كنت تتحدث لغة غير اإلنجليزية، تتوفر إليك خدمات مساعدة اللغة مجانًا. اتصل بالرقم الموجود ببطاقة الهوية لعضويتك )TTY: 711(. ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez au numéro indiqué sur votre carte de membre (ATS : 711). توجہ ديں: اگر آپ انگريزی کے عالوہ دوسری زبان بولتے ہيں تو، آپ کے ليے زبان کی اعانت کی خدمات مفت دستياب ہيں۔ اپنے ممبر آئی ڈی کارڈ پر درج نمبر پر کال کر ي ں )TTY: 711(۔ ATENSYON: Kung nagsasalita kayo ng wikang iba sa Ingles, magagamit niyo ang mga serbisyo sa tulong sa wika nang walang bayad. Tawagan ang numero sa inyong card miyembro ID (TTY: 711). ΠΡΟΣΟΧΗ: Αν δεν μιλάτε Αγγλικά, υπάρχουν στη διάθεσή σας υπηρεσίες γλωσσικής υποστήριξης οι οποίες παρέχονται δωρεάν. Καλέστε τον αριθμό που θα βρείτε στην ατομική σας ταυτότητα μέλους (TTY: 711). VINI RE: Nëse flisni një gjuhë jo-anglisht, shërbime falas të ndihmës së gjuhës janë në dispozicion për ju. Telefonojini numrit në kartën tuaj të ID të anëtarit (TTY: 711). INTRODUCTION Capital District Physicians' Health Plan, Inc. (CDPHP) is pleased to provide the CDPHP Commercial Clinical Formulary-1 2021 as a useful reference and informational tool to assist practitioners in selecting clinically appropriate and cost-effective drug therapies. The information contained in this CDPHP Commercial Clinical Formulary-1 and its appendices is provided by CDPHP, solely for the convenience of medical practitioners. CDPHP does not warrant or assure accuracy of such information nor is it intended to be comprehensive in nature. This CDPHP Commercial Clinical Formulary-1 is not intended to be a substitute for the knowledge, expertise, skill, and judgment of the medical practitioner in his/her choice of prescription drugs. All the information in the CDPHP Commercial Clinical Formulary-1 is provided as a reference for drug therapy selection. Specific drug selection for an individual patient rests solely with the prescriber. The document is subject to state-specific regulations and rules, including, but not limited to, those regarding generic substitution, controlled substance schedules, preference for brands and mandatory generics whenever applicable. CDPHP assumes no responsibility for the actions or omissions of any medical practitioner based upon reliance, in whole or in part, on the information contained herein. The medical practitioner should consult the drug manufacturer's product literature or standard references for more detailed information. National guidelines can be found on the National Guideline Clearinghouse site at http://www.guideline.gov.

Please note, the information found in the CDPHP Commercial Clinical Formulary-1 does not apply to any of the CDPHP Medicare or Medicaid products that offer prescription drug benefits. For information on these plans, please visit the Medicare or Medicaid Information section on http://www.cdphp.com. PREFACE The CDPHP Commercial Clinical Formulary-1 represents CDPHP's prescription drug formulary and is organized by sections. Each section is divided by therapeutic drug class primarily defined by mechanism of action. Unless exceptions are noted, generally all applicable dosage forms and strengths of the drug cited are included in the CDPHP Commercial Clinical Formulary-1. Generics should be considered the first line of prescribing. The CDPHP formulary is a closed formulary. In a closed formulary, drugs are either covered or excluded (not covered). Excluded products are only available by medical exception. Coverage of any agent listed in the formulary is subject to the member's contract and prescription drug rider. Quantity limits, prior authorization, dose optimization, and/or step therapy requirements may apply. Injectables are generally covered under the medical benefit. Injectables that are listed in the CDPHP Commercial Clinical Formulary-1 are covered under the pharmacy benefit (and require a drug rider) unless otherwise noted by the "^" symbol. Pharmacy benefits may impose additional coverage restrictions or may not cover selected drug products. In addition, over-the- counter (OTC) products, with the exception of insulin and diabetes monitoring products, are usually not covered benefits unless the OTC product has been added to the formulary. Drugs represented in the CDPHP Commercial Clinical Formulary-1 may have varying cost to the member. Tier 1 medications are available at the lowest cost, and tier 3 medications and medications not on the list will cost the most. The tiered format places drugs into tiers in the following manner: Tier 1: Generic prescription drugs which offer the most cost-effective alternative to available brand-name prescription drug products. This tier also includes those over-the-counter drugs on the CDPHP formulary. It may also include those brand-name prescription drug products determined by the Plan's Pharmacy and Therapeutics (P&T) Committee to be included in quality initiative programs. Tier 2: Preferred brand-name prescription drug products which offer overall clinical and/or financial value. Selected generic prescription drug products may also be included in this tier if they are not as cost-effective as a tier 1 generic drug. Tier 3: All other covered brand-name or generic prescription drugs which do not offer significant clinical and/or cost advantages over a tier 1 or a tier 2 drug.

Due to Federal and New York State mandates, certain drug classes will have no member cost share or a reduced member cost share than what is stated in this document. Examples of these drug classes include, but are not limited to, diabetic drugs, oral contraceptives and oral oncology drugs.

Please note that all new drugs will be excluded from the formulary and require prior authorization until reviewed by the CDPHP P&T Committee. PHARMACY AND THERAPEUTICS (P&T) COMMITTEE The CDPHP P&T Committee includes a cross-section of practicing network physicians and pharmacists whose primary role on the committee is to ensure that the most clinically appropriate and cost-effective drugs will be available for CDPHP members. The P&T Committee is responsible for reviewing new drugs, reviewing and revising pharmacy policies, reviewing patient profiles and drug utilization review quarterly reports, and reviewing clinical initiatives/programs for all lines of business. The members of the P&T Committee are bound by a confidentiality and conflict of interest agreement, which is renewed annually.

The actions of the CDPHP P&T Committee are communicated after each committee meeting by posting final decisions on the CDPHP Web page Formulary Updates section of Rx Corner on the Providers tab of http://www.cdphp.com. PRODUCT SELECTION CRITERIA All new drugs will be excluded from the formulary and require prior authorization review until reviewed by the P&T Committee. CDPHP P&T Committee will consider inclusion to the formulary based on recommendations by CVS Caremark®. When a new drug is considered for formulary inclusion, it will be reviewed relative to similar drugs currently on formulary. In addition, the entire CDPHP formulary is reviewed on an annual basis. Quantity limitations, prior authorizations, dose optimization, and/or step therapy may also apply to formulary drugs. Excluded drugs are not covered unless medical exception procedures have been followed and a medical exception is approved. Please note that certain drugs are additionally excluded in member contracts (e.g., cosmetic agents). GENERIC SUBSTITUTION Generic substitution is a pharmacy action whereby a generic version is dispensed rather than a prescribed brand- name product. Lowercase font indicates generic availability. One way to reduce out-of-pocket cost is by requesting a generic drug. Generic drugs are usually priced lower than their brand-name equivalents. Research shows that members can save an average of 30-80% when they fill their prescriptions with a generic drug instead of a brand- name drug. Prescription generic drugs undergo a strict U.S. Food and Drug Administration (FDA) approval process. Here are just some of the FDA standards and practices that generic manufacturers must follow:

• A generic medicine must be bioequivalent (performs in the same manner) to its brand-name counterpart. • A generic medicine must pass the FDA's review for both active and inactive ingredients. • The manufacturer facility of the generic medicine must pass FDA inspection. • The generic medicine must have the same active ingredients and be available in the same strength and dosage form as its brand-name counterpart. • The label of the generic medicine must include the same information found on the packaging of its brand- name counterpart. • Finally, the FDA continues to monitor the generic drug for quality control after it has been approved (http://www.fda.gov). The FDA is very strict in their view of a generic medicine before it goes to market. In most cases, the average person would not be able to tell the difference between a generic and a brand-name drug, other than the size, color or shape. In fact, U.S. trademark laws require that generics look different from their brand-name equivalents. SPECIALTY DRUGS (SP) Specialty pharmaceuticals are used in the management of complex chronic or genetic conditions and certain catastrophic diseases. They are often injectable medications, but they may also include oral agents. CDPHP has chosen CVS Specialty™ Pharmacy to dispense certain high-cost injectables and biotech drugs for its members. Eligible members will need to register and will receive a 30-day supply of medications and additional supplies needed to administer the medications. Getting started with CVS Specialty Pharmacy is easy. There are three different options for contacting them: by phone toll-free at 1-800-237-2767, by fax toll-free at 1-800-323-2445 or online at https://www.cvsspecialty.com. CVS Caremark

provides side-effect counseling, condition-specific materials, refill reminder calls, and access to health care professionals for emergency consultation 24 hours a day, seven days a week. CVS Caremark also provides Patient Resource Centers online at https://www.cvsspecialty.com. CDPHP members can access the latest news, helpful tips, interactive tools, drug information, safety alerts, support groups, links to communities, as well as other useful resources. Drugs that are available to be filled through CVS Specialty Pharmacy are noted within this booklet by the "SP" symbol, and drugs which are required to be filled through CVS Specialty Pharmacy are noted by the symbol "SPC". CVS Specialty Pharmacy can be contacted by calling, toll-free at 1-800-237-2767. PRIOR AUTHORIZATION (PA) CDPHP requires prior authorization for certain drugs before they will be approved for coverage. Coverage will be approved when specific approval criteria for that drug is met, according to CDPHP policies. Drugs indicated as requiring prior authorization is subject to change from time to time.. If a drug is listed as requiring prior authorization, the prescribing practitioner should initiate a prior authorization request with CDPHP. Prior authorization can be requested through the CDPHP Pharmacy Department by faxing the request to (518) 641-3208. Drugs that require prior authorization are noted within this booklet by the "PA" symbol ^ Covered under the medical benefit OTC Over the Counter PA Prior Authorization PD Preventive Drug QL Quantity Limitations apply SP Available through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 SPC Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST Step Therapy criteria applies ACA Covered under the Affordable Care Act; no member cost share RXC/M Pharmacy Care Management Program

PRESCRIPTION QUANTITY MANAGEMENT CDPHP, working closely with the P&T Committee members, has chosen to limit the quantity of certain drugs that CDPHP may cover for a member. Quantity limits are in place for quality and/or clinical considerations. The list of drugs that have quantity limits is subject to change from time to time and may not be all-inclusive. Drugs that have quantity limits are noted within this booklet by the "QL" symbol. DOSE OPTIMIZATION Dose optimization is a program to support appropriate and cost-effective drug therapy by recommending a higher once-daily dose of a product when members are taking multiple-daily doses of a lower strength. For example, a member may be taking two 20 mg tablets of a drug per day when only one 40 mg tablet could be used. If a practitioner determines that multiple daily doses are medically necessary, please submit the CDPHP Medical Exception Form by fax to (518) 641-3208 for consideration. STEP THERAPY (ST) The Step Therapy (ST) program is another form of prior authorization. The step therapy program uses a standard protocol to determine if members qualify for a drug that otherwise would not be covered. Using the standard protocol, certain drugs are not covered unless members have tried one or more "prerequisite therapy" medication(s) first. If it is

medically necessary for a member to use a step therapy medication as initial therapy without trying a "prerequisite therapy" drug, the practitioner can request coverage of the step therapy medication through a medical exception. The list of drugs that require step therapy is subject to change from time to time and may not be all-inclusive. If a drug is required and the practitioner determines that the drug is medically necessary, please submit the CDPHP Medical Exception Form by fax to (518) 641-3208 for consideration. Drugs that require step therapy are noted within this booklet by the "ST" symbol. MEDICAL EXCEPTION PROCESS The CDPHP P&T Committee developed the Medical Exception policy so that practitioners may request an excluded drug for a specific patient when medically necessary. The Medical Exception process is coordinated through CDPHP's Pharmacy Department. Requests are processed in the order received. Medical exceptions can be requested through the CDPHP Pharmacy Department by faxing the request to (518) 641-3208. In addition, a member may initiate a medical exception request by calling the telephone number to CVS Caremark printed on their CDPHP identification card or by utilizing the "Medical Exception Request" option found under Prescription Forms & Lists on the Forms and Tools section on the members tab of CDPHP's website, www.cdphp.com. A response will be sent to both the medical practitioner and member as soon as possible. EDITOR Your comments and suggestions regarding the CDPHP Commercial Clinical Formulary-1 2021 are encouraged. Your input is vital to this formulary's continued success. All responses will be reviewed and considered. Please send your comments to: CDPHP, Pharmacy Department 500 Patroon Creek Boulevard Albany, NY 12206-1057 E-mail: [email protected] Internet: http://www.cdphp.com LEGEND ^ Covered under the medical benefit OTC Over the counter PA Prior Authorization; refer to Prior Authorization section PD Preventive Drug QL Quantity Limitations; refer to Prescription Quantity Management section SP Available through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 SPC Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST Step Therapy; refer to Step Therapy section ACA Covered under the Affordable Care Act; no member cost share RXC/M Pharmacy Care Management Program

NOTICE The information contained in this document is proprietary. The information may not be copied in whole or in part without the written permission of Capital District Physicians' Health Plan, Inc., Capital Physicians' Healthcare Network, Inc., and CDPHP Universal Benefits, Inc. (collectively known as CDPHP). ©2021. All rights reserved.

The drug names listed here are the registered and/or unregistered trademarks of third-party pharmaceutical companies unrelated to and unaffiliated with CDPHP. These trademarked brand names are included here for informational purposes only and are not intended to imply or suggest any affiliation between CDPHP and such third- party pharmaceutical companies. CDPHP and CVS Caremark do not operate the websites/organizations listed here, nor are they responsible for the availability or reliability of the websites' content. These listings do not imply or constitute an endorsement, sponsorship or recommendation by CDPHP or CVS Caremark.

CDPHP Formulary1 eff 07/01/2021 Drug Name Drug Tier Requirements/Limits ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS AMPHETAMINES amphetamine-dextroamphetamine cap er 1 QL (60 caps / 30 days) 24hr 5 mg (generic of ADDERALL XR) amphetamine-dextroamphetamine cap er 1 QL (60 caps / 30 days) 24hr 10 mg (generic of ADDERALL XR) amphetamine-dextroamphetamine cap er 1 QL (60 caps / 30 days) 24hr 15 mg (generic of ADDERALL XR) amphetamine-dextroamphetamine cap er 1 QL (60 caps / 30 days) 24hr 20 mg (generic of ADDERALL XR) amphetamine-dextroamphetamine cap er 1 QL (60 caps / 30 days) 24hr 25 mg (generic of ADDERALL XR) amphetamine-dextroamphetamine cap er 1 QL (60 caps / 30 days) 24hr 30 mg (generic of ADDERALL XR) amphetamine-dextroamphetamine tab 5 1 QL (90 tabs / 30 days) mg (generic of ADDERALL) amphetamine-dextroamphetamine tab 7.5 1 QL (90 tabs / 30 days) mg (generic of ADDERALL) amphetamine-dextroamphetamine tab 10 1 QL (90 tabs / 30 days) mg (generic of ADDERALL) amphetamine-dextroamphetamine tab 1 QL (90 tabs / 30 days) 12.5 mg (generic of ADDERALL) amphetamine-dextroamphetamine tab 15 1 QL (90 tabs / 30 days) mg (generic of ADDERALL) amphetamine-dextroamphetamine tab 20 1 QL (90 tabs / 30 days) mg (generic of ADDERALL) amphetamine-dextroamphetamine tab 30 1 QL (90 tabs / 30 days) mg (generic of ADDERALL) dexedrine tab 5mg 1 QL (120 tabs / 30 days) dexedrine tab 10mg 1 QL (120 tabs / 30 days) dextroamphetamine sulfate cap er 24hr 5 1 QL (120 caps / 30 days) mg (generic of DEXEDRINE) dextroamphetamine sulfate cap er 24hr 10 1 QL (120 caps / 30 days) mg (generic of DEXEDRINE) dextroamphetamine sulfate cap er 24hr 15 1 QL (120 caps / 30 days) mg (generic of DEXEDRINE) dextroamphetamine sulfate oral solution 5 1 mg/5ml VYVANSE CAP 10MG 2 QL (30 caps / 30 days) VYVANSE CAP 20MG 2 QL (30 caps / 30 days) VYVANSE CAP 30MG 2 QL (30 caps / 30 days) VYVANSE CAP 40MG 2 QL (30 caps / 30 days)

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 8 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits VYVANSE CAP 50MG 2 QL (30 caps / 30 days) VYVANSE CAP 60MG 2 QL (30 caps / 30 days) VYVANSE CAP 70MG 2 QL (30 caps / 30 days) ANOREXIANTS NON-AMPHETAMINE benzphetamine hcl tab 50 mg 1 PA; PD diethylpropion hcl tab 25 mg 1 PA; PD diethylpropion hcl tab er 24hr 75 mg 1 PA; PD phendimetrazine tartrate tab 35 mg 1 PA; PD phentermine hcl cap 15 mg 1 PA; PD phentermine hcl cap 30 mg 1 PA; PD phentermine hcl cap 37.5 mg (generic of 1 PA; PD ADIPEX-P) phentermine hcl tab 37.5 mg (generic of 1 PA; PD ADIPEX-P) QSYMIA CAP 3.75-23 2 PA; PD QSYMIA CAP 7.5-46MG 2 PA; PD QSYMIA CAP 11.25-69 2 PA; PD QSYMIA CAP 15-92MG 2 PA; PD ANTI-OBESITY AGENTS CONTRAVE TAB 8-90MG 3 PA; PD SAXENDA INJ 18MG/3ML 3 PA; PD XENICAL CAP 120MG 3 PA; PD ATTENTION-DEFICIT/HYPERACTIVITY DISORDER (ADHD) AGENTS atomoxetine hcl cap 10 mg (base equiv) 1 (generic of STRATTERA) atomoxetine hcl cap 18 mg (base equiv) 1 (generic of STRATTERA) atomoxetine hcl cap 25 mg (base equiv) 1 (generic of STRATTERA) atomoxetine hcl cap 40 mg (base equiv) 1 (generic of STRATTERA) atomoxetine hcl cap 60 mg (base equiv) 1 (generic of STRATTERA) atomoxetine hcl cap 80 mg (base equiv) 1 (generic of STRATTERA) atomoxetine hcl cap 100 mg (base equiv) 1 (generic of STRATTERA) clonidine hcl tab er 12hr 0.1 mg (generic of 1 KAPVAY) guanfacine hcl tab er 24hr 1 mg (base 1 equiv) (generic of INTUNIV)

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 9 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits guanfacine hcl tab er 24hr 2 mg (base 1 equiv) (generic of INTUNIV) guanfacine hcl tab er 24hr 3 mg (base 1 equiv) (generic of INTUNIV) guanfacine hcl tab er 24hr 4 mg (base 1 equiv) (generic of INTUNIV) STIMULANTS - MISC. armodafinil tab 50 mg (generic of 3 QL (30 tabs / 30 days) NUVIGIL) armodafinil tab 150 mg (generic of 3 QL (30 tabs / 30 days) NUVIGIL) armodafinil tab 200 mg (generic of 3 QL (30 tabs / 30 days) NUVIGIL) armodafinil tab 250 mg (generic of 3 QL (30 tabs / 30 days) NUVIGIL) DAYTRANA DIS 10MG/9HR 2 QL (30 patches / 30 days) DAYTRANA DIS 15MG/9HR 2 QL (30 patches / 30 days) DAYTRANA DIS 20MG/9HR 2 QL (30 patches / 30 days) DAYTRANA DIS 30MG/9HR 2 QL (30 patches / 30 days) dexmethylphenidate hcl cap er 24 hr 5 mg 2 QL (30 caps / 30 days) (generic of FOCALIN XR) dexmethylphenidate hcl cap er 24 hr 10 2 QL (30 caps / 30 days) mg (generic of FOCALIN XR) dexmethylphenidate hcl cap er 24 hr 15 2 QL (30 caps / 30 days) mg (generic of FOCALIN XR) dexmethylphenidate hcl cap er 24 hr 20 2 QL (30 caps / 30 days) mg (generic of FOCALIN XR) dexmethylphenidate hcl cap er 24 hr 25 2 QL (30 caps / 30 days) mg (generic of FOCALIN XR) dexmethylphenidate hcl cap er 24 hr 30 2 QL (30 caps / 30 days) mg (generic of FOCALIN XR) dexmethylphenidate hcl cap er 24 hr 35 2 QL (30 caps / 30 days) mg (generic of FOCALIN XR) dexmethylphenidate hcl cap er 24 hr 40 2 QL (30 caps / 30 days) mg (generic of FOCALIN XR) dexmethylphenidate hcl tab 2.5 mg 1 QL (90 tabs / 30 days) (generic of FOCALIN) dexmethylphenidate hcl tab 5 mg (generic 1 QL (90 tabs / 30 days) of FOCALIN)

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 10 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits dexmethylphenidate hcl tab 10 mg 1 QL (90 tabs / 30 days) (generic of FOCALIN) methylphenidate hcl cap er 10 mg (cd) 1 QL (60 ea / 30 days) methylphenidate hcl cap er 20 mg (cd) 1 QL (60 caps / 30 days) methylphenidate hcl cap er 24hr 10 mg 3 (la) (generic of RITALIN LA) methylphenidate hcl cap er 24hr 20 mg 1 QL (60 caps / 30 days) (la) (generic of RITALIN LA) methylphenidate hcl cap er 24hr 30 mg 1 QL (60 caps / 30 days) (la) (generic of RITALIN LA) methylphenidate hcl cap er 24hr 40 mg 1 QL (60 caps / 30 days) (la) (generic of RITALIN LA) methylphenidate hcl cap er 24hr 60 mg 1 QL (60 caps / 30 days) (la) methylphenidate hcl cap er 30 mg (cd) 1 QL (60 ea / 30 days) methylphenidate hcl cap er 40 mg (cd) 1 QL (60 caps / 30 days) methylphenidate hcl cap er 50 mg (cd) 1 QL (60 caps / 30 days) methylphenidate hcl cap er 60 mg (cd) 1 QL (60 caps / 30 days) methylphenidate hcl chew tab 2.5 mg 3 methylphenidate hcl chew tab 5 mg 3 methylphenidate hcl chew tab 10 mg 3 methylphenidate hcl soln 5 mg/5ml 2 QL (1800 mL / 30 days) (generic of METHYLIN) methylphenidate hcl soln 10 mg/5ml 2 (generic of METHYLIN) methylphenidate hcl tab 5 mg (generic of 1 QL (90 tabs / 30 days) RITALIN) methylphenidate hcl tab 10 mg (generic of 1 QL (90 tabs / 30 days) RITALIN) methylphenidate hcl tab 20 mg (generic of 1 QL (90 tabs / 30 days) RITALIN) methylphenidate hcl tab er 10 mg 1 QL (60 tabs / 30 days) methylphenidate hcl tab er 20 mg 1 QL (60 tabs / 30 days) methylphenidate hcl tab er 24hr 18 mg 1 QL (60 tabs / 30 days) methylphenidate hcl tab er 24hr 27 mg 1 QL (60 tabs / 30 days) methylphenidate hcl tab er 24hr 36 mg 1 QL (60 tabs / 30 days) methylphenidate hcl tab er 24hr 54 mg 1 QL (60 tabs / 30 days) methylphenidate hcl tab er osmotic release 1 QL (60 tabs / 30 days) (osm) 18 mg (generic of CONCERTA) methylphenidate hcl tab er osmotic release 1 QL (60 ea / 30 days) (osm) 27 mg (generic of CONCERTA) methylphenidate hcl tab er osmotic release 1 QL (60 ea / 30 days) (osm) 36 mg (generic of CONCERTA)

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 11 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits methylphenidate hcl tab er osmotic release 1 QL (60 ea / 30 days) (osm) 54 mg (generic of CONCERTA) QUILLICHEW CHW 20MG ER 3 QL (60 tabs / 30 days) QUILLICHEW CHW 30MG ER 3 QL (60 tabs / 30 days) QUILLICHEW CHW 40MG ER 3 QL (60 tabs / 30 days) QUILLIVANT SUS 25MG/5ML 3 QL (360 mL / 30 days) RITALIN LA CAP 60MG 3 ALLERGENIC EXTRACTS/BIOLOGICALS MISC ALLERGENIC EXTRACTS PALFORZIA CAP ESCALAT 3 PA PALFORZIA CAP LEVEL 1 3 PA PALFORZIA CAP LEVEL 2 3 PA PALFORZIA CAP LEVEL 3 3 PA PALFORZIA CAP LEVEL 4 3 PA PALFORZIA CAP LEVEL 5 3 PA PALFORZIA CAP LEVEL 6 3 PA PALFORZIA CAP LEVEL 7 3 PA PALFORZIA CAP LEVEL 8 3 PA PALFORZIA CAP LEVEL 9 3 PA PALFORZIA CAP LEVEL 10 3 PA PALFORZIA POW LEVEL 11 3 PA AMINOGLYCOSIDES AMINOGLYCOSIDES gentamicin sulfate inj 40 mg/ml 1 PA; ^ neomycin sulfate tab 500 mg 1 paromomycin sulfate cap 250 mg (generic 1 of HUMATIN) TOBI PODHALR CAP 28MG 2 SPC tobramycin nebu soln 300 mg/5ml (generic 2 SPC of KITABIS PAK) ANALGESICS - ANTI-INFLAMMATORY ANTI-TNF-ALPHA - MONOCLONAL ANTIBODIES HUMIRA INJ 10/0.1ML 2 PA, QL ; SPC HUMIRA INJ 10MG/0.2 2 PA, QL ; SPC HUMIRA INJ 20/0.2ML 2 PA, QL ; SPC HUMIRA INJ 40/0.4ML 2 PA, QL ; SPC HUMIRA KIT 20MG/0.4 2 PA, QL ; SPC HUMIRA KIT 40MG/0.8 2 PA, QL ; SPC HUMIRA PEDIA INJ CROHNS 2 PA, QL ; SPC HUMIRA PEN INJ 40/0.4ML 2 PA, QL ; SPC HUMIRA PEN INJ 40MG/0.8 2 PA, QL ; SPC

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 12 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits HUMIRA PEN KIT CD/UC/HS 2 PA, QL ; SPC HUMIRA PEN KIT PS/UV 2 PA, QL ; SPC ANTIRHEUMATIC - ENZYME INHIBITORS RINVOQ TAB 15MG ER 2 PA, QL ; SPC XELJANZ SOL 1MG/ML 2 PA, QL (60 mL / 30 days) XELJANZ TAB 5MG 2 PA, QL ; SPC XELJANZ TAB 10MG 2 PA, QL ; SPC XELJANZ XR TAB 11MG 2 PA, QL ; SPC XELJANZ XR TAB 22MG 2 PA, QL ; SPC ANTIRHEUMATIC ANTIMETABOLITES RHEUMATREX TAB 2.5MG 3 INTERLEUKIN-1 BLOCKERS ARCALYST INJ 220MG 3 PA; SPC INTERLEUKIN-6 RECEPTOR INHIBITORS ACTEMRA INJ 162/0.9 2 PA, QL ; SPC ACTEMRA INJ ACTPEN 2 PA, QL ; SPC NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS) celecoxib cap 50 mg (generic of 2 QL (60 caps / 30 days) CELEBREX) celecoxib cap 100 mg (generic of 2 QL (60 caps / 30 days) CELEBREX) celecoxib cap 200 mg (generic of 2 QL (60 caps / 30 days) CELEBREX) celecoxib cap 400 mg (generic of 2 QL (60 caps / 30 days) CELEBREX) diclofenac potassium tab 50 mg 1 diclofenac sodium tab delayed release 25 1 mg diclofenac sodium tab delayed release 50 1 Rx4L mg diclofenac sodium tab delayed release 75 1 Rx4L mg diclofenac sodium tab er 24hr 100 mg 1 diclofenac w/ misoprostol tab delayed 3 release 50-0.2 mg (generic of ARTHROTEC 50) diclofenac w/ misoprostol tab delayed 3 release 75-0.2 mg (generic of ARTHROTEC 75) etodolac cap 200 mg 1 etodolac cap 300 mg 1

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 13 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits etodolac tab 400 mg (generic of LODINE) 1 etodolac tab 500 mg 1 etodolac tab er 24hr 400 mg 1 etodolac tab er 24hr 500 mg 1 etodolac tab er 24hr 600 mg 1 fenoprofen calcium cap 400 mg 3 fenoprofen calcium tab 600 mg 1 flurbiprofen tab 50 mg 1 flurbiprofen tab 100 mg 1 ibuprofen susp 100 mg/5ml 1 ibuprofen tab 400 mg 1 Rx4L ibuprofen tab 600 mg 1 Rx4L ibuprofen tab 800 mg 1 Rx4L INDOCIN SUP 50MG 2 INDOCIN SUS 25MG/5ML 2 indomethacin cap 25 mg 1 Rx4L indomethacin cap 50 mg 1 indomethacin cap er 75 mg 1 ketoprofen cap 50 mg 1 ketoprofen cap 75 mg 1 ketoprofen cap er 24hr 200 mg 1 ketorolac tromethamine im inj 60 mg/2ml 1 PA; ^ (30 mg/ml) ketorolac tromethamine inj 30 mg/ml 1 PA; ^ ketorolac tromethamine inj 300 mg/10ml 1 PA; ^ (30 mg/ml) ketorolac tromethamine tab 10 mg 1 QL (20 tabs / year) meclofenamate sodium cap 50 mg 1 meclofenamate sodium cap 100 mg 1 mefenamic acid cap 250 mg 2 meloxicam susp 7.5 mg/5ml 1 meloxicam tab 7.5 mg (generic of MOBIC) 1 Rx4L meloxicam tab 15 mg (generic of MOBIC) 1 Rx4L nabumetone tab 500 mg 1 PD nabumetone tab 750 mg 1 PD naproxen dr tab 375mg (generic of EC- 1 NAPROSYN) naproxen dr tab 500mg (generic of EC- 1 NAPROSYN) naproxen sodium tab 275 mg 1 naproxen sodium tab 550 mg (generic of 1 ANAPROX DS)

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 14 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits naproxen susp 125 mg/5ml (generic of 1 NAPROSYN) naproxen tab 250 mg 1 naproxen tab 375 mg 1 Rx4L naproxen tab 500 mg (generic of 1 Rx4L NAPROSYN) oxaprozin tab 600 mg (generic of DAYPRO) 1 piroxicam cap 10 mg (generic of FELDENE) 1 piroxicam cap 20 mg (generic of FELDENE) 1 sulindac tab 150 mg 1 sulindac tab 200 mg 1 tolmetin sodium cap 400 mg 1 tolmetin sodium tab 200 mg 1 tolmetin sodium tab 600 mg 1 PHOSPHODIESTERASE 4 (PDE4) INHIBITORS OTEZLA TAB 10/20/30 2 PA, QL ; SPC OTEZLA TAB 30MG 2 PA, QL ; SPC PYRIMIDINE SYNTHESIS INHIBITORS leflunomide tab 10 mg (generic of ARAVA) 1 SP leflunomide tab 20 mg (generic of ARAVA) 1 SP SOLUBLE TUMOR NECROSIS FACTOR RECEPTOR AGENTS ENBREL INJ 25/0.5ML 2 PA, QL ; SPC ENBREL INJ 25MG 2 PA, QL ; SPC ENBREL INJ 50MG/ML 2 PA, QL ; SPC ENBREL MINI INJ 50MG/ML 2 PA, QL ; SPC ENBREL SRCLK INJ 50MG/ML 2 PA, QL ; SPC ANALGESICS - NONNARCOTIC ANALGESIC COMBINATIONS butalbital-acetaminophen tab 50-325 mg 1 butalbital-acetaminophen-caffeine cap 50- 1 300-40 mg (generic of FIORICET) butalbital-acetaminophen-caffeine cap 50- 1 325-40 mg butalbital-acetaminophen-caffeine tab 50- 1 325-40 mg (generic of ESGIC) butalbital-aspirin-caffeine cap 50-325-40 1 mg SALICYLATES aspirin chw 81mg 1 QL (100 tabs / 30 days), OTC; ACA

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 15 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits aspirin low tab 81mg ec 1 QL (100 tabs / 30 days), OTC; ACA aspirin tab 81mg 1 QL (100 tabs / 30 days), OTC; ACA aspirin tab 325 mg 1 QL (100 tabs / 30 days), OTC; ACA aspirin tab delayed release 325 mg 1 QL (100 tabs / 30 days), OTC; ACA choline & magnesium salicylates liq 500 1 mg/5ml choline & magnesium salicylates tab 1000 1 mg diflunisal tab 500 mg 1 salsalate tab 500 mg 1 salsalate tab 750 mg 1 ANALGESICS – OPIOID The quantity of opioid products covered (including those that are combined with acetaminophen, aspirin or ibuprofen) will be limited to up to 90 morphine milligram equivalents (MME) per day OPIOID AGONISTS fentanyl citrate lozenge on a handle 200 1 PA, QL mcg (generic of ACTIQ) fentanyl citrate lozenge on a handle 400 1 PA, QL mcg (generic of ACTIQ) fentanyl citrate lozenge on a handle 600 1 PA, QL mcg (generic of ACTIQ) fentanyl citrate lozenge on a handle 800 1 PA, QL mcg (generic of ACTIQ) fentanyl citrate lozenge on a handle 1200 1 PA, QL mcg (generic of ACTIQ) fentanyl citrate lozenge on a handle 1600 1 PA, QL mcg (generic of ACTIQ) fentanyl td patch 72hr 12 mcg/hr (generic 1 PA, QL of DURAGESIC) fentanyl td patch 72hr 25 mcg/hr (generic 1 PA, QL of DURAGESIC) fentanyl td patch 72hr 50 mcg/hr (generic 1 PA, QL of DURAGESIC) fentanyl td patch 72hr 75 mcg/hr (generic 1 PA, QL of DURAGESIC) fentanyl td patch 72hr 100 mcg/hr (generic 1 PA, QL of DURAGESIC) hydromorphone hcl liqd 1 mg/ml (generic 1 QL of DILAUDID)

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 16 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits hydromorphone hcl tab 2 mg (generic of 1 QL DILAUDID) hydromorphone hcl tab 4 mg (generic of 1 QL DILAUDID) hydromorphone hcl tab 8 mg (generic of 1 PA, QL DILAUDID) hydromorphone hcl tab er 24hr 8 mg 3 PA, QL hydromorphone hcl tab er 24hr 12 mg 3 PA, QL hydromorphone hcl tab er 24hr 16 mg 3 PA, QL hydromorphone hcl tab er 24hr 32 mg 3 PA, QL meperidine hcl oral soln 50 mg/5ml 1 methadone hcl tab 5 mg 1 PA, QL methadone hcl tab 10 mg 1 PA, QL morphine sulfate oral soln 10 mg/5ml 1 QL morphine sulfate oral soln 20 mg/5ml 1 QL morphine sulfate oral soln 100 mg/5ml (20 1 QL mg/ml) morphine sulfate suppos 5 mg 1 QL morphine sulfate suppos 10 mg 1 QL morphine sulfate suppos 20 mg 1 QL MORPHINE SULFATE SUPPOS 30 MG 1 QL morphine sulfate tab 15 mg 1 QL morphine sulfate tab 30 mg 1 PA, QL morphine sulfate tab er 15 mg (generic of 1 PA, QL MS CONTIN) morphine sulfate tab er 30 mg (generic of 1 PA, QL MS CONTIN) morphine sulfate tab er 60 mg (generic of 1 PA, QL MS CONTIN) NUCYNTA ER TAB 50MG 3 PA, QL NUCYNTA ER TAB 100MG 3 PA, QL NUCYNTA ER TAB 150MG 3 PA, QL NUCYNTA ER TAB 200MG 3 PA, QL NUCYNTA ER TAB 250MG 3 PA, QL NUCYNTA TAB 50MG 2 PA NUCYNTA TAB 75MG 2 PA NUCYNTA TAB 100MG 2 PA oxycodone hcl cap 5 mg 1 QL oxycodone hcl soln 5 mg/5ml 1 QL oxycodone hcl tab 5 mg (generic of 1 QL ROXICODONE) oxycodone hcl tab 10 mg 1 QL

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 17 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits oxycodone hcl tab 15 mg (generic of 1 PA, QL ROXICODONE) oxycodone hcl tab 20 mg 1 PA, QL oxycodone hcl tab 30 mg (generic of 1 PA, QL ROXICODONE) oxycodone hcl tab er 12hr deter 10 mg 3 PA, QL oxycodone hcl tab er 12hr deter 15 mg 3 PA, QL oxycodone hcl tab er 12hr deter 20 mg 3 PA, QL oxycodone hcl tab er 12hr deter 40 mg 3 PA, QL oxycodone hcl tab er 12hr deter 80 mg 3 PA, QL OXYCONTIN TAB 10MG CR 3 PA, QL OXYCONTIN TAB 15MG CR 3 PA, QL OXYCONTIN TAB 20MG CR 3 PA, QL OXYCONTIN TAB 40MG CR 3 PA, QL OXYCONTIN TAB 80MG CR 3 PA, QL oxymorphone hcl tab 5 mg 1 PA, QL oxymorphone hcl tab 10 mg 1 PA, QL oxymorphone hcl tab er 12hr 5 mg 3 PA, QL oxymorphone hcl tab er 12hr 7.5 mg 3 PA, QL oxymorphone hcl tab er 12hr 10 mg 3 PA, QL oxymorphone hcl tab er 12hr 15 mg 3 PA, QL oxymorphone hcl tab er 12hr 20 mg 3 PA, QL oxymorphone hcl tab er 12hr 30 mg 3 PA, QL oxymorphone hcl tab er 12hr 40 mg 3 PA, QL tramadol hcl tab 50 mg (generic of 1 QL ULTRAM) tramadol hcl tab er 24hr 100 mg 1 QL tramadol hcl tab er 24hr 200 mg 1 QL tramadol hcl tab er 24hr 300 mg 1 QL OPIOID COMBINATIONS acetaminophen w/ codeine soln 120-12 1 QL mg/5ml acetaminophen w/ codeine tab 300-15 mg 1 QL acetaminophen w/ codeine tab 300-30 mg 1 QL acetaminophen w/ codeine tab 300-60 mg 1 QL ascomp/cod cap 30mg 1 aspirin-caffeine-dihydrocodeine cap 356.4- 1 30-16 mg butalbital-acetaminophen-caff w/ cod cap 1 50-300-40-30 mg butalbital-acetaminophen-caff w/ cod cap 1 50-325-40-30 mg

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 18 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits hydrocodone-acetaminophen soln 7.5-325 1 QL mg/15ml hydrocodone-acetaminophen soln 10-325 1 QL mg/15ml hydrocodone-acetaminophen tab 2.5-325 1 QL mg hydrocodone-acetaminophen tab 5-325 mg 1 QL hydrocodone-acetaminophen tab 7.5-325 1 QL mg hydrocodone-acetaminophen tab 10-325 1 QL mg hydrocodone-ibuprofen tab 5-200 mg 1 QL hydrocodone-ibuprofen tab 7.5-200 mg 1 QL hydrocodone-ibuprofen tab 10-200 mg 1 QL oxycodone w/ acetaminophen soln 5-325 1 mg/5ml oxycodone w/ acetaminophen tab 2.5-325 1 QL mg (generic of PERCOCET) oxycodone w/ acetaminophen tab 5-325 1 QL mg (generic of PERCOCET) oxycodone w/ acetaminophen tab 7.5-325 1 QL mg (generic of PERCOCET) oxycodone w/ acetaminophen tab 10-325 1 QL mg (generic of PERCOCET) oxycodone-aspirin tab 4.8355-325 mg 1 QL oxycodone-ibuprofen tab 5-400 mg 1 QL ROXICET SOL 5-325/5 2 tramadol-acetaminophen tab 37.5-325 mg 1 QL (generic of ULTRACET) OPIOID PARTIAL AGONISTS buprenorphine hcl sl tab 2 mg (base equiv) 1 QL (90 tabs / 30 days) buprenorphine hcl sl tab 8 mg (base equiv) 1 QL (90 tabs / 30 days) buprenorphine hcl-naloxone hcl sl film 2- 2 QL (90 films / 30 days) 0.5 mg (base equiv) (generic of SUBOXONE) buprenorphine hcl-naloxone hcl sl film 4-1 2 QL (90 films / 30 days) mg (base equiv) (generic of SUBOXONE) buprenorphine hcl-naloxone hcl sl film 8-2 2 QL (90 films / 30 days) mg (base equiv) (generic of SUBOXONE) buprenorphine hcl-naloxone hcl sl film 12-3 2 QL (60 films / 30 days) mg (base equiv) (generic of SUBOXONE) buprenorphine hcl-naloxone hcl sl tab 8-2 2 QL (90 tabs / 30 days) mg (base equiv)

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 19 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits buprenorphine td patch weekly 5 mcg/hr 1 QL (4 patches / 30 days) buprenorphine td patch weekly 7.5 mcg/hr 1 QL (4 patches / 30 (generic of BUTRANS) days) buprenorphine td patch weekly 10 mcg/hr 1 QL (4 patches / 30 days) buprenorphine td patch weekly 15 mcg/hr 1 QL (4 patches / 30 days) buprenorphine td patch weekly 20 mcg/hr 1 QL (4 patches / 30 days) butorphanol tartrate nasal soln 10 mg/ml 1 ZUBSOLV SUB 0.7-0.18 2 QL (90 tabs / 30 days) ZUBSOLV SUB 1.4-0.36 2 QL (90 tabs / 30 days) ZUBSOLV SUB 2.9-0.71 2 QL (90 tabs / 30 days) ZUBSOLV SUB 5.7-1.4 2 QL (90 tabs / 30 days) ZUBSOLV SUB 8.6-2.1 2 QL (60 tabs / 30 days) ZUBSOLV SUB 11.4-2.9 2 QL (30 tabs / 30 days) ANDROGENS-ANABOLIC ANDROGENS ANDRODERM DIS 2MG/24HR 2 QL (30 patches / 30 days) ANDRODERM DIS 4MG/24HR 2 QL (30 patches / 30 days) danazol cap 50 mg 1 danazol cap 100 mg 1 danazol cap 200 mg 1 STRIANT MIS 30MG 3 PA testosterone cypionate im inj in oil 100 1 ^ mg/ml (generic of DEPO-TESTOSTERONE) testosterone cypionate im inj in oil 200 1 ^ mg/ml (generic of DEPO-TESTOSTERONE) testosterone enanthate im inj in oil 200 1 mg/ml testosterone td gel 12.5 mg/act (1%) 2 QL (300 gm / 30 days) testosterone td gel 20.25 mg/1.25gm 2 QL (150 gm / 30 days) (1.62%) (generic of ANDROGEL) testosterone td gel 20.25 mg/act (1.62%) 2 QL (150 gm / 30 days) (generic of ANDROGEL PUMP) testosterone td gel 25 mg/2.5gm (1%) 2 QL (300 gm / 30 days) testosterone td gel 40.5 mg/2.5gm 2 QL (150 gm / 30 days) (1.62%) (generic of ANDROGEL) testosterone td gel 50 mg/5gm (1%) 2 QL (300 gm / 30 days)

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 20 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits ANORECTAL AGENTS INTRARECTAL STEROIDS CORTIFOAM AER 90MG 2 hydrocortisone enema 100 mg/60ml 1 (generic of CORTENEMA) RECTAL COMBINATIONS hydrocortisone acetate w/ pramoxine 1 perianal cream 1-1% hydrocortisone acetate w/ pramoxine 1 perianal cream 2.5-1% lidocaine-hydrocortisone acetate perianal 1 cream 3-0.5% lidocaine-hydrocortisone acetate rectal 1 cream kit 3-0.5% lidocaine-hydrocortisone acetate rectal 1 cream kit 3-1% lidocaine-hydrocortisone acetate rectal gel 1 kit 3-2.5% PROCTOFOAM AER HC 1% 2 RECTAL STEROIDS anusol-hc sup 25mg 1 hydrocortisone acetate suppos 30 mg 1 procto-pak cre 1% (generic of 1 PROCTOCORT) proctozone cre -hc 2.5% (generic of 1 ANUSOL-HC) ANTHELMINTICS ANTHELMINTICS albendazole tab 200 mg (generic of 3 ALBENZA) ivermectin tab 3 mg (generic of 3 STROMECTOL) praziquantel tab 600 mg (generic of 3 BILTRICIDE) ANTI-INFECTIVE AGENTS - MISC. ANTI-INFECTIVE AGENTS - MISC. FLAGYL ER TAB 750MG 3 metronidazole cap 375 mg (generic of 3 FLAGYL) metronidazole tab 250 mg 1 metronidazole tab 500 mg (generic of 1 FLAGYL)

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 21 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits pentamidine isethionate for nebulization 2 soln 300 mg (generic of NEBUPENT) PRIMSOL SOL 50MG/5ML 3 tinidazole tab 250 mg 2 tinidazole tab 500 mg 2 trimethoprim tab 100 mg 1 XIFAXAN TAB 200MG 2 QL (126 tabs / 30 days) XIFAXAN TAB 550MG 2 ANTI-INFECTIVE MISC. - COMBINATIONS sulfamethoxazole-trimethoprim susp 200- 1 40 mg/5ml sulfamethoxazole-trimethoprim tab 400-80 1 mg (generic of BACTRIM) sulfamethoxazole-trimethoprim tab 800- 1 160 mg (generic of BACTRIM DS) ANTIPROTOZOAL AGENTS ALINIA SUS 100/5ML 2 atovaquone susp 750 mg/5ml (generic of 2 MEPRON) nitazoxanide tab 500 mg (generic of 2 ALINIA) GLYCOPEPTIDES FIRVANQ SOL 25MG/ML 2 FIRVANQ SOL 50MG/ML 2 vancomycin hcl cap 125 mg (base 2 equivalent) (generic of VANCOCIN HCL) vancomycin hcl cap 250 mg (base 2 equivalent) (generic of VANCOCIN) LEPROSTATICS dapsone tab 25 mg 1 dapsone tab 100 mg 1 LINCOSAMIDES clindamycin hcl cap 75 mg (generic of 1 CLEOCIN) clindamycin hcl cap 150 mg (generic of 1 CLEOCIN) clindamycin hcl cap 300 mg (generic of 1 CLEOCIN) clindamycin palmitate hcl for soln 75 1 mg/5ml (base equiv) (generic of CLEOCIN PEDIATRIC GRANULE)

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 22 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits MONOBACTAMS CAYSTON INH 75MG 3 SP OXAZOLIDINONES linezolid for susp 100 mg/5ml (generic of 2 ZYVOX) linezolid tab 600 mg (generic of ZYVOX) 2 URINARY ANTI-INFECTIVES fosfomycin tromethamine powd pack 3 gm 3 QL (4 packets / 25 days) (base equivalent) (generic of MONUROL) ANTIANGINAL AGENTS ANTIANGINALS-OTHER ranolazine tab er 12hr 500 mg (generic of 2 RANEXA) ranolazine tab er 12hr 1000 mg (generic of 2 RANEXA) NITRATES isosorbide dinitrate tab 5 mg (generic of 1 PD ISORDIL TITRADOSE) isosorbide dinitrate tab 10 mg 1 PD isosorbide dinitrate tab 20 mg 1 PD isosorbide dinitrate tab 30 mg 1 PD isosorbide dinitrate tab 40 mg (generic of 2 PD ISORDIL TITRADOSE) isosorbide dinitrate tab er 40 mg 1 PD isosorbide mononitrate tab 10 mg 1 PD isosorbide mononitrate tab 20 mg 1 PD isosorbide mononitrate tab er 24hr 30 mg 1 PD isosorbide mononitrate tab er 24hr 60 mg 1 PD isosorbide mononitrate tab er 24hr 120 mg 1 PD NITRO-BID OIN 2% 3 PD NITRO-DUR DIS 0.3MG/HR 2 PD NITRO-DUR DIS 0.8MG/HR 3 PD nitroglycerin lingual aerosol 400 mcg/spray 1 nitroglycerin sl tab 0.3 mg (generic of 2 NITROSTAT) nitroglycerin sl tab 0.4 mg (generic of 2 NITROSTAT) nitroglycerin sl tab 0.6 mg (generic of 2 NITROSTAT) nitroglycerin td patch 24hr 0.1 mg/hr 1 PD nitroglycerin td patch 24hr 0.2 mg/hr 1 PD

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 23 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits nitroglycerin td patch 24hr 0.4 mg/hr 1 PD nitroglycerin td patch 24hr 0.6 mg/hr 1 PD nitroglycerin tl soln 0.4 mg/spray (400 1 mcg/spray) (generic of NITROLINGUAL PUMPSPRAY) NITROMIST AER 400MCG 2 ANTIANXIETY AGENTS ANTIANXIETY AGENTS - MISC. buspirone hcl tab 5 mg 1 Rx4L buspirone hcl tab 7.5 mg 1 buspirone hcl tab 10 mg 1 Rx4L buspirone hcl tab 15 mg 1 buspirone hcl tab 30 mg 1 hydroxyzine 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 (generic 1 of VISTARIL) hydroxyzine pamoate cap 50 mg (generic 1 of VISTARIL) hydroxyzine pamoate cap 100 mg 1 BENZODIAZEPINES ALPRAZOLAM CON 1 MG/ML 2 QL (300 mL / 30 days) alprazolam orally disintegrating tab 0.5 mg 1 QL (150 ea / 30 days) alprazolam orally disintegrating tab 0.25 1 QL (150 ea / 30 days) mg alprazolam orally disintegrating tab 1 mg 1 QL (150 ea / 30 days) alprazolam orally disintegrating tab 2 mg 1 QL (150 ea / 30 days) alprazolam tab 0.5 mg (generic of XANAX) 1 QL (150 tabs / 30 days) alprazolam tab 0.5mg xr (generic of 1 XANAX XR) alprazolam tab 0.25 mg (generic of 1 QL (150 tabs / 30 days) XANAX) alprazolam tab 1 mg (generic of XANAX) 1 QL (150 tabs / 30 days) alprazolam tab 1mg xr (generic of XANAX 1 XR) alprazolam tab 2 mg (generic of XANAX) 1 QL (150 tabs / 30 days) alprazolam tab 2mg xr (generic of XANAX 1 XR) alprazolam tab 3mg xr (generic of XANAX 1 XR)

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 24 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits chlordiazepoxide hcl cap 5 mg 1 chlordiazepoxide hcl cap 10 mg 1 chlordiazepoxide hcl cap 25 mg 1 clorazepate dipotassium tab 3.75 mg 1 clorazepate dipotassium tab 7.5 mg 1 clorazepate dipotassium tab 15 mg 1 diazepam con 5mg/ml 2 QL (240 mL / 30 days) diazepam oral soln 1 mg/ml 1 QL (1200 mL / 30 days) diazepam tab 2 mg (generic of VALIUM) 1 QL (120 ea / 30 days) diazepam tab 5 mg (generic of VALIUM) 1 QL (120 ea / 30 days) diazepam tab 10 mg (generic of VALIUM) 1 QL (120 ea / 30 days) lorazepam conc 2 mg/ml 2 QL (150 mL / 30 days) lorazepam tab 0.5 mg (generic of ATIVAN) 1 QL (150 ea / 30 days) lorazepam tab 1 mg (generic of ATIVAN) 1 QL (150 ea / 30 days) lorazepam tab 2 mg (generic of ATIVAN) 1 QL (150 ea / 30 days) oxazepam cap 10 mg 1 QL (120 caps / 30 days) oxazepam cap 15 mg 1 QL (120 caps / 30 days) oxazepam cap 30 mg 1 QL (120 caps / 30 days) ANTIARRHYTHMICS ANTIARRHYTHMICS TYPE I-A disopyramide phosphate cap 100 mg 1 (generic of NORPACE) disopyramide phosphate cap 150 mg 1 (generic of NORPACE) NORPACE CAP 100MG CR 3 NORPACE CAP 150MG CR 3 quinidine gluconate tab er 324 mg 1 ANTIARRHYTHMICS TYPE I-B mexiletine hcl cap 150 mg 1 mexiletine hcl cap 200 mg 1 mexiletine hcl cap 250 mg 1 ANTIARRHYTHMICS TYPE I-C flecainide acetate tab 50 mg 1 flecainide acetate tab 100 mg 1 flecainide acetate tab 150 mg 1 propafenone hcl cap er 12hr 225 mg 2 (generic of RYTHMOL SR) propafenone hcl cap er 12hr 325 mg 2 (generic of RYTHMOL SR) propafenone hcl cap er 12hr 425 mg 2 (generic of RYTHMOL SR)

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 25 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits propafenone hcl tab 150 mg 1 propafenone hcl tab 225 mg 1 propafenone hcl tab 300 mg 1 ANTIARRHYTHMICS TYPE III amiodarone hcl tab 100 mg 1 amiodarone hcl tab 200 mg 1 amiodarone hcl tab 400 mg 1 dofetilide cap 125 mcg (0.125 mg) 2 SP (generic of TIKOSYN) dofetilide cap 250 mcg (0.25 mg) (generic 2 SP of TIKOSYN) dofetilide cap 500 mcg (0.5 mg) (generic 2 SP of TIKOSYN) MULTAQ TAB 400MG 3 PD ANTIASTHMATIC AND BRONCHODILATOR AGENTS ANTI-INFLAMMATORY AGENTS cromolyn sodium soln nebu 20 mg/2ml 1 PD BRONCHODILATORS - ANTICHOLINERGICS ATROVENT HFA AER 17MCG 3 INCRUSE ELPT INH 62.5MCG 3 QL (30 blisters / 30 days); PD ipratropium bromide inhal soln 0.02% 1 Rx4L SPIRIVA AER 1.25MCG 2 QL (0.25 inhalers / 30 days) SPIRIVA CAP HANDIHLR 2 QL (1 cap / 30 days) SPIRIVA SPR 2.5MCG 2 QL (0.25 inhalers / 30 days) LEUKOTRIENE MODULATORS montelukast sodium chew tab 4 mg (base 1 PD equiv) (generic of SINGULAIR) montelukast sodium chew tab 5 mg (base 1 PD equiv) (generic of SINGULAIR) montelukast sodium oral granules packet 4 1 PD mg (base equiv) (generic of SINGULAIR) montelukast sodium tab 10 mg (base 1 PD; Rx4L equiv) (generic of SINGULAIR) zafirlukast tab 10 mg (generic of 2 PD ACCOLATE) zafirlukast tab 20 mg (generic of 2 PD ACCOLATE) zileuton tab er 12hr 600 mg 3 PD

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 26 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits SELECTIVE PHOSPHODIESTERASE 4 (PDE4) INHIBITORS DALIRESP TAB 250MCG 3 PD DALIRESP TAB 500MCG 3 PD STEROID INHALANTS ARNUITY ELPT INH 50MCG 2 QL (1 inhaler / 30 days); PD ARNUITY ELPT INH 100MCG 2 QL (30 blisters / 30 days); PD ARNUITY ELPT INH 200MCG 2 QL (30 blisters / 30 days); PD budesonide inhalation susp 0.5 mg/2ml 1 PD (generic of PULMICORT) budesonide inhalation susp 0.25 mg/2ml 1 PD (generic of PULMICORT) budesonide inhalation susp 1 mg/2ml 2 PD (generic of PULMICORT) FLOVENT DISK AER 50MCG 2 QL (120 inhalations / 30 days); PD FLOVENT DISK AER 100MCG 2 QL (120 inhalations / 30 days); PD FLOVENT DISK AER 250MCG 2 QL (240 inhalations / 30 days); PD FLOVENT HFA AER 44MCG 2 QL (2 inhalers / 30 days); PD FLOVENT HFA AER 110MCG 2 QL (2 inhalers / 30 days); PD FLOVENT HFA AER 220MCG 2 QL (2 inhalers / 30 days); PD PULMICORT INH 90MCG 2 QL (1 inhaler / 30 days); PD PULMICORT INH 180MCG 2 QL (1 inhaler / 30 days); PD QVAR AER 40MCG 2 PD QVAR AER 80MCG 2 PD QVAR REDIHA AER 80MCG 2 QVAR REDIHAL AER 40MCG 2 SYMPATHOMIMETICS ADVAIR DISKU AER 100/50 2 QL (60 inhalations / 30 days); PD ADVAIR DISKU AER 250/50 2 QL (60 inhalations / 30 days); PD ADVAIR DISKU AER 500/50 2 QL (60 inhalations / 30 days); PD

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 27 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits ADVAIR HFA AER 45/21 2 QL (1 inhaler / 30 days); PD ADVAIR HFA AER 115/21 2 QL (1 inhaler / 30 days); PD ADVAIR HFA AER 230/21 2 QL (1 inhaler / 30 days); PD albuterol sulfate inhal aero 108 mcg/act 2 QL (2 inhalers / 30 (90mcg base equiv) (generic of PROAIR days) HFA) albuterol sulfate soln nebu 0.5% (5 mg/ml) 1 albuterol sulfate soln nebu 0.63 mg/3ml 1 (base equiv) albuterol sulfate soln nebu 0.083% (2.5 1 Rx4L mg/3ml) albuterol sulfate soln nebu 1.25 mg/3ml 1 (base equiv) albuterol sulfate syrup 2 mg/5ml 1 albuterol sulfate tab 2 mg 1 albuterol sulfate tab 4 mg 1 albuterol sulfate tab er 12hr 4 mg 1 albuterol sulfate tab er 12hr 8 mg 1 ANORO ELLIPT AER 62.5-25 2 QL (60 blisters / 30 days); PD ARCAPTA CAP 75MCG 3 PD BREO ELLIPTA INH 100-25 2 QL (60 blisters / 30 days); PD BREO ELLIPTA INH 200-25 2 QL (60 blisters / 30 days); PD BREZTRI AERO AER SPHERE 2 QL (1 inhaler / 30 days); PD BREZTRI AERO AER SPHERE 2 QL (4 inhalers / 28 days); PD; institutional pack BROVANA NEB 15MCG 3 PD budesonide-formoterol fumarate dihyd 2 PD aerosol 80-4.5 mcg/act budesonide-formoterol fumarate dihyd 2 PD aerosol 160-4.5 mcg/act COMBIVENT AER 20-100 2 DULERA AER 50-5MCG 2 QL (1 inhaler / 30 days); PD DULERA AER 100-5MCG 2 QL (1 inhaler / 30 days); PD

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 28 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits DULERA AER 200-5MCG 2 QL (1 inhaler / 30 days); PD fluticasone-salmeterol aer powder ba 55- 1 QL (1 inhaler / 30 14 mcg/act days); PD fluticasone-salmeterol aer powder ba 100- 1 QL (60 inhalations / 30 50 mcg/dose (generic of ADVAIR DISKUS) days); PD fluticasone-salmeterol aer powder ba 113- 1 QL (1 inhaler / 30 14 mcg/act days); PD fluticasone-salmeterol aer powder ba 232- 1 QL (1 inhaler / 30 14 mcg/act days); PD fluticasone-salmeterol aer powder ba 250- 1 QL (60 inhalations / 30 50 mcg/dose (generic of ADVAIR DISKUS) days); PD fluticasone-salmeterol aer powder ba 500- 1 QL (60 inhalations / 30 50 mcg/dose (generic of ADVAIR DISKUS) days); PD FORADIL CAP AEROLIZE 2 PD ipratropium-albuterol nebu soln 0.5-2.5(3) 1 mg/3ml levalbuterol hcl soln nebu 0.31 mg/3ml 3 (base equiv) (generic of XOPENEX) levalbuterol hcl soln nebu 0.63 mg/3ml 3 (base equiv) (generic of XOPENEX) levalbuterol hcl soln nebu 1.25 mg/3ml 3 (base equiv) (generic of XOPENEX) levalbuterol hcl soln nebu conc 1.25 3 mg/0.5ml (base equiv) (generic of XOPENEX CONCENTRATE) levalbuterol tartrate inhal aerosol 45 2 QL (2 inhalers / 30 mcg/act (base equiv) days) PERFOROMIST NEB 20MCG 3 PD SEREVENT DIS AER 50MCG 2 QL (60 inhalations / 30 days); PD STIOLTO AER 2.5-2.5 2 QL (1 inhaler / 30 days); PD SYMBICORT AER 80-4.5 2 PD SYMBICORT AER 160-4.5 2 PD terbutaline sulfate tab 2.5 mg 1 terbutaline sulfate tab 5 mg 1 TRELEGY AER ELLIPTA 2 QL (1 inhaler / 30 days); PD wixela inhub aer 100/50 (generic of 1 QL (60 inhalations / 30 ADVAIR DISKUS) days); PD wixela inhub aer 250/50 (generic of 1 QL (60 inhalations / 30 ADVAIR DISKUS) days); PD

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 29 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits wixela inhub aer 500/50 (generic of 1 QL (60 inhalations / 30 ADVAIR DISKUS) days); PD XANTHINES ELIXOPHYLLIN ELX 80/15ML 2 THEO-24 CAP 100MG CR 2 THEO-24 CAP 200MG CR 2 THEO-24 CAP 300MG CR 2 THEO-24 CAP 400MG ER 2 theophylline tab er 12hr 100 mg 1 theophylline tab er 12hr 200 mg 1 theophylline tab er 12hr 300 mg 1 theophylline tab er 12hr 450 mg 1 theophylline tab er 24hr 400 mg 1 theophylline tab er 24hr 600 mg 1 ANTICOAGULANTS COUMARIN ANTICOAGULANTS COUMADIN TAB 1MG 2 PD COUMADIN TAB 2.5MG 2 PD COUMADIN TAB 2MG 2 PD COUMADIN TAB 3MG 2 PD COUMADIN TAB 4MG 2 PD COUMADIN TAB 5MG 2 PD COUMADIN TAB 6MG 2 PD COUMADIN TAB 7.5MG 2 PD COUMADIN TAB 10MG 2 PD warfarin sodium tab 1 mg 1 PD; Rx4L warfarin sodium tab 2 mg 1 PD; Rx4L warfarin sodium tab 2.5 mg 1 PD; Rx4L warfarin sodium tab 3 mg 1 PD; Rx4L warfarin sodium tab 4 mg 1 PD; Rx4L warfarin sodium tab 5 mg 1 PD; Rx4L warfarin sodium tab 6 mg 1 PD; Rx4L warfarin sodium tab 7.5 mg 1 PD; Rx4L warfarin sodium tab 10 mg 1 PD; Rx4L DIRECT FACTOR XA INHIBITORS ELIQUIS TAB 2.5MG 2 PD ELIQUIS TAB 5MG 2 PD XARELTO STAR TAB 15/20MG 2 PD XARELTO TAB 2.5MG 2 PD XARELTO TAB 10MG 2 PD XARELTO TAB 15MG 2 PD

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 30 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits XARELTO TAB 20MG 2 PD HEPARINS AND HEPARINOID-LIKE AGENTS enoxaparin sodium inj 30 mg/0.3ml 1 ^ (generic of LOVENOX) enoxaparin sodium inj 40 mg/0.4ml 1 ^ (generic of LOVENOX) enoxaparin sodium inj 60 mg/0.6ml 1 ^ (generic of LOVENOX) enoxaparin sodium inj 80 mg/0.8ml 1 ^ (generic of LOVENOX) enoxaparin sodium inj 100 mg/ml (generic 1 ^ of LOVENOX) enoxaparin sodium inj 120 mg/0.8ml 1 ^ (generic of LOVENOX) enoxaparin sodium inj 150 mg/ml (generic 1 ^ of LOVENOX) enoxaparin sodium inj 300 mg/3ml 1 ^ (generic of LOVENOX) fondaparinux sodium subcutaneous inj 2.5 1 ^ mg/0.5ml (generic of ARIXTRA) fondaparinux sodium subcutaneous inj 5 1 ^ mg/0.4ml (generic of ARIXTRA) fondaparinux sodium subcutaneous inj 7.5 1 ^ mg/0.6ml (generic of ARIXTRA) fondaparinux sodium subcutaneous inj 10 1 ^ mg/0.8ml (generic of ARIXTRA) FRAGMIN INJ 2500/0.2 3 ^ FRAGMIN INJ 5000/0.2 3 ^ FRAGMIN INJ 7500/0.3 3 ^ FRAGMIN INJ 10000/ML 3 ^ FRAGMIN INJ 12500UNT 3 ^ FRAGMIN INJ 15000UNT 3 ^ FRAGMIN INJ 18000UNT 3 ^ FRAGMIN INJ 95000UNT 3 ^ hep flush-10 inj 10unt/ml 1 ^ HEP SOD/NACL INJ 25000UNT 3 ^ heparin sod (porcine)-nacl iv soln 1000 1 ^ unit/500ml-0.9% HEPARIN SOD INJ 2000/ML 3 ^ HEPARIN SOD INJ 2500/ML 3 ^ heparin sod lock flush & nacl lock flush 10 1 ^ unt/ml-0.9% kit

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 31 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits heparin sod lock flush & nacl lock flush 100 1 ^ unt/ml-0.9% kit heparin sodium (porcine) 100 unit/ml in 1 ^ d5w heparin sodium (porcine) inj 1000 unit/ml 1 ^ heparin sodium (porcine) inj 5000 unit/ml 1 ^ heparin sodium (porcine) inj 10000 unit/ml 1 ^ heparin sodium (porcine) inj 20000 unit/ml 1 ^ heparin sodium (porcine) lock flush iv soln 1 ^ 1 unit/ml heparin sodium (porcine) lock flush iv soln 1 ^ 2 unit/ml heparin sodium (porcine) lock flush iv soln 1 ^ 100 unit/ml heparin sodium (porcine) pf inj 5000 1 ^ unit/0.5ml heparin sodium (porcine)-dextrose iv sol 1 ^ 20000 unit/500ml-5% heparin sodium (porcine)-dextrose iv sol 1 ^ 25000 unit/500ml-5% HEPARIN/D5W INJ 25000UNT 3 ^ THROMBIN INHIBITORS ANGIOMAX INJ 250MG 3 ^ ARGATROBAN INJ 50MG/50M 3 PA; ^ ARGATROBAN INJ 125/125 3 PA; ^ argatroban inj 250 mg/2.5ml (concentrate 1 PA; ^ for iv infusion) (generic of ARGATROBAN) ARGATROBAN INJ 250/250 3 PA; ^ bivalirudin trifluoroacetate for iv soln 250 1 ^ mg (base equiv) (generic of ANGIOMAX) IPRIVASK INJ 15MG 3 PD, ^ ANTICONVULSANTS ANTICONVULSANTS - BENZODIAZEPINES clobazam suspension 2.5 mg/ml (generic 3 PD of ONFI) clobazam tab 10 mg (generic of ONFI) 3 PD clobazam tab 20 mg (generic of ONFI) 3 PD clonazepam orally disintegrating tab 0.5 1 PD mg clonazepam orally disintegrating tab 0.25 1 PD mg

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 32 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits clonazepam orally disintegrating tab 0.125 1 PD mg clonazepam orally disintegrating tab 1 mg 1 PD clonazepam orally disintegrating tab 2 mg 1 PD clonazepam tab 0.5 mg (generic of 1 QL (300 ea / 30 days); KLONOPIN) PD clonazepam tab 1 mg (generic of 1 QL (300 ea / 30 days); KLONOPIN) PD clonazepam tab 2 mg (generic of 1 QL (300 ea / 30 days); KLONOPIN) PD DIASTAT ACDL GEL 5-10MG 3 DIASTAT ACDL GEL 12.5-20 3 DIASTAT PED GEL 2.5M GEL 3 diazepam rectal gel delivery system 2.5 2 mg diazepam rectal gel delivery system 10 mg 2 diazepam rectal gel delivery system 20 mg 2 KLONOPIN TAB 0.5MG 2 QL (300 tabs / 30 days); PD KLONOPIN TAB 1MG 2 QL (300 tabs / 30 days); PD KLONOPIN TAB 2MG 2 QL (300 tabs / 30 days); PD NAYZILAM SPR 5MG 3 QL (2 bottles / 30 days) VALTOCO LIQ 15MG 3 QL (2 doses (1 carton) / 30 days) VALTOCO LIQ 20MG 3 QL (2 doses (1 carton) / 30 days) VALTOCO SPR 5MG 3 QL (2 doses (1 carton) / 30 days) VALTOCO SPR 10MG 3 QL (2 doses (1 carton) / 30 days) ANTICONVULSANTS - MISC. BANZEL TAB 200MG 3 PD BANZEL TAB 400MG 3 PD carbamazepine cap er 12hr 100 mg 1 PD (generic of CARBATROL) carbamazepine cap er 12hr 200 mg 1 PD (generic of CARBATROL) carbamazepine cap er 12hr 300 mg 1 PD (generic of CARBATROL) carbamazepine chew tab 100 mg 1 PD

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 33 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits carbamazepine susp 100 mg/5ml (generic 1 PD of TEGRETOL) carbamazepine tab 200 mg (generic of 1 PD TEGRETOL) carbamazepine tab er 12hr 100 mg 1 PD (generic of TEGRETOL-XR) carbamazepine tab er 12hr 200 mg 1 PD (generic of TEGRETOL-XR) carbamazepine tab er 12hr 400 mg 1 PD (generic of TEGRETOL-XR) FINTEPLA SOL 2.2MG/ML 3 PA; SP gabapentin cap 100 mg (generic of 1 NEURONTIN) gabapentin cap 300 mg (generic of 1 NEURONTIN) gabapentin cap 400 mg (generic of 1 NEURONTIN) gabapentin oral soln 250 mg/5ml (generic 1 of NEURONTIN) gabapentin tab 600 mg (generic of 1 NEURONTIN) gabapentin tab 800 mg (generic of 1 NEURONTIN) lamotrigine orally disintegrating tab 25 mg 2 PD (generic of LAMICTAL ODT) lamotrigine orally disintegrating tab 50 mg 2 PD (generic of LAMICTAL ODT) lamotrigine orally disintegrating tab 100 2 PD mg (generic of LAMICTAL ODT) lamotrigine orally disintegrating tab 200 2 PD mg (generic of LAMICTAL ODT) lamotrigine tab 25 mg (generic of 1 PD LAMICTAL) lamotrigine tab 100 mg (generic of 1 PD LAMICTAL) lamotrigine tab 150 mg (generic of 1 PD LAMICTAL) lamotrigine tab 200 mg (generic of 1 PD LAMICTAL) lamotrigine tab chewable dispersible 5 mg 1 PD (generic of LAMICTAL CHEWABLE DISPERS)

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 34 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits lamotrigine tab chewable dispersible 25 mg 1 PD (generic of LAMICTAL CHEWABLE DISPERS) lamotrigine tab disint 21 x 25 mg & 7 x 50 2 PD mg titration kit lamotrigine tab disint 25 (14) & 50 mg 2 PD (14) & 100 mg (7) kit (generic of LAMICTAL ODT) lamotrigine tab disint 42 x 50mg & 14 x 2 PD 100mg titration kit lamotrigine tab er 24hr 25 mg (generic of 2 PD LAMICTAL XR) lamotrigine tab er 24hr 50 mg (generic of 2 PD LAMICTAL XR) lamotrigine tab er 24hr 100 mg (generic of 2 PD LAMICTAL XR) lamotrigine tab er 24hr 200 mg (generic of 2 PD LAMICTAL XR) lamotrigine tab er 24hr 250 mg (generic of 2 PD LAMICTAL XR) lamotrigine tab er 24hr 300 mg (generic of 2 PD LAMICTAL XR) levetiracetam oral soln 100 mg/ml (generic 1 PD of KEPPRA) levetiracetam tab 250 mg (generic of 1 PD KEPPRA) levetiracetam tab 500 mg (generic of 1 PD KEPPRA) levetiracetam tab 750 mg (generic of 1 PD KEPPRA) levetiracetam tab 1000 mg (generic of 1 PD KEPPRA) levetiracetam tab er 24hr 500 mg (generic 1 PD of KEPPRA XR) levetiracetam tab er 24hr 750 mg (generic 1 PD of KEPPRA XR) oxcarbazepine susp 300 mg/5ml (60 1 PD mg/ml) (generic of TRILEPTAL) oxcarbazepine tab 150 mg (generic of 1 PD TRILEPTAL) oxcarbazepine tab 300 mg (generic of 1 PD TRILEPTAL) oxcarbazepine tab 600 mg (generic of 1 PD TRILEPTAL)

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 35 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits pregabalin cap 25 mg (generic of LYRICA) 1 pregabalin cap 50 mg (generic of LYRICA) 1 pregabalin cap 75 mg (generic of LYRICA) 1 pregabalin cap 100 mg (generic of LYRICA) 1 pregabalin cap 150 mg (generic of LYRICA) 1 pregabalin cap 200 mg (generic of LYRICA) 1 pregabalin cap 225 mg (generic of LYRICA) 1 pregabalin cap 300 mg (generic of LYRICA) 1 pregabalin soln 20 mg/ml (generic of 1 LYRICA) primidone tab 50 mg (generic of 1 PD MYSOLINE) primidone tab 250 mg (generic of 1 PD MYSOLINE) rufinamide susp 40 mg/ml (generic of 3 PD BANZEL) topiramate sprinkle cap 15 mg (generic of 1 PD TOPAMAX SPRINKLE) topiramate sprinkle cap 25 mg (generic of 1 PD TOPAMAX SPRINKLE) topiramate tab 25 mg (generic of 1 PD TOPAMAX) topiramate tab 50 mg (generic of 1 PD TOPAMAX) topiramate tab 100 mg (generic of 1 PD TOPAMAX) topiramate tab 200 mg (generic of 1 PD TOPAMAX) TROKENDI XR CAP 25MG 3 ST; ACA; PD TROKENDI XR CAP 50MG 3 ST; ACA; PD TROKENDI XR CAP 100MG 3 ST; ACA; PD TROKENDI XR CAP 200MG 3 ST; ACA; PD VIMPAT SOL 10MG/ML 2 PD VIMPAT TAB 50MG 2 PD VIMPAT TAB 100MG 2 PD VIMPAT TAB 150MG 2 PD VIMPAT TAB 200MG 2 PD zonisamide cap 25 mg (generic of 1 PD ZONEGRAN) zonisamide cap 50 mg 1 PD zonisamide cap 100 mg (generic of 1 PD ZONEGRAN)

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 36 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits CARBAMATES felbamate susp 600 mg/5ml (generic of 1 PD FELBATOL) felbamate tab 400 mg (generic of 3 PD FELBATOL) felbamate tab 600 mg (generic of 3 PD FELBATOL) XCOPRI PAK 12.5-25 3 PD XCOPRI PAK 50-100MG 3 PD XCOPRI PAK 50-200MG 3 PD XCOPRI PAK 100-150 3 PD XCOPRI PAK 150-200 3 PD XCOPRI TAB 50MG 3 PD XCOPRI TAB 100MG 3 PD XCOPRI TAB 150MG 3 PD XCOPRI TAB 200MG 3 PD GABA MODULATORS tiagabine hcl tab 2 mg (generic of 2 PD GABITRIL) tiagabine hcl tab 4 mg (generic of 2 PD GABITRIL) tiagabine hcl tab 12 mg (generic of 2 PD GABITRIL) tiagabine hcl tab 16 mg (generic of 2 PD GABITRIL) vigabatrin powd pack 500 mg (generic of 3 PA; PD, SPC SABRIL) vigabatrin tab 500 mg (generic of SABRIL) 3 PA; PD, SPC HYDANTOINS DILANTIN CAP 30MG 2 PD DILANTIN CAP 100MG 2 PD DILANTIN CHW 50MG 2 PD DILANTIN-125 SUS 125/5ML 2 PD PHENYTEK CAP 200MG 2 PD PHENYTEK CAP 300MG 2 PD phenytoin chew tab 50 mg (generic of 2 PD DILANTIN INFATABS) phenytoin sodium extended cap 100 mg 1 PD (generic of DILANTIN) phenytoin sodium extended cap 200 mg 1 PD (generic of PHENYTEK)

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 37 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits phenytoin sodium extended cap 300 mg 1 PD (generic of PHENYTEK) phenytoin susp 125 mg/5ml (generic of 1 PD DILANTIN-125) SUCCINIMIDES ethosuximide cap 250 mg (generic of 1 PD ZARONTIN) ethosuximide soln 250 mg/5ml (generic of 1 PD ZARONTIN) VALPROIC ACID divalproex sodium cap delayed release 1 PD sprinkle 125 mg (generic of DEPAKOTE SPRINKLES) divalproex sodium tab delayed release 125 1 PD mg (generic of DEPAKOTE) divalproex sodium tab delayed release 250 1 PD mg (generic of DEPAKOTE) divalproex sodium tab delayed release 500 1 PD mg (generic of DEPAKOTE) divalproex sodium tab er 24 hr 250 mg 1 PD (generic of DEPAKOTE ER) divalproex sodium tab er 24 hr 500 mg 1 PD (generic of DEPAKOTE ER) valproate sodium oral soln 250 mg/5ml 1 PD (base equiv) valproic acid cap 250 mg 1 PD ANTIDEPRESSANTS ALPHA-2 RECEPTOR ANTAGONISTS (TETRACYCLICS) mirtazapine orally disintegrating tab 15 mg 1 (generic of REMERON SOLTAB) mirtazapine orally disintegrating tab 30 mg 1 (generic of REMERON SOLTAB) mirtazapine orally disintegrating tab 45 mg 1 (generic of REMERON SOLTAB) mirtazapine tab 7.5 mg 1 mirtazapine tab 15 mg (generic of 1 REMERON) mirtazapine tab 30 mg (generic of 1 REMERON) mirtazapine tab 45 mg 1 ANTIDEPRESSANTS - MISC. bupropion hcl tab 75 mg 1

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 38 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits bupropion hcl tab 100 mg 1 bupropion hcl tab er 12hr 100 mg (generic 1 of WELLBUTRIN SR) bupropion hcl tab er 12hr 150 mg (generic 1 of WELLBUTRIN SR) bupropion hcl tab er 12hr 200 mg (generic 1 of WELLBUTRIN SR) bupropion hcl tab er 24hr 150 mg (generic 1 of WELLBUTRIN XL) bupropion hcl tab er 24hr 300 mg (generic 1 of WELLBUTRIN XL) maprotiline hcl tab 25 mg 1 maprotiline hcl tab 50 mg 1 maprotiline hcl tab 75 mg 1 MONOAMINE OXIDASE INHIBITORS (MAOIS) EMSAM DIS 6MG/24HR 3 EMSAM DIS 9MG/24HR 3 EMSAM DIS 12MG/24H 3 phenelzine sulfate tab 15 mg (generic of 2 NARDIL) tranylcypromine sulfate tab 10 mg (generic 1 of PARNATE) SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIS) citalopram hydrobromide oral soln 10 1 PD mg/5ml citalopram hydrobromide tab 10 mg (base 1 PD equiv) (generic of CELEXA) citalopram hydrobromide tab 20 mg (base 1 PD; Rx4L equiv) (generic of CELEXA) citalopram hydrobromide tab 40 mg (base 1 PD; Rx4L equiv) (generic of CELEXA) escitalopram oxalate soln 5 mg/5ml (base 1 PD equiv) escitalopram oxalate tab 5 mg (base 1 PD equiv) (generic of LEXAPRO) escitalopram oxalate tab 10 mg (base 1 PD; Rx4L equiv) (generic of LEXAPRO) escitalopram oxalate tab 20 mg (base 1 Rx4L; PD equiv) (generic of LEXAPRO) fluoxetine hcl cap 10 mg (generic of 1 PD; Rx4L PROZAC) fluoxetine hcl cap 20 mg (generic of 1 PD; Rx4L PROZAC)

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 39 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits fluoxetine hcl cap 40 mg (generic of 1 PD PROZAC) fluoxetine hcl cap delayed release 90 mg 1 PD fluoxetine hcl solution 20 mg/5ml 1 PD fluoxetine hcl tab 10 mg 2 PD fluoxetine hcl tab 20 mg 2 PD fluoxetine hcl tab 60 mg (generic of 2 PD FLUOXETINE HYDROCHLORIDE) fluvoxamine maleate cap er 24hr 100 mg 3 PD fluvoxamine maleate cap er 24hr 150 mg 3 PD fluvoxamine maleate tab 25 mg 1 PD fluvoxamine maleate tab 50 mg 1 PD fluvoxamine maleate tab 100 mg 1 PD paroxetine hcl tab 10 mg (generic of 1 PD; Rx4L PAXIL) paroxetine hcl tab 20 mg (generic of 1 PD; Rx4L PAXIL) paroxetine hcl tab 30 mg (generic of 1 PD PAXIL) paroxetine hcl tab 40 mg (generic of 1 PD PAXIL) paroxetine hcl tab er 24hr 12.5 mg 2 PD (generic of PAXIL CR) paroxetine hcl tab er 24hr 25 mg (generic 2 PD of PAXIL CR) paroxetine hcl tab er 24hr 37.5 mg 2 PD (generic of PAXIL CR) sertraline hcl oral concentrate for solution 1 PD 20 mg/ml (generic of ZOLOFT) sertraline hcl tab 25 mg (generic of 1 PD; Rx4L ZOLOFT) sertraline hcl tab 50 mg (generic of 1 PD; Rx4L ZOLOFT) sertraline hcl tab 100 mg (generic of 1 PD; Rx4L ZOLOFT) SEROTONIN MODULATORS nefazodone hcl tab 50 mg 1 nefazodone hcl tab 100 mg 1 nefazodone hcl tab 150 mg 1 nefazodone hcl tab 200 mg 1 nefazodone hcl tab 250 mg 1 trazodone hcl tab 50 mg 1 Rx4L trazodone hcl tab 100 mg 1 Rx4L

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 40 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits trazodone hcl tab 150 mg 1 Rx4L trazodone hcl tab 300 mg 1 TRINTELLIX TAB 5MG 3 ST TRINTELLIX TAB 10MG 3 ST TRINTELLIX TAB 20MG 3 ST SEROTONIN-NOREPINEPHRINE REUPTAKE INHIBITORS (SNRIS) desvenlafaxine succinate tab er 24hr 25 2 mg (base equiv) (generic of PRISTIQ) desvenlafaxine succinate tab er 24hr 50 2 mg (base equiv) (generic of PRISTIQ) desvenlafaxine succinate tab er 24hr 100 2 mg (base equiv) (generic of PRISTIQ) duloxetine hcl enteric coated pellets cap 20 1 mg (base eq) (generic of CYMBALTA) duloxetine hcl enteric coated pellets cap 30 1 mg (base eq) (generic of CYMBALTA) duloxetine hcl enteric coated pellets cap 60 1 mg (base eq) (generic of CYMBALTA) venlafaxine hcl cap er 24hr 37.5 mg (base 1 Rx4L equivalent) (generic of EFFEXOR XR) venlafaxine hcl cap er 24hr 75 mg (base 1 Rx4L equivalent) (generic of EFFEXOR XR) venlafaxine hcl cap er 24hr 150 mg (base 1 Rx4L equivalent) (generic of EFFEXOR XR) venlafaxine hcl tab 25 mg (base 1 equivalent) venlafaxine hcl tab 37.5 mg (base 1 equivalent) venlafaxine hcl tab 50 mg (base 1 equivalent) venlafaxine hcl tab 75 mg (base 1 equivalent) venlafaxine hcl tab 100 mg (base 1 equivalent) TRICYCLIC AGENTS amitriptyline hcl tab 10 mg 1 amitriptyline hcl tab 25 mg 1 amitriptyline hcl tab 50 mg 1 amitriptyline hcl tab 75 mg 1 amitriptyline hcl tab 100 mg 1 amitriptyline hcl tab 150 mg 1 clomipramine hcl cap 25 mg (generic of 1 ANAFRANIL)

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 41 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits clomipramine hcl cap 50 mg (generic of 1 ANAFRANIL) clomipramine hcl cap 75 mg (generic of 1 ANAFRANIL) desipramine hcl tab 10 mg (generic of 1 NORPRAMIN) desipramine hcl tab 25 mg (generic of 1 NORPRAMIN) desipramine hcl tab 50 mg 1 desipramine hcl tab 75 mg 1 desipramine hcl tab 100 mg 1 desipramine hcl tab 150 mg 1 doxepin hcl cap 10 mg 1 doxepin hcl cap 25 mg 1 doxepin hcl cap 50 mg 1 doxepin hcl cap 75 mg 1 doxepin hcl cap 100 mg 1 doxepin hcl cap 150 mg 1 doxepin hcl conc 10 mg/ml 1 imipramine hcl tab 10 mg 1 imipramine hcl tab 25 mg 1 imipramine hcl tab 50 mg 1 nortriptyline hcl cap 10 mg (generic of 1 Rx4L PAMELOR) nortriptyline hcl cap 25 mg (generic of 1 Rx4L PAMELOR) nortriptyline hcl cap 50 mg (generic of 1 PAMELOR) nortriptyline hcl cap 75 mg (generic of 1 PAMELOR) nortriptyline hcl soln 10 mg/5ml 1 protriptyline hcl tab 5 mg 1 protriptyline hcl tab 10 mg 1 trimipramine maleate cap 25 mg 3 trimipramine maleate cap 50 mg 3 trimipramine maleate cap 100 mg 3 ANTIDIABETICS Diabetic drugs are covered under the New York State Diabetic mandate ALPHA-GLUCOSIDASE INHIBITORS acarbose tab 25 mg (generic of PRECOSE) 1 PD acarbose tab 50 mg (generic of PRECOSE) 1 PD

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 42 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits acarbose tab 100 mg (generic of 1 PD PRECOSE) miglitol tab 25 mg 3 PD miglitol tab 50 mg 3 PD miglitol tab 100 mg 3 PD ANTIDIABETIC - AMYLIN ANALOGS SYMLINPEN 60 INJ 1000MCG 2 PD ANTIDIABETIC COMBINATIONS ACTOPLUS MET TAB XR 2 PD glipizide-metformin hcl tab 2.5-250 mg 1 PD glipizide-metformin hcl tab 2.5-500 mg 1 PD glipizide-metformin hcl tab 5-500 mg 1 PD glyburide-metformin tab 1.25-250 mg 1 PD glyburide-metformin tab 2.5-500 mg 1 PD glyburide-metformin tab 5-500 mg 1 PD GLYXAMBI TAB 10-5 MG 2 QL (30 tabs / 30 days); PD GLYXAMBI TAB 25-5 MG 2 QL (30 tabs / 30 days); PD JENTADUETO TAB 2.5-500 2 QL (60 tabs / 30 days); PD JENTADUETO TAB 2.5-850 2 QL (60 tabs / 30 days); PD JENTADUETO TAB 2.5-1000 2 QL (60 tabs / 30 days); PD JENTADUETO TAB XR 2 QL (30 tabs / 30 days); PD; 5-1000 mg tab JENTADUETO TAB XR 2 QL (60 tabs / 30 days); PD; 2.5-1000 mg tab pioglitazone hcl-glimepiride tab 30-2 mg 2 PD (generic of DUETACT) pioglitazone hcl-glimepiride tab 30-4 mg 2 PD (generic of DUETACT) pioglitazone hcl-metformin hcl tab 15-500 2 PD mg (generic of ACTOPLUS MET) pioglitazone hcl-metformin hcl tab 15-850 2 PD mg (generic of ACTOPLUS MET) SOLIQUA INJ 100/33 2 PD SYNJARDY TAB 2 PD SYNJARDY TAB 5-500MG 2 PD SYNJARDY TAB 5-1000MG 2 PD SYNJARDY TAB 12.5-500 2 PD

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 43 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits SYNJARDY XR TAB 2 PD SYNJARDY XR TAB 5-1000MG 2 PD SYNJARDY XR TAB 10-1000 2 PD SYNJARDY XR TAB 25-1000 2 PD TRIJARDY XR TAB 2 PD XIGDUO XR TAB 2.5-1000 2 PD XIGDUO XR TAB 5-500MG 2 PD XIGDUO XR TAB 5-1000MG 2 PD XIGDUO XR TAB 10-500MG 2 PD XIGDUO XR TAB 10-1000 2 PD XULTOPHY INJ 100/3.6 2 PD BIGUANIDES metformin hcl tab 500 mg 1 PD; Rx4L metformin hcl tab 850 mg 1 PD; Rx4L metformin hcl tab 1000 mg 1 PD; Rx4L metformin hcl tab er 24hr 500 mg 1 PD; Rx4L metformin hcl tab er 24hr 750 mg 1 PD; Rx4L RIOMET ER SUS 500/5ML 3 PD RIOMET SOL 3 PD DIABETIC OTHER BAQSIMI ONE POW 3MG/DOSE 2 BD GLUCOSE CHW 5GM 1 OTC diazoxide susp 50 mg/ml (generic of 3 PROGLYCEM) glucagon (rdna) for inj kit 1 mg (generic of 2 GLUCAGON EMERGENCY KIT) GLUCAGON EMR SOL 1MG 2 GLUCOSE BITS CHW 1GM 1 OTC GLUCOSE CHW 4GM 1 OTC GLUCOSE CHW RASPBERY 3 OTC glucose drnk liq 15/59ml 1 OTC glucose gel 40% 1 OTC GVOKE HYPO 1 INJ 1MG/.2ML 2 GVOKE HYPO 1 INJ .5/.1ML 2 GVOKE PFS INJ 2 KORLYM TAB 300MG 3 PA DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS TRADJENTA TAB 5MG 2 QL (30 tabs / 30 days); PD DOPAMINE RECEPTOR AGONISTS - ANTIDIABETIC CYCLOSET TAB 0.8MG 3

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 44 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits INCRETIN MIMETIC AGENTS (GLP-1 RECEPTOR AGONISTS) OZEMPIC INJ 2/1.5ML 2 PD RYBELSUS TAB 3MG 2 PD RYBELSUS TAB 7MG 2 PD RYBELSUS TAB 14MG 2 PD TRULICITY INJ 0.75/0.5 2 PD TRULICITY INJ 1.5/0.5 2 PD TRULICITY INJ 3/0.5 2 PD TRULICITY INJ 4.5/0.5 2 PD VICTOZA INJ 18MG/3ML 2 PD INSULIN BASAGLAR INJ 100UNIT 2 PD FIASP FLEX INJ TOUCH 2 PD FIASP INJ 100/ML 2 PD FIASP PENFIL INJ U-100 2 PD HUMULIN R INJ U-500 2 PD HUMULIN R INJ U-500 2 QL (6 pens / 30 days); PD INSULIN ASPA INJ 70/30 2 PD INSULIN ASPA INJ 100/ML 2 PD INSULIN ASPA INJ FLEXPEN 2 PD INSULIN ASPA INJ PENFILL 2 PD NOVOLIN INJ 70/30 2 OTC; PD, OTC NOVOLIN INJ 70/30 FP 2 OTC; PD, OTC NOVOLIN N INJ U-100 2 OTC; PD, OTC NOVOLIN R INJ U-100 2 OTC; PD, OTC NOVOLOG INJ 100/ML 2 PD NOVOLOG INJ FLEXPEN 2 PD NOVOLOG INJ PENFILL 2 PD NOVOLOG MIX INJ 70/30 2 PD NOVOLOG MIX INJ FLEXPEN 2 PD INSULIN SENSITIZING AGENTS pioglitazone hcl tab 15 mg (base equiv) 1 PD; subject to dose (generic of ACTOS) optimization pioglitazone hcl tab 30 mg (base equiv) 1 PD (generic of ACTOS) pioglitazone hcl tab 45 mg (base equiv) 1 PD (generic of ACTOS) MEGLITINIDE ANALOGUES nateglinide tab 60 mg 1 PD nateglinide tab 120 mg 1 PD

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 45 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits repaglinide tab 0.5 mg 1 PD repaglinide tab 1 mg 1 PD repaglinide tab 2 mg 1 PD SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITORS FARXIGA TAB 5MG 2 PD FARXIGA TAB 10MG 2 PD JARDIANCE TAB 10MG 2 PD JARDIANCE TAB 25MG 2 PD SULFONYLUREAS glimepiride tab 1 mg (generic of AMARYL) 1 PD; Rx4L glimepiride tab 2 mg (generic of AMARYL) 1 PD; Rx4L glimepiride tab 4 mg (generic of AMARYL) 1 PD; Rx4L glipizide tab 5 mg 1 PD; Rx4L glipizide tab 10 mg (generic of 1 PD; Rx4L GLUCOTROL) glipizide tab er 24hr 5 mg (generic of 1 PD; Rx4L GLUCOTROL XL) glipizide tab er 24hr 10 mg (generic of 1 PD; Rx4L GLUCOTROL XL) glipizide xl tab 2.5mg (generic of 1 PD; Rx4L GLUCOTROL XL) glyburide micronized tab 1.5 mg (generic 1 PD of GLYNASE) glyburide micronized tab 3 mg (generic of 1 PD GLYNASE) glyburide micronized tab 6 mg (generic of 1 PD GLYNASE) glyburide tab 1.25 mg 1 PD glyburide tab 2.5 mg 1 PD glyburide tab 5 mg 1 PD ANTIDIARRHEALS ANTIDIARRHEAL - CHLORIDE CHANNEL ANTAGONISTS MYTESI TAB 125MG 3 ANTIPERISTALTIC AGENTS diphenoxylate w/ atropine liq 2.5-0.025 1 mg/5ml diphenoxylate w/ atropine tab 2.5-0.025 1 mg (generic of LOMOTIL) loperamide hcl cap 2 mg 1

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 46 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits ANTIDOTES AND SPECIFIC ANTAGONISTS ANTIDOTES - CHELATING AGENTS deferasirox tab for oral susp 125 mg 3 SPC (generic of EXJADE) deferasirox tab for oral susp 250 mg 3 SPC (generic of EXJADE) deferasirox tab for oral susp 500 mg 3 SPC (generic of EXJADE) deferiprone tab 500 mg (generic of 3 FERRIPROX) FERPRX 2-DAY TAB 1000MG 3 PA FERRIPROX SOL 100MG/ML 3 PA FERRIPROX TAB 500MG 3 PA FERRIPROX TAB 1000MG 3 PA OPIOID ANTAGONISTS naloxone hcl soln prefilled syringe 2 1 mg/2ml naltrexone hcl tab 50 mg 1 NARCAN SPR 3 VIVITROL INJ 380MG 2 ^ ANTIEMETICS 5-HT3 RECEPTOR ANTAGONISTS granisetron hcl tab 1 mg 1 ondansetron hcl oral soln 4 mg/5ml 1 ondansetron hcl tab 4 mg (generic of 1 ZOFRAN) ondansetron hcl tab 8 mg 1 ondansetron hcl tab 24 mg 1 ondansetron orally disintegrating tab 4 mg 1 ondansetron orally disintegrating tab 8 mg 1 SANCUSO DIS 3.1MG 3 QL (2 patches / 30 days) ANTIEMETICS - ANTICHOLINERGIC meclizine hcl tab 12.5 mg 1 meclizine hcl tab 25 mg 1 OTC scopolamine td patch 72hr 1 mg/3days 2 (generic of TRANSDERM SCOP) trimethobenzamide hcl cap 300 mg 1 ANTIEMETICS - MISCELLANEOUS BONJESTA TAB 20-20MG 2 90 day supply every year

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 47 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits CESAMET CAP 1MG 3 doxylamine-pyridoxine tab delayed release 2 90 day supply every 10-10 mg (generic of DICLEGIS) year dronabinol cap 2.5 mg (generic of 1 PA MARINOL) dronabinol cap 5 mg (generic of MARINOL) 1 PA dronabinol cap 10 mg (generic of 1 PA MARINOL) SUBSTANCE P/NEUROKININ 1 (NK1) RECEPTOR ANTAGONISTS aprepitant capsule 40 mg 2 QL (2 capsules / 23 days) aprepitant capsule 80 mg (generic of 2 QL (4 capsules / 23 EMEND) days) aprepitant capsule 125 mg 2 QL (2 capsules / 23 days) aprepitant capsule therapy pack 80 & 125 2 QL (2 packs (6 capsules) mg / 23 days) EMEND SUS 125MG 2 QL (3 kits / 15 days) VARUBI TAB 90MG 2 PA, QL (4 tabs / 28 days) ANTIFUNGALS ANTIFUNGALS flucytosine cap 250 mg (generic of 3 ANCOBON) flucytosine cap 500 mg (generic of 3 ANCOBON) griseofulvin microsize susp 125 mg/5ml 1 griseofulvin microsize tab 500 mg 3 griseofulvin ultramicrosize tab 125 mg 3 griseofulvin ultramicrosize tab 250 mg 3 LAMISIL GRA 125MG 3 LAMISIL GRA 187.5MG 3 nystatin oral powder 1 nystatin tab 500000 unit 1 terbinafine hcl tab 250 mg (generic of 1 LAMISIL) IMIDAZOLE-RELATED ANTIFUNGALS fluconazole for susp 10 mg/ml (generic of 1 DIFLUCAN) fluconazole for susp 40 mg/ml (generic of 1 DIFLUCAN)

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 48 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits fluconazole tab 50 mg (generic of 1 DIFLUCAN) fluconazole tab 100 mg (generic of 1 DIFLUCAN) fluconazole tab 150 mg (generic of 1 DIFLUCAN) fluconazole tab 200 mg (generic of 1 DIFLUCAN) itraconazole cap 100 mg (generic of 1 SPORANOX) itraconazole oral soln 10 mg/ml (generic of 3 SPORANOX) ketoconazole tab 200 mg 1 NOXAFIL SUS 40MG/ML 3 ONMEL TAB 200MG 3 posaconazole tab delayed release 100 mg 3 (generic of NOXAFIL) voriconazole for susp 40 mg/ml (generic of 2 VFEND) voriconazole tab 50 mg (generic of VFEND) 2 voriconazole tab 200 mg (generic of 2 VFEND) ANTIHISTAMINES ANTIHISTAMINES - ETHANOLAMINES clemastine fumarate tab 2.68 mg 1 diphenhydramine hcl cap 50 mg 1 OTC ANTIHISTAMINES - PHENOTHIAZINES promethazine hcl suppos 12.5 mg 1 promethazine hcl suppos 25 mg 1 promethazine hcl suppos 50 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 ANTIHISTAMINES - PIPERIDINES cyproheptadine hcl syrup 2 mg/5ml 1 cyproheptadine hcl tab 4 mg 1 ANTIHYPERLIPIDEMICS ANTIHYPERLIPIDEMICS - COMBINATIONS ezetimibe-simvastatin tab 10-10 mg 3 PD (generic of VYTORIN)

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 49 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits ezetimibe-simvastatin tab 10-20 mg 3 PD (generic of VYTORIN) ezetimibe-simvastatin tab 10-40 mg 3 PD (generic of VYTORIN) ezetimibe-simvastatin tab 10-80 mg 3 PD (generic of VYTORIN) ANTIHYPERLIPIDEMICS - MISC. icosapent ethyl cap 1 gm 2 PD KYNAMRO INJ 200MG/ML 3 PA; SPC omega-3-acid ethyl esters cap 1 gm 3 PD (generic of LOVAZA) VASCEPA CAP 0.5GM 2 PD; Generic for Vascepa VASCEPA CAP 1GM 2 PD; Generic for Vascepa BILE ACID SEQUESTRANTS cholestyramine light powder packets 4 gm 1 PD cholestyramine powder 4 gm/dose (generic 1 PD of QUESTRAN) cholestyramine powder packets 4 gm 1 PD (generic of QUESTRAN) colesevelam hcl packet for susp 3.75 gm 2 PD (generic of WELCHOL) colesevelam hcl tab 625 mg (generic of 2 PD WELCHOL) colestipol hcl granule packets 5 gm 1 PD (generic of COLESTID) colestipol hcl granules 5 gm (generic of 1 PD COLESTID) colestipol tab 1gm (generic of COLESTID) 1 PD prevalite pow 4gm (generic of QUESTRAN 1 PD LIGHT) FIBRIC ACID DERIVATIVES choline fenofibrate cap dr 45 mg (fenofibric 1 PD acid equiv) (generic of TRILIPIX) choline fenofibrate cap dr 135 mg 1 PD (fenofibric acid equiv) (generic of TRILIPIX) fenofibrate cap 50 mg 2 PD fenofibrate cap 150 mg 2 PD fenofibrate micronized cap 43 mg 2 PD fenofibrate micronized cap 67 mg 1 PD fenofibrate micronized cap 130 mg 3 PD fenofibrate micronized cap 134 mg 1 PD

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 50 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits fenofibrate micronized cap 200 mg 1 PD fenofibrate tab 40 mg (generic of 3 PD FENOGLIDE) fenofibrate tab 48 mg (generic of TRICOR) 1 PD fenofibrate tab 54 mg 1 PD fenofibrate tab 120 mg (generic of 3 PD FENOGLIDE) fenofibrate tab 145 mg (generic of 2 PD TRICOR) fenofibrate tab 160 mg 1 PD fenofibric acid tab 35 mg 1 PD fenofibric acid tab 105 mg 2 PD FIBRICOR TAB 105MG 2 PD gemfibrozil tab 600 mg (generic of LOPID) 1 PD TRIGLIDE TAB 160MG 3 PD HMG COA REDUCTASE INHIBITORS atorvastatin calcium tab 10 mg (base 1 ACA, PD; subject to equivalent) (generic of LIPITOR) dose optimization; Rx4L atorvastatin calcium tab 20 mg (base 1 ACA, PD; subject to equivalent) (generic of LIPITOR) dose optimization; Rx4L atorvastatin calcium tab 40 mg (base 1 PD; subject to dose equivalent) (generic of LIPITOR) optimization; Rx4L atorvastatin calcium tab 80 mg (base 1 PD; Rx4L equivalent) (generic of LIPITOR) lovastatin tab 10 mg 1 PD, ACA; Rx4L lovastatin tab 20 mg 1 PD, ACA; Rx4L lovastatin tab 40 mg 1 PD, ACA; Rx4L pravastatin sodium tab 10 mg 1 PD, ACA; Subject to dose optimization pravastatin sodium tab 20 mg (generic of 1 PD, ACA; Subject to PRAVACHOL) dose optimization pravastatin sodium tab 40 mg (generic of 1 PD, ACA; Rx4L PRAVACHOL) pravastatin sodium tab 80 mg 1 PD, ACA rosuvastatin calcium tab 5 mg (generic of 2 PD, ACA; Subject to CRESTOR) dose optimization rosuvastatin calcium tab 10 mg (generic of 2 PD, ACA; Subject to CRESTOR) dose optimization rosuvastatin calcium tab 20 mg (generic of 2 PD; Subject to dose CRESTOR) optimization rosuvastatin calcium tab 40 mg (generic of 2 PD CRESTOR) SIMCOR TAB 500-20MG 3 PD

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 51 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits SIMCOR TAB 500-40MG 3 PD SIMCOR TAB 750-20MG 3 PD SIMCOR TAB 1000-20 3 PD SIMCOR TAB 1000-40 3 PD simvastatin tab 5 mg 1 PD, ACA; subject to dose optimization simvastatin tab 10 mg (generic of ZOCOR) 1 PD, ACA; Subject to dose optimization simvastatin tab 20 mg (generic of ZOCOR) 1 PD, ACA; Subject to dose optimization simvastatin tab 40 mg (generic of ZOCOR) 1 PD, ACA; Rx4L simvastatin tab 80 mg (generic of ZOCOR) 1 PD; Rx4L INTESTINAL CHOLESTEROL ABSORPTION INHIBITORS ezetimibe tab 10 mg (generic of ZETIA) 2 PD NICOTINIC ACID DERIVATIVES niacin tab er 500 mg (antihyperlipidemic) 2 PD (generic of NIASPAN) niacin tab er 750 mg (antihyperlipidemic) 2 PD (generic of NIASPAN) niacin tab er 1000 mg (antihyperlipidemic) 2 PD (generic of NIASPAN) niacor tab 500mg 1 PD PROPROTEIN CONVERTASE SUBTILISIN/KEXIN TYPE 9 INHIBITORS REPATHA INJ 140MG/ML 2 PA REPATHA PUSH INJ 420/3.5 2 PA REPATHA SURE INJ 140MG/ML 2 PA ANTIHYPERTENSIVES ACE INHIBITORS benazepril hcl tab 5 mg 1 PD; Rx4L benazepril hcl tab 10 mg (generic of 1 PD; Rx4L LOTENSIN) benazepril hcl tab 20 mg (generic of 1 PD; Rx4L LOTENSIN) benazepril hcl tab 40 mg (generic of 1 PD; Rx4L LOTENSIN) captopril tab 12.5 mg 1 PD captopril tab 25 mg 1 PD captopril tab 50 mg 1 PD captopril tab 100 mg 1 PD enalapril maleate tab 2.5 mg (generic of 1 PD; Rx4L VASOTEC)

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 52 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits enalapril maleate tab 5 mg (generic of 1 PD; Rx4L VASOTEC) enalapril maleate tab 10 mg (generic of 1 PD; Rx4L VASOTEC) enalapril maleate tab 20 mg (generic of 1 PD; Rx4L VASOTEC) fosinopril sodium tab 10 mg 1 PD; Rx4L fosinopril sodium tab 20 mg 1 PD; Rx4L fosinopril sodium tab 40 mg 1 PD; Rx4L lisinopril tab 2.5 mg (generic of ZESTRIL) 1 PD; subject to dose optimization; Rx4L lisinopril tab 5 mg (generic of ZESTRIL) 1 PD; subject to dose optimization; Rx4L lisinopril tab 10 mg (generic of ZESTRIL) 1 PD; subject to dose optimization; Rx4L lisinopril tab 20 mg (generic of PRINIVIL) 1 PD; Rx4L lisinopril tab 30 mg (generic of ZESTRIL) 1 PD; Rx4L lisinopril tab 40 mg (generic of ZESTRIL) 1 PD; Rx4L moexipril hcl tab 7.5 mg 1 PD moexipril hcl tab 15 mg 1 PD perindopril erbumine tab 2 mg 1 PD perindopril erbumine tab 4 mg 1 PD perindopril erbumine tab 8 mg 1 PD quinapril hcl tab 5 mg (generic of 1 PD; Rx4L ACCUPRIL) quinapril hcl tab 10 mg (generic of 1 PD; Rx4L ACCUPRIL) quinapril hcl tab 20 mg (generic of 1 PD; Rx4L ACCUPRIL) quinapril hcl tab 40 mg (generic of 1 PD; Rx4L ACCUPRIL) ramipril cap 1.25 mg (generic of ALTACE) 1 PD; Rx4L ramipril cap 2.5 mg (generic of ALTACE) 1 PD; Rx4L ramipril cap 5 mg (generic of ALTACE) 1 PD; Rx4L ramipril cap 10 mg (generic of ALTACE) 1 PD; Rx4L trandolapril tab 1 mg 1 PD trandolapril tab 2 mg 1 PD trandolapril tab 4 mg (generic of MAVIK) 1 PD AGENTS FOR PHEOCHROMOCYTOMA phenoxybenzamine hcl cap 10 mg (generic 3 of DIBENZYLINE)

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 53 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits ANGIOTENSIN II RECEPTOR ANTAGONISTS candesartan cilexetil tab 4 mg (generic of 2 PD ATACAND) candesartan cilexetil tab 8 mg (generic of 2 PD ATACAND) candesartan cilexetil tab 16 mg (generic of 2 PD ATACAND) candesartan cilexetil tab 32 mg (generic of 2 PD ATACAND) eprosartan mesylate tab 600 mg 3 PD irbesartan tab 75 mg (generic of AVAPRO) 1 PD; subject to dose optimization; Rx4L irbesartan tab 150 mg (generic of 1 PD; Rx4L AVAPRO) irbesartan tab 300 mg (generic of 1 PD; Rx4L AVAPRO) losartan potassium tab 25 mg (generic of 1 PD; Rx4L COZAAR) losartan potassium tab 50 mg (generic of 1 PD; Rx4L COZAAR) losartan potassium tab 100 mg (generic of 1 PD; Rx4L COZAAR) olmesartan medoxomil tab 5 mg (generic 2 PD of BENICAR) olmesartan medoxomil tab 20 mg (generic 2 PD of BENICAR) olmesartan medoxomil tab 40 mg (generic 2 PD of BENICAR) telmisartan tab 20 mg (generic of 3 PD; subject to dose MICARDIS) optimization telmisartan tab 40 mg (generic of 3 PD MICARDIS) telmisartan tab 80 mg (generic of 3 PD MICARDIS) valsartan tab 40 mg (generic of DIOVAN) 1 PD valsartan tab 80 mg (generic of DIOVAN) 1 PD valsartan tab 160 mg (generic of DIOVAN) 1 PD valsartan tab 320 mg (generic of DIOVAN) 1 PD ANTIADRENERGIC ANTIHYPERTENSIVES clonidine hcl tab 0.1 mg 1 PD; Rx4L clonidine hcl tab 0.2 mg 1 PD; Rx4L clonidine hcl tab 0.3 mg 1 PD; Rx4L

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 54 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits clonidine td patch weekly 0.1 mg/24hr 1 PD (generic of CATAPRES-TTS-1) clonidine td patch weekly 0.2 mg/24hr 1 PD (generic of CATAPRES-TTS-2) clonidine td patch weekly 0.3 mg/24hr 1 PD (generic of CATAPRES-TTS-3) doxazosin mesylate tab 1 mg (generic of 1 CARDURA) doxazosin mesylate tab 2 mg (generic of 1 CARDURA) doxazosin mesylate tab 4 mg (generic of 1 CARDURA) doxazosin mesylate tab 8 mg (generic of 1 CARDURA) guanfacine hcl tab 1 mg 1 PD; Rx4L guanfacine hcl tab 2 mg 1 PD; Rx4L methyldopa tab 250 mg 1 PD methyldopa tab 500 mg 1 PD prazosin hcl cap 1 mg (generic of 1 MINIPRESS) prazosin hcl cap 2 mg (generic of 1 MINIPRESS) prazosin hcl cap 5 mg (generic of 1 MINIPRESS) terazosin hcl cap 1 mg (base equivalent) 1 Rx4L terazosin hcl cap 2 mg (base equivalent) 1 Rx4L terazosin hcl cap 5 mg (base equivalent) 1 Rx4L terazosin hcl cap 10 mg (base equivalent) 1 Rx4L ANTIHYPERTENSIVE COMBINATIONS amlodipine besylate-benazepril hcl cap 2.5- 1 PD 10 mg amlodipine besylate-benazepril hcl cap 5- 1 PD 10 mg (generic of LOTREL) amlodipine besylate-benazepril hcl cap 5- 1 PD 20 mg (generic of LOTREL) amlodipine besylate-benazepril hcl cap 5- 1 PD 40 mg amlodipine besylate-benazepril hcl cap 10- 1 PD 20 mg (generic of LOTREL) amlodipine besylate-benazepril hcl cap 10- 1 PD 40 mg (generic of LOTREL) amlodipine besylate-olmesartan medoxomil 3 PD tab 5-20 mg (generic of AZOR)

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 55 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits amlodipine besylate-olmesartan medoxomil 3 PD tab 5-40 mg (generic of AZOR) amlodipine besylate-olmesartan medoxomil 3 PD tab 10-20 mg (generic of AZOR) amlodipine besylate-olmesartan medoxomil 3 PD tab 10-40 mg (generic of AZOR) amlodipine besylate-valsartan tab 5-160 2 PD mg (generic of EXFORGE) amlodipine besylate-valsartan tab 5-320 2 PD mg (generic of EXFORGE) amlodipine besylate-valsartan tab 10-160 2 PD mg (generic of EXFORGE) amlodipine besylate-valsartan tab 10-320 2 PD mg (generic of EXFORGE) amlodipine-valsartan-hydrochlorothiazide 2 PD tab 5-160-12.5 mg amlodipine-valsartan-hydrochlorothiazide 2 PD tab 5-160-25 mg amlodipine-valsartan-hydrochlorothiazide 2 PD tab 10-160-12.5 mg amlodipine-valsartan-hydrochlorothiazide 2 PD tab 10-160-25 mg amlodipine-valsartan-hydrochlorothiazide 2 PD tab 10-320-25 mg atenolol & chlorthalidone tab 50-25 mg 1 PD; Rx4L (generic of TENORETIC 50) atenolol & chlorthalidone tab 100-25 mg 1 PD; Rx4L (generic of TENORETIC 100) benazepril & hydrochlorothiazide tab 5- 1 PD 6.25 mg benazepril & hydrochlorothiazide tab 10- 1 PD 12.5 mg benazepril & hydrochlorothiazide tab 20- 1 PD 12.5 mg (generic of LOTENSIN HCT) benazepril & hydrochlorothiazide tab 20-25 1 PD mg (generic of LOTENSIN HCT) bisoprolol & hydrochlorothiazide tab 2.5- 1 PD; Rx4L 6.25 mg (generic of ZIAC) bisoprolol & hydrochlorothiazide tab 5-6.25 1 PD; Rx4L mg (generic of ZIAC) bisoprolol & hydrochlorothiazide tab 10- 1 PD; Rx4L 6.25 mg (generic of ZIAC) candesartan cilexetil-hydrochlorothiazide 2 PD tab 16-12.5 mg (generic of ATACAND HCT)

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 56 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits candesartan cilexetil-hydrochlorothiazide 2 PD tab 32-12.5 mg (generic of ATACAND HCT) candesartan cilexetil-hydrochlorothiazide 2 PD tab 32-25 mg (generic of ATACAND HCT) captopril & hydrochlorothiazide tab 25-15 1 PD mg captopril & hydrochlorothiazide tab 25-25 1 PD mg captopril & hydrochlorothiazide tab 50-15 1 PD mg captopril & hydrochlorothiazide tab 50-25 1 PD mg enalapril maleate & hydrochlorothiazide tab 1 PD; Rx4L 5-12.5 mg enalapril maleate & hydrochlorothiazide tab 1 PD; Rx4L 10-25 mg (generic of VASERETIC) fosinopril sodium & hydrochlorothiazide tab 1 PD 10-12.5 mg fosinopril sodium & hydrochlorothiazide tab 1 PD 20-12.5 mg irbesartan-hydrochlorothiazide tab 150- 1 PD 12.5 mg (generic of AVALIDE) irbesartan-hydrochlorothiazide tab 300- 1 PD 12.5 mg (generic of AVALIDE) lisinopril & hydrochlorothiazide tab 10-12.5 1 PD; Rx4L mg (generic of ZESTORETIC) lisinopril & hydrochlorothiazide tab 20-12.5 1 PD; Rx4L mg (generic of ZESTORETIC) lisinopril & hydrochlorothiazide tab 20-25 1 PD; Rx4L mg (generic of ZESTORETIC) losartan potassium & hydrochlorothiazide 1 PD tab 50-12.5 mg (generic of HYZAAR) losartan potassium & hydrochlorothiazide 1 PD tab 100-12.5 mg (generic of HYZAAR) losartan potassium & hydrochlorothiazide 1 PD tab 100-25 mg (generic of HYZAAR) metoprolol & hydrochlorothiazide tab 50- 1 PD 25 mg metoprolol & hydrochlorothiazide tab 100- 1 PD 25 mg metoprolol & hydrochlorothiazide tab 100- 1 PD 50 mg moexipril-hydrochlorothiazide tab 7.5-12.5 1 PD mg

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 57 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits moexipril-hydrochlorothiazide tab 15-12.5 1 PD mg moexipril-hydrochlorothiazide tab 15-25 1 PD mg nadolol & bendroflumethiazide tab 40-5 mg 1 PD nadolol & bendroflumethiazide tab 80-5 mg 1 PD olmesartan-amlodipine-hydrochlorothiazide 3 PD tab 20-5-12.5 mg (generic of TRIBENZOR) olmesartan-amlodipine-hydrochlorothiazide 3 PD tab 40-5-12.5 mg (generic of TRIBENZOR) olmesartan-amlodipine-hydrochlorothiazide 3 PD tab 40-5-25 mg (generic of TRIBENZOR) olmesartan-amlodipine-hydrochlorothiazide 3 PD tab 40-10-12.5 mg (generic of TRIBENZOR) olmesartan-amlodipine-hydrochlorothiazide 3 PD tab 40-10-25 mg (generic of TRIBENZOR) propranolol & hydrochlorothiazide tab 40- 1 PD 25 mg propranolol & hydrochlorothiazide tab 80- 1 PD 25 mg quinapril-hydrochlorothiazide tab 10-12.5 1 PD; Rx4L mg (generic of ACCURETIC) quinapril-hydrochlorothiazide tab 20-12.5 1 PD; Rx4L mg (generic of ACCURETIC) quinapril-hydrochlorothiazide tab 20-25 mg 1 PD (generic of ACCURETIC) TEKTURNA HCT TAB 150-12.5 3 PD TEKTURNA HCT TAB 150-25MG 3 PD TEKTURNA HCT TAB 300-12.5 3 PD TEKTURNA HCT TAB 300-25MG 3 PD telmisartan-hydrochlorothiazide tab 40- 3 PD 12.5 mg (generic of MICARDIS HCT) telmisartan-hydrochlorothiazide tab 80- 3 PD 12.5 mg (generic of MICARDIS HCT) telmisartan-hydrochlorothiazide tab 80-25 3 PD mg (generic of MICARDIS HCT) trandolapril-verapamil hcl tab er 1-240 mg 3 PD trandolapril-verapamil hcl tab er 2-180 mg 3 PD (generic of TARKA) trandolapril-verapamil hcl tab er 2-240 mg 3 PD (generic of TARKA)

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 58 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits trandolapril-verapamil hcl tab er 4-240 mg 3 PD (generic of TARKA) valsartan-hydrochlorothiazide tab 80-12.5 1 PD mg (generic of DIOVAN HCT) valsartan-hydrochlorothiazide tab 160-12.5 1 PD mg (generic of DIOVAN HCT) valsartan-hydrochlorothiazide tab 160-25 1 PD mg (generic of DIOVAN HCT) valsartan-hydrochlorothiazide tab 320-12.5 1 PD mg (generic of DIOVAN HCT) valsartan-hydrochlorothiazide tab 320-25 1 PD mg (generic of DIOVAN HCT) DIRECT RENIN INHIBITORS aliskiren fumarate tab 150 mg (base 3 PD equivalent) (generic of TEKTURNA) aliskiren fumarate tab 300 mg (base 3 PD equivalent) (generic of TEKTURNA) SELECTIVE ALDOSTERONE RECEPTOR ANTAGONISTS (SARAS) eplerenone tab 25 mg (generic of INSPRA) 1 eplerenone tab 50 mg (generic of INSPRA) 1 VASODILATORS hydralazine hcl tab 10 mg 1 PD hydralazine hcl tab 25 mg 1 PD hydralazine hcl tab 50 mg 1 PD hydralazine hcl tab 100 mg 1 PD minoxidil tab 2.5 mg 1 PD minoxidil tab 10 mg 1 PD ANTIMALARIALS ANTIMALARIAL COMBINATIONS atovaquone-proguanil hcl tab 62.5-25 mg 2 (generic of MALARONE) atovaquone-proguanil hcl tab 250-100 mg 2 (generic of MALARONE) COARTEM TAB 20-120MG 3 ANTIMALARIALS chloroquine phosphate tab 250 mg 1 chloroquine phosphate tab 500 mg 1 hydroxychloroquine sulfate tab 200 mg 1 (generic of PLAQUENIL) mefloquine hcl tab 250 mg 1 PLAQUENIL TAB 200MG 3

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 59 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits primaquine phosphate tab 26.3 mg (15 mg 3 base) (generic of PRIMAQUINE PHOSPHATE) pyrimethamine tab 25 mg (generic of 3 PA DARAPRIM) quinine sulfate cap 324 mg (generic of 3 QUALAQUIN) ANTIMYASTHENIC/CHOLINERGIC AGENTS ANTIMYASTHENIC/CHOLINERGIC AGENTS pyridostigmine bromide oral soln 60 2 mg/5ml (generic of MESTINON) pyridostigmine bromide tab 60 mg (generic 1 of MESTINON) pyridostigmine bromide tab er 180 mg 2 (generic of MESTINON TIMESPAN) RUZURGI TAB 10MG 3 PA ANTIMYCOBACTERIAL AGENTS ANTIMYCOBACTERIAL AGENTS ethambutol hcl tab 100 mg 1 ethambutol hcl tab 400 mg (generic of 1 MYAMBUTOL) isoniazid syrup 50 mg/5ml 1 isoniazid tab 100 mg 1 isoniazid tab 300 mg 1 PRETOMANID TAB 200MG 3 PA PRIFTIN TAB 150MG 2 pyrazinamide tab 500 mg 1 rifabutin cap 150 mg (generic of 2 MYCOBUTIN) rifampin cap 150 mg 1 rifampin cap 300 mg 1 SIRTURO TAB 20MG 3 PA SIRTURO TAB 100MG 3 PA ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Oral drugs for cancer treatment are covered under the New York State Oral Oncology mandate ALKYLATING AGENTS ALKERAN TAB 2MG 2 cyclophosphamide cap 25 mg 2 CYCLOPHOSPHAMIDE CAP 25 MG 2 cyclophosphamide cap 50 mg 2 CYCLOPHOSPHAMIDE CAP 50 MG 2 GLEOSTINE CAP 5MG 2

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 60 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits HEXALEN CAP 50MG 2 LEUKERAN TAB 2MG 2 melphalan tab 2 mg (generic of ALKERAN) 2 MYLERAN TAB 2MG 2 temozolomide cap 5 mg 2 PA; SPC temozolomide cap 20 mg 2 PA; SPC temozolomide cap 100 mg (generic of 2 PA; SPC TEMODAR) temozolomide cap 140 mg (generic of 2 PA; SPC TEMODAR) temozolomide cap 180 mg (generic of 2 PA; SPC TEMODAR) temozolomide cap 250 mg (generic of 2 PA; SPC TEMODAR) ANTIMETABOLITES capecitabine tab 150 mg (generic of 2 PA; SPC XELODA) capecitabine tab 500 mg (generic of 2 PA; SPC XELODA) mercaptopurine tab 50 mg 1 methotrexate sodium inj 50 mg/2ml (25 1 ^ mg/ml) methotrexate sodium inj pf 1000 mg/40ml 1 ^ (25 mg/ml) methotrexate sodium tab 2.5 mg (base 1 equiv) PURIXAN SUS 20MG/ML 2 SPC TABLOID TAB 40MG 2 TREXALL TAB 5MG 2 TREXALL TAB 7.5MG 2 TREXALL TAB 10MG 2 TREXALL TAB 15MG 2 ANTINEOPLASTIC - BCL-2 INHIBITORS VENCLEXTA TAB 10MG 3 PA VENCLEXTA TAB 50MG 3 PA VENCLEXTA TAB 100MG 3 PA VENCLEXTA TAB START PK 3 PA ANTINEOPLASTIC - HEDGEHOG PATHWAY INHIBITORS ERIVEDGE CAP 150MG 3 PA; SPC ODOMZO CAP 200MG 3 PA; SPC

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 61 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS abiraterone acetate tab 250 mg (generic of 2 PA; SPC ZYTIGA) abiraterone acetate tab 500 mg (generic of 2 PA; SPC ZYTIGA) anastrozole tab 1 mg (generic of 1 ARIMIDEX) bicalutamide tab 50 mg (generic of 1 CASODEX) EMCYT CAP 140MG 2 ERLEADA TAB 60MG 2 PA; SPC exemestane tab 25 mg (generic of 2 AROMASIN) flutamide cap 125 mg 1 letrozole tab 2.5 mg (generic of FEMARA) 1 leuprolide acetate inj kit 5 mg/ml 1 SPC LUPRON DEPOT INJ 3.75MG 2 ^, SPC LUPRON DEPOT INJ 7.5MG 2 ^, SPC LUPRON DEPOT INJ 11.25MG 2 ^, SPC LUPRON DEPOT INJ 22.5MG 2 ^, SPC LUPRON DEPOT INJ 30MG 2 ^, SPC LUPRON DEPOT INJ 45MG 2 ^, SPC LYSODREN TAB 500MG 2 megestrol acetate susp 40 mg/ml 1 megestrol acetate tab 20 mg 1 megestrol acetate tab 40 mg 1 NUBEQA TAB 300MG 2 PA; SPC ORGOVYX TAB 120MG 3 PA SOLTAMOX SOL 10MG/5ML 1 tamoxifen citrate tab 10 mg (base 1 ACA equivalent) tamoxifen citrate tab 20 mg (base 1 ACA equivalent) toremifene citrate tab 60 mg (base 2 equivalent) (generic of FARESTON) XTANDI CAP 40MG 2 PA; SPC XTANDI TAB 40MG 2 PA; SPC XTANDI TAB 80MG 2 PA; SPC ANTINEOPLASTIC - XPO1 INHIBITORS XPOVIO PAK 40MG 3 PA; SP XPOVIO PAK 50MG 3 PA; SP XPOVIO PAK 60MG 3 PA; SP

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 62 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits XPOVIO PAK 80MG 3 PA; SP XPOVIO PAK 100MG 3 PA; SP ANTINEOPLASTIC COMBINATIONS KISQALI 200 PAK FEMARA 2 PA; SPC KISQALI 400 PAK FEMARA 2 PA; SPC KISQALI 600 PAK FEMARA 2 PA; SPC LONSURF TAB 15-6.14 3 PA; SPC LONSURF TAB 20-8.19 3 PA; SPC ANTINEOPLASTIC ENZYME INHIBITORS AFINITOR DIS TAB 2MG 3 PA; SPC AFINITOR DIS TAB 3MG 3 PA; SPC AFINITOR DIS TAB 5MG 3 PA; SPC AFINITOR TAB 10MG 3 PA; SPC ALECENSA CAP 150MG 3 PA; SPC AYVAKIT TAB 100MG 3 PA, QL (30 tabs / 30 days); SPC AYVAKIT TAB 200MG 3 PA, QL (30 tabs / 30 days); SPC AYVAKIT TAB 300MG 3 PA, QL (30 tabs / 30 days); SPC BALVERSA TAB 3MG 3 PA BALVERSA TAB 4MG 3 PA BALVERSA TAB 5MG 3 PA BOSULIF TAB 100MG 3 PA; SPC BOSULIF TAB 400MG 3 PA; SPC BOSULIF TAB 500MG 3 PA; SPC BRUKINSA CAP 80MG 3 PA; SP CABOMETYX TAB 20MG 2 PA; SPC CABOMETYX TAB 40MG 2 PA; SPC CABOMETYX TAB 60MG 2 PA; SPC CAPRELSA TAB 100MG 3 PA CAPRELSA TAB 300MG 3 PA COMETRIQ KIT 60MG 3 PA; SP COMETRIQ KIT 100MG 3 PA; SP COMETRIQ KIT 140MG 3 PA; SP COTELLIC TAB 20MG 3 PA; SPC erlotinib hcl tab 25 mg (base equivalent) 2 PA; SPC (generic of TARCEVA) erlotinib hcl tab 100 mg (base equivalent) 2 PA; SPC (generic of TARCEVA) erlotinib hcl tab 150 mg (base equivalent) 2 PA; SPC (generic of TARCEVA)

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 63 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits everolimus tab 2.5 mg (generic of 3 PA; SPC AFINITOR) everolimus tab 5 mg (generic of AFINITOR) 3 PA; SPC everolimus tab 7.5 mg (generic of 3 PA; SPC AFINITOR) GAVRETO CAP 100MG 3 PA; SPC GILOTRIF TAB 20MG 3 PA; SP GILOTRIF TAB 30MG 3 PA; SP GILOTRIF TAB 40MG 3 PA; SP IBRANCE CAP 75MG 2 PA; SPC IBRANCE CAP 100MG 2 PA; SPC IBRANCE CAP 125MG 2 PA; SPC IBRANCE TAB 75MG 2 PA; SPC IBRANCE TAB 100MG 2 PA; SPC IBRANCE TAB 125MG 2 PA; SPC imatinib mesylate tab 100 mg (base 2 PA; SPC equivalent) (generic of GLEEVEC) imatinib mesylate tab 400 mg (base 2 PA; SPC equivalent) (generic of GLEEVEC) IMBRUVICA CAP 70MG 3 PA; SP IMBRUVICA CAP 140MG 3 PA; SP IMBRUVICA TAB 140MG 3 PA; SP IMBRUVICA TAB 280MG 3 PA; SP IMBRUVICA TAB 420MG 3 PA; SP IMBRUVICA TAB 560MG 3 PA; SP INLYTA TAB 1MG 3 PA; SPC INLYTA TAB 5MG 3 PA; SPC JAKAFI TAB 5MG 3 PA, QL (60 tabs / 30 days); SPC JAKAFI TAB 10MG 3 PA, QL (60 tabs / 30 days); SPC JAKAFI TAB 15MG 3 PA, QL (60 tabs / 30 days); SPC JAKAFI TAB 20MG 3 PA, QL (60 tabs / 30 days); SPC JAKAFI TAB 25MG 3 PA, QL (60 tabs / 30 days); SPC KISQALI TAB 200DOSE 2 PA; SPC KISQALI TAB 400DOSE 2 PA; SPC KISQALI TAB 600DOSE 2 PA; SPC lapatinib ditosylate tab 250 mg (base 2 PA; SPC equiv) (generic of TYKERB)

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 64 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits LENVIMA CAP 4MG 3 PA; SPC LENVIMA CAP 8 MG 3 PA; SPC LENVIMA CAP 10 MG 3 PA; SPC LENVIMA CAP 12MG 3 PA; SPC LENVIMA CAP 14 MG 3 PA; SPC LENVIMA CAP 18 MG 3 PA; SPC LENVIMA CAP 20 MG 3 PA; SPC LENVIMA CAP 24 MG 3 PA; SPC LYNPARZA TAB 100MG 2 PA; SPC LYNPARZA TAB 150MG 2 PA; SPC MEKINIST TAB 0.5MG 3 PA; SPC MEKINIST TAB 2MG 3 PA; SPC NEXAVAR TAB 200MG 2 PA; SPC NINLARO CAP 2.3MG 3 PA; SPC NINLARO CAP 3MG 3 PA; SPC NINLARO CAP 4MG 3 PA; SPC PIQRAY 200MG TAB DOSE 3 PA; SPC PIQRAY 250MG TAB DOSE 3 PA; SPC PIQRAY 300MG TAB DOSE 3 PA; SPC RETEVMO CAP 40MG 3 PA; SPC RETEVMO CAP 80MG 3 PA; SPC ROZLYTREK CAP 100MG 3 PA; SPC ROZLYTREK CAP 200MG 3 PA; SPC RUBRACA TAB 200MG 2 PA; SPC RUBRACA TAB 250MG 2 PA; SPC RUBRACA TAB 300MG 2 PA; SPC RYDAPT CAP 25MG 3 PA; SPC SPRYCEL TAB 20MG 2 PA; SPC SPRYCEL TAB 50MG 2 PA; SPC SPRYCEL TAB 70MG 2 PA; SPC SPRYCEL TAB 80MG 2 PA; SPC SPRYCEL TAB 100MG 2 PA; SPC SPRYCEL TAB 140MG 2 PA; SPC STIVARGA TAB 40MG 3 PA; SPC SUTENT CAP 12.5MG 2 PA; SPC SUTENT CAP 25MG 2 PA; SPC SUTENT CAP 37.5MG 2 PA; SPC SUTENT CAP 50MG 2 PA; SPC TABRECTA TAB 150MG 3 PA; SPC TABRECTA TAB 200MG 3 PA; SPC TAFINLAR CAP 50MG 3 PA; SPC

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 65 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits TAFINLAR CAP 75MG 3 PA; SPC TAGRISSO TAB 40MG 3 PA; SPC TAGRISSO TAB 80MG 3 PA; SPC TASIGNA CAP 50MG 2 PA; SPC TASIGNA CAP 150MG 2 PA; SPC TASIGNA CAP 200MG 2 PA; SPC TAZVERIK TAB 200MG 3 PA; SPC UKONIQ TAB 200MG 3 PA VERZENIO TAB 50MG 3 PA; SPC VERZENIO TAB 100MG 3 PA; SPC VERZENIO TAB 150MG 3 PA; SPC VERZENIO TAB 200MG 3 PA; SPC VIZIMPRO TAB 15MG 3 PA; SPC VIZIMPRO TAB 30MG 3 PA; SPC VIZIMPRO TAB 45MG 3 PA; SPC VOTRIENT TAB 200MG 3 PA; SPC XALKORI CAP 200MG 3 PA; SPC XALKORI CAP 250MG 3 PA; SPC XOSPATA TAB 40MG 3 PA ZEJULA CAP 100MG 2 PA; SP ZELBORAF TAB 240MG 3 PA; SPC ZOLINZA CAP 100MG 2 PA; SPC ZYDELIG TAB 100MG 3 PA; SPC ZYDELIG TAB 150MG 3 PA; SPC ZYKADIA CAP 150MG 3 PA; SPC ZYKADIA TAB 150MG 3 PA; SPC ANTINEOPLASTICS MISC. bexarotene cap 75 mg (generic of 2 PA; SPC TARGRETIN) hydroxyurea cap 500 mg (generic of 1 HYDREA) MATULANE CAP 50MG 2 SYLATRON KIT 200MCG 3 PA SYLATRON KIT 300MCG 3 PA SYLATRON KIT 600MCG 3 PA tretinoin cap 10 mg 1 CHEMOTHERAPY RESCUE/ANTIDOTE AGENTS leucovorin calcium tab 5 mg 1 leucovorin calcium tab 10 mg 1 leucovorin calcium tab 15 mg 1 leucovorin calcium tab 25 mg 1

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 66 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits MESNEX TAB 400MG 2 MITOTIC INHIBITORS etoposide cap 50 mg 1 TOPOISOMERASE I INHIBITORS HYCAMTIN CAP 0.25MG 2 PA; SPC HYCAMTIN CAP 1MG 2 PA; SPC ONIVYDE INJ 4.3MG/ML 3 ^ ANTIPARKINSON AGENTS ANTIPARKINSON ANTICHOLINERGICS benztropine mesylate tab 0.5 mg 1 benztropine mesylate tab 1 mg 1 benztropine mesylate tab 2 mg 1 trihexyphenidyl hcl oral soln 0.4 mg/ml 1 trihexyphenidyl hcl tab 2 mg 1 trihexyphenidyl hcl tab 5 mg 1 ANTIPARKINSON COMT INHIBITORS entacapone tab 200 mg (generic of 2 COMTAN) tolcapone tab 100 mg (generic of TASMAR) 3 ANTIPARKINSON DOPAMINERGICS amantadine hcl cap 100 mg 1 amantadine hcl syrup 50 mg/5ml 1 amantadine hcl tab 100 mg 1 APOKYN INJ 10MG/ML 3 SPC bromocriptine mesylate cap 5 mg (base 1 equivalent) (generic of PARLODEL) bromocriptine mesylate tab 2.5 mg (base 1 equivalent) carbidopa & levodopa orally disintegrating 1 tab 10-100 mg carbidopa & levodopa orally disintegrating 1 tab 25-100 mg carbidopa & levodopa orally disintegrating 1 tab 25-250 mg carbidopa & levodopa tab 10-100 mg 1 (generic of SINEMET) carbidopa & levodopa tab 25-100 mg 1 (generic of SINEMET) carbidopa & levodopa tab 25-250 mg 1 carbidopa & levodopa tab er 25-100 mg 1 carbidopa & levodopa tab er 50-200 mg 1

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 67 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits carbidopa-levodopa-entacapone tabs 12.5- 2 50-200 mg carbidopa-levodopa-entacapone tabs 2 18.75-75-200 mg (generic of STALEVO 75) carbidopa-levodopa-entacapone tabs 25- 2 100-200 mg (generic of STALEVO 100) carbidopa-levodopa-entacapone tabs 2 31.25-125-200 mg (generic of STALEVO 125) carbidopa-levodopa-entacapone tabs 37.5- 2 150-200 mg (generic of STALEVO 150) carbidopa-levodopa-entacapone tabs 50- 2 200-200 mg DUOPA SUS 4.63-20 3 INBRIJA CAP 42MG 3 PA; RxC/M, SPC NEUPRO DIS 1MG/24HR 2 NEUPRO DIS 2MG/24HR 2 NEUPRO DIS 3MG/24HR 2 NEUPRO DIS 4MG/24HR 2 NEUPRO DIS 6MG/24HR 2 NEUPRO DIS 8MG/24HR 2 pramipexole dihydrochloride tab 0.5 mg 1 (generic of MIRAPEX) pramipexole dihydrochloride tab 0.25 mg 1 pramipexole dihydrochloride tab 0.75 mg 1 (generic of MIRAPEX) pramipexole dihydrochloride tab 0.125 mg 1 (generic of MIRAPEX) pramipexole dihydrochloride tab 1 mg 1 (generic of MIRAPEX) pramipexole dihydrochloride tab 1.5 mg 1 pramipexole dihydrochloride tab er 24hr 3 0.75 mg (generic of MIRAPEX ER) pramipexole dihydrochloride tab er 24hr 3 0.375 mg (generic of MIRAPEX ER) pramipexole dihydrochloride tab er 24hr 3 1.5 mg (generic of MIRAPEX ER) pramipexole dihydrochloride tab er 24hr 3 2.25 mg (generic of MIRAPEX ER) pramipexole dihydrochloride tab er 24hr 3 3 mg (generic of MIRAPEX ER) pramipexole dihydrochloride tab er 24hr 3 3.75 mg (generic of MIRAPEX ER)

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 68 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits pramipexole dihydrochloride tab er 24hr 3 4.5 mg (generic of MIRAPEX ER) ropinirole hydrochloride tab 0.5 mg 1 ropinirole hydrochloride tab 0.25 mg 1 ropinirole hydrochloride tab 1 mg 1 ropinirole hydrochloride tab 2 mg 1 ropinirole hydrochloride tab 3 mg 1 ropinirole hydrochloride tab 4 mg 1 ropinirole hydrochloride tab 5 mg 1 ropinirole hydrochloride tab er 24hr 2 mg 2 (base equivalent) ropinirole hydrochloride tab er 24hr 4 mg 3 (base equivalent) ropinirole hydrochloride tab er 24hr 6 mg 3 (base equivalent) ropinirole hydrochloride tab er 24hr 8 mg 3 (base equivalent) ropinirole hydrochloride tab er 24hr 12 mg 3 (base equivalent) ANTIPARKINSON MONOAMINE OXIDASE INHIBITORS rasagiline mesylate tab 0.5 mg (base 2 equiv) (generic of AZILECT) rasagiline mesylate tab 1 mg (base equiv) 2 (generic of AZILECT) selegiline hcl cap 5 mg 1 selegiline hcl tab 5 mg 1 ZELAPAR TAB 1.25MG 3 ANTIPSYCHOTICS/ANTIMANIC AGENTS ANTIMANIC AGENTS lithium carbonate cap 150 mg 1 Rx4L lithium carbonate cap 300 mg 1 Rx4L lithium carbonate cap 600 mg 1 lithium carbonate tab 300 mg 1 lithium carbonate tab er 300 mg (generic 1 of LITHOBID) lithium carbonate tab er 450 mg 1 LITHIUM SOL 8MEQ/5ML 1 ANTIPSYCHOTICS - MISC. CAPLYTA CAP 42MG 3 PA EQUETRO CAP 100MG 2 EQUETRO CAP 200MG 2 EQUETRO CAP 300MG 2

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 69 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits LATUDA TAB 20MG 3 PA, QL (30 tabs / 25 days) LATUDA TAB 40MG 3 PA, QL (30 ea / 25 days) LATUDA TAB 60MG 3 PA, QL (30 ea / 25 days) LATUDA TAB 80MG 3 PA, QL (30 ea / 25 days) LATUDA TAB 120MG 3 PA, QL (30 tabs / 25 days) VRAYLAR CAP 1.5-3MG 3 PA, QL (30 caps / 30 days) VRAYLAR CAP 1.5MG 3 PA, QL (30 caps / 30 days) VRAYLAR CAP 3MG 3 PA, QL (30 caps / 30 days) VRAYLAR CAP 4.5MG 3 PA, QL (30 caps / 30 days) VRAYLAR CAP 6MG 3 PA, QL (30 caps / 30 days) ziprasidone hcl cap 20 mg (generic of 2 PA, QL (60 ea / 25 GEODON) days); PA if < 18 yoa ziprasidone hcl cap 40 mg (generic of 2 PA, QL (60 ea / 25 GEODON) days); PA if < 18 yoa ziprasidone hcl cap 60 mg (generic of 2 PA, QL (60 ea / 25 GEODON) days); PA if < 18 yoa ziprasidone hcl cap 80 mg (generic of 2 PA, QL (60 ea / 25 GEODON) days); PA if < 18 yoa BENZISOXAZOLES FANAPT PAK 3 PA, QL (60 tabs / 25 days) FANAPT TAB 1MG 3 PA, QL (60 tabs / 25 days) FANAPT TAB 2MG 3 PA, QL (60 tabs / 25 days) FANAPT TAB 4MG 3 PA, QL (60 tabs / 25 days) FANAPT TAB 6MG 3 PA, QL (60 tabs / 25 days) FANAPT TAB 8MG 3 PA, QL (60 tabs / 25 days) FANAPT TAB 10MG 3 PA, QL (60 tabs / 25 days) FANAPT TAB 12MG 3 PA, QL (60 tabs / 25 days) INVEGA SUST INJ 39/0.25 3 PA; ^

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 70 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits INVEGA SUST INJ 78/0.5ML 3 PA; ^ INVEGA SUST INJ 117/0.75 3 PA; ^ INVEGA SUST INJ 156MG/ML 3 PA; ^ INVEGA SUST INJ 234/1.5 3 PA; ^ INVEGA TRINZ INJ 273MG 3 PA; ^ INVEGA TRINZ INJ 410MG 3 PA; ^ INVEGA TRINZ INJ 546MG 3 PA; ^ INVEGA TRINZ INJ 819MG 3 PA; ^ paliperidone tab er 24hr 1.5 mg (generic of 3 PA, QL (30 tabs / 25 INVEGA) days) paliperidone tab er 24hr 3 mg (generic of 3 PA, QL (30 tabs / 25 INVEGA) days) paliperidone tab er 24hr 6 mg (generic of 3 PA, QL (30 tabs / 25 INVEGA) days) paliperidone tab er 24hr 9 mg (generic of 3 PA, QL (30 tabs / 25 INVEGA) days) risperidone orally disintegrating tab 0.5 mg 1 QL (30 ea / 25 days) risperidone orally disintegrating tab 0.25 1 QL (30 ea / 25 days) mg risperidone orally disintegrating tab 1 mg 1 QL (30 ea / 25 days) risperidone orally disintegrating tab 2 mg 1 QL (30 ea / 25 days) risperidone orally disintegrating tab 3 mg 1 QL (30 ea / 25 days) risperidone orally disintegrating tab 4 mg 1 QL (30 ea / 25 days) risperidone soln 1 mg/ml (generic of 1 QL (30 mL / 25 days) RISPERDAL) risperidone tab 0.5 mg (generic of 1 QL (30 tabs / 25 days); RISPERDAL) Rx4L risperidone tab 0.25 mg 1 QL (30 tabs / 25 days); Rx4L risperidone tab 1 mg (generic of 1 QL (30 tabs / 25 days); RISPERDAL) Rx4L risperidone tab 2 mg (generic of 1 QL (30 tabs / 25 days); RISPERDAL) Rx4L risperidone tab 3 mg (generic of 1 QL (30 tabs / 25 days) RISPERDAL) risperidone tab 4 mg (generic of 1 QL (30 tabs / 25 days) RISPERDAL) BUTYROPHENONES HALDOL DECAN INJ 50MG/ML 3 PA; ^ HALDOL DECAN INJ 100MG/ML 3 PA; ^ HALDOL INJ 5MG/ML 3 PA; ^ haloperidol decanoate im soln 50 mg/ml 1 PA; ^ (generic of HALDOL DECANOATE 50)

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 71 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits haloperidol decanoate im soln 100 mg/ml 1 PA; ^ (generic of HALDOL DECANOATE 100) haloperidol lactate inj 5 mg/ml (generic of 1 PA; ^ HALDOL) haloperidol lactate oral conc 2 mg/ml 1 ^ haloperidol tab 0.5 mg 1 haloperidol tab 1 mg 1 haloperidol tab 2 mg 1 haloperidol tab 5 mg 1 haloperidol tab 10 mg 1 haloperidol tab 20 mg 1 DIBENZAPINES asenapine maleate sl tab 2.5 mg (base 2 PA, QL (60 tabs / 30 equiv) (generic of SAPHRIS) days) asenapine maleate sl tab 5 mg (base 2 PA, QL (60 tabs / 30 equiv) (generic of SAPHRIS) days) asenapine maleate sl tab 10 mg (base 2 PA, QL (60 tabs / 30 equiv) (generic of SAPHRIS) days) clozapine orally disintegrating tab 12.5 mg 3 clozapine orally disintegrating tab 25 mg 3 clozapine orally disintegrating tab 100 mg 3 clozapine orally disintegrating tab 150 mg 3 clozapine orally disintegrating tab 200 mg 3 clozapine tab 25 mg (generic of CLOZARIL) 1 clozapine tab 50 mg (generic of CLOZARIL) 1 clozapine tab 100 mg (generic of 1 CLOZARIL) clozapine tab 200 mg (generic of 1 CLOZARIL) loxapine succinate cap 5 mg 1 loxapine succinate cap 10 mg 1 loxapine succinate cap 25 mg 1 loxapine succinate cap 50 mg 1 olanzapine orally disintegrating tab 5 mg 2 PA, QL (30 ea / 25 (generic of ZYPREXA ZYDIS) days); PA if < 13 yoa olanzapine orally disintegrating tab 10 mg 2 PA, QL (30 ea / 25 (generic of ZYPREXA ZYDIS) days); PA if < 13 yoa olanzapine orally disintegrating tab 15 mg 2 PA, QL (30 ea / 25 (generic of ZYPREXA ZYDIS) days); PA if < 13 yoa olanzapine orally disintegrating tab 20 mg 2 PA, QL (30 ea / 25 (generic of ZYPREXA ZYDIS) days); PA if < 13 yoa

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 72 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits olanzapine tab 2.5 mg (generic of 1 PA, QL (30 ea / 25 ZYPREXA) days); PA if < 13 yoa olanzapine tab 5 mg (generic of ZYPREXA) 1 PA, QL (30 tabs / 25 days); PA if < 13 yoa olanzapine tab 7.5 mg (generic of 1 PA, QL (30 tabs / 25 ZYPREXA) days); PA if < 13 yoa olanzapine tab 10 mg (generic of 1 PA, QL (30 tabs / 25 ZYPREXA) days); PA if < 13 yoa olanzapine tab 15 mg (generic of 1 PA, QL (30 ea / 25 ZYPREXA) days); PA if < 13 yoa olanzapine tab 20 mg (generic of 1 PA, QL (30 ea / 25 ZYPREXA) days); PA if < 13 yoa quetiapine fumarate tab 25 mg (generic of 1 PA, QL (90 tabs / 30 SEROQUEL) days); PA if < 10 yoa quetiapine fumarate tab 50 mg (generic of 1 PA, QL (90 tabs / 30 SEROQUEL) days); PA if < 10 yoa; Rx4L quetiapine fumarate tab 100 mg (generic 1 PA, QL (90 tabs / 30 of SEROQUEL) days); PA if < 10 yoa; Rx4L quetiapine fumarate tab 200 mg (generic 1 PA, QL (90 tabs / 30 of SEROQUEL) days); PA if < 10 yoa; Rx4L quetiapine fumarate tab 300 mg (generic 1 PA, QL (90 tabs / 30 of SEROQUEL) days); PA if < 10 yoa; Rx4L quetiapine fumarate tab 400 mg (generic 1 PA, QL (90 tabs / 30 of SEROQUEL) days); PA if < 10 yoa quetiapine fumarate tab er 24hr 50 mg 2 PA, QL (60 tabs / 30 (generic of SEROQUEL XR) days); PA if < 10 yoa quetiapine fumarate tab er 24hr 150 mg 2 PA, QL (30 tabs / 30 (generic of SEROQUEL XR) days); PA if < 10 yoa quetiapine fumarate tab er 24hr 200 mg 2 PA, QL (30 tabs / 30 (generic of SEROQUEL XR) days); PA if < 10 yoa quetiapine fumarate tab er 24hr 300 mg 2 PA, QL (30 tabs / 30 (generic of SEROQUEL XR) days); PA if < 10 yoa quetiapine fumarate tab er 24hr 400 mg 2 PA, QL (30 tabs / 30 (generic of SEROQUEL XR) days); PA if < 10 yoa SECUADO DIS 3.8MG 3 PA SECUADO DIS 5.7MG 3 PA SECUADO DIS 7.6MG 3 PA PHENOTHIAZINES chlorpromazine hcl tab 10 mg 1

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 73 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits chlorpromazine hcl tab 25 mg 1 chlorpromazine hcl tab 50 mg 1 chlorpromazine hcl tab 100 mg 1 chlorpromazine hcl tab 200 mg 1 fluphenazine decanoate inj 25 mg/ml 1 PA fluphenazine hcl elixir 2.5 mg/5ml 1 fluphenazine hcl oral conc 5 mg/ml 1 fluphenazine hcl tab 1 mg 1 fluphenazine hcl tab 2.5 mg 1 fluphenazine hcl tab 5 mg 1 fluphenazine hcl tab 10 mg 1 perphenazine tab 2 mg 1 perphenazine tab 4 mg 1 perphenazine tab 8 mg 1 perphenazine tab 16 mg 1 prochlorperazine maleate tab 5 mg (base 1 equivalent) prochlorperazine maleate tab 10 mg (base 1 equivalent) prochlorperazine suppos 25 mg 1 thioridazine hcl tab 10 mg 1 thioridazine hcl tab 25 mg 1 thioridazine hcl tab 50 mg 1 thioridazine hcl tab 100 mg 1 trifluoperazine hcl tab 1 mg (base 1 equivalent) trifluoperazine hcl tab 2 mg (base 1 equivalent) trifluoperazine hcl tab 5 mg (base 1 equivalent) trifluoperazine hcl tab 10 mg (base 1 equivalent) QUINOLINONE DERIVATIVES aripiprazole oral solution 1 mg/ml 2 PA, QL (600 mL / 30 days) ARIPIPRAZOLE ORALLY DISINTEGRATING 2 PA, QL (30 tabs / 25 TAB 10 MG days) ARIPIPRAZOLE ORALLY DISINTEGRATING 2 PA, QL (30 tabs / 25 TAB 15 MG days) aripiprazole tab 2 mg (generic of ABILIFY) 2 QL (30 tabs / 25 days) aripiprazole tab 5 mg (generic of ABILIFY) 2 QL (30 tabs / 25 days) aripiprazole tab 10 mg (generic of ABILIFY) 2 QL (30 tabs / 25 days)

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 74 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits aripiprazole tab 15 mg (generic of ABILIFY) 2 QL (30 tabs / 25 days) aripiprazole tab 20 mg (generic of ABILIFY) 2 QL (30 tabs / 25 days) aripiprazole tab 30 mg (generic of ABILIFY) 2 QL (30 tabs / 25 days) REXULTI TAB 0.5MG 3 PA, QL (30 tabs / 25 days) REXULTI TAB 0.25MG 3 PA, QL (30 tabs / 25 days) REXULTI TAB 1MG 3 PA, QL (30 tabs / 25 days) REXULTI TAB 2MG 3 PA, QL (30 tabs / 25 days) REXULTI TAB 3MG 3 PA, QL (30 tabs / 25 days) REXULTI TAB 4MG 3 PA, QL (30 tabs / 25 days) THIOXANTHENES thiothixene cap 1 mg 1 thiothixene cap 2 mg 1 thiothixene cap 5 mg 1 thiothixene cap 10 mg 1 ANTISEPTICS & DISINFECTANTS ANTISEPTIC COMBINATIONS IV PREP WIPE PAD 2 OTC ANTIVIRALS ANTIRETROVIRALS abacavir sulfate soln 20 mg/ml (base 2 SP equiv) (generic of ZIAGEN) abacavir sulfate tab 300 mg (base equiv) 2 SP (generic of ZIAGEN) abacavir sulfate-lamivudine tab 600-300 2 SP mg (generic of EPZICOM) abacavir sulfate-lamivudine-zidovudine tab 2 SP 300-150-300 mg (generic of TRIZIVIR) APTIVUS CAP 250MG 2 SP APTIVUS SOL 2 SP atazanavir sulfate cap 150 mg (base equiv) 2 SP (generic of REYATAZ) atazanavir sulfate cap 200 mg (base equiv) 2 SP (generic of REYATAZ) atazanavir sulfate cap 300 mg (base equiv) 2 SP (generic of REYATAZ) BIKTARVY TAB 2 SP

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 75 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits CIMDUO TAB 300-300 2 SP COMPLERA TAB 2 SP CRIXIVAN CAP 200MG 2 SP CRIXIVAN CAP 400MG 2 SP DESCOVY TAB 200/25MG 2 SP didanosine delayed release capsule 125 mg 1 SP didanosine delayed release capsule 200 mg 1 SP didanosine delayed release capsule 250 mg 1 SP didanosine delayed release capsule 400 mg 1 SP DOVATO TAB 50-300MG 2 SP EDURANT TAB 25MG 2 SP efavirenz cap 50 mg (generic of SUSTIVA) 2 SP efavirenz cap 200 mg (generic of 2 SP SUSTIVA) efavirenz tab 600 mg (generic of SUSTIVA) 2 SP efavirenz-emtricitabine-tenofovir df tab 2 SP 600-200-300 mg (generic of ATRIPLA) efavirenz-lamivudine-tenofovir df tab 400- 2 SP 300-300 mg (generic of SYMFI LO) efavirenz-lamivudine-tenofovir df tab 600- 2 SP 300-300 mg (generic of SYMFI) emtricitabine caps 200 mg (generic of 2 SP EMTRIVA) emtricitabine-tenofovir disoproxil fumarate 2 SP tab 100-150 mg (generic of TRUVADA) emtricitabine-tenofovir disoproxil fumarate 2 SP tab 133-200 mg (generic of TRUVADA) emtricitabine-tenofovir disoproxil fumarate 2 SP tab 167-250 mg (generic of TRUVADA) emtricitabine-tenofovir disoproxil fumarate 2 SP tab 200-300 mg (generic of TRUVADA) EMTRIVA SOL 10MG/ML 2 SP EVOTAZ TAB 300-150 2 SP fosamprenavir calcium tab 700 mg (base 2 SP equiv) (generic of LEXIVA) FUZEON INJ 90MG 2 SPC GENVOYA TAB 2 SP INTELENCE TAB 25MG 2 SP INTELENCE TAB 100MG 2 SP INTELENCE TAB 200MG 2 SP INVIRASE CAP 200MG 2 SP INVIRASE TAB 500MG 2 SP

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 76 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits ISENTRESS CHW 25MG 2 SP ISENTRESS CHW 100MG 2 SP ISENTRESS HD TAB 600MG 2 SP ISENTRESS POW 100MG 2 SP ISENTRESS TAB 400MG 2 SP JULUCA TAB 50-25MG 2 SP KALETRA TAB 100-25MG 2 SP KALETRA TAB 200-50MG 2 SP lamivudine oral soln 10 mg/ml (generic of 2 SP EPIVIR) lamivudine tab 150 mg (generic of EPIVIR) 2 SP lamivudine tab 300 mg (generic of EPIVIR) 2 SP lamivudine-zidovudine tab 150-300 mg 2 SP (generic of COMBIVIR) LEXIVA SUS 50MG/ML 2 SP lopinavir-ritonavir soln 400-100 mg/5ml 2 SP (80-20 mg/ml) (generic of KALETRA) nevirapine susp 50 mg/5ml (generic of 1 SP VIRAMUNE) nevirapine tab 200 mg 1 SP nevirapine tab er 24hr 100 mg 2 SP nevirapine tab er 24hr 400 mg (generic of 2 SP VIRAMUNE XR) NORVIR CAP 100MG 2 SP NORVIR SOL 80MG/ML 2 SP ODEFSEY TAB 2 SP PREZCOBIX TAB 800-150 2 SP PREZISTA SUS 100MG/ML 2 SP PREZISTA TAB 75MG 2 SP PREZISTA TAB 150MG 2 SP PREZISTA TAB 600MG 2 SP PREZISTA TAB 800MG 2 SP RESCRIPTOR TAB 100 MG 2 SP RESCRIPTOR TAB 200MG 2 SP REYATAZ POW 50MG 2 SP ritonavir tab 100 mg (generic of NORVIR) 2 SP RUKOBIA TAB 600MG ER 2 SP SELZENTRY SOL 20MG/ML 2 SP SELZENTRY TAB 25MG 2 SP SELZENTRY TAB 75MG 2 SP SELZENTRY TAB 150MG 2 SP SELZENTRY TAB 300MG 2 SP

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 77 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits stavudine cap 15 mg 1 SP stavudine cap 20 mg 1 SP stavudine cap 30 mg 1 SP stavudine cap 40 mg 1 SP stavudine for oral soln 1 mg/ml 1 SP STRIBILD TAB 2 SP SYMTUZA TAB 2 SP tenofovir disoproxil fumarate tab 300 mg 2 SP (generic of VIREAD) TIVICAY PD TAB 5MG 2 SP; Coverage limited to members 18 years old or younger TIVICAY TAB 10MG 2 SP TIVICAY TAB 25MG 2 SP TIVICAY TAB 50MG 2 SP TRIUMEQ TAB 2 SP TYBOST TAB 150MG 2 SP VIDEX EC CAP 400MG 2 SP VIDEX SOL 2GM 2 SP VIDEX SOL 4GM 2 SP VIRACEPT TAB 250MG 2 SP VIRACEPT TAB 625MG 2 SP VIREAD POW 40MG/GM 2 SP VIREAD TAB 150MG 2 SP VIREAD TAB 200MG 2 SP VIREAD TAB 250MG 2 SP VITEKTA TAB 85MG 2 SP VITEKTA TAB 150MG 2 SP zidovudine cap 100 mg (generic of 1 SP RETROVIR) zidovudine syrup 10 mg/ml (generic of 1 SP RETROVIR) zidovudine tab 300 mg 1 SP CMV AGENTS PREVYMIS TAB 240MG 3 PA PREVYMIS TAB 480MG 3 PA valganciclovir hcl for soln 50 mg/ml (base 2 equiv) (generic of VALCYTE) valganciclovir hcl tab 450 mg (base 2 equivalent) (generic of VALCYTE)

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 78 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits HEPATITIS AGENTS adefovir dipivoxil tab 10 mg (generic of 2 SP HEPSERA) BARACLUDE SOL 2 SP entecavir tab 0.5 mg (generic of 2 SP BARACLUDE) entecavir tab 1 mg (generic of 2 SP BARACLUDE) EPIVIR HBV SOL 5MG/ML 2 SP lamivudine tab 100 mg (hbv) (generic of 2 SP EPIVIR HBV) MAVYRET TAB 100-40MG 3 PA; SPC PEGASYS INJ 2 PA; SPC PEGASYS INJ 180MCG/M 2 PA; SPC PEGASYS INJ PROCLICK 2 PA; SPC REBETOL SOL 40MG/ML 2 PA; SPC ribasphere tab 400mg 3 PA; SPC ribavirin cap 200 mg 1 PA; SPC ribavirin tab 200 mg 1 PA; SPC ribavirin tab 600 mg 3 PA; SPC TYZEKA TAB 600MG 2 SP HERPES AGENTS acyclovir cap 200 mg 1 acyclovir susp 200 mg/5ml (generic of 1 ZOVIRAX) acyclovir tab 400 mg 1 acyclovir tab 800 mg 1 famciclovir tab 125 mg 1 famciclovir tab 250 mg 1 famciclovir tab 500 mg 1 valacyclovir hcl tab 1 gm (generic of 1 VALTREX) valacyclovir hcl tab 500 mg (generic of 1 VALTREX) INFLUENZA AGENTS oseltamivir phosphate cap 30 mg (base 2 QL (28 caps / 180 equiv) (generic of TAMIFLU) days); 2 courses per year (cumulative by class)

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 79 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits oseltamivir phosphate cap 45 mg (base 2 QL (14 caps / 180 equiv) (generic of TAMIFLU) days); 2 courses per year (cumulative by class) oseltamivir phosphate cap 75 mg (base 2 QL (28 caps / 180 equiv) (generic of TAMIFLU) days); 2 courses per year (cumulative by class) oseltamivir phosphate for susp 6 mg/ml 2 QL (180 mL / 180 days) (base equiv) (generic of TAMIFLU) RELENZA MIS DISKHALE 2 QL (0.1 inhalers / year); 2 courses per year (cumulative by class) rimantadine hydrochloride tab 100 mg 1 #14 for one course or #28 for 365 days XOFLUZA TAB 20MG 2 QL (2 tabs / 180 days) XOFLUZA TAB 40MG 2 QL (2 tabs / 180 days) BETA BLOCKERS ALPHA-BETA BLOCKERS carvedilol phosphate cap er 24hr 10 mg 2 PD (generic of COREG CR) carvedilol phosphate cap er 24hr 20 mg 2 PD (generic of COREG CR) carvedilol phosphate cap er 24hr 40 mg 2 PD (generic of COREG CR) carvedilol phosphate cap er 24hr 80 mg 2 PD (generic of COREG CR) carvedilol tab 3.125 mg (generic of 1 PD; Rx4L COREG) carvedilol tab 6.25 mg (generic of COREG) 1 PD; Rx4L carvedilol tab 12.5 mg (generic of COREG) 1 PD; Rx4L carvedilol tab 25 mg (generic of COREG) 1 PD; Rx4L labetalol hcl tab 100 mg 1 PD labetalol hcl tab 200 mg 1 PD labetalol hcl tab 300 mg 1 PD BETA BLOCKERS CARDIO-SELECTIVE acebutolol hcl cap 200 mg 1 PD acebutolol hcl cap 400 mg 1 PD atenolol tab 25 mg (generic of TENORMIN) 1 PD; Rx4L atenolol tab 50 mg (generic of TENORMIN) 1 PD; Rx4L atenolol tab 100 mg (generic of 1 PD; Rx4L TENORMIN)

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 80 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits betaxolol hcl tab 10 mg 1 PD betaxolol hcl tab 20 mg 1 PD bisoprolol fumarate tab 5 mg 1 PD bisoprolol fumarate tab 10 mg 1 PD BYSTOLIC TAB 2.5MG 2 PD BYSTOLIC TAB 5MG 2 PD BYSTOLIC TAB 10MG 2 PD BYSTOLIC TAB 20MG 2 PD metoprolol succinate tab er 24hr 25 mg 1 PD; Rx4L (tartrate equiv) (generic of TOPROL XL) metoprolol succinate tab er 24hr 50 mg 1 PD; Rx4L (tartrate equiv) (generic of TOPROL XL) metoprolol succinate tab er 24hr 100 mg 1 PD; Rx4L (tartrate equiv) (generic of TOPROL XL) metoprolol succinate tab er 24hr 200 mg 1 PD (tartrate equiv) (generic of TOPROL XL) metoprolol tartrate tab 25 mg 1 PD; Rx4L metoprolol tartrate tab 50 mg (generic of 1 PD; Rx4L LOPRESSOR) metoprolol tartrate tab 100 mg (generic of 1 PD; Rx4L LOPRESSOR) BETA BLOCKERS NON-SELECTIVE LEVATOL TAB 20MG 3 PD nadolol tab 20 mg (generic of CORGARD) 1 PD nadolol tab 40 mg (generic of CORGARD) 1 PD nadolol tab 80 mg (generic of CORGARD) 1 PD pindolol tab 5 mg 1 PD pindolol tab 10 mg 1 PD propranolol hcl cap er 24hr 60 mg (generic 1 PD of INDERAL LA) propranolol hcl cap er 24hr 80 mg (generic 1 PD of INDERAL LA) propranolol hcl cap er 24hr 120 mg 1 PD (generic of INDERAL LA) propranolol hcl cap er 24hr 160 mg 1 PD (generic of INDERAL LA) propranolol hcl oral soln 20 mg/5ml 1 PD propranolol hcl oral soln 40 mg/5ml 1 PD propranolol hcl tab 10 mg 1 PD; Rx4L propranolol hcl tab 20 mg 1 PD; Rx4L propranolol hcl tab 40 mg 1 PD; Rx4L propranolol hcl tab 60 mg 1 PD

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 81 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits propranolol hcl tab 80 mg 1 PD; Rx4L sotalol hcl (afib/afl) tab 80 mg (generic of 1 PD BETAPACE AF) sotalol hcl (afib/afl) tab 120 mg (generic of 1 PD BETAPACE AF) sotalol hcl (afib/afl) tab 160 mg (generic of 1 PD BETAPACE AF) sotalol hcl tab 80 mg (generic of 1 PD BETAPACE) sotalol hcl tab 120 mg (generic of 1 PD BETAPACE) sotalol hcl tab 160 mg (generic of 1 PD BETAPACE) sotalol hcl tab 240 mg 1 PD SOTYLIZE SOL 5MG/ML 3 PD timolol maleate tab 5 mg 1 PD timolol maleate tab 10 mg 1 PD timolol maleate tab 20 mg 1 PD CALCIUM CHANNEL BLOCKERS CALCIUM CHANNEL BLOCKERS amlodipine besylate tab 2.5 mg (base 1 PD; subject to dose equivalent) (generic of NORVASC) optimization; Rx4L amlodipine besylate tab 5 mg (base 1 PD; subject to dose equivalent) (generic of NORVASC) optimization; Rx4L amlodipine besylate tab 10 mg (base 1 PD; Rx4L equivalent) (generic of NORVASC) CARDIZEM LA TAB 120MG 3 PD diltiazem hcl cap er 12hr 60 mg 1 PD diltiazem hcl cap er 12hr 90 mg 1 PD diltiazem hcl cap er 12hr 120 mg 1 PD diltiazem hcl cap er 24hr 120 mg 1 PD diltiazem hcl cap er 24hr 180 mg 1 PD diltiazem hcl cap er 24hr 240 mg 1 PD diltiazem hcl coated beads cap er 24hr 120 1 PD mg (generic of CARDIZEM CD) diltiazem hcl coated beads cap er 24hr 180 1 PD mg (generic of CARDIZEM CD) diltiazem hcl coated beads cap er 24hr 240 1 PD mg (generic of CARDIZEM CD) diltiazem hcl coated beads cap er 24hr 300 1 PD mg (generic of CARDIZEM CD) diltiazem hcl coated beads cap er 24hr 360 1 PD mg (generic of CARDIZEM CD)

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 82 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits diltiazem hcl coated beads tab er 24hr 180 1 PD mg (generic of CARDIZEM LA) diltiazem hcl coated beads tab er 24hr 240 1 PD mg (generic of CARDIZEM LA) diltiazem hcl coated beads tab er 24hr 300 1 PD mg (generic of CARDIZEM LA) diltiazem hcl coated beads tab er 24hr 360 1 PD mg (generic of CARDIZEM LA) diltiazem hcl coated beads tab er 24hr 420 1 PD mg (generic of CARDIZEM LA) diltiazem hcl extended release beads cap 1 PD er 24hr 120 mg (generic of TIAZAC) diltiazem hcl extended release beads cap 1 PD er 24hr 180 mg (generic of TIAZAC) diltiazem hcl extended release beads cap 1 PD er 24hr 240 mg (generic of TIAZAC) diltiazem hcl extended release beads cap 1 PD er 24hr 300 mg (generic of TIAZAC) diltiazem hcl extended release beads cap 1 PD er 24hr 360 mg (generic of TIAZAC) diltiazem hcl extended release beads cap 1 PD er 24hr 420 mg (generic of TIAZAC) diltiazem hcl tab 30 mg (generic of 1 PD; Rx4L CARDIZEM) diltiazem hcl tab 60 mg (generic of 1 PD; Rx4L CARDIZEM) diltiazem hcl tab 90 mg 1 PD; Rx4L diltiazem hcl tab 120 mg (generic of 1 PD; Rx4L CARDIZEM) felodipine tab er 24hr 2.5 mg 1 PD felodipine tab er 24hr 5 mg 1 PD felodipine tab er 24hr 10 mg 1 PD isradipine cap 2.5 mg 1 PD isradipine cap 5 mg 1 PD nicardipine hcl cap 20 mg 1 PD nicardipine hcl cap 30 mg 1 PD nifedipine cap 10 mg 1 PD nifedipine cap 20 mg 1 PD nifedipine tab er 24hr 30 mg 1 PD nifedipine tab er 24hr 60 mg 1 PD nifedipine tab er 24hr 90 mg 1 PD nifedipine tab er 24hr osmotic release 30 1 PD mg (generic of PROCARDIA XL)

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 83 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits nifedipine tab er 24hr osmotic release 60 1 PD mg (generic of PROCARDIA XL) nifedipine tab er 24hr osmotic release 90 1 PD mg (generic of PROCARDIA XL) nimodipine cap 30 mg 1 nisoldipine tab er 24hr 8.5 mg (generic of 1 PD SULAR) nisoldipine tab er 24hr 17 mg (generic of 1 PD SULAR) nisoldipine tab er 24hr 20 mg 1 PD; subject to dose optimization nisoldipine tab er 24hr 25.5 mg 1 PD nisoldipine tab er 24hr 30 mg 1 PD nisoldipine tab er 24hr 34 mg (generic of 1 PD SULAR) nisoldipine tab er 24hr 40 mg 1 PD verapamil hcl cap er 24hr 100 mg (generic 1 PD of VERELAN PM) verapamil hcl cap er 24hr 120 mg (generic 1 PD of VERELAN) verapamil hcl cap er 24hr 180 mg (generic 1 PD of VERELAN) verapamil hcl cap er 24hr 200 mg (generic 1 PD of VERELAN PM) verapamil hcl cap er 24hr 240 mg (generic 1 PD of VERELAN) verapamil hcl cap er 24hr 300 mg 1 PD verapamil hcl cap er 24hr 360 mg 1 PD verapamil hcl tab 40 mg 1 PD verapamil hcl tab 80 mg 1 PD; Rx4L verapamil hcl tab 120 mg 1 PD; Rx4L verapamil hcl tab er 120 mg (generic of 1 PD CALAN SR) verapamil hcl tab er 180 mg 1 PD verapamil hcl tab er 240 mg (generic of 1 PD CALAN SR) CARDIOTONICS CARDIAC GLYCOSIDES digoxin oral soln 0.05 mg/ml 1 digoxin tab 125 mcg (0.125 mg) (generic 1 of LANOXIN) digoxin tab 250 mcg (0.25 mg) (generic of 1 LANOXIN)

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 84 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits LANOXIN TAB 0.25MG 3 LANOXIN TAB 0.125MG 3 LANOXIN TAB 0.0625MG 3 LANOXIN TAB 0.1875MG 3 CARDIOVASCULAR AGENTS - MISC. CARDIOVASCULAR AGENTS MISC. - COMBINATIONS amlodipine besylate-atorvastatin calcium 3 PD tab 2.5-10 mg amlodipine besylate-atorvastatin calcium 3 PD tab 2.5-20 mg amlodipine besylate-atorvastatin calcium 3 PD tab 2.5-40 mg amlodipine besylate-atorvastatin calcium 3 PD tab 5-10 mg (generic of CADUET) amlodipine besylate-atorvastatin calcium 3 PD tab 5-20 mg (generic of CADUET) amlodipine besylate-atorvastatin calcium 3 PD tab 5-40 mg (generic of CADUET) amlodipine besylate-atorvastatin calcium 3 PD tab 5-80 mg (generic of CADUET) amlodipine besylate-atorvastatin calcium 3 PD tab 10-10 mg (generic of CADUET) amlodipine besylate-atorvastatin calcium 3 PD tab 10-20 mg (generic of CADUET) amlodipine besylate-atorvastatin calcium 3 PD tab 10-40 mg (generic of CADUET) amlodipine besylate-atorvastatin calcium 3 PD tab 10-80 mg (generic of CADUET) BIDIL TAB 2 ENTRESTO TAB 24-26MG 3 ENTRESTO TAB 49-51MG 3 ENTRESTO TAB 97-103MG 3 IMPOTENCE AGENTS CAVERJECT INJ 20MCG 3 QL (6 vials / 30 days); coverage limited to males only; 18 years of age and older and cumulative by class CAVERJECT INJ 40MCG 3 QL (6 vials / 30 days); coverage limited to males only; 18 years of age and older and cumulative by class

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 85 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits EDEX KIT 10MCG 3 QL (6 each / 30 days); coverage limited to males only; 18 years of age and older and cumulative by class EDEX KIT 20MCG 3 QL (6 kits / 30 days); coverage limited to males only; 18 years of age and older and cumulative by class EDEX KIT 40MCG 3 QL (6 kits / 30 days); coverage limited to males only; 18 years of age and older and cumulative by class MUSE SUP 125MCG 3 QL (6 sup / 30 days); coverage limited to males only; 18 years of age and older and cumulative by class MUSE SUP 250MCG 3 QL (6 sup / 30 days); coverage limited to males only; 18 years of age and older and cumulative by class MUSE SUP 500MCG 3 QL (6 sup / 30 days); coverage limited to males only; 18 years of age and older and cumulative by class MUSE SUP 1000MCG 3 QL (6 sup / 30 days); coverage limited to males only; 18 years of age and older and cumulative by class sildenafil citrate tab 25 mg (generic of 2 QL (4 tabs / 30 days); VIAGRA) coverage limited to males only; 18 years of age and older and cumulative by class

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 86 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits sildenafil citrate tab 50 mg (generic of 2 QL (4 tabs / 30 days); VIAGRA) coverage limited to males only; 18 years of age and older and cumulative by class sildenafil citrate tab 100 mg (generic of 2 QL (4 tabs / 30 days); VIAGRA) coverage limited to males only; 18 years of age and older and cumulative by class tadalafil tab 2.5 mg (generic of CIALIS) 3 QL (4 tabs / 30 days) tadalafil tab 5 mg (generic of CIALIS) 3 QL (30 tabs / 30 days) tadalafil tab 10 mg (generic of CIALIS) 3 QL (4 tabs / 30 days) tadalafil tab 20 mg (generic of CIALIS) 3 QL (4 tabs / 30 days) PROSTAGLANDIN VASODILATORS TYVASO START SOL 0.6MG/ML 3 SPC VENTAVIS SOL 10MCG/ML 2 SPC VENTAVIS SOL 20MCG/ML 2 SPC PULMONARY HYPERTENSION - ENDOTHELIN RECEPTOR ANTAGONISTS ambrisentan tab 5 mg (generic of 2 SPC LETAIRIS) ambrisentan tab 10 mg (generic of 2 SPC LETAIRIS) bosentan tab 62.5 mg (generic of 2 SPC TRACLEER) bosentan tab 125 mg (generic of 2 SPC TRACLEER) OPSUMIT TAB 10MG 3 PA; SPC PULMONARY HYPERTENSION - PHOSPHODIESTERASE INHIBITORS sildenafil citrate for suspension 10 mg/ml 3 PA; SPC (generic of REVATIO) sildenafil citrate tab 20 mg (generic of 2 PA, QL (30 tabs / 30 REVATIO) days); SPC tadalafil tab 20 mg (pah) (generic of 3 PA; SPC ADCIRCA) PULMONARY HYPERTENSION - SOL GUANYLATE CYCLASE STIMULATOR ADEMPAS TAB 0.5MG 3 PA; SPC ADEMPAS TAB 1.5MG 3 PA; SPC ADEMPAS TAB 1MG 3 PA; SPC ADEMPAS TAB 2.5MG 3 PA; SPC

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 87 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits ADEMPAS TAB 2MG 3 PA; SPC SINUS NODE INHIBITORS CORLANOR SOL 5MG/5ML 3 CORLANOR TAB 5MG 3 CORLANOR TAB 7.5MG 3 TRANSTHYRETIN STABILIZERS VYNDAMAX CAP 61MG 3 PA; SPC VYNDAQEL CAP 20MG 3 PA; SPC CEPHALOSPORINS CEPHALOSPORINS - 1ST GENERATION cefadroxil cap 500 mg 1 cefadroxil for susp 250 mg/5ml 1 cefadroxil for susp 500 mg/5ml 1 cefadroxil tab 1 gm 1 cephalexin cap 250 mg 1 cephalexin cap 500 mg 1 cephalexin cap 750 mg (generic of 1 KEFLEX) cephalexin for susp 125 mg/5ml 1 cephalexin for susp 250 mg/5ml 1 cephalexin tab 250 mg 1 cephalexin tab 500 mg 1 CEPHALOSPORINS - 2ND GENERATION cefaclor cap 250 mg 1 cefaclor cap 500 mg 1 cefaclor for susp 125 mg/5ml 1 cefaclor for susp 250 mg/5ml 1 cefaclor for susp 375 mg/5ml 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 CEFTIN SUS 125/5ML 3 CEFTIN SUS 250/5ML 3 cefuroxime axetil tab 250 mg 1 cefuroxime axetil tab 500 mg 1 CEPHALOSPORINS - 3RD GENERATION cefdinir cap 300 mg 1 cefdinir for susp 125 mg/5ml 1 cefdinir for susp 250 mg/5ml 1

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 88 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits cefixime cap 400 mg (generic of SUPRAX) 2 cefixime for susp 100 mg/5ml (generic of 2 SUPRAX) cefixime for susp 200 mg/5ml (generic of 2 SUPRAX) cefpodoxime proxetil for susp 50 mg/5ml 1 cefpodoxime proxetil for susp 100 mg/5ml 1 cefpodoxime proxetil tab 100 mg 1 cefpodoxime proxetil tab 200 mg 1 ceftibuten cap 400 mg 3 ceftibuten for susp 180 mg/5ml 3 SUPRAX CHW 100MG 2 SUPRAX CHW 200MG 2 SUPRAX SUS 500/5ML 2 CONTRACEPTIVES COMBINATION CONTRACEPTIVES - ORAL amethyst tab 90-20mcg 1 ACA apri tab 1 ACA aranelle tab 1 ACA aviane tab 1 ACA balziva tab 1 ACA camrese lo tab (generic of 1 ACA LOSEASONIQUE) camrese tab (generic of SEASONIQUE) 1 ACA cryselle-28 tab 28 tabs 1 ACA drospirenone-ethinyl estrad-levomefolate 3 ACA tab 3-0.02-0.451 mg (generic of BEYAZ) drospirenone-ethinyl estrad-levomefolate 3 ACA tab 3-0.03-0.451 mg (generic of SAFYRAL) enpresse-28 tab 1 ACA FALESSA KIT 3 ACA gianvi tab 3-0.02mg (generic of YAZ) 1 ACA jolessa tab 1 ACA junel 1.5/30 tab 1 ACA junel 1/20 tab 1 ACA junel fe 24 tab 1/20 1 ACA junel fe tab 1.5/30 1 ACA junel fe tab 1/20 1 ACA kariva tab 28 day (generic of MIRCETTE) 1 ACA kelnor tab 1/35 1 ACA layolis fe chw (generic of GENERESS FE) 1 ACA leena tab 1 ACA

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 89 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits lessina tab 1 ACA levora-28 tab 0.15/30 1 ACA LO LOESTRIN TAB 1-10-10 2 ACA; PD lomedia 24 tab fe 1 ACA low-ogestrel tab 1 ACA lutera tab 1 ACA micrgstin 24 tab fe 1/20 1 ACA microgestin tab 1.5/30 1 ACA microgestin tab 1/20 1 ACA microgestin tab fe1.5/30 1 ACA mononessa tab 1 ACA NATAZIA TAB 3 ACA necon tab 0.5/35 1 ACA necon tab 1/35 1 ACA necon tab 1/50-28 1 ACA necon tab 7/7/7 1 ACA NECON TAB 10/11-28 3 ACA norethindrone ace-eth estradiol-fe chew 3 ACA tab 1 mg-20 mcg (24) (generic of MINASTRIN 24 FE) norethindrone ace-ethinyl estradiol-fe cap 2 ACA; PD 1 mg-20 mcg (24) (generic of TAYTULLA) nortrel tab 0.5/35 1 ACA nortrel tab 1/35 1 ACA nortrel tab 7/7/7 1 ACA ocella tab 3-0.03mg (generic of YASMIN 1 ACA 28) ogestrel tab 1 ACA portia-28 tab 1 ACA previfem tab 1 ACA quasense tab 1 ACA reclipsen tab 1 ACA rivelsa tab (generic of QUARTETTE) 3 ACA sprintec 28 tab 28 day 1 ACA tilia fe tab (generic of ESTROSTEP FE) 1 ACA tri-legest tab fe (generic of ESTROSTEP FE) 1 ACA tri-lo- tab sprintec (generic of ORTHO TRI- 1 ACA CYCLEN LO) tri-sprintec tab 1 ACA trivora-28 tab 1 ACA velivet pak 1 ACA zenchent fe chw 0.4mg-35 1 ACA

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 90 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits zovia 1/35e tab 1 ACA zovia 1/50e tab 1 ACA COMBINATION CONTRACEPTIVES - TRANSDERMAL xulane dis 150-35 2 QL (3 patches / 28 days); ACA COMBINATION CONTRACEPTIVES - VAGINAL eluryng mis (generic of NUVARING) 2 ACA COPPER CONTRACEPTIVES - IUD PARAGARD IUD T380A 3 ACA EMERGENCY CONTRACEPTIVES ELLA TAB 30MG 3 ACA next choice tab 1.5mg 1 ACA PROGESTIN CONTRACEPTIVES - IMPLANTS NEXPLANON IMP 68MG 3 ACA PROGESTIN CONTRACEPTIVES - INJECTABLE DEPO-SQ PROV INJ 104 3 ACA medroxyprogesterone acetate im susp 150 1 ACA mg/ml (generic of DEPO-PROVERA CONTRACEPTIV) PROGESTIN CONTRACEPTIVES - IUD KYLEENA IUD 19.5MG 3 ACA LILETTA IUD 52MG 2 ACA MIRENA IUD SYSTEM 2 ACA SKYLA IUD 13.5MG 3 ACA PROGESTIN CONTRACEPTIVES - ORAL camila tab 0.35mg 1 ACA errin tab 0.35mg 1 ACA jolivette tab 0.35mg 1 ACA nora-be tab 0.35mg 1 ACA CORTICOSTEROIDS GLUCOCORTICOSTEROIDS budesonide delayed release particles cap 3 2 mg (generic of ENTOCORT EC) cortisone acetate tab 25 mg 1 DEXAMETHASON CON 1MG/ML 2 dexamethasone elixir 0.5 mg/5ml 1 dexamethasone sodium phosphate inj 4 1 mg/ml dexamethasone sodium phosphate inj 20 1 mg/5ml

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 91 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits dexamethasone soln 0.5 mg/5ml 1 dexamethasone tab 0.5 mg 1 dexamethasone tab 0.75 mg 1 dexamethasone tab 1 mg 1 dexamethasone tab 1.5 mg 1 dexamethasone tab 2 mg 1 dexamethasone tab 4 mg 1 dexamethasone tab 6 mg 1 hydrocortisone tab 5 mg (generic of 1 CORTEF) hydrocortisone tab 10 mg (generic of 1 CORTEF) hydrocortisone tab 20 mg (generic of 1 CORTEF) MEDROL TAB 2MG 2 methylprednisolone tab 4 mg (generic of 1 MEDROL) methylprednisolone tab 8 mg (generic of 1 MEDROL) methylprednisolone tab 16 mg (generic of 1 MEDROL) methylprednisolone tab 32 mg (generic of 1 MEDROL) methylprednisolone tab therapy pack 4 mg 1 (21) (generic of MEDROL DOSEPAK) prednisolone sod phos orally disintegr tab 2 10 mg (base eq) (generic of ORAPRED ODT) prednisolone sod phos orally disintegr tab 2 15 mg (base eq) (generic of ORAPRED ODT) prednisolone sod phos orally disintegr tab 2 30 mg (base eq) (generic of ORAPRED ODT) prednisolone sod phosph oral soln 6.7 1 mg/5ml (5 mg/5ml base) (generic of PEDIAPRED) prednisolone sod phosphate oral soln 15 1 mg/5ml (base equiv) prednisolone sodium phosphate oral soln 1 25 mg/5ml (base eq) prednisolone syrup 15 mg/5ml (usp 1 solution equivalent)

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 92 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits PREDNISONE CON 5MG/ML 1 prednisone oral soln 5 mg/5ml 1 prednisone tab 1 mg 1 prednisone tab 2.5 mg 1 prednisone tab 5 mg 1 Rx4L prednisone tab 10 mg 1 Rx4L prednisone tab 20 mg 1 prednisone tab 50 mg 1 prednisone tab therapy pack 5 mg (21) 1 prednisone tab therapy pack 10 mg (21) 1 SOLU-CORTEF INJ 100MG 1 MINERALOCORTICOIDS fludrocortisone acetate tab 0.1 mg 1 COUGH/COLD/ALLERGY ANTITUSSIVES benzonatate cap 100 mg (generic of 1 TESSALON PERLES) benzonatate cap 150 mg 3 benzonatate cap 200 mg 1 hydrocodone w/ homatropine syrup 5-1.5 1 mg/5ml (generic of HYCODAN) hydrocodone w/ homatropine tab 5-1.5 mg 1 COUGH/COLD/ALLERGY COMBINATIONS CAPCOF SYP 5-2-10MG 3 OTC cheratussin sol dac 1 OTC cheratussin syp ac 1 OTC CODAR AR LIQ 2-8/5ML 3 CODAR D LIQ 30-8/5ML 3 OTC codar gf liq 200-8/5 1 OTC DEX-TUSS LIQ 300-10/5 3 OTC hydrocod polst-chlorphen polst er susp 10- 2 8 mg/5ml M-END MAX D LIQ 3 OTC M-END PE LIQ 3 OTC m-end wc liq 1 OTC MAR-COF BP LIQ 30-2-7.5 3 OTC PHENHIST DH LIQ 30-2-10 3 OTC PRO-CLEAR AC SYP 9-8.33MG 3 OTC PRO-RED AC SYP 5-1-9/5 3 OTC promethazine & phenylephrine syrup 6.25- 1 5 mg/5ml

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 93 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits promethazine w/ codeine syrup 6.25-10 1 mg/5ml promethazine-dm syrup 6.25-15 mg/5ml 1 promethazine-phenylephrine-codeine syrup 1 6.25-5-10 mg/5ml pseudoeph-chlorphen w/ hydrocodone soln 3 60-4-5 mg/5ml pseudoephed-bromphen-dm syrup 30-2-10 1 OTC mg/5ml relcof c sol 100-6.3 1 OTC REZIRA SOL 60-5/5ML 3 STATUSS LIQ GREEN 3 OTC TRICODE AR LIQ 30-2-8 3 OTC TRICODE GF LIQ 30-8-200 3 OTC trymine cg liq 225-7.5 1 OTC VANACOF CD LIQ 5-1-10 3 OTC Z-TUSS AC LIQ 2-9/5ML 3 OTC EXPECTORANTS SSKI SOL 1GM/ML 3 MISC. RESPIRATORY INHALANTS nebusal neb 3% 1 sodium chloride soln nebu 0.9% 1 sodium chloride soln nebu 7% 3 MUCOLYTICS acetylcysteine inhal soln 10% 1 acetylcysteine inhal soln 20% 1 DERMATOLOGICALS ACNE PRODUCTS adapalene cream 0.1% (generic of 1 DIFFERIN) adapalene gel 0.1% 1 adapalene gel 0.3% (generic of DIFFERIN) 2 adapalene lotion 0.1% 2 adapalene-benzoyl peroxide gel 0.1-2.5% 3 (generic of EPIDUO) amnesteem cap 10mg 1 amnesteem cap 20mg 1 amnesteem cap 40mg 1 AZELEX CRE 20% 3 BENZAMYCIN GEL PAK 3 benzoyl peroxide foam 5.3% 1

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 94 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits benzoyl peroxide foam 9.8% 1 benzoyl peroxide-erythromycin gel 5-3% 1 (generic of BENZAMYCIN) bp 10-1 emu 1 bp cleansing emu 10-4% 1 bp foaming liq wash 10% 1 bp wash liq 2.5% 1 bp wash liq 5.25% 1 OTC claravis cap 10mg 1 claravis cap 20mg 1 claravis cap 30mg 3 claravis cap 40mg 1 clearplex x gel 10% 1 clindamycin phosph-benzoyl peroxide 2 (refrig) gel 1.2 (1)-5% clindamycin phosphate foam 1% (generic 2 of EVOCLIN) clindamycin phosphate gel 1% 1 clindamycin phosphate lotion 1% (generic 1 of CLEOCIN-T) clindamycin phosphate soln 1% 1 clindamycin phosphate swab 1% 1 clindamycin phosphate-benzoyl peroxide 2 gel 1-5% (generic of BENZACLIN) clindamycin phosphate-benzoyl peroxide 3 gel 1.2-2.5% (generic of ACANYA) clindamycin phosphate-tretinoin gel 1.2- 3 0.025% (generic of ZIANA) dapsone gel 5% (generic of ACZONE) 3 DIFFERIN LOT 0.1% 2 ery pad 2% 1 erythromycin gel 2% (generic of ERYGEL) 1 erythromycin soln 2% 1 myorisan cap 10mg 1 myorisan cap 20mg 1 myorisan cap 30mg 3 myorisan cap 40mg 1 neuac gel 1.2-5% 2 pr benzoyl liq 7% wash 1 RETIN-A MICR GEL 0.08% 3 ROSULA PAD 10-5% 2 SOD SUL/SULF EMU 10-5% 1

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 95 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits SOD SUL/SULF SUS 10-5% 1 sulfacetamide sodium lotion 10% (acne) 1 (generic of KLARON) sulfacetamide sodium w/ sulfur cleanser 1 10-2% sulfacetamide sodium w/ sulfur cleansing 1 pad 10-4% sulfacetamide sodium w/ sulfur cream 10- 1 2% sulfacetamide sodium w/ sulfur cream 10- 1 5% sulfacetamide sodium w/ sulfur emulsion 1 10-5% sulfacetamide sodium w/ sulfur foam 10- 1 5% sulfacetamide sodium w/ sulfur lotion 10- 1 5% sulfacetamide sodium w/ sulfur susp 8-4% 1 sulfacetamide sodium w/ sulfur wash 9-4% 1 sulfacetamide sodium w/ sulfur wash 9- 1 4.5% sulfacetamide sodium-sulfur in urea gel 1 10-5% tretinoin cream 0.1% (generic of RETIN-A) 1 tretinoin cream 0.05% (generic of RETIN- 1 A) tretinoin cream 0.025% (generic of RETIN- 1 A) tretinoin gel 0.01% (generic of RETIN-A) 1 tretinoin gel 0.05% (generic of ATRALIN) 3 tretinoin gel 0.025% (generic of RETIN-A) 1 tretinoin microsphere gel 0.1% (generic of 3 RETIN-A MICRO) tretinoin microsphere gel 0.04% (generic 3 of RETIN-A MICRO) zenatane cap 10mg 1 zenatane cap 20mg 1 zenatane cap 30mg 3 zenatane cap 40mg 1 ANTI-INFLAMMATORY AGENTS - TOPICAL diclofenac sodium gel 1% (generic of 2 QL (1000 gm / 30 days) VOLTAREN)

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 96 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits ANTIBIOTICS - TOPICAL ALTABAX OIN 1% 3 CORTISPORIN CRE 0.5% 3 CORTISPORIN OIN 1% 3 gentamicin sulfate cream 0.1% 1 gentamicin sulfate oint 0.1% 1 mupirocin calcium cream 2% 2 mupirocin oint 2% 1 ANTIFUNGALS - TOPICAL ciclopirox gel 0.77% 1 ciclopirox olamine cream 0.77% (base 1 equiv) (generic of LOPROX) ciclopirox olamine susp 0.77% (base 1 equiv) (generic of LOPROX) ciclopirox shampoo 1% (generic of LOPROX 1 SHAMPOO) ciclopirox solution 8% 1 clotrimazole cream 1% 1 clotrimazole soln 1% 1 clotrimazole w/ betamethasone cream 1- 1 0.05% clotrimazole w/ betamethasone lotion 1- 1 0.05% econazole nitrate cream 1% 1 ERTACZO CRE 2% 3 iodoquinol-hc cream 1-1% 1 iodoquinol-hydrocortisone in aloe vehicle 3 cream 1-1.9% ketoconazole cream 2% 1 ketoconazole foam 2% (generic of EXTINA) 3 ketoconazole shampoo 2% 1 MENTAX CRE 1% 3 miconazole-zinc oxide-white petrolatum 3 oint 0.25-15-81.35% naftifine hcl cream 1% 3 naftifine hcl cream 2% 3 naftifine hcl gel 1% (generic of NAFTIN) 3 NAFTIN GEL 2% 3 nystatin cream 100000 unit/gm 1 nystatin oint 100000 unit/gm 1 nystatin topical powder 100000 unit/gm 1

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 97 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits nystatin-triamcinolone cream 100000-0.1 1 unit/gm-% nystatin-triamcinolone oint 100000-0.1 1 unit/gm-% oxiconazole nitrate cream 1% (generic of 3 OXISTAT) OXISTAT LOT 1% 3 sulconazole nitrate cream 1% 3 sulconazole nitrate solution 1% 3 ANTINEOPLASTIC OR PREMALIGNANT LESION AGENTS - TOPICAL diclofenac sodium (actinic keratoses) gel 2 3% FLUOROPLEX CRE 1% 3 fluorouracil cream 0.5% (generic of 2 CARAC) fluorouracil cream 5% (generic of EFUDEX) 1 fluorouracil soln 2% 1 fluorouracil soln 5% 1 LEVULAN KERA SOL 20% 3 PICATO GEL 0.05% 3 PA PICATO GEL 0.015% 3 PA VALCHLOR GEL 0.016% 3 PA ANTIPRURITICS - TOPICAL doxepin hcl cream 5% 1 PRUDOXIN CRE 5% 1 ANTIPSORIATICS acitretin cap 10 mg (generic of 2 SORIATANE) acitretin cap 17.5 mg 2 acitretin cap 25 mg (generic of 2 SORIATANE) calcipotriene cream 0.005% (generic of 1 DOVONEX) calcipotriene oint 0.005% 1 calcipotriene soln 0.005% (50 mcg/ml) 1 calcitriol oint 3 mcg/gm 3 COSENTYX INJ 150MG/ML 2 PA, QL ; SPC COSENTYX INJ 300DOSE 2 PA, QL ; SPC COSENTYX PEN INJ 150MG/ML 2 PA, QL ; SPC COSENTYX PEN INJ 300DOSE 2 PA, QL ; SPC DRITHO-CREME CRE HP 1% 3 methoxsalen rapid cap 10 mg 2

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 98 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits SKYRIZI INJ 150DOSE 2 PA, QL ; SPC SKYRIZI INJ 150MG/ML 2 PA, QL (1 syringe / 84 days); SPC SKYRIZI PEN INJ 150MG/ML 2 PA, QL (1 pen / 84 days); SPC STELARA INJ 45MG/0.5 2 PA, QL ; ^, SPC STELARA INJ 90MG/ML 2 PA, QL ; ^, SPC tazarotene cream 0.1% (generic of 3 TAZORAC) TAZORAC CRE 0.05% 3 TAZORAC GEL 0.1% 3 TAZORAC GEL 0.05% 3 TREMFYA INJ 100MG/ML 2 PA, QL ; SPC ANTISEBORRHEIC PRODUCTS OVACE PLUS LOT 9.8% 3 selenium sulfide lotion 2.5% 1 sulfacetamide sodium liquid 10% 1 ANTIVIRALS - TOPICAL acyclovir cream 5% (generic of ZOVIRAX) 2 acyclovir oint 5% (generic of ZOVIRAX) 2 XERESE CRE 5-1% 3 BURN PRODUCTS ssd cre 1% (generic of SILVADENE) 1 CORTICOSTEROIDS - TOPICAL alclometasone dipropionate cream 0.05% 2 alclometasone dipropionate oint 0.05% 2 amcinonide cream 0.1% 1 amcinonide lotion 0.1% 1 APEXICON E CRE 0.05% 3 betamethasone dipropionate augmented 1 cream 0.05% (generic of DIPROLENE AF) betamethasone dipropionate augmented 1 gel 0.05% betamethasone dipropionate augmented 1 lotion 0.05% betamethasone dipropionate augmented 1 oint 0.05% (generic of DIPROLENE) betamethasone dipropionate cream 0.05% 1 betamethasone dipropionate lotion 0.05% 1 betamethasone dipropionate oint 0.05% 1 betamethasone valerate aerosol foam 3 0.12% (generic of LUXIQ)

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 99 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits betamethasone valerate cream 0.1% (base 1 equivalent) betamethasone valerate lotion 0.1% (base 1 equivalent) betamethasone valerate oint 0.1% (base 1 equivalent) calcipotriene-betamethasone dipropionate 3 oint 0.005-0.064% (generic of TACLONEX) calcipotriene-betamethasone dipropionate 3 susp 0.005-0.064% (generic of TACLONEX) clobetasol e cre 0.05% 1 clobetasol propionate cream 0.05% 1 (generic of TEMOVATE) clobetasol propionate foam 0.05% (generic 1 of OLUX) clobetasol propionate gel 0.05% 1 clobetasol propionate lotion 0.05% 2 (generic of CLOBEX) clobetasol propionate oint 0.05% (generic 1 of TEMOVATE) clobetasol propionate soln 0.05% 1 clobetasol propionate spray 0.05% 2 (generic of CLOBEX) clodan sha 0.05% (generic of CLOBEX) 2 CORDRAN 24X3 TAP 4MCG/CM 3 desonide cream 0.05% (generic of 1 DESOWEN) desonide gel 0.05% (generic of 2 DESONATE) desonide lotion 0.05% 1 desonide oint 0.05% 1 desoximetasone cream 0.05% (generic of 1 TOPICORT) desoximetasone cream 0.25% (generic of 1 TOPICORT) desoximetasone gel 0.05% (generic of 1 TOPICORT) desoximetasone oint 0.05% (generic of 1 TOPICORT) desoximetasone oint 0.25% (generic of 1 TOPICORT) diflorasone diacetate cream 0.05% 1

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 100 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits diflorasone diacetate oint 0.05% 1 fluocinolone acetonide cream 0.01% 1 fluocinolone acetonide cream 0.025% 1 (generic of SYNALAR) fluocinolone acetonide oil 0.01% (body oil) 2 (generic of DERMA-SMOOTHE/FS BODY) fluocinolone acetonide oil 0.01% (scalp oil) 2 (generic of DERMA-SMOOTHE/FS SCALP) fluocinolone acetonide oint 0.025% 1 (generic of SYNALAR) fluocinolone acetonide soln 0.01% (generic 1 of SYNALAR) fluocinonide cream 0.1% (generic of 3 VANOS) fluocinonide cream 0.05% 1 fluocinonide emulsified base cream 0.05% 1 fluocinonide gel 0.05% 1 fluocinonide oint 0.05% 1 fluocinonide soln 0.05% 1 flurandrenolide cream 0.05% (generic of 3 CORDRAN) flurandrenolide lotion 0.05% (generic of 3 CORDRAN) flurandrenolide oint 0.05% (generic of 3 CORDRAN) fluticasone propionate cream 0.05% 1 fluticasone propionate lotion 0.05% 1 (generic of CUTIVATE) fluticasone propionate oint 0.005% 1 halobetasol propionate cream 0.05% 1 halobetasol propionate oint 0.05% 1 hydrocortisone butyrate cream 0.1% 1 hydrocortisone butyrate hydrophilic lipo 3 base cream 0.1% (generic of LOCOID LIPOCREAM) hydrocortisone butyrate lotion 0.1% 3 (generic of LOCOID) hydrocortisone butyrate oint 0.1% 1 hydrocortisone butyrate soln 0.1% 1 hydrocortisone cream 1% 1 hydrocortisone cream 2.5% 1 hydrocortisone lotion 1% 1 OTC hydrocortisone lotion 2.5% 1

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 101 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits hydrocortisone oint 1% 1 hydrocortisone oint 2.5% 1 hydrocortisone valerate cream 0.2% 1 hydrocortisone valerate oint 0.2% 1 mometasone furoate cream 0.1% 1 mometasone furoate oint 0.1% 1 mometasone furoate solution 0.1% (lotion) 1 PRAMOSONE CRE 1-1% 3 PRAMOSONE LOT 2.5% 3 PRAMOSONE OIN 2.5% 3 pramoxine-hc cream 1-2.5% 1 prednicarbate cream 0.1% 1 prednicarbate oint 0.1% 1 triamcinolone acetonide aerosol soln 0.147 3 mg/gm (generic of KENALOG) triamcinolone acetonide cream 0.1% 1 triamcinolone acetonide cream 0.5% 1 triamcinolone acetonide cream 0.025% 1 triamcinolone acetonide lotion 0.1% 1 triamcinolone acetonide lotion 0.025% 1 triamcinolone acetonide oint 0.1% 1 triamcinolone acetonide oint 0.5% 1 triamcinolone acetonide oint 0.025% 1 VERDESO AER 0.05% 3 ECZEMA AGENTS DUPIXENT INJ 300/2ML 3 PA; SPC DUPIXENT INJ 300/2ML 3 PA; SPC EMOLLIENT/KERATOLYTIC AGENTS umecta mouss aer 40% 1 urea cream 39% 1 urea cream 40% 1 urea cream 45% 1 urea cream 47% 1 urea cream 50% 1 urea gel 40% 1 urea in zinc undecylenate-lactic acid 1 vehicle emulsion 50% urea lotion 40% 1 urea lotion 45% 1 urea nail gel 45% 1 UREA NAIL MIS 50% 3

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 102 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits urea suspension 40% 1 EMOLLIENTS lactic acid (ammonium lactate) cream 12% 1 lactic acid (ammonium lactate) lotion 12% 1 ENZYMES - TOPICAL SANTYL OIN 250/GM 3 IMMUNOMODULATING AGENTS - TOPICAL imiquimod cream 3.75% (generic of 3 ZYCLARA) imiquimod cream 5% (generic of ALDARA) 1 ZYCLARA PUMP CRE 2.5% 3 IMMUNOSUPPRESSIVE AGENTS - TOPICAL pimecrolimus cream 1% (generic of 2 QL (30 gm / 30 days) ELIDEL) tacrolimus oint 0.1% (generic of 2 QL (30 gm / 30 days) PROTOPIC) tacrolimus oint 0.03% (generic of 2 QL (30 gm / 30 days) PROTOPIC) KERATOLYTIC/ANTIMITOTIC AGENTS CONDYLOX GEL 0.5% 2 podofilox soln 0.5% 1 salicylic ac liq 27.5% 1 salicylic acid cream 6% 1 salicylic acid gel 6% 1 salicylic acid lotion 6% 1 salicylic acid shampoo 6% 1 SALICYLIC ACID SOLN 26% 1 LOCAL ANESTHETICS - TOPICAL lidocaine hcl cream 3% 1 lidocaine hcl lotion 3% 1 lidocaine hcl soln 4% 1 lidocaine hcl urethral/mucosal gel prefilled 1 syringe 2% lidocaine oint 5% 1 lidocaine patch 5% (generic of LIDODERM) 2 QL (90 patches / 30 days) lidocaine-prilocaine cream 2.5-2.5% 1 lidocaine-prilocaine cream kit 2.5-2.5% 1 MISC. TOPICAL DRYSOL SOL 20% 3 XERAC-AC SOL 6.25% 2

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 103 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits ROSACEA AGENTS azelaic acid gel 15% (generic of FINACEA) 2 doxycycline (rosacea) cap delayed release 2 40 mg FINACEA AER 15% 2 ivermectin cream 1% 3 metronidazole gel 0.75% 1 metronidazole gel 1% (generic of 2 METROGEL) metronidazole lotion 0.75% (generic of 1 METROLOTION) rosadan cre 0.75% (generic of 1 METROCREAM) SOOLANTRA CRE 1% 3 SCABICIDES & PEDICULICIDES crotan lot 10% 2 EURAX CRE 10% 2 lindane lotion 1% 1 lindane shampoo 1% 1 malathion lotion 0.5% 1 permethrin cream 5% (generic of ELIMITE) 1 spinosad susp 0.9% 3 ULESFIA LOT 5% 3 WOUND CARE PRODUCTS REGRANEX GEL 0.01% 2 DIAGNOSTIC PRODUCTS DIAGNOSTIC TESTS ACETEST TAB TABLETS 2 OTC BREEZE 2 MIS TEST 2 QL (100 ea / 30 days), OTC CHEMSTRIP 2 TES LN 1 OTC CHEMSTRIP 9 TES STRIPS 2 OTC CLINITEST TAB CHLD RES 1 OTC CONTOUR TES BLD GLUC 2 QL (100 strips / 30 days), OTC CONTOUR TES NEXT 2 QL (100 strips / 30 days), OTC DIASTIX TES STRIPS 2 OTC KETO-DIASTIX TES 2 OTC KETONE TEST TES 2 OTC PRECISN XTRA TES KETONE 2 OTC

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 104 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS DIETARY MANAGEMENT PRODUCTS FOLBEE AR TAB 3 folbic tab 1 OTC westab max tab 2.5-25-2 1 INFANT FOODS ENFA NUTRAMI CON LIPIL 2 OTC ENFAMIL ENFA POW LIPIL 2 OTC ENFAMIL PREM LIQ LIPIL 2 OTC NUTRITIONAL SUPPLEMENTS NUTREN 1.0 LIQ UNFLAVOR 2 OTC PEPTAMEN JUN POW VANILLA 2 OTC RESOURCE ARG PAK LEMON 2 OTC DIGESTIVE AIDS DIGESTIVE ENZYMES CREON CAP 3000UNIT 2 CREON CAP 6000UNIT 2 CREON CAP 12000UNT 2 CREON CAP 24000UNT 2 CREON CAP 36000UNT 2 PANCREAZE CAP 3 PANCREAZE CAP 4200UNIT 3 PANCREAZE CAP 10500UNT 3 PANCREAZE CAP 16800UNT 3 PANCREAZE CAP 21000UNT 3 PERTZYE CAP 16000U 3 PERTZYE CAP 24000U 3 ZENPEP CAP 3000UNIT 2 ZENPEP CAP 5000UNIT 2 ZENPEP CAP 10000UNT 2 ZENPEP CAP 15000UNT 2 ZENPEP CAP 20000UNT 2 ZENPEP CAP 25000 2 ZENPEP CAP 25000UNT 2 ZENPEP CAP 40000 2 DIURETICS CARBONIC ANHYDRASE INHIBITORS acetazolamide cap er 12hr 500 mg 1 acetazolamide tab 125 mg 1 acetazolamide tab 250 mg 1

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 105 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits methazolamide tab 25 mg 1 methazolamide tab 50 mg 1 DIURETIC COMBINATIONS ALDACTAZIDE TAB 50/50 2 PD amiloride & hydrochlorothiazide tab 5-50 1 PD mg spironolactone & hydrochlorothiazide tab 1 PD 25-25 mg (generic of ALDACTAZIDE) triamterene & hydrochlorothiazide cap 1 PD; Rx4L 37.5-25 mg triamterene & hydrochlorothiazide cap 50- 1 PD 25 mg triamterene & hydrochlorothiazide tab 1 PD; Rx4L 37.5-25 mg (generic of MAXZIDE-25) triamterene & hydrochlorothiazide tab 75- 1 PD; Rx4L 50 mg (generic of MAXZIDE) LOOP DIURETICS bumetanide tab 0.5 mg (generic of 1 PD; Rx4L BUMEX) bumetanide tab 1 mg 1 PD; Rx4L bumetanide tab 2 mg 1 PD; Rx4L ethacrynic acid tab 25 mg (generic of 3 EDECRIN) furosemide oral soln 10 mg/ml 1 PD furosemide tab 20 mg (generic of LASIX) 1 PD; Rx4L furosemide tab 40 mg (generic of LASIX) 1 PD; Rx4L furosemide tab 80 mg (generic of LASIX) 1 PD; Rx4L torsemide tab 5 mg 1 torsemide tab 10 mg 1 torsemide tab 20 mg 1 torsemide tab 100 mg 1 POTASSIUM SPARING DIURETICS amiloride hcl tab 5 mg 1 CAROSPIR SUS 25MG/5ML 2 PD spironolactone tab 25 mg (generic of 1 PD; Rx4L ALDACTONE) spironolactone tab 50 mg (generic of 1 PD; Rx4L ALDACTONE) spironolactone tab 100 mg (generic of 1 PD ALDACTONE) triamterene cap 50 mg (generic of 3 DYRENIUM)

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 106 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits triamterene cap 100 mg (generic of 3 DYRENIUM) THIAZIDES AND THIAZIDE-LIKE DIURETICS chlorothiazide tab 250 mg 1 PD chlorothiazide tab 500 mg 1 PD chlorthalidone tab 25 mg 1 PD chlorthalidone tab 50 mg 1 PD chlorthalidone tab 100 mg 1 PD DIURIL SUS 250/5ML 3 PD hydrochlorothiazide cap 12.5 mg 1 PD; Rx4L hydrochlorothiazide tab 12.5 mg 1 PD hydrochlorothiazide tab 25 mg 1 PD; Rx4L hydrochlorothiazide tab 50 mg 1 PD; Rx4L indapamide tab 1.25 mg 1 PD indapamide tab 2.5 mg 1 PD metolazone tab 2.5 mg 1 metolazone tab 5 mg 1 metolazone tab 10 mg 1 ENDOCRINE AND METABOLIC AGENTS - MISC. BONE DENSITY REGULATORS alendronate sodium oral soln 70 mg/75ml 1 PD alendronate sodium tab 5 mg 1 PD alendronate sodium tab 10 mg 1 PD alendronate sodium tab 35 mg 1 PD; Rx4L alendronate sodium tab 40 mg 1 PD alendronate sodium tab 70 mg (generic of 1 PD; Rx4L FOSAMAX) calcitonin (salmon) inj 200 unit/ml (generic 2 PD of MIACALCIN) calcitonin (salmon) nasal soln 200 unit/act 1 PD (generic of MIACALCIN) FORTEO INJ 620/2.48 2 QL (316.667 pens in lifetime); 2 year maximum benefit per lifetime; SPC FORTICAL SPR 200/ACT 2 PD ibandronate sodium tab 150 mg (base 3 PD equivalent) (generic of BONIVA) MIACALCIN INJ 200/ML 2 PD MIACALCIN SPR 200/ACT 2 PD NATPARA INJ 25MCG 3 PA; SPC NATPARA INJ 50MCG 3 PA; SPC

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 107 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits NATPARA INJ 75MCG 3 PA; SPC NATPARA INJ 100MCG 3 PA; SPC risedronate sodium tab 5 mg 2 PD risedronate sodium tab 30 mg 2 PD risedronate sodium tab 35 mg (generic of 2 PD ACTONEL) risedronate sodium tab 150 mg (generic of 2 PD ACTONEL) risedronate sodium tab delayed release 35 3 PD mg (generic of ATELVIA) TYMLOS INJ 2 QL (1 pen / 30 days); SPC zoledronic acid inj conc for iv infusion 4 1 PA; ^, SPC mg/5ml CORTICOTROPIN ACTHAR INJ 80UNIT 3 PA; SPC FERTILITY REGULATORS chor gonadot inj 10000unt 1 PA; Coverage limited to 6 cycles, alone or in any combination, to achieve pregnancy. Infertility drugs resulting in a live birth, or an established pregnancy (fetal heart rate is detected) resulting in a miscarriage, will renew the six cycle limit; SPC clomiphene citrate tab 50 mg 1 FOLLISTIM AQ INJ 300UNIT 2 PA; Coverage limited to 6 cycles, alone or in any combination, to achieve pregnancy. Infertility drugs resulting in a live birth, or an established pregnancy (fetal heart rate is detected) resulting in a miscarriage, will renew the six cycle limit; SPC

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 108 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits FOLLISTIM AQ INJ 600UNIT 2 PA; Coverage limited to 6 cycles, alone or in any combination, to achieve pregnancy. Infertility drugs resulting in a live birth, or an established pregnancy (fetal heart rate is detected) resulting in a miscarriage, will renew the six cycle limit; SPC FOLLISTIM AQ INJ 900UNIT 2 PA; Coverage limited to 6 cycles, alone or in any combination, to achieve pregnancy. Infertility drugs resulting in a live birth, or an established pregnancy (fetal heart rate is detected) resulting in a miscarriage, will renew the six cycle limit; SPC MENOPUR INJ 75UNIT 2 PA; Coverage limited to 6 cycles, alone or in any combination, to achieve pregnancy. Infertility drugs resulting in a live birth, or an established pregnancy (fetal heart rate is detected) resulting in a miscarriage, will renew the six cycle limit; SPC novarel inj 10000unt 1 PA; Coverage limited to 6 cycles, alone or in any combination, to achieve pregnancy. Infertility drugs resulting in a live birth, or an established pregnancy (fetal heart rate is detected) resulting in a miscarriage, will renew the six cycle limit; SPC

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 109 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits OVIDREL INJ 2 PA; Coverage limited to 6 cycles, alone or in any combination, to achieve pregnancy. Infertility drugs resulting in a live birth, or an established pregnancy (fetal heart rate is detected) resulting in a miscarriage, will renew the six cycle limit; SPC REPRONEX INJ 75UNIT 3 PA; Coverage limited to 6 cycles, alone or in any combination, to achieve pregnancy. Infertility drugs resulting in a live birth, or an established pregnancy (fetal heart rate is detected) resulting in a miscarriage, will renew the six cycle limit; SPC GNRH/LHRH ANTAGONISTS CETROTIDE KIT 0.25MG 2 PA; Coverage limited to 6 cycles, alone or in any combination, to achieve pregnancy. Infertility drugs resulting in a live birth, or an established pregnancy (fetal heart rate is detected) resulting in a miscarriage, will renew the six cycle limit; SPC

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 110 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits ganirelix acetate soln prefilled syringe 250 2 PA; Coverage limited to mcg/0.5ml (generic of GANIRELIX 6 cycles, alone or in any ACETATE) combination, to achieve pregnancy. Infertility drugs resulting in a live birth, or an established pregnancy (fetal heart rate is detected) resulting in a miscarriage, will renew the six cycle limit; SPC ORILISSA TAB 150MG 2 PA ORILISSA TAB 200MG 2 PA GROWTH HORMONE RECEPTOR ANTAGONISTS SOMAVERT INJ 10MG 2 SPC SOMAVERT INJ 15MG 2 SPC SOMAVERT INJ 20MG 2 SPC SOMAVERT INJ 25MG 2 SPC SOMAVERT INJ 30MG 2 SPC GROWTH HORMONE RELEASING HORMONES (GHRH) EGRIFTA SOL 1MG 3 PA; SPC EGRIFTA SOL 2MG 3 PA; SPC GROWTH HORMONES GENOTROPIN INJ 0.2MG 3 PA; SPC GENOTROPIN INJ 0.4MG 3 PA; SPC GENOTROPIN INJ 0.6MG 3 PA; SPC GENOTROPIN INJ 0.8MG 3 PA; SPC GENOTROPIN INJ 1.2MG 3 PA; SPC GENOTROPIN INJ 1.4MG 3 PA; SPC GENOTROPIN INJ 1.6MG 3 PA; SPC GENOTROPIN INJ 1.8MG 3 PA; SPC GENOTROPIN INJ 1MG 3 PA; SPC GENOTROPIN INJ 2MG 3 PA; SPC GENOTROPIN INJ 12MG 3 PA; SPC HUMATROPE INJ 5MG 3 PA; SPC HUMATROPE INJ 6MG 3 PA; SPC HUMATROPE INJ 12MG 3 PA; SPC HUMATROPE INJ 24MG 3 PA; SPC NORDITROPIN INJ 5/1.5ML 2 PA; SPC NORDITROPIN INJ 10/1.5ML 2 PA; SPC NORDITROPIN INJ 15/1.5ML 2 PA; SPC NORDITROPIN INJ 30/3ML 2 PA; SPC

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 111 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits NUTROPIN AQ INJ 10MG/2ML 3 PA; SPC NUTROPIN AQ INJ 20MG/2ML 3 PA; SPC NUTROPIN AQ INJ NUSPIN 5 3 PA; SPC OMNITROPE INJ 5.8MG 3 PA; SPC SAIZEN INJ 5MG 3 PA; SPC SAIZEN INJ 8.8MG 3 PA; SPC SEROSTIM INJ 4MG 2 PA; SPC SEROSTIM INJ 5MG 2 PA; SPC SEROSTIM INJ 6MG 2 PA; SPC ZOMACTON INJ 5MG 3 PA; SPC ZORBTIVE INJ 8.8MG 2 PA; SPC HORMONE RECEPTOR MODULATORS OSPHENA TAB 60MG 2 raloxifene hcl tab 60 mg (generic of 2 PD EVISTA) INSULIN-LIKE GROWTH FACTORS (SOMATOMEDINS) INCRELEX INJ 40MG/4ML 3 PA; SPC LHRH/GNRH AGONIST ANALOG PITUITARY SUPPRESSANTS SYNAREL SOL 2MG/ML 2 METABOLIC MODIFIERS calcitriol cap 0.5 mcg (generic of 1 ROCALTROL) calcitriol cap 0.25 mcg (generic of 1 ROCALTROL) calcitriol oral soln 1 mcg/ml (generic of 1 ROCALTROL) CARBAGLU TAB 200MG 3 PA cinacalcet hcl tab 30 mg (base equiv) 2 SPC (generic of SENSIPAR) cinacalcet hcl tab 60 mg (base equiv) 2 SPC (generic of SENSIPAR) cinacalcet hcl tab 90 mg (base equiv) 2 SPC (generic of SENSIPAR) doxercalciferol cap 0.5 mcg 2 doxercalciferol cap 1 mcg 2 doxercalciferol cap 2.5 mcg 2 levocarnitine oral soln 1 gm/10ml (10%) 1 (generic of CARNITOR) levocarnitine tab 330 mg (generic of 1 CARNITOR) paricalcitol cap 1 mcg (generic of 2 ZEMPLAR)

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 112 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits paricalcitol cap 2 mcg (generic of 2 ZEMPLAR) paricalcitol cap 4 mcg 2 RAVICTI LIQ 1.1GM/ML 3 PA; SPC sapropterin dihydrochloride powder packet 3 PA; SPC 100 mg (generic of KUVAN) sapropterin dihydrochloride powder packet 3 PA; SPC 500 mg (generic of KUVAN) sapropterin dihydrochloride tab 100 mg 3 PA; SPC (generic of KUVAN) sodium phenylbutyrate oral powder 3 1 SPC gm/teaspoonful (generic of BUPHENYL) sodium phenylbutyrate tab 500 mg 3 SPC (SP for existing (generic of BUPHENYL) utilizers) STRENSIQ INJ 18/0.45 3 PA; SP STRENSIQ INJ 28/0.7ML 3 PA; SP STRENSIQ INJ 40MG/ML 3 PA; SP STRENSIQ INJ 80/0.8ML 3 PA; SP POSTERIOR PITUITARY HORMONES desmopressin acetate nasal soln 0.01% 1 (refrigerated) desmopressin acetate nasal spray soln 1 0.01% desmopressin acetate nasal spray soln 1 0.01% (refrigerated) desmopressin acetate tab 0.1 mg (generic 1 of DDAVP) desmopressin acetate tab 0.2 mg (generic 1 of DDAVP) NOCDURNA SUB 27.7MCG 3 PA NOCDURNA SUB 55.3MCG 3 PA NOCTIVA EMU 0.83/0.1 3 PA NOCTIVA SPR 1.66/0.1 3 PA STIMATE SOL 1.5MG/ML 3 SPC PROLACTIN INHIBITORS cabergoline tab 0.5 mg 1 SOMATOSTATIC AGENTS octreotide acetate inj 50 mcg/ml (0.05 2 SPC mg/ml) (generic of SANDOSTATIN) octreotide acetate inj 100 mcg/ml (0.1 2 SPC mg/ml) (generic of SANDOSTATIN)

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 113 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits octreotide acetate inj 200 mcg/ml (0.2 2 SPC mg/ml) octreotide acetate inj 500 mcg/ml (0.5 2 SPC mg/ml) (generic of SANDOSTATIN) octreotide acetate inj 1000 mcg/ml (1 2 SPC mg/ml) SIGNIFOR INJ 0.3MG/ML 3 PA; SP SIGNIFOR INJ 0.6MG/ML 3 PA; SP SIGNIFOR INJ 0.9MG/ML 3 PA; SP VASOPRESSIN RECEPTOR ANTAGONISTS tolvaptan tab 15 mg 3 PA; SPC tolvaptan tab 30 mg (generic of SAMSCA) 3 PA; SPC ESTROGENS ESTROGEN COMBINATIONS BIJUVA CAP 1-100MG 2 CLIMARA PRO DIS WEEKLY 2 COMBIPATCH DIS 3 estradiol & norethindrone acetate tab 0.5- 1 0.1 mg estradiol & norethindrone acetate tab 1-0.5 1 mg (generic of ACTIVELLA) jinteli tab 1mg-5mcg 3 norethindrone acetate-ethinyl estradiol tab 3 0.5 mg-2.5 mcg (generic of FEMHRT) ORIAHNN CAP 2 PA PREMPHASE TAB 2 PREMPRO TAB 2 PREMPRO TAB 0.3-1.5 2 PREMPRO TAB 0.45-1.5 2 PREMPRO TAB 0.625-5 2 ESTROGENS ALORA DIS 0.1MG 3 ALORA DIS 0.05MG 3 ALORA DIS 0.025MG 3 ALORA DIS 0.075MG 3 DELESTROGEN INJ 10MG/ML 3 ^ DELESTROGEN INJ 20MG/ML 3 ^ DELESTROGEN INJ 40MG/ML 3 ^ DEPO-ESTRADI INJ 5MG/ML 3 ^ DIVIGEL GEL 0.5MG 3 DIVIGEL GEL 0.25MG 3

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 114 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits DIVIGEL GEL 0.75MG 3 DIVIGEL GEL 1.25MG 3 DIVIGEL GEL 1MG/GM 3 ELESTRIN GEL 0.06% 3 ENJUVIA TAB 0.3MG 3 ENJUVIA TAB 0.9MG 3 ENJUVIA TAB 0.45MG 3 ENJUVIA TAB 0.625MG 3 ENJUVIA TAB 1.25MG 3 estradiol tab 0.5 mg (generic of ESTRACE) 1 estradiol tab 1 mg (generic of ESTRACE) 1 estradiol tab 2 mg (generic of ESTRACE) 1 estradiol td patch twice weekly 0.1 2 mg/24hr (generic of VIVELLE-DOT) estradiol td patch twice weekly 0.05 2 mg/24hr (generic of VIVELLE-DOT) estradiol td patch twice weekly 0.025 2 mg/24hr (generic of VIVELLE-DOT) estradiol td patch twice weekly 0.075 2 mg/24hr (generic of VIVELLE-DOT) estradiol td patch twice weekly 0.0375 2 mg/24hr (generic of VIVELLE-DOT) estradiol td patch weekly 0.1 mg/24hr 1 (generic of CLIMARA) estradiol td patch weekly 0.05 mg/24hr 1 (generic of CLIMARA) estradiol td patch weekly 0.06 mg/24hr 1 (generic of CLIMARA) estradiol td patch weekly 0.025 mg/24hr 1 (generic of CLIMARA) estradiol td patch weekly 0.075 mg/24hr 1 (generic of CLIMARA) estradiol td patch weekly 0.0375 mg/24hr 1 (37.5 mcg/24hr) (generic of CLIMARA) estradiol valerate im in oil 20 mg/ml 1 ^ (generic of DELESTROGEN) estradiol valerate im in oil 40 mg/ml 1 ^ (generic of DELESTROGEN) ESTROGEL GEL 3 estropipate tab 0.75 mg 1 estropipate tab 1.5 mg 1 estropipate tab 3 mg 1 EVAMIST SPR 1.53MG 3

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 115 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits MENEST TAB 0.3MG 3 MENEST TAB 0.625MG 3 MENEST TAB 1.25MG 3 MENEST TAB 2.5MG 3 MENOSTAR DIS 14MCG 3 PREMARIN INJ 25MG 3 ^ PREMARIN TAB 0.3MG 2 PREMARIN TAB 0.9MG 2 PREMARIN TAB 0.45MG 2 PREMARIN TAB 0.625MG 2 PREMARIN TAB 1.25MG 2 FLUOROQUINOLONES FLUOROQUINOLONES CIPRO (5%) SUS 250MG/5 2 ciprofloxacin for oral susp 250 mg/5ml 2 (5%) (5 gm/100ml) ciprofloxacin for oral susp 500 mg/5ml 2 (10%) (10 gm/100ml) ciprofloxacin hcl tab 100 mg (base equiv) 1 ciprofloxacin hcl tab 250 mg (base equiv) 1 (generic of CIPRO) ciprofloxacin hcl tab 500 mg (base equiv) 1 (generic of CIPRO) ciprofloxacin hcl tab 750 mg (base equiv) 1 ciprofloxacin-ciprofloxacin hcl tab er 24hr 1 500 mg (base eq) ciprofloxacin-ciprofloxacin hcl tab er 24hr 1 1000 mg(base eq) FACTIVE TAB 320MG 3 levofloxacin oral soln 25 mg/ml 1 levofloxacin tab 250 mg (generic of 1 LEVAQUIN) levofloxacin tab 500 mg (generic of 1 LEVAQUIN) levofloxacin tab 750 mg (generic of 1 LEVAQUIN) moxifloxacin hcl tab 400 mg (base equiv) 2 ofloxacin tab 400 mg 1 GASTROINTESTINAL AGENTS - MISC. AGENTS FOR CHRONIC IDIOPATHIC CONSTIPATION (CIC) TRULANCE TAB 3MG 2

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 116 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits GALLSTONE SOLUBILIZING AGENTS ursodiol cap 300 mg 1 ursodiol tab 250 mg (generic of URSO 250) 1 ursodiol tab 500 mg (generic of URSO 1 FORTE) GASTROINTESTINAL ANTIALLERGY AGENTS cromolyn sodium oral conc 100 mg/5ml 3 PD (generic of GASTROCROM) GASTROINTESTINAL STIMULANTS metoclopramide hcl orally disintegrating 3 tab 5 mg (base eq) metoclopramide hcl soln 5 mg/5ml (10 1 mg/10ml) (base equiv) metoclopramide hcl tab 5 mg (base 1 equivalent) (generic of REGLAN) metoclopramide hcl tab 10 mg (base 1 equivalent) (generic of REGLAN) INFLAMMATORY BOWEL AGENTS balsalazide disodium cap 750 mg (generic 1 of COLAZAL) DIPENTUM CAP 250MG 3 mesalamine cap dr 400 mg (generic of 2 DELZICOL) mesalamine cap er 24hr 0.375 gm (generic 3 of APRISO) mesalamine enema 4 gm 1 mesalamine rectal enema 4 gm & cleanser 1 wipe kit (generic of ROWASA) mesalamine suppos 1000 mg (generic of 2 CANASA) mesalamine tab delayed release 1.2 gm 2 (generic of LIALDA) mesalamine tab delayed release 800 mg 2 (generic of ASACOL HD) PENTASA CAP 250MG CR 2 PENTASA CAP 500MG CR 2 SFROWASA ENE 4GM 2 sulfasalazine tab 500 mg (generic of 1 AZULFIDINE) sulfasalazine tab delayed release 500 mg 1 (generic of AZULFIDINE EN-TABS)

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 117 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits INTESTINAL ACIDIFIERS lactulose (encephalopathy) solution 10 1 gm/15ml IRRITABLE BOWEL SYNDROME (IBS) AGENTS alosetron hcl tab 0.5 mg (base equiv) 3 Covered for females (generic of LOTRONEX) only alosetron hcl tab 1 mg (base equiv) 3 Covered for females (generic of LOTRONEX) only LINZESS CAP 72MCG 2 LINZESS CAP 145MCG 2 LINZESS CAP 290MCG 2 VIBERZI TAB 75MG 3 PA VIBERZI TAB 100MG 3 PA ZELNORM TAB 6MG 3 PERIPHERAL OPIOID RECEPTOR ANTAGONISTS MOVANTIK TAB 12.5MG 2 QL (30 tabs / 30 days) MOVANTIK TAB 25MG 2 QL (30 tabs / 30 days) PHOSPHATE BINDER AGENTS calcium acetate (phosphate binder) cap 1 667 mg (169 mg ca) (generic of PHOSLO) calcium acetate (phosphate binder) tab 3 667 mg FOSRENOL POW 1000MG 2 lanthanum carbonate chew tab 500 mg 2 (elemental) (generic of FOSRENOL) lanthanum carbonate chew tab 750 mg 2 (elemental) (generic of FOSRENOL) lanthanum carbonate chew tab 1000 mg 2 (elemental) (generic of FOSRENOL) PHOSLYRA SOL 3 RENAGEL TAB 400MG 2 sevelamer carbonate packet 0.8 gm 2 (generic of RENVELA) sevelamer carbonate packet 2.4 gm 2 (generic of RENVELA) sevelamer carbonate tab 800 mg (generic 2 of RENVELA) sevelamer hcl tab 800 mg (generic of 2 RENAGEL) SHORT BOWEL SYNDROME (SBS) AGENTS GATTEX KIT 5MG 3 PA; SPC

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 118 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits GENITOURINARY AGENTS - MISCELLANEOUS ALKALINIZERS potassium citrate tab er 5 meq (540 mg) 1 (generic of UROCIT-K 5) potassium citrate tab er 10 meq (1080 mg) 1 (generic of UROCIT-K 10) potassium citrate tab er 15 meq (1620 mg) 1 (generic of UROCIT-K 15) INTERSTITIAL CYSTITIS AGENTS ELMIRON CAP 100MG 2 PROSTATIC HYPERTROPHY AGENTS alfuzosin hcl tab er 24hr 10 mg (generic of 1 UROXATRAL) CARDURA XL TAB 4MG 3 CARDURA XL TAB 8MG 3 dutasteride cap 0.5 mg (generic of 2 AVODART) finasteride tab 5 mg (generic of PROSCAR) 1 silodosin cap 4 mg (generic of RAPAFLO) 2 silodosin cap 8 mg (generic of RAPAFLO) 2 tamsulosin hcl cap 0.4 mg (generic of 1 FLOMAX) URINARY ANALGESICS phenazopyridine hcl tab 100 mg 1 phenazopyridine hcl tab 200 mg 1 URINARY STONE AGENTS THIOLA TAB 100MG 3 PA tiopronin tab 100 mg (generic of THIOLA) 3 PA GOUT AGENTS GOUT AGENT COMBINATIONS colchicine w/ probenecid tab 0.5-500 mg 1 GOUT AGENTS allopurinol tab 100 mg (generic of 1 Rx4L ZYLOPRIM) allopurinol tab 300 mg (generic of 1 Rx4L ZYLOPRIM) colchicine cap 0.6 mg 2 colchicine tab 0.6 mg (generic of 2 COLCRYS) febuxostat tab 40 mg (generic of ULORIC) 3 febuxostat tab 80 mg (generic of ULORIC) 3

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 119 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits URICOSURICS probenecid tab 500 mg 1 HEMATOLOGICAL AGENTS - MISC. COMPLEMENT INHIBITORS BERINERT INJ 500UNIT 3 PA; ^, SPC SOLIRIS INJ 10MG/ML 3 PA; ^, SPC HEMATORHEOLOGIC AGENTS pentoxifylline tab er 400 mg 1 PLASMA KALLIKREIN INHIBITORS KALBITOR INJ 10MG/ML 3 PA; ^, SPC TAKHZYRO INJ 300/2ML 3 PA; ^, SPC PLATELET AGGREGATION INHIBITORS anagrelide hcl cap 0.5 mg (generic of 1 AGRYLIN) anagrelide hcl cap 1 mg 1 aspirin-dipyridamole cap er 12hr 25-200 2 PD mg BRILINTA TAB 60MG 2 PD BRILINTA TAB 90MG 2 PD cilostazol tab 50 mg 1 cilostazol tab 100 mg 1 clopidogrel bisulfate tab 75 mg (base 1 PD equiv) (generic of PLAVIX) clopidogrel bisulfate tab 300 mg (base 1 QL (1 ea / 30 days); PD equiv) dipyridamole tab 25 mg 1 PD dipyridamole tab 50 mg 1 PD dipyridamole tab 75 mg 1 PD prasugrel hcl tab 5 mg (base equiv) 2 PD (generic of EFFIENT) prasugrel hcl tab 10 mg (base equiv) 2 PD (generic of EFFIENT) HEMATOPOIETIC AGENTS AGENTS FOR GAUCHER DISEASE miglustat cap 100 mg (generic of 3 SPC ZAVESCA) AGENTS FOR SICKLE CELL ANEMIA DROXIA CAP 200MG 2 DROXIA CAP 300MG 2 DROXIA CAP 400MG 2

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 120 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits COBALAMINS cyanocobalamin inj 1000 mcg/ml 1 ^ FOLIC ACID/FOLATES folic acid tab 1 mg 1 Rx4L folic acid tab 400 mcg 1 QL (100 tabs / 30 days), OTC; ACA folic acid tab 800 mcg 1 QL (100 tabs / 30 days), OTC; ACA HEMATOPOIETIC GROWTH FACTORS ARANESP INJ 10MCG 2 PA; ^, SPC ARANESP INJ 25MCG 2 PA; ^, SPC ARANESP INJ 40MCG 2 PA; ^, SPC ARANESP INJ 60MCG 2 PA; ^, SPC ARANESP INJ 100MCG 2 PA; ^, SPC ARANESP INJ 150MCG 2 PA; ^, SPC ARANESP INJ 200MCG 2 PA; ^, SPC ARANESP INJ 300MCG 2 PA; ^, SPC ARANESP INJ 500MCG 2 PA; ^, SPC DOPTELET TAB 20MG 3 PA; SPC EPOGEN INJ 2000/ML 2 PA; ^, SPC EPOGEN INJ 3000/ML 2 PA; ^, SPC EPOGEN INJ 4000/ML 2 PA; ^, SPC EPOGEN INJ 10000/ML 2 PA; ^, SPC EPOGEN INJ 20000/ML 2 PA; ^, SPC MULPLETA TAB 3MG 3 PA; SPC PROCRIT INJ 2000/ML 2 PA; ^, SPC PROCRIT INJ 3000/ML 2 PA; ^, SPC PROCRIT INJ 4000/ML 2 PA; ^, SPC PROCRIT INJ 10000/ML 2 PA; ^, SPC PROCRIT INJ 20000/ML 2 PA; ^, SPC PROCRIT INJ 40000/ML 2 PA; ^, SPC PROMACTA PAK 25MG 3 SPC PROMACTA POW 12.5MG 3 SPC PROMACTA TAB 12.5MG 3 SPC PROMACTA TAB 25MG 3 SPC PROMACTA TAB 50MG 3 SPC PROMACTA TAB 75MG 3 SPC RETACRIT INJ 2000UNIT 2 PA; SPC RETACRIT INJ 3000UNIT 2 PA; SPC RETACRIT INJ 4000UNIT 2 PA; SPC RETACRIT INJ 10000UNT 2 PA; SPC

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 121 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits RETACRIT INJ 20000UNI 2 PA; SPC RETACRIT INJ 40000UNT 2 PA; SPC ZARXIO INJ 300/0.5 2 PA; ^, SPC ZARXIO INJ 480/0.8 2 PA; ^, SPC ZIEXTENZO INJ 6/0.6ML 2 PA; SPC ^ HEMATOPOIETIC MIXTURES av-vite fb tab 2.5-25-1 1 BIFERARX TAB 3 corvita 150 tab 3 ferocon cap 1 FERRALET 90 TAB 3 FERRAPLUS 90 TAB 3 ferrogels fo cap forte 1 FOLIVANE-PLS CAP 3 folplex 2.2 tab 1 icar-c plus tab 2 MULTIGEN TAB 3 MULTIGEN TAB FOLIC 3 myferon 150 cap forte 1 virt-gard tab 2.2-25-1 1 IRON FER-IN-SOL DRO 15MG/ML 1 OTC; ACA FERROUS SULF SYP 300/5ML 1 OTC; ACA ferrous sulfate elixir 220 mg/5ml (44 1 OTC; ACA mg/5ml elemental fe) ICAR PEDS SUS GRAPE 1 OTC; ACA iron supplmt dro 15mg/ml 1 OTC; ACA MYKIDZ IRON SUS 15/1.5ML 1 OTC; ACA SLOW RELEASE TAB 143MG 1 OTC; ACA wee care sus 15/1.25 1 OTC; ACA HEMOSTATICS HEMOSTATICS - SYSTEMIC AMICAR SYP 25% 3 AMICAR TAB 500MG 3 AMICAR TAB 1000MG 3 aminocaproic acid oral soln 0.25 gm/ml 3 (generic of AMICAR) aminocaproic acid tab 500 mg (generic of 3 AMICAR) aminocaproic acid tab 1000 mg (generic of 3 AMICAR)

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 122 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits tranexamic acid tab 650 mg (generic of 3 LYSTEDA) HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS BARBITURATE HYPNOTICS phenobarbital elixir 20 mg/5ml 1 PD phenobarbital tab 15 mg 1 PD phenobarbital tab 16.2 mg 1 PD phenobarbital tab 30 mg 1 PD phenobarbital tab 32.4 mg 1 PD phenobarbital tab 60 mg 1 PD phenobarbital tab 64.8 mg 1 PD phenobarbital tab 97.2 mg 1 PD phenobarbital tab 100 mg 1 PD NON-BARBITURATE HYPNOTICS EDLUAR SUB 5MG 3 QL (30 tabs / 30 days); Cumulative by class EDLUAR SUB 10MG 3 QL (30 tabs / 30 days); Cumulative by class estazolam tab 1 mg 1 QL (30 tabs / 30 days); Cumulative by class estazolam tab 2 mg 1 QL (30 tabs / 30 days); Cumulative by class eszopiclone tab 1 mg (generic of LUNESTA) 2 QL (30 tabs / 30 days) eszopiclone tab 2 mg (generic of LUNESTA) 2 QL (30 tabs / 30 days) eszopiclone tab 3 mg (generic of LUNESTA) 2 QL (30 tabs / 30 days) flurazepam hcl cap 15 mg 1 flurazepam hcl cap 30 mg 1 midazolam hcl syrup 2 mg/ml (base 1 equivalent) temazepam cap 7.5 mg (generic of 1 QL (30 caps / 30 days); RESTORIL) Cumulative by class temazepam cap 15 mg (generic of 1 QL (30 ea / 30 days); RESTORIL) Cumulative by class temazepam cap 22.5 mg (generic of 1 QL (30 caps / 30 days) RESTORIL) temazepam cap 30 mg (generic of 1 QL (30 ea / 30 days); RESTORIL) Cumulative by class triazolam tab 0.25 mg (generic of 1 HALCION) triazolam tab 0.125 mg 1 zaleplon cap 5 mg 1 QL (30 caps / 30 days); Cumulative by class

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 123 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits zaleplon cap 10 mg 1 QL (30 caps / 30 days); Cumulative by class zolpidem tartrate tab 5 mg (generic of 1 QL (30 ea / 30 days); AMBIEN) Cumulative by class zolpidem tartrate tab 10 mg (generic of 1 QL (30 ea / 30 days); AMBIEN) Cumulative by class zolpidem tartrate tab er 6.25 mg (generic 1 QL (30 tabs / 30 days); of AMBIEN CR) Cumulative by class zolpidem tartrate tab er 12.5 mg (generic 1 QL (30 ea / 30 days); of AMBIEN CR) Cumulative by class SELECTIVE MELATONIN RECEPTOR AGONISTS ramelteon tab 8 mg (generic of ROZEREM) 3 QL (30 tabs / 30 days) LAXATIVES LAXATIVE COMBINATIONS GOLYTELY SOL 2 peg 3350-kcl-na bicarb-nacl-na sulfate for 1 soln 236 gm (generic of GOLYTELY) peg 3350-kcl-na bicarb-nacl-na sulfate for 1 soln 240 gm SUPREP BOWEL SOL PREP KIT 3 trilyte sol (generic of NULYTELY) 1 LAXATIVES - MISCELLANEOUS KRISTALOSE PAK 10GM 2 KRISTALOSE PAK 20GM 3 lactulose solution 10 gm/15ml 1 polyethylene glycol 3350 oral powder 17 1 ACA gm/scoop MACROLIDES AZITHROMYCIN azithromycin for susp 100 mg/5ml (generic 1 of ZITHROMAX) azithromycin for susp 200 mg/5ml (generic 1 of ZITHROMAX) azithromycin powd pack for susp 1 gm 1 azithromycin tab 250 mg (generic of 1 ZITHROMAX) azithromycin tab 500 mg (generic of 1 ZITHROMAX) azithromycin tab 600 mg 1 ZMAX SUS 2GM 2 CLARITHROMYCIN clarithromycin for susp 125 mg/5ml 1

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 124 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits clarithromycin for susp 250 mg/5ml 1 clarithromycin tab 250 mg 1 clarithromycin tab 500 mg 1 clarithromycin tab er 24hr 500 mg (generic 1 of BIAXIN XL) ERYTHROMYCINS e.e.s. 400 tab 400mg 1 ery-tab tab 250mg ec 3 ery-tab tab 333mg ec 3 ery-tab tab 500mg ec 3 erythrocin tab 250mg 1 erythromycin ethylsuccinate for susp 200 3 mg/5ml (generic of E.E.S. GRANULES) erythromycin ethylsuccinate for susp 400 3 mg/5ml (generic of ERYPED 400) erythromycin tab 250 mg 1 erythromycin tab 500 mg 1 erythromycin w/ delayed release particles 1 cap 250 mg PCE TAB 333MG EC 3 PCE TAB 500MG EC 3 FIDAXOMICIN DIFICID SUS 3 PA DIFICID TAB 200MG 3 PA MEDICAL DEVICES AND SUPPLIES BANDAGES-DRESSINGS-TAPE OPSITE IV MIS 3000 2 OTC CONTRACEPTIVES CAYA DPR 2 ACA FC FEMALE MIS CONDOM 2 OTC; ACA FEMCAP MIS 22MM 2 ACA FEMCAP MIS 26MM 2 ACA FEMCAP MIS 30MM 2 ACA OMNIFLEX DPR 2 ACA WIDE-SEAL DPR KIT 60 2 ACA WIDE-SEAL DPR KIT 65 2 ACA WIDE-SEAL DPR KIT 70 2 ACA WIDE-SEAL DPR KIT 75 2 ACA WIDE-SEAL DPR KIT 80 2 ACA WIDE-SEAL DPR KIT 85 2 ACA WIDE-SEAL DPR KIT 90 2 ACA

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 125 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits WIDE-SEAL DPR KIT 95 2 ACA DIABETIC SUPPLIES AUTOLET II KIT CLINISAF 2 OTC AUTOLET MINI MIS 2 OTC AUTOLET PLAT MIS 2.4MM 2 OTC BAYER BREEZE KIT 2 SYSTEM 2 OTC; PD 3ML CARTRIDG MIS PLASTIC 2 OTC CHEMSTRIP BG MIS LOG 2 OTC; PD CONTOUR KIT LINK 2 OTC; PD EASYMAX SOL HIGH 2 OTC EASYMAX SOL LOW 2 OTC GLUC CONTROL LIQ NORMAL 2 OTC INSUL-EZE MIS 2 OTC INSUL-TOTE MIS 2 OTC; PD MINILINK RT KIT STARTER 2 OMNIPOD MIS 5 PACK 2 QL (10 boxes / 30 days) QUICKTEK LIQ SOLUTION 2 OTC SINGLE-LET MIS 23G 2 OTC URIN-TEK KIT 1 OTC URIN-TEK MIS 1 OTC MISC. DEVICES ALCOHOL SWAB PAD 1 OTC PARENTERAL THERAPY SUPPLIES AUTOSHIELD MIS 29X3/16" 2 OTC AUTOSHIELD MIS 29X5/16" 2 OTC AUTOSHIELD MIS 30GX5MM 2 OTC BD PEN MINI MIS 2 OTC EASY TOUCH MIS 30G 2 OTC INSUFLON MIS 25GX0.71 2 INSULIN SRYG MIS 1ML/32G 2 OTC INSULIN SYRG MIS 0.3/28G 2 OTC INSULIN SYRG MIS 0.3/29G 2 OTC INSULIN SYRG MIS 0.3/30G 2 OTC INSULIN SYRG MIS 0.3/31G 2 OTC INSULIN SYRG MIS 0.5/27G 2 OTC INSULIN SYRG MIS 0.5/28G 2 OTC INSULIN SYRG MIS 0.5/29G 2 INSULIN SYRG MIS 0.5/29G 2 OTC INSULIN SYRG MIS 0.5/30G 2 OTC INSULIN SYRG MIS 0.5/31G 2 OTC INSULIN SYRG MIS 0.5/32G 2 OTC

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 126 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits INSULIN SYRG MIS 1ML/25G 2 OTC INSULIN SYRG MIS 1ML/26G 2 OTC INSULIN SYRG MIS 1ML/27G 2 OTC INSULIN SYRG MIS 1ML/28G 2 OTC INSULIN SYRG MIS 1ML/29G 2 INSULIN SYRG MIS 1ML/29G 2 OTC INSULIN SYRG MIS 1ML/30G 2 OTC INSULIN SYRG MIS 1ML/31G 2 OTC INSULIN SYRG MIS 2/27.5G 2 OTC INSUPEN SENS MIS 32GX6MM 2 OTC INSUPEN SENS MIS 32GX8MM 2 OTC INSUPEN ULTR MIS 30GX8MM 2 OTC LITETOUCH MIS 29GX12.7 2 OTC PEN NEEDLES MIS 29GX1/2" 2 OTC PEN NEEDLES MIS 31GX1/4" 2 OTC PEN NEEDLES MIS 31GX5/16 2 OTC PEN NEEDLES MIS 32GX5MM 2 OTC SHARPS-A-GAT MIS 1 GALLON 2 OTC; OTC SYRINGE MIS 0.5/30G 2 OTC 1ML SYRINGE MIS 30G 2 OTC UNIFINE PNTP MIS 31GX3/16 2 OTC UNIFINE PNTP MIS 32GX4MM 2 OTC RESPIRATORY THERAPY SUPPLIES AERCHMBR Z- MIS STAT PLS 2 AEROCHAMBER KIT ACTION 2 PD BREATHERITE MIS MDI CHMB 2 INSPIRATION MIS ELITE 2 INSPIREASE MIS RES BAG 2 MICROCHAMBER MIS 2 PULMONEB LT MIS NEBULIZE 2 TRUZONE PEAK MIS FLOW MTR 2 PD MIGRAINE PRODUCTS MIGRAINE COMBINATIONS ergotamine w/ caffeine tab 1-100 mg 3 (generic of CAFERGOT) isometheptene-dichloral-acetaminophen 1 cap 65-100-325 mg migergot sup 2/100 2 MIGRAINE PRODUCTS dihydroergotamine mesylate inj 1 mg/ml 1 (generic of D.H.E. 45)

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 127 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits dihydroergotamine mesylate nasal spray 4 2 QL (8 mL / 30 days); 1 mg/ml (generic of MIGRANAL) x 8 pack in 30 days MIGRANAL SPR 4MG/ML 2 MIGRAINE PRODUCTS - MONOCLONAL ANTIBODIES AIMOVIG INJ 70MG/ML 3 PA AIMOVIG INJ 140MG/ML 3 PA AJOVY INJ 225/1.5 3 PA NURTEC TAB 75MG ODT 3 PA, QL (15 tabs / 30 days) UBRELVY TAB 50MG 3 PA, QL (16 tabs / 30 days) UBRELVY TAB 100MG 3 PA, QL (16 tabs / 30 days) SEROTONIN AGONISTS almotriptan malate tab 6.25 mg 3 QL (8 tabs / 30 days) almotriptan malate tab 12.5 mg 3 QL (8 ea / 30 days) eletriptan hydrobromide tab 20 mg (base 2 QL (6 ea / 30 days) equivalent) (generic of RELPAX) eletriptan hydrobromide tab 40 mg (base 2 QL (6 tabs / 30 days) equivalent) (generic of RELPAX) naratriptan hcl tab 1 mg (base equiv) 1 QL (12 tabs / 30 days); (generic of AMERGE) QL cumulative by class naratriptan hcl tab 2.5 mg (base equiv) 1 QL (12 tabs / 30 days); (generic of AMERGE) QL cumulative by class REYVOW TAB 50MG 3 PA, QL (4 tabs / 30 days) REYVOW TAB 100MG 3 PA, QL (8 tabs / 30 days) rizatriptan benzoate oral disintegrating tab 1 QL (12 tabs / 30 days); 5 mg (base eq) QL cumulative by class rizatriptan benzoate oral disintegrating tab 1 QL (12 tabs / 30 days); 10 mg (base eq) (generic of MAXALT-MLT) QL cumulative by class rizatriptan benzoate tab 5 mg (base 1 QL (12 tabs / 30 days); equivalent) QL cumulative by class rizatriptan benzoate tab 10 mg (base 1 QL (12 tabs / 30 days); equivalent) (generic of MAXALT) QL cumulative by class sumatriptan nasal spray 5 mg/act (generic 1 QL (6 inhalers / 30 of IMITREX) days); 1 box per 30 days (cumulative by class)

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 128 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits sumatriptan nasal spray 20 mg/act 1 QL (6 inhalers / 30 (generic of IMITREX) days); 1 box per 30 days (cumulative by class) sumatriptan succinate inj 6 mg/0.5ml 1 QL (6 injections / 30 (generic of IMITREX) days); 6 injections per 30 days (cumulative by class) sumatriptan succinate solution auto- 1 QL (6 injections / 30 injector 4 mg/0.5ml (generic of IMITREX days); 6 injections per STATDOSE SYSTEM) 30 days (cumulative by class) sumatriptan succinate solution auto- 1 QL (6 injections / 30 injector 6 mg/0.5ml (generic of IMITREX days); 6 injections per STATDOSE SYSTEM) 30 days (cumulative by class) sumatriptan succinate solution cartridge 4 1 QL (6 injections / 30 mg/0.5ml (generic of IMITREX STATDOSE days); 6 injections per REFILL) 30 days (cumulative by class) sumatriptan succinate solution cartridge 6 1 QL (6 injections / 30 mg/0.5ml (generic of IMITREX STATDOSE days); 6 injections per REFILL) 30 days (cumulative by class) sumatriptan succinate solution prefilled 1 QL (6 injections / 30 syringe 6 mg/0.5ml days); 6 injections per 30 days (cumulative by class) sumatriptan succinate tab 25 mg (generic 1 QL (12 tabs / 30 days); of IMITREX) QL cumulative by class sumatriptan succinate tab 50 mg (generic 1 QL (12 tabs / 30 days); of IMITREX) QL cumulative by class sumatriptan succinate tab 100 mg (generic 1 QL (12 tabs / 30 days); of IMITREX) QL cumulative by class zolmitriptan nasal spray 2.5 mg/spray unit 2 QL (6 bottles / 30 days) zolmitriptan nasal spray 5 mg/spray unit 2 QL (6 bottles / 30 days) zolmitriptan orally disintegrating tab 2.5 2 QL (12 tabs / 30 days); mg (generic of ZOMIG ZMT) QL cumulative by class zolmitriptan orally disintegrating tab 5 mg 2 QL (12 tabs / 30 days); (generic of ZOMIG ZMT) QL cumulative by class zolmitriptan tab 2.5 mg (generic of 2 QL (12 tabs / 30 days); ZOMIG) QL cumulative by class zolmitriptan tab 5 mg (generic of ZOMIG) 2 QL (12 tabs / 30 days); QL cumulative by class

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 129 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits MINERALS & ELECTROLYTES FLUORIDE FLUOR-A-DAY CHW 0.5MG F 2 ACA FLUOR-A-DAY CHW 0.25MG F 2 ACA FLUOR-A-DAY CHW 1MG F 2 FLUORABON DRO 2 ACA flura-drops dro 0.25mg f 1 ACA flura-drops dro 0.125mg 1 ACA sodium fluoride chew tab 0.5 mg f (from 1 ACA 1.1 mg naf) sodium fluoride chew tab 0.25 mg f (from 1 ACA 0.55 mg naf) sodium fluoride chew tab 1 mg f (from 2.2 1 ACA mg naf) sodium fluoride soln 0.5 mg/ml f (from 1.1 1 ACA mg/ml naf) sodium fluoride tab 0.5 mg f (from 1.1 mg 1 ACA naf) sodium fluoride tab 1 mg f (from 2.2 mg 1 naf) PHOSPHATE virt-phos tab 250 neut 1 POTASSIUM EFFER-K TAB 10MEQ 3 EFFER-K TAB 20MEQ 3 klor-con 8 tab 8meq er 1 KLOR-CON M15 TAB 15MEQ ER 3 KLOR-CON/25 POW 25MEQ 3 pot bicarbonate & chloride effer tab 25 1 meq potassium bicarbonate effer tab 25 meq 1 potassium chloride cap er 8 meq 1 potassium chloride cap er 10 meq 1 potassium chloride microencapsulated crys 1 er tab 10 meq potassium chloride microencapsulated crys 1 er tab 20 meq potassium chloride oral soln 10% (20 1 meq/15ml) potassium chloride oral soln 20% (40 1 meq/15ml) potassium chloride powder packet 20 meq 1

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 130 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits potassium chloride tab er 10 meq 1 potassium chloride tab er 20 meq (1500 1 mg) (generic of K-TAB) MISCELLANEOUS THERAPEUTIC CLASSES CHELATING AGENTS trientine hcl cap 250 mg (generic of 3 PA SYPRINE) IMMUNOMODULATORS REVLIMID CAP 2.5MG 3 PA; SPC REVLIMID CAP 5MG 3 PA; SPC REVLIMID CAP 10MG 3 PA; SPC REVLIMID CAP 15MG 3 PA; SPC REVLIMID CAP 20MG 3 PA; SPC REVLIMID CAP 25MG 3 PA; SPC THALOMID CAP 50MG 2 PA; SPC THALOMID CAP 100MG 2 PA; SPC THALOMID CAP 150MG 2 PA; SPC THALOMID CAP 200MG 2 PA; SPC IMMUNOSUPPRESSIVE AGENTS AZASAN TAB 75 MG 2 AZASAN TAB 100MG 2 azathioprine tab 50 mg (generic of 1 IMURAN) CELLCEPT CAP 250MG 2 SP CELLCEPT SUS 200MG/ML 2 SP CELLCEPT TAB 500MG 2 SP cyclosporine cap 25 mg (generic of 1 SP SANDIMMUNE) cyclosporine cap 100 mg (generic of 1 SP SANDIMMUNE) cyclosporine modified cap 25 mg (generic 1 SP of NEORAL) cyclosporine modified cap 50 mg 1 cyclosporine modified cap 100 mg (generic 1 SP of NEORAL) cyclosporine modified oral soln 100 mg/ml 1 SP (generic of NEORAL) ENSPRYNG INJ 3 PA; SPC everolimus tab 0.5 mg (generic of 3 PA; SP ZORTRESS) everolimus tab 0.25 mg (generic of 3 PA; SP ZORTRESS)

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 131 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits everolimus tab 0.75 mg (generic of 3 PA; SP ZORTRESS) IMURAN TAB 50MG 3 LUPKYNIS CAP 7.9MG 3 PA mycophenolate mofetil cap 250 mg 1 SP (generic of CELLCEPT) mycophenolate mofetil for oral susp 200 2 SP mg/ml (generic of CELLCEPT) mycophenolate mofetil tab 500 mg 1 SP (generic of CELLCEPT) mycophenolate sodium tab dr 180 mg 2 SP (mycophenolic acid equiv) (generic of MYFORTIC) mycophenolate sodium tab dr 360 mg 2 SP (mycophenolic acid equiv) (generic of MYFORTIC) MYFORTIC TAB 180MG 3 SP MYFORTIC TAB 360MG 3 SP NEORAL CAP 25MG 2 SP NEORAL CAP 100MG 2 SP NEORAL SOL 100MG/ML 2 SP PROGRAF CAP 0.5MG 2 SP PROGRAF CAP 1MG 2 SP PROGRAF CAP 5MG 2 SP RAPAMUNE SOL 1MG/ML 2 SP RAPAMUNE TAB 0.5MG 3 SP RAPAMUNE TAB 1MG 3 SP RAPAMUNE TAB 2MG 3 SP SANDIMMUNE CAP 25MG 2 SP SANDIMMUNE CAP 100MG 2 SP SANDIMMUNE SOL 100MG/ML 2 SP sirolimus oral soln 1 mg/ml (generic of 2 SP RAPAMUNE) sirolimus tab 0.5 mg (generic of 2 SP RAPAMUNE) sirolimus tab 1 mg (generic of RAPAMUNE) 2 SP sirolimus tab 2 mg (generic of RAPAMUNE) 2 SP tacrolimus cap 0.5 mg (generic of 1 SP PROGRAF) tacrolimus cap 1 mg (generic of PROGRAF) 1 SP tacrolimus cap 5 mg (generic of PROGRAF) 1 SP ZORTRESS TAB 1MG 3 PA; SP

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 132 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits IRRIGATION SOLUTIONS water for irrigation, sterile irrigation soln 1 POTASSIUM REMOVING AGENTS LOKELMA PAK 5GM 2 LOKELMA PAK 10GM 2 sodium polystyrene sulfonate powder 1 sodium polystyrene sulfonate rectal susp 1 30 gm/120ml sps sus 15gm/60 1 VELTASSA POW 8.4GM 2 VELTASSA POW 16.8GM 2 VELTASSA POW 25.2GM 2 SYSTEMIC LUPUS ERYTHEMATOSUS AGENTS BENLYSTA INJ 200MG/ML 3 PA; SPC MOUTH/THROAT/DENTAL AGENTS ANESTHETICS TOPICAL ORAL FIRST-MOUTHW SUS BLM 1 lidocaine hcl viscous soln 2% 1 ANTI-INFECTIVES - THROAT clotrimazole troche 10 mg 1 nystatin susp 100000 unit/ml 1 ANTISEPTICS - MOUTH/THROAT chlorhexidine gluconate soln 0.12% 1 (generic of PERIDEX) DENTAL PRODUCTS clinpro 5000 pst 1.1% 1 fluoridex dd pst sensitiv 1 PREVIDENT SOL 0.2% 2 sf 5000 plus cre 1.1% 1 sf gel 1.1% 1 sod fluoride sol 0.2% 1 STEROIDS - MOUTH/THROAT triamcinolone acetonide dental paste 0.1% 1 THROAT PRODUCTS - MISC. cevimeline hcl cap 30 mg (generic of 2 EVOXAC) GELCLAIR GEL 2 pilocarpine hcl tab 5 mg (generic of 1 SALAGEN)

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 133 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits pilocarpine hcl tab 7.5 mg (generic of 1 SALAGEN) MULTIVITAMINS B-COMPLEX W/ FOLIC ACID folbee plus tab 1 folbee plus tab cz 1 mynephrocaps cap 1 NEPHPLEX RX TAB 3 nephronex tab 1 MULTIPLE VITAMINS W/ MINERALS AP-ZEL TAB 3 FORTAVIT CAP 3 multiple vitamins w/ minerals tab 1 OTC SUPPORT LIQ 3 v-c forte cap 1 VITAROCA PLU TAB 3 MULTIPLE VITAMINS W/ MINERALS & CALCIUM-FOLIC ACID FOLGARD OS TAB 3 PED MULTI VITAMINS W/FL & FE ESCAVITE D CHW 3 PD multi-vit/fe dro /fl 0.25 1 PD POLY-VI-FLOR CHW W/IRON 3 PD POLY-VI-FLOR SUS /IRON 3 PD tri-vit/fe dro /fl 0.25 1 PD PED MV W/ FLUORIDE multi-vit/fl dro 0.5mg/ml 1 PD multi-vit/fl dro 0.25mg 1 PD mvc-fluoride chw 0.5mg 1 PD mvc-fluoride chw 0.25mg 1 PD mvc-fluoride chw 1mg 1 PD POLY-VI-FLOR CHW 0.5MG 3 PD POLY-VI-FLOR CHW 0.25MG 3 PD POLY-VI-FLOR CHW 1MG 3 PD POLY-VI-FLOR SUS 0.25/ML 3 PD tri-vit/fluo dro 0.5mg 1 PD tri-vit/fluo dro 0.25mg 1 PD PRENATAL VITAMINS ACTIVE OB CAP 3 ATABEX EC TAB 3 BAL-CARE MIS DHA 3

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 134 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits bp folinatal tab plus b 1 bp multinatl chw plus 1 bp multinatl tab plus 1 CITRANATAL CAP HARMONY 3 CITRANATAL CAP MEDLEY 3 CITRANATAL PAK ESSENCE 3 CITRANATAL TAB BLOOM 3 CITRANATAL TAB RX 3 COMPLETE NAT PAK DHA 3 CONCEPT DHA CAP 3 CONCEPT OB CAP 3 DUET DHA 400 MIS 25-1-400 3 DUET DHA MIS BALANCED 3 elite-ob tab 1 ENBRACE HR CAP 3 FOCALGIN 90 MIS DHA 3 FOCALGIN CA MIS 3 FOLCAPS CAP OMEGA 3 3 FOLET DHA PAK 3 FOLET ONE CAP 38-1-225 3 HEMENATAL OB MIS + DHA 3 inatal adv tab 1 INFANATE CAP BALANCE 3 KOSHR PRENAT TAB 30-1MG 3 LEVOMEFOLATE CAP DHA 3 MARNATAL-F CAP 3 MYNATAL CAP 3 MYNATAL TAB 3 MYNATAL-Z TAB 3 MYNATE 90 TAB PLUS 3 NATACHEW CHW 3 NATALVIT TAB 75-1MG 3 NATELLE ONE CAP 3 NEONATAL 19 TAB 3 NEONATAL FE TAB 3 NEONATAL/DHA MIS 3 NESTABS ABC MIS 3 NESTABS DHA PAK 3 NESTABS ONE CAP 3 NEWGEN TAB 32-1MG 3 NEXA PLUS CAP 3

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 135 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits O-CAL TAB PRENATAL 3 OB COMPLETE CAP 3 OB COMPLETE CAP GOLD 3 OB COMPLETE CAP ONE 3 OB COMPLETE CAP PETITE 3 OB COMPLETE TAB 3 OB COMPLETE TAB PREMIER 3 OB COMPLETE/ CAP DHA 3 OBSTETRIX EC TAB 3 OBSTETRIX PAK DHA 3 PAIRE OB MIS 3 PNV OB+DHA PAK 3 pnv-dha cap 1 PNV-DHA CAP DOCUSATE 3 PNV-OMEGA CAP 3 pnv-select tab 1 PNV-TOTAL CAP 3 PR NATAL 400 PAK 3 PR NATAL 400 PAK EC 3 PR NATAL 430 PAK 3 PR NATAL 430 PAK EC 3 PREFERA OB TAB 3 PREFERAOB MIS +DHA 3 PRENA1 CHW 3 PRENA1 PEARL CAP 3 PRENAISSANCE CAP 3 PRENAISSANCE CAP BALANCE 3 PRENAISSANCE CAP PLUS 3 PRENAISSANCE MIS HARMONY 3 PRENAISSANCE TAB NEXT 3 PRENAISSANCE TAB NEXT-B 3 PRENATA CHW 29-1MG 3 prenatabs fa tab 29-1mg 1 OTC prenatabs rx tab 1 PRENATAL 19 CHW 29-1MG 3 prenatal 19 chw tab 1 prenatal 19 tab 1 OTC PRENATAL 19 TAB 29-1MG 3 PRENATAL DHA PAK 27-1-250 3 PRENATAL MIS COMPLEAT 3 PRENATAL TAB 27-1MG 3

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 136 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits PRENATAL+FE TAB 29-1MG 3 PRENATAL-U CAP 106.5-1 3 PRENATE AM TAB 1MG 3 PRENATE CAP ENHANCE 3 PRENATE CAP ESSENTIA 3 PRENATE CAP PIXIE 3 PRENATE CAP RESTORE 3 PRENATE CHW 0.6-0.4 3 PRENATE DHA CAP 3 PRENATE MINI CAP 3 PRENATE STAR TAB 20-1MG 3 PRENATE TAB ELITE 3 PREQUE 10 TAB 3 PRETAB TAB 29-1MG 3 PRIMACARE CAP 3 PROVIDA DHA CAP 3 PROVIDA OB CAP 3 PUREFE OB CAP PLUS 3 RELNATE DHA CAP 3 RULAVITE DHA CAP 3 SE-TAN DHA CAP 3 SELECT-OB CHW 3 SELECT-OB+ PAK DHA 3 TARON-BC MIS 3 TARON-PREX CAP 3 TL FOLATE TAB 3 TRICARE CHW PRENATAL 3 TRICARE PRE CAP 27-1-500 3 trinate tab 1 TRISTART DHA CAP 3 TRISTART ONE CAP 35-1-215 3 ULTIMATECARE CAP ONE NF 3 VINACAL B MIS 3 VINATE C TAB 3 VINATE CAL TAB 3 VINATE CARE CHW 40-1MG 3 OTC VINATE DHA CAP 27-1.13 3 VINATE II TAB 3 VINATE M TAB 3 VINATE ONE TAB 3 VIRT NATE TAB 3

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 137 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits VIRT-PN TAB 3 VIRTPREX CAP 3 VITA-PREN TAB 3 VITAFOL CAP ULTRA 3 VITAFOL CHW GUMMIES 3 VITAFOL FE+ CAP 3 VITAFOL STRP MIS 1MG 3 VITAFOL-NANO TAB 3 VITAFOL-OB PAK +DHA 3 VITAFOL-ONE CAP 3 VITAMEDMD CAP ONE RX 3 VITAMEDMD MIS PLUS RX 3 VITATRUE MIS 3 VP-HEME OB TAB 3 VP-HEME ONE CAP 3 VP-PNV-DHA CAP 3 ZATEAN-CH CAP 3 VITAMIN MIXTURES NICOMIDE TAB 3 MUSCULOSKELETAL THERAPY AGENTS CENTRAL MUSCLE RELAXANTS baclofen tab 5 mg 1 baclofen tab 10 mg 1 baclofen tab 20 mg 1 chlorzoxazone tab 500 mg 1 cyclobenzaprine hcl tab 5 mg 1 cyclobenzaprine hcl tab 7.5 mg 1 cyclobenzaprine hcl tab 10 mg 1 metaxalone tab 800 mg (generic of 3 SKELAXIN) methocarbamol tab 500 mg 1 methocarbamol tab 750 mg 1 orphenadrine citrate tab er 12hr 100 mg 1 tizanidine hcl cap 2 mg (base equivalent) 1 (generic of ZANAFLEX) tizanidine hcl cap 4 mg (base equivalent) 1 (generic of ZANAFLEX) tizanidine hcl cap 6 mg (base equivalent) 1 (generic of ZANAFLEX) tizanidine hcl tab 2 mg (base equivalent) 1

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 138 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits tizanidine hcl tab 4 mg (base equivalent) 1 (generic of ZANAFLEX) DIRECT MUSCLE RELAXANTS dantrolene sodium cap 25 mg (generic of 1 DANTRIUM) dantrolene sodium cap 50 mg (generic of 1 DANTRIUM) dantrolene sodium cap 100 mg 1 MUSCLE RELAXANT COMBINATIONS orphenadrine w/ aspirin & caffeine tab 25- 1 385-30 mg NASAL AGENTS - SYSTEMIC AND TOPICAL NASAL ANTI-INFECTIVES BACTROBAN OIN NASAL 2% 2 NASAL ANTIALLERGY azelastine hcl nasal spray 0.1% (137 1 mcg/spray) azelastine hcl nasal spray 0.15% (205.5 2 mcg/spray) olopatadine hcl nasal soln 0.6% (generic of 3 PATANASE) NASAL ANTICHOLINERGICS ipratropium bromide nasal soln 0.03% (21 1 mcg/spray) ipratropium bromide nasal soln 0.06% (42 1 mcg/spray) NASAL STEROIDS flunisolide nasal soln 25 mcg/act (0.025%) 3 fluticasone propionate nasal susp 50 3 mcg/act mometasone furoate nasal susp 50 2 mcg/act (generic of NASONEX) NEUROMUSCULAR AGENTS ALS AGENTS riluzole tab 50 mg (generic of RILUTEK) 3 NUTRIENTS MISC. NUTRITIONAL SUBSTANCES OMEGA-3 2100 CAP 1050MG 2 OTC omega-3 fatty acids cap 1000 mg 1 OTC PROTEINS acetylcysteine cap 600 mg 1

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 139 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits ADD-INS PAK COMPLETE 2 OTC amino acids tab complex 1 OTC OPHTHALMIC AGENTS ARTIFICIAL TEARS AND LUBRICANTS LACRISERT MIS 5MG OP 3 BETA-BLOCKERS - OPHTHALMIC betaxolol hcl ophth soln 0.5% 1 BETIMOL SOL 0.5% 2 BETIMOL SOL 0.25% 2 BETOPTIC-S SUS 0.25% OP 3 carteolol hcl ophth soln 1% 1 COMBIGAN SOL 0.2/0.5% 2 dorzolamide hcl-timolol maleate ophth sol 2 22.3-6.8 mg/ml pf (generic of COSOPT PF) dorzolamide hcl-timolol maleate ophth soln 1 22.3-6.8 mg/ml (generic of COSOPT) levobunolol hcl ophth soln 0.5% 1 levobunolol hcl ophth soln 0.25% 1 metipranolol ophth soln 0.3% 1 timolol maleate ophth gel forming soln 1 0.5% (generic of TIMOPTIC-XE) timolol maleate ophth gel forming soln 1 0.25% (generic of TIMOPTIC-XE) timolol maleate ophth soln 0.5% (generic 1 of TIMOPTIC) timolol maleate ophth soln 0.5% (once- 3 daily) (generic of ISTALOL) timolol maleate ophth soln 0.25% (generic 1 of TIMOPTIC) timolol maleate preservative free ophth 3 soln 0.5% (generic of TIMOPTIC OCUDOSE) TIMOPTIC OCU SOL 0.25% OP 3 CYCLOPLEGIC MYDRIATICS ATROPINE SUL OIN 1% OP 1 cyclopentolate hcl ophth soln 1% (generic 1 of CYCLOGYL) cyclopentolate hcl ophth soln 2% 1 homatropine hbr ophth soln 5% 1 ISOPTO ATROP SOL 1% OP 1 phenylephrine hcl ophth soln 2.5% 1

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 140 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits tropicamide ophth soln 1% (generic of 1 MYDRIACYL) MIOTICS pilocarpine hcl ophth soln 1% (generic of 1 ISOPTO CARPINE) pilocarpine hcl ophth soln 2% (generic of 1 ISOPTO CARPINE) pilocarpine hcl ophth soln 4% (generic of 1 ISOPTO CARPINE) OPHTHALMIC ADRENERGIC AGENTS ALPHAGAN P SOL 0.1% 2 apraclonidine hcl ophth soln 0.5% (base 1 equivalent) brimonidine tartrate ophth soln 0.2% 1 brimonidine tartrate ophth soln 0.15% 1 (generic of ALPHAGAN P) SIMBRINZA SUS 1-0.2% 3 OPHTHALMIC ANTI-INFECTIVES AZASITE SOL 1% 3 bacitracin ophth oint 500 unit/gm 1 bacitracin-polymyxin b ophth oint 1 BESIVANCE SUS 0.6% 2 CILOXAN OIN 0.3% OP 3 ciprofloxacin hcl ophth soln 0.3% (base 1 equivalent) erythromycin ophth oint 5 mg/gm 1 gatifloxacin ophth soln 0.5% (generic of 3 ZYMAXID) gentak oin 0.3% op 1 gentamicin sulfate ophth soln 0.3% 1 levofloxacin ophth soln 0.5% 1 moxifloxacin hcl ophth soln 0.5% (base 2 equiv) (generic of VIGAMOX) neomycin-bacitrac zn-polymyx 5(3.5)mg- 1 400unt-10000unt op oin neomycin-polymy-gramicid op sol 1.75- 1 10000-0.025mg-unt-mg/ml ofloxacin ophth soln 0.3% (generic of 1 OCUFLOX) polymyxin b-trimethoprim ophth soln 1 10000 unit/ml-0.1% (generic of POLYTRIM)

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 141 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits sulfacetamide sodium ophth soln 10% 1 (generic of BLEPH-10) tobramycin ophth soln 0.3% (generic of 1 TOBREX) TOBREX OIN 0.3% OP 3 trifluridine ophth soln 1% 1 ZIRGAN GEL 0.15% 3 OPHTHALMIC DECONGESTANTS naphazoline hcl ophth soln 0.1% 1 OPHTHALMIC IMMUNOMODULATORS RESTASIS EMU 0.05% 2 OPHTHALMIC INTEGRIN ANTAGONISTS XIIDRA DRO 5% 2 OPHTHALMIC KINASE INHIBITORS RHOPRESSA SOL 0.02% 3 ROCKLATAN DRO 3 OPHTHALMIC LOCAL ANESTHETICS tetcaine sol 0.5% op 1 OPHTHALMIC STEROIDS ALREX SUS 0.2% 2 bacitracin-polymyxin-neomycin-hc ophth 1 oint 1% BLEPHAMIDE OIN S.O.P. 3 BLEPHAMIDE SUS OP 3 dexamethasone sodium phosphate ophth 1 soln 0.1% DUREZOL EMU 0.05% 2 FLAREX SUS 0.1% OP 3 fluorometholone ophth susp 0.1% 1 FML FORTE SUS 0.25% OP 3 FML OIN 0.1% OP 3 LOTEMAX OIN 0.5% 2 LOTEMAX SM GEL 0.38% 2 loteprednol etabonate ophth gel 0.5% 2 (generic of LOTEMAX) loteprednol etabonate ophth susp 0.5% 2 (generic of LOTEMAX) neomycin-polymyxin-dexamethasone 1 ophth oint 0.1% (generic of MAXITROL) neomycin-polymyxin-dexamethasone 1 ophth susp 0.1% (generic of MAXITROL)

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 142 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits neomycin-polymyxin-hc ophth susp 1 PRED MILD SUS 0.12% OP 3 PRED SOD PHO SOL 1% OP 3 PRED-G S.O.P OIN OP 3 PRED-G SUS OP 3 prednisolone acetate ophth susp 1% 1 (generic of PRED FORTE) sulfacetamide sodium-prednisolone ophth 1 soln 10-0.23(0.25)% TOBRADEX OIN 0.3-0.1% 3 tobramycin-dexamethasone ophth susp 1 0.3-0.1% (generic of TOBRADEX) ZYLET SUS 0.5-0.3% 2 OPHTHALMICS - MISC. ACUVAIL SOL 0.45% 3 ALOCRIL SOL 2% 3 ALOMIDE SOL 0.1% OP 3 azelastine hcl ophth soln 0.05% 1 BEPREVE DRO 1.5% 3 brinzolamide ophth susp 1% (generic of 2 AZOPT) bromfenac sodium ophth soln 0.09% (base 2 equiv) (once-daily) bromfenac sodium ophth soln 0.09% (base 2 equivalent) cromolyn sodium ophth soln 4% 1 PD diclofenac sodium ophth soln 0.1% 1 dorzolamide hcl ophth soln 2% (generic of 1 TRUSOPT) epinastine hcl ophth soln 0.05% 2 flurbiprofen sodium ophth soln 0.03% 1 ILEVRO DRO 0.3% OP 3 ketorolac tromethamine ophth soln 0.4% 1 (generic of ACULAR LS) ketorolac tromethamine ophth soln 0.5% 1 (generic of ACULAR) NEVANAC SUS 0.1% 3 olopatadine hcl ophth soln 0.1% (base 2 equivalent) olopatadine hcl ophth soln 0.2% (base 3 equivalent) PROLENSA SOL 0.07% 3

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 143 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits PROSTAGLANDINS - OPHTHALMIC bimatoprost ophth soln 0.03% 2 latanoprost ophth soln 0.005% (generic of 1 XALATAN) LUMIGAN SOL 0.01% 2 travoprost ophth soln 0.004% 1 travoprost ophth soln 0.004% 2 (benzalkonium free) (bak free) (generic of TRAVATAN Z) VYZULTA SOL 0.024% 3 ZIOPTAN DRO 0.0015% 3 OTIC AGENTS OTIC AGENTS - MISCELLANEOUS acetic acid 2% in aluminum acetate otic 1 soln acetic acid otic soln 2% 1 OTIC ANTI-INFECTIVES ciprofloxacin hcl otic soln 0.2% (base 3 equivalent) ofloxacin otic soln 0.3% 3 OTIC COMBINATIONS CIPRO HC SUS OTIC 3 CIPRODEX SUS 0.3-0.1% 2 ciprofloxacin-dexamethasone otic susp 0.3- 2 0.1% (generic of CIPRODEX) CORTISPORIN SUS -TC OTIC 3 cyotic dro 1 neomycin-polymyxin-hc otic soln 1% 1 neomycin-polymyxin-hc otic susp 3.5 1 mg/ml-10000 unit/ml-1% OTIC STEROIDS acetasol hc sol otic 1 fluocinolone acetonide (otic) oil 0.01% 1 (generic of DERMOTIC) OXYTOCICS OXYTOCICS methylergonovine maleate inj 0.2 mg/ml 2 methylergonovine maleate tab 0.2 mg 2 PENICILLINS AMINOPENICILLINS amoxicillin (trihydrate) cap 250 mg 1

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 144 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits amoxicillin (trihydrate) cap 500 mg 1 amoxicillin (trihydrate) chew tab 125 mg 2 amoxicillin (trihydrate) chew tab 250 mg 1 amoxicillin (trihydrate) for susp 125 1 mg/5ml amoxicillin (trihydrate) for susp 200 1 mg/5ml amoxicillin (trihydrate) for susp 250 1 mg/5ml amoxicillin (trihydrate) for susp 400 1 mg/5ml amoxicillin (trihydrate) tab 500 mg 1 amoxicillin (trihydrate) tab 875 mg 1 amoxicillin (trihydrate) tab er 24hr 775 mg 3 ampicillin cap 250 mg 1 ampicillin cap 500 mg 1 ampicillin for susp 125 mg/5ml 1 ampicillin for susp 250 mg/5ml 1 NATURAL PENICILLINS 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 PENICILLIN COMBINATIONS amoxicillin & k clavulanate chew tab 200- 1 28.5 mg amoxicillin & k clavulanate chew tab 400- 1 57 mg amoxicillin & k clavulanate for susp 200- 1 28.5 mg/5ml amoxicillin & k clavulanate for susp 250- 1 62.5 mg/5ml (generic of AUGMENTIN) amoxicillin & k clavulanate for susp 400-57 1 mg/5ml amoxicillin & k clavulanate for susp 600- 1 42.9 mg/5ml amoxicillin & k clavulanate tab 250-125 mg 1 amoxicillin & k clavulanate tab 500-125 mg 1 amoxicillin & k clavulanate tab 875-125 mg 1 amoxicillin & k clavulanate tab er 12hr 1 1000-62.5 mg AUGMENTIN SUS 125/5ML 3

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 145 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits PENICILLINASE-RESISTANT PENICILLINS dicloxacillin sodium cap 250 mg 1 dicloxacillin sodium cap 500 mg 1 PROGESTINS PROGESTINS MAKENA INJ 250MG/ML 2 PA MAKENA INJ 275MG 2 PA medroxyprogesterone acetate tab 2.5 mg 1 (generic of PROVERA) medroxyprogesterone acetate tab 5 mg 1 (generic of PROVERA) medroxyprogesterone acetate tab 10 mg 1 (generic of PROVERA) megestrol acetate susp 625 mg/5ml 2 norethindrone acetate tab 5 mg (generic of 1 AYGESTIN) progesterone cap 100 mg (generic of 1 PROMETRIUM) progesterone cap 200 mg (generic of 1 PROMETRIUM) PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. AGENTS FOR CHEMICAL DEPENDENCY acamprosate calcium tab delayed release 2 333 mg disulfiram tab 250 mg 2 disulfiram tab 500 mg 2 ANTI-CATAPLECTIC AGENTS XYREM SOL 500MG/ML 3 PA ANTIDEMENTIA AGENTS donepezil hydrochloride orally 1 disintegrating tab 5 mg donepezil hydrochloride orally 1 disintegrating tab 10 mg donepezil hydrochloride tab 5 mg (generic 1 of ARICEPT) donepezil hydrochloride tab 10 mg (generic 1 of ARICEPT) donepezil hydrochloride tab 23 mg (generic 3 of ARICEPT) galantamine hydrobromide cap er 24hr 8 1 mg (generic of RAZADYNE ER)

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 146 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits galantamine hydrobromide cap er 24hr 16 1 mg (generic of RAZADYNE ER) galantamine hydrobromide cap er 24hr 24 1 mg (generic of RAZADYNE ER) galantamine hydrobromide oral soln 4 1 mg/ml galantamine hydrobromide tab 4 mg 1 galantamine hydrobromide tab 8 mg 1 galantamine hydrobromide tab 12 mg 1 memantine hcl cap er 24hr 7 mg (generic 2 of NAMENDA XR) memantine hcl cap er 24hr 14 mg (generic 2 of NAMENDA XR) memantine hcl cap er 24hr 21 mg (generic 2 of NAMENDA XR) memantine hcl cap er 24hr 28 mg (generic 2 of NAMENDA XR) memantine hcl oral solution 2 mg/ml 2 memantine hcl tab 5 mg (generic of 2 NAMENDA) memantine hcl tab 10 mg (generic of 2 NAMENDA) memantine hcl tab 28 x 5 mg & 21 x 10 2 mg titration pack (generic of NAMENDA TITRATION PAK) NAMENDA XR CAP TITRATIO 2 rivastigmine tartrate cap 1.5 mg (base 1 equivalent) rivastigmine tartrate cap 3 mg (base 1 equivalent) rivastigmine tartrate cap 4.5 mg (base 1 equivalent) rivastigmine tartrate cap 6 mg (base 1 equivalent) rivastigmine td patch 24hr 4.6 mg/24hr 2 (generic of EXELON) rivastigmine td patch 24hr 9.5 mg/24hr 2 (generic of EXELON) rivastigmine td patch 24hr 13.3 mg/24hr 2 (generic of EXELON) COMBINATION PSYCHOTHERAPEUTICS chlordiazepoxide-amitriptyline tab 5-12.5 1 mg

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 147 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits chlordiazepoxide-amitriptyline tab 10-25 1 mg perphenazine-amitriptyline tab 2-10 mg 1 perphenazine-amitriptyline tab 2-25 mg 1 perphenazine-amitriptyline tab 4-10 mg 1 perphenazine-amitriptyline tab 4-25 mg 1 perphenazine-amitriptyline tab 4-50 mg 1 FIBROMYALGIA AGENTS SAVELLA MIS TITR PAK 2 SAVELLA TAB 12.5MG 2 SAVELLA TAB 25MG 2 SAVELLA TAB 50MG 2 SAVELLA TAB 100MG 2 MOVEMENT DISORDER DRUG THERAPY AUSTEDO TAB 6MG 3 PA; SPC AUSTEDO TAB 9MG 3 PA; SPC AUSTEDO TAB 12MG 3 PA; SPC INGREZZA CAP 40-80MG 3 PA; SP INGREZZA CAP 40MG 3 PA; SP INGREZZA CAP 60MG 3 PA; SP INGREZZA CAP 80MG 3 PA; SP tetrabenazine tab 12.5 mg (generic of 3 PA; SPC XENAZINE) tetrabenazine tab 25 mg (generic of 3 PA; SPC XENAZINE) MULTIPLE SCLEROSIS AGENTS AUBAGIO TAB 7MG 2 PA; SPC AUBAGIO TAB 14MG 2 PA; SPC AVONEX KIT 30MCG 3 PA; SPC AVONEX PEN KIT 30MCG 3 PA; SPC AVONEX PREFL KIT 30MCG 3 PA; SPC BAFIERTAM CAP 95MG 2 PA; SPC BETASERON INJ 0.3MG 2 PA; SPC COPAXONE INJ 20MG/ML 2 PA; SPC COPAXONE INJ 40MG/ML 2 PA; SPC dalfampridine tab er 12hr 10 mg (generic 3 PA; SPC of AMPYRA) dimethyl fumarate capsule delayed release 2 PA; SPC 120 mg (generic of TECFIDERA) dimethyl fumarate capsule delayed release 2 PA; SPC 240 mg (generic of TECFIDERA)

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 148 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits dimethyl fumarate capsule dr starter pack 2 PA; SPC 120 mg & 240 mg (generic of TECFIDERA STARTER PACK) GILENYA CAP 0.5MG 2 PA; SPC KESIMPTA INJ 20/.4ML 3 PA; SPC MAVENCLAD PAK 10MG (4) 3 PA; RxC/M, SPC MAVENCLAD PAK 10MG (5) 3 PA; RxC/M, SPC MAVENCLAD PAK 10MG (6) 3 PA; RxC/M, SPC MAVENCLAD PAK 10MG (7) 3 PA; RxC/M, SPC MAVENCLAD PAK 10MG (8) 3 PA; RxC/M, SPC MAVENCLAD PAK 10MG (9) 3 PA; RxC/M, SPC MAVENCLAD PAK 10MG(10) 3 PA; RxC/M, SPC MAYZENT TAB 0.25MG 2 PA; RxC/M, SPC MAYZENT TAB 2MG 2 PA; RxC/M, SPC REBIF INJ 22/0.5 2 PA; SPC REBIF INJ 44/0.5 2 PA; SPC REBIF REBIDO INJ 22/0.5 2 PA; SPC REBIF REBIDO INJ 44/0.5 2 PA; SPC REBIF REBIDO INJ TITRATN 2 PA; SPC REBIF TITRTN INJ PACK 2 PA; SPC VUMERITY CAP 231MG 2 PA; SPC ZEPOSIA 7DAY CAP STR PACK 2 PA; SPC ZEPOSIA CAP .92MG 2 PA; SPC ZEPOSIA CAP STR KIT 2 PA; SPC PREMENSTRUAL DYSPHORIC DISORDER (PMDD) AGENTS fluoxetine hcl (pmdd) tab 10 mg 3 fluoxetine hcl (pmdd) tab 20 mg 3 PSEUDOBULBAR AFFECT (PBA) AGENTS NUEDEXTA CAP 20-10MG 3 PA PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. pimozide tab 1 mg 3 pimozide tab 2 mg 3 SMOKING DETERRENTS bupropion hcl (smoking deterrent) tab er 1 ACA; PD 12hr 150 mg CHANTIX PAK 0.5& 1MG 3 ACA; PD CHANTIX PAK 1MG 3 ACA; PD CHANTIX TAB 0.5MG 3 ACA; PD nicotine polacrilex gum 2 mg 1 OTC; PD; ACA nicotine polacrilex gum 4 mg 1 OTC; PD; ACA nicotine polacrilex lozenge 2 mg 1 OTC; PD; ACA

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 149 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits nicotine polacrilex lozenge 4 mg 1 OTC; PD; ACA NICOTINE SYS KIT TRANSDER 1 OTC; PD; ACA nicotine td dis 21mg/24h 1 OTC; PD; ACA nicotine td patch 24hr 7 mg/24hr 1 OTC; PD; ACA nicotine td patch 24hr 14 mg/24hr 1 OTC; PD; ACA NICOTROL INH 3 PA; PD; ACA NICOTROL NS SPR 10MG/ML 3 PA; PD, ACA RESPIRATORY AGENTS - MISC. CYSTIC FIBROSIS AGENTS KALYDECO PAK 25MG 3 PA; SP KALYDECO PAK 50MG 3 PA; SP KALYDECO PAK 75MG 3 PA; SP KALYDECO TAB 150MG 3 PA; SP ORKAMBI GRA 100-125 3 PA ORKAMBI GRA 150-188 3 PA ORKAMBI TAB 100-125 3 PA ORKAMBI TAB 200-125 3 PA; SP PULMOZYME SOL 1MG/ML 2 SPC SYMDEKO TAB 50-75MG 3 PA SYMDEKO TAB 100-150 3 PA TRIKAFTA TAB 3 PA; SP PULMONARY FIBROSIS AGENTS ESBRIET CAP 267MG 3 PA; SPC ESBRIET TAB 267MG 3 PA; SPC ESBRIET TAB 801MG 3 PA; SPC OFEV CAP 100MG 3 PA; SPC OFEV CAP 150MG 3 PA; SPC SULFONAMIDES SULFONAMIDES SULFADIAZINE TAB 500MG 3 TETRACYCLINES TETRACYCLINES demeclocycline hcl tab 150 mg 1 demeclocycline hcl tab 300 mg 1 doxycycline hyclate cap 50 mg 1 doxycycline hyclate cap 100 mg (generic of 1 VIBRAMYCIN) doxycycline hyclate tab 100 mg 1 doxycycline hyclate tab delayed release 50 3 ST mg (generic of DORYX)

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 150 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits doxycycline hyclate tab delayed release 75 3 ST mg doxycycline hyclate tab delayed release 3 ST 100 mg doxycycline hyclate tab delayed release 3 ST 150 mg doxycycline hyclate tab delayed release 3 ST 200 mg (generic of DORYX) doxycycline monohydrate cap 50 mg 1 doxycycline monohydrate cap 75 mg 1 doxycycline monohydrate cap 100 mg 1 doxycycline monohydrate cap 150 mg 1 doxycycline monohydrate for susp 25 3 mg/5ml (generic of VIBRAMYCIN) doxycycline monohydrate tab 50 mg 1 doxycycline monohydrate tab 75 mg 1 doxycycline monohydrate tab 100 mg 1 doxycycline monohydrate tab 150 mg 1 minocycline hcl cap 50 mg 1 minocycline hcl cap 75 mg 1 minocycline hcl cap 100 mg (generic of 1 MINOCIN) minocycline hcl tab 50 mg 1 minocycline hcl tab 75 mg 1 minocycline hcl tab 100 mg 1 minocycline hcl tab er 24hr 45 mg 1 PA minocycline hcl tab er 24hr 55 mg (generic 3 PA of SOLODYN) minocycline hcl tab er 24hr 65 mg (generic 3 PA of SOLODYN) minocycline hcl tab er 24hr 80 mg (generic 3 PA of SOLODYN) minocycline hcl tab er 24hr 90 mg 1 PA minocycline hcl tab er 24hr 105 mg 3 PA (generic of SOLODYN) minocycline hcl tab er 24hr 115 mg 3 PA (generic of SOLODYN) minocycline hcl tab er 24hr 135 mg 1 PA tetracycline hcl cap 250 mg 1 tetracycline hcl cap 500 mg 1 VIBRAMYCIN SYP 50MG/5ML 2

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 151 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits THYROID AGENTS ANTITHYROID AGENTS methimazole tab 5 mg (generic of 1 TAPAZOLE) methimazole tab 10 mg (generic of 1 TAPAZOLE) propylthiouracil tab 50 mg 1 TAPAZOLE TAB 5MG 2 TAPAZOLE TAB 10MG 2 THYROID HORMONES ARMOUR THYRO TAB 15MG 1 ARMOUR THYRO TAB 30MG 1 ARMOUR THYRO TAB 60MG 1 ARMOUR THYRO TAB 90MG 1 ARMOUR THYRO TAB 120MG 1 ARMOUR THYRO TAB 180MG 1 ARMOUR THYRO TAB 240MG 1 ARMOUR THYRO TAB 300MG 1 CYTOMEL TAB 5MCG 3 CYTOMEL TAB 25MCG 3 CYTOMEL TAB 50MCG 3 levothyroxine sodium cap 13 mcg 3 levothyroxine sodium cap 25 mcg 3 levothyroxine sodium cap 50 mcg 3 levothyroxine sodium cap 75 mcg (generic 3 of TIROSINT) levothyroxine sodium cap 88 mcg 3 levothyroxine sodium cap 100 mcg 3 levothyroxine sodium cap 112 mcg 3 levothyroxine sodium cap 125 mcg 3 levothyroxine sodium cap 137 mcg 3 levothyroxine sodium cap 150 mcg 3 (generic of TIROSINT) levothyroxine sodium cap 175 mcg 3 levothyroxine sodium cap 200 mcg 3 levothyroxine sodium tab 25 mcg (generic 1 of SYNTHROID) levothyroxine sodium tab 50 mcg (generic 1 of SYNTHROID) levothyroxine sodium tab 75 mcg (generic 1 of SYNTHROID)

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 152 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits levothyroxine sodium tab 88 mcg (generic 1 of SYNTHROID) levothyroxine sodium tab 100 mcg (generic 1 of SYNTHROID) levothyroxine sodium tab 112 mcg (generic 1 of SYNTHROID) levothyroxine sodium tab 125 mcg (generic 1 of SYNTHROID) levothyroxine sodium tab 137 mcg (generic 1 of SYNTHROID) levothyroxine sodium tab 150 mcg (generic 1 of SYNTHROID) levothyroxine sodium tab 175 mcg (generic 1 of SYNTHROID) levothyroxine sodium tab 200 mcg (generic 1 of SYNTHROID) levothyroxine sodium tab 300 mcg (generic 1 of SYNTHROID) levoxyl tab 25mcg (generic of SYNTHROID) 1 levoxyl tab 50mcg (generic of SYNTHROID) 1 levoxyl tab 75mcg (generic of SYNTHROID) 1 levoxyl tab 88mcg (generic of SYNTHROID) 1 levoxyl tab 100mcg (generic of 1 SYNTHROID) levoxyl tab 112mcg (generic of 1 SYNTHROID) levoxyl tab 125mcg (generic of 1 SYNTHROID) levoxyl tab 137mcg (generic of 1 SYNTHROID) levoxyl tab 150mcg (generic of 1 SYNTHROID) levoxyl tab 175mcg (generic of 1 SYNTHROID) levoxyl tab 200mcg (generic of 1 SYNTHROID) liothyronine sodium tab 5 mcg (generic of 1 CYTOMEL) liothyronine sodium tab 25 mcg (generic of 1 CYTOMEL) liothyronine sodium tab 50 mcg (generic of 1 CYTOMEL) NATURE THROI TAB 162.5MG 1

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 153 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits NATURE-THROI TAB 16.25MG 1 NATURE-THROI TAB 32.5MG 1 NATURE-THROI TAB 48.75MG 1 NATURE-THROI TAB 65MG 1 NATURE-THROI TAB 81.25MG 1 NATURE-THROI TAB 97.5MG 1 NATURE-THROI TAB 113.75MG 1 NATURE-THROI TAB 130MG 1 NATURE-THROI TAB 146.25MG 1 NATURE-THROI TAB 195MG 1 NATURE-THROI TAB 260MG 1 NATURE-THROI TAB 325MG 1 np thyroid tab 15mg 1 np thyroid tab 30mg 1 np thyroid tab 60mg 1 np thyroid tab 90mg 1 np thyroid tab 120mg 1 SYNTHROID TAB 25MCG 2 SYNTHROID TAB 50MCG 2 SYNTHROID TAB 75MCG 2 SYNTHROID TAB 88MCG 2 SYNTHROID TAB 100MCG 2 SYNTHROID TAB 112MCG 2 SYNTHROID TAB 125MCG 2 SYNTHROID TAB 137MCG 2 SYNTHROID TAB 150MCG 2 SYNTHROID TAB 175MCG 2 SYNTHROID TAB 200MCG 2 SYNTHROID TAB 300MCG 2 TIROSINT CAP 13MCG 3 TIROSINT CAP 25MCG 3 TIROSINT CAP 50MCG 3 TIROSINT CAP 75MCG 3 TIROSINT CAP 88MCG 3 TIROSINT CAP 100MCG 3 TIROSINT CAP 112MCG 3 TIROSINT CAP 125MCG 3 TIROSINT CAP 137MCG 3 TIROSINT CAP 150MCG 3 TIROSINT CAP 175MCG 3 TIROSINT CAP 200 3

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 154 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits unithroid tab 25mcg (generic of 1 SYNTHROID) unithroid tab 50mcg (generic of 1 SYNTHROID) unithroid tab 75mcg (generic of 1 SYNTHROID) unithroid tab 88mcg (generic of 1 SYNTHROID) unithroid tab 100mcg (generic of 1 SYNTHROID) unithroid tab 112mcg (generic of 1 SYNTHROID) unithroid tab 125mcg (generic of 1 SYNTHROID) unithroid tab 150mcg (generic of 1 SYNTHROID) unithroid tab 175mcg (generic of 1 SYNTHROID) unithroid tab 200mcg (generic of 1 SYNTHROID) unithroid tab 300mcg (generic of 1 SYNTHROID) ULCER DRUGS ANTISPASMODICS BELLA/OPIUM SUP 16.2-30 1 BELLA/OPIUM SUP 16.2-60 1 chlordiazepoxide hcl-clidinium bromide cap 1 5-2.5 mg CUVPOSA SOL 1MG/5ML 3 PA dicyclomine hcl cap 10 mg 1 dicyclomine hcl oral soln 10 mg/5ml 1 dicyclomine hcl tab 20 mg 1 glycopyrrolate tab 1 mg 1 glycopyrrolate tab 2 mg 1 hyoscyamine sulfate elixir 0.125 mg/5ml 1 hyoscyamine sulfate sl tab 0.125 mg 1 hyoscyamine sulfate soln 0.125 mg/ml 1 hyoscyamine sulfate tab 0.125 mg 1 hyoscyamine sulfate tab disint 0.125 mg 1 hyoscyamine sulfate tab er 12hr 0.375 mg 1 methscopolamine bromide tab 2.5 mg 1 methscopolamine bromide tab 5 mg 1

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 155 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits propantheline bromide tab 15 mg 1 H-2 ANTAGONISTS cimetidine hcl soln 300 mg/5ml 1 cimetidine tab 200 mg 3 cimetidine tab 300 mg 3 cimetidine tab 400 mg 3 cimetidine tab 800 mg 3 famotidine for susp 40 mg/5ml 3 famotidine tab 20 mg (generic of PEPCID) 3 famotidine tab 40 mg (generic of PEPCID) 3 nizatidine cap 150 mg 3 nizatidine cap 300 mg 3 nizatidine oral soln 15 mg/ml 1 ranitidine hcl cap 150 mg 3 ranitidine hcl cap 300 mg 3 ranitidine hcl syrup 15 mg/ml (75 mg/5ml) 3 ranitidine hcl tab 150 mg 3 ranitidine hcl tab 300 mg 3 MISC. ANTI-ULCER sucralfate susp 1 gm/10ml (generic of 2 CARAFATE) sucralfate tab 1 gm (generic of CARAFATE) 1 PROTON PUMP INHIBITORS esomeprazole magnesium cap delayed 3 release 40 mg (base eq) (generic of NEXIUM) lansoprazole cap delayed release 15 mg 3 (generic of PREVACID) lansoprazole cap delayed release 30 mg 3 (generic of PREVACID) LANSOPRAZOLE SUS 3MG/ML 2 *Covered for children 5 years of age or less lansoprazole tab delayed release orally 2 disintegrating 15 mg (generic of PREVACID SOLUTAB) lansoprazole tab delayed release orally 2 disintegrating 30 mg (generic of PREVACID SOLUTAB) OMEPRAZOLE + SUS SYRSPEND 2 *Covered for children 5 years of age or less omeprazole cap delayed release 10 mg 3 omeprazole cap delayed release 20 mg 3

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 156 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits omeprazole cap delayed release 40 mg 3 pantoprazole sodium ec tab 20 mg (base 3 equiv) (generic of PROTONIX) pantoprazole sodium ec tab 40 mg (base 3 equiv) (generic of PROTONIX) ULCER DRUGS - PROSTAGLANDINS misoprostol tab 100 mcg (generic of 1 CYTOTEC) misoprostol tab 200 mcg (generic of 1 CYTOTEC) ULCER THERAPY COMBINATIONS amoxicillin cap-clarithro tab-lansopraz cap 2 dr therapy pack OMECLAMOX- MIS PAK 3 PYLERA CAP 2 URINARY ANTI-INFECTIVES URINARY ANTI-INFECTIVE COMBINATIONS hyolev mb tab 81mg 3 uribel cap 118mg 3 URINARY ANTI-INFECTIVES methenamine hippurate tab 1 gm (generic 1 of HIPREX) methenamine mandelate tab 0.5 gm 1 methenamine mandelate tab 1 gm 1 nitrofurantoin macrocrystalline cap 25 mg 3 (generic of MACRODANTIN) nitrofurantoin macrocrystalline cap 50 mg 1 (generic of MACRODANTIN) nitrofurantoin macrocrystalline cap 100 mg 1 (generic of MACRODANTIN) nitrofurantoin monohydrate 1 macrocrystalline cap 100 mg (generic of MACROBID) nitrofurantoin susp 25 mg/5ml 2 URINARY ANTISPASMODICS URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC) darifenacin hydrobromide tab er 24hr 7.5 3 mg (base equiv) darifenacin hydrobromide tab er 24hr 15 3 mg (base equiv) (generic of ENABLEX) GELNIQUE GEL 3% 2

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 157 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits GELNIQUE GEL 10% 2 oxybutynin chloride syrup 5 mg/5ml 1 oxybutynin chloride tab 5 mg 1 oxybutynin chloride tab er 24hr 5 mg 1 (generic of DITROPAN XL) oxybutynin chloride tab er 24hr 10 mg 1 (generic of DITROPAN XL) oxybutynin chloride tab er 24hr 15 mg 1 solifenacin succinate tab 5 mg (generic of 2 VESICARE) solifenacin succinate tab 10 mg (generic of 2 VESICARE) tolterodine tartrate cap er 24hr 2 mg 2 (generic of DETROL LA) tolterodine tartrate cap er 24hr 4 mg 2 (generic of DETROL LA) tolterodine tartrate tab 1 mg (generic of 2 DETROL) tolterodine tartrate tab 2 mg (generic of 2 DETROL) trospium chloride cap er 24hr 60 mg 2 trospium chloride tab 20 mg 2 URINARY ANTISPASMODICS - BETA-3 ADRENERGIC AGONISTS MYRBETRIQ TAB 25MG 2 MYRBETRIQ TAB 50MG 2 URINARY ANTISPASMODICS - CHOLINERGIC AGONISTS bethanechol chloride tab 5 mg 1 bethanechol chloride tab 10 mg 1 bethanechol chloride tab 25 mg 1 bethanechol chloride tab 50 mg 1 VAGINAL PRODUCTS SPERMICIDES ENCARE SUP 100MG 2 OTC; ACA GYNOL II GEL 3% 2 OTC; ACA SHUR-SEAL GEL 2% 2 OTC; ACA TODAY SPONGE MIS 2 OTC; ACA VCF VAGINAL AER CONTRACP 2 OTC; ACA vcf vaginal gel contrace 2 OTC; ACA VCF VAGINAL MIS CONTRACP 2 OTC; ACA VAGINAL ANTI-INFECTIVES AVC CRE 15% 3

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 158 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits CLEOCIN SUP 100MG 2 clindamycin phosphate vaginal cream 2% 1 (generic of CLEOCIN) GYNAZOLE-1 CRE 2% 3 metronidazole vaginal gel 0.75% 1 miconazole 3 sup 200mg 1 terconazole vaginal cream 0.4% 1 terconazole vaginal cream 0.8% 1 terconazole vaginal suppos 80 mg 1 VAGINAL ESTROGENS estradiol vaginal cream 0.1 mg/gm 3 (generic of ESTRACE) ESTRING MIS 2MG 3 FEMRING MIS 0.1MG/24 3 FEMRING MIS 0.05/24H 3 PREMARIN VAG CRE 0.625MG 2 yuvafem tab 10mcg (generic of VAGIFEM) 2 VAGINAL PROGESTINS CRINONE GEL 4% VAG 2 PA; Coverage limited to 6 cycles, alone or in any combination, to achieve pregnancy. Infertility drugs resulting in a live birth, or an established pregnancy (fetal heart rate is detected) resulting in a miscarriage, will renew the six cycle limit; SPC CRINONE GEL 8% VAG 2 PA; Coverage limited to 6 cycles, alone or in any combination, to achieve pregnancy. Infertility drugs resulting in a live birth, or an established pregnancy (fetal heart rate is detected) resulting in a miscarriage, will renew the six cycle limit; SPC

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 159 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits ENDOMETRIN SUP 100MG 3 PA; Coverage limited to 6 cycles, alone or in any combination, to achieve pregnancy. Infertility drugs resulting in a live birth, or an established pregnancy (fetal heart rate is detected) resulting in a miscarriage, will renew the six cycle limit; SPC PROGESTERONE SUP VGS 100 3 PROGESTERONE SUP VGS 200 3 PROGESTERONE SUP VGS 400 3 VASOPRESSORS ANAPHYLAXIS THERAPY AGENTS epinephrine solution auto-injector 0.3 2 QL of 2 (age 19+) or 6 mg/0.3ml (1:1000) pens/syringes (age <19) per 365 days. epinephrine solution auto-injector 0.15 2 QL of 2 (age 19+) or 6 mg/0.3ml (1:2000) (generic of EPIPEN-JR pens/syringes (age 2-PAK) <19) per 365 days. epinephrine solution auto-injector 0.15 2 QL of 2 (age 19+) or 6 mg/0.15ml (1:1000) pens/syringes (age <19) per 365 days. EPIPEN 2-PAK INJ 0.3MG 2 QL of 2 (age 19+) or 6 pens/syringes (age <19) per 365 days. EPIPEN-JR INJ 0.15MG 2 QL of 2 (age 19+) or 6 pens/syringes (age <19) per 365 days. SYMJEPI INJ 0.3MG 2 QL of 2 (age 19+) or 6 pens/syringes (age <19) per 365 days. SYMJEPI INJ 0.15MG 2 QL of 2 (age 19+) or 6 pens/syringes (age <19) per 365 days. VASOPRESSORS midodrine hcl tab 2.5 mg 1 midodrine hcl tab 5 mg 1 midodrine hcl tab 10 mg 1

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 160 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Drug Name Drug Tier Requirements/Limits VITAMINS OIL SOLUBLE VITAMINS bio-d-mulsio liq 400unit 1 OTC; ACA cholecalciferol cap 10 mcg (400 unit) 1 OTC; ACA cholecalciferol oral liquid 10 mcg/ml (400 1 OTC; ACA unit/ml) ergocalciferol cap 1.25 mg (50000 unit) 1 (generic of DRISDOL) phytonadione tab 5 mg (generic of 2 MEPHYTON) vitamin d3 chw 400unit 1 OTC; ACA vitamin d3 tab 400unit 1 OTC; ACA WATER SOLUBLE VITAMINS POTABA CAP 500MG 3

ACA - Covered under the Affordable Care Act; no member cost share OTC - Over the 161 counter PA - Prior Authorization; refer to Prior Authorization section PD - Preventive Drug QL - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program SPC - Required to fill through CVS Specialty Pharmacy, toll-free at 1-800-237-2767 ST - Step Therapy; refer to Step Therapy section ^ - Covered under the medical benefit

Index 1 acebutolol hcl cap 400 mg ...... 80 1ML SYRINGE MIS 30G ...... 127 acetaminophen w/ codeine soln 120-12 3 mg/5ml ...... 18 3ML CARTRIDG MIS PLASTIC ...... 126 acetaminophen w/ codeine tab 300-15 A mg ...... 18 abacavir sulfate soln 20 mg/ml (base acetaminophen w/ codeine tab 300-30 equiv) ...... 75 mg ...... 18 abacavir sulfate tab 300 mg (base acetaminophen w/ codeine tab 300-60 equiv) ...... 75 mg ...... 18 abacavir sulfate-lamivudine tab 600- acetasol hc sol otic ...... 144 300 mg ...... 75 acetazolamide cap er 12hr 500 mg 105 abacavir sulfate-lamivudine-zidovudine acetazolamide tab 125 mg ...... 105 tab 300-150-300 mg ...... 75 acetazolamide tab 250 mg ...... 105 ABILIFY ACETEST TAB TABLETS ...... 104 see aripiprazole tab 10 mg ...... 74 acetic acid 2% in aluminum acetate see aripiprazole tab 15 mg ...... 75 otic soln ...... 144 see aripiprazole tab 2 mg ...... 74 acetic acid otic soln 2% ...... 144 see aripiprazole tab 20 mg ...... 75 acetylcysteine cap 600 mg ...... 139 see aripiprazole tab 30 mg ...... 75 acetylcysteine inhal soln 10% ...... 94 see aripiprazole tab 5 mg ...... 74 acetylcysteine inhal soln 20% ...... 94 abiraterone acetate tab 250 mg ...... 62 acitretin cap 10 mg ...... 98 abiraterone acetate tab 500 mg ...... 62 acitretin cap 17.5 mg ...... 98 acamprosate calcium tab delayed acitretin cap 25 mg ...... 98 release 333 mg ...... 146 ACTEMRA INJ 162/0.9 ...... 13 ACANYA ACTEMRA INJ ACTPEN ...... 13 see clindamycin phosphate-benzoyl ACTHAR INJ 80UNIT ...... 108 peroxide gel 1.2-2.5% ...... 95 ACTIQ acarbose tab 100 mg ...... 43 see fentanyl citrate lozenge on a acarbose tab 25 mg ...... 42 handle 1200 mcg ...... 16 acarbose tab 50 mg ...... 42 see fentanyl citrate lozenge on a ACCOLATE handle 1600 mcg ...... 16 see zafirlukast tab 10 mg ...... 26 see fentanyl citrate lozenge on a see zafirlukast tab 20 mg ...... 26 handle 200 mcg ...... 16 ACCUPRIL see fentanyl citrate lozenge on a see quinapril hcl tab 10 mg ...... 53 handle 400 mcg ...... 16 see quinapril hcl tab 20 mg ...... 53 see fentanyl citrate lozenge on a see quinapril hcl tab 40 mg ...... 53 handle 600 mcg ...... 16 see quinapril hcl tab 5 mg ...... 53 see fentanyl citrate lozenge on a ACCURETIC handle 800 mcg ...... 16 see quinapril-hydrochlorothiazide tab ACTIVE OB CAP ...... 134 10-12.5 mg ...... 58 ACTIVELLA see quinapril-hydrochlorothiazide tab see estradiol & norethindrone acetate 20-12.5 mg ...... 58 tab 1-0.5 mg ...... 114 see quinapril-hydrochlorothiazide tab ACTONEL 20-25 mg ...... 58 see risedronate sodium tab 150 mg acebutolol hcl cap 200 mg ...... 80 ...... 108 162

see risedronate sodium tab 35 mg see amphetamine- ...... 108 dextroamphetamine tab 30 mg .... 8 ACTOPLUS MET see amphetamine- see pioglitazone hcl-metformin hcl dextroamphetamine tab 5 mg ...... 8 tab 15-500 mg ...... 43 see amphetamine- see pioglitazone hcl-metformin hcl dextroamphetamine tab 7.5 mg ... 8 tab 15-850 mg ...... 43 ADDERALL XR ACTOPLUS MET TAB XR ...... 43 see amphetamine- ACTOS dextroamphetamine cap er 24hr 10 see pioglitazone hcl tab 15 mg (base mg ...... 8 equiv) ...... 45 see amphetamine- see pioglitazone hcl tab 30 mg (base dextroamphetamine cap er 24hr 15 equiv) ...... 45 mg ...... 8 see pioglitazone hcl tab 45 mg (base see amphetamine- equiv) ...... 45 dextroamphetamine cap er 24hr 20 ACULAR mg ...... 8 see ketorolac tromethamine ophth see amphetamine- soln 0.5% ...... 143 dextroamphetamine cap er 24hr 25 ACULAR LS mg ...... 8 see ketorolac tromethamine ophth see amphetamine- soln 0.4% ...... 143 dextroamphetamine cap er 24hr 30 ACUVAIL SOL 0.45% ...... 143 mg ...... 8 acyclovir cap 200 mg ...... 79 see amphetamine- acyclovir cream 5% ...... 99 dextroamphetamine cap er 24hr 5 acyclovir oint 5% ...... 99 mg ...... 8 acyclovir susp 200 mg/5ml ...... 79 ADD-INS PAK COMPLETE ...... 140 acyclovir tab 400 mg ...... 79 adefovir dipivoxil tab 10 mg ...... 79 acyclovir tab 800 mg ...... 79 ADEMPAS TAB 0.5MG ...... 87 ACZONE ADEMPAS TAB 1.5MG ...... 87 see dapsone gel 5% ...... 95 ADEMPAS TAB 1MG ...... 87 adapalene cream 0.1% ...... 94 ADEMPAS TAB 2.5MG ...... 87 adapalene gel 0.1% ...... 94 ADEMPAS TAB 2MG ...... 88 adapalene gel 0.3% ...... 94 ADIPEX-P adapalene lotion 0.1% ...... 94 see phentermine hcl cap 37.5 mg .... 9 adapalene-benzoyl peroxide gel 0.1- see phentermine hcl tab 37.5 mg .... 9 2.5% ...... 94 ADVAIR DISKU AER 100/50 ...... 27 ADCIRCA ADVAIR DISKU AER 250/50 ...... 27 see tadalafil tab 20 mg (pah) ...... 87 ADVAIR DISKU AER 500/50 ...... 27 ADDERALL ADVAIR DISKUS see amphetamine- see fluticasone-salmeterol aer dextroamphetamine tab 10 mg ... 8 powder ba 100-50 mcg/dose ..... 29 see amphetamine- see fluticasone-salmeterol aer dextroamphetamine tab 12.5 mg . 8 powder ba 250-50 mcg/dose ..... 29 see amphetamine- see fluticasone-salmeterol aer dextroamphetamine tab 15 mg ... 8 powder ba 500-50 mcg/dose ..... 29 see amphetamine- see wixela inhub aer 100/50 ...... 29 dextroamphetamine tab 20 mg ... 8 see wixela inhub aer 250/50 ...... 29 163

see wixela inhub aer 500/50 ...... 30 ALDACTONE ADVAIR HFA AER 115/21 ...... 28 see spironolactone tab 100 mg ... 106 ADVAIR HFA AER 230/21 ...... 28 see spironolactone tab 25 mg ..... 106 ADVAIR HFA AER 45/21 ...... 28 see spironolactone tab 50 mg ..... 106 AERCHMBR Z- MIS STAT PLS ...... 127 ALDARA AEROCHAMBER KIT ACTION ...... 127 see imiquimod cream 5% ...... 103 AFINITOR ALECENSA CAP 150MG ...... 63 see everolimus tab 2.5 mg ...... 64 alendronate sodium oral soln 70 see everolimus tab 5 mg ...... 64 mg/75ml ...... 107 see everolimus tab 7.5 mg ...... 64 alendronate sodium tab 10 mg ...... 107 AFINITOR DIS TAB 2MG ...... 63 alendronate sodium tab 35 mg ...... 107 AFINITOR DIS TAB 3MG ...... 63 alendronate sodium tab 40 mg ...... 107 AFINITOR DIS TAB 5MG ...... 63 alendronate sodium tab 5 mg ...... 107 AFINITOR TAB 10MG ...... 63 alendronate sodium tab 70 mg ...... 107 AGRYLIN alfuzosin hcl tab er 24hr 10 mg ..... 119 see anagrelide hcl cap 0.5 mg ..... 120 ALINIA AIMOVIG INJ 140MG/ML ...... 128 see nitazoxanide tab 500 mg ...... 22 AIMOVIG INJ 70MG/ML ...... 128 ALINIA SUS 100/5ML ...... 22 AJOVY INJ 225/1.5 ...... 128 aliskiren fumarate tab 150 mg (base albendazole tab 200 mg ...... 21 equivalent) ...... 59 ALBENZA aliskiren fumarate tab 300 mg (base see albendazole tab 200 mg ...... 21 equivalent) ...... 59 albuterol sulfate inhal aero 108 ALKERAN mcg/act (90mcg base equiv) ...... 28 see melphalan tab 2 mg ...... 61 albuterol sulfate soln nebu 0.083% ALKERAN TAB 2MG ...... 60 (2.5 mg/3ml) ...... 28 allopurinol tab 100 mg ...... 119 albuterol sulfate soln nebu 0.5% (5 allopurinol tab 300 mg ...... 119 mg/ml) ...... 28 almotriptan malate tab 12.5 mg .... 128 albuterol sulfate soln nebu 0.63 almotriptan malate tab 6.25 mg .... 128 mg/3ml (base equiv) ...... 28 ALOCRIL SOL 2% ...... 143 albuterol sulfate soln nebu 1.25 ALOMIDE SOL 0.1% OP ...... 143 mg/3ml (base equiv) ...... 28 ALORA DIS 0.025MG ...... 114 albuterol sulfate syrup 2 mg/5ml ..... 28 ALORA DIS 0.05MG ...... 114 albuterol sulfate tab 2 mg ...... 28 ALORA DIS 0.075MG ...... 114 albuterol sulfate tab 4 mg ...... 28 ALORA DIS 0.1MG ...... 114 albuterol sulfate tab er 12hr 4 mg .... 28 alosetron hcl tab 0.5 mg (base equiv) albuterol sulfate tab er 12hr 8 mg .... 28 ...... 118 alclometasone dipropionate cream alosetron hcl tab 1 mg (base equiv) 118 0.05% ...... 99 ALPHAGAN P alclometasone dipropionate oint 0.05% see brimonidine tartrate ophth soln ...... 99 0.15% ...... 141 ALCOHOL SWAB PAD ...... 126 ALPHAGAN P SOL 0.1% ...... 141 ALDACTAZIDE ALPRAZOLAM CON 1 MG/ML ...... 24 see spironolactone & alprazolam orally disintegrating tab hydrochlorothiazide tab 25-25 mg 0.25 mg ...... 24 ...... 106 alprazolam orally disintegrating tab 0.5 ALDACTAZIDE TAB 50/50 ...... 106 mg ...... 24 164 alprazolam orally disintegrating tab 1 see aminocaproic acid tab 1000 mg mg ...... 24 ...... 122 alprazolam orally disintegrating tab 2 see aminocaproic acid tab 500 mg mg ...... 24 ...... 122 alprazolam tab 0.25 mg ...... 24 AMICAR SYP 25% ...... 122 alprazolam tab 0.5 mg ...... 24 AMICAR TAB 1000MG ...... 122 alprazolam tab 0.5mg xr ...... 24 AMICAR TAB 500MG ...... 122 alprazolam tab 1 mg ...... 24 amiloride & hydrochlorothiazide tab 5- alprazolam tab 1mg xr ...... 24 50 mg ...... 106 alprazolam tab 2 mg ...... 24 amiloride hcl tab 5 mg ...... 106 alprazolam tab 2mg xr ...... 24 amino acids tab complex ...... 140 alprazolam tab 3mg xr ...... 24 aminocaproic acid oral soln 0.25 gm/ml ALREX SUS 0.2% ...... 142 ...... 122 ALTABAX OIN 1% ...... 97 aminocaproic acid tab 1000 mg ..... 122 ALTACE aminocaproic acid tab 500 mg ...... 122 see ramipril cap 1.25 mg ...... 53 amiodarone hcl tab 100 mg ...... 26 see ramipril cap 10 mg ...... 53 amiodarone hcl tab 200 mg ...... 26 see ramipril cap 2.5 mg ...... 53 amiodarone hcl tab 400 mg ...... 26 see ramipril cap 5 mg ...... 53 amitriptyline hcl tab 10 mg ...... 41 amantadine hcl cap 100 mg ...... 67 amitriptyline hcl tab 100 mg ...... 41 amantadine hcl syrup 50 mg/5ml ..... 67 amitriptyline hcl tab 150 mg ...... 41 amantadine hcl tab 100 mg ...... 67 amitriptyline hcl tab 25 mg ...... 41 AMARYL amitriptyline hcl tab 50 mg ...... 41 see glimepiride tab 1 mg ...... 46 amitriptyline hcl tab 75 mg ...... 41 see glimepiride tab 2 mg ...... 46 amlodipine besylate tab 10 mg (base see glimepiride tab 4 mg ...... 46 equivalent) ...... 82 AMBIEN amlodipine besylate tab 2.5 mg (base see zolpidem tartrate tab 10 mg . 124 equivalent) ...... 82 see zolpidem tartrate tab 5 mg ... 124 amlodipine besylate tab 5 mg (base AMBIEN CR equivalent) ...... 82 see zolpidem tartrate tab er 12.5 mg amlodipine besylate-atorvastatin ...... 124 calcium tab 10-10 mg ...... 85 see zolpidem tartrate tab er 6.25 mg amlodipine besylate-atorvastatin ...... 124 calcium tab 10-20 mg ...... 85 ambrisentan tab 10 mg ...... 87 amlodipine besylate-atorvastatin ambrisentan tab 5 mg ...... 87 calcium tab 10-40 mg ...... 85 amcinonide cream 0.1% ...... 99 amlodipine besylate-atorvastatin amcinonide lotion 0.1% ...... 99 calcium tab 10-80 mg ...... 85 AMERGE amlodipine besylate-atorvastatin see naratriptan hcl tab 1 mg (base calcium tab 2.5-10 mg ...... 85 equiv) ...... 128 amlodipine besylate-atorvastatin see naratriptan hcl tab 2.5 mg (base calcium tab 2.5-20 mg ...... 85 equiv) ...... 128 amlodipine besylate-atorvastatin amethyst tab 90-20mcg ...... 89 calcium tab 2.5-40 mg ...... 85 AMICAR amlodipine besylate-atorvastatin see aminocaproic acid oral soln 0.25 calcium tab 5-10 mg ...... 85 gm/ml ...... 122 165 amlodipine besylate-atorvastatin amlodipine-valsartan- calcium tab 5-20 mg ...... 85 hydrochlorothiazide tab 5-160-25 mg amlodipine besylate-atorvastatin ...... 56 calcium tab 5-40 mg ...... 85 amnesteem cap 10mg ...... 94 amlodipine besylate-atorvastatin amnesteem cap 20mg ...... 94 calcium tab 5-80 mg ...... 85 amnesteem cap 40mg ...... 94 amlodipine besylate-benazepril hcl cap amoxicillin & k clavulanate chew tab 10-20 mg ...... 55 200-28.5 mg ...... 145 amlodipine besylate-benazepril hcl cap amoxicillin & k clavulanate chew tab 10-40 mg ...... 55 400-57 mg...... 145 amlodipine besylate-benazepril hcl cap amoxicillin & k clavulanate for susp 2.5-10 mg...... 55 200-28.5 mg/5ml ...... 145 amlodipine besylate-benazepril hcl cap amoxicillin & k clavulanate for susp 5-10 mg ...... 55 250-62.5 mg/5ml ...... 145 amlodipine besylate-benazepril hcl cap amoxicillin & k clavulanate for susp 5-20 mg ...... 55 400-57 mg/5ml ...... 145 amlodipine besylate-benazepril hcl cap amoxicillin & k clavulanate for susp 5-40 mg ...... 55 600-42.9 mg/5ml ...... 145 amlodipine besylate-olmesartan amoxicillin & k clavulanate tab 250-125 medoxomil tab 10-20 mg ...... 56 mg ...... 145 amlodipine besylate-olmesartan amoxicillin & k clavulanate tab 500-125 medoxomil tab 10-40 mg ...... 56 mg ...... 145 amlodipine besylate-olmesartan amoxicillin & k clavulanate tab 875-125 medoxomil tab 5-20 mg ...... 55 mg ...... 145 amlodipine besylate-olmesartan amoxicillin & k clavulanate tab er 12hr medoxomil tab 5-40 mg ...... 56 1000-62.5 mg ...... 145 amlodipine besylate-valsartan tab 10- amoxicillin (trihydrate) cap 250 mg 144 160 mg ...... 56 amoxicillin (trihydrate) cap 500 mg 145 amlodipine besylate-valsartan tab 10- amoxicillin (trihydrate) chew tab 125 320 mg ...... 56 mg ...... 145 amlodipine besylate-valsartan tab 5- amoxicillin (trihydrate) chew tab 250 160 mg ...... 56 mg ...... 145 amlodipine besylate-valsartan tab 5- amoxicillin (trihydrate) for susp 125 320 mg ...... 56 mg/5ml ...... 145 amlodipine-valsartan- amoxicillin (trihydrate) for susp 200 hydrochlorothiazide tab 10-160-12.5 mg/5ml ...... 145 mg ...... 56 amoxicillin (trihydrate) for susp 250 amlodipine-valsartan- mg/5ml ...... 145 hydrochlorothiazide tab 10-160-25 amoxicillin (trihydrate) for susp 400 mg ...... 56 mg/5ml ...... 145 amlodipine-valsartan- amoxicillin (trihydrate) tab 500 mg 145 hydrochlorothiazide tab 10-320-25 amoxicillin (trihydrate) tab 875 mg 145 mg ...... 56 amoxicillin (trihydrate) tab er 24hr 775 amlodipine-valsartan- mg ...... 145 hydrochlorothiazide tab 5-160-12.5 amoxicillin cap-clarithro tab-lansopraz mg ...... 56 cap dr therapy pack ...... 157

166 amphetamine-dextroamphetamine cap ANDROGEL er 24hr 10 mg ...... 8 see testosterone td gel 20.25 amphetamine-dextroamphetamine cap mg/1.25gm (1.62%) ...... 20 er 24hr 15 mg ...... 8 see testosterone td gel 40.5 amphetamine-dextroamphetamine cap mg/2.5gm (1.62%) ...... 20 er 24hr 20 mg ...... 8 ANDROGEL PUMP amphetamine-dextroamphetamine cap see testosterone td gel 20.25 mg/act er 24hr 25 mg ...... 8 (1.62%) ...... 20 amphetamine-dextroamphetamine cap ANGIOMAX er 24hr 30 mg ...... 8 see bivalirudin trifluoroacetate for iv amphetamine-dextroamphetamine cap soln 250 mg (base equiv) ...... 32 er 24hr 5 mg ...... 8 ANGIOMAX INJ 250MG ...... 32 amphetamine-dextroamphetamine tab ANORO ELLIPT AER 62.5-25 ...... 28 10 mg ...... 8 ANUSOL-HC amphetamine-dextroamphetamine tab see proctozone cre -hc 2.5% ...... 21 12.5 mg ...... 8 anusol-hc sup 25mg ...... 21 amphetamine-dextroamphetamine tab APEXICON E CRE 0.05% ...... 99 15 mg ...... 8 APOKYN INJ 10MG/ML ...... 67 amphetamine-dextroamphetamine tab apraclonidine hcl ophth soln 0.5% 20 mg ...... 8 (base equivalent) ...... 141 amphetamine-dextroamphetamine tab aprepitant capsule 125 mg ...... 48 30 mg ...... 8 aprepitant capsule 40 mg ...... 48 amphetamine-dextroamphetamine tab aprepitant capsule 80 mg ...... 48 5 mg ...... 8 aprepitant capsule therapy pack 80 & amphetamine-dextroamphetamine tab 125 mg ...... 48 7.5 mg ...... 8 apri tab ...... 89 ampicillin cap 250 mg ...... 145 APRISO ampicillin cap 500 mg ...... 145 see mesalamine cap er 24hr 0.375 ampicillin for susp 125 mg/5ml ...... 145 gm ...... 117 ampicillin for susp 250 mg/5ml ...... 145 APTIVUS CAP 250MG ...... 75 AMPYRA APTIVUS SOL ...... 75 see dalfampridine tab er 12hr 10 mg AP-ZEL TAB ...... 134 ...... 148 aranelle tab ...... 89 ANAFRANIL ARANESP INJ 100MCG ...... 121 see clomipramine hcl cap 25 mg ... 41 ARANESP INJ 10MCG ...... 121 see clomipramine hcl cap 50 mg ... 42 ARANESP INJ 150MCG ...... 121 see clomipramine hcl cap 75 mg ... 42 ARANESP INJ 200MCG ...... 121 anagrelide hcl cap 0.5 mg ...... 120 ARANESP INJ 25MCG ...... 121 anagrelide hcl cap 1 mg ...... 120 ARANESP INJ 300MCG ...... 121 ANAPROX DS ARANESP INJ 40MCG ...... 121 see naproxen sodium tab 550 mg .. 14 ARANESP INJ 500MCG ...... 121 anastrozole tab 1 mg ...... 62 ARANESP INJ 60MCG ...... 121 ANCOBON ARAVA see flucytosine cap 250 mg ...... 48 see leflunomide tab 10 mg ...... 15 see flucytosine cap 500 mg ...... 48 see leflunomide tab 20 mg ...... 15 ANDRODERM DIS 2MG/24HR ...... 20 ARCALYST INJ 220MG ...... 13 ANDRODERM DIS 4MG/24HR ...... 20 ARCAPTA CAP 75MCG ...... 28 167

ARGATROBAN ARMOUR THYRO TAB 60MG ...... 152 see argatroban inj 250 mg/2.5ml ARMOUR THYRO TAB 90MG ...... 152 (concentrate for iv infusion) ...... 32 ARNUITY ELPT INH 100MCG ...... 27 ARGATROBAN INJ 125/125 ...... 32 ARNUITY ELPT INH 200MCG ...... 27 argatroban inj 250 mg/2.5ml ARNUITY ELPT INH 50MCG ...... 27 (concentrate for iv infusion) ...... 32 AROMASIN ARGATROBAN INJ 250/250 ...... 32 see exemestane tab 25 mg ...... 62 ARGATROBAN INJ 50MG/50M ...... 32 ARTHROTEC 50 ARICEPT see diclofenac w/ misoprostol tab see donepezil hydrochloride tab 10 delayed release 50-0.2 mg ...... 13 mg ...... 146 ARTHROTEC 75 see donepezil hydrochloride tab 23 see diclofenac w/ misoprostol tab mg ...... 146 delayed release 75-0.2 mg ...... 13 see donepezil hydrochloride tab 5 mg ASACOL HD ...... 146 see mesalamine tab delayed release ARIMIDEX 800 mg ...... 117 see anastrozole tab 1 mg ...... 62 ascomp/cod cap 30mg ...... 18 aripiprazole oral solution 1 mg/ml .... 74 asenapine maleate sl tab 10 mg (base ARIPIPRAZOLE ORALLY equiv) ...... 72 DISINTEGRATING TAB 10 MG ...... 74 asenapine maleate sl tab 2.5 mg (base ARIPIPRAZOLE ORALLY equiv) ...... 72 DISINTEGRATING TAB 15 MG ...... 74 asenapine maleate sl tab 5 mg (base aripiprazole tab 10 mg ...... 74 equiv) ...... 72 aripiprazole tab 15 mg ...... 75 aspirin chw 81mg ...... 15 aripiprazole tab 2 mg ...... 74 aspirin low tab 81mg ec ...... 16 aripiprazole tab 20 mg ...... 75 aspirin tab 325 mg ...... 16 aripiprazole tab 30 mg ...... 75 aspirin tab 81mg ...... 16 aripiprazole tab 5 mg ...... 74 aspirin tab delayed release 325 mg .. 16 ARIXTRA aspirin-caffeine-dihydrocodeine cap see fondaparinux sodium 356.4-30-16 mg ...... 18 subcutaneous inj 10 mg/0.8ml ... 31 aspirin-dipyridamole cap er 12hr 25- see fondaparinux sodium 200 mg ...... 120 subcutaneous inj 2.5 mg/0.5ml .. 31 ATABEX EC TAB ...... 134 see fondaparinux sodium ATACAND subcutaneous inj 5 mg/0.4ml ..... 31 see candesartan cilexetil tab 16 mg see fondaparinux sodium ...... 54 subcutaneous inj 7.5 mg/0.6ml .. 31 see candesartan cilexetil tab 32 mg armodafinil tab 150 mg ...... 10 ...... 54 armodafinil tab 200 mg ...... 10 see candesartan cilexetil tab 4 mg. 54 armodafinil tab 250 mg ...... 10 see candesartan cilexetil tab 8 mg. 54 armodafinil tab 50 mg ...... 10 ATACAND HCT ARMOUR THYRO TAB 120MG ...... 152 see candesartan cilexetil- ARMOUR THYRO TAB 15MG ...... 152 hydrochlorothiazide tab 16-12.5 ARMOUR THYRO TAB 180MG ...... 152 mg ...... 56 ARMOUR THYRO TAB 240MG ...... 152 see candesartan cilexetil- ARMOUR THYRO TAB 300MG ...... 152 hydrochlorothiazide tab 32-12.5 ARMOUR THYRO TAB 30MG ...... 152 mg ...... 57 168

see candesartan cilexetil- atovaquone-proguanil hcl tab 250-100 hydrochlorothiazide tab 32-25 mg mg ...... 59 ...... 57 atovaquone-proguanil hcl tab 62.5-25 atazanavir sulfate cap 150 mg (base mg ...... 59 equiv) ...... 75 ATRALIN atazanavir sulfate cap 200 mg (base see tretinoin gel 0.05% ...... 96 equiv) ...... 75 ATRIPLA atazanavir sulfate cap 300 mg (base see efavirenz-emtricitabine-tenofovir equiv) ...... 75 df tab 600-200-300 mg ...... 76 ATELVIA ATROPINE SUL OIN 1% OP ...... 140 see risedronate sodium tab delayed ATROVENT HFA AER 17MCG ...... 26 release 35 mg ...... 108 AUBAGIO TAB 14MG ...... 148 atenolol & chlorthalidone tab 100-25 AUBAGIO TAB 7MG ...... 148 mg ...... 56 AUGMENTIN atenolol & chlorthalidone tab 50-25 mg see amoxicillin & k clavulanate for ...... 56 susp 250-62.5 mg/5ml ...... 145 atenolol tab 100 mg ...... 80 AUGMENTIN SUS 125/5ML ...... 145 atenolol tab 25 mg ...... 80 AUSTEDO TAB 12MG ...... 148 atenolol tab 50 mg ...... 80 AUSTEDO TAB 6MG ...... 148 ATIVAN AUSTEDO TAB 9MG ...... 148 see lorazepam tab 0.5 mg ...... 25 AUTOLET II KIT CLINISAF ...... 126 see lorazepam tab 1 mg ...... 25 AUTOLET MINI MIS ...... 126 see lorazepam tab 2 mg ...... 25 AUTOLET PLAT MIS 2.4MM ...... 126 atomoxetine hcl cap 10 mg (base AUTOSHIELD MIS 29X3/16 ...... 126 equiv) ...... 9 AUTOSHIELD MIS 29X5/16 ...... 126 atomoxetine hcl cap 100 mg (base AUTOSHIELD MIS 30GX5MM ...... 126 equiv) ...... 9 AVALIDE atomoxetine hcl cap 18 mg (base see irbesartan-hydrochlorothiazide equiv) ...... 9 tab 150-12.5 mg ...... 57 atomoxetine hcl cap 25 mg (base see irbesartan-hydrochlorothiazide equiv) ...... 9 tab 300-12.5 mg ...... 57 atomoxetine hcl cap 40 mg (base AVAPRO equiv) ...... 9 see irbesartan tab 150 mg ...... 54 atomoxetine hcl cap 60 mg (base see irbesartan tab 300 mg ...... 54 equiv) ...... 9 see irbesartan tab 75 mg ...... 54 atomoxetine hcl cap 80 mg (base AVC CRE 15% ...... 158 equiv) ...... 9 aviane tab ...... 89 atorvastatin calcium tab 10 mg (base AVODART equivalent)...... 51 see dutasteride cap 0.5 mg ...... 119 atorvastatin calcium tab 20 mg (base AVONEX KIT 30MCG ...... 148 equivalent)...... 51 AVONEX PEN KIT 30MCG ...... 148 atorvastatin calcium tab 40 mg (base AVONEX PREFL KIT 30MCG ...... 148 equivalent)...... 51 av-vite fb tab 2.5-25-1 ...... 122 atorvastatin calcium tab 80 mg (base AYGESTIN equivalent)...... 51 see norethindrone acetate tab 5 mg atovaquone susp 750 mg/5ml ...... 22 ...... 146 AYVAKIT TAB 100MG ...... 63 169

AYVAKIT TAB 200MG ...... 63 baclofen tab 20 mg ...... 138 AYVAKIT TAB 300MG ...... 63 baclofen tab 5 mg ...... 138 AZASAN TAB 100MG ...... 131 BACTRIM AZASAN TAB 75 MG ...... 131 see sulfamethoxazole-trimethoprim AZASITE SOL 1% ...... 141 tab 400-80 mg ...... 22 azathioprine tab 50 mg ...... 131 BACTRIM DS azelaic acid gel 15% ...... 104 see sulfamethoxazole-trimethoprim azelastine hcl nasal spray 0.1% (137 tab 800-160 mg ...... 22 mcg/spray) ...... 139 BACTROBAN OIN NASAL 2% ...... 139 azelastine hcl nasal spray 0.15% BAFIERTAM CAP 95MG ...... 148 (205.5 mcg/spray) ...... 139 BAL-CARE MIS DHA ...... 134 azelastine hcl ophth soln 0.05% ..... 143 balsalazide disodium cap 750 mg ... 117 AZELEX CRE 20% ...... 94 BALVERSA TAB 3MG ...... 63 AZILECT BALVERSA TAB 4MG ...... 63 see rasagiline mesylate tab 0.5 mg BALVERSA TAB 5MG ...... 63 (base equiv) ...... 69 balziva tab ...... 89 see rasagiline mesylate tab 1 mg BANZEL (base equiv) ...... 69 see rufinamide susp 40 mg/ml ...... 36 azithromycin for susp 100 mg/5ml . 124 BANZEL TAB 200MG ...... 33 azithromycin for susp 200 mg/5ml . 124 BANZEL TAB 400MG ...... 33 azithromycin powd pack for susp 1 gm BAQSIMI ONE POW 3MG/DOSE ...... 44 ...... 124 BARACLUDE azithromycin tab 250 mg ...... 124 see entecavir tab 0.5 mg ...... 79 azithromycin tab 500 mg ...... 124 see entecavir tab 1 mg ...... 79 azithromycin tab 600 mg ...... 124 BARACLUDE SOL ...... 79 AZOPT BASAGLAR INJ 100UNIT ...... 45 see brinzolamide ophth susp 1% . 143 BAYER BREEZE KIT 2 SYSTEM ...... 126 AZOR BD GLUCOSE CHW 5GM ...... 44 see amlodipine besylate-olmesartan BD PEN MINI MIS ...... 126 medoxomil tab 10-20 mg ...... 56 BELLA/OPIUM SUP 16.2-30 ...... 155 see amlodipine besylate-olmesartan BELLA/OPIUM SUP 16.2-60 ...... 155 medoxomil tab 10-40 mg ...... 56 benazepril & hydrochlorothiazide tab see amlodipine besylate-olmesartan 10-12.5 mg ...... 56 medoxomil tab 5-20 mg ...... 55 benazepril & hydrochlorothiazide tab see amlodipine besylate-olmesartan 20-12.5 mg ...... 56 medoxomil tab 5-40 mg ...... 56 benazepril & hydrochlorothiazide tab AZULFIDINE 20-25 mg ...... 56 see sulfasalazine tab 500 mg ...... 117 benazepril & hydrochlorothiazide tab 5- AZULFIDINE EN-TABS 6.25 mg ...... 56 see sulfasalazine tab delayed release benazepril hcl tab 10 mg ...... 52 500 mg ...... 117 benazepril hcl tab 20 mg ...... 52 B benazepril hcl tab 40 mg ...... 52 bacitracin ophth oint 500 unit/gm .. 141 benazepril hcl tab 5 mg ...... 52 bacitracin-polymyxin b ophth oint .. 141 BENICAR bacitracin-polymyxin-neomycin-hc see olmesartan medoxomil tab 20 ophth oint 1% ...... 142 mg ...... 54 baclofen tab 10 mg ...... 138 170

see olmesartan medoxomil tab 40 betamethasone valerate oint 0.1% mg ...... 54 (base equivalent) ...... 100 see olmesartan medoxomil tab 5 mg BETAPACE ...... 54 see sotalol hcl tab 120 mg ...... 82 BENLYSTA INJ 200MG/ML ...... 133 see sotalol hcl tab 160 mg ...... 82 BENZACLIN see sotalol hcl tab 80 mg ...... 82 see clindamycin phosphate-benzoyl BETAPACE AF peroxide gel 1-5% ...... 95 see sotalol hcl (afib/afl) tab 120 mg BENZAMYCIN ...... 82 see benzoyl peroxide-erythromycin see sotalol hcl (afib/afl) tab 160 mg gel 5-3% ...... 95 ...... 82 BENZAMYCIN GEL PAK ...... 94 see sotalol hcl (afib/afl) tab 80 mg 82 benzonatate cap 100 mg ...... 93 BETASERON INJ 0.3MG ...... 148 benzonatate cap 150 mg ...... 93 betaxolol hcl ophth soln 0.5% ...... 140 benzonatate cap 200 mg ...... 93 betaxolol hcl tab 10 mg ...... 81 benzoyl peroxide foam 5.3% ...... 94 betaxolol hcl tab 20 mg ...... 81 benzoyl peroxide foam 9.8% ...... 95 bethanechol chloride tab 10 mg ..... 158 benzoyl peroxide-erythromycin gel 5- bethanechol chloride tab 25 mg ..... 158 3% ...... 95 bethanechol chloride tab 5 mg ...... 158 benzphetamine hcl tab 50 mg ...... 9 bethanechol chloride tab 50 mg ..... 158 benztropine mesylate tab 0.5 mg ..... 67 BETIMOL SOL 0.25% ...... 140 benztropine mesylate tab 1 mg ...... 67 BETIMOL SOL 0.5% ...... 140 benztropine mesylate tab 2 mg ...... 67 BETOPTIC-S SUS 0.25% OP ...... 140 BEPREVE DRO 1.5% ...... 143 bexarotene cap 75 mg ...... 66 BERINERT INJ 500UNIT ...... 120 BEYAZ BESIVANCE SUS 0.6% ...... 141 see drospirenone-ethinyl estrad- betamethasone dipropionate levomefolate tab 3-0.02-0.451 mg augmented cream 0.05% ...... 99 ...... 89 betamethasone dipropionate BIAXIN XL augmented gel 0.05% ...... 99 see clarithromycin tab er 24hr 500 betamethasone dipropionate mg ...... 125 augmented lotion 0.05% ...... 99 bicalutamide tab 50 mg ...... 62 betamethasone dipropionate BIDIL TAB ...... 85 augmented oint 0.05% ...... 99 BIFERARX TAB ...... 122 betamethasone dipropionate cream BIJUVA CAP 1-100MG ...... 114 0.05% ...... 99 BIKTARVY TAB ...... 75 betamethasone dipropionate lotion BILTRICIDE 0.05% ...... 99 see praziquantel tab 600 mg ...... 21 betamethasone dipropionate oint bimatoprost ophth soln 0.03% ...... 144 0.05% ...... 99 bio-d-mulsio liq 400unit ...... 161 betamethasone valerate aerosol foam bisoprolol & hydrochlorothiazide tab 0.12% ...... 99 10-6.25 mg ...... 56 betamethasone valerate cream 0.1% bisoprolol & hydrochlorothiazide tab (base equivalent) ...... 100 2.5-6.25 mg...... 56 betamethasone valerate lotion 0.1% bisoprolol & hydrochlorothiazide tab 5- (base equivalent) ...... 100 6.25 mg ...... 56 bisoprolol fumarate tab 10 mg ...... 81 171 bisoprolol fumarate tab 5 mg ...... 81 budesonide delayed release particles bivalirudin trifluoroacetate for iv soln cap 3 mg ...... 91 250 mg (base equiv) ...... 32 budesonide inhalation susp 0.25 BLEPH-10 mg/2ml ...... 27 see sulfacetamide sodium ophth soln budesonide inhalation susp 0.5 mg/2ml 10% ...... 142 ...... 27 BLEPHAMIDE OIN S.O.P...... 142 budesonide inhalation susp 1 mg/2ml BLEPHAMIDE SUS OP ...... 142 ...... 27 BONIVA budesonide-formoterol fumarate dihyd see ibandronate sodium tab 150 mg aerosol 160-4.5 mcg/act ...... 28 (base equivalent) ...... 107 budesonide-formoterol fumarate dihyd BONJESTA TAB 20-20MG ...... 47 aerosol 80-4.5 mcg/act...... 28 bosentan tab 125 mg ...... 87 bumetanide tab 0.5 mg ...... 106 bosentan tab 62.5 mg ...... 87 bumetanide tab 1 mg ...... 106 BOSULIF TAB 100MG ...... 63 bumetanide tab 2 mg ...... 106 BOSULIF TAB 400MG ...... 63 BUMEX BOSULIF TAB 500MG ...... 63 see bumetanide tab 0.5 mg ...... 106 bp 10-1 emu ...... 95 BUPHENYL bp cleansing emu 10-4% ...... 95 see sodium phenylbutyrate oral bp foaming liq wash 10% ...... 95 powder 3 gm/teaspoonful ...... 113 bp folinatal tab plus b ...... 135 see sodium phenylbutyrate tab 500 bp multinatl chw plus ...... 135 mg ...... 113 bp multinatl tab plus ...... 135 buprenorphine hcl sl tab 2 mg (base bp wash liq 2.5% ...... 95 equiv) ...... 19 bp wash liq 5.25% ...... 95 buprenorphine hcl sl tab 8 mg (base BREATHERITE MIS MDI CHMB ...... 127 equiv) ...... 19 BREEZE 2 MIS TEST ...... 104 buprenorphine hcl-naloxone hcl sl film BREO ELLIPTA INH 100-25 ...... 28 12-3 mg (base equiv) ...... 19 BREO ELLIPTA INH 200-25 ...... 28 buprenorphine hcl-naloxone hcl sl film BREZTRI AERO AER SPHERE ...... 28 2-0.5 mg (base equiv) ...... 19 BRILINTA TAB 60MG ...... 120 buprenorphine hcl-naloxone hcl sl film BRILINTA TAB 90MG ...... 120 4-1 mg (base equiv) ...... 19 brimonidine tartrate ophth soln 0.15% buprenorphine hcl-naloxone hcl sl film ...... 141 8-2 mg (base equiv) ...... 19 brimonidine tartrate ophth soln 0.2% buprenorphine hcl-naloxone hcl sl tab ...... 141 8-2 mg (base equiv) ...... 19 brinzolamide ophth susp 1% ...... 143 buprenorphine td patch weekly 10 bromfenac sodium ophth soln 0.09% mcg/hr ...... 20 (base equiv) (once-daily) ...... 143 buprenorphine td patch weekly 15 bromfenac sodium ophth soln 0.09% mcg/hr ...... 20 (base equivalent) ...... 143 buprenorphine td patch weekly 20 bromocriptine mesylate cap 5 mg (base mcg/hr ...... 20 equivalent)...... 67 buprenorphine td patch weekly 5 bromocriptine mesylate tab 2.5 mg mcg/hr ...... 20 (base equivalent) ...... 67 buprenorphine td patch weekly 7.5 BROVANA NEB 15MCG ...... 28 mcg/hr ...... 20 BRUKINSA CAP 80MG ...... 63 172 bupropion hcl (smoking deterrent) tab see amlodipine besylate-atorvastatin er 12hr 150 mg ...... 149 calcium tab 10-40 mg ...... 85 bupropion hcl tab 100 mg ...... 39 see amlodipine besylate-atorvastatin bupropion hcl tab 75 mg ...... 38 calcium tab 10-80 mg ...... 85 bupropion hcl tab er 12hr 100 mg .... 39 see amlodipine besylate-atorvastatin bupropion hcl tab er 12hr 150 mg .... 39 calcium tab 5-10 mg ...... 85 bupropion hcl tab er 12hr 200 mg .... 39 see amlodipine besylate-atorvastatin bupropion hcl tab er 24hr 150 mg .... 39 calcium tab 5-20 mg ...... 85 bupropion hcl tab er 24hr 300 mg .... 39 see amlodipine besylate-atorvastatin buspirone hcl tab 10 mg ...... 24 calcium tab 5-40 mg ...... 85 buspirone hcl tab 15 mg ...... 24 see amlodipine besylate-atorvastatin buspirone hcl tab 30 mg ...... 24 calcium tab 5-80 mg ...... 85 buspirone hcl tab 5 mg ...... 24 CAFERGOT buspirone hcl tab 7.5 mg ...... 24 see ergotamine w/ caffeine tab 1-100 butalbital-acetaminophen tab 50-325 mg ...... 127 mg ...... 15 CALAN SR butalbital-acetaminophen-caff w/ cod see verapamil hcl tab er 120 mg ... 84 cap 50-300-40-30 mg ...... 18 see verapamil hcl tab er 240 mg ... 84 butalbital-acetaminophen-caff w/ cod calcipotriene cream 0.005% ...... 98 cap 50-325-40-30 mg ...... 18 calcipotriene oint 0.005% ...... 98 butalbital-acetaminophen-caffeine cap calcipotriene soln 0.005% (50 mcg/ml) 50-300-40 mg ...... 15 ...... 98 butalbital-acetaminophen-caffeine cap calcipotriene-betamethasone 50-325-40 mg ...... 15 dipropionate oint 0.005-0.064% . 100 butalbital-acetaminophen-caffeine tab calcipotriene-betamethasone 50-325-40 mg ...... 15 dipropionate susp 0.005-0.064% 100 butalbital-aspirin-caffeine cap 50-325- calcitonin (salmon) inj 200 unit/ml . 107 40 mg ...... 15 calcitonin (salmon) nasal soln 200 butorphanol tartrate nasal soln 10 unit/act ...... 107 mg/ml ...... 20 calcitriol cap 0.25 mcg ...... 112 BUTRANS calcitriol cap 0.5 mcg ...... 112 see buprenorphine td patch weekly calcitriol oint 3 mcg/gm ...... 98 7.5 mcg/hr ...... 20 calcitriol oral soln 1 mcg/ml ...... 112 BYSTOLIC TAB 10MG ...... 81 calcium acetate (phosphate binder) cap BYSTOLIC TAB 2.5MG ...... 81 667 mg (169 mg ca) ...... 118 BYSTOLIC TAB 20MG ...... 81 calcium acetate (phosphate binder) tab BYSTOLIC TAB 5MG ...... 81 667 mg ...... 118 C camila tab 0.35mg ...... 91 cabergoline tab 0.5 mg ...... 113 camrese lo tab ...... 89 CABOMETYX TAB 20MG ...... 63 camrese tab ...... 89 CABOMETYX TAB 40MG ...... 63 CANASA CABOMETYX TAB 60MG ...... 63 see mesalamine suppos 1000 mg 117 CADUET candesartan cilexetil tab 16 mg ...... 54 see amlodipine besylate-atorvastatin candesartan cilexetil tab 32 mg ...... 54 calcium tab 10-10 mg ...... 85 candesartan cilexetil tab 4 mg ...... 54 see amlodipine besylate-atorvastatin candesartan cilexetil tab 8 mg ...... 54 calcium tab 10-20 mg ...... 85 173 candesartan cilexetil- see carbamazepine cap er 12hr 300 hydrochlorothiazide tab 16-12.5 mg mg ...... 33 ...... 56 carbidopa & levodopa orally candesartan cilexetil- disintegrating tab 10-100 mg ...... 67 hydrochlorothiazide tab 32-12.5 mg carbidopa & levodopa orally ...... 57 disintegrating tab 25-100 mg ...... 67 candesartan cilexetil- carbidopa & levodopa orally hydrochlorothiazide tab 32-25 mg . 57 disintegrating tab 25-250 mg ...... 67 CAPCOF SYP 5-2-10MG ...... 93 carbidopa & levodopa tab 10-100 mg 67 capecitabine tab 150 mg ...... 61 carbidopa & levodopa tab 25-100 mg 67 capecitabine tab 500 mg ...... 61 carbidopa & levodopa tab 25-250 mg 67 CAPLYTA CAP 42MG ...... 69 carbidopa & levodopa tab er 25-100 CAPRELSA TAB 100MG ...... 63 mg ...... 67 CAPRELSA TAB 300MG ...... 63 carbidopa & levodopa tab er 50-200 captopril & hydrochlorothiazide tab 25- mg ...... 67 15 mg ...... 57 carbidopa-levodopa-entacapone tabs captopril & hydrochlorothiazide tab 25- 12.5-50-200 mg ...... 68 25 mg ...... 57 carbidopa-levodopa-entacapone tabs captopril & hydrochlorothiazide tab 50- 18.75-75-200 mg ...... 68 15 mg ...... 57 carbidopa-levodopa-entacapone tabs captopril & hydrochlorothiazide tab 50- 25-100-200 mg ...... 68 25 mg ...... 57 carbidopa-levodopa-entacapone tabs captopril tab 100 mg ...... 52 31.25-125-200 mg ...... 68 captopril tab 12.5 mg ...... 52 carbidopa-levodopa-entacapone tabs captopril tab 25 mg ...... 52 37.5-150-200 mg ...... 68 captopril tab 50 mg ...... 52 carbidopa-levodopa-entacapone tabs CARAC 50-200-200 mg ...... 68 see fluorouracil cream 0.5% ...... 98 CARDIZEM CARAFATE see diltiazem hcl tab 120 mg ...... 83 see sucralfate susp 1 gm/10ml ... 156 see diltiazem hcl tab 30 mg ...... 83 see sucralfate tab 1 gm ...... 156 see diltiazem hcl tab 60 mg ...... 83 CARBAGLU TAB 200MG ...... 112 CARDIZEM CD carbamazepine cap er 12hr 100 mg .. 33 see diltiazem hcl coated beads cap er carbamazepine cap er 12hr 200 mg .. 33 24hr 120 mg ...... 82 carbamazepine cap er 12hr 300 mg .. 33 see diltiazem hcl coated beads cap er carbamazepine chew tab 100 mg ..... 33 24hr 180 mg ...... 82 carbamazepine susp 100 mg/5ml ..... 34 see diltiazem hcl coated beads cap er carbamazepine tab 200 mg ...... 34 24hr 240 mg ...... 82 carbamazepine tab er 12hr 100 mg .. 34 see diltiazem hcl coated beads cap er carbamazepine tab er 12hr 200 mg .. 34 24hr 300 mg ...... 82 carbamazepine tab er 12hr 400 mg .. 34 see diltiazem hcl coated beads cap er CARBATROL 24hr 360 mg ...... 82 see carbamazepine cap er 12hr 100 CARDIZEM LA mg ...... 33 see diltiazem hcl coated beads tab er see carbamazepine cap er 12hr 200 24hr 180 mg ...... 83 mg ...... 33 see diltiazem hcl coated beads tab er 24hr 240 mg ...... 83 174

see diltiazem hcl coated beads tab er cefaclor cap 250 mg ...... 88 24hr 300 mg ...... 83 cefaclor cap 500 mg ...... 88 see diltiazem hcl coated beads tab er cefaclor for susp 125 mg/5ml ...... 88 24hr 360 mg ...... 83 cefaclor for susp 250 mg/5ml ...... 88 see diltiazem hcl coated beads tab er cefaclor for susp 375 mg/5ml ...... 88 24hr 420 mg ...... 83 cefadroxil cap 500 mg ...... 88 CARDIZEM LA TAB 120MG ...... 82 cefadroxil for susp 250 mg/5ml ...... 88 CARDURA cefadroxil for susp 500 mg/5ml ...... 88 see doxazosin mesylate tab 1 mg .. 55 cefadroxil tab 1 gm ...... 88 see doxazosin mesylate tab 2 mg .. 55 cefdinir cap 300 mg ...... 88 see doxazosin mesylate tab 4 mg .. 55 cefdinir for susp 125 mg/5ml ...... 88 see doxazosin mesylate tab 8 mg .. 55 cefdinir for susp 250 mg/5ml ...... 88 CARDURA XL TAB 4MG ...... 119 cefixime cap 400 mg ...... 89 CARDURA XL TAB 8MG ...... 119 cefixime for susp 100 mg/5ml ...... 89 CARNITOR cefixime for susp 200 mg/5ml ...... 89 see levocarnitine oral soln 1 gm/10ml cefpodoxime proxetil for susp 100 (10%) ...... 112 mg/5ml ...... 89 see levocarnitine tab 330 mg ...... 112 cefpodoxime proxetil for susp 50 CAROSPIR SUS 25MG/5ML ...... 106 mg/5ml ...... 89 carteolol hcl ophth soln 1% ...... 140 cefpodoxime proxetil tab 100 mg ..... 89 carvedilol phosphate cap er 24hr 10 cefpodoxime proxetil tab 200 mg ..... 89 mg ...... 80 cefprozil for susp 125 mg/5ml ...... 88 carvedilol phosphate cap er 24hr 20 cefprozil for susp 250 mg/5ml ...... 88 mg ...... 80 cefprozil tab 250 mg ...... 88 carvedilol phosphate cap er 24hr 40 cefprozil tab 500 mg ...... 88 mg ...... 80 ceftibuten cap 400 mg ...... 89 carvedilol phosphate cap er 24hr 80 ceftibuten for susp 180 mg/5ml ...... 89 mg ...... 80 CEFTIN SUS 125/5ML ...... 88 carvedilol tab 12.5 mg ...... 80 CEFTIN SUS 250/5ML ...... 88 carvedilol tab 25 mg ...... 80 cefuroxime axetil tab 250 mg ...... 88 carvedilol tab 3.125 mg ...... 80 cefuroxime axetil tab 500 mg ...... 88 carvedilol tab 6.25 mg ...... 80 CELEBREX CASODEX see celecoxib cap 100 mg ...... 13 see bicalutamide tab 50 mg ...... 62 see celecoxib cap 200 mg ...... 13 CATAPRES-TTS-1 see celecoxib cap 400 mg ...... 13 see clonidine td patch weekly 0.1 see celecoxib cap 50 mg ...... 13 mg/24hr ...... 55 celecoxib cap 100 mg ...... 13 CATAPRES-TTS-2 celecoxib cap 200 mg ...... 13 see clonidine td patch weekly 0.2 celecoxib cap 400 mg ...... 13 mg/24hr ...... 55 celecoxib cap 50 mg ...... 13 CATAPRES-TTS-3 CELEXA see clonidine td patch weekly 0.3 see citalopram hydrobromide tab 10 mg/24hr ...... 55 mg (base equiv) ...... 39 CAVERJECT INJ 20MCG ...... 85 see citalopram hydrobromide tab 20 CAVERJECT INJ 40MCG ...... 85 mg (base equiv) ...... 39 CAYA DPR ...... 125 see citalopram hydrobromide tab 40 CAYSTON INH 75MG ...... 23 mg (base equiv) ...... 39 175

CELLCEPT chlorthalidone tab 100 mg ...... 107 see mycophenolate mofetil cap 250 chlorthalidone tab 25 mg ...... 107 mg ...... 132 chlorthalidone tab 50 mg ...... 107 see mycophenolate mofetil for oral chlorzoxazone tab 500 mg ...... 138 susp 200 mg/ml ...... 132 cholecalciferol cap 10 mcg (400 unit) see mycophenolate mofetil tab 500 ...... 161 mg ...... 132 cholecalciferol oral liquid 10 mcg/ml CELLCEPT CAP 250MG ...... 131 (400 unit/ml) ...... 161 CELLCEPT SUS 200MG/ML ...... 131 cholestyramine light powder packets 4 CELLCEPT TAB 500MG ...... 131 gm ...... 50 cephalexin cap 250 mg ...... 88 cholestyramine powder 4 gm/dose ... 50 cephalexin cap 500 mg ...... 88 cholestyramine powder packets 4 gm50 cephalexin cap 750 mg ...... 88 choline & magnesium salicylates liq cephalexin for susp 125 mg/5ml ...... 88 500 mg/5ml ...... 16 cephalexin for susp 250 mg/5ml ...... 88 choline & magnesium salicylates tab cephalexin tab 250 mg ...... 88 1000 mg ...... 16 cephalexin tab 500 mg ...... 88 choline fenofibrate cap dr 135 mg CESAMET CAP 1MG ...... 48 (fenofibric acid equiv) ...... 50 CETROTIDE KIT 0.25MG ...... 110 choline fenofibrate cap dr 45 mg cevimeline hcl cap 30 mg ...... 133 (fenofibric acid equiv) ...... 50 CHANTIX PAK 0.5& 1MG ...... 149 chor gonadot inj 10000unt ...... 108 CHANTIX PAK 1MG ...... 149 CIALIS CHANTIX TAB 0.5MG ...... 149 see tadalafil tab 10 mg ...... 87 CHEMSTRIP 2 TES LN ...... 104 see tadalafil tab 2.5 mg ...... 87 CHEMSTRIP 9 TES STRIPS ...... 104 see tadalafil tab 20 mg ...... 87 CHEMSTRIP BG MIS LOG ...... 126 see tadalafil tab 5 mg ...... 87 cheratussin sol dac ...... 93 ciclopirox gel 0.77% ...... 97 cheratussin syp ac ...... 93 ciclopirox olamine cream 0.77% (base chlordiazepoxide hcl cap 10 mg ...... 25 equiv) ...... 97 chlordiazepoxide hcl cap 25 mg ...... 25 ciclopirox olamine susp 0.77% (base chlordiazepoxide hcl cap 5 mg ...... 25 equiv) ...... 97 chlordiazepoxide hcl-clidinium bromide ciclopirox shampoo 1% ...... 97 cap 5-2.5 mg...... 155 ciclopirox solution 8% ...... 97 chlordiazepoxide-amitriptyline tab 10- cilostazol tab 100 mg ...... 120 25 mg ...... 148 cilostazol tab 50 mg ...... 120 chlordiazepoxide-amitriptyline tab 5- CILOXAN OIN 0.3% OP ...... 141 12.5 mg ...... 147 CIMDUO TAB 300-300 ...... 76 chlorhexidine gluconate soln 0.12% 133 cimetidine hcl soln 300 mg/5ml ..... 156 chloroquine phosphate tab 250 mg ... 59 cimetidine tab 200 mg ...... 156 chloroquine phosphate tab 500 mg ... 59 cimetidine tab 300 mg ...... 156 chlorothiazide tab 250 mg ...... 107 cimetidine tab 400 mg ...... 156 chlorothiazide tab 500 mg ...... 107 cimetidine tab 800 mg ...... 156 chlorpromazine hcl tab 10 mg ...... 73 cinacalcet hcl tab 30 mg (base equiv) chlorpromazine hcl tab 100 mg ...... 74 ...... 112 chlorpromazine hcl tab 200 mg ...... 74 cinacalcet hcl tab 60 mg (base equiv) chlorpromazine hcl tab 25 mg ...... 74 ...... 112 chlorpromazine hcl tab 50 mg ...... 74 176 cinacalcet hcl tab 90 mg (base equiv) CITRANATAL TAB RX ...... 135 ...... 112 claravis cap 10mg ...... 95 CIPRO claravis cap 20mg ...... 95 see ciprofloxacin hcl tab 250 mg claravis cap 30mg ...... 95 (base equiv) ...... 116 claravis cap 40mg ...... 95 see ciprofloxacin hcl tab 500 mg clarithromycin for susp 125 mg/5ml 124 (base equiv) ...... 116 clarithromycin for susp 250 mg/5ml 125 CIPRO (5%) SUS 250MG/5 ...... 116 clarithromycin tab 250 mg ...... 125 CIPRO HC SUS OTIC ...... 144 clarithromycin tab 500 mg ...... 125 CIPRODEX clarithromycin tab er 24hr 500 mg . 125 see ciprofloxacin-dexamethasone otic clearplex x gel 10% ...... 95 susp 0.3-0.1% ...... 144 clemastine fumarate tab 2.68 mg .... 49 CIPRODEX SUS 0.3-0.1% ...... 144 CLEOCIN ciprofloxacin for oral susp 250 mg/5ml see clindamycin hcl cap 150 mg .... 22 (5%) (5 gm/100ml) ...... 116 see clindamycin hcl cap 300 mg .... 22 ciprofloxacin for oral susp 500 mg/5ml see clindamycin hcl cap 75 mg ...... 22 (10%) (10 gm/100ml) ...... 116 see clindamycin phosphate vaginal ciprofloxacin hcl ophth soln 0.3% (base cream 2% ...... 159 equivalent)...... 141 CLEOCIN PEDIATRIC GRANULE ciprofloxacin hcl otic soln 0.2% (base see clindamycin palmitate hcl for soln equivalent)...... 144 75 mg/5ml (base equiv) ...... 22 ciprofloxacin hcl tab 100 mg (base CLEOCIN SUP 100MG ...... 159 equiv) ...... 116 CLEOCIN-T ciprofloxacin hcl tab 250 mg (base see clindamycin phosphate lotion 1% equiv) ...... 116 ...... 95 ciprofloxacin hcl tab 500 mg (base CLIMARA equiv) ...... 116 see estradiol td patch weekly 0.025 ciprofloxacin hcl tab 750 mg (base mg/24hr ...... 115 equiv) ...... 116 see estradiol td patch weekly 0.0375 ciprofloxacin-ciprofloxacin hcl tab er mg/24hr (37.5 mcg/24hr) ...... 115 24hr 1000 mg(base eq) ...... 116 see estradiol td patch weekly 0.05 ciprofloxacin-ciprofloxacin hcl tab er mg/24hr ...... 115 24hr 500 mg (base eq) ...... 116 see estradiol td patch weekly 0.06 ciprofloxacin-dexamethasone otic susp mg/24hr ...... 115 0.3-0.1% ...... 144 see estradiol td patch weekly 0.075 citalopram hydrobromide oral soln 10 mg/24hr ...... 115 mg/5ml ...... 39 see estradiol td patch weekly 0.1 citalopram hydrobromide tab 10 mg mg/24hr ...... 115 (base equiv) ...... 39 CLIMARA PRO DIS WEEKLY ...... 114 citalopram hydrobromide tab 20 mg clindamycin hcl cap 150 mg ...... 22 (base equiv) ...... 39 clindamycin hcl cap 300 mg ...... 22 citalopram hydrobromide tab 40 mg clindamycin hcl cap 75 mg ...... 22 (base equiv) ...... 39 clindamycin palmitate hcl for soln 75 CITRANATAL CAP HARMONY ...... 135 mg/5ml (base equiv) ...... 22 CITRANATAL CAP MEDLEY ...... 135 clindamycin phosphate foam 1% ..... 95 CITRANATAL PAK ESSENCE ...... 135 clindamycin phosphate gel 1% ...... 95 CITRANATAL TAB BLOOM ...... 135 clindamycin phosphate lotion 1% ..... 95 177 clindamycin phosphate soln 1% ...... 95 clonazepam tab 1 mg ...... 33 clindamycin phosphate swab 1% ...... 95 clonazepam tab 2 mg ...... 33 clindamycin phosphate vaginal cream clonidine hcl tab 0.1 mg ...... 54 2% ...... 159 clonidine hcl tab 0.2 mg ...... 54 clindamycin phosphate-benzoyl clonidine hcl tab 0.3 mg ...... 54 peroxide gel 1.2-2.5% ...... 95 clonidine hcl tab er 12hr 0.1 mg ...... 9 clindamycin phosphate-benzoyl clonidine td patch weekly 0.1 mg/24hr peroxide gel 1-5% ...... 95 ...... 55 clindamycin phosphate-tretinoin gel clonidine td patch weekly 0.2 mg/24hr 1.2-0.025% ...... 95 ...... 55 clindamycin phosph-benzoyl peroxide clonidine td patch weekly 0.3 mg/24hr (refrig) gel 1.2 (1)-5% ...... 95 ...... 55 CLINITEST TAB CHLD RES ...... 104 clopidogrel bisulfate tab 300 mg (base clinpro 5000 pst 1.1% ...... 133 equiv) ...... 120 clobazam suspension 2.5 mg/ml ...... 32 clopidogrel bisulfate tab 75 mg (base clobazam tab 10 mg ...... 32 equiv) ...... 120 clobazam tab 20 mg ...... 32 clorazepate dipotassium tab 15 mg .. 25 clobetasol e cre 0.05% ...... 100 clorazepate dipotassium tab 3.75 mg 25 clobetasol propionate cream 0.05% 100 clorazepate dipotassium tab 7.5 mg . 25 clobetasol propionate foam 0.05% . 100 clotrimazole cream 1% ...... 97 clobetasol propionate gel 0.05% .... 100 clotrimazole soln 1% ...... 97 clobetasol propionate lotion 0.05% . 100 clotrimazole troche 10 mg ...... 133 clobetasol propionate oint 0.05% ... 100 clotrimazole w/ betamethasone cream clobetasol propionate soln 0.05% ... 100 1-0.05% ...... 97 clobetasol propionate spray 0.05% . 100 clotrimazole w/ betamethasone lotion CLOBEX 1-0.05% ...... 97 see clobetasol propionate lotion clozapine orally disintegrating tab 100 0.05% ...... 100 mg ...... 72 see clobetasol propionate spray clozapine orally disintegrating tab 12.5 0.05% ...... 100 mg ...... 72 see clodan sha 0.05% ...... 100 clozapine orally disintegrating tab 150 clodan sha 0.05% ...... 100 mg ...... 72 clomiphene citrate tab 50 mg ...... 108 clozapine orally disintegrating tab 200 clomipramine hcl cap 25 mg ...... 41 mg ...... 72 clomipramine hcl cap 50 mg ...... 42 clozapine orally disintegrating tab 25 clomipramine hcl cap 75 mg ...... 42 mg ...... 72 clonazepam orally disintegrating tab clozapine tab 100 mg ...... 72 0.125 mg ...... 33 clozapine tab 200 mg ...... 72 clonazepam orally disintegrating tab clozapine tab 25 mg ...... 72 0.25 mg ...... 32 clozapine tab 50 mg ...... 72 clonazepam orally disintegrating tab CLOZARIL 0.5 mg ...... 32 see clozapine tab 100 mg ...... 72 clonazepam orally disintegrating tab 1 see clozapine tab 200 mg ...... 72 mg ...... 33 see clozapine tab 25 mg ...... 72 clonazepam orally disintegrating tab 2 see clozapine tab 50 mg ...... 72 mg ...... 33 COARTEM TAB 20-120MG ...... 59 clonazepam tab 0.5 mg ...... 33 CODAR AR LIQ 2-8/5ML...... 93 178

CODAR D LIQ 30-8/5ML ...... 93 CONTOUR KIT LINK ...... 126 codar gf liq 200-8/5 ...... 93 CONTOUR TES BLD GLUC ...... 104 COLAZAL CONTOUR TES NEXT ...... 104 see balsalazide disodium cap 750 mg CONTRAVE TAB 8-90MG ...... 9 ...... 117 COPAXONE INJ 20MG/ML ...... 148 colchicine cap 0.6 mg ...... 119 COPAXONE INJ 40MG/ML ...... 148 colchicine tab 0.6 mg ...... 119 CORDRAN colchicine w/ probenecid tab 0.5-500 see flurandrenolide cream 0.05% 101 mg ...... 119 see flurandrenolide lotion 0.05% . 101 COLCRYS see flurandrenolide oint 0.05% ... 101 see colchicine tab 0.6 mg ...... 119 CORDRAN 24X3 TAP 4MCG/CM ...... 100 colesevelam hcl packet for susp 3.75 COREG gm ...... 50 see carvedilol tab 12.5 mg ...... 80 colesevelam hcl tab 625 mg ...... 50 see carvedilol tab 25 mg ...... 80 COLESTID see carvedilol tab 3.125 mg ...... 80 see colestipol hcl granule packets 5 see carvedilol tab 6.25 mg ...... 80 gm ...... 50 COREG CR see colestipol hcl granules 5 gm .... 50 see carvedilol phosphate cap er 24hr see colestipol tab 1gm ...... 50 10 mg ...... 80 colestipol hcl granule packets 5 gm .. 50 see carvedilol phosphate cap er 24hr colestipol hcl granules 5 gm ...... 50 20 mg ...... 80 colestipol tab 1gm ...... 50 see carvedilol phosphate cap er 24hr COMBIGAN SOL 0.2/0.5% ...... 140 40 mg ...... 80 COMBIPATCH DIS ...... 114 see carvedilol phosphate cap er 24hr COMBIVENT AER 20-100 ...... 28 80 mg ...... 80 COMBIVIR CORGARD see lamivudine-zidovudine tab 150- see nadolol tab 20 mg ...... 81 300 mg ...... 77 see nadolol tab 40 mg ...... 81 COMETRIQ KIT 100MG ...... 63 see nadolol tab 80 mg ...... 81 COMETRIQ KIT 140MG ...... 63 CORLANOR SOL 5MG/5ML ...... 88 COMETRIQ KIT 60MG ...... 63 CORLANOR TAB 5MG...... 88 COMPLERA TAB ...... 76 CORLANOR TAB 7.5MG ...... 88 COMPLETE NAT PAK DHA ...... 135 CORTEF COMTAN see hydrocortisone tab 10 mg ...... 92 see entacapone tab 200 mg ...... 67 see hydrocortisone tab 20 mg ...... 92 CONCEPT DHA CAP ...... 135 see hydrocortisone tab 5 mg ...... 92 CONCEPT OB CAP ...... 135 CORTENEMA CONCERTA see hydrocortisone enema 100 see methylphenidate hcl tab er mg/60ml ...... 21 osmotic release (osm) 18 mg ..... 11 CORTIFOAM AER 90MG ...... 21 see methylphenidate hcl tab er cortisone acetate tab 25 mg ...... 91 osmotic release (osm) 27 mg ..... 11 CORTISPORIN CRE 0.5% ...... 97 see methylphenidate hcl tab er CORTISPORIN OIN 1% ...... 97 osmotic release (osm) 36 mg ..... 11 CORTISPORIN SUS -TC OTIC ...... 144 see methylphenidate hcl tab er corvita 150 tab ...... 122 osmotic release (osm) 54 mg ..... 12 COSENTYX INJ 150MG/ML ...... 98 CONDYLOX GEL 0.5% ...... 103 COSENTYX INJ 300DOSE ...... 98 179

COSENTYX PEN INJ 150MG/ML ...... 98 see fluticasone propionate lotion COSENTYX PEN INJ 300DOSE ...... 98 0.05% ...... 101 COSOPT CUVPOSA SOL 1MG/5ML ...... 155 see dorzolamide hcl-timolol maleate cyanocobalamin inj 1000 mcg/ml ... 121 ophth soln 22.3-6.8 mg/ml ...... 140 cyclobenzaprine hcl tab 10 mg ...... 138 COSOPT PF cyclobenzaprine hcl tab 5 mg ...... 138 see dorzolamide hcl-timolol maleate cyclobenzaprine hcl tab 7.5 mg ..... 138 ophth sol 22.3-6.8 mg/ml pf .... 140 CYCLOGYL COTELLIC TAB 20MG ...... 63 see cyclopentolate hcl ophth soln 1% COUMADIN TAB 10MG ...... 30 ...... 140 COUMADIN TAB 1MG ...... 30 cyclopentolate hcl ophth soln 1% ... 140 COUMADIN TAB 2.5MG ...... 30 cyclopentolate hcl ophth soln 2% ... 140 COUMADIN TAB 2MG ...... 30 cyclophosphamide cap 25 mg ...... 60 COUMADIN TAB 3MG ...... 30 CYCLOPHOSPHAMIDE CAP 25 MG .... 60 COUMADIN TAB 4MG ...... 30 cyclophosphamide cap 50 mg ...... 60 COUMADIN TAB 5MG ...... 30 CYCLOPHOSPHAMIDE CAP 50 MG .... 60 COUMADIN TAB 6MG ...... 30 CYCLOSET TAB 0.8MG ...... 44 COUMADIN TAB 7.5MG ...... 30 cyclosporine cap 100 mg ...... 131 COZAAR cyclosporine cap 25 mg ...... 131 see losartan potassium tab 100 mg54 cyclosporine modified cap 100 mg . 131 see losartan potassium tab 25 mg . 54 cyclosporine modified cap 25 mg ... 131 see losartan potassium tab 50 mg . 54 cyclosporine modified cap 50 mg ... 131 CREON CAP 12000UNT ...... 105 cyclosporine modified oral soln 100 CREON CAP 24000UNT ...... 105 mg/ml ...... 131 CREON CAP 3000UNIT ...... 105 CYMBALTA CREON CAP 36000UNT ...... 105 see duloxetine hcl enteric coated CREON CAP 6000UNIT ...... 105 pellets cap 20 mg (base eq) ...... 41 CRESTOR see duloxetine hcl enteric coated see rosuvastatin calcium tab 10 mg pellets cap 30 mg (base eq) ...... 41 ...... 51 see duloxetine hcl enteric coated see rosuvastatin calcium tab 20 mg pellets cap 60 mg (base eq) ...... 41 ...... 51 cyotic dro ...... 144 see rosuvastatin calcium tab 40 mg cyproheptadine hcl syrup 2 mg/5ml . 49 ...... 51 cyproheptadine hcl tab 4 mg ...... 49 see rosuvastatin calcium tab 5 mg . 51 CYTOMEL CRINONE GEL 4% VAG ...... 159 see liothyronine sodium tab 25 mcg CRINONE GEL 8% VAG ...... 159 ...... 153 CRIXIVAN CAP 200MG ...... 76 see liothyronine sodium tab 5 mcg CRIXIVAN CAP 400MG ...... 76 ...... 153 cromolyn sodium ophth soln 4% .... 143 see liothyronine sodium tab 50 mcg cromolyn sodium oral conc 100 mg/5ml ...... 153 ...... 117 CYTOMEL TAB 25MCG ...... 152 cromolyn sodium soln nebu 20 mg/2ml CYTOMEL TAB 50MCG ...... 152 ...... 26 CYTOMEL TAB 5MCG ...... 152 crotan lot 10% ...... 104 CYTOTEC cryselle-28 tab 28 tabs ...... 89 see misoprostol tab 100 mcg ...... 157 CUTIVATE see misoprostol tab 200 mcg ...... 157 180

D DELESTROGEN INJ 40MG/ML ...... 114 D.H.E. 45 DELZICOL see dihydroergotamine mesylate inj 1 see mesalamine cap dr 400 mg .. 117 mg/ml ...... 127 demeclocycline hcl tab 150 mg ...... 150 dalfampridine tab er 12hr 10 mg .... 148 demeclocycline hcl tab 300 mg ...... 150 DALIRESP TAB 250MCG ...... 27 DEPAKOTE DALIRESP TAB 500MCG ...... 27 see divalproex sodium tab delayed danazol cap 100 mg ...... 20 release 125 mg ...... 38 danazol cap 200 mg ...... 20 see divalproex sodium tab delayed danazol cap 50 mg ...... 20 release 250 mg ...... 38 DANTRIUM see divalproex sodium tab delayed see dantrolene sodium cap 25 mg 139 release 500 mg ...... 38 see dantrolene sodium cap 50 mg 139 DEPAKOTE ER dantrolene sodium cap 100 mg ...... 139 see divalproex sodium tab er 24 hr dantrolene sodium cap 25 mg ...... 139 250 mg ...... 38 dantrolene sodium cap 50 mg ...... 139 see divalproex sodium tab er 24 hr dapsone gel 5% ...... 95 500 mg ...... 38 dapsone tab 100 mg ...... 22 DEPAKOTE SPRINKLES dapsone tab 25 mg ...... 22 see divalproex sodium cap delayed DARAPRIM release sprinkle 125 mg ...... 38 see pyrimethamine tab 25 mg ...... 60 DEPO-ESTRADI INJ 5MG/ML ...... 114 darifenacin hydrobromide tab er 24hr DEPO-PROVERA CONTRACEPTIV 15 mg (base equiv) ...... 157 see medroxyprogesterone acetate im darifenacin hydrobromide tab er 24hr susp 150 mg/ml ...... 91 7.5 mg (base equiv) ...... 157 DEPO-SQ PROV INJ 104 ...... 91 DAYPRO DEPO-TESTOSTERONE see oxaprozin tab 600 mg ...... 15 see testosterone cypionate im inj in DAYTRANA DIS 10MG/9HR ...... 10 oil 100 mg/ml ...... 20 DAYTRANA DIS 15MG/9HR ...... 10 see testosterone cypionate im inj in DAYTRANA DIS 20MG/9HR ...... 10 oil 200 mg/ml ...... 20 DAYTRANA DIS 30MG/9HR ...... 10 DERMA-SMOOTHE/FS BODY DDAVP see fluocinolone acetonide oil 0.01% see desmopressin acetate tab 0.1 mg (body oil) ...... 101 ...... 113 DERMA-SMOOTHE/FS SCALP see desmopressin acetate tab 0.2 mg see fluocinolone acetonide oil 0.01% ...... 113 (scalp oil) ...... 101 deferasirox tab for oral susp 125 mg 47 DERMOTIC deferasirox tab for oral susp 250 mg 47 see fluocinolone acetonide (otic) oil deferasirox tab for oral susp 500 mg 47 0.01% ...... 144 deferiprone tab 500 mg ...... 47 DESCOVY TAB 200/25MG ...... 76 DELESTROGEN desipramine hcl tab 10 mg ...... 42 see estradiol valerate im in oil 20 desipramine hcl tab 100 mg ...... 42 mg/ml ...... 115 desipramine hcl tab 150 mg ...... 42 see estradiol valerate im in oil 40 desipramine hcl tab 25 mg ...... 42 mg/ml ...... 115 desipramine hcl tab 50 mg ...... 42 DELESTROGEN INJ 10MG/ML ...... 114 desipramine hcl tab 75 mg ...... 42 DELESTROGEN INJ 20MG/ML ...... 114 181 desmopressin acetate nasal soln 0.01% dexamethasone tab 1.5 mg ...... 92 (refrigerated) ...... 113 dexamethasone tab 2 mg ...... 92 desmopressin acetate nasal spray soln dexamethasone tab 4 mg ...... 92 0.01% ...... 113 dexamethasone tab 6 mg ...... 92 desmopressin acetate nasal spray soln DEXEDRINE 0.01% (refrigerated) ...... 113 see dextroamphetamine sulfate cap desmopressin acetate tab 0.1 mg ... 113 er 24hr 10 mg ...... 8 desmopressin acetate tab 0.2 mg ... 113 see dextroamphetamine sulfate cap DESONATE er 24hr 15 mg ...... 8 see desonide gel 0.05% ...... 100 see dextroamphetamine sulfate cap desonide cream 0.05% ...... 100 er 24hr 5 mg ...... 8 desonide gel 0.05% ...... 100 dexedrine tab 10mg ...... 8 desonide lotion 0.05% ...... 100 dexedrine tab 5mg ...... 8 desonide oint 0.05% ...... 100 dexmethylphenidate hcl cap er 24 hr DESOWEN 10 mg ...... 10 see desonide cream 0.05% ...... 100 dexmethylphenidate hcl cap er 24 hr desoximetasone cream 0.05% ...... 100 15 mg ...... 10 desoximetasone cream 0.25% ...... 100 dexmethylphenidate hcl cap er 24 hr desoximetasone gel 0.05% ...... 100 20 mg ...... 10 desoximetasone oint 0.05% ...... 100 dexmethylphenidate hcl cap er 24 hr desoximetasone oint 0.25% ...... 100 25 mg ...... 10 desvenlafaxine succinate tab er 24hr dexmethylphenidate hcl cap er 24 hr 100 mg (base equiv) ...... 41 30 mg ...... 10 desvenlafaxine succinate tab er 24hr dexmethylphenidate hcl cap er 24 hr 25 mg (base equiv) ...... 41 35 mg ...... 10 desvenlafaxine succinate tab er 24hr dexmethylphenidate hcl cap er 24 hr 50 mg (base equiv) ...... 41 40 mg ...... 10 DETROL dexmethylphenidate hcl cap er 24 hr 5 see tolterodine tartrate tab 1 mg . 158 mg ...... 10 see tolterodine tartrate tab 2 mg . 158 dexmethylphenidate hcl tab 10 mg .. 11 DETROL LA dexmethylphenidate hcl tab 2.5 mg . 10 see tolterodine tartrate cap er 24hr 2 dexmethylphenidate hcl tab 5 mg .... 10 mg ...... 158 dextroamphetamine sulfate cap er 24hr see tolterodine tartrate cap er 24hr 4 10 mg ...... 8 mg ...... 158 dextroamphetamine sulfate cap er 24hr DEXAMETHASON CON 1MG/ML ...... 91 15 mg ...... 8 dexamethasone elixir 0.5 mg/5ml .... 91 dextroamphetamine sulfate cap er 24hr dexamethasone sodium phosphate inj 5 mg ...... 8 20 mg/5ml ...... 91 dextroamphetamine sulfate oral dexamethasone sodium phosphate inj solution 5 mg/5ml ...... 8 4 mg/ml ...... 91 DEX-TUSS LIQ 300-10/5 ...... 93 dexamethasone sodium phosphate DIASTAT ACDL GEL 12.5-20 ...... 33 ophth soln 0.1% ...... 142 DIASTAT ACDL GEL 5-10MG ...... 33 dexamethasone soln 0.5 mg/5ml ..... 92 DIASTAT PED GEL 2.5M GEL ...... 33 dexamethasone tab 0.5 mg ...... 92 DIASTIX TES STRIPS ...... 104 dexamethasone tab 0.75 mg ...... 92 diazepam con 5mg/ml ...... 25 dexamethasone tab 1 mg ...... 92 diazepam oral soln 1 mg/ml ...... 25 182 diazepam rectal gel delivery system 10 diethylpropion hcl tab 25 mg ...... 9 mg ...... 33 diethylpropion hcl tab er 24hr 75 mg .. 9 diazepam rectal gel delivery system 2.5 DIFFERIN mg ...... 33 see adapalene cream 0.1% ...... 94 diazepam rectal gel delivery system 20 see adapalene gel 0.3% ...... 94 mg ...... 33 DIFFERIN LOT 0.1% ...... 95 diazepam tab 10 mg ...... 25 DIFICID SUS ...... 125 diazepam tab 2 mg ...... 25 DIFICID TAB 200MG ...... 125 diazepam tab 5 mg ...... 25 diflorasone diacetate cream 0.05% 100 diazoxide susp 50 mg/ml ...... 44 diflorasone diacetate oint 0.05% .... 101 DIBENZYLINE DIFLUCAN see phenoxybenzamine hcl cap 10 see fluconazole for susp 10 mg/ml 48 mg ...... 53 see fluconazole for susp 40 mg/ml 48 DICLEGIS see fluconazole tab 100 mg ...... 49 see doxylamine-pyridoxine tab see fluconazole tab 150 mg ...... 49 delayed release 10-10 mg ...... 48 see fluconazole tab 200 mg ...... 49 diclofenac potassium tab 50 mg ...... 13 see fluconazole tab 50 mg ...... 49 diclofenac sodium (actinic keratoses) diflunisal tab 500 mg ...... 16 gel 3% ...... 98 digoxin oral soln 0.05 mg/ml ...... 84 diclofenac sodium gel 1% ...... 96 digoxin tab 125 mcg (0.125 mg)...... 84 diclofenac sodium ophth soln 0.1% 143 digoxin tab 250 mcg (0.25 mg) ...... 84 diclofenac sodium tab delayed release dihydroergotamine mesylate inj 1 25 mg ...... 13 mg/ml ...... 127 diclofenac sodium tab delayed release dihydroergotamine mesylate nasal 50 mg ...... 13 spray 4 mg/ml...... 128 diclofenac sodium tab delayed release DILANTIN 75 mg ...... 13 see phenytoin sodium extended cap diclofenac sodium tab er 24hr 100 mg 100 mg ...... 37 ...... 13 DILANTIN CAP 100MG ...... 37 diclofenac w/ misoprostol tab delayed DILANTIN CAP 30MG ...... 37 release 50-0.2 mg ...... 13 DILANTIN CHW 50MG ...... 37 diclofenac w/ misoprostol tab delayed DILANTIN INFATABS release 75-0.2 mg ...... 13 see phenytoin chew tab 50 mg ..... 37 dicloxacillin sodium cap 250 mg ..... 146 DILANTIN-125 dicloxacillin sodium cap 500 mg ..... 146 see phenytoin susp 125 mg/5ml ... 38 dicyclomine hcl cap 10 mg ...... 155 DILANTIN-125 SUS 125/5ML ...... 37 dicyclomine hcl oral soln 10 mg/5ml DILAUDID ...... 155 see hydromorphone hcl liqd 1 mg/ml dicyclomine hcl tab 20 mg ...... 155 ...... 16 didanosine delayed release capsule 125 see hydromorphone hcl tab 2 mg .. 17 mg ...... 76 see hydromorphone hcl tab 4 mg .. 17 didanosine delayed release capsule 200 see hydromorphone hcl tab 8 mg .. 17 mg ...... 76 diltiazem hcl cap er 12hr 120 mg ..... 82 didanosine delayed release capsule 250 diltiazem hcl cap er 12hr 60 mg ...... 82 mg ...... 76 diltiazem hcl cap er 12hr 90 mg ...... 82 didanosine delayed release capsule 400 diltiazem hcl cap er 24hr 120 mg ..... 82 mg ...... 76 diltiazem hcl cap er 24hr 180 mg ..... 82 183 diltiazem hcl cap er 24hr 240 mg ..... 82 see valsartan tab 80 mg ...... 54 diltiazem hcl coated beads cap er 24hr DIOVAN HCT 120 mg ...... 82 see valsartan-hydrochlorothiazide tab diltiazem hcl coated beads cap er 24hr 160-12.5 mg ...... 59 180 mg ...... 82 see valsartan-hydrochlorothiazide tab diltiazem hcl coated beads cap er 24hr 160-25 mg ...... 59 240 mg ...... 82 see valsartan-hydrochlorothiazide tab diltiazem hcl coated beads cap er 24hr 320-12.5 mg ...... 59 300 mg ...... 82 see valsartan-hydrochlorothiazide tab diltiazem hcl coated beads cap er 24hr 320-25 mg ...... 59 360 mg ...... 82 see valsartan-hydrochlorothiazide tab diltiazem hcl coated beads tab er 24hr 80-12.5 mg ...... 59 180 mg ...... 83 DIPENTUM CAP 250MG ...... 117 diltiazem hcl coated beads tab er 24hr diphenhydramine hcl cap 50 mg ...... 49 240 mg ...... 83 diphenoxylate w/ atropine liq 2.5-0.025 diltiazem hcl coated beads tab er 24hr mg/5ml ...... 46 300 mg ...... 83 diphenoxylate w/ atropine tab 2.5- diltiazem hcl coated beads tab er 24hr 0.025 mg ...... 46 360 mg ...... 83 DIPROLENE diltiazem hcl coated beads tab er 24hr see betamethasone dipropionate 420 mg ...... 83 augmented oint 0.05% ...... 99 diltiazem hcl extended release beads DIPROLENE AF cap er 24hr 120 mg ...... 83 see betamethasone dipropionate diltiazem hcl extended release beads augmented cream 0.05% ...... 99 cap er 24hr 180 mg ...... 83 dipyridamole tab 25 mg ...... 120 diltiazem hcl extended release beads dipyridamole tab 50 mg ...... 120 cap er 24hr 240 mg ...... 83 dipyridamole tab 75 mg ...... 120 diltiazem hcl extended release beads disopyramide phosphate cap 100 mg 25 cap er 24hr 300 mg ...... 83 disopyramide phosphate cap 150 mg 25 diltiazem hcl extended release beads disulfiram tab 250 mg ...... 146 cap er 24hr 360 mg ...... 83 disulfiram tab 500 mg ...... 146 diltiazem hcl extended release beads DITROPAN XL cap er 24hr 420 mg ...... 83 see oxybutynin chloride tab er 24hr diltiazem hcl tab 120 mg ...... 83 10 mg ...... 158 diltiazem hcl tab 30 mg ...... 83 see oxybutynin chloride tab er 24hr 5 diltiazem hcl tab 60 mg ...... 83 mg ...... 158 diltiazem hcl tab 90 mg ...... 83 DIURIL SUS 250/5ML ...... 107 dimethyl fumarate capsule delayed divalproex sodium cap delayed release release 120 mg ...... 148 sprinkle 125 mg ...... 38 dimethyl fumarate capsule delayed divalproex sodium tab delayed release release 240 mg ...... 148 125 mg ...... 38 dimethyl fumarate capsule dr starter divalproex sodium tab delayed release pack 120 mg & 240 mg ...... 149 250 mg ...... 38 DIOVAN divalproex sodium tab delayed release see valsartan tab 160 mg ...... 54 500 mg ...... 38 see valsartan tab 320 mg ...... 54 divalproex sodium tab er 24 hr 250 mg see valsartan tab 40 mg ...... 54 ...... 38 184 divalproex sodium tab er 24 hr 500 mg doxycycline (rosacea) cap delayed ...... 38 release 40 mg ...... 104 DIVIGEL GEL 0.25MG ...... 114 doxycycline hyclate cap 100 mg .... 150 DIVIGEL GEL 0.5MG ...... 114 doxycycline hyclate cap 50 mg ...... 150 DIVIGEL GEL 0.75MG ...... 115 doxycycline hyclate tab 100 mg ..... 150 DIVIGEL GEL 1.25MG ...... 115 doxycycline hyclate tab delayed release DIVIGEL GEL 1MG/GM ...... 115 100 mg ...... 151 dofetilide cap 125 mcg (0.125 mg) ... 26 doxycycline hyclate tab delayed release dofetilide cap 250 mcg (0.25 mg) .... 26 150 mg ...... 151 dofetilide cap 500 mcg (0.5 mg) ...... 26 doxycycline hyclate tab delayed release donepezil hydrochloride orally 200 mg ...... 151 disintegrating tab 10 mg ...... 146 doxycycline hyclate tab delayed release donepezil hydrochloride orally 50 mg ...... 150 disintegrating tab 5 mg ...... 146 doxycycline hyclate tab delayed release donepezil hydrochloride tab 10 mg . 146 75 mg ...... 151 donepezil hydrochloride tab 23 mg . 146 doxycycline monohydrate cap 100 mg donepezil hydrochloride tab 5 mg ... 146 ...... 151 DOPTELET TAB 20MG ...... 121 doxycycline monohydrate cap 150 mg DORYX ...... 151 see doxycycline hyclate tab delayed doxycycline monohydrate cap 50 mg release 200 mg ...... 151 ...... 151 see doxycycline hyclate tab delayed doxycycline monohydrate cap 75 mg release 50 mg ...... 150 ...... 151 dorzolamide hcl ophth soln 2% ...... 143 doxycycline monohydrate for susp 25 dorzolamide hcl-timolol maleate ophth mg/5ml ...... 151 sol 22.3-6.8 mg/ml pf ...... 140 doxycycline monohydrate tab 100 mg dorzolamide hcl-timolol maleate ophth ...... 151 soln 22.3-6.8 mg/ml ...... 140 doxycycline monohydrate tab 150 mg DOVATO TAB 50-300MG ...... 76 ...... 151 DOVONEX doxycycline monohydrate tab 50 mg see calcipotriene cream 0.005% .... 98 ...... 151 doxazosin mesylate tab 1 mg ...... 55 doxycycline monohydrate tab 75 mg doxazosin mesylate tab 2 mg ...... 55 ...... 151 doxazosin mesylate tab 4 mg ...... 55 doxylamine-pyridoxine tab delayed doxazosin mesylate tab 8 mg ...... 55 release 10-10 mg ...... 48 doxepin hcl cap 10 mg ...... 42 DRISDOL doxepin hcl cap 100 mg ...... 42 see ergocalciferol cap 1.25 mg doxepin hcl cap 150 mg ...... 42 (50000 unit) ...... 161 doxepin hcl cap 25 mg ...... 42 DRITHO-CREME CRE HP 1% ...... 98 doxepin hcl cap 50 mg ...... 42 dronabinol cap 10 mg ...... 48 doxepin hcl cap 75 mg ...... 42 dronabinol cap 2.5 mg ...... 48 doxepin hcl conc 10 mg/ml ...... 42 dronabinol cap 5 mg ...... 48 doxepin hcl cream 5% ...... 98 drospirenone-ethinyl estrad- doxercalciferol cap 0.5 mcg ...... 112 levomefolate tab 3-0.02-0.451 mg 89 doxercalciferol cap 1 mcg ...... 112 drospirenone-ethinyl estrad- doxercalciferol cap 2.5 mcg ...... 112 levomefolate tab 3-0.03-0.451 mg 89 DROXIA CAP 200MG ...... 120 185

DROXIA CAP 300MG ...... 120 see naproxen dr tab 500mg ...... 14 DROXIA CAP 400MG ...... 120 econazole nitrate cream 1% ...... 97 DRYSOL SOL 20% ...... 103 EDECRIN DUET DHA 400 MIS 25-1-400 ...... 135 see ethacrynic acid tab 25 mg .... 106 DUET DHA MIS BALANCED ...... 135 EDEX KIT 10MCG ...... 86 DUETACT EDEX KIT 20MCG ...... 86 see pioglitazone hcl-glimepiride tab EDEX KIT 40MCG ...... 86 30-2 mg...... 43 EDLUAR SUB 10MG ...... 123 see pioglitazone hcl-glimepiride tab EDLUAR SUB 5MG...... 123 30-4 mg...... 43 EDURANT TAB 25MG ...... 76 DULERA AER 100-5MCG ...... 28 efavirenz cap 200 mg ...... 76 DULERA AER 200-5MCG ...... 29 efavirenz cap 50 mg ...... 76 DULERA AER 50-5MCG ...... 28 efavirenz tab 600 mg ...... 76 duloxetine hcl enteric coated pellets efavirenz-emtricitabine-tenofovir df tab cap 20 mg (base eq) ...... 41 600-200-300 mg ...... 76 duloxetine hcl enteric coated pellets efavirenz-lamivudine-tenofovir df tab cap 30 mg (base eq) ...... 41 400-300-300 mg ...... 76 duloxetine hcl enteric coated pellets efavirenz-lamivudine-tenofovir df tab cap 60 mg (base eq) ...... 41 600-300-300 mg ...... 76 DUOPA SUS 4.63-20 ...... 68 EFFER-K TAB 10MEQ ...... 130 DUPIXENT INJ 300/2ML ...... 102 EFFER-K TAB 20MEQ ...... 130 DURAGESIC EFFEXOR XR see fentanyl td patch 72hr 100 see venlafaxine hcl cap er 24hr 150 mcg/hr ...... 16 mg (base equivalent) ...... 41 see fentanyl td patch 72hr 12 mcg/hr see venlafaxine hcl cap er 24hr 37.5 ...... 16 mg (base equivalent) ...... 41 see fentanyl td patch 72hr 25 mcg/hr see venlafaxine hcl cap er 24hr 75 ...... 16 mg (base equivalent) ...... 41 see fentanyl td patch 72hr 50 mcg/hr EFFIENT ...... 16 see prasugrel hcl tab 10 mg (base see fentanyl td patch 72hr 75 mcg/hr equiv) ...... 120 ...... 16 see prasugrel hcl tab 5 mg (base DUREZOL EMU 0.05% ...... 142 equiv) ...... 120 dutasteride cap 0.5 mg ...... 119 EFUDEX DYRENIUM see fluorouracil cream 5% ...... 98 see triamterene cap 100 mg ...... 107 EGRIFTA SOL 1MG ...... 111 see triamterene cap 50 mg ...... 106 EGRIFTA SOL 2MG ...... 111 E ELESTRIN GEL 0.06% ...... 115 e.e.s. 400 tab 400mg ...... 125 eletriptan hydrobromide tab 20 mg E.E.S. GRANULES (base equivalent) ...... 128 see erythromycin ethylsuccinate for eletriptan hydrobromide tab 40 mg susp 200 mg/5ml ...... 125 (base equivalent) ...... 128 EASY TOUCH MIS 30G ...... 126 ELIDEL EASYMAX SOL HIGH ...... 126 see pimecrolimus cream 1% ...... 103 EASYMAX SOL LOW ...... 126 ELIMITE EC-NAPROSYN see permethrin cream 5% ...... 104 see naproxen dr tab 375mg ...... 14 ELIQUIS TAB 2.5MG ...... 30 186

ELIQUIS TAB 5MG ...... 30 ENJUVIA TAB 0.3MG ...... 115 elite-ob tab ...... 135 ENJUVIA TAB 0.45MG ...... 115 ELIXOPHYLLIN ELX 80/15ML ...... 30 ENJUVIA TAB 0.625MG ...... 115 ELLA TAB 30MG ...... 91 ENJUVIA TAB 0.9MG ...... 115 ELMIRON CAP 100MG ...... 119 ENJUVIA TAB 1.25MG ...... 115 eluryng mis ...... 91 enoxaparin sodium inj 100 mg/ml .... 31 EMCYT CAP 140MG ...... 62 enoxaparin sodium inj 120 mg/0.8ml 31 EMEND enoxaparin sodium inj 150 mg/ml .... 31 see aprepitant capsule 80 mg ...... 48 enoxaparin sodium inj 30 mg/0.3ml . 31 EMEND SUS 125MG ...... 48 enoxaparin sodium inj 300 mg/3ml .. 31 EMSAM DIS 12MG/24H ...... 39 enoxaparin sodium inj 40 mg/0.4ml . 31 EMSAM DIS 6MG/24HR ...... 39 enoxaparin sodium inj 60 mg/0.6ml . 31 EMSAM DIS 9MG/24HR ...... 39 enoxaparin sodium inj 80 mg/0.8ml . 31 emtricitabine caps 200 mg ...... 76 enpresse-28 tab ...... 89 emtricitabine-tenofovir disoproxil ENSPRYNG INJ ...... 131 fumarate tab 100-150 mg ...... 76 entacapone tab 200 mg ...... 67 emtricitabine-tenofovir disoproxil entecavir tab 0.5 mg ...... 79 fumarate tab 133-200 mg ...... 76 entecavir tab 1 mg ...... 79 emtricitabine-tenofovir disoproxil ENTOCORT EC fumarate tab 167-250 mg ...... 76 see budesonide delayed release emtricitabine-tenofovir disoproxil particles cap 3 mg ...... 91 fumarate tab 200-300 mg ...... 76 ENTRESTO TAB 24-26MG ...... 85 EMTRIVA ENTRESTO TAB 49-51MG ...... 85 see emtricitabine caps 200 mg ...... 76 ENTRESTO TAB 97-103MG ...... 85 EMTRIVA SOL 10MG/ML ...... 76 EPIDUO ENABLEX see adapalene-benzoyl peroxide gel see darifenacin hydrobromide tab er 0.1-2.5% ...... 94 24hr 15 mg (base equiv) ...... 157 epinastine hcl ophth soln 0.05% .... 143 enalapril maleate & hydrochlorothiazide epinephrine solution auto-injector 0.15 tab 10-25 mg ...... 57 mg/0.15ml (1:1000) ...... 160 enalapril maleate & hydrochlorothiazide epinephrine solution auto-injector 0.15 tab 5-12.5 mg ...... 57 mg/0.3ml (1:2000) ...... 160 enalapril maleate tab 10 mg ...... 53 epinephrine solution auto-injector 0.3 enalapril maleate tab 2.5 mg ...... 52 mg/0.3ml (1:1000) ...... 160 enalapril maleate tab 20 mg ...... 53 EPIPEN 2-PAK INJ 0.3MG ...... 160 enalapril maleate tab 5 mg ...... 53 EPIPEN-JR 2-PAK ENBRACE HR CAP ...... 135 see epinephrine solution auto- ENBREL INJ 25/0.5ML ...... 15 injector 0.15 mg/0.3ml (1:2000) ENBREL INJ 25MG ...... 15 ...... 160 ENBREL INJ 50MG/ML ...... 15 EPIPEN-JR INJ 0.15MG ...... 160 ENBREL MINI INJ 50MG/ML ...... 15 EPIVIR ENBREL SRCLK INJ 50MG/ML...... 15 see lamivudine oral soln 10 mg/ml 77 ENCARE SUP 100MG ...... 158 see lamivudine tab 150 mg ...... 77 ENDOMETRIN SUP 100MG ...... 160 see lamivudine tab 300 mg ...... 77 ENFA NUTRAMI CON LIPIL ...... 105 EPIVIR HBV ENFAMIL ENFA POW LIPIL ...... 105 see lamivudine tab 100 mg (hbv) .. 79 ENFAMIL PREM LIQ LIPIL ...... 105 EPIVIR HBV SOL 5MG/ML ...... 79 187 eplerenone tab 25 mg ...... 59 erythromycin w/ delayed release eplerenone tab 50 mg ...... 59 particles cap 250 mg ...... 125 EPOGEN INJ 10000/ML ...... 121 ESBRIET CAP 267MG ...... 150 EPOGEN INJ 2000/ML ...... 121 ESBRIET TAB 267MG ...... 150 EPOGEN INJ 20000/ML ...... 121 ESBRIET TAB 801MG ...... 150 EPOGEN INJ 3000/ML ...... 121 ESCAVITE D CHW ...... 134 EPOGEN INJ 4000/ML ...... 121 escitalopram oxalate soln 5 mg/5ml eprosartan mesylate tab 600 mg ...... 54 (base equiv) ...... 39 EPZICOM escitalopram oxalate tab 10 mg (base see abacavir sulfate-lamivudine tab equiv) ...... 39 600-300 mg ...... 75 escitalopram oxalate tab 20 mg (base EQUETRO CAP 100MG ...... 69 equiv) ...... 39 EQUETRO CAP 200MG ...... 69 escitalopram oxalate tab 5 mg (base EQUETRO CAP 300MG ...... 69 equiv) ...... 39 ergocalciferol cap 1.25 mg (50000 unit) ESGIC ...... 161 see butalbital-acetaminophen- ergotamine w/ caffeine tab 1-100 mg caffeine tab 50-325-40 mg ...... 15 ...... 127 esomeprazole magnesium cap delayed ERIVEDGE CAP 150MG ...... 61 release 40 mg (base eq) ...... 156 ERLEADA TAB 60MG ...... 62 estazolam tab 1 mg ...... 123 erlotinib hcl tab 100 mg (base estazolam tab 2 mg ...... 123 equivalent)...... 63 ESTRACE erlotinib hcl tab 150 mg (base see estradiol tab 0.5 mg ...... 115 equivalent)...... 63 see estradiol tab 1 mg ...... 115 erlotinib hcl tab 25 mg (base see estradiol tab 2 mg ...... 115 equivalent)...... 63 see estradiol vaginal cream 0.1 errin tab 0.35mg ...... 91 mg/gm ...... 159 ERTACZO CRE 2% ...... 97 estradiol & norethindrone acetate tab ery pad 2% ...... 95 0.5-0.1 mg ...... 114 ERYGEL estradiol & norethindrone acetate tab see erythromycin gel 2% ...... 95 1-0.5 mg ...... 114 ERYPED 400 estradiol tab 0.5 mg ...... 115 see erythromycin ethylsuccinate for estradiol tab 1 mg ...... 115 susp 400 mg/5ml ...... 125 estradiol tab 2 mg ...... 115 ery-tab tab 250mg ec ...... 125 estradiol td patch twice weekly 0.025 ery-tab tab 333mg ec ...... 125 mg/24hr ...... 115 ery-tab tab 500mg ec ...... 125 estradiol td patch twice weekly 0.0375 erythrocin tab 250mg ...... 125 mg/24hr ...... 115 erythromycin ethylsuccinate for susp estradiol td patch twice weekly 0.05 200 mg/5ml ...... 125 mg/24hr ...... 115 erythromycin ethylsuccinate for susp estradiol td patch twice weekly 0.075 400 mg/5ml ...... 125 mg/24hr ...... 115 erythromycin gel 2% ...... 95 estradiol td patch twice weekly 0.1 erythromycin ophth oint 5 mg/gm .. 141 mg/24hr ...... 115 erythromycin soln 2% ...... 95 estradiol td patch weekly 0.025 erythromycin tab 250 mg ...... 125 mg/24hr ...... 115 erythromycin tab 500 mg ...... 125 188 estradiol td patch weekly 0.0375 EVISTA mg/24hr (37.5 mcg/24hr) ...... 115 see raloxifene hcl tab 60 mg...... 112 estradiol td patch weekly 0.05 mg/24hr EVOCLIN ...... 115 see clindamycin phosphate foam 1% estradiol td patch weekly 0.06 mg/24hr ...... 95 ...... 115 EVOTAZ TAB 300-150 ...... 76 estradiol td patch weekly 0.075 EVOXAC mg/24hr ...... 115 see cevimeline hcl cap 30 mg ..... 133 estradiol td patch weekly 0.1 mg/24hr EXELON ...... 115 see rivastigmine td patch 24hr 13.3 estradiol vaginal cream 0.1 mg/gm 159 mg/24hr ...... 147 estradiol valerate im in oil 20 mg/ml see rivastigmine td patch 24hr 4.6 ...... 115 mg/24hr ...... 147 estradiol valerate im in oil 40 mg/ml see rivastigmine td patch 24hr 9.5 ...... 115 mg/24hr ...... 147 ESTRING MIS 2MG ...... 159 exemestane tab 25 mg ...... 62 ESTROGEL GEL ...... 115 EXFORGE estropipate tab 0.75 mg ...... 115 see amlodipine besylate-valsartan estropipate tab 1.5 mg ...... 115 tab 10-160 mg ...... 56 estropipate tab 3 mg ...... 115 see amlodipine besylate-valsartan ESTROSTEP FE tab 10-320 mg ...... 56 see tilia fe tab ...... 90 see amlodipine besylate-valsartan see tri-legest tab fe ...... 90 tab 5-160 mg ...... 56 eszopiclone tab 1 mg ...... 123 see amlodipine besylate-valsartan eszopiclone tab 2 mg ...... 123 tab 5-320 mg ...... 56 eszopiclone tab 3 mg ...... 123 EXJADE ethacrynic acid tab 25 mg ...... 106 see deferasirox tab for oral susp 125 ethambutol hcl tab 100 mg ...... 60 mg ...... 47 ethambutol hcl tab 400 mg ...... 60 see deferasirox tab for oral susp 250 ethosuximide cap 250 mg ...... 38 mg ...... 47 ethosuximide soln 250 mg/5ml ...... 38 see deferasirox tab for oral susp 500 etodolac cap 200 mg ...... 13 mg ...... 47 etodolac cap 300 mg ...... 13 EXTINA etodolac tab 400 mg ...... 14 see ketoconazole foam 2% ...... 97 etodolac tab 500 mg ...... 14 ezetimibe tab 10 mg ...... 52 etodolac tab er 24hr 400 mg ...... 14 ezetimibe-simvastatin tab 10-10 mg 49 etodolac tab er 24hr 500 mg ...... 14 ezetimibe-simvastatin tab 10-20 mg 50 etodolac tab er 24hr 600 mg ...... 14 ezetimibe-simvastatin tab 10-40 mg 50 etoposide cap 50 mg ...... 67 ezetimibe-simvastatin tab 10-80 mg 50 EURAX CRE 10% ...... 104 F EVAMIST SPR 1.53MG ...... 115 FACTIVE TAB 320MG ...... 116 everolimus tab 0.25 mg ...... 131 FALESSA KIT ...... 89 everolimus tab 0.5 mg ...... 131 famciclovir tab 125 mg ...... 79 everolimus tab 0.75 mg ...... 132 famciclovir tab 250 mg ...... 79 everolimus tab 2.5 mg ...... 64 famciclovir tab 500 mg ...... 79 everolimus tab 5 mg ...... 64 famotidine for susp 40 mg/5ml ...... 156 everolimus tab 7.5 mg ...... 64 famotidine tab 20 mg ...... 156 189 famotidine tab 40 mg ...... 156 fenofibrate tab 120 mg ...... 51 FANAPT PAK ...... 70 fenofibrate tab 145 mg ...... 51 FANAPT TAB 10MG ...... 70 fenofibrate tab 160 mg ...... 51 FANAPT TAB 12MG ...... 70 fenofibrate tab 40 mg ...... 51 FANAPT TAB 1MG ...... 70 fenofibrate tab 48 mg ...... 51 FANAPT TAB 2MG ...... 70 fenofibrate tab 54 mg ...... 51 FANAPT TAB 4MG ...... 70 fenofibric acid tab 105 mg ...... 51 FANAPT TAB 6MG ...... 70 fenofibric acid tab 35 mg ...... 51 FANAPT TAB 8MG ...... 70 FENOGLIDE FARESTON see fenofibrate tab 120 mg ...... 51 see toremifene citrate tab 60 mg see fenofibrate tab 40 mg ...... 51 (base equivalent) ...... 62 fenoprofen calcium cap 400 mg ...... 14 FARXIGA TAB 10MG ...... 46 fenoprofen calcium tab 600 mg ...... 14 FARXIGA TAB 5MG ...... 46 fentanyl citrate lozenge on a handle FC FEMALE MIS CONDOM ...... 125 1200 mcg ...... 16 febuxostat tab 40 mg ...... 119 fentanyl citrate lozenge on a handle febuxostat tab 80 mg ...... 119 1600 mcg ...... 16 felbamate susp 600 mg/5ml ...... 37 fentanyl citrate lozenge on a handle felbamate tab 400 mg ...... 37 200 mcg ...... 16 felbamate tab 600 mg ...... 37 fentanyl citrate lozenge on a handle FELBATOL 400 mcg ...... 16 see felbamate susp 600 mg/5ml ... 37 fentanyl citrate lozenge on a handle see felbamate tab 400 mg ...... 37 600 mcg ...... 16 see felbamate tab 600 mg ...... 37 fentanyl citrate lozenge on a handle FELDENE 800 mcg ...... 16 see piroxicam cap 10 mg ...... 15 fentanyl td patch 72hr 100 mcg/hr ... 16 see piroxicam cap 20 mg ...... 15 fentanyl td patch 72hr 12 mcg/hr .... 16 felodipine tab er 24hr 10 mg ...... 83 fentanyl td patch 72hr 25 mcg/hr .... 16 felodipine tab er 24hr 2.5 mg ...... 83 fentanyl td patch 72hr 50 mcg/hr .... 16 felodipine tab er 24hr 5 mg ...... 83 fentanyl td patch 72hr 75 mcg/hr .... 16 FEMARA FER-IN-SOL DRO 15MG/ML ...... 122 see letrozole tab 2.5 mg ...... 62 ferocon cap ...... 122 FEMCAP MIS 22MM ...... 125 FERPRX 2-DAY TAB 1000MG ...... 47 FEMCAP MIS 26MM ...... 125 FERRALET 90 TAB ...... 122 FEMCAP MIS 30MM ...... 125 FERRAPLUS 90 TAB ...... 122 FEMHRT FERRIPROX see norethindrone acetate-ethinyl see deferiprone tab 500 mg ...... 47 estradiol tab 0.5 mg-2.5 mcg ... 114 FERRIPROX SOL 100MG/ML ...... 47 FEMRING MIS 0.05/24H ...... 159 FERRIPROX TAB 1000MG ...... 47 FEMRING MIS 0.1MG/24 ...... 159 FERRIPROX TAB 500MG ...... 47 fenofibrate cap 150 mg ...... 50 ferrogels fo cap forte ...... 122 fenofibrate cap 50 mg ...... 50 FERROUS SULF SYP 300/5ML ...... 122 fenofibrate micronized cap 130 mg ... 50 ferrous sulfate elixir 220 mg/5ml (44 fenofibrate micronized cap 134 mg ... 50 mg/5ml elemental fe) ...... 122 fenofibrate micronized cap 200 mg ... 51 FIASP FLEX INJ TOUCH ...... 45 fenofibrate micronized cap 43 mg .... 50 FIASP INJ 100/ML ...... 45 fenofibrate micronized cap 67 mg .... 50 FIASP PENFIL INJ U-100 ...... 45 190

FIBRICOR TAB 105MG ...... 51 fluocinolone acetonide oil 0.01% (scalp FINACEA oil) ...... 101 see azelaic acid gel 15% ...... 104 fluocinolone acetonide oint 0.025% 101 FINACEA AER 15% ...... 104 fluocinolone acetonide soln 0.01% . 101 finasteride tab 5 mg ...... 119 fluocinonide cream 0.05% ...... 101 FINTEPLA SOL 2.2MG/ML ...... 34 fluocinonide cream 0.1% ...... 101 FIORICET fluocinonide emulsified base cream see butalbital-acetaminophen- 0.05% ...... 101 caffeine cap 50-300-40 mg ...... 15 fluocinonide gel 0.05% ...... 101 FIRST-MOUTHW SUS BLM ...... 133 fluocinonide oint 0.05% ...... 101 FIRVANQ SOL 25MG/ML ...... 22 fluocinonide soln 0.05% ...... 101 FIRVANQ SOL 50MG/ML ...... 22 FLUORABON DRO ...... 130 FLAGYL FLUOR-A-DAY CHW 0.25MG F ...... 130 see metronidazole cap 375 mg ...... 21 FLUOR-A-DAY CHW 0.5MG F ...... 130 see metronidazole tab 500 mg ...... 21 FLUOR-A-DAY CHW 1MG F ...... 130 FLAGYL ER TAB 750MG ...... 21 fluoridex dd pst sensitiv ...... 133 FLAREX SUS 0.1% OP ...... 142 fluorometholone ophth susp 0.1%.. 142 flecainide acetate tab 100 mg ...... 25 FLUOROPLEX CRE 1% ...... 98 flecainide acetate tab 150 mg ...... 25 fluorouracil cream 0.5% ...... 98 flecainide acetate tab 50 mg...... 25 fluorouracil cream 5% ...... 98 FLOMAX fluorouracil soln 2% ...... 98 see tamsulosin hcl cap 0.4 mg .... 119 fluorouracil soln 5% ...... 98 FLOVENT DISK AER 100MCG ...... 27 fluoxetine hcl (pmdd) tab 10 mg .... 149 FLOVENT DISK AER 250MCG ...... 27 fluoxetine hcl (pmdd) tab 20 mg .... 149 FLOVENT DISK AER 50MCG ...... 27 fluoxetine hcl cap 10 mg ...... 39 FLOVENT HFA AER 110MCG ...... 27 fluoxetine hcl cap 20 mg ...... 39 FLOVENT HFA AER 220MCG ...... 27 fluoxetine hcl cap 40 mg ...... 40 FLOVENT HFA AER 44MCG ...... 27 fluoxetine hcl cap delayed release 90 fluconazole for susp 10 mg/ml ...... 48 mg ...... 40 fluconazole for susp 40 mg/ml ...... 48 fluoxetine hcl solution 20 mg/5ml .... 40 fluconazole tab 100 mg ...... 49 fluoxetine hcl tab 10 mg ...... 40 fluconazole tab 150 mg ...... 49 fluoxetine hcl tab 20 mg ...... 40 fluconazole tab 200 mg ...... 49 fluoxetine hcl tab 60 mg ...... 40 fluconazole tab 50 mg ...... 49 FLUOXETINE HYDROCHLORIDE flucytosine cap 250 mg ...... 48 see fluoxetine hcl tab 60 mg ...... 40 flucytosine cap 500 mg ...... 48 fluphenazine decanoate inj 25 mg/ml 74 fludrocortisone acetate tab 0.1 mg ... 93 fluphenazine hcl elixir 2.5 mg/5ml ... 74 flunisolide nasal soln 25 mcg/act fluphenazine hcl oral conc 5 mg/ml .. 74 (0.025%) ...... 139 fluphenazine hcl tab 1 mg ...... 74 fluocinolone acetonide (otic) oil 0.01% fluphenazine hcl tab 10 mg ...... 74 ...... 144 fluphenazine hcl tab 2.5 mg ...... 74 fluocinolone acetonide cream 0.01% fluphenazine hcl tab 5 mg ...... 74 ...... 101 flura-drops dro 0.125mg ...... 130 fluocinolone acetonide cream 0.025% flura-drops dro 0.25mg f ...... 130 ...... 101 flurandrenolide cream 0.05% ...... 101 fluocinolone acetonide oil 0.01% (body flurandrenolide lotion 0.05% ...... 101 oil) ...... 101 flurandrenolide oint 0.05% ...... 101 191 flurazepam hcl cap 15 mg ...... 123 see dexmethylphenidate hcl cap er flurazepam hcl cap 30 mg ...... 123 24 hr 15 mg ...... 10 flurbiprofen sodium ophth soln 0.03% see dexmethylphenidate hcl cap er ...... 143 24 hr 20 mg ...... 10 flurbiprofen tab 100 mg ...... 14 see dexmethylphenidate hcl cap er flurbiprofen tab 50 mg ...... 14 24 hr 25 mg ...... 10 flutamide cap 125 mg ...... 62 see dexmethylphenidate hcl cap er fluticasone propionate cream 0.05% 24 hr 30 mg ...... 10 ...... 101 see dexmethylphenidate hcl cap er fluticasone propionate lotion 0.05% 101 24 hr 35 mg ...... 10 fluticasone propionate nasal susp 50 see dexmethylphenidate hcl cap er mcg/act ...... 139 24 hr 40 mg ...... 10 fluticasone propionate oint 0.005% 101 see dexmethylphenidate hcl cap er fluticasone-salmeterol aer powder ba 24 hr 5 mg ...... 10 100-50 mcg/dose ...... 29 FOLBEE AR TAB ...... 105 fluticasone-salmeterol aer powder ba folbee plus tab ...... 134 113-14 mcg/act ...... 29 folbee plus tab cz ...... 134 fluticasone-salmeterol aer powder ba folbic tab ...... 105 232-14 mcg/act ...... 29 FOLCAPS CAP OMEGA 3 ...... 135 fluticasone-salmeterol aer powder ba FOLET DHA PAK ...... 135 250-50 mcg/dose ...... 29 FOLET ONE CAP 38-1-225 ...... 135 fluticasone-salmeterol aer powder ba FOLGARD OS TAB ...... 134 500-50 mcg/dose ...... 29 folic acid tab 1 mg ...... 121 fluticasone-salmeterol aer powder ba folic acid tab 400 mcg ...... 121 55-14 mcg/act ...... 29 folic acid tab 800 mcg ...... 121 fluvoxamine maleate cap er 24hr 100 FOLIVANE-PLS CAP ...... 122 mg ...... 40 FOLLISTIM AQ INJ 300UNIT ...... 108 fluvoxamine maleate cap er 24hr 150 FOLLISTIM AQ INJ 600UNIT ...... 109 mg ...... 40 FOLLISTIM AQ INJ 900UNIT ...... 109 fluvoxamine maleate tab 100 mg ..... 40 folplex 2.2 tab ...... 122 fluvoxamine maleate tab 25 mg ...... 40 fondaparinux sodium subcutaneous inj fluvoxamine maleate tab 50 mg ...... 40 10 mg/0.8ml ...... 31 FML FORTE SUS 0.25% OP ...... 142 fondaparinux sodium subcutaneous inj FML OIN 0.1% OP ...... 142 2.5 mg/0.5ml ...... 31 FOCALGIN 90 MIS DHA ...... 135 fondaparinux sodium subcutaneous inj FOCALGIN CA MIS ...... 135 5 mg/0.4ml ...... 31 FOCALIN fondaparinux sodium subcutaneous inj see dexmethylphenidate hcl tab 10 7.5 mg/0.6ml ...... 31 mg ...... 11 FORADIL CAP AEROLIZE ...... 29 see dexmethylphenidate hcl tab 2.5 FORTAVIT CAP ...... 134 mg ...... 10 FORTEO INJ 620/2.48 ...... 107 see dexmethylphenidate hcl tab 5 mg FORTICAL SPR 200/ACT ...... 107 ...... 10 FOSAMAX FOCALIN XR see alendronate sodium tab 70 mg see dexmethylphenidate hcl cap er ...... 107 24 hr 10 mg ...... 10 fosamprenavir calcium tab 700 mg (base equiv) ...... 76 192 fosfomycin tromethamine powd pack 3 galantamine hydrobromide cap er 24hr gm (base equivalent) ...... 23 8 mg ...... 146 fosinopril sodium & hydrochlorothiazide galantamine hydrobromide oral soln 4 tab 10-12.5 mg ...... 57 mg/ml ...... 147 fosinopril sodium & hydrochlorothiazide galantamine hydrobromide tab 12 mg tab 20-12.5 mg ...... 57 ...... 147 fosinopril sodium tab 10 mg ...... 53 galantamine hydrobromide tab 4 mg fosinopril sodium tab 20 mg ...... 53 ...... 147 fosinopril sodium tab 40 mg ...... 53 galantamine hydrobromide tab 8 mg FOSRENOL ...... 147 see lanthanum carbonate chew tab GANIRELIX ACETATE 1000 mg (elemental) ...... 118 see ganirelix acetate soln prefilled see lanthanum carbonate chew tab syringe 250 mcg/0.5ml ...... 111 500 mg (elemental) ...... 118 ganirelix acetate soln prefilled syringe see lanthanum carbonate chew tab 250 mcg/0.5ml ...... 111 750 mg (elemental) ...... 118 GASTROCROM FOSRENOL POW 1000MG ...... 118 see cromolyn sodium oral conc 100 FRAGMIN INJ 10000/ML ...... 31 mg/5ml ...... 117 FRAGMIN INJ 12500UNT ...... 31 gatifloxacin ophth soln 0.5% ...... 141 FRAGMIN INJ 15000UNT ...... 31 GATTEX KIT 5MG ...... 118 FRAGMIN INJ 18000UNT ...... 31 GAVRETO CAP 100MG ...... 64 FRAGMIN INJ 2500/0.2 ...... 31 GELCLAIR GEL ...... 133 FRAGMIN INJ 5000/0.2 ...... 31 GELNIQUE GEL 10% ...... 158 FRAGMIN INJ 7500/0.3 ...... 31 GELNIQUE GEL 3% ...... 157 FRAGMIN INJ 95000UNT ...... 31 gemfibrozil tab 600 mg ...... 51 furosemide oral soln 10 mg/ml ...... 106 GENERESS FE furosemide tab 20 mg ...... 106 see layolis fe chw ...... 89 furosemide tab 40 mg ...... 106 GENOTROPIN INJ 0.2MG ...... 111 furosemide tab 80 mg ...... 106 GENOTROPIN INJ 0.4MG ...... 111 FUZEON INJ 90MG ...... 76 GENOTROPIN INJ 0.6MG ...... 111 G GENOTROPIN INJ 0.8MG ...... 111 gabapentin cap 100 mg ...... 34 GENOTROPIN INJ 1.2MG ...... 111 gabapentin cap 300 mg ...... 34 GENOTROPIN INJ 1.4MG ...... 111 gabapentin cap 400 mg ...... 34 GENOTROPIN INJ 1.6MG ...... 111 gabapentin oral soln 250 mg/5ml ..... 34 GENOTROPIN INJ 1.8MG ...... 111 gabapentin tab 600 mg ...... 34 GENOTROPIN INJ 12MG ...... 111 gabapentin tab 800 mg ...... 34 GENOTROPIN INJ 1MG ...... 111 GABITRIL GENOTROPIN INJ 2MG ...... 111 see tiagabine hcl tab 12 mg ...... 37 gentak oin 0.3% op ...... 141 see tiagabine hcl tab 16 mg ...... 37 gentamicin sulfate cream 0.1% ...... 97 see tiagabine hcl tab 2 mg ...... 37 gentamicin sulfate inj 40 mg/ml ...... 12 see tiagabine hcl tab 4 mg ...... 37 gentamicin sulfate oint 0.1% ...... 97 galantamine hydrobromide cap er 24hr gentamicin sulfate ophth soln 0.3% 141 16 mg ...... 147 GENVOYA TAB ...... 76 galantamine hydrobromide cap er 24hr GEODON 24 mg ...... 147 see ziprasidone hcl cap 20 mg ...... 70 see ziprasidone hcl cap 40 mg ...... 70 193

see ziprasidone hcl cap 60 mg ...... 70 glyburide tab 2.5 mg ...... 46 see ziprasidone hcl cap 80 mg ...... 70 glyburide tab 5 mg ...... 46 gianvi tab 3-0.02mg ...... 89 glyburide-metformin tab 1.25-250 mg GILENYA CAP 0.5MG ...... 149 ...... 43 GILOTRIF TAB 20MG ...... 64 glyburide-metformin tab 2.5-500 mg 43 GILOTRIF TAB 30MG ...... 64 glyburide-metformin tab 5-500 mg .. 43 GILOTRIF TAB 40MG ...... 64 glycopyrrolate tab 1 mg...... 155 GLEEVEC glycopyrrolate tab 2 mg...... 155 see imatinib mesylate tab 100 mg GLYNASE (base equivalent) ...... 64 see glyburide micronized tab 1.5 mg see imatinib mesylate tab 400 mg ...... 46 (base equivalent) ...... 64 see glyburide micronized tab 3 mg 46 GLEOSTINE CAP 5MG ...... 60 see glyburide micronized tab 6 mg 46 glimepiride tab 1 mg ...... 46 GLYXAMBI TAB 10-5 MG ...... 43 glimepiride tab 2 mg ...... 46 GLYXAMBI TAB 25-5 MG ...... 43 glimepiride tab 4 mg ...... 46 GOLYTELY glipizide tab 10 mg ...... 46 see peg 3350-kcl-na bicarb-nacl-na glipizide tab 5 mg ...... 46 sulfate for soln 236 gm ...... 124 glipizide tab er 24hr 10 mg ...... 46 GOLYTELY SOL ...... 124 glipizide tab er 24hr 5 mg ...... 46 granisetron hcl tab 1 mg...... 47 glipizide xl tab 2.5mg ...... 46 griseofulvin microsize susp 125 mg/5ml glipizide-metformin hcl tab 2.5-250 mg ...... 48 ...... 43 griseofulvin microsize tab 500 mg .... 48 glipizide-metformin hcl tab 2.5-500 mg griseofulvin ultramicrosize tab 125 mg ...... 43 ...... 48 glipizide-metformin hcl tab 5-500 mg43 griseofulvin ultramicrosize tab 250 mg GLUC CONTROL LIQ NORMAL ...... 126 ...... 48 glucagon (rdna) for inj kit 1 mg ...... 44 guanfacine hcl tab 1 mg ...... 55 GLUCAGON EMERGENCY KIT guanfacine hcl tab 2 mg ...... 55 see glucagon (rdna) for inj kit 1 mg guanfacine hcl tab er 24hr 1 mg (base ...... 44 equiv) ...... 9 GLUCAGON EMR SOL 1MG ...... 44 guanfacine hcl tab er 24hr 2 mg (base GLUCOSE BITS CHW 1GM ...... 44 equiv) ...... 10 GLUCOSE CHW 4GM ...... 44 guanfacine hcl tab er 24hr 3 mg (base GLUCOSE CHW RASPBERY ...... 44 equiv) ...... 10 glucose drnk liq 15/59ml ...... 44 guanfacine hcl tab er 24hr 4 mg (base glucose gel 40% ...... 44 equiv) ...... 10 GLUCOTROL GVOKE HYPO 1 INJ .5/.1ML ...... 44 see glipizide tab 10 mg ...... 46 GVOKE HYPO 1 INJ 1MG/.2ML ...... 44 GLUCOTROL XL GVOKE PFS INJ ...... 44 see glipizide tab er 24hr 10 mg ..... 46 GYNAZOLE-1 CRE 2% ...... 159 see glipizide tab er 24hr 5 mg ...... 46 GYNOL II GEL 3% ...... 158 see glipizide xl tab 2.5mg ...... 46 H glyburide micronized tab 1.5 mg ...... 46 HALCION glyburide micronized tab 3 mg ...... 46 see triazolam tab 0.25 mg ...... 123 glyburide micronized tab 6 mg ...... 46 HALDOL glyburide tab 1.25 mg ...... 46 see haloperidol lactate inj 5 mg/ml 72 194

HALDOL DECAN INJ 100MG/ML ...... 71 heparin sodium (porcine) lock flush iv HALDOL DECAN INJ 50MG/ML ...... 71 soln 100 unit/ml ...... 32 HALDOL DECANOATE 100 heparin sodium (porcine) lock flush iv see haloperidol decanoate im soln soln 2 unit/ml ...... 32 100 mg/ml ...... 72 heparin sodium (porcine) pf inj 5000 HALDOL DECANOATE 50 unit/0.5ml ...... 32 see haloperidol decanoate im soln 50 heparin sodium (porcine)-dextrose iv mg/ml ...... 71 sol 20000 unit/500ml-5% ...... 32 HALDOL INJ 5MG/ML ...... 71 heparin sodium (porcine)-dextrose iv halobetasol propionate cream 0.05% sol 25000 unit/500ml-5% ...... 32 ...... 101 HEPARIN/D5W INJ 25000UNT ...... 32 halobetasol propionate oint 0.05% . 101 HEPSERA haloperidol decanoate im soln 100 see adefovir dipivoxil tab 10 mg .... 79 mg/ml ...... 72 HEXALEN CAP 50MG ...... 61 haloperidol decanoate im soln 50 HIPREX mg/ml ...... 71 see methenamine hippurate tab 1 gm haloperidol lactate inj 5 mg/ml ...... 72 ...... 157 haloperidol lactate oral conc 2 mg/ml72 homatropine hbr ophth soln 5% .... 140 haloperidol tab 0.5 mg ...... 72 HUMATIN haloperidol tab 1 mg ...... 72 see paromomycin sulfate cap 250 mg haloperidol tab 10 mg ...... 72 ...... 12 haloperidol tab 2 mg ...... 72 HUMATROPE INJ 12MG ...... 111 haloperidol tab 20 mg ...... 72 HUMATROPE INJ 24MG ...... 111 haloperidol tab 5 mg ...... 72 HUMATROPE INJ 5MG ...... 111 HEMENATAL OB MIS + DHA ...... 135 HUMATROPE INJ 6MG ...... 111 hep flush-10 inj 10unt/ml ...... 31 HUMIRA INJ 10/0.1ML ...... 12 HEP SOD/NACL INJ 25000UNT ...... 31 HUMIRA INJ 10MG/0.2 ...... 12 heparin sod (porcine)-nacl iv soln 1000 HUMIRA INJ 20/0.2ML ...... 12 unit/500ml-0.9% ...... 31 HUMIRA INJ 40/0.4ML ...... 12 HEPARIN SOD INJ 2000/ML ...... 31 HUMIRA KIT 20MG/0.4 ...... 12 HEPARIN SOD INJ 2500/ML ...... 31 HUMIRA KIT 40MG/0.8 ...... 12 heparin sod lock flush & nacl lock flush HUMIRA PEDIA INJ CROHNS ...... 12 10 unt/ml-0.9% kit ...... 31 HUMIRA PEN INJ 40/0.4ML ...... 12 heparin sod lock flush & nacl lock flush HUMIRA PEN INJ 40MG/0.8 ...... 12 100 unt/ml-0.9% kit ...... 32 HUMIRA PEN KIT CD/UC/HS ...... 13 heparin sodium (porcine) 100 unit/ml HUMIRA PEN KIT PS/UV...... 13 in d5w ...... 32 HUMULIN R INJ U-500 ...... 45 heparin sodium (porcine) inj 1000 HYCAMTIN CAP 0.25MG ...... 67 unit/ml ...... 32 HYCAMTIN CAP 1MG ...... 67 heparin sodium (porcine) inj 10000 HYCODAN unit/ml ...... 32 see hydrocodone w/ homatropine heparin sodium (porcine) inj 20000 syrup 5-1.5 mg/5ml ...... 93 unit/ml ...... 32 hydralazine hcl tab 10 mg ...... 59 heparin sodium (porcine) inj 5000 hydralazine hcl tab 100 mg ...... 59 unit/ml ...... 32 hydralazine hcl tab 25 mg ...... 59 heparin sodium (porcine) lock flush iv hydralazine hcl tab 50 mg ...... 59 soln 1 unit/ml ...... 32 HYDREA 195

see hydroxyurea cap 500 mg ...... 66 hydrocortisone lotion 2.5% ...... 101 hydrochlorothiazide cap 12.5 mg ... 107 hydrocortisone oint 1% ...... 102 hydrochlorothiazide tab 12.5 mg .... 107 hydrocortisone oint 2.5% ...... 102 hydrochlorothiazide tab 25 mg ...... 107 hydrocortisone tab 10 mg ...... 92 hydrochlorothiazide tab 50 mg ...... 107 hydrocortisone tab 20 mg ...... 92 hydrocod polst-chlorphen polst er susp hydrocortisone tab 5 mg ...... 92 10-8 mg/5ml ...... 93 hydrocortisone valerate cream 0.2% hydrocodone w/ homatropine syrup 5- ...... 102 1.5 mg/5ml ...... 93 hydrocortisone valerate oint 0.2% . 102 hydrocodone w/ homatropine tab 5-1.5 hydromorphone hcl liqd 1 mg/ml ..... 16 mg ...... 93 hydromorphone hcl tab 2 mg ...... 17 hydrocodone-acetaminophen soln 10- hydromorphone hcl tab 4 mg ...... 17 325 mg/15ml ...... 19 hydromorphone hcl tab 8 mg ...... 17 hydrocodone-acetaminophen soln 7.5- hydromorphone hcl tab er 24hr 12 mg 325 mg/15ml ...... 19 ...... 17 hydrocodone-acetaminophen tab 10- hydromorphone hcl tab er 24hr 16 mg 325 mg ...... 19 ...... 17 hydrocodone-acetaminophen tab 2.5- hydromorphone hcl tab er 24hr 32 mg 325 mg ...... 19 ...... 17 hydrocodone-acetaminophen tab 5-325 hydromorphone hcl tab er 24hr 8 mg 17 mg ...... 19 hydroxychloroquine sulfate tab 200 mg hydrocodone-acetaminophen tab 7.5- ...... 59 325 mg ...... 19 hydroxyurea cap 500 mg ...... 66 hydrocodone-ibuprofen tab 10-200 mg hydroxyzine hcl syrup 10 mg/5ml .... 24 ...... 19 hydroxyzine hcl tab 10 mg ...... 24 hydrocodone-ibuprofen tab 5-200 mg hydroxyzine hcl tab 25 mg ...... 24 ...... 19 hydroxyzine hcl tab 50 mg ...... 24 hydrocodone-ibuprofen tab 7.5-200 mg hydroxyzine pamoate cap 100 mg .... 24 ...... 19 hydroxyzine pamoate cap 25 mg ..... 24 hydrocortisone acetate suppos 30 mg hydroxyzine pamoate cap 50 mg ..... 24 ...... 21 hyolev mb tab 81mg ...... 157 hydrocortisone acetate w/ pramoxine hyoscyamine sulfate elixir 0.125 perianal cream 1-1% ...... 21 mg/5ml ...... 155 hydrocortisone acetate w/ pramoxine hyoscyamine sulfate sl tab 0.125 mg perianal cream 2.5-1% ...... 21 ...... 155 hydrocortisone butyrate cream 0.1% hyoscyamine sulfate soln 0.125 mg/ml ...... 101 ...... 155 hydrocortisone butyrate hydrophilic lipo hyoscyamine sulfate tab 0.125 mg . 155 base cream 0.1% ...... 101 hyoscyamine sulfate tab disint 0.125 hydrocortisone butyrate lotion 0.1% mg ...... 155 ...... 101 hyoscyamine sulfate tab er 12hr 0.375 hydrocortisone butyrate oint 0.1% . 101 mg ...... 155 hydrocortisone butyrate soln 0.1% . 101 HYZAAR hydrocortisone cream 1% ...... 101 see losartan potassium & hydrocortisone cream 2.5% ...... 101 hydrochlorothiazide tab 100-12.5 hydrocortisone enema 100 mg/60ml 21 mg ...... 57 hydrocortisone lotion 1% ...... 101 196

see losartan potassium & see sumatriptan succinate tab 25 mg hydrochlorothiazide tab 100-25 mg ...... 129 ...... 57 see sumatriptan succinate tab 50 mg see losartan potassium & ...... 129 hydrochlorothiazide tab 50-12.5 IMITREX STATDOSE REFILL mg ...... 57 see sumatriptan succinate solution I cartridge 4 mg/0.5ml ...... 129 ibandronate sodium tab 150 mg (base see sumatriptan succinate solution equivalent)...... 107 cartridge 6 mg/0.5ml ...... 129 IBRANCE CAP 100MG ...... 64 IMITREX STATDOSE SYSTEM IBRANCE CAP 125MG ...... 64 see sumatriptan succinate solution IBRANCE CAP 75MG ...... 64 auto-injector 4 mg/0.5ml ...... 129 IBRANCE TAB 100MG ...... 64 see sumatriptan succinate solution IBRANCE TAB 125MG ...... 64 auto-injector 6 mg/0.5ml ...... 129 IBRANCE TAB 75MG ...... 64 IMURAN ibuprofen susp 100 mg/5ml ...... 14 see azathioprine tab 50 mg ...... 131 ibuprofen tab 400 mg ...... 14 IMURAN TAB 50MG ...... 132 ibuprofen tab 600 mg ...... 14 inatal adv tab ...... 135 ibuprofen tab 800 mg ...... 14 INBRIJA CAP 42MG ...... 68 ICAR PEDS SUS GRAPE ...... 122 INCRELEX INJ 40MG/4ML ...... 112 icar-c plus tab ...... 122 INCRUSE ELPT INH 62.5MCG ...... 26 icosapent ethyl cap 1 gm ...... 50 indapamide tab 1.25 mg ...... 107 ILEVRO DRO 0.3% OP ...... 143 indapamide tab 2.5 mg ...... 107 imatinib mesylate tab 100 mg (base INDERAL LA equivalent)...... 64 see propranolol hcl cap er 24hr 120 imatinib mesylate tab 400 mg (base mg ...... 81 equivalent)...... 64 see propranolol hcl cap er 24hr 160 IMBRUVICA CAP 140MG ...... 64 mg ...... 81 IMBRUVICA CAP 70MG ...... 64 see propranolol hcl cap er 24hr 60 IMBRUVICA TAB 140MG ...... 64 mg ...... 81 IMBRUVICA TAB 280MG ...... 64 see propranolol hcl cap er 24hr 80 IMBRUVICA TAB 420MG ...... 64 mg ...... 81 IMBRUVICA TAB 560MG ...... 64 INDOCIN SUP 50MG ...... 14 imipramine hcl tab 10 mg ...... 42 INDOCIN SUS 25MG/5ML ...... 14 imipramine hcl tab 25 mg ...... 42 indomethacin cap 25 mg ...... 14 imipramine hcl tab 50 mg ...... 42 indomethacin cap 50 mg ...... 14 imiquimod cream 3.75% ...... 103 indomethacin cap er 75 mg ...... 14 imiquimod cream 5% ...... 103 INFANATE CAP BALANCE ...... 135 IMITREX INGREZZA CAP 40-80MG ...... 148 see sumatriptan nasal spray 20 INGREZZA CAP 40MG ...... 148 mg/act ...... 129 INGREZZA CAP 60MG ...... 148 see sumatriptan nasal spray 5 INGREZZA CAP 80MG ...... 148 mg/act ...... 128 INLYTA TAB 1MG ...... 64 see sumatriptan succinate inj 6 INLYTA TAB 5MG ...... 64 mg/0.5ml ...... 129 INSPIRATION MIS ELITE ...... 127 see sumatriptan succinate tab 100 INSPIREASE MIS RES BAG ...... 127 mg ...... 129 INSPRA 197

see eplerenone tab 25 mg ...... 59 see paliperidone tab er 24hr 6 mg . 71 see eplerenone tab 50 mg ...... 59 see paliperidone tab er 24hr 9 mg . 71 INSUFLON MIS 25GX0.71 ...... 126 INVEGA SUST INJ 117/0.75 ...... 71 INSUL-EZE MIS ...... 126 INVEGA SUST INJ 156MG/ML ...... 71 INSULIN ASPA INJ 100/ML ...... 45 INVEGA SUST INJ 234/1.5 ...... 71 INSULIN ASPA INJ 70/30 ...... 45 INVEGA SUST INJ 39/0.25 ...... 70 INSULIN ASPA INJ FLEXPEN ...... 45 INVEGA SUST INJ 78/0.5ML ...... 71 INSULIN ASPA INJ PENFILL ...... 45 INVEGA TRINZ INJ 273MG ...... 71 INSULIN SRYG MIS 1ML/32G ...... 126 INVEGA TRINZ INJ 410MG ...... 71 INSULIN SYRG MIS 0.3/28G ...... 126 INVEGA TRINZ INJ 546MG ...... 71 INSULIN SYRG MIS 0.3/29G ...... 126 INVEGA TRINZ INJ 819MG ...... 71 INSULIN SYRG MIS 0.3/30G ...... 126 INVIRASE CAP 200MG ...... 76 INSULIN SYRG MIS 0.3/31G ...... 126 INVIRASE TAB 500MG ...... 76 INSULIN SYRG MIS 0.5/27G ...... 126 iodoquinol-hc cream 1-1% ...... 97 INSULIN SYRG MIS 0.5/28G ...... 126 iodoquinol-hydrocortisone in aloe INSULIN SYRG MIS 0.5/29G ...... 126 vehicle cream 1-1.9% ...... 97 INSULIN SYRG MIS 0.5/30G ...... 126 ipratropium bromide inhal soln 0.02% INSULIN SYRG MIS 0.5/31G ...... 126 ...... 26 INSULIN SYRG MIS 0.5/32G ...... 126 ipratropium bromide nasal soln 0.03% INSULIN SYRG MIS 1ML/25G ...... 127 (21 mcg/spray) ...... 139 INSULIN SYRG MIS 1ML/26G ...... 127 ipratropium bromide nasal soln 0.06% INSULIN SYRG MIS 1ML/27G ...... 127 (42 mcg/spray) ...... 139 INSULIN SYRG MIS 1ML/28G ...... 127 ipratropium-albuterol nebu soln 0.5- INSULIN SYRG MIS 1ML/29G ...... 127 2.5(3) mg/3ml ...... 29 INSULIN SYRG MIS 1ML/30G ...... 127 IPRIVASK INJ 15MG ...... 32 INSULIN SYRG MIS 1ML/31G ...... 127 irbesartan tab 150 mg ...... 54 INSULIN SYRG MIS 2/27.5G ...... 127 irbesartan tab 300 mg ...... 54 INSUL-TOTE MIS ...... 126 irbesartan tab 75 mg ...... 54 INSUPEN SENS MIS 32GX6MM ...... 127 irbesartan-hydrochlorothiazide tab INSUPEN SENS MIS 32GX8MM ...... 127 150-12.5 mg ...... 57 INSUPEN ULTR MIS 30GX8MM ...... 127 irbesartan-hydrochlorothiazide tab INTELENCE TAB 100MG ...... 76 300-12.5 mg ...... 57 INTELENCE TAB 200MG ...... 76 iron supplmt dro 15mg/ml ...... 122 INTELENCE TAB 25MG ...... 76 ISENTRESS CHW 100MG ...... 77 INTUNIV ISENTRESS CHW 25MG ...... 77 see guanfacine hcl tab er 24hr 1 mg ISENTRESS HD TAB 600MG ...... 77 (base equiv) ...... 9 ISENTRESS POW 100MG ...... 77 see guanfacine hcl tab er 24hr 2 mg ISENTRESS TAB 400MG ...... 77 (base equiv) ...... 10 isometheptene-dichloral- see guanfacine hcl tab er 24hr 3 mg acetaminophen cap 65-100-325 mg (base equiv) ...... 10 ...... 127 see guanfacine hcl tab er 24hr 4 mg isoniazid syrup 50 mg/5ml ...... 60 (base equiv) ...... 10 isoniazid tab 100 mg ...... 60 INVEGA isoniazid tab 300 mg ...... 60 see paliperidone tab er 24hr 1.5 mg ISOPTO ATROP SOL 1% OP ...... 140 ...... 71 ISOPTO CARPINE see paliperidone tab er 24hr 3 mg . 71 see pilocarpine hcl ophth soln 1% 141 198

see pilocarpine hcl ophth soln 2% 141 junel fe 24 tab 1/20 ...... 89 see pilocarpine hcl ophth soln 4% 141 junel fe tab 1.5/30 ...... 89 ISORDIL TITRADOSE junel fe tab 1/20 ...... 89 see isosorbide dinitrate tab 40 mg . 23 K see isosorbide dinitrate tab 5 mg ... 23 KALBITOR INJ 10MG/ML ...... 120 isosorbide dinitrate tab 10 mg ...... 23 KALETRA isosorbide dinitrate tab 20 mg ...... 23 see lopinavir-ritonavir soln 400-100 isosorbide dinitrate tab 30 mg ...... 23 mg/5ml (80-20 mg/ml) ...... 77 isosorbide dinitrate tab 40 mg ...... 23 KALETRA TAB 100-25MG ...... 77 isosorbide dinitrate tab 5 mg ...... 23 KALETRA TAB 200-50MG ...... 77 isosorbide dinitrate tab er 40 mg ..... 23 KALYDECO PAK 25MG ...... 150 isosorbide mononitrate tab 10 mg .... 23 KALYDECO PAK 50MG ...... 150 isosorbide mononitrate tab 20 mg .... 23 KALYDECO PAK 75MG ...... 150 isosorbide mononitrate tab er 24hr 120 KALYDECO TAB 150MG ...... 150 mg ...... 23 KAPVAY isosorbide mononitrate tab er 24hr 30 see clonidine hcl tab er 12hr 0.1 mg 9 mg ...... 23 kariva tab 28 day ...... 89 isosorbide mononitrate tab er 24hr 60 KEFLEX mg ...... 23 see cephalexin cap 750 mg ...... 88 isradipine cap 2.5 mg ...... 83 kelnor tab 1/35 ...... 89 isradipine cap 5 mg ...... 83 KENALOG ISTALOL see triamcinolone acetonide aerosol see timolol maleate ophth soln 0.5% soln 0.147 mg/gm ...... 102 (once-daily) ...... 140 KEPPRA itraconazole cap 100 mg ...... 49 see levetiracetam oral soln 100 itraconazole oral soln 10 mg/ml ...... 49 mg/ml ...... 35 IV PREP WIPE PAD ...... 75 see levetiracetam tab 1000 mg ..... 35 ivermectin cream 1% ...... 104 see levetiracetam tab 250 mg ...... 35 ivermectin tab 3 mg ...... 21 see levetiracetam tab 500 mg ...... 35 J see levetiracetam tab 750 mg ...... 35 JAKAFI TAB 10MG ...... 64 KEPPRA XR JAKAFI TAB 15MG ...... 64 see levetiracetam tab er 24hr 500 JAKAFI TAB 20MG ...... 64 mg ...... 35 JAKAFI TAB 25MG ...... 64 see levetiracetam tab er 24hr 750 JAKAFI TAB 5MG ...... 64 mg ...... 35 JARDIANCE TAB 10MG ...... 46 KESIMPTA INJ 20/.4ML ...... 149 JARDIANCE TAB 25MG ...... 46 ketoconazole cream 2% ...... 97 JENTADUETO TAB 2.5-1000 ...... 43 ketoconazole foam 2% ...... 97 JENTADUETO TAB 2.5-500 ...... 43 ketoconazole shampoo 2% ...... 97 JENTADUETO TAB 2.5-850 ...... 43 ketoconazole tab 200 mg ...... 49 JENTADUETO TAB XR ...... 43 KETO-DIASTIX TES ...... 104 jinteli tab 1mg-5mcg ...... 114 KETONE TEST TES ...... 104 jolessa tab ...... 89 ketoprofen cap 50 mg ...... 14 jolivette tab 0.35mg ...... 91 ketoprofen cap 75 mg ...... 14 JULUCA TAB 50-25MG ...... 77 ketoprofen cap er 24hr 200 mg ...... 14 junel 1.5/30 tab ...... 89 ketorolac tromethamine im inj 60 junel 1/20 tab ...... 89 mg/2ml (30 mg/ml) ...... 14 199 ketorolac tromethamine inj 30 mg/ml L ...... 14 labetalol hcl tab 100 mg ...... 80 ketorolac tromethamine inj 300 labetalol hcl tab 200 mg ...... 80 mg/10ml (30 mg/ml) ...... 14 labetalol hcl tab 300 mg ...... 80 ketorolac tromethamine ophth soln LACRISERT MIS 5MG OP ...... 140 0.4% ...... 143 lactic acid (ammonium lactate) cream ketorolac tromethamine ophth soln 12% ...... 103 0.5% ...... 143 lactic acid (ammonium lactate) lotion ketorolac tromethamine tab 10 mg ... 14 12% ...... 103 KISQALI 200 PAK FEMARA ...... 63 lactulose (encephalopathy) solution 10 KISQALI 400 PAK FEMARA ...... 63 gm/15ml ...... 118 KISQALI 600 PAK FEMARA ...... 63 lactulose solution 10 gm/15ml ...... 124 KISQALI TAB 200DOSE ...... 64 LAMICTAL KISQALI TAB 400DOSE ...... 64 see lamotrigine tab 100 mg ...... 34 KISQALI TAB 600DOSE ...... 64 see lamotrigine tab 150 mg ...... 34 KITABIS PAK see lamotrigine tab 200 mg ...... 34 see tobramycin nebu soln 300 see lamotrigine tab 25 mg ...... 34 mg/5ml ...... 12 LAMICTAL CHEWABLE DISPERS KLARON see lamotrigine tab chewable see sulfacetamide sodium lotion 10% dispersible 25 mg ...... 35 (acne) ...... 96 see lamotrigine tab chewable KLONOPIN dispersible 5 mg ...... 34 see clonazepam tab 0.5 mg ...... 33 LAMICTAL ODT see clonazepam tab 1 mg ...... 33 see lamotrigine orally disintegrating see clonazepam tab 2 mg ...... 33 tab 100 mg ...... 34 KLONOPIN TAB 0.5MG ...... 33 see lamotrigine orally disintegrating KLONOPIN TAB 1MG ...... 33 tab 200 mg ...... 34 KLONOPIN TAB 2MG ...... 33 see lamotrigine orally disintegrating klor-con 8 tab 8meq er ...... 130 tab 25 mg ...... 34 KLOR-CON M15 TAB 15MEQ ER ...... 130 see lamotrigine orally disintegrating KLOR-CON/25 POW 25MEQ ...... 130 tab 50 mg ...... 34 KORLYM TAB 300MG ...... 44 see lamotrigine tab disint 25 (14) & KOSHR PRENAT TAB 30-1MG ...... 135 50 mg (14) & 100 mg (7) kit ..... 35 KRISTALOSE PAK 10GM ...... 124 LAMICTAL XR KRISTALOSE PAK 20GM ...... 124 see lamotrigine tab er 24hr 100 mg K-TAB ...... 35 see potassium chloride tab er 20 meq see lamotrigine tab er 24hr 200 mg (1500 mg)...... 131 ...... 35 KUVAN see lamotrigine tab er 24hr 25 mg 35 see sapropterin dihydrochloride see lamotrigine tab er 24hr 250 mg powder packet 100 mg ...... 113 ...... 35 see sapropterin dihydrochloride see lamotrigine tab er 24hr 300 mg powder packet 500 mg ...... 113 ...... 35 see sapropterin dihydrochloride tab see lamotrigine tab er 24hr 50 mg 35 100 mg ...... 113 LAMISIL KYLEENA IUD 19.5MG ...... 91 see terbinafine hcl tab 250 mg ...... 48 KYNAMRO INJ 200MG/ML ...... 50 LAMISIL GRA 125MG ...... 48 200

LAMISIL GRA 187.5MG ...... 48 lansoprazole cap delayed release 30 lamivudine oral soln 10 mg/ml ...... 77 mg ...... 156 lamivudine tab 100 mg (hbv) ...... 79 LANSOPRAZOLE SUS 3MG/ML ...... 156 lamivudine tab 150 mg ...... 77 lansoprazole tab delayed release orally lamivudine tab 300 mg ...... 77 disintegrating 15 mg ...... 156 lamivudine-zidovudine tab 150-300 mg lansoprazole tab delayed release orally ...... 77 disintegrating 30 mg ...... 156 lamotrigine orally disintegrating tab lanthanum carbonate chew tab 1000 100 mg ...... 34 mg (elemental) ...... 118 lamotrigine orally disintegrating tab lanthanum carbonate chew tab 500 mg 200 mg ...... 34 (elemental) ...... 118 lamotrigine orally disintegrating tab 25 lanthanum carbonate chew tab 750 mg mg ...... 34 (elemental) ...... 118 lamotrigine orally disintegrating tab 50 lapatinib ditosylate tab 250 mg (base mg ...... 34 equiv) ...... 64 lamotrigine tab 100 mg ...... 34 LASIX lamotrigine tab 150 mg ...... 34 see furosemide tab 20 mg ...... 106 lamotrigine tab 200 mg ...... 34 see furosemide tab 40 mg ...... 106 lamotrigine tab 25 mg ...... 34 see furosemide tab 80 mg ...... 106 lamotrigine tab chewable dispersible 25 latanoprost ophth soln 0.005% ...... 144 mg ...... 35 LATUDA TAB 120MG ...... 70 lamotrigine tab chewable dispersible 5 LATUDA TAB 20MG ...... 70 mg ...... 34 LATUDA TAB 40MG ...... 70 lamotrigine tab disint 21 x 25 mg & 7 x LATUDA TAB 60MG ...... 70 50 mg titration kit ...... 35 LATUDA TAB 80MG ...... 70 lamotrigine tab disint 25 (14) & 50 mg layolis fe chw ...... 89 (14) & 100 mg (7) kit ...... 35 leena tab ...... 89 lamotrigine tab disint 42 x 50mg & 14 leflunomide tab 10 mg ...... 15 x 100mg titration kit ...... 35 leflunomide tab 20 mg ...... 15 lamotrigine tab er 24hr 100 mg ...... 35 LENVIMA CAP 10 MG ...... 65 lamotrigine tab er 24hr 200 mg ...... 35 LENVIMA CAP 12MG ...... 65 lamotrigine tab er 24hr 25 mg ...... 35 LENVIMA CAP 14 MG ...... 65 lamotrigine tab er 24hr 250 mg ...... 35 LENVIMA CAP 18 MG ...... 65 lamotrigine tab er 24hr 300 mg ...... 35 LENVIMA CAP 20 MG ...... 65 lamotrigine tab er 24hr 50 mg ...... 35 LENVIMA CAP 24 MG ...... 65 LANOXIN LENVIMA CAP 4MG ...... 65 see digoxin tab 125 mcg (0.125 mg) LENVIMA CAP 8 MG...... 65 ...... 84 lessina tab ...... 90 see digoxin tab 250 mcg (0.25 mg) LETAIRIS ...... 84 see ambrisentan tab 10 mg ...... 87 LANOXIN TAB 0.0625MG ...... 85 see ambrisentan tab 5 mg...... 87 LANOXIN TAB 0.125MG ...... 85 letrozole tab 2.5 mg ...... 62 LANOXIN TAB 0.1875MG ...... 85 leucovorin calcium tab 10 mg ...... 66 LANOXIN TAB 0.25MG ...... 85 leucovorin calcium tab 15 mg ...... 66 lansoprazole cap delayed release 15 leucovorin calcium tab 25 mg ...... 66 mg ...... 156 leucovorin calcium tab 5 mg ...... 66 LEUKERAN TAB 2MG ...... 61 201 leuprolide acetate inj kit 5 mg/ml ..... 62 levothyroxine sodium tab 100 mcg . 153 levalbuterol hcl soln nebu 0.31 mg/3ml levothyroxine sodium tab 112 mcg . 153 (base equiv) ...... 29 levothyroxine sodium tab 125 mcg . 153 levalbuterol hcl soln nebu 0.63 mg/3ml levothyroxine sodium tab 137 mcg . 153 (base equiv) ...... 29 levothyroxine sodium tab 150 mcg . 153 levalbuterol hcl soln nebu 1.25 mg/3ml levothyroxine sodium tab 175 mcg . 153 (base equiv) ...... 29 levothyroxine sodium tab 200 mcg . 153 levalbuterol hcl soln nebu conc 1.25 levothyroxine sodium tab 25 mcg .. 152 mg/0.5ml (base equiv) ...... 29 levothyroxine sodium tab 300 mcg . 153 levalbuterol tartrate inhal aerosol 45 levothyroxine sodium tab 50 mcg .. 152 mcg/act (base equiv) ...... 29 levothyroxine sodium tab 75 mcg .. 152 LEVAQUIN levothyroxine sodium tab 88 mcg .. 153 see levofloxacin tab 250 mg ...... 116 levoxyl tab 100mcg ...... 153 see levofloxacin tab 500 mg ...... 116 levoxyl tab 112mcg ...... 153 see levofloxacin tab 750 mg ...... 116 levoxyl tab 125mcg ...... 153 LEVATOL TAB 20MG ...... 81 levoxyl tab 137mcg ...... 153 levetiracetam oral soln 100 mg/ml ... 35 levoxyl tab 150mcg ...... 153 levetiracetam tab 1000 mg ...... 35 levoxyl tab 175mcg ...... 153 levetiracetam tab 250 mg ...... 35 levoxyl tab 200mcg ...... 153 levetiracetam tab 500 mg ...... 35 levoxyl tab 25mcg ...... 153 levetiracetam tab 750 mg ...... 35 levoxyl tab 50mcg ...... 153 levetiracetam tab er 24hr 500 mg .... 35 levoxyl tab 75mcg ...... 153 levetiracetam tab er 24hr 750 mg .... 35 levoxyl tab 88mcg ...... 153 levobunolol hcl ophth soln 0.25% ... 140 LEVULAN KERA SOL 20% ...... 98 levobunolol hcl ophth soln 0.5% .... 140 LEXAPRO levocarnitine oral soln 1 gm/10ml see escitalopram oxalate tab 10 mg (10%) ...... 112 (base equiv) ...... 39 levocarnitine tab 330 mg ...... 112 see escitalopram oxalate tab 20 mg levofloxacin ophth soln 0.5% ...... 141 (base equiv) ...... 39 levofloxacin oral soln 25 mg/ml ..... 116 see escitalopram oxalate tab 5 mg levofloxacin tab 250 mg ...... 116 (base equiv) ...... 39 levofloxacin tab 500 mg ...... 116 LEXIVA levofloxacin tab 750 mg ...... 116 see fosamprenavir calcium tab 700 LEVOMEFOLATE CAP DHA ...... 135 mg (base equiv) ...... 76 levora-28 tab 0.15/30 ...... 90 LEXIVA SUS 50MG/ML ...... 77 levothyroxine sodium cap 100 mcg. 152 LIALDA levothyroxine sodium cap 112 mcg. 152 see mesalamine tab delayed release levothyroxine sodium cap 125 mcg. 152 1.2 gm ...... 117 levothyroxine sodium cap 13 mcg .. 152 lidocaine hcl cream 3% ...... 103 levothyroxine sodium cap 137 mcg. 152 lidocaine hcl lotion 3% ...... 103 levothyroxine sodium cap 150 mcg. 152 lidocaine hcl soln 4% ...... 103 levothyroxine sodium cap 175 mcg. 152 lidocaine hcl urethral/mucosal gel levothyroxine sodium cap 200 mcg. 152 prefilled syringe 2% ...... 103 levothyroxine sodium cap 25 mcg .. 152 lidocaine hcl viscous soln 2% ...... 133 levothyroxine sodium cap 50 mcg .. 152 lidocaine oint 5% ...... 103 levothyroxine sodium cap 75 mcg .. 152 lidocaine patch 5% ...... 103 levothyroxine sodium cap 88 mcg .. 152 202 lidocaine-hydrocortisone acetate lithium carbonate cap 150 mg ...... 69 perianal cream 3-0.5% ...... 21 lithium carbonate cap 300 mg ...... 69 lidocaine-hydrocortisone acetate rectal lithium carbonate cap 600 mg ...... 69 cream kit 3-0.5% ...... 21 lithium carbonate tab 300 mg ...... 69 lidocaine-hydrocortisone acetate rectal lithium carbonate tab er 300 mg ...... 69 cream kit 3-1% ...... 21 lithium carbonate tab er 450 mg ...... 69 lidocaine-hydrocortisone acetate rectal LITHIUM SOL 8MEQ/5ML ...... 69 gel kit 3-2.5% ...... 21 LITHOBID lidocaine-prilocaine cream 2.5-2.5% see lithium carbonate tab er 300 mg ...... 103 ...... 69 lidocaine-prilocaine cream kit 2.5-2.5% LO LOESTRIN TAB 1-10-10 ...... 90 ...... 103 LOCOID LIDODERM see hydrocortisone butyrate lotion see lidocaine patch 5% ...... 103 0.1% ...... 101 LILETTA IUD 52MG ...... 91 LOCOID LIPOCREAM lindane lotion 1% ...... 104 see hydrocortisone butyrate lindane shampoo 1% ...... 104 hydrophilic lipo base cream 0.1% linezolid for susp 100 mg/5ml ...... 23 ...... 101 linezolid tab 600 mg ...... 23 LODINE LINZESS CAP 145MCG ...... 118 see etodolac tab 400 mg ...... 14 LINZESS CAP 290MCG ...... 118 LOKELMA PAK 10GM ...... 133 LINZESS CAP 72MCG...... 118 LOKELMA PAK 5GM ...... 133 liothyronine sodium tab 25 mcg ..... 153 lomedia 24 tab fe ...... 90 liothyronine sodium tab 5 mcg ...... 153 LOMOTIL liothyronine sodium tab 50 mcg ..... 153 see diphenoxylate w/ atropine tab LIPITOR 2.5-0.025 mg ...... 46 see atorvastatin calcium tab 10 mg LONSURF TAB 15-6.14 ...... 63 (base equivalent) ...... 51 LONSURF TAB 20-8.19 ...... 63 see atorvastatin calcium tab 20 mg loperamide hcl cap 2 mg ...... 46 (base equivalent) ...... 51 LOPID see atorvastatin calcium tab 40 mg see gemfibrozil tab 600 mg ...... 51 (base equivalent) ...... 51 lopinavir-ritonavir soln 400-100 see atorvastatin calcium tab 80 mg mg/5ml (80-20 mg/ml) ...... 77 (base equivalent) ...... 51 LOPRESSOR lisinopril & hydrochlorothiazide tab 10- see metoprolol tartrate tab 100 mg81 12.5 mg ...... 57 see metoprolol tartrate tab 50 mg . 81 lisinopril & hydrochlorothiazide tab 20- LOPROX 12.5 mg ...... 57 see ciclopirox olamine cream 0.77% lisinopril & hydrochlorothiazide tab 20- (base equiv) ...... 97 25 mg ...... 57 see ciclopirox olamine susp 0.77% lisinopril tab 10 mg ...... 53 (base equiv) ...... 97 lisinopril tab 2.5 mg ...... 53 LOPROX SHAMPOO lisinopril tab 20 mg ...... 53 see ciclopirox shampoo 1% ...... 97 lisinopril tab 30 mg ...... 53 lorazepam conc 2 mg/ml ...... 25 lisinopril tab 40 mg ...... 53 lorazepam tab 0.5 mg ...... 25 lisinopril tab 5 mg ...... 53 lorazepam tab 1 mg ...... 25 LITETOUCH MIS 29GX12.7 ...... 127 lorazepam tab 2 mg ...... 25 203 losartan potassium & lovastatin tab 10 mg ...... 51 hydrochlorothiazide tab 100-12.5 mg lovastatin tab 20 mg ...... 51 ...... 57 lovastatin tab 40 mg ...... 51 losartan potassium & LOVAZA hydrochlorothiazide tab 100-25 mg 57 see omega-3-acid ethyl esters cap 1 losartan potassium & gm ...... 50 hydrochlorothiazide tab 50-12.5 mg LOVENOX ...... 57 see enoxaparin sodium inj 100 losartan potassium tab 100 mg ...... 54 mg/ml ...... 31 losartan potassium tab 25 mg ...... 54 see enoxaparin sodium inj 120 losartan potassium tab 50 mg ...... 54 mg/0.8ml ...... 31 LOSEASONIQUE see enoxaparin sodium inj 150 see camrese lo tab ...... 89 mg/ml ...... 31 LOTEMAX see enoxaparin sodium inj 30 see loteprednol etabonate ophth gel mg/0.3ml ...... 31 0.5% ...... 142 see enoxaparin sodium inj 300 see loteprednol etabonate ophth susp mg/3ml ...... 31 0.5% ...... 142 see enoxaparin sodium inj 40 LOTEMAX OIN 0.5% ...... 142 mg/0.4ml ...... 31 LOTEMAX SM GEL 0.38% ...... 142 see enoxaparin sodium inj 60 LOTENSIN mg/0.6ml ...... 31 see benazepril hcl tab 10 mg ...... 52 see enoxaparin sodium inj 80 see benazepril hcl tab 20 mg ...... 52 mg/0.8ml ...... 31 see benazepril hcl tab 40 mg ...... 52 low-ogestrel tab ...... 90 LOTENSIN HCT loxapine succinate cap 10 mg ...... 72 see benazepril & hydrochlorothiazide loxapine succinate cap 25 mg ...... 72 tab 20-12.5 mg ...... 56 loxapine succinate cap 5 mg ...... 72 see benazepril & hydrochlorothiazide loxapine succinate cap 50 mg ...... 72 tab 20-25 mg ...... 56 LUMIGAN SOL 0.01% ...... 144 loteprednol etabonate ophth gel 0.5% LUNESTA ...... 142 see eszopiclone tab 1 mg ...... 123 loteprednol etabonate ophth susp 0.5% see eszopiclone tab 2 mg ...... 123 ...... 142 see eszopiclone tab 3 mg ...... 123 LOTREL LUPKYNIS CAP 7.9MG ...... 132 see amlodipine besylate-benazepril LUPRON DEPOT INJ 11.25MG ...... 62 hcl cap 10-20 mg ...... 55 LUPRON DEPOT INJ 22.5MG ...... 62 see amlodipine besylate-benazepril LUPRON DEPOT INJ 3.75MG ...... 62 hcl cap 10-40 mg ...... 55 LUPRON DEPOT INJ 30MG ...... 62 see amlodipine besylate-benazepril LUPRON DEPOT INJ 45MG ...... 62 hcl cap 5-10 mg ...... 55 LUPRON DEPOT INJ 7.5MG ...... 62 see amlodipine besylate-benazepril lutera tab ...... 90 hcl cap 5-20 mg ...... 55 LUXIQ LOTRONEX see betamethasone valerate aerosol see alosetron hcl tab 0.5 mg (base foam 0.12% ...... 99 equiv) ...... 118 LYNPARZA TAB 100MG ...... 65 see alosetron hcl tab 1 mg (base LYNPARZA TAB 150MG ...... 65 equiv) ...... 118 LYRICA 204

see pregabalin cap 100 mg ...... 36 MAVENCLAD PAK 10MG(10) ...... 149 see pregabalin cap 150 mg ...... 36 MAVIK see pregabalin cap 200 mg ...... 36 see trandolapril tab 4 mg ...... 53 see pregabalin cap 225 mg ...... 36 MAVYRET TAB 100-40MG ...... 79 see pregabalin cap 25 mg ...... 36 MAXALT see pregabalin cap 300 mg ...... 36 see rizatriptan benzoate tab 10 mg see pregabalin cap 50 mg ...... 36 (base equivalent) ...... 128 see pregabalin cap 75 mg ...... 36 MAXALT-MLT see pregabalin soln 20 mg/ml ...... 36 see rizatriptan benzoate oral LYSODREN TAB 500MG ...... 62 disintegrating tab 10 mg (base eq) LYSTEDA ...... 128 see tranexamic acid tab 650 mg .. 123 MAXITROL M see neomycin-polymyxin- MACROBID dexamethasone ophth oint 0.1% see nitrofurantoin monohydrate ...... 142 macrocrystalline cap 100 mg ... 157 see neomycin-polymyxin- MACRODANTIN dexamethasone ophth susp 0.1% see nitrofurantoin macrocrystalline ...... 142 cap 100 mg ...... 157 MAXZIDE see nitrofurantoin macrocrystalline see triamterene & cap 25 mg ...... 157 hydrochlorothiazide tab 75-50 mg see nitrofurantoin macrocrystalline ...... 106 cap 50 mg ...... 157 MAXZIDE-25 MAKENA INJ 250MG/ML ...... 146 see triamterene & MAKENA INJ 275MG ...... 146 hydrochlorothiazide tab 37.5-25 MALARONE mg ...... 106 see atovaquone-proguanil hcl tab MAYZENT TAB 0.25MG ...... 149 250-100 mg ...... 59 MAYZENT TAB 2MG ...... 149 see atovaquone-proguanil hcl tab meclizine hcl tab 12.5 mg ...... 47 62.5-25 mg ...... 59 meclizine hcl tab 25 mg ...... 47 malathion lotion 0.5% ...... 104 meclofenamate sodium cap 100 mg . 14 maprotiline hcl tab 25 mg ...... 39 meclofenamate sodium cap 50 mg ... 14 maprotiline hcl tab 50 mg ...... 39 MEDROL maprotiline hcl tab 75 mg ...... 39 see methylprednisolone tab 16 mg 92 MAR-COF BP LIQ 30-2-7.5 ...... 93 see methylprednisolone tab 32 mg 92 MARINOL see methylprednisolone tab 4 mg .. 92 see dronabinol cap 10 mg ...... 48 see methylprednisolone tab 8 mg .. 92 see dronabinol cap 2.5 mg ...... 48 MEDROL DOSEPAK see dronabinol cap 5 mg ...... 48 see methylprednisolone tab therapy MARNATAL-F CAP ...... 135 pack 4 mg (21) ...... 92 MATULANE CAP 50MG ...... 66 MEDROL TAB 2MG ...... 92 MAVENCLAD PAK 10MG (4) ...... 149 medroxyprogesterone acetate im susp MAVENCLAD PAK 10MG (5) ...... 149 150 mg/ml ...... 91 MAVENCLAD PAK 10MG (6) ...... 149 medroxyprogesterone acetate tab 10 MAVENCLAD PAK 10MG (7) ...... 149 mg ...... 146 MAVENCLAD PAK 10MG (8) ...... 149 medroxyprogesterone acetate tab 2.5 MAVENCLAD PAK 10MG (9) ...... 149 mg ...... 146 205 medroxyprogesterone acetate tab 5 mg mesalamine tab delayed release 1.2 ...... 146 gm ...... 117 mefenamic acid cap 250 mg ...... 14 mesalamine tab delayed release 800 mefloquine hcl tab 250 mg ...... 59 mg ...... 117 megestrol acetate susp 40 mg/ml .... 62 MESNEX TAB 400MG ...... 67 megestrol acetate susp 625 mg/5ml MESTINON ...... 146 see pyridostigmine bromide oral soln megestrol acetate tab 20 mg ...... 62 60 mg/5ml ...... 60 megestrol acetate tab 40 mg ...... 62 see pyridostigmine bromide tab 60 MEKINIST TAB 0.5MG ...... 65 mg ...... 60 MEKINIST TAB 2MG ...... 65 MESTINON TIMESPAN meloxicam susp 7.5 mg/5ml...... 14 see pyridostigmine bromide tab er meloxicam tab 15 mg ...... 14 180 mg ...... 60 meloxicam tab 7.5 mg ...... 14 metaxalone tab 800 mg ...... 138 melphalan tab 2 mg ...... 61 metformin hcl tab 1000 mg ...... 44 memantine hcl cap er 24hr 14 mg .. 147 metformin hcl tab 500 mg ...... 44 memantine hcl cap er 24hr 21 mg .. 147 metformin hcl tab 850 mg ...... 44 memantine hcl cap er 24hr 28 mg .. 147 metformin hcl tab er 24hr 500 mg ... 44 memantine hcl cap er 24hr 7 mg ... 147 metformin hcl tab er 24hr 750 mg ... 44 memantine hcl oral solution 2 mg/ml methadone hcl tab 10 mg ...... 17 ...... 147 methadone hcl tab 5 mg ...... 17 memantine hcl tab 10 mg ...... 147 methazolamide tab 25 mg ...... 106 memantine hcl tab 28 x 5 mg & 21 x methazolamide tab 50 mg ...... 106 10 mg titration pack ...... 147 methenamine hippurate tab 1 gm .. 157 memantine hcl tab 5 mg ...... 147 methenamine mandelate tab 0.5 gm M-END MAX D LIQ ...... 93 ...... 157 M-END PE LIQ ...... 93 methenamine mandelate tab 1 gm . 157 m-end wc liq ...... 93 methimazole tab 10 mg ...... 152 MENEST TAB 0.3MG ...... 116 methimazole tab 5 mg ...... 152 MENEST TAB 0.625MG ...... 116 methocarbamol tab 500 mg ...... 138 MENEST TAB 1.25MG ...... 116 methocarbamol tab 750 mg ...... 138 MENEST TAB 2.5MG ...... 116 methotrexate sodium inj 50 mg/2ml MENOPUR INJ 75UNIT ...... 109 (25 mg/ml) ...... 61 MENOSTAR DIS 14MCG ...... 116 methotrexate sodium inj pf 1000 MENTAX CRE 1% ...... 97 mg/40ml (25 mg/ml) ...... 61 meperidine hcl oral soln 50 mg/5ml .. 17 methotrexate sodium tab 2.5 mg (base MEPHYTON equiv) ...... 61 see phytonadione tab 5 mg ...... 161 methoxsalen rapid cap 10 mg ...... 98 MEPRON methscopolamine bromide tab 2.5 mg see atovaquone susp 750 mg/5ml . 22 ...... 155 mercaptopurine tab 50 mg ...... 61 methscopolamine bromide tab 5 mg mesalamine cap dr 400 mg ...... 117 ...... 155 mesalamine cap er 24hr 0.375 gm . 117 methyldopa tab 250 mg ...... 55 mesalamine enema 4 gm ...... 117 methyldopa tab 500 mg ...... 55 mesalamine rectal enema 4 gm & methylergonovine maleate inj 0.2 cleanser wipe kit ...... 117 mg/ml ...... 144 mesalamine suppos 1000 mg ...... 117 206 methylergonovine maleate tab 0.2 mg methylphenidate hcl tab er 24hr 54 mg ...... 144 ...... 11 METHYLIN methylphenidate hcl tab er osmotic see methylphenidate hcl soln 10 release (osm) 18 mg ...... 11 mg/5ml ...... 11 methylphenidate hcl tab er osmotic see methylphenidate hcl soln 5 release (osm) 27 mg ...... 11 mg/5ml ...... 11 methylphenidate hcl tab er osmotic methylphenidate hcl cap er 10 mg (cd) release (osm) 36 mg ...... 11 ...... 11 methylphenidate hcl tab er osmotic methylphenidate hcl cap er 20 mg (cd) release (osm) 54 mg ...... 12 ...... 11 methylprednisolone tab 16 mg ...... 92 methylphenidate hcl cap er 24hr 10 mg methylprednisolone tab 32 mg ...... 92 (la) ...... 11 methylprednisolone tab 4 mg ...... 92 methylphenidate hcl cap er 24hr 20 mg methylprednisolone tab 8 mg ...... 92 (la) ...... 11 methylprednisolone tab therapy pack 4 methylphenidate hcl cap er 24hr 30 mg mg (21) ...... 92 (la) ...... 11 metipranolol ophth soln 0.3% ...... 140 methylphenidate hcl cap er 24hr 40 mg metoclopramide hcl orally (la) ...... 11 disintegrating tab 5 mg (base eq) 117 methylphenidate hcl cap er 24hr 60 mg metoclopramide hcl soln 5 mg/5ml (10 (la) ...... 11 mg/10ml) (base equiv) ...... 117 methylphenidate hcl cap er 30 mg (cd) metoclopramide hcl tab 10 mg (base ...... 11 equivalent) ...... 117 methylphenidate hcl cap er 40 mg (cd) metoclopramide hcl tab 5 mg (base ...... 11 equivalent) ...... 117 methylphenidate hcl cap er 50 mg (cd) metolazone tab 10 mg ...... 107 ...... 11 metolazone tab 2.5 mg ...... 107 methylphenidate hcl cap er 60 mg (cd) metolazone tab 5 mg ...... 107 ...... 11 metoprolol & hydrochlorothiazide tab methylphenidate hcl chew tab 10 mg 11 100-25 mg...... 57 methylphenidate hcl chew tab 2.5 mg metoprolol & hydrochlorothiazide tab ...... 11 100-50 mg...... 57 methylphenidate hcl chew tab 5 mg . 11 metoprolol & hydrochlorothiazide tab methylphenidate hcl soln 10 mg/5ml 11 50-25 mg ...... 57 methylphenidate hcl soln 5 mg/5ml .. 11 metoprolol succinate tab er 24hr 100 methylphenidate hcl tab 10 mg ...... 11 mg (tartrate equiv) ...... 81 methylphenidate hcl tab 20 mg ...... 11 metoprolol succinate tab er 24hr 200 methylphenidate hcl tab 5 mg ...... 11 mg (tartrate equiv) ...... 81 methylphenidate hcl tab er 10 mg .... 11 metoprolol succinate tab er 24hr 25 mg methylphenidate hcl tab er 20 mg .... 11 (tartrate equiv) ...... 81 methylphenidate hcl tab er 24hr 18 mg metoprolol succinate tab er 24hr 50 mg ...... 11 (tartrate equiv) ...... 81 methylphenidate hcl tab er 24hr 27 mg metoprolol tartrate tab 100 mg ...... 81 ...... 11 metoprolol tartrate tab 25 mg ...... 81 methylphenidate hcl tab er 24hr 36 mg metoprolol tartrate tab 50 mg ...... 81 ...... 11 METROCREAM see rosadan cre 0.75% ...... 104 207

METROGEL miglitol tab 25 mg ...... 43 see metronidazole gel 1% ...... 104 miglitol tab 50 mg ...... 43 METROLOTION miglustat cap 100 mg ...... 120 see metronidazole lotion 0.75% .. 104 MIGRANAL metronidazole cap 375 mg ...... 21 see dihydroergotamine mesylate metronidazole gel 0.75% ...... 104 nasal spray 4 mg/ml ...... 128 metronidazole gel 1% ...... 104 MIGRANAL SPR 4MG/ML ...... 128 metronidazole lotion 0.75% ...... 104 MINASTRIN 24 FE metronidazole tab 250 mg ...... 21 see norethindrone ace-eth estradiol- metronidazole tab 500 mg ...... 21 fe chew tab 1 mg-20 mcg (24) ... 90 metronidazole vaginal gel 0.75% ... 159 MINILINK RT KIT STARTER ...... 126 mexiletine hcl cap 150 mg ...... 25 MINIPRESS mexiletine hcl cap 200 mg ...... 25 see prazosin hcl cap 1 mg ...... 55 mexiletine hcl cap 250 mg ...... 25 see prazosin hcl cap 2 mg ...... 55 MIACALCIN see prazosin hcl cap 5 mg ...... 55 see calcitonin (salmon) inj 200 MINOCIN unit/ml ...... 107 see minocycline hcl cap 100 mg .. 151 see calcitonin (salmon) nasal soln minocycline hcl cap 100 mg ...... 151 200 unit/act ...... 107 minocycline hcl cap 50 mg ...... 151 MIACALCIN INJ 200/ML ...... 107 minocycline hcl cap 75 mg ...... 151 MIACALCIN SPR 200/ACT ...... 107 minocycline hcl tab 100 mg ...... 151 MICARDIS minocycline hcl tab 50 mg ...... 151 see telmisartan tab 20 mg ...... 54 minocycline hcl tab 75 mg ...... 151 see telmisartan tab 40 mg ...... 54 minocycline hcl tab er 24hr 105 mg 151 see telmisartan tab 80 mg ...... 54 minocycline hcl tab er 24hr 115 mg 151 MICARDIS HCT minocycline hcl tab er 24hr 135 mg 151 see telmisartan-hydrochlorothiazide minocycline hcl tab er 24hr 45 mg . 151 tab 40-12.5 mg ...... 58 minocycline hcl tab er 24hr 55 mg . 151 see telmisartan-hydrochlorothiazide minocycline hcl tab er 24hr 65 mg . 151 tab 80-12.5 mg ...... 58 minocycline hcl tab er 24hr 80 mg . 151 see telmisartan-hydrochlorothiazide minocycline hcl tab er 24hr 90 mg . 151 tab 80-25 mg ...... 58 minoxidil tab 10 mg ...... 59 miconazole 3 sup 200mg ...... 159 minoxidil tab 2.5 mg ...... 59 miconazole-zinc oxide-white MIRAPEX petrolatum oint 0.25-15-81.35% ... 97 see pramipexole dihydrochloride tab micrgstin 24 tab fe 1/20 ...... 90 0.125 mg ...... 68 MICROCHAMBER MIS ...... 127 see pramipexole dihydrochloride tab microgestin tab 1.5/30 ...... 90 0.5 mg ...... 68 microgestin tab 1/20 ...... 90 see pramipexole dihydrochloride tab microgestin tab fe1.5/30 ...... 90 0.75 mg ...... 68 midazolam hcl syrup 2 mg/ml (base see pramipexole dihydrochloride tab equivalent)...... 123 1 mg ...... 68 midodrine hcl tab 10 mg ...... 160 MIRAPEX ER midodrine hcl tab 2.5 mg ...... 160 see pramipexole dihydrochloride tab midodrine hcl tab 5 mg ...... 160 er 24hr 0.375 mg ...... 68 migergot sup 2/100 ...... 127 see pramipexole dihydrochloride tab miglitol tab 100 mg ...... 43 er 24hr 0.75 mg ...... 68 208

see pramipexole dihydrochloride tab montelukast sodium oral granules er 24hr 1.5 mg ...... 68 packet 4 mg (base equiv) ...... 26 see pramipexole dihydrochloride tab montelukast sodium tab 10 mg (base er 24hr 2.25 mg ...... 68 equiv) ...... 26 see pramipexole dihydrochloride tab MONUROL er 24hr 3 mg ...... 68 see fosfomycin tromethamine powd see pramipexole dihydrochloride tab pack 3 gm (base equivalent)...... 23 er 24hr 3.75 mg ...... 68 morphine sulfate oral soln 10 mg/5ml see pramipexole dihydrochloride tab ...... 17 er 24hr 4.5 mg ...... 69 morphine sulfate oral soln 100 mg/5ml MIRCETTE (20 mg/ml) ...... 17 see kariva tab 28 day ...... 89 morphine sulfate oral soln 20 mg/5ml MIRENA IUD SYSTEM ...... 91 ...... 17 mirtazapine orally disintegrating tab 15 morphine sulfate suppos 10 mg ...... 17 mg ...... 38 morphine sulfate suppos 20 mg ...... 17 mirtazapine orally disintegrating tab 30 MORPHINE SULFATE SUPPOS 30 MG 17 mg ...... 38 morphine sulfate suppos 5 mg ...... 17 mirtazapine orally disintegrating tab 45 morphine sulfate tab 15 mg ...... 17 mg ...... 38 morphine sulfate tab 30 mg ...... 17 mirtazapine tab 15 mg ...... 38 morphine sulfate tab er 15 mg ...... 17 mirtazapine tab 30 mg ...... 38 morphine sulfate tab er 30 mg ...... 17 mirtazapine tab 45 mg ...... 38 morphine sulfate tab er 60 mg ...... 17 mirtazapine tab 7.5 mg ...... 38 MOVANTIK TAB 12.5MG...... 118 misoprostol tab 100 mcg ...... 157 MOVANTIK TAB 25MG ...... 118 misoprostol tab 200 mcg ...... 157 moxifloxacin hcl ophth soln 0.5% (base MOBIC equiv) ...... 141 see meloxicam tab 15 mg ...... 14 moxifloxacin hcl tab 400 mg (base see meloxicam tab 7.5 mg ...... 14 equiv) ...... 116 moexipril hcl tab 15 mg ...... 53 MS CONTIN moexipril hcl tab 7.5 mg ...... 53 see morphine sulfate tab er 15 mg 17 moexipril-hydrochlorothiazide tab 15- see morphine sulfate tab er 30 mg 17 12.5 mg ...... 58 see morphine sulfate tab er 60 mg 17 moexipril-hydrochlorothiazide tab 15- MULPLETA TAB 3MG ...... 121 25 mg ...... 58 MULTAQ TAB 400MG ...... 26 moexipril-hydrochlorothiazide tab 7.5- MULTIGEN TAB ...... 122 12.5 mg ...... 57 MULTIGEN TAB FOLIC ...... 122 mometasone furoate cream 0.1% .. 102 multiple vitamins w/ minerals tab .. 134 mometasone furoate nasal susp 50 multi-vit/fe dro /fl 0.25 ...... 134 mcg/act ...... 139 multi-vit/fl dro 0.25mg ...... 134 mometasone furoate oint 0.1% ...... 102 multi-vit/fl dro 0.5mg/ml ...... 134 mometasone furoate solution 0.1% mupirocin calcium cream 2% ...... 97 (lotion) ...... 102 mupirocin oint 2% ...... 97 mononessa tab ...... 90 MUSE SUP 1000MCG ...... 86 montelukast sodium chew tab 4 mg MUSE SUP 125MCG ...... 86 (base equiv) ...... 26 MUSE SUP 250MCG ...... 86 montelukast sodium chew tab 5 mg MUSE SUP 500MCG ...... 86 (base equiv) ...... 26 mvc-fluoride chw 0.25mg ...... 134 209 mvc-fluoride chw 0.5mg ...... 134 nadolol & bendroflumethiazide tab 40-5 mvc-fluoride chw 1mg ...... 134 mg ...... 58 MYAMBUTOL nadolol & bendroflumethiazide tab 80-5 see ethambutol hcl tab 400 mg ..... 60 mg ...... 58 MYCOBUTIN nadolol tab 20 mg ...... 81 see rifabutin cap 150 mg ...... 60 nadolol tab 40 mg ...... 81 mycophenolate mofetil cap 250 mg 132 nadolol tab 80 mg ...... 81 mycophenolate mofetil for oral susp naftifine hcl cream 1% ...... 97 200 mg/ml ...... 132 naftifine hcl cream 2% ...... 97 mycophenolate mofetil tab 500 mg 132 naftifine hcl gel 1% ...... 97 mycophenolate sodium tab dr 180 mg NAFTIN (mycophenolic acid equiv) ...... 132 see naftifine hcl gel 1% ...... 97 mycophenolate sodium tab dr 360 mg NAFTIN GEL 2% ...... 97 (mycophenolic acid equiv) ...... 132 naloxone hcl soln prefilled syringe 2 MYDRIACYL mg/2ml ...... 47 see tropicamide ophth soln 1% ... 141 naltrexone hcl tab 50 mg ...... 47 myferon 150 cap forte ...... 122 NAMENDA MYFORTIC see memantine hcl tab 10 mg ..... 147 see mycophenolate sodium tab dr see memantine hcl tab 5 mg ...... 147 180 mg (mycophenolic acid equiv) NAMENDA TITRATION PAK ...... 132 see memantine hcl tab 28 x 5 mg & see mycophenolate sodium tab dr 21 x 10 mg titration pack ...... 147 360 mg (mycophenolic acid equiv) NAMENDA XR ...... 132 see memantine hcl cap er 24hr 14 MYFORTIC TAB 180MG ...... 132 mg ...... 147 MYFORTIC TAB 360MG ...... 132 see memantine hcl cap er 24hr 21 MYKIDZ IRON SUS 15/1.5ML ...... 122 mg ...... 147 MYLERAN TAB 2MG ...... 61 see memantine hcl cap er 24hr 28 MYNATAL CAP ...... 135 mg ...... 147 MYNATAL TAB ...... 135 see memantine hcl cap er 24hr 7 mg MYNATAL-Z TAB ...... 135 ...... 147 MYNATE 90 TAB PLUS ...... 135 NAMENDA XR CAP TITRATIO ...... 147 mynephrocaps cap ...... 134 naphazoline hcl ophth soln 0.1% ... 142 myorisan cap 10mg ...... 95 NAPROSYN myorisan cap 20mg ...... 95 see naproxen susp 125 mg/5ml .... 15 myorisan cap 30mg ...... 95 see naproxen tab 500 mg ...... 15 myorisan cap 40mg ...... 95 naproxen dr tab 375mg ...... 14 MYRBETRIQ TAB 25MG ...... 158 naproxen dr tab 500mg ...... 14 MYRBETRIQ TAB 50MG ...... 158 naproxen sodium tab 275 mg ...... 14 MYSOLINE naproxen sodium tab 550 mg ...... 14 see primidone tab 250 mg ...... 36 naproxen susp 125 mg/5ml ...... 15 see primidone tab 50 mg ...... 36 naproxen tab 250 mg ...... 15 MYTESI TAB 125MG ...... 46 naproxen tab 375 mg ...... 15 N naproxen tab 500 mg ...... 15 nabumetone tab 500 mg ...... 14 naratriptan hcl tab 1 mg (base equiv) nabumetone tab 750 mg ...... 14 ...... 128

210 naratriptan hcl tab 2.5 mg (base equiv) neomycin-bacitrac zn-polymyx ...... 128 5(3.5)mg-400unt-10000unt op oin NARCAN SPR ...... 47 ...... 141 NARDIL neomycin-polymy-gramicid op sol see phenelzine sulfate tab 15 mg .. 39 1.75-10000-0.025mg-unt-mg/ml 141 NASONEX neomycin-polymyxin-dexamethasone see mometasone furoate nasal susp ophth oint 0.1% ...... 142 50 mcg/act ...... 139 neomycin-polymyxin-dexamethasone NATACHEW CHW ...... 135 ophth susp 0.1% ...... 142 NATALVIT TAB 75-1MG ...... 135 neomycin-polymyxin-hc ophth susp 143 NATAZIA TAB ...... 90 neomycin-polymyxin-hc otic soln 1% nateglinide tab 120 mg ...... 45 ...... 144 nateglinide tab 60 mg ...... 45 neomycin-polymyxin-hc otic susp 3.5 NATELLE ONE CAP ...... 135 mg/ml-10000 unit/ml-1% ...... 144 NATPARA INJ 100MCG ...... 108 NEONATAL 19 TAB ...... 135 NATPARA INJ 25MCG ...... 107 NEONATAL FE TAB ...... 135 NATPARA INJ 50MCG ...... 107 NEONATAL/DHA MIS ...... 135 NATPARA INJ 75MCG ...... 108 NEORAL NATURE THROI TAB 162.5MG ...... 153 see cyclosporine modified cap 100 NATURE-THROI TAB 113.75MG ...... 154 mg ...... 131 NATURE-THROI TAB 130MG ...... 154 see cyclosporine modified cap 25 mg NATURE-THROI TAB 146.25MG ...... 154 ...... 131 NATURE-THROI TAB 16.25MG ...... 154 see cyclosporine modified oral soln NATURE-THROI TAB 195MG ...... 154 100 mg/ml ...... 131 NATURE-THROI TAB 260MG ...... 154 NEORAL CAP 100MG ...... 132 NATURE-THROI TAB 32.5MG ...... 154 NEORAL CAP 25MG ...... 132 NATURE-THROI TAB 325MG ...... 154 NEORAL SOL 100MG/ML ...... 132 NATURE-THROI TAB 48.75MG ...... 154 NEPHPLEX RX TAB ...... 134 NATURE-THROI TAB 65MG ...... 154 nephronex tab...... 134 NATURE-THROI TAB 81.25MG ...... 154 NESTABS ABC MIS ...... 135 NATURE-THROI TAB 97.5MG ...... 154 NESTABS DHA PAK ...... 135 NAYZILAM SPR 5MG ...... 33 NESTABS ONE CAP ...... 135 NEBUPENT neuac gel 1.2-5% ...... 95 see pentamidine isethionate for NEUPRO DIS 1MG/24HR ...... 68 nebulization soln 300 mg ...... 22 NEUPRO DIS 2MG/24HR ...... 68 nebusal neb 3% ...... 94 NEUPRO DIS 3MG/24HR ...... 68 necon tab 0.5/35 ...... 90 NEUPRO DIS 4MG/24HR ...... 68 necon tab 1/35 ...... 90 NEUPRO DIS 6MG/24HR ...... 68 necon tab 1/50-28 ...... 90 NEUPRO DIS 8MG/24HR ...... 68 NECON TAB 10/11-28 ...... 90 NEURONTIN necon tab 7/7/7 ...... 90 see gabapentin cap 100 mg ...... 34 nefazodone hcl tab 100 mg ...... 40 see gabapentin cap 300 mg ...... 34 nefazodone hcl tab 150 mg ...... 40 see gabapentin cap 400 mg ...... 34 nefazodone hcl tab 200 mg ...... 40 see gabapentin oral soln 250 mg/5ml nefazodone hcl tab 250 mg ...... 40 ...... 34 nefazodone hcl tab 50 mg ...... 40 see gabapentin tab 600 mg ...... 34 neomycin sulfate tab 500 mg ...... 12 see gabapentin tab 800 mg ...... 34 211

NEVANAC SUS 0.1% ...... 143 nifedipine tab er 24hr osmotic release nevirapine susp 50 mg/5ml ...... 77 30 mg ...... 83 nevirapine tab 200 mg ...... 77 nifedipine tab er 24hr osmotic release nevirapine tab er 24hr 100 mg ...... 77 60 mg ...... 84 nevirapine tab er 24hr 400 mg ...... 77 nifedipine tab er 24hr osmotic release NEWGEN TAB 32-1MG ...... 135 90 mg ...... 84 NEXA PLUS CAP ...... 135 nimodipine cap 30 mg ...... 84 NEXAVAR TAB 200MG ...... 65 NINLARO CAP 2.3MG ...... 65 NEXIUM NINLARO CAP 3MG ...... 65 see esomeprazole magnesium cap NINLARO CAP 4MG ...... 65 delayed release 40 mg (base eq) nisoldipine tab er 24hr 17 mg ...... 84 ...... 156 nisoldipine tab er 24hr 20 mg ...... 84 NEXPLANON IMP 68MG ...... 91 nisoldipine tab er 24hr 25.5 mg ...... 84 next choice tab 1.5mg ...... 91 nisoldipine tab er 24hr 30 mg ...... 84 niacin tab er 1000 mg nisoldipine tab er 24hr 34 mg ...... 84 (antihyperlipidemic) ...... 52 nisoldipine tab er 24hr 40 mg ...... 84 niacin tab er 500 mg nisoldipine tab er 24hr 8.5 mg ...... 84 (antihyperlipidemic) ...... 52 nitazoxanide tab 500 mg ...... 22 niacin tab er 750 mg NITRO-BID OIN 2% ...... 23 (antihyperlipidemic) ...... 52 NITRO-DUR DIS 0.3MG/HR ...... 23 niacor tab 500mg ...... 52 NITRO-DUR DIS 0.8MG/HR ...... 23 NIASPAN nitrofurantoin macrocrystalline cap 100 see niacin tab er 1000 mg mg ...... 157 (antihyperlipidemic) ...... 52 nitrofurantoin macrocrystalline cap 25 see niacin tab er 500 mg mg ...... 157 (antihyperlipidemic) ...... 52 nitrofurantoin macrocrystalline cap 50 see niacin tab er 750 mg mg ...... 157 (antihyperlipidemic) ...... 52 nitrofurantoin monohydrate nicardipine hcl cap 20 mg ...... 83 macrocrystalline cap 100 mg ...... 157 nicardipine hcl cap 30 mg ...... 83 nitrofurantoin susp 25 mg/5ml ...... 157 NICOMIDE TAB ...... 138 nitroglycerin lingual aerosol 400 nicotine polacrilex gum 2 mg ...... 149 mcg/spray ...... 23 nicotine polacrilex gum 4 mg ...... 149 nitroglycerin sl tab 0.3 mg ...... 23 nicotine polacrilex lozenge 2 mg .... 149 nitroglycerin sl tab 0.4 mg ...... 23 nicotine polacrilex lozenge 4 mg .... 150 nitroglycerin sl tab 0.6 mg ...... 23 NICOTINE SYS KIT TRANSDER ...... 150 nitroglycerin td patch 24hr 0.1 mg/hr nicotine td dis 21mg/24h ...... 150 ...... 23 nicotine td patch 24hr 14 mg/24hr . 150 nitroglycerin td patch 24hr 0.2 mg/hr nicotine td patch 24hr 7 mg/24hr ... 150 ...... 23 NICOTROL INH ...... 150 nitroglycerin td patch 24hr 0.4 mg/hr NICOTROL NS SPR 10MG/ML ...... 150 ...... 24 nifedipine cap 10 mg ...... 83 nitroglycerin td patch 24hr 0.6 mg/hr nifedipine cap 20 mg ...... 83 ...... 24 nifedipine tab er 24hr 30 mg ...... 83 nitroglycerin tl soln 0.4 mg/spray (400 nifedipine tab er 24hr 60 mg ...... 83 mcg/spray) ...... 24 nifedipine tab er 24hr 90 mg ...... 83 NITROLINGUAL PUMPSPRAY

212

see nitroglycerin tl soln 0.4 mg/spray see amlodipine besylate tab 2.5 mg (400 mcg/spray) ...... 24 (base equivalent) ...... 82 NITROMIST AER 400MCG ...... 24 see amlodipine besylate tab 5 mg NITROSTAT (base equivalent) ...... 82 see nitroglycerin sl tab 0.3 mg ...... 23 NORVIR see nitroglycerin sl tab 0.4 mg ...... 23 see ritonavir tab 100 mg ...... 77 see nitroglycerin sl tab 0.6 mg ...... 23 NORVIR CAP 100MG ...... 77 nizatidine cap 150 mg ...... 156 NORVIR SOL 80MG/ML ...... 77 nizatidine cap 300 mg ...... 156 novarel inj 10000unt ...... 109 nizatidine oral soln 15 mg/ml ...... 156 NOVOLIN INJ 70/30 ...... 45 NOCDURNA SUB 27.7MCG ...... 113 NOVOLIN INJ 70/30 FP ...... 45 NOCDURNA SUB 55.3MCG ...... 113 NOVOLIN N INJ U-100 ...... 45 NOCTIVA EMU 0.83/0.1 ...... 113 NOVOLIN R INJ U-100 ...... 45 NOCTIVA SPR 1.66/0.1 ...... 113 NOVOLOG INJ 100/ML ...... 45 nora-be tab 0.35mg ...... 91 NOVOLOG INJ FLEXPEN ...... 45 NORDITROPIN INJ 10/1.5ML ...... 111 NOVOLOG INJ PENFILL ...... 45 NORDITROPIN INJ 15/1.5ML ...... 111 NOVOLOG MIX INJ 70/30 ...... 45 NORDITROPIN INJ 30/3ML ...... 111 NOVOLOG MIX INJ FLEXPEN ...... 45 NORDITROPIN INJ 5/1.5ML ...... 111 NOXAFIL norethindrone ace-eth estradiol-fe see posaconazole tab delayed release chew tab 1 mg-20 mcg (24) ...... 90 100 mg ...... 49 norethindrone ace-ethinyl estradiol-fe NOXAFIL SUS 40MG/ML ...... 49 cap 1 mg-20 mcg (24) ...... 90 np thyroid tab 120mg ...... 154 norethindrone acetate tab 5 mg ..... 146 np thyroid tab 15mg ...... 154 norethindrone acetate-ethinyl estradiol np thyroid tab 30mg ...... 154 tab 0.5 mg-2.5 mcg ...... 114 np thyroid tab 60mg ...... 154 NORPACE np thyroid tab 90mg ...... 154 see disopyramide phosphate cap 100 NUBEQA TAB 300MG ...... 62 mg ...... 25 NUCYNTA ER TAB 100MG ...... 17 see disopyramide phosphate cap 150 NUCYNTA ER TAB 150MG ...... 17 mg ...... 25 NUCYNTA ER TAB 200MG ...... 17 NORPACE CAP 100MG CR ...... 25 NUCYNTA ER TAB 250MG ...... 17 NORPACE CAP 150MG CR ...... 25 NUCYNTA ER TAB 50MG ...... 17 NORPRAMIN NUCYNTA TAB 100MG ...... 17 see desipramine hcl tab 10 mg...... 42 NUCYNTA TAB 50MG ...... 17 see desipramine hcl tab 25 mg...... 42 NUCYNTA TAB 75MG ...... 17 nortrel tab 0.5/35 ...... 90 NUEDEXTA CAP 20-10MG ...... 149 nortrel tab 1/35 ...... 90 NULYTELY nortrel tab 7/7/7...... 90 see trilyte sol ...... 124 nortriptyline hcl cap 10 mg ...... 42 NURTEC TAB 75MG ODT ...... 128 nortriptyline hcl cap 25 mg ...... 42 NUTREN 1.0 LIQ UNFLAVOR ...... 105 nortriptyline hcl cap 50 mg ...... 42 NUTROPIN AQ INJ 10MG/2ML ...... 112 nortriptyline hcl cap 75 mg ...... 42 NUTROPIN AQ INJ 20MG/2ML ...... 112 nortriptyline hcl soln 10 mg/5ml ...... 42 NUTROPIN AQ INJ NUSPIN 5 ...... 112 NORVASC NUVARING see amlodipine besylate tab 10 mg see eluryng mis ...... 91 (base equivalent) ...... 82 NUVIGIL 213

see armodafinil tab 150 mg ...... 10 olanzapine orally disintegrating tab 10 see armodafinil tab 200 mg ...... 10 mg ...... 72 see armodafinil tab 250 mg ...... 10 olanzapine orally disintegrating tab 15 see armodafinil tab 50 mg ...... 10 mg ...... 72 nystatin cream 100000 unit/gm ...... 97 olanzapine orally disintegrating tab 20 nystatin oint 100000 unit/gm ...... 97 mg ...... 72 nystatin oral powder ...... 48 olanzapine orally disintegrating tab 5 nystatin susp 100000 unit/ml ...... 133 mg ...... 72 nystatin tab 500000 unit ...... 48 olanzapine tab 10 mg ...... 73 nystatin topical powder 100000 olanzapine tab 15 mg ...... 73 unit/gm ...... 97 olanzapine tab 2.5 mg ...... 73 nystatin-triamcinolone cream 100000- olanzapine tab 20 mg ...... 73 0.1 unit/gm-% ...... 98 olanzapine tab 5 mg ...... 73 nystatin-triamcinolone oint 100000-0.1 olanzapine tab 7.5 mg ...... 73 unit/gm-% ...... 98 olmesartan medoxomil tab 20 mg .... 54 O olmesartan medoxomil tab 40 mg .... 54 OB COMPLETE CAP ...... 136 olmesartan medoxomil tab 5 mg ...... 54 OB COMPLETE CAP GOLD ...... 136 olmesartan-amlodipine- OB COMPLETE CAP ONE ...... 136 hydrochlorothiazide tab 20-5-12.5 OB COMPLETE CAP PETITE ...... 136 mg ...... 58 OB COMPLETE TAB ...... 136 olmesartan-amlodipine- OB COMPLETE TAB PREMIER ...... 136 hydrochlorothiazide tab 40-10-12.5 OB COMPLETE/ CAP DHA ...... 136 mg ...... 58 OBSTETRIX EC TAB ...... 136 olmesartan-amlodipine- OBSTETRIX PAK DHA ...... 136 hydrochlorothiazide tab 40-10-25 mg O-CAL TAB PRENATAL ...... 136 ...... 58 ocella tab 3-0.03mg ...... 90 olmesartan-amlodipine- octreotide acetate inj 100 mcg/ml (0.1 hydrochlorothiazide tab 40-5-12.5 mg/ml) ...... 113 mg ...... 58 octreotide acetate inj 1000 mcg/ml (1 olmesartan-amlodipine- mg/ml) ...... 114 hydrochlorothiazide tab 40-5-25 mg octreotide acetate inj 200 mcg/ml (0.2 ...... 58 mg/ml) ...... 114 olopatadine hcl nasal soln 0.6% ..... 139 octreotide acetate inj 50 mcg/ml (0.05 olopatadine hcl ophth soln 0.1% (base mg/ml) ...... 113 equivalent) ...... 143 octreotide acetate inj 500 mcg/ml (0.5 olopatadine hcl ophth soln 0.2% (base mg/ml) ...... 114 equivalent) ...... 143 OCUFLOX OLUX see ofloxacin ophth soln 0.3% .... 141 see clobetasol propionate foam ODEFSEY TAB ...... 77 0.05% ...... 100 ODOMZO CAP 200MG ...... 61 OMECLAMOX- MIS PAK ...... 157 OFEV CAP 100MG ...... 150 OMEGA-3 2100 CAP 1050MG ...... 139 OFEV CAP 150MG ...... 150 omega-3 fatty acids cap 1000 mg .. 139 ofloxacin ophth soln 0.3% ...... 141 omega-3-acid ethyl esters cap 1 gm . 50 ofloxacin otic soln 0.3% ...... 144 OMEPRAZOLE + SUS SYRSPEND .... 156 ofloxacin tab 400 mg ...... 116 omeprazole cap delayed release 10 mg ogestrel tab ...... 90 ...... 156 214 omeprazole cap delayed release 20 mg oseltamivir phosphate cap 45 mg (base ...... 156 equiv) ...... 80 omeprazole cap delayed release 40 mg oseltamivir phosphate cap 75 mg (base ...... 157 equiv) ...... 80 OMNIFLEX DPR ...... 125 oseltamivir phosphate for susp 6 OMNIPOD MIS 5 PACK ...... 126 mg/ml (base equiv) ...... 80 OMNITROPE INJ 5.8MG ...... 112 OSPHENA TAB 60MG ...... 112 ondansetron hcl oral soln 4 mg/5ml .. 47 OTEZLA TAB 10/20/30 ...... 15 ondansetron hcl tab 24 mg ...... 47 OTEZLA TAB 30MG ...... 15 ondansetron hcl tab 4 mg ...... 47 OVACE PLUS LOT 9.8% ...... 99 ondansetron hcl tab 8 mg ...... 47 OVIDREL INJ ...... 110 ondansetron orally disintegrating tab 4 oxaprozin tab 600 mg ...... 15 mg ...... 47 oxazepam cap 10 mg ...... 25 ondansetron orally disintegrating tab 8 oxazepam cap 15 mg ...... 25 mg ...... 47 oxazepam cap 30 mg ...... 25 ONFI oxcarbazepine susp 300 mg/5ml (60 see clobazam suspension 2.5 mg/ml mg/ml)...... 35 ...... 32 oxcarbazepine tab 150 mg ...... 35 see clobazam tab 10 mg ...... 32 oxcarbazepine tab 300 mg ...... 35 see clobazam tab 20 mg ...... 32 oxcarbazepine tab 600 mg ...... 35 ONIVYDE INJ 4.3MG/ML ...... 67 oxiconazole nitrate cream 1% ...... 98 ONMEL TAB 200MG ...... 49 OXISTAT OPSITE IV MIS 3000 ...... 125 see oxiconazole nitrate cream 1% . 98 OPSUMIT TAB 10MG ...... 87 OXISTAT LOT 1% ...... 98 ORAPRED ODT oxybutynin chloride syrup 5 mg/5ml see prednisolone sod phos orally ...... 158 disintegr tab 10 mg (base eq) .... 92 oxybutynin chloride tab 5 mg ...... 158 see prednisolone sod phos orally oxybutynin chloride tab er 24hr 10 mg disintegr tab 15 mg (base eq) .... 92 ...... 158 see prednisolone sod phos orally oxybutynin chloride tab er 24hr 15 mg disintegr tab 30 mg (base eq) .... 92 ...... 158 ORGOVYX TAB 120MG ...... 62 oxybutynin chloride tab er 24hr 5 mg ORIAHNN CAP ...... 114 ...... 158 ORILISSA TAB 150MG ...... 111 oxycodone hcl cap 5 mg ...... 17 ORILISSA TAB 200MG ...... 111 oxycodone hcl soln 5 mg/5ml ...... 17 ORKAMBI GRA 100-125 ...... 150 oxycodone hcl tab 10 mg ...... 17 ORKAMBI GRA 150-188 ...... 150 oxycodone hcl tab 15 mg ...... 18 ORKAMBI TAB 100-125 ...... 150 oxycodone hcl tab 20 mg ...... 18 ORKAMBI TAB 200-125 ...... 150 oxycodone hcl tab 30 mg ...... 18 orphenadrine citrate tab er 12hr 100 oxycodone hcl tab 5 mg ...... 17 mg ...... 138 oxycodone hcl tab er 12hr deter 10 mg orphenadrine w/ aspirin & caffeine tab ...... 18 25-385-30 mg ...... 139 oxycodone hcl tab er 12hr deter 15 mg ORTHO TRI-CYCLEN LO ...... 18 see tri-lo- tab sprintec ...... 90 oxycodone hcl tab er 12hr deter 20 mg oseltamivir phosphate cap 30 mg (base ...... 18 equiv) ...... 79 215 oxycodone hcl tab er 12hr deter 40 mg paliperidone tab er 24hr 3 mg ...... 71 ...... 18 paliperidone tab er 24hr 6 mg ...... 71 oxycodone hcl tab er 12hr deter 80 mg paliperidone tab er 24hr 9 mg ...... 71 ...... 18 PAMELOR oxycodone w/ acetaminophen soln 5- see nortriptyline hcl cap 10 mg ..... 42 325 mg/5ml ...... 19 see nortriptyline hcl cap 25 mg ..... 42 oxycodone w/ acetaminophen tab 10- see nortriptyline hcl cap 50 mg ..... 42 325 mg ...... 19 see nortriptyline hcl cap 75 mg ..... 42 oxycodone w/ acetaminophen tab 2.5- PANCREAZE CAP...... 105 325 mg ...... 19 PANCREAZE CAP 10500UNT ...... 105 oxycodone w/ acetaminophen tab 5- PANCREAZE CAP 16800UNT ...... 105 325 mg ...... 19 PANCREAZE CAP 21000UNT ...... 105 oxycodone w/ acetaminophen tab 7.5- PANCREAZE CAP 4200UNIT ...... 105 325 mg ...... 19 pantoprazole sodium ec tab 20 mg oxycodone-aspirin tab 4.8355-325 mg (base equiv) ...... 157 ...... 19 pantoprazole sodium ec tab 40 mg oxycodone-ibuprofen tab 5-400 mg .. 19 (base equiv) ...... 157 OXYCONTIN TAB 10MG CR ...... 18 PARAGARD IUD T380A ...... 91 OXYCONTIN TAB 15MG CR ...... 18 paricalcitol cap 1 mcg ...... 112 OXYCONTIN TAB 20MG CR ...... 18 paricalcitol cap 2 mcg ...... 113 OXYCONTIN TAB 40MG CR ...... 18 paricalcitol cap 4 mcg ...... 113 OXYCONTIN TAB 80MG CR ...... 18 PARLODEL oxymorphone hcl tab 10 mg ...... 18 see bromocriptine mesylate cap 5 mg oxymorphone hcl tab 5 mg ...... 18 (base equivalent) ...... 67 oxymorphone hcl tab er 12hr 10 mg . 18 PARNATE oxymorphone hcl tab er 12hr 15 mg . 18 see tranylcypromine sulfate tab 10 oxymorphone hcl tab er 12hr 20 mg . 18 mg ...... 39 oxymorphone hcl tab er 12hr 30 mg . 18 paromomycin sulfate cap 250 mg .... 12 oxymorphone hcl tab er 12hr 40 mg . 18 paroxetine hcl tab 10 mg ...... 40 oxymorphone hcl tab er 12hr 5 mg... 18 paroxetine hcl tab 20 mg ...... 40 oxymorphone hcl tab er 12hr 7.5 mg 18 paroxetine hcl tab 30 mg ...... 40 OZEMPIC INJ 2/1.5ML ...... 45 paroxetine hcl tab 40 mg ...... 40 P paroxetine hcl tab er 24hr 12.5 mg .. 40 PAIRE OB MIS ...... 136 paroxetine hcl tab er 24hr 25 mg ..... 40 PALFORZIA CAP ESCALAT ...... 12 paroxetine hcl tab er 24hr 37.5 mg .. 40 PALFORZIA CAP LEVEL 1 ...... 12 PATANASE PALFORZIA CAP LEVEL 10 ...... 12 see olopatadine hcl nasal soln 0.6% PALFORZIA CAP LEVEL 2 ...... 12 ...... 139 PALFORZIA CAP LEVEL 3 ...... 12 PAXIL PALFORZIA CAP LEVEL 4 ...... 12 see paroxetine hcl tab 10 mg ...... 40 PALFORZIA CAP LEVEL 5 ...... 12 see paroxetine hcl tab 20 mg ...... 40 PALFORZIA CAP LEVEL 6 ...... 12 see paroxetine hcl tab 30 mg ...... 40 PALFORZIA CAP LEVEL 7 ...... 12 see paroxetine hcl tab 40 mg ...... 40 PALFORZIA CAP LEVEL 8 ...... 12 PAXIL CR PALFORZIA CAP LEVEL 9 ...... 12 see paroxetine hcl tab er 24hr 12.5 PALFORZIA POW LEVEL 11 ...... 12 mg ...... 40 paliperidone tab er 24hr 1.5 mg ...... 71 216

see paroxetine hcl tab er 24hr 25 mg see chlorhexidine gluconate soln ...... 40 0.12% ...... 133 see paroxetine hcl tab er 24hr 37.5 perindopril erbumine tab 2 mg ...... 53 mg ...... 40 perindopril erbumine tab 4 mg ...... 53 PCE TAB 333MG EC ...... 125 perindopril erbumine tab 8 mg ...... 53 PCE TAB 500MG EC ...... 125 permethrin cream 5% ...... 104 PEDIAPRED perphenazine tab 16 mg ...... 74 see prednisolone sod phosph oral perphenazine tab 2 mg ...... 74 soln 6.7 mg/5ml (5 mg/5ml base) perphenazine tab 4 mg ...... 74 ...... 92 perphenazine tab 8 mg ...... 74 peg 3350-kcl-na bicarb-nacl-na sulfate perphenazine-amitriptyline tab 2-10 for soln 236 gm ...... 124 mg ...... 148 peg 3350-kcl-na bicarb-nacl-na sulfate perphenazine-amitriptyline tab 2-25 for soln 240 gm ...... 124 mg ...... 148 PEGASYS INJ ...... 79 perphenazine-amitriptyline tab 4-10 PEGASYS INJ 180MCG/M ...... 79 mg ...... 148 PEGASYS INJ PROCLICK ...... 79 perphenazine-amitriptyline tab 4-25 PEN NEEDLES MIS 29GX1/2 ...... 127 mg ...... 148 PEN NEEDLES MIS 31GX1/4 ...... 127 perphenazine-amitriptyline tab 4-50 PEN NEEDLES MIS 31GX5/16 ...... 127 mg ...... 148 PEN NEEDLES MIS 32GX5MM ...... 127 PERTZYE CAP 16000U ...... 105 penicillin v potassium for soln 125 PERTZYE CAP 24000U ...... 105 mg/5ml ...... 145 phenazopyridine hcl tab 100 mg .... 119 penicillin v potassium for soln 250 phenazopyridine hcl tab 200 mg .... 119 mg/5ml ...... 145 phendimetrazine tartrate tab 35 mg ... 9 penicillin v potassium tab 250 mg .. 145 phenelzine sulfate tab 15 mg ...... 39 penicillin v potassium tab 500 mg .. 145 PHENHIST DH LIQ 30-2-10 ...... 93 pentamidine isethionate for phenobarbital elixir 20 mg/5ml ...... 123 nebulization soln 300 mg ...... 22 phenobarbital tab 100 mg ...... 123 PENTASA CAP 250MG CR ...... 117 phenobarbital tab 15 mg ...... 123 PENTASA CAP 500MG CR ...... 117 phenobarbital tab 16.2 mg ...... 123 pentoxifylline tab er 400 mg ...... 120 phenobarbital tab 30 mg ...... 123 PEPCID phenobarbital tab 32.4 mg ...... 123 see famotidine tab 20 mg ...... 156 phenobarbital tab 60 mg ...... 123 see famotidine tab 40 mg ...... 156 phenobarbital tab 64.8 mg ...... 123 PEPTAMEN JUN POW VANILLA...... 105 phenobarbital tab 97.2 mg ...... 123 PERCOCET phenoxybenzamine hcl cap 10 mg ... 53 see oxycodone w/ acetaminophen tab phentermine hcl cap 15 mg ...... 9 10-325 mg ...... 19 phentermine hcl cap 30 mg ...... 9 see oxycodone w/ acetaminophen tab phentermine hcl cap 37.5 mg ...... 9 2.5-325 mg ...... 19 phentermine hcl tab 37.5 mg ...... 9 see oxycodone w/ acetaminophen tab phenylephrine hcl ophth soln 2.5% 140 5-325 mg ...... 19 PHENYTEK see oxycodone w/ acetaminophen tab see phenytoin sodium extended cap 7.5-325 mg ...... 19 200 mg ...... 37 PERFOROMIST NEB 20MCG ...... 29 see phenytoin sodium extended cap PERIDEX 300 mg ...... 38 217

PHENYTEK CAP 200MG ...... 37 PLAQUENIL PHENYTEK CAP 300MG ...... 37 see hydroxychloroquine sulfate tab phenytoin chew tab 50 mg ...... 37 200 mg ...... 59 phenytoin sodium extended cap 100 PLAQUENIL TAB 200MG ...... 59 mg ...... 37 PLAVIX phenytoin sodium extended cap 200 see clopidogrel bisulfate tab 75 mg mg ...... 37 (base equiv) ...... 120 phenytoin sodium extended cap 300 PNV OB+DHA PAK ...... 136 mg ...... 38 pnv-dha cap ...... 136 phenytoin susp 125 mg/5ml ...... 38 PNV-DHA CAP DOCUSATE ...... 136 PHOSLO PNV-OMEGA CAP ...... 136 see calcium acetate (phosphate pnv-select tab ...... 136 binder) cap 667 mg (169 mg ca) PNV-TOTAL CAP ...... 136 ...... 118 podofilox soln 0.5% ...... 103 PHOSLYRA SOL ...... 118 polyethylene glycol 3350 oral powder phytonadione tab 5 mg ...... 161 17 gm/scoop ...... 124 PICATO GEL 0.015% ...... 98 polymyxin b-trimethoprim ophth soln PICATO GEL 0.05% ...... 98 10000 unit/ml-0.1% ...... 141 pilocarpine hcl ophth soln 1% ...... 141 POLYTRIM pilocarpine hcl ophth soln 2% ...... 141 see polymyxin b-trimethoprim ophth pilocarpine hcl ophth soln 4% ...... 141 soln 10000 unit/ml-0.1% ...... 141 pilocarpine hcl tab 5 mg ...... 133 POLY-VI-FLOR CHW 0.25MG ...... 134 pilocarpine hcl tab 7.5 mg ...... 134 POLY-VI-FLOR CHW 0.5MG ...... 134 pimecrolimus cream 1% ...... 103 POLY-VI-FLOR CHW 1MG ...... 134 pimozide tab 1 mg ...... 149 POLY-VI-FLOR CHW W/IRON ...... 134 pimozide tab 2 mg ...... 149 POLY-VI-FLOR SUS /IRON ...... 134 pindolol tab 10 mg ...... 81 POLY-VI-FLOR SUS 0.25/ML ...... 134 pindolol tab 5 mg ...... 81 portia-28 tab ...... 90 pioglitazone hcl tab 15 mg (base equiv) posaconazole tab delayed release 100 ...... 45 mg ...... 49 pioglitazone hcl tab 30 mg (base equiv) pot bicarbonate & chloride effer tab 25 ...... 45 meq ...... 130 pioglitazone hcl tab 45 mg (base equiv) POTABA CAP 500MG ...... 161 ...... 45 potassium bicarbonate effer tab 25 pioglitazone hcl-glimepiride tab 30-2 meq ...... 130 mg ...... 43 potassium chloride cap er 10 meq .. 130 pioglitazone hcl-glimepiride tab 30-4 potassium chloride cap er 8 meq ... 130 mg ...... 43 potassium chloride microencapsulated pioglitazone hcl-metformin hcl tab 15- crys er tab 10 meq ...... 130 500 mg ...... 43 potassium chloride microencapsulated pioglitazone hcl-metformin hcl tab 15- crys er tab 20 meq ...... 130 850 mg ...... 43 potassium chloride oral soln 10% (20 PIQRAY 200MG TAB DOSE...... 65 meq/15ml) ...... 130 PIQRAY 250MG TAB DOSE...... 65 potassium chloride oral soln 20% (40 PIQRAY 300MG TAB DOSE...... 65 meq/15ml) ...... 130 piroxicam cap 10 mg ...... 15 potassium chloride powder packet 20 piroxicam cap 20 mg ...... 15 meq ...... 130 218 potassium chloride tab er 10 meq .. 131 PRAVACHOL potassium chloride tab er 20 meq see pravastatin sodium tab 20 mg . 51 (1500 mg) ...... 131 see pravastatin sodium tab 40 mg . 51 potassium citrate tab er 10 meq (1080 pravastatin sodium tab 10 mg ...... 51 mg) ...... 119 pravastatin sodium tab 20 mg ...... 51 potassium citrate tab er 15 meq (1620 pravastatin sodium tab 40 mg ...... 51 mg) ...... 119 pravastatin sodium tab 80 mg ...... 51 potassium citrate tab er 5 meq (540 praziquantel tab 600 mg ...... 21 mg) ...... 119 prazosin hcl cap 1 mg ...... 55 pr benzoyl liq 7% wash ...... 95 prazosin hcl cap 2 mg ...... 55 PR NATAL 400 PAK ...... 136 prazosin hcl cap 5 mg ...... 55 PR NATAL 400 PAK EC ...... 136 PRECISN XTRA TES KETONE ...... 104 PR NATAL 430 PAK ...... 136 PRECOSE PR NATAL 430 PAK EC ...... 136 see acarbose tab 100 mg ...... 43 pramipexole dihydrochloride tab 0.125 see acarbose tab 25 mg ...... 42 mg ...... 68 see acarbose tab 50 mg ...... 42 pramipexole dihydrochloride tab 0.25 PRED FORTE mg ...... 68 see prednisolone acetate ophth susp pramipexole dihydrochloride tab 0.5 1% ...... 143 mg ...... 68 PRED MILD SUS 0.12% OP ...... 143 pramipexole dihydrochloride tab 0.75 PRED SOD PHO SOL 1% OP ...... 143 mg ...... 68 PRED-G S.O.P OIN OP ...... 143 pramipexole dihydrochloride tab 1 mg PRED-G SUS OP ...... 143 ...... 68 prednicarbate cream 0.1% ...... 102 pramipexole dihydrochloride tab 1.5 prednicarbate oint 0.1% ...... 102 mg ...... 68 prednisolone acetate ophth susp 1% pramipexole dihydrochloride tab er ...... 143 24hr 0.375 mg ...... 68 prednisolone sod phos orally disintegr pramipexole dihydrochloride tab er tab 10 mg (base eq) ...... 92 24hr 0.75 mg ...... 68 prednisolone sod phos orally disintegr pramipexole dihydrochloride tab er tab 15 mg (base eq) ...... 92 24hr 1.5 mg ...... 68 prednisolone sod phos orally disintegr pramipexole dihydrochloride tab er tab 30 mg (base eq) ...... 92 24hr 2.25 mg ...... 68 prednisolone sod phosph oral soln 6.7 pramipexole dihydrochloride tab er mg/5ml (5 mg/5ml base) ...... 92 24hr 3 mg ...... 68 prednisolone sod phosphate oral soln pramipexole dihydrochloride tab er 15 mg/5ml (base equiv) ...... 92 24hr 3.75 mg ...... 68 prednisolone sodium phosphate oral pramipexole dihydrochloride tab er soln 25 mg/5ml (base eq) ...... 92 24hr 4.5 mg ...... 69 prednisolone syrup 15 mg/5ml (usp PRAMOSONE CRE 1-1% ...... 102 solution equivalent) ...... 92 PRAMOSONE LOT 2.5% ...... 102 PREDNISONE CON 5MG/ML ...... 93 PRAMOSONE OIN 2.5% ...... 102 prednisone oral soln 5 mg/5ml ...... 93 pramoxine-hc cream 1-2.5% ...... 102 prednisone tab 1 mg ...... 93 prasugrel hcl tab 10 mg (base equiv) prednisone tab 10 mg ...... 93 ...... 120 prednisone tab 2.5 mg ...... 93 prasugrel hcl tab 5 mg (base equiv) 120 prednisone tab 20 mg ...... 93 219 prednisone tab 5 mg ...... 93 PRENATAL+FE TAB 29-1MG ...... 137 prednisone tab 50 mg ...... 93 PRENATAL-U CAP 106.5-1 ...... 137 prednisone tab therapy pack 10 mg PRENATE AM TAB 1MG ...... 137 (21) ...... 93 PRENATE CAP ENHANCE ...... 137 prednisone tab therapy pack 5 mg (21) PRENATE CAP ESSENTIA ...... 137 ...... 93 PRENATE CAP PIXIE ...... 137 PREFERA OB TAB ...... 136 PRENATE CAP RESTORE ...... 137 PREFERAOB MIS +DHA ...... 136 PRENATE CHW 0.6-0.4 ...... 137 pregabalin cap 100 mg ...... 36 PRENATE DHA CAP ...... 137 pregabalin cap 150 mg ...... 36 PRENATE MINI CAP ...... 137 pregabalin cap 200 mg ...... 36 PRENATE STAR TAB 20-1MG ...... 137 pregabalin cap 225 mg ...... 36 PRENATE TAB ELITE ...... 137 pregabalin cap 25 mg ...... 36 PREQUE 10 TAB ...... 137 pregabalin cap 300 mg ...... 36 PRETAB TAB 29-1MG ...... 137 pregabalin cap 50 mg ...... 36 PRETOMANID TAB 200MG ...... 60 pregabalin cap 75 mg ...... 36 PREVACID pregabalin soln 20 mg/ml ...... 36 see lansoprazole cap delayed release PREMARIN INJ 25MG ...... 116 15 mg ...... 156 PREMARIN TAB 0.3MG ...... 116 see lansoprazole cap delayed release PREMARIN TAB 0.45MG ...... 116 30 mg ...... 156 PREMARIN TAB 0.625MG ...... 116 PREVACID SOLUTAB PREMARIN TAB 0.9MG ...... 116 see lansoprazole tab delayed release PREMARIN TAB 1.25MG ...... 116 orally disintegrating 15 mg ...... 156 PREMARIN VAG CRE 0.625MG ...... 159 see lansoprazole tab delayed release PREMPHASE TAB ...... 114 orally disintegrating 30 mg ...... 156 PREMPRO TAB ...... 114 prevalite pow 4gm ...... 50 PREMPRO TAB 0.3-1.5 ...... 114 PREVIDENT SOL 0.2% ...... 133 PREMPRO TAB 0.45-1.5 ...... 114 previfem tab ...... 90 PREMPRO TAB 0.625-5 ...... 114 PREVYMIS TAB 240MG ...... 78 PRENA1 CHW ...... 136 PREVYMIS TAB 480MG ...... 78 PRENA1 PEARL CAP ...... 136 PREZCOBIX TAB 800-150 ...... 77 PRENAISSANCE CAP ...... 136 PREZISTA SUS 100MG/ML ...... 77 PRENAISSANCE CAP BALANCE ...... 136 PREZISTA TAB 150MG ...... 77 PRENAISSANCE CAP PLUS ...... 136 PREZISTA TAB 600MG ...... 77 PRENAISSANCE MIS HARMONY ...... 136 PREZISTA TAB 75MG ...... 77 PRENAISSANCE TAB NEXT ...... 136 PREZISTA TAB 800MG ...... 77 PRENAISSANCE TAB NEXT-B ...... 136 PRIFTIN TAB 150MG ...... 60 PRENATA CHW 29-1MG ...... 136 PRIMACARE CAP ...... 137 prenatabs fa tab 29-1mg ...... 136 PRIMAQUINE PHOSPHATE prenatabs rx tab ...... 136 see primaquine phosphate tab 26.3 PRENATAL 19 CHW 29-1MG ...... 136 mg (15 mg base) ...... 60 prenatal 19 chw tab ...... 136 primaquine phosphate tab 26.3 mg (15 prenatal 19 tab ...... 136 mg base) ...... 60 PRENATAL 19 TAB 29-1MG ...... 136 primidone tab 250 mg ...... 36 PRENATAL DHA PAK 27-1-250 ...... 136 primidone tab 50 mg ...... 36 PRENATAL MIS COMPLEAT ...... 136 PRIMSOL SOL 50MG/5ML ...... 22 PRENATAL TAB 27-1MG ...... 136 PRINIVIL 220

see lisinopril tab 20 mg ...... 53 PROGRAF CAP 0.5MG ...... 132 PRISTIQ PROGRAF CAP 1MG ...... 132 see desvenlafaxine succinate tab er PROGRAF CAP 5MG ...... 132 24hr 100 mg (base equiv) ...... 41 PROLENSA SOL 0.07% ...... 143 see desvenlafaxine succinate tab er PROMACTA PAK 25MG ...... 121 24hr 25 mg (base equiv) ...... 41 PROMACTA POW 12.5MG ...... 121 see desvenlafaxine succinate tab er PROMACTA TAB 12.5MG ...... 121 24hr 50 mg (base equiv) ...... 41 PROMACTA TAB 25MG ...... 121 PROAIR HFA PROMACTA TAB 50MG ...... 121 see albuterol sulfate inhal aero 108 PROMACTA TAB 75MG ...... 121 mcg/act (90mcg base equiv) ...... 28 promethazine & phenylephrine syrup probenecid tab 500 mg ...... 120 6.25-5 mg/5ml ...... 93 PROCARDIA XL promethazine hcl suppos 12.5 mg .... 49 see nifedipine tab er 24hr osmotic promethazine hcl suppos 25 mg ...... 49 release 30 mg ...... 83 promethazine hcl suppos 50 mg ...... 49 see nifedipine tab er 24hr osmotic promethazine hcl syrup 6.25 mg/5ml 49 release 60 mg ...... 84 promethazine hcl tab 12.5 mg ...... 49 see nifedipine tab er 24hr osmotic promethazine hcl tab 25 mg ...... 49 release 90 mg ...... 84 promethazine hcl tab 50 mg ...... 49 prochlorperazine maleate tab 10 mg promethazine w/ codeine syrup 6.25- (base equivalent) ...... 74 10 mg/5ml ...... 94 prochlorperazine maleate tab 5 mg promethazine-dm syrup 6.25-15 (base equivalent) ...... 74 mg/5ml ...... 94 prochlorperazine suppos 25 mg ...... 74 promethazine-phenylephrine-codeine PRO-CLEAR AC SYP 9-8.33MG ...... 93 syrup 6.25-5-10 mg/5ml ...... 94 PROCRIT INJ 10000/ML ...... 121 PROMETRIUM PROCRIT INJ 2000/ML ...... 121 see progesterone cap 100 mg ..... 146 PROCRIT INJ 20000/ML ...... 121 see progesterone cap 200 mg ..... 146 PROCRIT INJ 3000/ML ...... 121 propafenone hcl cap er 12hr 225 mg 25 PROCRIT INJ 4000/ML ...... 121 propafenone hcl cap er 12hr 325 mg 25 PROCRIT INJ 40000/ML ...... 121 propafenone hcl cap er 12hr 425 mg 25 PROCTOCORT propafenone hcl tab 150 mg ...... 26 see procto-pak cre 1% ...... 21 propafenone hcl tab 225 mg ...... 26 PROCTOFOAM AER HC 1% ...... 21 propafenone hcl tab 300 mg ...... 26 procto-pak cre 1% ...... 21 propantheline bromide tab 15 mg .. 156 proctozone cre -hc 2.5% ...... 21 propranolol & hydrochlorothiazide tab progesterone cap 100 mg ...... 146 40-25 mg ...... 58 progesterone cap 200 mg ...... 146 propranolol & hydrochlorothiazide tab PROGESTERONE SUP VGS 100 ...... 160 80-25 mg ...... 58 PROGESTERONE SUP VGS 200 ...... 160 propranolol hcl cap er 24hr 120 mg .. 81 PROGESTERONE SUP VGS 400 ...... 160 propranolol hcl cap er 24hr 160 mg .. 81 PROGLYCEM propranolol hcl cap er 24hr 60 mg ... 81 see diazoxide susp 50 mg/ml ...... 44 propranolol hcl cap er 24hr 80 mg ... 81 PROGRAF propranolol hcl oral soln 20 mg/5ml . 81 see tacrolimus cap 0.5 mg ...... 132 propranolol hcl oral soln 40 mg/5ml . 81 see tacrolimus cap 1 mg ...... 132 propranolol hcl tab 10 mg ...... 81 see tacrolimus cap 5 mg ...... 132 propranolol hcl tab 20 mg ...... 81 221 propranolol hcl tab 40 mg ...... 81 PURIXAN SUS 20MG/ML ...... 61 propranolol hcl tab 60 mg ...... 81 PYLERA CAP ...... 157 propranolol hcl tab 80 mg ...... 82 pyrazinamide tab 500 mg ...... 60 propylthiouracil tab 50 mg ...... 152 pyridostigmine bromide oral soln 60 PRO-RED AC SYP 5-1-9/5 ...... 93 mg/5ml ...... 60 PROSCAR pyridostigmine bromide tab 60 mg ... 60 see finasteride tab 5 mg ...... 119 pyridostigmine bromide tab er 180 mg PROTONIX ...... 60 see pantoprazole sodium ec tab 20 pyrimethamine tab 25 mg ...... 60 mg (base equiv) ...... 157 Q see pantoprazole sodium ec tab 40 QSYMIA CAP 11.25-69 ...... 9 mg (base equiv) ...... 157 QSYMIA CAP 15-92MG ...... 9 PROTOPIC QSYMIA CAP 3.75-23 ...... 9 see tacrolimus oint 0.03% ...... 103 QSYMIA CAP 7.5-46MG ...... 9 see tacrolimus oint 0.1% ...... 103 QUALAQUIN protriptyline hcl tab 10 mg ...... 42 see quinine sulfate cap 324 mg ..... 60 protriptyline hcl tab 5 mg ...... 42 QUARTETTE PROVERA see rivelsa tab ...... 90 see medroxyprogesterone acetate quasense tab ...... 90 tab 10 mg ...... 146 QUESTRAN see medroxyprogesterone acetate see cholestyramine powder 4 tab 2.5 mg ...... 146 gm/dose ...... 50 see medroxyprogesterone acetate see cholestyramine powder packets 4 tab 5 mg ...... 146 gm ...... 50 PROVIDA DHA CAP ...... 137 QUESTRAN LIGHT PROVIDA OB CAP ...... 137 see prevalite pow 4gm ...... 50 PROZAC quetiapine fumarate tab 100 mg ...... 73 see fluoxetine hcl cap 10 mg ...... 39 quetiapine fumarate tab 200 mg ...... 73 see fluoxetine hcl cap 20 mg ...... 39 quetiapine fumarate tab 25 mg ...... 73 see fluoxetine hcl cap 40 mg ...... 40 quetiapine fumarate tab 300 mg ...... 73 PRUDOXIN CRE 5% ...... 98 quetiapine fumarate tab 400 mg ...... 73 pseudoeph-chlorphen w/ hydrocodone quetiapine fumarate tab 50 mg ...... 73 soln 60-4-5 mg/5ml ...... 94 quetiapine fumarate tab er 24hr 150 pseudoephed-bromphen-dm syrup 30- mg ...... 73 2-10 mg/5ml ...... 94 quetiapine fumarate tab er 24hr 200 PULMICORT mg ...... 73 see budesonide inhalation susp 0.25 quetiapine fumarate tab er 24hr 300 mg/2ml ...... 27 mg ...... 73 see budesonide inhalation susp 0.5 quetiapine fumarate tab er 24hr 400 mg/2ml ...... 27 mg ...... 73 see budesonide inhalation susp 1 quetiapine fumarate tab er 24hr 50 mg mg/2ml ...... 27 ...... 73 PULMICORT INH 180MCG ...... 27 QUICKTEK LIQ SOLUTION ...... 126 PULMICORT INH 90MCG ...... 27 QUILLICHEW CHW 20MG ER ...... 12 PULMONEB LT MIS NEBULIZE ...... 127 QUILLICHEW CHW 30MG ER ...... 12 PULMOZYME SOL 1MG/ML ...... 150 QUILLICHEW CHW 40MG ER ...... 12 PUREFE OB CAP PLUS ...... 137 QUILLIVANT SUS 25MG/5ML ...... 12 222 quinapril hcl tab 10 mg ...... 53 rasagiline mesylate tab 0.5 mg (base quinapril hcl tab 20 mg ...... 53 equiv) ...... 69 quinapril hcl tab 40 mg ...... 53 rasagiline mesylate tab 1 mg (base quinapril hcl tab 5 mg ...... 53 equiv) ...... 69 quinapril-hydrochlorothiazide tab 10- RAVICTI LIQ 1.1GM/ML ...... 113 12.5 mg ...... 58 RAZADYNE ER quinapril-hydrochlorothiazide tab 20- see galantamine hydrobromide cap 12.5 mg ...... 58 er 24hr 16 mg ...... 147 quinapril-hydrochlorothiazide tab 20-25 see galantamine hydrobromide cap mg ...... 58 er 24hr 24 mg ...... 147 quinidine gluconate tab er 324 mg ... 25 see galantamine hydrobromide cap quinine sulfate cap 324 mg ...... 60 er 24hr 8 mg ...... 146 QVAR AER 40MCG ...... 27 REBETOL SOL 40MG/ML ...... 79 QVAR AER 80MCG ...... 27 REBIF INJ 22/0.5 ...... 149 QVAR REDIHA AER 80MCG ...... 27 REBIF INJ 44/0.5 ...... 149 QVAR REDIHAL AER 40MCG ...... 27 REBIF REBIDO INJ 22/0.5 ...... 149 R REBIF REBIDO INJ 44/0.5 ...... 149 raloxifene hcl tab 60 mg ...... 112 REBIF REBIDO INJ TITRATN ...... 149 ramelteon tab 8 mg ...... 124 REBIF TITRTN INJ PACK ...... 149 ramipril cap 1.25 mg ...... 53 reclipsen tab ...... 90 ramipril cap 10 mg ...... 53 REGLAN ramipril cap 2.5 mg ...... 53 see metoclopramide hcl tab 10 mg ramipril cap 5 mg ...... 53 (base equivalent) ...... 117 RANEXA see metoclopramide hcl tab 5 mg see ranolazine tab er 12hr 1000 mg (base equivalent) ...... 117 ...... 23 REGRANEX GEL 0.01% ...... 104 see ranolazine tab er 12hr 500 mg 23 relcof c sol 100-6.3 ...... 94 ranitidine hcl cap 150 mg ...... 156 RELENZA MIS DISKHALE ...... 80 ranitidine hcl cap 300 mg ...... 156 RELNATE DHA CAP ...... 137 ranitidine hcl syrup 15 mg/ml (75 RELPAX mg/5ml) ...... 156 see eletriptan hydrobromide tab 20 ranitidine hcl tab 150 mg ...... 156 mg (base equivalent) ...... 128 ranitidine hcl tab 300 mg ...... 156 see eletriptan hydrobromide tab 40 ranolazine tab er 12hr 1000 mg ...... 23 mg (base equivalent) ...... 128 ranolazine tab er 12hr 500 mg ...... 23 REMERON RAPAFLO see mirtazapine tab 15 mg ...... 38 see silodosin cap 4 mg ...... 119 see mirtazapine tab 30 mg ...... 38 see silodosin cap 8 mg ...... 119 REMERON SOLTAB RAPAMUNE see mirtazapine orally disintegrating see sirolimus oral soln 1 mg/ml ... 132 tab 15 mg ...... 38 see sirolimus tab 0.5 mg ...... 132 see mirtazapine orally disintegrating see sirolimus tab 1 mg ...... 132 tab 30 mg ...... 38 see sirolimus tab 2 mg ...... 132 see mirtazapine orally disintegrating RAPAMUNE SOL 1MG/ML ...... 132 tab 45 mg ...... 38 RAPAMUNE TAB 0.5MG ...... 132 RENAGEL RAPAMUNE TAB 1MG ...... 132 see sevelamer hcl tab 800 mg .... 118 RAPAMUNE TAB 2MG ...... 132 RENAGEL TAB 400MG ...... 118 223

RENVELA see sildenafil citrate for suspension see sevelamer carbonate packet 0.8 10 mg/ml ...... 87 gm ...... 118 see sildenafil citrate tab 20 mg ..... 87 see sevelamer carbonate packet 2.4 REVLIMID CAP 10MG ...... 131 gm ...... 118 REVLIMID CAP 15MG ...... 131 see sevelamer carbonate tab 800 mg REVLIMID CAP 2.5MG ...... 131 ...... 118 REVLIMID CAP 20MG ...... 131 repaglinide tab 0.5 mg ...... 46 REVLIMID CAP 25MG ...... 131 repaglinide tab 1 mg ...... 46 REVLIMID CAP 5MG ...... 131 repaglinide tab 2 mg ...... 46 REXULTI TAB 0.25MG ...... 75 REPATHA INJ 140MG/ML ...... 52 REXULTI TAB 0.5MG ...... 75 REPATHA PUSH INJ 420/3.5 ...... 52 REXULTI TAB 1MG ...... 75 REPATHA SURE INJ 140MG/ML ...... 52 REXULTI TAB 2MG ...... 75 REPRONEX INJ 75UNIT ...... 110 REXULTI TAB 3MG ...... 75 RESCRIPTOR TAB 100 MG ...... 77 REXULTI TAB 4MG ...... 75 RESCRIPTOR TAB 200MG ...... 77 REYATAZ RESOURCE ARG PAK LEMON ...... 105 see atazanavir sulfate cap 150 mg RESTASIS EMU 0.05% ...... 142 (base equiv) ...... 75 RESTORIL see atazanavir sulfate cap 200 mg see temazepam cap 15 mg ...... 123 (base equiv) ...... 75 see temazepam cap 22.5 mg ...... 123 see atazanavir sulfate cap 300 mg see temazepam cap 30 mg ...... 123 (base equiv) ...... 75 see temazepam cap 7.5 mg ...... 123 REYATAZ POW 50MG ...... 77 RETACRIT INJ 10000UNT ...... 121 REYVOW TAB 100MG ...... 128 RETACRIT INJ 20000UNI ...... 122 REYVOW TAB 50MG ...... 128 RETACRIT INJ 2000UNIT ...... 121 REZIRA SOL 60-5/5ML ...... 94 RETACRIT INJ 3000UNIT ...... 121 RHEUMATREX TAB 2.5MG ...... 13 RETACRIT INJ 40000UNT ...... 122 RHOPRESSA SOL 0.02% ...... 142 RETACRIT INJ 4000UNIT ...... 121 ribasphere tab 400mg ...... 79 RETEVMO CAP 40MG ...... 65 ribavirin cap 200 mg ...... 79 RETEVMO CAP 80MG ...... 65 ribavirin tab 200 mg ...... 79 RETIN-A ribavirin tab 600 mg ...... 79 see tretinoin cream 0.025% ...... 96 rifabutin cap 150 mg ...... 60 see tretinoin cream 0.05% ...... 96 rifampin cap 150 mg ...... 60 see tretinoin cream 0.1% ...... 96 rifampin cap 300 mg ...... 60 see tretinoin gel 0.01% ...... 96 RILUTEK see tretinoin gel 0.025% ...... 96 see riluzole tab 50 mg ...... 139 RETIN-A MICR GEL 0.08% ...... 95 riluzole tab 50 mg ...... 139 RETIN-A MICRO rimantadine hydrochloride tab 100 mg see tretinoin microsphere gel 0.04% ...... 80 ...... 96 RINVOQ TAB 15MG ER ...... 13 see tretinoin microsphere gel 0.1% 96 RIOMET ER SUS 500/5ML ...... 44 RETROVIR RIOMET SOL ...... 44 see zidovudine cap 100 mg ...... 78 risedronate sodium tab 150 mg ..... 108 see zidovudine syrup 10 mg/ml ..... 78 risedronate sodium tab 30 mg ...... 108 REVATIO risedronate sodium tab 35 mg ...... 108 risedronate sodium tab 5 mg ...... 108 224 risedronate sodium tab delayed release rivastigmine tartrate cap 4.5 mg (base 35 mg ...... 108 equivalent) ...... 147 RISPERDAL rivastigmine tartrate cap 6 mg (base see risperidone soln 1 mg/ml ...... 71 equivalent) ...... 147 see risperidone tab 0.5 mg ...... 71 rivastigmine td patch 24hr 13.3 see risperidone tab 1 mg ...... 71 mg/24hr ...... 147 see risperidone tab 2 mg ...... 71 rivastigmine td patch 24hr 4.6 mg/24hr see risperidone tab 3 mg ...... 71 ...... 147 see risperidone tab 4 mg ...... 71 rivastigmine td patch 24hr 9.5 mg/24hr risperidone orally disintegrating tab ...... 147 0.25 mg ...... 71 rivelsa tab ...... 90 risperidone orally disintegrating tab 0.5 rizatriptan benzoate oral disintegrating mg ...... 71 tab 10 mg (base eq) ...... 128 risperidone orally disintegrating tab 1 rizatriptan benzoate oral disintegrating mg ...... 71 tab 5 mg (base eq) ...... 128 risperidone orally disintegrating tab 2 rizatriptan benzoate tab 10 mg (base mg ...... 71 equivalent) ...... 128 risperidone orally disintegrating tab 3 rizatriptan benzoate tab 5 mg (base mg ...... 71 equivalent) ...... 128 risperidone orally disintegrating tab 4 ROCALTROL mg ...... 71 see calcitriol cap 0.25 mcg ...... 112 risperidone soln 1 mg/ml ...... 71 see calcitriol cap 0.5 mcg ...... 112 risperidone tab 0.25 mg ...... 71 see calcitriol oral soln 1 mcg/ml .. 112 risperidone tab 0.5 mg ...... 71 ROCKLATAN DRO...... 142 risperidone tab 1 mg ...... 71 ropinirole hydrochloride tab 0.25 mg 69 risperidone tab 2 mg ...... 71 ropinirole hydrochloride tab 0.5 mg .. 69 risperidone tab 3 mg ...... 71 ropinirole hydrochloride tab 1 mg .... 69 risperidone tab 4 mg ...... 71 ropinirole hydrochloride tab 2 mg .... 69 RITALIN ropinirole hydrochloride tab 3 mg .... 69 see methylphenidate hcl tab 10 mg11 ropinirole hydrochloride tab 4 mg .... 69 see methylphenidate hcl tab 20 mg11 ropinirole hydrochloride tab 5 mg .... 69 see methylphenidate hcl tab 5 mg . 11 ropinirole hydrochloride tab er 24hr 12 RITALIN LA mg (base equivalent) ...... 69 see methylphenidate hcl cap er 24hr ropinirole hydrochloride tab er 24hr 2 10 mg (la) ...... 11 mg (base equivalent) ...... 69 see methylphenidate hcl cap er 24hr ropinirole hydrochloride tab er 24hr 4 20 mg (la) ...... 11 mg (base equivalent) ...... 69 see methylphenidate hcl cap er 24hr ropinirole hydrochloride tab er 24hr 6 30 mg (la) ...... 11 mg (base equivalent) ...... 69 see methylphenidate hcl cap er 24hr ropinirole hydrochloride tab er 24hr 8 40 mg (la) ...... 11 mg (base equivalent) ...... 69 RITALIN LA CAP 60MG ...... 12 rosadan cre 0.75% ...... 104 ritonavir tab 100 mg ...... 77 ROSULA PAD 10-5% ...... 95 rivastigmine tartrate cap 1.5 mg (base rosuvastatin calcium tab 10 mg ...... 51 equivalent)...... 147 rosuvastatin calcium tab 20 mg ...... 51 rivastigmine tartrate cap 3 mg (base rosuvastatin calcium tab 40 mg ...... 51 equivalent)...... 147 rosuvastatin calcium tab 5 mg ...... 51 225

ROWASA salicylic acid shampoo 6% ...... 103 see mesalamine rectal enema 4 gm & SALICYLIC ACID SOLN 26% ...... 103 cleanser wipe kit ...... 117 salsalate tab 500 mg ...... 16 ROXICET SOL 5-325/5 ...... 19 salsalate tab 750 mg ...... 16 ROXICODONE SAMSCA see oxycodone hcl tab 15 mg ...... 18 see tolvaptan tab 30 mg ...... 114 see oxycodone hcl tab 30 mg ...... 18 SANCUSO DIS 3.1MG ...... 47 see oxycodone hcl tab 5 mg ...... 17 SANDIMMUNE ROZEREM see cyclosporine cap 100 mg ...... 131 see ramelteon tab 8 mg ...... 124 see cyclosporine cap 25 mg ...... 131 ROZLYTREK CAP 100MG ...... 65 SANDIMMUNE CAP 100MG ...... 132 ROZLYTREK CAP 200MG ...... 65 SANDIMMUNE CAP 25MG ...... 132 RUBRACA TAB 200MG ...... 65 SANDIMMUNE SOL 100MG/ML ...... 132 RUBRACA TAB 250MG ...... 65 SANDOSTATIN RUBRACA TAB 300MG ...... 65 see octreotide acetate inj 100 rufinamide susp 40 mg/ml ...... 36 mcg/ml (0.1 mg/ml) ...... 113 RUKOBIA TAB 600MG ER ...... 77 see octreotide acetate inj 50 mcg/ml RULAVITE DHA CAP ...... 137 (0.05 mg/ml) ...... 113 RUZURGI TAB 10MG ...... 60 see octreotide acetate inj 500 RYBELSUS TAB 14MG ...... 45 mcg/ml (0.5 mg/ml) ...... 114 RYBELSUS TAB 3MG ...... 45 SANTYL OIN 250/GM ...... 103 RYBELSUS TAB 7MG ...... 45 SAPHRIS RYDAPT CAP 25MG ...... 65 see asenapine maleate sl tab 10 mg RYTHMOL SR (base equiv) ...... 72 see propafenone hcl cap er 12hr 225 see asenapine maleate sl tab 2.5 mg mg ...... 25 (base equiv) ...... 72 see propafenone hcl cap er 12hr 325 see asenapine maleate sl tab 5 mg mg ...... 25 (base equiv) ...... 72 see propafenone hcl cap er 12hr 425 sapropterin dihydrochloride powder mg ...... 25 packet 100 mg ...... 113 S sapropterin dihydrochloride powder SABRIL packet 500 mg ...... 113 see vigabatrin powd pack 500 mg . 37 sapropterin dihydrochloride tab 100 mg see vigabatrin tab 500 mg ...... 37 ...... 113 SAFYRAL SAVELLA MIS TITR PAK ...... 148 see drospirenone-ethinyl estrad- SAVELLA TAB 100MG ...... 148 levomefolate tab 3-0.03-0.451 mg SAVELLA TAB 12.5MG ...... 148 ...... 89 SAVELLA TAB 25MG ...... 148 SAIZEN INJ 5MG ...... 112 SAVELLA TAB 50MG ...... 148 SAIZEN INJ 8.8MG ...... 112 SAXENDA INJ 18MG/3ML ...... 9 SALAGEN scopolamine td patch 72hr 1 mg/3days see pilocarpine hcl tab 5 mg ...... 133 ...... 47 see pilocarpine hcl tab 7.5 mg .... 134 SEASONIQUE salicylic ac liq 27.5% ...... 103 see camrese tab ...... 89 salicylic acid cream 6% ...... 103 SECUADO DIS 3.8MG ...... 73 salicylic acid gel 6% ...... 103 SECUADO DIS 5.7MG ...... 73 salicylic acid lotion 6% ...... 103 SECUADO DIS 7.6MG ...... 73 226

SELECT-OB CHW ...... 137 sertraline hcl tab 50 mg ...... 40 SELECT-OB+ PAK DHA ...... 137 SE-TAN DHA CAP ...... 137 selegiline hcl cap 5 mg ...... 69 sevelamer carbonate packet 0.8 gm 118 selegiline hcl tab 5 mg ...... 69 sevelamer carbonate packet 2.4 gm 118 selenium sulfide lotion 2.5% ...... 99 sevelamer carbonate tab 800 mg ... 118 SELZENTRY SOL 20MG/ML ...... 77 sevelamer hcl tab 800 mg ...... 118 SELZENTRY TAB 150MG ...... 77 sf 5000 plus cre 1.1% ...... 133 SELZENTRY TAB 25MG ...... 77 sf gel 1.1% ...... 133 SELZENTRY TAB 300MG ...... 77 SFROWASA ENE 4GM ...... 117 SELZENTRY TAB 75MG ...... 77 SHARPS-A-GAT MIS 1 GALLON ...... 127 SENSIPAR SHUR-SEAL GEL 2% ...... 158 see cinacalcet hcl tab 30 mg (base SIGNIFOR INJ 0.3MG/ML ...... 114 equiv) ...... 112 SIGNIFOR INJ 0.6MG/ML ...... 114 see cinacalcet hcl tab 60 mg (base SIGNIFOR INJ 0.9MG/ML ...... 114 equiv) ...... 112 sildenafil citrate for suspension 10 see cinacalcet hcl tab 90 mg (base mg/ml ...... 87 equiv) ...... 112 sildenafil citrate tab 100 mg ...... 87 SEREVENT DIS AER 50MCG ...... 29 sildenafil citrate tab 20 mg ...... 87 SEROQUEL sildenafil citrate tab 25 mg ...... 86 see quetiapine fumarate tab 100 mg sildenafil citrate tab 50 mg ...... 87 ...... 73 silodosin cap 4 mg ...... 119 see quetiapine fumarate tab 200 mg silodosin cap 8 mg ...... 119 ...... 73 SILVADENE see quetiapine fumarate tab 25 mg73 see ssd cre 1% ...... 99 see quetiapine fumarate tab 300 mg SIMBRINZA SUS 1-0.2% ...... 141 ...... 73 SIMCOR TAB 1000-20 ...... 52 see quetiapine fumarate tab 400 mg SIMCOR TAB 1000-40 ...... 52 ...... 73 SIMCOR TAB 500-20MG ...... 51 see quetiapine fumarate tab 50 mg73 SIMCOR TAB 500-40MG ...... 52 SEROQUEL XR SIMCOR TAB 750-20MG ...... 52 see quetiapine fumarate tab er 24hr simvastatin tab 10 mg ...... 52 150 mg ...... 73 simvastatin tab 20 mg ...... 52 see quetiapine fumarate tab er 24hr simvastatin tab 40 mg ...... 52 200 mg ...... 73 simvastatin tab 5 mg ...... 52 see quetiapine fumarate tab er 24hr simvastatin tab 80 mg ...... 52 300 mg ...... 73 SINEMET see quetiapine fumarate tab er 24hr see carbidopa & levodopa tab 10-100 400 mg ...... 73 mg ...... 67 see quetiapine fumarate tab er 24hr see carbidopa & levodopa tab 25-100 50 mg ...... 73 mg ...... 67 SEROSTIM INJ 4MG ...... 112 SINGLE-LET MIS 23G ...... 126 SEROSTIM INJ 5MG ...... 112 SINGULAIR SEROSTIM INJ 6MG ...... 112 see montelukast sodium chew tab 4 sertraline hcl oral concentrate for mg (base equiv) ...... 26 solution 20 mg/ml ...... 40 see montelukast sodium chew tab 5 sertraline hcl tab 100 mg ...... 40 mg (base equiv) ...... 26 sertraline hcl tab 25 mg ...... 40 227

see montelukast sodium oral see minocycline hcl tab er 24hr 105 granules packet 4 mg (base equiv) mg ...... 151 ...... 26 see minocycline hcl tab er 24hr 115 see montelukast sodium tab 10 mg mg ...... 151 (base equiv) ...... 26 see minocycline hcl tab er 24hr 55 sirolimus oral soln 1 mg/ml ...... 132 mg ...... 151 sirolimus tab 0.5 mg ...... 132 see minocycline hcl tab er 24hr 65 sirolimus tab 1 mg ...... 132 mg ...... 151 sirolimus tab 2 mg ...... 132 see minocycline hcl tab er 24hr 80 SIRTURO TAB 100MG ...... 60 mg ...... 151 SIRTURO TAB 20MG ...... 60 SOLTAMOX SOL 10MG/5ML ...... 62 SKELAXIN SOLU-CORTEF INJ 100MG ...... 93 see metaxalone tab 800 mg ...... 138 SOMAVERT INJ 10MG ...... 111 SKYLA IUD 13.5MG ...... 91 SOMAVERT INJ 15MG ...... 111 SKYRIZI INJ 150DOSE ...... 99 SOMAVERT INJ 20MG ...... 111 SKYRIZI INJ 150MG/ML ...... 99 SOMAVERT INJ 25MG ...... 111 SKYRIZI PEN INJ 150MG/ML ...... 99 SOMAVERT INJ 30MG ...... 111 SLOW RELEASE TAB 143MG ...... 122 SOOLANTRA CRE 1% ...... 104 sod fluoride sol 0.2% ...... 133 SORIATANE SOD SUL/SULF EMU 10-5% ...... 95 see acitretin cap 10 mg ...... 98 SOD SUL/SULF SUS 10-5% ...... 96 see acitretin cap 25 mg ...... 98 sodium chloride soln nebu 0.9% ...... 94 sotalol hcl (afib/afl) tab 120 mg ...... 82 sodium chloride soln nebu 7% ...... 94 sotalol hcl (afib/afl) tab 160 mg ...... 82 sodium fluoride chew tab 0.25 mg f sotalol hcl (afib/afl) tab 80 mg ...... 82 (from 0.55 mg naf) ...... 130 sotalol hcl tab 120 mg ...... 82 sodium fluoride chew tab 0.5 mg f sotalol hcl tab 160 mg ...... 82 (from 1.1 mg naf) ...... 130 sotalol hcl tab 240 mg ...... 82 sodium fluoride chew tab 1 mg f (from sotalol hcl tab 80 mg ...... 82 2.2 mg naf) ...... 130 SOTYLIZE SOL 5MG/ML ...... 82 sodium fluoride soln 0.5 mg/ml f (from spinosad susp 0.9% ...... 104 1.1 mg/ml naf) ...... 130 SPIRIVA AER 1.25MCG ...... 26 sodium fluoride tab 0.5 mg f (from 1.1 SPIRIVA CAP HANDIHLR ...... 26 mg naf) ...... 130 SPIRIVA SPR 2.5MCG ...... 26 sodium fluoride tab 1 mg f (from 2.2 spironolactone & hydrochlorothiazide mg naf) ...... 130 tab 25-25 mg ...... 106 sodium phenylbutyrate oral powder 3 spironolactone tab 100 mg ...... 106 gm/teaspoonful ...... 113 spironolactone tab 25 mg ...... 106 sodium phenylbutyrate tab 500 mg 113 spironolactone tab 50 mg ...... 106 sodium polystyrene sulfonate powder SPORANOX ...... 133 see itraconazole cap 100 mg ...... 49 sodium polystyrene sulfonate rectal see itraconazole oral soln 10 mg/ml susp 30 gm/120ml ...... 133 ...... 49 solifenacin succinate tab 10 mg ..... 158 sprintec 28 tab 28 day ...... 90 solifenacin succinate tab 5 mg ...... 158 SPRYCEL TAB 100MG ...... 65 SOLIQUA INJ 100/33 ...... 43 SPRYCEL TAB 140MG ...... 65 SOLIRIS INJ 10MG/ML ...... 120 SPRYCEL TAB 20MG ...... 65 SOLODYN SPRYCEL TAB 50MG ...... 65 228

SPRYCEL TAB 70MG ...... 65 STRIANT MIS 30MG ...... 20 SPRYCEL TAB 80MG ...... 65 STRIBILD TAB ...... 78 sps sus 15gm/60 ...... 133 STROMECTOL ssd cre 1% ...... 99 see ivermectin tab 3 mg ...... 21 SSKI SOL 1GM/ML ...... 94 SUBOXONE STALEVO 100 see buprenorphine hcl-naloxone hcl see carbidopa-levodopa-entacapone sl film 12-3 mg (base equiv) ...... 19 tabs 25-100-200 mg ...... 68 see buprenorphine hcl-naloxone hcl STALEVO 125 sl film 2-0.5 mg (base equiv) ..... 19 see carbidopa-levodopa-entacapone see buprenorphine hcl-naloxone hcl tabs 31.25-125-200 mg ...... 68 sl film 4-1 mg (base equiv) ...... 19 STALEVO 150 see buprenorphine hcl-naloxone hcl see carbidopa-levodopa-entacapone sl film 8-2 mg (base equiv) ...... 19 tabs 37.5-150-200 mg ...... 68 sucralfate susp 1 gm/10ml ...... 156 STALEVO 75 sucralfate tab 1 gm ...... 156 see carbidopa-levodopa-entacapone SULAR tabs 18.75-75-200 mg ...... 68 see nisoldipine tab er 24hr 17 mg . 84 STATUSS LIQ GREEN ...... 94 see nisoldipine tab er 24hr 34 mg . 84 stavudine cap 15 mg ...... 78 see nisoldipine tab er 24hr 8.5 mg 84 stavudine cap 20 mg ...... 78 sulconazole nitrate cream 1% ...... 98 stavudine cap 30 mg ...... 78 sulconazole nitrate solution 1% ...... 98 stavudine cap 40 mg ...... 78 sulfacetamide sodium liquid 10% ..... 99 stavudine for oral soln 1 mg/ml ...... 78 sulfacetamide sodium lotion 10% STELARA INJ 45MG/0.5 ...... 99 (acne) ...... 96 STELARA INJ 90MG/ML ...... 99 sulfacetamide sodium ophth soln 10% STIMATE SOL 1.5MG/ML ...... 113 ...... 142 STIOLTO AER 2.5-2.5 ...... 29 sulfacetamide sodium w/ sulfur STIVARGA TAB 40MG ...... 65 cleanser 10-2% ...... 96 STRATTERA sulfacetamide sodium w/ sulfur see atomoxetine hcl cap 10 mg (base cleansing pad 10-4% ...... 96 equiv) ...... 9 sulfacetamide sodium w/ sulfur cream see atomoxetine hcl cap 100 mg 10-2% ...... 96 (base equiv) ...... 9 sulfacetamide sodium w/ sulfur cream see atomoxetine hcl cap 18 mg (base 10-5% ...... 96 equiv) ...... 9 sulfacetamide sodium w/ sulfur see atomoxetine hcl cap 25 mg (base emulsion 10-5% ...... 96 equiv) ...... 9 sulfacetamide sodium w/ sulfur foam see atomoxetine hcl cap 40 mg (base 10-5% ...... 96 equiv) ...... 9 sulfacetamide sodium w/ sulfur lotion see atomoxetine hcl cap 60 mg (base 10-5% ...... 96 equiv) ...... 9 sulfacetamide sodium w/ sulfur susp 8- see atomoxetine hcl cap 80 mg (base 4% ...... 96 equiv) ...... 9 sulfacetamide sodium w/ sulfur wash STRENSIQ INJ 18/0.45 ...... 113 9-4% ...... 96 STRENSIQ INJ 28/0.7ML ...... 113 sulfacetamide sodium w/ sulfur wash STRENSIQ INJ 40MG/ML ...... 113 9-4.5% ...... 96 STRENSIQ INJ 80/0.8ML ...... 113 229 sulfacetamide sodium-prednisolone SUTENT CAP 25MG ...... 65 ophth soln 10-0.23(0.25)% ...... 143 SUTENT CAP 37.5MG ...... 65 sulfacetamide sodium-sulfur in urea gel SUTENT CAP 50MG ...... 65 10-5% ...... 96 SYLATRON KIT 200MCG ...... 66 SULFADIAZINE TAB 500MG ...... 150 SYLATRON KIT 300MCG ...... 66 sulfamethoxazole-trimethoprim susp SYLATRON KIT 600MCG ...... 66 200-40 mg/5ml ...... 22 SYMBICORT AER 160-4.5 ...... 29 sulfamethoxazole-trimethoprim tab SYMBICORT AER 80-4.5 ...... 29 400-80 mg ...... 22 SYMDEKO TAB 100-150 ...... 150 sulfamethoxazole-trimethoprim tab SYMDEKO TAB 50-75MG ...... 150 800-160 mg ...... 22 SYMFI sulfasalazine tab 500 mg ...... 117 see efavirenz-lamivudine-tenofovir df sulfasalazine tab delayed release 500 tab 600-300-300 mg ...... 76 mg ...... 117 SYMFI LO sulindac tab 150 mg ...... 15 see efavirenz-lamivudine-tenofovir df sulindac tab 200 mg ...... 15 tab 400-300-300 mg ...... 76 sumatriptan nasal spray 20 mg/act 129 SYMJEPI INJ 0.15MG ...... 160 sumatriptan nasal spray 5 mg/act .. 128 SYMJEPI INJ 0.3MG ...... 160 sumatriptan succinate inj 6 mg/0.5ml SYMLINPEN 60 INJ 1000MCG ...... 43 ...... 129 SYMTUZA TAB ...... 78 sumatriptan succinate solution auto- SYNALAR injector 4 mg/0.5ml ...... 129 see fluocinolone acetonide cream sumatriptan succinate solution auto- 0.025% ...... 101 injector 6 mg/0.5ml ...... 129 see fluocinolone acetonide oint sumatriptan succinate solution 0.025% ...... 101 cartridge 4 mg/0.5ml ...... 129 see fluocinolone acetonide soln sumatriptan succinate solution 0.01% ...... 101 cartridge 6 mg/0.5ml ...... 129 SYNAREL SOL 2MG/ML ...... 112 sumatriptan succinate solution prefilled SYNJARDY TAB ...... 43 syringe 6 mg/0.5ml ...... 129 SYNJARDY TAB 12.5-500 ...... 43 sumatriptan succinate tab 100 mg . 129 SYNJARDY TAB 5-1000MG ...... 43 sumatriptan succinate tab 25 mg ... 129 SYNJARDY TAB 5-500MG ...... 43 sumatriptan succinate tab 50 mg ... 129 SYNJARDY XR TAB ...... 44 SUPPORT LIQ ...... 134 SYNJARDY XR TAB 10-1000 ...... 44 SUPRAX SYNJARDY XR TAB 25-1000 ...... 44 see cefixime cap 400 mg ...... 89 SYNJARDY XR TAB 5-1000MG ...... 44 see cefixime for susp 100 mg/5ml . 89 SYNTHROID see cefixime for susp 200 mg/5ml . 89 see levothyroxine sodium tab 100 SUPRAX CHW 100MG ...... 89 mcg ...... 153 SUPRAX CHW 200MG ...... 89 see levothyroxine sodium tab 112 SUPRAX SUS 500/5ML ...... 89 mcg ...... 153 SUPREP BOWEL SOL PREP KIT ...... 124 see levothyroxine sodium tab 125 SUSTIVA mcg ...... 153 see efavirenz cap 200 mg ...... 76 see levothyroxine sodium tab 137 see efavirenz cap 50 mg ...... 76 mcg ...... 153 see efavirenz tab 600 mg ...... 76 see levothyroxine sodium tab 150 SUTENT CAP 12.5MG ...... 65 mcg ...... 153 230

see levothyroxine sodium tab 175 SYNTHROID TAB 88MCG ...... 154 mcg...... 153 SYPRINE see levothyroxine sodium tab 200 see trientine hcl cap 250 mg ...... 131 mcg...... 153 SYRINGE MIS 0.5/30G ...... 127 see levothyroxine sodium tab 25 mcg T ...... 152 TABLOID TAB 40MG ...... 61 see levothyroxine sodium tab 300 TABRECTA TAB 150MG ...... 65 mcg...... 153 TABRECTA TAB 200MG ...... 65 see levothyroxine sodium tab 50 mcg TACLONEX ...... 152 see calcipotriene-betamethasone see levothyroxine sodium tab 75 mcg dipropionate oint 0.005-0.064% ...... 152 ...... 100 see levothyroxine sodium tab 88 mcg see calcipotriene-betamethasone ...... 153 dipropionate susp 0.005-0.064% see levoxyl tab 100mcg ...... 153 ...... 100 see levoxyl tab 112mcg ...... 153 tacrolimus cap 0.5 mg ...... 132 see levoxyl tab 125mcg ...... 153 tacrolimus cap 1 mg ...... 132 see levoxyl tab 137mcg ...... 153 tacrolimus cap 5 mg ...... 132 see levoxyl tab 150mcg ...... 153 tacrolimus oint 0.03% ...... 103 see levoxyl tab 175mcg ...... 153 tacrolimus oint 0.1% ...... 103 see levoxyl tab 200mcg ...... 153 tadalafil tab 10 mg ...... 87 see levoxyl tab 25mcg ...... 153 tadalafil tab 2.5 mg ...... 87 see levoxyl tab 50mcg ...... 153 tadalafil tab 20 mg ...... 87 see levoxyl tab 75mcg ...... 153 tadalafil tab 20 mg (pah) ...... 87 see levoxyl tab 88mcg ...... 153 tadalafil tab 5 mg ...... 87 see unithroid tab 100mcg ...... 155 TAFINLAR CAP 50MG ...... 65 see unithroid tab 112mcg ...... 155 TAFINLAR CAP 75MG ...... 66 see unithroid tab 125mcg ...... 155 TAGRISSO TAB 40MG ...... 66 see unithroid tab 150mcg ...... 155 TAGRISSO TAB 80MG ...... 66 see unithroid tab 175mcg ...... 155 TAKHZYRO INJ 300/2ML ...... 120 see unithroid tab 200mcg ...... 155 TAMIFLU see unithroid tab 25mcg ...... 155 see oseltamivir phosphate cap 30 mg see unithroid tab 300mcg ...... 155 (base equiv) ...... 79 see unithroid tab 50mcg ...... 155 see oseltamivir phosphate cap 45 mg see unithroid tab 75mcg ...... 155 (base equiv) ...... 80 see unithroid tab 88mcg ...... 155 see oseltamivir phosphate cap 75 mg SYNTHROID TAB 100MCG ...... 154 (base equiv) ...... 80 SYNTHROID TAB 112MCG ...... 154 see oseltamivir phosphate for susp 6 SYNTHROID TAB 125MCG ...... 154 mg/ml (base equiv) ...... 80 SYNTHROID TAB 137MCG ...... 154 tamoxifen citrate tab 10 mg (base SYNTHROID TAB 150MCG ...... 154 equivalent) ...... 62 SYNTHROID TAB 175MCG ...... 154 tamoxifen citrate tab 20 mg (base SYNTHROID TAB 200MCG ...... 154 equivalent) ...... 62 SYNTHROID TAB 25MCG ...... 154 tamsulosin hcl cap 0.4 mg ...... 119 SYNTHROID TAB 300MCG ...... 154 TAPAZOLE SYNTHROID TAB 50MCG ...... 154 see methimazole tab 10 mg ...... 152 SYNTHROID TAB 75MCG ...... 154 see methimazole tab 5 mg ...... 152 231

TAPAZOLE TAB 10MG ...... 152 see carbamazepine tab 200 mg .... 34 TAPAZOLE TAB 5MG ...... 152 TEGRETOL-XR TARCEVA see carbamazepine tab er 12hr 100 see erlotinib hcl tab 100 mg (base mg ...... 34 equivalent) ...... 63 see carbamazepine tab er 12hr 200 see erlotinib hcl tab 150 mg (base mg ...... 34 equivalent) ...... 63 see carbamazepine tab er 12hr 400 see erlotinib hcl tab 25 mg (base mg ...... 34 equivalent) ...... 63 TEKTURNA TARGRETIN see aliskiren fumarate tab 150 mg see bexarotene cap 75 mg ...... 66 (base equivalent) ...... 59 TARKA see aliskiren fumarate tab 300 mg see trandolapril-verapamil hcl tab er (base equivalent) ...... 59 2-180 mg ...... 58 TEKTURNA HCT TAB 150-12.5 ...... 58 see trandolapril-verapamil hcl tab er TEKTURNA HCT TAB 150-25MG ...... 58 2-240 mg ...... 58 TEKTURNA HCT TAB 300-12.5 ...... 58 see trandolapril-verapamil hcl tab er TEKTURNA HCT TAB 300-25MG ...... 58 4-240 mg ...... 59 telmisartan tab 20 mg ...... 54 TARON-BC MIS ...... 137 telmisartan tab 40 mg ...... 54 TARON-PREX CAP ...... 137 telmisartan tab 80 mg ...... 54 TASIGNA CAP 150MG ...... 66 telmisartan-hydrochlorothiazide tab 40- TASIGNA CAP 200MG ...... 66 12.5 mg ...... 58 TASIGNA CAP 50MG ...... 66 telmisartan-hydrochlorothiazide tab 80- TASMAR 12.5 mg ...... 58 see tolcapone tab 100 mg ...... 67 telmisartan-hydrochlorothiazide tab 80- TAYTULLA 25 mg ...... 58 see norethindrone ace-ethinyl temazepam cap 15 mg ...... 123 estradiol-fe cap 1 mg-20 mcg (24) temazepam cap 22.5 mg ...... 123 ...... 90 temazepam cap 30 mg ...... 123 tazarotene cream 0.1% ...... 99 temazepam cap 7.5 mg ...... 123 TAZORAC TEMODAR see tazarotene cream 0.1% ...... 99 see temozolomide cap 100 mg ...... 61 TAZORAC CRE 0.05% ...... 99 see temozolomide cap 140 mg ...... 61 TAZORAC GEL 0.05% ...... 99 see temozolomide cap 180 mg ...... 61 TAZORAC GEL 0.1% ...... 99 see temozolomide cap 250 mg ...... 61 TAZVERIK TAB 200MG ...... 66 TEMOVATE TECFIDERA see clobetasol propionate cream see dimethyl fumarate capsule 0.05% ...... 100 delayed release 120 mg ...... 148 see clobetasol propionate oint 0.05% see dimethyl fumarate capsule ...... 100 delayed release 240 mg ...... 148 temozolomide cap 100 mg ...... 61 TECFIDERA STARTER PACK temozolomide cap 140 mg ...... 61 see dimethyl fumarate capsule dr temozolomide cap 180 mg ...... 61 starter pack 120 mg & 240 mg . 149 temozolomide cap 20 mg ...... 61 TEGRETOL temozolomide cap 250 mg ...... 61 see carbamazepine susp 100 mg/5ml temozolomide cap 5 mg ...... 61 ...... 34 232 tenofovir disoproxil fumarate tab 300 tetrabenazine tab 25 mg ...... 148 mg ...... 78 tetracycline hcl cap 250 mg ...... 151 TENORETIC 100 tetracycline hcl cap 500 mg ...... 151 see atenolol & chlorthalidone tab THALOMID CAP 100MG ...... 131 100-25 mg ...... 56 THALOMID CAP 150MG ...... 131 TENORETIC 50 THALOMID CAP 200MG ...... 131 see atenolol & chlorthalidone tab 50- THALOMID CAP 50MG ...... 131 25 mg ...... 56 THEO-24 CAP 100MG CR ...... 30 TENORMIN THEO-24 CAP 200MG CR ...... 30 see atenolol tab 100 mg ...... 80 THEO-24 CAP 300MG CR ...... 30 see atenolol tab 25 mg ...... 80 THEO-24 CAP 400MG ER ...... 30 see atenolol tab 50 mg ...... 80 theophylline tab er 12hr 100 mg ...... 30 terazosin hcl cap 1 mg (base theophylline tab er 12hr 200 mg ...... 30 equivalent)...... 55 theophylline tab er 12hr 300 mg ...... 30 terazosin hcl cap 10 mg (base theophylline tab er 12hr 450 mg ...... 30 equivalent)...... 55 theophylline tab er 24hr 400 mg ...... 30 terazosin hcl cap 2 mg (base theophylline tab er 24hr 600 mg ...... 30 equivalent)...... 55 THIOLA terazosin hcl cap 5 mg (base see tiopronin tab 100 mg ...... 119 equivalent)...... 55 THIOLA TAB 100MG ...... 119 terbinafine hcl tab 250 mg ...... 48 thioridazine hcl tab 10 mg ...... 74 terbutaline sulfate tab 2.5 mg ...... 29 thioridazine hcl tab 100 mg ...... 74 terbutaline sulfate tab 5 mg ...... 29 thioridazine hcl tab 25 mg ...... 74 terconazole vaginal cream 0.4% .... 159 thioridazine hcl tab 50 mg ...... 74 terconazole vaginal cream 0.8% .... 159 thiothixene cap 1 mg ...... 75 terconazole vaginal suppos 80 mg .. 159 thiothixene cap 10 mg ...... 75 TESSALON PERLES thiothixene cap 2 mg ...... 75 see benzonatate cap 100 mg ...... 93 thiothixene cap 5 mg ...... 75 testosterone cypionate im inj in oil 100 tiagabine hcl tab 12 mg ...... 37 mg/ml ...... 20 tiagabine hcl tab 16 mg ...... 37 testosterone cypionate im inj in oil 200 tiagabine hcl tab 2 mg ...... 37 mg/ml ...... 20 tiagabine hcl tab 4 mg ...... 37 testosterone enanthate im inj in oil 200 TIAZAC mg/ml ...... 20 see diltiazem hcl extended release testosterone td gel 12.5 mg/act (1%) beads cap er 24hr 120 mg ...... 83 ...... 20 see diltiazem hcl extended release testosterone td gel 20.25 mg/1.25gm beads cap er 24hr 180 mg ...... 83 (1.62%) ...... 20 see diltiazem hcl extended release testosterone td gel 20.25 mg/act beads cap er 24hr 240 mg ...... 83 (1.62%) ...... 20 see diltiazem hcl extended release testosterone td gel 25 mg/2.5gm (1%) beads cap er 24hr 300 mg ...... 83 ...... 20 see diltiazem hcl extended release testosterone td gel 40.5 mg/2.5gm beads cap er 24hr 360 mg ...... 83 (1.62%) ...... 20 see diltiazem hcl extended release testosterone td gel 50 mg/5gm (1%) 20 beads cap er 24hr 420 mg ...... 83 tetcaine sol 0.5% op ...... 142 TIKOSYN tetrabenazine tab 12.5 mg ...... 148 233

see dofetilide cap 125 mcg (0.125 TIROSINT CAP 150MCG ...... 154 mg) ...... 26 TIROSINT CAP 175MCG ...... 154 see dofetilide cap 250 mcg (0.25 mg) TIROSINT CAP 200 ...... 154 ...... 26 TIROSINT CAP 25MCG ...... 154 see dofetilide cap 500 mcg (0.5 mg) TIROSINT CAP 50MCG ...... 154 ...... 26 TIROSINT CAP 75MCG ...... 154 tilia fe tab ...... 90 TIROSINT CAP 88MCG ...... 154 timolol maleate ophth gel forming soln TIVICAY PD TAB 5MG ...... 78 0.25% ...... 140 TIVICAY TAB 10MG ...... 78 timolol maleate ophth gel forming soln TIVICAY TAB 25MG ...... 78 0.5% ...... 140 TIVICAY TAB 50MG ...... 78 timolol maleate ophth soln 0.25% .. 140 tizanidine hcl cap 2 mg (base timolol maleate ophth soln 0.5% .... 140 equivalent) ...... 138 timolol maleate ophth soln 0.5% tizanidine hcl cap 4 mg (base (once-daily) ...... 140 equivalent) ...... 138 timolol maleate preservative free ophth tizanidine hcl cap 6 mg (base soln 0.5% ...... 140 equivalent) ...... 138 timolol maleate tab 10 mg ...... 82 tizanidine hcl tab 2 mg (base timolol maleate tab 20 mg ...... 82 equivalent) ...... 138 timolol maleate tab 5 mg ...... 82 tizanidine hcl tab 4 mg (base TIMOPTIC equivalent) ...... 139 see timolol maleate ophth soln TL FOLATE TAB ...... 137 0.25% ...... 140 TOBI PODHALR CAP 28MG ...... 12 see timolol maleate ophth soln 0.5% TOBRADEX ...... 140 see tobramycin-dexamethasone TIMOPTIC OCU SOL 0.25% OP ...... 140 ophth susp 0.3-0.1% ...... 143 TIMOPTIC OCUDOSE TOBRADEX OIN 0.3-0.1% ...... 143 see timolol maleate preservative free tobramycin nebu soln 300 mg/5ml ... 12 ophth soln 0.5% ...... 140 tobramycin ophth soln 0.3% ...... 142 TIMOPTIC-XE tobramycin-dexamethasone ophth susp see timolol maleate ophth gel 0.3-0.1% ...... 143 forming soln 0.25% ...... 140 TOBREX see timolol maleate ophth gel see tobramycin ophth soln 0.3% . 142 forming soln 0.5% ...... 140 TOBREX OIN 0.3% OP ...... 142 tinidazole tab 250 mg ...... 22 TODAY SPONGE MIS ...... 158 tinidazole tab 500 mg ...... 22 tolcapone tab 100 mg ...... 67 tiopronin tab 100 mg ...... 119 tolmetin sodium cap 400 mg ...... 15 TIROSINT tolmetin sodium tab 200 mg ...... 15 see levothyroxine sodium cap 150 tolmetin sodium tab 600 mg ...... 15 mcg...... 152 tolterodine tartrate cap er 24hr 2 mg see levothyroxine sodium cap 75 mcg ...... 158 ...... 152 tolterodine tartrate cap er 24hr 4 mg TIROSINT CAP 100MCG ...... 154 ...... 158 TIROSINT CAP 112MCG ...... 154 tolterodine tartrate tab 1 mg ...... 158 TIROSINT CAP 125MCG ...... 154 tolterodine tartrate tab 2 mg ...... 158 TIROSINT CAP 137MCG ...... 154 tolvaptan tab 15 mg ...... 114 TIROSINT CAP 13MCG ...... 154 tolvaptan tab 30 mg ...... 114 234

TOPAMAX trandolapril tab 1 mg ...... 53 see topiramate tab 100 mg ...... 36 trandolapril tab 2 mg ...... 53 see topiramate tab 200 mg ...... 36 trandolapril tab 4 mg ...... 53 see topiramate tab 25 mg ...... 36 trandolapril-verapamil hcl tab er 1-240 see topiramate tab 50 mg ...... 36 mg ...... 58 TOPAMAX SPRINKLE trandolapril-verapamil hcl tab er 2-180 see topiramate sprinkle cap 15 mg 36 mg ...... 58 see topiramate sprinkle cap 25 mg 36 trandolapril-verapamil hcl tab er 2-240 TOPICORT mg ...... 58 see desoximetasone cream 0.05% trandolapril-verapamil hcl tab er 4-240 ...... 100 mg ...... 59 see desoximetasone cream 0.25% tranexamic acid tab 650 mg ...... 123 ...... 100 TRANSDERM SCOP see desoximetasone gel 0.05% ... 100 see scopolamine td patch 72hr 1 see desoximetasone oint 0.05% .. 100 mg/3days ...... 47 see desoximetasone oint 0.25% .. 100 tranylcypromine sulfate tab 10 mg ... 39 topiramate sprinkle cap 15 mg ...... 36 TRAVATAN Z topiramate sprinkle cap 25 mg ...... 36 see travoprost ophth soln 0.004% topiramate tab 100 mg ...... 36 (benzalkonium free) (bak free) 144 topiramate tab 200 mg ...... 36 travoprost ophth soln 0.004% ...... 144 topiramate tab 25 mg ...... 36 travoprost ophth soln 0.004% topiramate tab 50 mg ...... 36 (benzalkonium free) (bak free) ... 144 TOPROL XL trazodone hcl tab 100 mg ...... 40 see metoprolol succinate tab er 24hr trazodone hcl tab 150 mg ...... 41 100 mg (tartrate equiv) ...... 81 trazodone hcl tab 300 mg ...... 41 see metoprolol succinate tab er 24hr trazodone hcl tab 50 mg ...... 40 200 mg (tartrate equiv) ...... 81 TRELEGY AER ELLIPTA ...... 29 see metoprolol succinate tab er 24hr TREMFYA INJ 100MG/ML ...... 99 25 mg (tartrate equiv) ...... 81 tretinoin cap 10 mg ...... 66 see metoprolol succinate tab er 24hr tretinoin cream 0.025% ...... 96 50 mg (tartrate equiv) ...... 81 tretinoin cream 0.05% ...... 96 toremifene citrate tab 60 mg (base tretinoin cream 0.1% ...... 96 equivalent)...... 62 tretinoin gel 0.01% ...... 96 torsemide tab 10 mg ...... 106 tretinoin gel 0.025% ...... 96 torsemide tab 100 mg ...... 106 tretinoin gel 0.05% ...... 96 torsemide tab 20 mg ...... 106 tretinoin microsphere gel 0.04% ...... 96 torsemide tab 5 mg ...... 106 tretinoin microsphere gel 0.1% ...... 96 TRACLEER TREXALL TAB 10MG ...... 61 see bosentan tab 125 mg ...... 87 TREXALL TAB 15MG ...... 61 see bosentan tab 62.5 mg ...... 87 TREXALL TAB 5MG ...... 61 TRADJENTA TAB 5MG ...... 44 TREXALL TAB 7.5MG ...... 61 tramadol hcl tab 50 mg ...... 18 triamcinolone acetonide aerosol soln tramadol hcl tab er 24hr 100 mg ...... 18 0.147 mg/gm ...... 102 tramadol hcl tab er 24hr 200 mg ...... 18 triamcinolone acetonide cream 0.025% tramadol hcl tab er 24hr 300 mg ...... 18 ...... 102 tramadol-acetaminophen tab 37.5-325 triamcinolone acetonide cream 0.1% mg ...... 19 ...... 102 235 triamcinolone acetonide cream 0.5% trientine hcl cap 250 mg ...... 131 ...... 102 trifluoperazine hcl tab 1 mg (base triamcinolone acetonide dental paste equivalent) ...... 74 0.1% ...... 133 trifluoperazine hcl tab 10 mg (base triamcinolone acetonide lotion 0.025% equivalent) ...... 74 ...... 102 trifluoperazine hcl tab 2 mg (base triamcinolone acetonide lotion 0.1% equivalent) ...... 74 ...... 102 trifluoperazine hcl tab 5 mg (base triamcinolone acetonide oint 0.025% equivalent) ...... 74 ...... 102 trifluridine ophth soln 1% ...... 142 triamcinolone acetonide oint 0.1% . 102 TRIGLIDE TAB 160MG ...... 51 triamcinolone acetonide oint 0.5% . 102 trihexyphenidyl hcl oral soln 0.4 mg/ml triamterene & hydrochlorothiazide cap ...... 67 37.5-25 mg ...... 106 trihexyphenidyl hcl tab 2 mg ...... 67 triamterene & hydrochlorothiazide cap trihexyphenidyl hcl tab 5 mg ...... 67 50-25 mg ...... 106 TRIJARDY XR TAB ...... 44 triamterene & hydrochlorothiazide tab TRIKAFTA TAB ...... 150 37.5-25 mg ...... 106 tri-legest tab fe ...... 90 triamterene & hydrochlorothiazide tab TRILEPTAL 75-50 mg ...... 106 see oxcarbazepine susp 300 mg/5ml triamterene cap 100 mg ...... 107 (60 mg/ml) ...... 35 triamterene cap 50 mg ...... 106 see oxcarbazepine tab 150 mg ..... 35 triazolam tab 0.125 mg ...... 123 see oxcarbazepine tab 300 mg ..... 35 triazolam tab 0.25 mg ...... 123 see oxcarbazepine tab 600 mg ..... 35 TRIBENZOR TRILIPIX see olmesartan-amlodipine- see choline fenofibrate cap dr 135 hydrochlorothiazide tab 20-5-12.5 mg (fenofibric acid equiv) ...... 50 mg ...... 58 see choline fenofibrate cap dr 45 mg see olmesartan-amlodipine- (fenofibric acid equiv) ...... 50 hydrochlorothiazide tab 40-10-12.5 tri-lo- tab sprintec ...... 90 mg ...... 58 trilyte sol ...... 124 see olmesartan-amlodipine- trimethobenzamide hcl cap 300 mg .. 47 hydrochlorothiazide tab 40-10-25 trimethoprim tab 100 mg ...... 22 mg ...... 58 trimipramine maleate cap 100 mg .... 42 see olmesartan-amlodipine- trimipramine maleate cap 25 mg ..... 42 hydrochlorothiazide tab 40-5-12.5 trimipramine maleate cap 50 mg ..... 42 mg ...... 58 trinate tab ...... 137 see olmesartan-amlodipine- TRINTELLIX TAB 10MG ...... 41 hydrochlorothiazide tab 40-5-25 TRINTELLIX TAB 20MG ...... 41 mg ...... 58 TRINTELLIX TAB 5MG ...... 41 TRICARE CHW PRENATAL ...... 137 tri-sprintec tab ...... 90 TRICARE PRE CAP 27-1-500 ...... 137 TRISTART DHA CAP ...... 137 TRICODE AR LIQ 30-2-8 ...... 94 TRISTART ONE CAP 35-1-215 ...... 137 TRICODE GF LIQ 30-8-200 ...... 94 TRIUMEQ TAB ...... 78 TRICOR tri-vit/fe dro /fl 0.25 ...... 134 see fenofibrate tab 145 mg ...... 51 tri-vit/fluo dro 0.25mg ...... 134 see fenofibrate tab 48 mg ...... 51 tri-vit/fluo dro 0.5mg ...... 134 236 trivora-28 tab ...... 90 ULTRACET TRIZIVIR see tramadol-acetaminophen tab see abacavir sulfate-lamivudine- 37.5-325 mg ...... 19 zidovudine tab 300-150-300 mg . 75 ULTRAM TROKENDI XR CAP 100MG ...... 36 see tramadol hcl tab 50 mg ...... 18 TROKENDI XR CAP 200MG ...... 36 umecta mouss aer 40% ...... 102 TROKENDI XR CAP 25MG ...... 36 UNIFINE PNTP MIS 31GX3/16 ...... 127 TROKENDI XR CAP 50MG ...... 36 UNIFINE PNTP MIS 32GX4MM ...... 127 tropicamide ophth soln 1%...... 141 unithroid tab 100mcg ...... 155 trospium chloride cap er 24hr 60 mg unithroid tab 112mcg ...... 155 ...... 158 unithroid tab 125mcg ...... 155 trospium chloride tab 20 mg ...... 158 unithroid tab 150mcg ...... 155 TRULANCE TAB 3MG ...... 116 unithroid tab 175mcg ...... 155 TRULICITY INJ 0.75/0.5 ...... 45 unithroid tab 200mcg ...... 155 TRULICITY INJ 1.5/0.5 ...... 45 unithroid tab 25mcg ...... 155 TRULICITY INJ 3/0.5 ...... 45 unithroid tab 300mcg ...... 155 TRULICITY INJ 4.5/0.5 ...... 45 unithroid tab 50mcg ...... 155 TRUSOPT unithroid tab 75mcg ...... 155 see dorzolamide hcl ophth soln 2% unithroid tab 88mcg ...... 155 ...... 143 urea cream 39% ...... 102 TRUVADA urea cream 40% ...... 102 see emtricitabine-tenofovir disoproxil urea cream 45% ...... 102 fumarate tab 100-150 mg ...... 76 urea cream 47% ...... 102 see emtricitabine-tenofovir disoproxil urea cream 50% ...... 102 fumarate tab 133-200 mg ...... 76 urea gel 40% ...... 102 see emtricitabine-tenofovir disoproxil urea in zinc undecylenate-lactic acid fumarate tab 167-250 mg ...... 76 vehicle emulsion 50% ...... 102 see emtricitabine-tenofovir disoproxil urea lotion 40% ...... 102 fumarate tab 200-300 mg ...... 76 urea lotion 45% ...... 102 TRUZONE PEAK MIS FLOW MTR ..... 127 urea nail gel 45% ...... 102 trymine cg liq 225-7.5 ...... 94 UREA NAIL MIS 50% ...... 102 TYBOST TAB 150MG ...... 78 urea suspension 40% ...... 103 TYKERB uribel cap 118mg ...... 157 see lapatinib ditosylate tab 250 mg URIN-TEK KIT ...... 126 (base equiv) ...... 64 URIN-TEK MIS ...... 126 TYMLOS INJ ...... 108 UROCIT-K 10 TYVASO START SOL 0.6MG/ML ...... 87 see potassium citrate tab er 10 meq TYZEKA TAB 600MG ...... 79 (1080 mg) ...... 119 U UROCIT-K 15 UBRELVY TAB 100MG ...... 128 see potassium citrate tab er 15 meq UBRELVY TAB 50MG ...... 128 (1620 mg) ...... 119 UKONIQ TAB 200MG ...... 66 UROCIT-K 5 ULESFIA LOT 5% ...... 104 see potassium citrate tab er 5 meq ULORIC (540 mg) ...... 119 see febuxostat tab 40 mg ...... 119 UROXATRAL see febuxostat tab 80 mg ...... 119 see alfuzosin hcl tab er 24hr 10 mg ULTIMATECARE CAP ONE NF ...... 137 ...... 119 237

URSO 250 VALTREX see ursodiol tab 250 mg ...... 117 see valacyclovir hcl tab 1 gm ...... 79 URSO FORTE see valacyclovir hcl tab 500 mg .... 79 see ursodiol tab 500 mg ...... 117 VANACOF CD LIQ 5-1-10 ...... 94 ursodiol cap 300 mg ...... 117 VANCOCIN ursodiol tab 250 mg ...... 117 see vancomycin hcl cap 250 mg ursodiol tab 500 mg ...... 117 (base equivalent) ...... 22 V VANCOCIN HCL VAGIFEM see vancomycin hcl cap 125 mg see yuvafem tab 10mcg ...... 159 (base equivalent) ...... 22 valacyclovir hcl tab 1 gm ...... 79 vancomycin hcl cap 125 mg (base valacyclovir hcl tab 500 mg ...... 79 equivalent) ...... 22 VALCHLOR GEL 0.016% ...... 98 vancomycin hcl cap 250 mg (base VALCYTE equivalent) ...... 22 see valganciclovir hcl for soln 50 VANOS mg/ml (base equiv) ...... 78 see fluocinonide cream 0.1% ...... 101 see valganciclovir hcl tab 450 mg VARUBI TAB 90MG ...... 48 (base equivalent) ...... 78 VASCEPA CAP 0.5GM ...... 50 valganciclovir hcl for soln 50 mg/ml VASCEPA CAP 1GM ...... 50 (base equiv) ...... 78 VASERETIC valganciclovir hcl tab 450 mg (base see enalapril maleate & equivalent)...... 78 hydrochlorothiazide tab 10-25 mg VALIUM ...... 57 see diazepam tab 10 mg ...... 25 VASOTEC see diazepam tab 2 mg ...... 25 see enalapril maleate tab 10 mg ... 53 see diazepam tab 5 mg ...... 25 see enalapril maleate tab 2.5 mg .. 52 valproate sodium oral soln 250 mg/5ml see enalapril maleate tab 20 mg ... 53 (base equiv) ...... 38 see enalapril maleate tab 5 mg ..... 53 valproic acid cap 250 mg ...... 38 v-c forte cap ...... 134 valsartan tab 160 mg ...... 54 VCF VAGINAL AER CONTRACP ...... 158 valsartan tab 320 mg ...... 54 vcf vaginal gel contrace ...... 158 valsartan tab 40 mg ...... 54 VCF VAGINAL MIS CONTRACP ...... 158 valsartan tab 80 mg ...... 54 velivet pak ...... 90 valsartan-hydrochlorothiazide tab 160- VELTASSA POW 16.8GM ...... 133 12.5 mg ...... 59 VELTASSA POW 25.2GM ...... 133 valsartan-hydrochlorothiazide tab 160- VELTASSA POW 8.4GM ...... 133 25 mg ...... 59 VENCLEXTA TAB 100MG ...... 61 valsartan-hydrochlorothiazide tab 320- VENCLEXTA TAB 10MG ...... 61 12.5 mg ...... 59 VENCLEXTA TAB 50MG ...... 61 valsartan-hydrochlorothiazide tab 320- VENCLEXTA TAB START PK ...... 61 25 mg ...... 59 venlafaxine hcl cap er 24hr 150 mg valsartan-hydrochlorothiazide tab 80- (base equivalent) ...... 41 12.5 mg ...... 59 venlafaxine hcl cap er 24hr 37.5 mg VALTOCO LIQ 15MG ...... 33 (base equivalent) ...... 41 VALTOCO LIQ 20MG ...... 33 venlafaxine hcl cap er 24hr 75 mg VALTOCO SPR 10MG ...... 33 (base equivalent) ...... 41 VALTOCO SPR 5MG ...... 33 238 venlafaxine hcl tab 100 mg (base VFEND equivalent)...... 41 see voriconazole for susp 40 mg/ml venlafaxine hcl tab 25 mg (base ...... 49 equivalent)...... 41 see voriconazole tab 200 mg ...... 49 venlafaxine hcl tab 37.5 mg (base see voriconazole tab 50 mg ...... 49 equivalent)...... 41 VIAGRA venlafaxine hcl tab 50 mg (base see sildenafil citrate tab 100 mg ... 87 equivalent)...... 41 see sildenafil citrate tab 25 mg ..... 86 venlafaxine hcl tab 75 mg (base see sildenafil citrate tab 50 mg ..... 87 equivalent)...... 41 VIBERZI TAB 100MG ...... 118 VENTAVIS SOL 10MCG/ML ...... 87 VIBERZI TAB 75MG ...... 118 VENTAVIS SOL 20MCG/ML ...... 87 VIBRAMYCIN verapamil hcl cap er 24hr 100 mg .... 84 see doxycycline hyclate cap 100 mg verapamil hcl cap er 24hr 120 mg .... 84 ...... 150 verapamil hcl cap er 24hr 180 mg .... 84 see doxycycline monohydrate for verapamil hcl cap er 24hr 200 mg .... 84 susp 25 mg/5ml ...... 151 verapamil hcl cap er 24hr 240 mg .... 84 VIBRAMYCIN SYP 50MG/5ML ...... 151 verapamil hcl cap er 24hr 300 mg .... 84 VICTOZA INJ 18MG/3ML ...... 45 verapamil hcl cap er 24hr 360 mg .... 84 VIDEX EC CAP 400MG ...... 78 verapamil hcl tab 120 mg ...... 84 VIDEX SOL 2GM ...... 78 verapamil hcl tab 40 mg ...... 84 VIDEX SOL 4GM ...... 78 verapamil hcl tab 80 mg ...... 84 vigabatrin powd pack 500 mg ...... 37 verapamil hcl tab er 120 mg ...... 84 vigabatrin tab 500 mg ...... 37 verapamil hcl tab er 180 mg ...... 84 VIGAMOX verapamil hcl tab er 240 mg ...... 84 see moxifloxacin hcl ophth soln 0.5% VERDESO AER 0.05% ...... 102 (base equiv) ...... 141 VERELAN VIMPAT SOL 10MG/ML ...... 36 see verapamil hcl cap er 24hr 120 VIMPAT TAB 100MG ...... 36 mg ...... 84 VIMPAT TAB 150MG ...... 36 see verapamil hcl cap er 24hr 180 VIMPAT TAB 200MG ...... 36 mg ...... 84 VIMPAT TAB 50MG ...... 36 see verapamil hcl cap er 24hr 240 VINACAL B MIS ...... 137 mg ...... 84 VINATE C TAB ...... 137 VERELAN PM VINATE CAL TAB ...... 137 see verapamil hcl cap er 24hr 100 VINATE CARE CHW 40-1MG ...... 137 mg ...... 84 VINATE DHA CAP 27-1.13 ...... 137 see verapamil hcl cap er 24hr 200 VINATE II TAB ...... 137 mg ...... 84 VINATE M TAB ...... 137 VERZENIO TAB 100MG ...... 66 VINATE ONE TAB ...... 137 VERZENIO TAB 150MG ...... 66 VIRACEPT TAB 250MG ...... 78 VERZENIO TAB 200MG ...... 66 VIRACEPT TAB 625MG ...... 78 VERZENIO TAB 50MG ...... 66 VIRAMUNE VESICARE see nevirapine susp 50 mg/5ml .... 77 see solifenacin succinate tab 10 mg VIRAMUNE XR ...... 158 see nevirapine tab er 24hr 400 mg 77 see solifenacin succinate tab 5 mg VIREAD ...... 158 239

see tenofovir disoproxil fumarate tab VOLTAREN 300 mg ...... 78 see diclofenac sodium gel 1% ...... 96 VIREAD POW 40MG/GM ...... 78 voriconazole for susp 40 mg/ml ...... 49 VIREAD TAB 150MG ...... 78 voriconazole tab 200 mg ...... 49 VIREAD TAB 200MG ...... 78 voriconazole tab 50 mg ...... 49 VIREAD TAB 250MG ...... 78 VOTRIENT TAB 200MG ...... 66 VIRT NATE TAB ...... 137 VP-HEME OB TAB ...... 138 virt-gard tab 2.2-25-1 ...... 122 VP-HEME ONE CAP ...... 138 virt-phos tab 250 neut ...... 130 VP-PNV-DHA CAP ...... 138 VIRT-PN TAB ...... 138 VRAYLAR CAP 1.5-3MG ...... 70 VIRTPREX CAP ...... 138 VRAYLAR CAP 1.5MG ...... 70 VISTARIL VRAYLAR CAP 3MG ...... 70 see hydroxyzine pamoate cap 25 mg VRAYLAR CAP 4.5MG ...... 70 ...... 24 VRAYLAR CAP 6MG ...... 70 see hydroxyzine pamoate cap 50 mg VUMERITY CAP 231MG ...... 149 ...... 24 VYNDAMAX CAP 61MG ...... 88 VITAFOL CAP ULTRA ...... 138 VYNDAQEL CAP 20MG ...... 88 VITAFOL CHW GUMMIES ...... 138 VYTORIN VITAFOL FE+ CAP ...... 138 see ezetimibe-simvastatin tab 10-10 VITAFOL STRP MIS 1MG ...... 138 mg ...... 49 VITAFOL-NANO TAB ...... 138 see ezetimibe-simvastatin tab 10-20 VITAFOL-OB PAK +DHA ...... 138 mg ...... 50 VITAFOL-ONE CAP ...... 138 see ezetimibe-simvastatin tab 10-40 VITAMEDMD CAP ONE RX ...... 138 mg ...... 50 VITAMEDMD MIS PLUS RX ...... 138 see ezetimibe-simvastatin tab 10-80 vitamin d3 chw 400unit ...... 161 mg ...... 50 vitamin d3 tab 400unit ...... 161 VYVANSE CAP 10MG ...... 8 VITA-PREN TAB ...... 138 VYVANSE CAP 20MG ...... 8 VITAROCA PLU TAB ...... 134 VYVANSE CAP 30MG ...... 8 VITATRUE MIS ...... 138 VYVANSE CAP 40MG ...... 8 VITEKTA TAB 150MG ...... 78 VYVANSE CAP 50MG ...... 9 VITEKTA TAB 85MG ...... 78 VYVANSE CAP 60MG ...... 9 VIVELLE-DOT VYVANSE CAP 70MG ...... 9 see estradiol td patch twice weekly VYZULTA SOL 0.024% ...... 144 0.025 mg/24hr ...... 115 W see estradiol td patch twice weekly warfarin sodium tab 1 mg ...... 30 0.0375 mg/24hr ...... 115 warfarin sodium tab 10 mg ...... 30 see estradiol td patch twice weekly warfarin sodium tab 2 mg ...... 30 0.05 mg/24hr ...... 115 warfarin sodium tab 2.5 mg ...... 30 see estradiol td patch twice weekly warfarin sodium tab 3 mg ...... 30 0.075 mg/24hr ...... 115 warfarin sodium tab 4 mg ...... 30 see estradiol td patch twice weekly warfarin sodium tab 5 mg ...... 30 0.1 mg/24hr ...... 115 warfarin sodium tab 6 mg ...... 30 VIVITROL INJ 380MG ...... 47 warfarin sodium tab 7.5 mg ...... 30 VIZIMPRO TAB 15MG ...... 66 water for irrigation, sterile irrigation VIZIMPRO TAB 30MG ...... 66 soln ...... 133 VIZIMPRO TAB 45MG ...... 66 wee care sus 15/1.25 ...... 122 240

WELCHOL XARELTO TAB 2.5MG ...... 30 see colesevelam hcl packet for susp XARELTO TAB 20MG ...... 31 3.75 gm ...... 50 XCOPRI PAK 100-150 ...... 37 see colesevelam hcl tab 625 mg .... 50 XCOPRI PAK 12.5-25 ...... 37 WELLBUTRIN SR XCOPRI PAK 150-200 ...... 37 see bupropion hcl tab er 12hr 100 XCOPRI PAK 50-100MG ...... 37 mg ...... 39 XCOPRI PAK 50-200MG ...... 37 see bupropion hcl tab er 12hr 150 XCOPRI TAB 100MG ...... 37 mg ...... 39 XCOPRI TAB 150MG ...... 37 see bupropion hcl tab er 12hr 200 XCOPRI TAB 200MG ...... 37 mg ...... 39 XCOPRI TAB 50MG ...... 37 WELLBUTRIN XL XELJANZ SOL 1MG/ML ...... 13 see bupropion hcl tab er 24hr 150 XELJANZ TAB 10MG ...... 13 mg ...... 39 XELJANZ TAB 5MG ...... 13 see bupropion hcl tab er 24hr 300 XELJANZ XR TAB 11MG ...... 13 mg ...... 39 XELJANZ XR TAB 22MG ...... 13 westab max tab 2.5-25-2 ...... 105 XELODA WIDE-SEAL DPR KIT 60 ...... 125 see capecitabine tab 150 mg ...... 61 WIDE-SEAL DPR KIT 65 ...... 125 see capecitabine tab 500 mg ...... 61 WIDE-SEAL DPR KIT 70 ...... 125 XENAZINE WIDE-SEAL DPR KIT 75 ...... 125 see tetrabenazine tab 12.5 mg ... 148 WIDE-SEAL DPR KIT 80 ...... 125 see tetrabenazine tab 25 mg ...... 148 WIDE-SEAL DPR KIT 85 ...... 125 XENICAL CAP 120MG ...... 9 WIDE-SEAL DPR KIT 90 ...... 125 XERAC-AC SOL 6.25% ...... 103 WIDE-SEAL DPR KIT 95 ...... 126 XERESE CRE 5-1% ...... 99 wixela inhub aer 100/50 ...... 29 XIFAXAN TAB 200MG ...... 22 wixela inhub aer 250/50 ...... 29 XIFAXAN TAB 550MG ...... 22 wixela inhub aer 500/50 ...... 30 XIGDUO XR TAB 10-1000 ...... 44 X XIGDUO XR TAB 10-500MG ...... 44 XALATAN XIGDUO XR TAB 2.5-1000 ...... 44 see latanoprost ophth soln 0.005% XIGDUO XR TAB 5-1000MG ...... 44 ...... 144 XIGDUO XR TAB 5-500MG ...... 44 XALKORI CAP 200MG ...... 66 XIIDRA DRO 5% ...... 142 XALKORI CAP 250MG ...... 66 XOFLUZA TAB 20MG ...... 80 XANAX XOFLUZA TAB 40MG ...... 80 see alprazolam tab 0.25 mg ...... 24 XOPENEX see alprazolam tab 0.5 mg ...... 24 see levalbuterol hcl soln nebu 0.31 see alprazolam tab 1 mg ...... 24 mg/3ml (base equiv) ...... 29 see alprazolam tab 2 mg ...... 24 see levalbuterol hcl soln nebu 0.63 XANAX XR mg/3ml (base equiv) ...... 29 see alprazolam tab 0.5mg xr ...... 24 see levalbuterol hcl soln nebu 1.25 see alprazolam tab 1mg xr ...... 24 mg/3ml (base equiv) ...... 29 see alprazolam tab 2mg xr ...... 24 XOPENEX CONCENTRATE see alprazolam tab 3mg xr ...... 24 see levalbuterol hcl soln nebu conc XARELTO STAR TAB 15/20MG ...... 30 1.25 mg/0.5ml (base equiv) ...... 29 XARELTO TAB 10MG ...... 30 XOSPATA TAB 40MG ...... 66 XARELTO TAB 15MG ...... 30 XPOVIO PAK 100MG ...... 63 241

XPOVIO PAK 40MG ...... 62 zenatane cap 30mg ...... 96 XPOVIO PAK 50MG ...... 62 zenatane cap 40mg ...... 96 XPOVIO PAK 60MG ...... 62 zenchent fe chw 0.4mg-35 ...... 90 XPOVIO PAK 80MG ...... 63 ZENPEP CAP 10000UNT ...... 105 XTANDI CAP 40MG ...... 62 ZENPEP CAP 15000UNT ...... 105 XTANDI TAB 40MG ...... 62 ZENPEP CAP 20000UNT ...... 105 XTANDI TAB 80MG ...... 62 ZENPEP CAP 25000 ...... 105 xulane dis 150-35 ...... 91 ZENPEP CAP 25000UNT ...... 105 XULTOPHY INJ 100/3.6 ...... 44 ZENPEP CAP 3000UNIT ...... 105 XYREM SOL 500MG/ML ...... 146 ZENPEP CAP 40000 ...... 105 Y ZENPEP CAP 5000UNIT ...... 105 YASMIN 28 ZEPOSIA 7DAY CAP STR PACK ...... 149 see ocella tab 3-0.03mg ...... 90 ZEPOSIA CAP .92MG ...... 149 YAZ ZEPOSIA CAP STR KIT ...... 149 see gianvi tab 3-0.02mg ...... 89 ZESTORETIC yuvafem tab 10mcg ...... 159 see lisinopril & hydrochlorothiazide Z tab 10-12.5 mg ...... 57 zafirlukast tab 10 mg ...... 26 see lisinopril & hydrochlorothiazide zafirlukast tab 20 mg ...... 26 tab 20-12.5 mg ...... 57 zaleplon cap 10 mg ...... 124 see lisinopril & hydrochlorothiazide zaleplon cap 5 mg ...... 123 tab 20-25 mg ...... 57 ZANAFLEX ZESTRIL see tizanidine hcl cap 2 mg (base see lisinopril tab 10 mg ...... 53 equivalent) ...... 138 see lisinopril tab 2.5 mg ...... 53 see tizanidine hcl cap 4 mg (base see lisinopril tab 30 mg ...... 53 equivalent) ...... 138 see lisinopril tab 40 mg ...... 53 see tizanidine hcl cap 6 mg (base see lisinopril tab 5 mg ...... 53 equivalent) ...... 138 ZETIA see tizanidine hcl tab 4 mg (base see ezetimibe tab 10 mg ...... 52 equivalent) ...... 139 ZIAC ZARONTIN see bisoprolol & hydrochlorothiazide see ethosuximide cap 250 mg ...... 38 tab 10-6.25 mg ...... 56 see ethosuximide soln 250 mg/5ml 38 see bisoprolol & hydrochlorothiazide ZARXIO INJ 300/0.5 ...... 122 tab 2.5-6.25 mg ...... 56 ZARXIO INJ 480/0.8 ...... 122 see bisoprolol & hydrochlorothiazide ZATEAN-CH CAP ...... 138 tab 5-6.25 mg ...... 56 ZAVESCA ZIAGEN see miglustat cap 100 mg ...... 120 see abacavir sulfate soln 20 mg/ml ZEJULA CAP 100MG ...... 66 (base equiv) ...... 75 ZELAPAR TAB 1.25MG ...... 69 see abacavir sulfate tab 300 mg ZELBORAF TAB 240MG ...... 66 (base equiv) ...... 75 ZELNORM TAB 6MG ...... 118 ZIANA ZEMPLAR see clindamycin phosphate-tretinoin see paricalcitol cap 1 mcg ...... 112 gel 1.2-0.025% ...... 95 see paricalcitol cap 2 mcg ...... 113 zidovudine cap 100 mg ...... 78 zenatane cap 10mg ...... 96 zidovudine syrup 10 mg/ml ...... 78 zenatane cap 20mg ...... 96 zidovudine tab 300 mg ...... 78 242

ZIEXTENZO INJ 6/0.6ML ...... 122 ZOMIG zileuton tab er 12hr 600 mg ...... 26 see zolmitriptan tab 2.5 mg ...... 129 ZIOPTAN DRO 0.0015% ...... 144 see zolmitriptan tab 5 mg ...... 129 ziprasidone hcl cap 20 mg ...... 70 ZOMIG ZMT ziprasidone hcl cap 40 mg ...... 70 see zolmitriptan orally disintegrating ziprasidone hcl cap 60 mg ...... 70 tab 2.5 mg ...... 129 ziprasidone hcl cap 80 mg ...... 70 see zolmitriptan orally disintegrating ZIRGAN GEL 0.15% ...... 142 tab 5 mg ...... 129 ZITHROMAX ZONEGRAN see azithromycin for susp 100 see zonisamide cap 100 mg ...... 36 mg/5ml ...... 124 see zonisamide cap 25 mg ...... 36 see azithromycin for susp 200 zonisamide cap 100 mg ...... 36 mg/5ml ...... 124 zonisamide cap 25 mg ...... 36 see azithromycin tab 250 mg ...... 124 zonisamide cap 50 mg ...... 36 see azithromycin tab 500 mg ...... 124 ZORBTIVE INJ 8.8MG ...... 112 ZMAX SUS 2GM ...... 124 ZORTRESS ZOCOR see everolimus tab 0.25 mg ...... 131 see simvastatin tab 10 mg ...... 52 see everolimus tab 0.5 mg ...... 131 see simvastatin tab 20 mg ...... 52 see everolimus tab 0.75 mg ...... 132 see simvastatin tab 40 mg ...... 52 ZORTRESS TAB 1MG ...... 132 see simvastatin tab 80 mg ...... 52 zovia 1/35e tab ...... 91 ZOFRAN zovia 1/50e tab ...... 91 see ondansetron hcl tab 4 mg ...... 47 ZOVIRAX zoledronic acid inj conc for iv infusion 4 see acyclovir cream 5% ...... 99 mg/5ml ...... 108 see acyclovir oint 5% ...... 99 ZOLINZA CAP 100MG ...... 66 see acyclovir susp 200 mg/5ml ..... 79 zolmitriptan nasal spray 2.5 mg/spray Z-TUSS AC LIQ 2-9/5ML ...... 94 unit ...... 129 ZUBSOLV SUB 0.7-0.18 ...... 20 zolmitriptan nasal spray 5 mg/spray ZUBSOLV SUB 1.4-0.36 ...... 20 unit ...... 129 ZUBSOLV SUB 11.4-2.9 ...... 20 zolmitriptan orally disintegrating tab ZUBSOLV SUB 2.9-0.71 ...... 20 2.5 mg ...... 129 ZUBSOLV SUB 5.7-1.4 ...... 20 zolmitriptan orally disintegrating tab 5 ZUBSOLV SUB 8.6-2.1 ...... 20 mg ...... 129 ZYCLARA zolmitriptan tab 2.5 mg ...... 129 see imiquimod cream 3.75% ...... 103 zolmitriptan tab 5 mg ...... 129 ZYCLARA PUMP CRE 2.5% ...... 103 ZOLOFT ZYDELIG TAB 100MG ...... 66 see sertraline hcl oral concentrate for ZYDELIG TAB 150MG ...... 66 solution 20 mg/ml ...... 40 ZYKADIA CAP 150MG ...... 66 see sertraline hcl tab 100 mg ...... 40 ZYKADIA TAB 150MG ...... 66 see sertraline hcl tab 25 mg ...... 40 ZYLET SUS 0.5-0.3% ...... 143 see sertraline hcl tab 50 mg ...... 40 ZYLOPRIM zolpidem tartrate tab 10 mg ...... 124 see allopurinol tab 100 mg ...... 119 zolpidem tartrate tab 5 mg ...... 124 see allopurinol tab 300 mg ...... 119 zolpidem tartrate tab er 12.5 mg ... 124 ZYMAXID zolpidem tartrate tab er 6.25 mg ... 124 see gatifloxacin ophth soln 0.5% . 141 ZOMACTON INJ 5MG ...... 112 ZYPREXA 243

see olanzapine tab 10 mg...... 73 see olanzapine orally disintegrating see olanzapine tab 15 mg...... 73 tab 20 mg ...... 72 see olanzapine tab 2.5 mg ...... 73 see olanzapine orally disintegrating see olanzapine tab 20 mg...... 73 tab 5 mg ...... 72 see olanzapine tab 5 mg ...... 73 ZYTIGA see olanzapine tab 7.5 mg ...... 73 see abiraterone acetate tab 250 mg ZYPREXA ZYDIS ...... 62 see olanzapine orally disintegrating see abiraterone acetate tab 500 mg tab 10 mg ...... 72 ...... 62 see olanzapine orally disintegrating ZYVOX tab 15 mg ...... 72 see linezolid for susp 100 mg/5ml . 23 see linezolid tab 600 mg ...... 23

244