BCBSM Clinical Drug List (Formulary)

Blue Cross Blue Shield of Michigan ® ®

Clinical Drug List (Formulary)

Please note that this listing of medications contained in this Blue Cross Blue Shield of Michigan Clinical Drug List (Formulary) is current at the time that the list is posted to this website, and is subject to change. INTRODUCTION

Blue Cross Blue Shield of Michigan is pleased to provide the Clinical Drug List as a useful reference and educational tool to assist providers in selecting cost-effective therapies. Please familiarize yourself with this information. To provide effective high-quality care, this Clinical Drug List requires the continuing support of physicians and phar - macists. Your questions and suggestions are welcome.

PREFACE

The Blue Cross Blue Shield of Michigan Clinical Drug List is a list of FDA-approved prescription drug medications reviewed by the BCBSM/BCN Pharmacy and Therapeutics (P&T) Committee. The Clinical Drug List will assist in maintaining the quality of patient care and containing cost for the member’s drug benefit plan. Providers, physicians, and pharmacists are encouraged to refer to the Clinical Drug List when selecting prescription drug therapy for eligible plan members.

Physicians are encouraged to prescribe med ications included in the Clinical Drug List whenever possible. If a prescrip tion is written for a nonpreferred drug or for a drug or dose not recommended for use in the elderly or pregnant, phar macists are encouraged to contact the physician. The benefit plan administrator will monitor provider- specific drug list prescribing and communicate with providers to optimize compliance.

The Clinical Drug List is divided into major therapeutic categories (chapters) for easy use. Products that are approved for more than one therapeutic indication may be included in more than one chapter. Drugs are listed by generics and brands. Generic drugs will have the trade name listed for reference purposes. Most dosage forms and strengths of a drug are included in the drug list.

i DRUG LIST MEDICATION COVERAGE

All drugs included in the Clinical Drug List are not necessarily covered by each patient’s prescription drug benefit plan. Patients should consult their prescription drug benefit packet or contact a Customer Service represen tative to determine specific coverage.

Approved Medications Only FDA-approved prescription medications are eligible for coverage under the member’s policy.

Dose optimization BCBSM dose optimization program encourages appropriate prescribing of medications intended for once-daily administration. For certain medications, physicians are encouraged to prescribe prescription drugs in once-daily dosage regimens, as opposed to using lower multiple doses of the same drug to help increase a members adherence to their medication.

Quantity Limits BCBSM sets quantity limits based on clinical appropriateness and manufacturer recommended dosing for particular drugs.

The Dose Optimization Program (PDF) and Quantity Limit Program (PDF) documents provide a list of medications that are targeted through these initiatives.

Experimental Indications Medications used for only experimental indications are not eligible for coverage.

Over-the-counter (OTC) Medications When a drug is available in the identical strength and dosage form as both a prescription and nonprescription drug, the prescription drug is usually not covered by BCBSM. In these cases, providers should refer the patient to the equivalent OTC product. Certain OTC products, such as omeprazole (Prilosec OTC), are covered for certain BCBSM members with a prescription. Coverage is dependant on the members specific prescription drug benefit. Other exceptions are identified in the Clinical Drug List.

Preventive drug coverage Under the Patient Protection and Affordable Care Act, also known as national health care reform, most health plans must cover certain preventive services and drugs with no cost-sharing. For a complete list of preventive drugs refer to Preventive drug coverage or go to: bcbsm.com/pharmacy. Members must meet plan requirements, and a prescription is required for coverage.

For details, see section Prior Authorization.

ii Prior Authorization The BCBSM Prior Authorization and Step-Therapy (PA/ST) Program provides a list of drugs that require prior approval or must meet step-therapy requirements prior to coverage. To view the most recent version, please go to bcbsm.com/RxInfo.

Members should consult their prescription drug benefit packet for information on how to obtain prior approval, or call the Customer Service number on the back of their Blues member ID card for additional information. Physicians can access the medication request forms on the web at bcbsm.com, Provider Secured Services - Login. Select the button titled Medication Prior Authorization. The prescribing physician can complete a form online and submit it to us electronically. Prescribers can also look up the status of an electronically submitted request for prior approval of a drug.

Call the number below if you have questions about prior approval, prefer to conduct a review over the phone or want hard-copy medication request forms.

Web - Provider Secured bcbsm.com/index.html Services - Login Select Medication Prior Authorization Call 1-800-437-3803 Fax 1-866-601-4425 Write Blue Cross Blue Shield of Michigan Pharmacy Services P.O. BOX 2320 Detroit, MI 48231-2320

GENERIC DRUG SUBSTITUTION

Generic drug substitution is the process by which a generic equivalent is dispensed rather than the brand-name product.

The Maximum Allowable Cost (MAC) list sets a ceiling price for the reimbursement of certain generic pre scription drugs. The drugs selected for inclusion on the MAC list are products that are commonly prescribed and dispensed and have generally gone through the FDA’s review and approval process. This process ensures that the following conditions are met:

1. The generic drug must contain the same active ingredient(s), be the same strength, and be the same dosage form as the brand-name counterpart.

2. The FDA has given the generic an “A” rating compared to the brand-name counterpart and has determined it to be therapeutically equivalent, and/or the BCBSM/BCN P&T Committee has reviewed the product and finds that it is acceptable for generic substitution.

When the above two criteria are met, a generic can be substituted with the full expectation that the substituted product will produce the same clinical effect and have the same safety profile as the prescribed product.

iii CO-PAYMENTS

The member’s prescription drug benefit plan design determines the applicable co-payment for the covered prescriptions.

SYMBOLS USED THROUGHOUTTHE DOCUMENT

KEY:

[PA] In limited circumstances, prior authorization may apply, based upon individual plan design. [QL] In limited circumstances, quantity limits may apply, based upon individual plan design. [PREVENT] Prevent drugs may be covered at $0 if criteria are met. For a detailed description, see Drug List Medication Coverage.

EDITOR’S NOTE

Your comments and suggestions regarding this Clinical Drug List are encouraged. Your input is vital to this Clinical Drug List’ continued success. All responses will be reviewed and considered. Please send your comments to:

Blue Cross Blue Shield of MI Pharmacy Services MC B773 Attn: Drug Information Services, 600 E. Lafayette Blvd. Detroit, MI 48226

iv Table of Contents THERAPEUTIC CHAPTERS

Introduction ...... i 3. Autonomic & CNS Drugs, Neurology & Psych ...... 11 Preface ...... i 3.1 Narcotic Analgesics ...... 11 3.1.1 Narcotics Drug List Medication Coverage ...... ii-iii 3.1.2 Combination Narcotic/Analgesics 3.3 Non-Narcotic Analgesics ...... 12 Generic Drug Substitution ...... iii 3.3.1 NSAIDs/COX-2 Inhibitors 3.3.1.1 NSAIDs Co-payments ...... iv 3.3.1.2 NSAIDs-Specific COX-2 Inhibitors Symbols Used Throughout the 3.3.2 Salicylates Document ...... iv 3.3.3 Miscellaneous Analgesics 3.3.4 Narcotic Antagonists Editor’s Note ...... iv 3.4 Migraine & Cluster Headache Therapy ...... 13 3.4.1 Headache Therapy 1. Anti-Infectives ...... 5 3.4.2 Antivertigo & Antiemetic Drugs 1.1 Penicillins ...... 5 3.5 Antiparkinsonism Agents ...... 13 1.2 Tetracyclines ...... 5 3.6 Anticonvulsants ...... 14 1.3 Cephalosporins ...... 5 3.7 Miscellaneous Neurological Therapy ...... 14 1.3.1 First Generation Cephalosporins 3.8 Muscle Relaxants & Antispasmodic 1.3.2 Second Generation Cephalosporins Therapy ...... 14-15 1.3.3 Third Generation Cephalosporins 3.8.1 Muscle Relaxants & Antispasmodic 1.3.4 Carbacephems Agents 1.4 Erythromycins & Other Macrolides ...... 5 3.8.2 Myasthenia Gravis 1.4.1 Erythromycins & Other Macrolides 3.9 Psychotherapeutic Drugs ...... 15-17 1.5 Quinolones ...... 6 3.9.1 Hypnotic Agents 1.5.1 Fluoroquinolones 3.9.2 Antidepressant Agents 1.6 Sulfas & Related Agents ...... 6 3.9.2.1 Tricyclics 1.7 Urinary Tract Agents ...... 6 3.9.2.2 Miscellaneous 1.8 Antivirals ...... 6 Antidepressants 1.8.1 Miscellaneous Antivirals 3.9.2.3 MAO Inhibitors 1.8.2 HIV/AIDS Therapy 3.9.2.4 Selective Serotonin Reuptake 1.9 Antifungal Agents ...... 7 Inhibitors 1.10 Vancomycin ...... 7 3.9.3 Antipsychotics 1.11 Miscellaneous Anti-Infectives ...... 8 3.9.3.1 Phenothiazines 1.11.1 Miscellaneous Anti-Infectives 3.9.3.2 Butyrophenones 1.11.2 Antiparasitics 3.9.3.3 Miscellaneous 1.11.3 Antimalarials Antipsychotics 1.11.4 Antimycobacterials 3.9.4 Miscellaneous Psychotherapeutic Agents 2. Antineoplastic & Immunosuppressant 3.9.5 Anxiolytics Drugs ...... 9 2.1 Antineoplastic & 4. Cardiovascular, Hypertension & Immunosuppressant Drugs ...... 9 Lipids ...... 18 2.1.1 Alkylating Agents 4.1 Antiarrhythmic Agents ...... 18 2.1.2 Antimetabolites 4.2 Cardiac Glycosides ...... 18 2.1.3 Androgens, Estrogens, Hormones & 4.3 Nitrates ...... 18 Related Drugs 4.3.1 Rapid Acting Nitrates 2.1.3.3 Hormones 4.3.2 Long Acting Nitrates 2.1.3.4 Antiestrogens 2.1.3.5 Antiandrogens 2.1.5 Immunosuppressant Drugs 2.1.6 Miscellaneous Antineoplastic Drugs 2.2 Adjunctive Agents ...... 10 2.2.1 Adjunctive Agents

1 4.4 Coagulation Therapy ...... 18 7.4.3 Miscellaneous Agents 4.4.1 Anticoagulants 7.4.4 Gonadotropin & Related Agents 4.4.2 Antiplatelet Drugs 7.5 Diabetes Therapy ...... 27-28 4.4.3 Heparin 7.5.1 Insulin Therapy 4.4.4 Vitamin K 7.5.2 Non-Insulin Hypoglycemic Agents 4.4.5 Hemostatics 7.5.3 Glucose Elevating Agents 4.4.6 Miscellaneous Coagulation Agents 7.5.4 Insulin Syringes/Miscellaneous Durable 4.5 Antihypertensive Therapy ...... 19-20 Medical Equipment 4.5.1 Thiazide & Related Diuretics 4.5.2 Beta Blockers 8. Gastroenterology ...... 29 4.5.3 Calcium Channel Blockers 8.1 Ulcer Therapy ...... 29 4.5.3.1 Calcium Channel Blockers/ 8.1.1 H2 Antagonists Non-Dihydropyridines 8.1.2 Prostaglandins 4.5.3.2 Calcium Channel Blockers/ 8.1.3 Other Ulcer Therapy Dihydropyridines 8.1.4 Proton Pump Inhibitors 4.5.4 ACE Inhibitors 8.2 Antidiarrheals & Antispasmodics ...... 29 4.5.5 Adrenergic Antagonists & Related 8.2.1 Antidiarrheals Drugs 8.2.2 Antispasmodics 4.5.6 Agents For Pheochromocytoma 8.2.3 Combination Anticholinergics 4.5.7 Vasodilators 8.3 Miscellaneous Gastrointestinal Agents . . . .29-30 4.5.8 Other Antihypertensive Combinations 8.3.1 Bile Acids 4.5.9 Angiotensin II Receptor Blockers 8.3.2 Digestive Enzymes 4.6 Lipid/Cholesterol Lowering Agents ...... 21 8.3.3 Miscellaneous Gastrointestinal Agents 4.7 Miscellaneous Cardiovascular Agents ...... 21 8.3.4 Antivertigo & Antiemetic Agents 8.3.5 Bowel Evacuants 5. Dermatologicals/Topical Therapy . . . .22 5.1 Topical Corticosteroids ...... 22 9. Immunology, Vaccines & 5.1.1 Topical Corticosteroids Very High Biotechnology ...... 31 Potency 9.1 Biotechnology Drugs ...... 31 5.1.2 Topical Corticosteroids High Potency 9.1.1 Erythroid Stimulants 5.1.3 Topical Corticosteroids Medium Potency 9.1.2 Myeloid Stimulants 5.1.4 Topical Corticosteroids Low Potency 9.1.3 Interferons 5.2 Topical Anesthetics ...... 22 9.1.4 Growth Hormones 5.3 Therapy for Acne ...... 23 9.1.5 Interleukins 5.4 Topical Antibacterials ...... 23 9.2 Immune Globulin ...... 31 5.5 Topical Antifungals ...... 23 5.6 Topical Antivirals ...... 23 10. Musculoskeletal & Rheumatology . . .32 5.7 Burn Therapy ...... 23 10.1 NSAID Agents ...... 32 5.8 Topical Enzymes ...... 23 10.1.1 NSAIDs COX-2 Inhibitors 5.10 Antipsoriatic/Antiseborrheic ...... 24 10.1.1.1 NSAIDs 5.11 Topical Scabicides/Pediculicides ...... 24 10.1.1.2 NSAIDs-Specific COX-2 5.12 Miscellaneous Dermatologicals ...... 24 Inhibitors 10.1.2 Salicylates 6. Ear, Nose & Throat Medications . . . . .25 10.2 Gout Therapy ...... 32 6.1 Intranasal Steroids ...... 25 10.3 Other Rheumatologicals ...... 32-33 6.2 Miscellaneous Otic Preparations ...... 25 10.3.1 Corticosteroids 6.3 Otic Steroid/Antibiotic ...... 25 10.3.2 Miscellaneous Rheumatological Agents 6.4 Miscellaneous Agents ...... 25 10.3.3 Muscle Relaxants & Antispasmodic Therapy 7. Endocrine/Diabetes ...... 26 10.4 Osteoporosis Therapy ...... 33 7.1 Antithyroid Agents ...... 26 7.2 Thyroid Hormones ...... 26 7.3 Adrenal Hormones ...... 26 7.4 Miscellaneous Hormones ...... 26-27 7.4.1 Androgens 7.4.2 Ovulatory Stimulants

2 11. Obstetrics & Gynecology ...... 33 14. Urologicals ...... 42 11.1 Oral Contraceptives & Related Agents ...... 33 14.1 Cholinergic Stimulants ...... 42 11.1.1 Monophasic/Biphasic/Triphasic/4-Phasic 14.2 Anticholinergic & Antispasmodics ...... 42 Agents 14.3 Urinary Anesthetics ...... 42 11.1.2 Progestin Only 14.4 Miscellaneous Urologicals ...... 42 11.3 Estrogens & Progestins ...... 33-34 14.5 Benign Prostatic Hyperplasia (BPH) 11.3.1 Progestins Therapy ...... 42 11.3.2 Estrogens 11.3.3 Estrogen Combinations 15. Vitamins, Hematinics & 11.4 Miscellaneous OB/GYN ...... 35 Electrolytes ...... 43 11.4.1 Drugs to Treat Infertility/IVF Agents 15.1 Vitamins & Hematinics ...... 43 11.4.2 Vaginal Cleanser/Anti-Infectives 15.2 Coagulation Therapy ...... 43 11.4.3 Vaginal Antifungals 15.2.1 Anticoagulants 11.4.4 Specialized OB/GYN Drugs 15.2.2 Antiplatelet Drugs 11.4.5 Diaphragms and Other Non-Oral 15.2.3 Heparin Contraceptives 15.2.4 Vitamin K 15.2.5 Hemostatics 12. Ophthalmology ...... 36 15.2.6 Miscellaneous Coagulation Agents 12.1 Beta Blockers ...... 36 15.3 Electrolytes ...... 43 12.2 Cholinesterase Inhibitor Miotics ...... 36 15.3.1 Potassium 12.3 Direct Acting Miotics ...... 36 15.3.2 Other Electrolytes 12.4 Other Glaucoma Drugs ...... 36 12.5 Oral Drugs for Glaucoma ...... 36 16. Diagnostics & Miscellaneous ...... 44 12.6 Cycloplegic Mydriatics ...... 36 16.1 Miscellaneous Agents ...... 44 12.7 Non-Steroidal Anti-Inflammatory 16.2 Smoking Deterrents ...... 44 Agents ...... 36 16.3 Anorexiants ...... 44 12.8 Vasoconstrictor Decongestants ...... 36 12.9 Antibiotics ...... 37 Index ...... 45 12.10 Sulfonamides ...... 37 12.11 Steroids ...... 37 12.12 Steroid-Antibiotic Combinations ...... 37 12.13 Steroid-Sulfonamide Combinations ...... 37 12.14 Sympathomimetics ...... 37 12.15 Miscellaneous Ophthalmologics ...... 38 12.16 Antivirals ...... 38 13. Respiratory, Allergy, Cough & Cold . .39 13.1 Antihistamine & Antiallergenic Agents ...... 39 13.1.1 Antihistamines 13.1.2 Adrenergics 13.1.3 Corticosteroids 13.2 Cough & Cold Therapy ...... 39 13.2.1 Antitussive Combinations 13.2.2 Expectorant Combinations 13.2.3 Decongestant/Antihistamines 13.3 Pulmonary Agents ...... 39 13.3.1 Xanthines 13.3.2 Beta Agonists Oral 13.3.3 Beta Agonist Inhalers 13.3.4 Inhaled Corticosteroids 13.3.5 Intranasal Steroids 13.3.6 Miscellaneous Pulmonary Agents

3 4 Anti-Infectives 1 (Ceftin Suspension) (Zithromax) (Zithromax) (Pediazole) (Pediazole) (Cefzil) (Cedax) (E.E.S.) (Vantin) (Vantin) (Spectracef) (Spectracef) (Erythrocin Stearate) PRODUCTS FORMULARY PRODUCTS FORMULARY PRODUCTS FORMULARY (Zithromax) (Zithromax) (Eryc) (Ceftin) (Biaxin) (Biaxin) (Biaxin XL) (Cedax) detailed description, see Drug List Medication Coverage. Coverage. Medication List Drug see description, detailed (Cefzil) (Omnicef) (Omnicef) (Ceclor) (Cefixime) (Cefixime) PRESCRIBED PRODUCTS NONFORMULARY COMMONLY PRESCRIBED PRODUCTS NONFORMULARY COMMONLY ERYTHROMYCINS ERYTHROMYCINS & OTHER MACROLIDES GENERICS SECOND GENERATION CEPHALOSPORINS SECOND GENERATION GENERICS CEPHALOSPORINS THIRD GENERATION GENERICS DRUG NAME DRUG NAME BRANDS DRUG NAME DRUG NAME DRUG NAME Cedax (90mg/5mL oral suspension) Spectracef (200mg) Tablet Azithromycin Azithromycin Suspension, Reconstituted, (ml) Oral Clarithromycin Clarithromycin Erythromycin Base Erythromycin Ethylsuccinate Acetyl Erythromycin Ethylsuccinate/Sulfisoxazole Erythromycin Stearate Dificid Suspension, Reconstituted, Oral EryPed (ml) 400mg/5ml 500mg Ery-Tab PCE Zmax Cefaclor Tablet Cefpodoxime Proxetil Cefprozil Cefprozil Suspension, Reconstituted, Oral Cefuroxime Axetil Cefuroxime Axetil Suspension, Reconstituted, (ml) Oral Cefdinir 400mg Cefditoren only Ceftibuten Ceftibuten, Reconstituted 180mg/5ml Suprax [PREVENT] Prevent drugs may be covered at $0 if criteria are met. For a For met. are criteria if $0 at covered be may drugs Prevent [PREVENT] [QL] 1.4 Erythromycins & Other Macrolides

1.4.1 1.3.2 1.3.3 5 (Vibramycin) (Vibramycin) (Vibramycin) (Vibramycin) (Augmentin) (Augmentin) (Augmentin ES) (Augmentin XR) (Doryx) (Solodyn (Solodyn 45mg, 90mg, 135mg) (Augmentin) (Augmentin) (Vibra-Tabs) (Vibra-Tabs) (Adoxa) (Adoxa) (Monodox) (Keflex) (Keflex) (Pen-Vee K) (Pen-Vee (Principen) (Principen) PRODUCTS FORMULARY PRODUCTS FORMULARY PRODUCTS FORMULARY (Dynapen) NFECTIVES (Duricef) (Duricef) (Dynacin) (Minocin) (Achromycin V) (Achromycin -I (Doxycycline (Doxycycline Calcium Syrup) (Amoxil) (Amoxil) NTI (Amoxicillin/Potassium Clavulanate) (Amoxicillin/Potassium individual plan design. design. plan individual design. plan individual PRESCRIBED PRODUCTS NONFORMULARY COMMONLY PRESCRIBED PRODUCTS NONFORMULARY COMMONLY FIRST GENERATION CEPHALOSPORINS FIRST GENERATION GENERICS DRUG NAME DRUG NAME BRANDS DRUG NAME GENERICS DRUG NAME BRANDS DRUG NAME GENERICS Cephalexin Cephalexin Monohydrate Cefadroxil Hydrate Acticlate Doryx 200mg Oracea Solodyn Minocycline Minocycline HCl, Extended Release HCl Tetracycline Vibramycin Doxycycline Monohydrate Suspension, Reconstituted, (ml) Doxycycline Oral Monohydrate Minocycline HCl Minocycline HCl Doxycycline Hyclate Tablet Doxycycline Hyclate Enteric Coated Tablet, Doxycycline Hyclate Doxycycline Monohydrate Doxycycline Monohydrate Doxycycline Hyclate Doxycycline Capsule Soft, Hyclate (Hard, Etc.) Moxatag Augmentin Augmentin Suspension, Reconstituted 125-31.25mg/5ml Amoxicillin Trihydrate/Potassium Clavulanate Trihydrate/Potassium Amoxicillin Trihydrate Ampicillin Dicloxacillin Sodium V Potassium Penicillin Amoxicillin Clavulanate Amoxicillin/Potassium Clavulanate Trihydrate/Potassium Amoxicillin Clavulanate Trihydrate/Potassium Amoxicillin [PA] upon based apply, may authorization prior circumstances, limited In [QL] upon based apply, may limits quantity circumstances, limited In [PA] [QL] [PA] [PA] [PA] [PA] [PA] [PA] [PA] [PA] [PA] 1. A

1.3 Cephalosporins

1.2 Tetracyclines

1.1 Penicillins 1.3.1 Anti-Infectives 1 (Valcyte) (Valcyte) (Macrodantin) (Macrodantin) (Entecavir) (Entecavir) (Mandelamine) (Mandelamine) (Hiprex) (Hiprex) PRODUCTS FORMULARY PRODUCTS FORMULARY (Hepsera) (Hepsera) (Flumadine) (Flumadine) (Ribavirin) (Symmetrel) (Symmetrel) (Valtrex) (Valtrex) (Proloprim) (Proloprim) detailed description, see Drug List Medication Coverage. Coverage. Medication List Drug see description, detailed (Famvir) (Famvir) (Copegus) (Rebetol) (Baraclude) (Baraclude) (Zovirax) (Zovirax) (Boceprevir) (Boceprevir) (Oseltamivir (Oseltamivir Phosphate) (Zanamivir) (Zanamivir) (Telaprevir) (Telaprevir) (Sofosbuvir) (Valganciclovir Hydrochloride Solution, Hydrochloride Reconstituted) (Valganciclovir (Simepevir (Simepevir Sodium) PRESCRIBED PRODUCTS NONFORMULARY COMMONLY PRESCRIBED PRODUCTS NONFORMULARY COMMONLY MISCELLANEOUS ANTIVIRALS MISCELLANEOUS GENERICS BRANDS DRUG NAME DRUG NAME GENERICS DRUG NAME DRUG NAME Entecavir Famciclovir Ribavirin Ribavirin Rimantadine HCl HCl Valacyclovir Tablet Hydrochloride Valganciclovir Baraclude Oral Solution Incivek Olysio Rebetol Solution Sovaldi Relenza Tamiflu Valcyte Victrelis Harvoni Sitavig Tyzeka Methenamine Methenamine Hippurate Methenamine Mandelate Macrocrystal Nitrofurantoin Trimethoprim Macrodantin 25mg Monurol Primsol Acyclovir Adefovir Dipivoxil Amantadine HCl [PREVENT] Prevent drugs may be covered at $0 if criteria are met. For a For met. are criteria if $0 at covered be may drugs Prevent [PREVENT] PA] [QL] PA] [QL] [PA] [QL] [PA] [QL] [QL] [QL] [PA] [QL] [PA] [QL] [PA]

1.7Agents Tract Urinary 1.8 Antivirals 1.8.1 6 ) (Pediazole) (Pediazole) ONTINUED (Bactrim (Bactrim DS) (Septra DS) (Levaquin) (Levaquin) (Cipro) (Cipro) (Cipro) (Cipro) PRODUCTS FORMULARY PRODUCTS FORMULARY NFECTIVES (C (Avelox) (Avelox) -I (Sulfadiazine) (Sulfadiazine) (Levaquin) (Levaquin) (Floxin) (Floxin) NTI (Norfloxacin) (Norfloxacin) individual plan design. design. plan individual individual plan design. plan individual (Cipro (Cipro XR) PRESCRIBED PRODUCTS NONFORMULARY COMMONLY [PA] upon based apply, may authorization prior circumstances, limited In FLUOROQUINOLONES GENERICS DRUG NAME GENERICS DRUG NAME BRANDS DRUG NAME Sulfadiazine Sulfamethoxazole/Trimethoprim Sulfamethoxazole/Trimethoprim Erythromycin Ethylsuccinate/Sulfisoxazole Acetyl Erythromycin Ethylsuccinate/Sulfisoxazole Factive Moxifloxacin HCl Moxifloxacin Ofloxacin Noroxin Ciprofloxacin Ciprofloxacin Suspension Levofloxacin Levofloxacin Solution, Oral Ciprofloxacin HCl - Betaine Combination Tablet, Sustained Release 24hr Ciprofloxacin HCl - Tablet, Betaine Combination Tablet Ciprofloxacin HCl [QL] upon based apply, may limits quantity circumstances, limited In 1. A

1.6 Sulfas & Agents Related

1.5 Quinolones 1.5.1 Anti-Infectives 1 (Grifulvin V) (Grifulvin (Gris-Peg) (Gris-Peg) (Grifulvin V) (Grifulvin (Vancocin) (Vancocin) (Vfend) (Lamisil) PRODUCTS FORMULARY PRODUCTS FORMULARY (Mycelex) (Mycelex) (Itraconazole) (Itraconazole) (Vfend) (Diflucan) (Diflucan) (Nizoral) (Nizoral) (Vfend Suspension, Reconstituted, Oral (mL)) (Sporanox) (Sporanox) (Ancobon) detailed description, see Drug List Medication Coverage. Coverage. Medication List Drug see description, detailed (Mycostatin) (Mycostatin) (Posaconazole) (Posaconazole) PRESCRIBED PRODUCTS NONFORMULARY COMMONLY GENERICS GENERICS BRANDS DRUG NAME DRUG NAME DRUG NAME Onmel Oravig HCl Capsule Vancomycin Clotrimazole Troche Clotrimazole Tablet Fluconazole Flucytosine Griseofulvin, Microsize (Final Suspension, Oral Dose Form) Tablet Griseofulvin, Microsize Tablet Griseofulvin Ultramicrosize Itraconazole Ketoconazole Nystatin Tablet HCl Terbinafine Voriconazole Suspension Voriconazole Tablet Voriconazole Noxafil Solution Sporanox Lamisil, Oral Granules [PREVENT] Prevent drugs may be covered at $0 if criteria are met. For a For met. are criteria if $0 at covered be may drugs Prevent [PREVENT] [PA] [QL] [PA] [QL] [QL] 1.10 Vancomycin 1.9Agents Antifungal 7 ) (Videx (Videx EC) ONTINUED (Trizivir) (Trizivir) (Viramune (Viramune XR) (Retrovir) (Retrovir) (Combivir) (Ziagen) (Ziagen) (Tipranavir/Vitamin) (Tipranavir/Vitamin) (Lamivudine) PRODUCTS FORMULARY NFECTIVES (C (Zerit) (Zerit) (Retrovir) (Retrovir) (Abacavir Sulfate) (Abacavir (Lamivudine) -I (Nevirapine) (Nevirapine) (Epivir) (Epivir) (Epivir-HBV) (Viramune) (Viramune) (Delavirdine Mesylate) (Delavirdine (Emtricitab/Rilpivirine/Tenofov) (Emtricitab/Rilpivirine/Tenofov) (Etravirine) (Etravirine) NTI (Abacavir Sulfate/Lamivudine) (Abacavir (Indinavir (Indinavir Sulfate) (Abacavir/Dolutegravir/Lamivudine) (Abacavir/Dolutegravir/Lamivudine) (Nelfinavir Mesylate) (Nelfinavir (Raltegravir Potassium) (Raltegravir Potassium) Chewable) Tablet, (Raltegravir Potassium (Rilpivirine) (Emtricitabine/Tenofovir Disoproxil Fumarate) Disoproxil Fumarate) (Emtricitabine/Tenofovir (Emtricitabine) (Emtricitabine) (Saquinavir (Saquinavir Mesylate) (Atazanavir (Atazanavir Sulfate) (Tipranavir) (Tipranavir) (Darunavir Ethanolate) (Elvitegravir/Cobicistat/Emtricitabine/Tenofovir Disoproxil Fumerate) Disoproxil Fumerate) (Elvitegravir/Cobicistat/Emtricitabine/Tenofovir (Elvitegravir) (Elvitegravir) (Dolutegravir) (Dolutegravir) (Enfuvirtide) (Enfuvirtide) (Ritonavir/Lopinavir) (Efavirenz) (Efavirenz) (Efavirenz/Emtricitabine/Tenofovir Disoproxil Fumarate) Disoproxil Fumarate) (Efavirenz/Emtricitabine/Tenofovir (Ritonavir) (Cobicistat) (Tenofovir Disoproxil Fumarate) Disoproxil Fumarate) (Tenofovir (Fosamprenavir Calcium Tablet) Tablet) Calcium (Fosamprenavir (Didanosine Solution, Reconstituted, Oral) individual plan design. design. plan individual design. plan individual HIV/AIDS THERAPY HIV/AIDS GENERICS BRANDS DRUG NAME Ziagen Ziagen Solution Viracept Viramune XR Viread Vitekta Triumeq Truvada Tybost Videx Sustiva Stribild Tivicay Norvir Prezista Rescriptor Reyataz Isentress Isentress Kaletra Lexiva Epzicom Fuzeon Intelence Invirase Emtriva Solution Epivir-HBV Epivir Solution Atripla Complera Crixivan Edurant Zidovudine Zidovudine Syrup Aptivus Aptivus Oral Solution Nevirapine Stavudine Capsule 400mg Disoproxil Fumarate Tenofovir Zidovudine Capsule Soft, (Hard, Etc.) Lamivudine Lamivudine Lamivudine/Zidovudine Abacavir Sulfate/Lamivudine/Zidovudine Abacavir Tablet Sulfate Abacavir Didanosine Capsule,Delayed Release (Enteric Coated) [PA] upon based apply, may authorization prior circumstances, limited In [QL] upon based apply, may limits quantity circumstances, limited In [QL] [QL] [QL] [QL] [QL] [QL] 1. A

1.8.2 1 1. ANTI-INFECTIVES (CONTINUED)

1.11 Miscellaneous Anti-infectives FORMULARY PRODUCTS FORMULARY PRODUCTS DRUG NAME DRUG NAME 1.11.1 MISCELLANEOUS ANTI-INFECTIVES 1.11.3 ANTIMALARIALS GENERICS GENERICS Clindamycin HCl (Cleocin HCl) Atovaquone/Proguanil HCl (Malarone) Neomycin Sulfate (Neomycin Sulfate) Chloroquine Phosphate (Aralen) [QL] Tobramycin/0.25 Normal Saline Ampul for Nebulization (mL) (Tobi) Hydroxychloroquine Sulfate (Plaquenil) BRANDS Mefloquine HCl (Lariam) Dapsone (Dapsone) Quinine Sulfate (Qualaquin) Anti-Infectives [QL] Sivextro Tablet (Rifaximin) BRANDS Xifaxan (Rifaximin) Coartem (Artemether/Lumefantrine) Zyvox (Linezolid) Daraprim (Pyrimethamine) Primaquine (Primaquine Phosphate)

COMMONLY PRESCRIBED NONFORMULARY PRODUCTS DRUG NAME FORMULARY PRODUCTS DRUG NAME [PA] [QL] Bethkis [PA] [QL] Cayston 1.11.4 ANTIMYCOBACTERIALS [PA] [QL] Tobi Podhaler GENERICS Isoniazid (Isoniazid) Pyrazinamide (Pyrazinamide) FORMULARY PRODUCTS DRUG NAME Rifabutin (Mycobutin) 1.11.2 ANTIPARASITICS Rifampin (Rifadin) GENERICS BRANDS Atovaquone (Mepron) Cycloserine (Cycloserine) [PA] Sirturo (Bedaquiline) Iodoquinol (Yodoxin) Metronidazole (Flagyl) Paromomycin Sulfate (Humatin) COMMONLY PRESCRIBED NONFORMULARY PRODUCTS Tinidazole (Tindamax) DRUG NAME BRANDS Priftin Alinia (Nitazoxanide) Alinia (Nitazoxanide Suspension, Reconstituted, Oral (ml)) Biltricide (Praziquantel) Flagyl ER (Metronidazole) NebuPent (Pentamidine Isethionate) Stromectol (Ivermectin)

COMMONLY PRESCRIBED NONFORMULARY PRODUCTS DRUG NAME Albenza [QL] Impavido

2.1.5 2.1.3 2.1.3.3 2.1.3.4 2.1.3.5 9 MMUNOSUPPRESSANT & I (Cytoxan) (Cytoxan) (Rheumatrex) (Rheumatrex) PRODUCTS FORMULARY PRODUCTS FORMULARY (Purinethol) (Purinethol) (Temodar) (Temodar) (Xeloda) (Xeloda) (Chlorambucil) (Chlorambucil) NTINEOPLASTIC (Busulfan) (Busulfan) (Melphalan) (Melphalan) (Thioguanine) (Methotrexate Sodium) (Methotrexate Drugs individual plan design. design. plan individual design. plan individual PRESCRIBED PRODUCTS NONFORMULARY COMMONLY PRESCRIBED PRODUCTS NONFORMULARY COMMONLY ANTIMETABOLITES GENERICS ALKYLATING AGENTS ALKYLATING GENERICS DRUG NAME BRANDS DRUG NAME DRUG NAME BRANDS DRUG NAME Purixan Trexall Methotrexate Sodium Methotrexate Tabloid Capecitabine Mercaptopurine Valchlor Leukeran Lomustine Myleran Temozolomide Alkeran Capsule Cyclophosphamide Cyclophosphamide Tablet Cyclophosphamide [PA] upon based apply, may authorization prior circumstances, limited In [QL] upon based apply, may limits quantity circumstances, limited In [PA] [PA] [PA] [PA] 2. A

2.1 Antineoplastic & Immunosuppressant 2.1.2 2.1.1 Anti-Infectives 2 ) (Depo-Provera) (Depo-Provera) ONTINUED PRODUCTS FORMULARY (Medroxyprogesterone Acet (Medroxyprogesterone Disposable Syringe (ml)) (Leucovorin (Leucovorin Calcium) (Medroxyprogesterone Acetate) (Medroxyprogesterone detailed description, see Drug List Medication Coverage. Coverage. Medication List Drug see description, detailed (Filgrastim) (Filgrastim) (Pegfilgrastim) (Pegfilgrastim) (Sargramostim) (Sargramostim) (Darbepoetin (Darbepoetin Alfa in Albumin Sol) (Mesna Tablet) Tablet) (Mesna (Filgrastim) (Filgrastim) (Epoetin Alfa Vial Vial (mL)) (Epoetin Alfa RUGS (C D PRESCRIBED PRODUCTS NONFORMULARY COMMONLY ADJUNCTIVE AGENTS ADJUNCTIVE GENERICS DRUG NAME BRANDS DRUG NAME Leucovorin Leucovorin Calcium Acetate Medroxyprogesterone Aranesp Depo-Provera Provera Depo-Subq Granix Leukine Mesnex Neulasta Neupogen Procrit Epogen [PREVENT] Prevent drugs may be covered at $0 if criteria are met. For a For met. are criteria if $0 at covered be may drugs Prevent [PREVENT] [PA] [PA] [QL] [PA] [PA] 2.2Agents Adjunctive 2.2.1 10 (Sandostatin) (Sandostatin) MMUNOSUPPRESSANT & I (Leuprolide (Leuprolide Acetate) PRODUCTS FORMULARY (Leuprolide (Leuprolide Acetate) (Lupron) (Lupron) (Octreotide Acetate (Octreotide Kit) (Everolimus Tablet for Suspension) Oral Tablet (Everolimus (Leuprolide (Leuprolide Acetate) (Gefitinib Tablet) Tablet) (Gefitinib (Hydrea) (Hydrea) (Topotecan HCl) (Topotecan (Cabozantinib) (Cabozantinib) (Procarbazine HCl) (Procarbazine (Mitotane) (Mitotane) NTINEOPLASTIC (VePesid) (VePesid) (Vesanoid) (Vesanoid) (Trametinib) (Trametinib) (Vismodegib) (Vismodegib) (Vandetanib) (Vandetanib) (Vemurafenib) (Vemurafenib) (Altretamine) (Altretamine) (Pazopanib) (Pazopanib) (Sorafenib Tosylate) Tosylate) (Sorafenib (Goserelin Acetate) (Goserelin (Ceritinib) (Ceritinib) (Everolimus) (Everolimus) (Regorafenib) (Regorafenib) (Dabrafenib) (Dabrafenib) (Imatinib (Imatinib Mesylate) (Vorinostat) (Vorinostat) (Afatinib) (Nilotinib Hydrochloride) (Nilotinib Hydrochloride) (Erlotinib HCl) (Erlotinib (Idelalisib) (Idelalisib) (Triptorelin Pamoate) Pamoate) (Triptorelin (Crizotinib) (Crizotinib) (Dasatinib) (Dasatinib) (Bosutinib) (Lapatinib Ditosylate) (Hydroxyurea) (Hydroxyurea) (Sunitinib (Sunitinib Malate) (Estramustine Phosphate (Estramustine Sodium) (Ponatinib) (Ponatinib) individual plan design. design. plan individual individual plan design. plan individual (Axitinib) (Ruxolitinib) (Ruxolitinib) PRESCRIBED PRODUCTS NONFORMULARY COMMONLY [PA] upon based apply, may authorization prior circumstances, limited In MISCELLANEOUS ANTINEOPLASTIC ANTINEOPLASTIC MISCELLANEOUS DRUGS GENERICS DRUG NAME BRANDS DRUG NAME Zortress Pomalyst capsules Targretin Zydelig Zykadia Xalkori Zelboraf Zoladex Zolinza Tasigna Trelstar Tykerb Votrient Sutent Tafinlar Tarceva Nexavar Sandostatin LAR Sprycel Stivarga Lupron Lupron Depot-Ped Lysodren Matulane Mekinist Iressa 250mg Iressa Jakafi Lupron Depot Lupron Depot-3 Month Iclusig Imbruvica Inlyta Gilotrif Gleevec Hexalen Hycamtin Cometriq Droxia Emcyt Erivedge Afinitor Afinitor Disperz Bosulif Caprelsa Octreotide Acetate Vial (SDV,MDV or Additive) (ml) Vial (SDV,MDV Acetate Octreotide Tretinoin Etoposide Hydroxyurea Leuprolide Acetate [QL] upon based apply, may limits quantity circumstances, limited In [PA] [QL] [PA] [PA] [PA] [QL] [PA] [QL] [PA] [PA] [QL] [PA] [QL] [PA] [QL] [QL] [QL] [QL] [PA] [QL] [QL] [PA] [QL] [QL] [PA] [PA] [QL] [PA] [PA] [QL] [PA] [PA] [QL] [PA] [QL] [PA] [QL] [PA] [PA] [QL] [PA] [PA] [QL] [PA] [QL] [PA] [QL] [QL] [PA] [QL] [PA] [PA] 2. A

2.1.6 Autonomic & CNS Drugs, Neurology & Psych 3 (Fioricet w/Codeine) (Fioricet (Fiorinal w/Codeine) (Fiorinal (Fioricet) (Fioricet) (Tylenol w/Codeine) (Tylenol (Esgic) (Esgic-Plus) (Anexsia) (Lorcet Plus) (Lorcet 10/650) (Lortab) (Vicodin) (Vicodin ES) (Percocet) (Percocet) (Tylox) (Fiorinal) (Fiorinal) (Vicoprofen) (Vicoprofen) (Combunox) (Combunox) (Phrenilin) (Phrenilin) PRODUCTS FORMULARY (Percodan) (Percodan) (Acetaminophen/Butalbital) (Acetaminophen/Butalbital) SYCH detailed description, see Drug List Medication Coverage. Coverage. Medication List Drug see description, detailed & P PRESCRIBED PRODUCTS NONFORMULARY COMMONLY COMBINATION NARCOTIC/ANALGESICS COMBINATION GENERICS BRANDS DRUG NAME DRUG NAME Phrenilin Phrenilin Forte Synalgos-DC Acetaminophen/Butalbital Acetaminophen/Caffeine/Butalbital Aspirin/Caffeine/Butalbital Butalbial/Acetaminophen/Caffeine Butalbial/Acetaminophen/Caffeine Codeine Phosphate/Acetaminophen Codeine Phosphate/Acetaminophen/Caffeine/Butalbital Codeine Phosphate/Aspirin/Caffeine/Butalbital Bit/Acetaminophen Hydrocodone Bit/Acetaminophen Hydrocodone Bit/Acetaminophen Hydrocodone Bit/Acetaminophen Hydrocodone Bit/Acetaminophen Hydrocodone Bit/Acetaminophen Hydrocodone Bit/Ibuprofen Hydrocodone Ibuprofen/Oxycodone HCl Oxycodone/Aspirin Oxycodone HCl/Acetaminophen Oxycodone HCl/Acetaminophen [PREVENT] Prevent drugs may be covered at $0 if criteria are met. For a For met. are criteria if $0 at covered be may drugs Prevent [PREVENT] [QL] [QL] [QL] [QL] [QL] [QL] [QL] [QL] [QL] [QL] [QL]

3.1.2 11 EUROLOGY , N RUGS (Avinza) (Avinza) (MS Contin) (Opana (Opana ER) & CNS D (Morphine (Morphine Sulfate) PRODUCTS FORMULARY (Dilaudid) (Dilaudid) (Exalgo) (Exalgo) (Kadian) (MSIR) (Rms-Suppository) (Demerol) (Demerol) (Dolophine (Dolophine HCl) (Actiq) (Actiq) (Roxicodone) (Roxicodone) (Codeine Sulfate) (Opana) (Opana) (Oxycodone HCl) UTONOMIC (Duragesic) (Duragesic) (Morphine Sulfate/Naltrexone) (Morphine Sulfate/Naltrexone) individual plan design. design. plan individual design. plan individual PRESCRIBED PRODUCTS NONFORMULARY COMMONLY NARCOTICS GENERICS DRUG NAME BRANDS DRUG NAME Targiniq ER Targiniq Xartemis XR Zohydro ER Onsolis Opana ER Oxecta Subsys Hysingla Hysingla ER Kadian (40mg, 200mg) Lazanda Abstral Butrans Fentora OxyContin Oxymorphone Oxymorphone HCl, Extended Release Embeda Morphine Morphine Sulfate Capsule, Release Multiphasic Morphine Sulfate Solution, Oral Sustained Action Tablet, Morphine Sulfate Oxycodone HCl Methadone Methadone HCl Morphine Sulfate Morphine Sulfate Morphine Sulfate Fentanyl Citrate Fentanyl ER Hydromorphone Meperidine HCl Codeine Sulfate HCl Hydromorphone Fentanyl [PA] upon based apply, may authorization prior circumstances, limited In [QL] upon based apply, may limits quantity circumstances, limited In [PA] [QL] [PA] [QL] [PA] [QL] [PA] [PA] [QL] [PA] [QL] [PA] [QL] [QL] [PA] [PA] [PA] [QL] [PA] [PA] [QL] [PA] [QL] [PA] [QL] [PA] [PA] [QL] [PA] [QL] [QL] [PA] [QL] [QL] [PA] [QL] [PA] [QL] 3. A

3.1Analgesics Narcotic 3.1.1 Autonomic & CNS Drugs, Neurology & Psych 3 ) (Choline Mag Trisalicylate) Trisalicylate) (Choline Mag (Suboxone SL Tab) Tab) SL (Suboxone (Talacen) (Talacen) (Talwin NX) (Talwin (Ultracet) (Ultracet) ONTINUED PRODUCTS FORMULARY PRODUCTS FORMULARY PRODUCTS FORMULARY (ReVia) (ReVia) (Buprenorphine HCl/Naloxone HCl) HCl/Naloxone (Buprenorphine (Ryzolt) (Ryzolt) (Ultram) (Ultram (Ultram ER) detailed description, see Drug List Medication Coverage. Coverage. Medication List Drug see description, detailed SYCH (C (Dolobid) (Dolobid) (Tapentadol) (Tapentadol) (Salflex) (Salflex) (Naloxone HCl) (Naloxone & P PRESCRIBED PRODUCTS NONFORMULARY COMMONLY PRESCRIBED PRODUCTS NONFORMULARY COMMONLY NARCOTIC ANTAGONISTS NARCOTIC GENERICS SALICYLATES GENERICS ANALGESICS MISCELLANEOUS GENERICS DRUG NAME DRUG NAME BRANDS DRUG NAME DRUG NAME DRUG NAME BRANDS Nucynta ER Nucynta HCl HCl/Naloxone Buprenorphine HCl Naltrexone Evzio Film Suboxone Bunavail Zubsolv Choline Salicylate/Magnesium Salicylate Diflunisal Salsalate HCl/Acetaminophen Pentazocine HCl HCl/Naloxone Pentazocine ER Tramadol HCl Tramadol HCl Tramadol HCl/Acetaminophen Tramadol Nucynta [PREVENT] Prevent drugs may be covered at $0 if criteria are met. For a For met. are criteria if $0 at covered be may drugs Prevent [PREVENT] [PA] [QL] [PA] [QL] [QL] [QL] [PA] [PA] [QL] [PA]

3.3.4 3.3.2 3.3.3 12 EUROLOGY , N RUGS (Oruvail) (Oruvail) (Voltaren-XR) (Voltaren-XR) (Naprelan 500mg) (Naprelan (Indocin (Indocin SR) (Lodine XL) & CNS D (Arthrotec) (EC-Naprosyn) (EC-Naprosyn) (Pennsaid) (Pennsaid) (Toradol) (Toradol) (Meclofenamate (Meclofenamate Sodium) PRODUCTS FORMULARY PRODUCTS FORMULARY (Cataflam) (Voltaren) (Voltaren) (Anaprox) (Anaprox) (Anaprox DS) (Naproxen Sodium Tablet, Sustained Action) Tablet, Sodium (Naproxen (Tolectin) (Tolectin) (Ponstel) (Ponstel) (Indocin) (Indocin) (Relafen) (Relafen) (Ansaid) (Mobic) (Mobic) (Daypro) (Daypro) (Orudis) (Feldene) (Feldene) (Naprosyn) (Naprosyn) (Motrin) (Motrin) (Celebrex) UTONOMIC (Clinoril) (Lodine) individual plan design. design. plan individual individual plan design. plan individual PRESCRIBED PRODUCTS NONFORMULARY COMMONLY [PA] upon based apply, may authorization prior circumstances, limited In NSAIDS- SPECIFIC COX-II INHIBITORS GENERICS NSAIDS GENERICS NSAIDS/COX NSAIDS/COX II INHIBITORS DRUG NAME DRUG NAME BRANDS DRUG NAME Celecoxib Zipsor Zorvolex Tivorbex Vimovo Gel 1% Voltaren Nalfon 500mg, Naprelan 750mg 2% Pennsaid Sprix Cambia Duexis Flector Patch Naprelan 375mg Naprelan Piroxicam Sulindac Sodium Tolmetin Naproxen Sodium Naproxen Sustained Action Tablet, Sodium Naproxen Sustained Release Naproxen, Oxaprozin Nabumetone Naproxen Sodium Naproxen Ketorolac Tromethamine Ketorolac Meclofenamate Sodium Mefenamic Acid Meloxicam Indomethacin Indomethacin Capsule, Sustained Action Ketoprofen Ketoprofen Capsule, 24hr Sustained Release Pellets Etodolac Sustained Release 24hr Tablet, Etodolac Flurbiprofen Ibuprofen Diclofenac Sodium 1.5% Sustained Release 24hr Diclofenac Tablet, Sodium Diclofenac Sodium-Misoprostol Diclofenac Potassium Diclofenac Sodium [QL] upon based apply, may limits quantity circumstances, limited In [PA] [QL] [PA] [QL] [PA] [PA] [QL] [PA] [QL] [PA] [QL] [PA] [PA] [QL] [PA] [QL] [PA] [QL] [PA] [QL] [PA] [QL] [PA] [QL] [QL] 3. A

3.3Analgesics Non-narcotic 3.3.1.2 3.3.1.1 3.3.1 Autonomic & CNS Drugs, Neurology & Psych 3 (Sinemet (Sinemet CR) ) (Requip (Requip XL) (Stalevo) (Stalevo) ONTINUED (Symmetrel) (Symmetrel) (Parlodel) (Parlodel) (Benadryl) PRODUCTS FORMULARY (Cogentin) (Artane) (Parcopa) (Parcopa) (Sinemet) (Requip) (Requip) (Eldepryl) SYCH (C (Comtan) (Mirapex) (Mirapex) (Lodosyn) detailed description, see Drug List Medication Coverage. Coverage. Medication List Drug see description, detailed (L-Dopa) (L-Dopa) (Apomorphine (Apomorphine HCl Cartridge (ml)) (Rasagiline Mesylate) & P PRESCRIBED PRODUCTS NONFORMULARY COMMONLY DRUG NAME GENERICS BRANDS DRUG NAME Mirapex Mirapex ER Neupro Tasmar Amantadine Tablet Amantadine HCl Benztropine Mesylate Bromocriptine Mesylate Carbidopa Carbidopa/Levodopa Carbidopa/Levodopa Carbidopa/Levodopa/Entacapone Sustained Action Tablet, Carbidopa/Levodopa HCl Diphenhydramine Entacapone Levodopa Pramipexol Ropinirole HCl Ropinirole HCl Sustained Release Selegiline HCl HCl Trihexyphenidyl Apokyn Azilect [PREVENT] Prevent drugs may be covered at $0 if criteria are met. For a For met. are criteria if $0 at covered be may drugs Prevent [PREVENT] [PA] [QL] [PA] [QL] [PA] [QL]

3.5Agents Antiparkinsonism 13 EUROLOGY , N (Midrin) (Midrin) RUGS (Migergot) (Migergot) (Prodrin) (Prodrin) (Compazine) (Compazine 25mg) (Maxalt MLT) (Maxalt MLT) (Zomig (Zomig ZMT) (Phenergan) (Phenergan) (Cafergot) (Fioricet) (Fioricet) (Imitrex Nasal Spray) (Imitrex Nasal & CNS D (Cocet) (Imitrex) (Imitrex) (D.H.E.45) (Migranal) (Maxalt) (Maxalt) (Fiorinal) (Fiorinal) (Imitrex) (Imitrex) (Phrenilin) (Phrenilin) (Phenergan) (Phenergan) (Compazine) (Tigan) (Tigan) (Alsuma) PRODUCTS FORMULARY PRODUCTS FORMULARY (Zomig) (Zomig) (Zofran) (Zofran) (Scopolamine Hydrobromide Patch, Transdermal 72 Hours) Transdermal (Scopolamine Patch, Hydrobromide (Kytril) (Kytril) (Acetaminophen/Butalbital) (Acetaminophen/Butalbital) (Antivert) (Zofran (Zofran ODT) (Amerge) (Marinol) (Marinol) UTONOMIC (Dolasetron Mesylate Tablet) Tablet) (Dolasetron Mesylate (Ergotamine Tartrate Tablet, Sublingual) Tablet, Tartrate (Ergotamine (Ergotamine Tartrate/Caffeine) Tartrate/Caffeine) (Ergotamine (Aprepitant) (Aprepitant) individual plan design. design. plan individual design. plan individual PRESCRIBED PRODUCTS NONFORMULARY COMMONLY ANTIVERTIGO ANTIEMETIC & DRUGS GENERICS HEADACHE THERAPY HEADACHE GENERICS BRANDS DRUG NAME DRUG NAME BRANDS DRUG NAME Emend Transderm-Scop Trimethobenzamide HCl Trimethobenzamide Anzemet Promethazine HCl Suppository, Rectal HCl Promethazine Suppository, Tablet HCl Promethazine Ondansetron Ondansetron HCl Meclizine Meclizine HCl Maleate Prochlorperazine Rectal Maleate Suppository, Prochlorperazine Rectal Maleate Suppository, Prochlorperazine Dronabinol HCl Granisetron Relpax Dose Sumavel Pro Treximet Zomig Spray Axert Frova Ergomar Phrenilin Forte Zolmitriptan Tablet, Orally Disintegrating Orally Tablet, Zolmitriptan Cafergot Sumatriptan Sumatriptan Succinatet Sumatriptan Succinate Kit Tablet Sumatriptan Succinate Tablet Zolmitriptan Naratriptan Tablet Rizatriptan Benzoate Rapid Dissolve Tablet, Rizatriptan Benzoate Solution Sumatriptan Intranasal Ergotamine Tartrate/Caffeine Suppository, Rectal Suppository, Tartrate/Caffeine Ergotamine Tablet Tartrate/Caffeine Ergotamine Isometheptene Mucate/Acetaminophen/Caffeine Isometheptene Mucate/Acetaminophen/Dichloralphenazone Aspirin/Caffeine/Butalbital Dihydroergotamine Mesylate Dihydroergotamine Mesylate Acetaminophen/Butalbital Acetaminophen/Caffeine/Butalbital With Codeine Acetaminophen [PA] upon based apply, may authorization prior circumstances, limited In [QL] upon based apply, may limits quantity circumstances, limited In [QL] [QL] [QL] [QL] [QL] [PA] [QL] [PA] [QL] [PA] [QL] [PA] [QL] [PA] [PA] [QL] [PA] [QL] [PA] [PA] [QL] [PA] [QL] [QL] [QL] [QL] [PA] [QL] [QL] [QL] [QL] [QL] 3. A

3.4 Migraine & Cluster Therapy Headache 3.4.2 3.4.1 3

3. AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH (CONTINUED) Psych & Neurology Drugs, CNS & Autonomic

3.6 Anticonvulsants 3.7 Miscellaneous Neurological Therapy FORMULARY PRODUCTS FORMULARY PRODUCTS DRUG NAME DRUG NAME GENERICS GENERICS Acetazolamide (Diamox) Donepezil HCl (Aricept) Carbamazepine (Carbatrol) [QL] Donepezil HCl (Aricept 23mg) Carbamazepine (Tegretol) Donepezil HCl Tablet, Rapid Dissolve (Aricept ODT) Carbamazepine Tablet, Sustained Release 12hr (Tegretol XR) Galantamine Hydrobromide (Razadyne) Clonazepam (Klonopin) Galantamine Hydrobromide Extended-Release Capsules (Razadyne ER) Clonazepam Tablet, Rapid Dissolve (Klonopin) Rivastigmine (Exelon) Diazepam (Diastat Acudial) BRANDS Divalproex Sodium (Depakote) [QL] Copaxone (Glatiramer Acetate Kit) Divalproex Sodium Sprinkle Capsules (Depakote Sprinkle) Exelon Patch (Rivastigmine Transdermal System) Divalproex Sodium Tablets, Delayed Release (Depakote ER) Exelon Solution (Rivastigmine Solution) Ethosuximide (Zarontin) [PA] [QL] Gilenya (Fingolimod) Ethosuximide Capsule (Hard, Soft, Etc.) (Zarontin) Namenda (Memantine HCl, Memantine HCl Solution, Oral) Felbamate (Felbatol) [PA] [QL] Nuedexta (Dextromethorphan HBR/Quinidine) Gabapentin (Neurontin) [PA] [QL] Tecfidera (Dimethyl Fumarate) Lamotrigine (Lamictal) [PA] [QL] Xenazine (Tetrabenazine) Lamotrigine Sustained Release (Lamictal XR) Lamotrigine Tablet, Dispersible (Lamictal) Levetiracetam (Keppra) COMMONLY PRESCRIBED NONFORMULARY PRODUCTS Oxcarbazepine (Trileptal) DRUG NAME Phenobarbital (Phenobarbital) [PA] [QL] Ampyra Phenytoin Sodium Extended (Dilantin) [PA] [QL] Aubagio Phenytoin Sodium Extended Capsule (Phenytek) [PA] [QL] Horizant Phenytoin Suspension, Oral (Final Dose Form) (Dilantin) [PA] [QL] Namenda XR Primidone Tablet (Mysoline) [QL] Revlimid Tiagabine HCl (Gabitril 2mg, 4mg) [PA] [QL] Savella Topiramate (Topamax Tablets) [PA] [QL] Xyrem

Topiramate Sprinkle Capsules (Topamax) Valproate Sodium Syrup (Depakene) 3.8 Muscle Relaxants & Antispasmodic Valproic Acid Capsule (Hard, Soft, Etc.) (Depakene) Zonisamide (Zonegran) Therapy BRANDS FORMULARY PRODUCTS Banzel (Rufinamide) DRUG NAME Diastat (Diazepam) 3.8.1 MUSCLE RELAXANTS & ANTISPASMODIC AGENTS Dilantin 30mg (Phenytoin Sodium Extended) GENERICS Gabitril 12mg, 16mg (Tiagabine HCl) Baclofen Tablet (Lioresal) Lamictal (Lamotrigine Tablet, Dose Pack) Carisoprodol Tablet (Soma) Lamictal ODT (Lamotrigine Orally Disintegrating) Carisoprodol/Aspirin (Soma Compound) Peganone (Ethotoin) Chlorzoxazone (Parafon Forte DSC) Potiga (Ezogabine) Cyclobenzaprine HCl (Flexeril) Sabril (Vigabatrin) Dantrolene Sodium (Dantrium) Vimpat (Lacosamide) Diazepam (Valium) Metaxalone (Skelaxin) Oxybutynin Chloride (Ditropan, Ditropan XL) COMMONLY PRESCRIBED NONFORMULARY PRODUCTS

DRUG NAME Tolterodine Tartrate (Detrol)

[PA] [QL] Aptiom Tolterodine Tartrate Capsule, Sustained Release 24 hr (Detrol LA) Equetro BRANDS [PA] [QL] Fycompa Enablex (Darifenacin Hydrobromide) [PA] [QL] Gralise [QL] Oxytrol (Oxybutynin Patch, Transdermal Semiweekly) [PA] Lyrica Vesicare (Solifenacin Succinate) [PA] [QL] Onfi [PA] [QL] Oxtellar XR [PA] [QL] COMMONLY PRESCRIBED NONFORMULARY PRODUCTS Qudexy XR DRUG NAME [PA] [QL] Trokendi XR [PA] Amrix

3.9.2 3.9.2.1 3.9.2.2 15 EUROLOGY , N RUGS (Ambien CR) & CNS D (Mestinon) (Mestinon) PRODUCTS FORMULARY PRODUCTS FORMULARY (Ambien) (Dalmane) (Dalmane) (Chloral Hydrate) (Chloral Hydrate) (Restoril) (Restoril) (Neostigmine Bromide) (Neostigmine (Lunesta) (Lunesta) (Halcion) (Halcion) (ProSom) (ProSom) (Pyridostigmine (Pyridostigmine Bromide Syrup) Sustained Action) Tablet, (Pyridostigmine Bromide UTONOMIC (Sonata) (Sonata) individual plan design. design. plan individual design. plan individual PRESCRIBED PRODUCTS NONFORMULARY COMMONLY HYPNOTIC AGENTS HYPNOTIC GENERICS MYASTHENIA GRAVIS MYASTHENIA GENERICS DRUG NAME DRUG NAME BRANDS DRUG NAME Silenor Zolpimist Intermezzo Sodium Nembutal Rozerem Seconal Sodium Belsomra Butisol Sodium Doral Edluar Triazolam Zaleplon Tartrate Zolpidem Controlled Release Tartrate Zolpidem Estazolam Eszopiclone HCl Flurazepam Temazepam Chloral Hydrate Chloral Mestinon Prostigmin Pyridostigmine Bromide Tablet Pyridostigmine Bromide Mestinon [PA] upon based apply, may authorization prior circumstances, limited In [QL] upon based apply, may limits quantity circumstances, limited In [PA] [QL] [PA] [PA] [PA] [QL] [PA] [QL] [PA] [PA] [QL] [QL] [PA] [QL] [QL] [QL] [QL] [QL] [QL] [QL] [QL] 3. A

3.9 Psychotherapeutic Drugs

3.9.1 3.8.2 3

3. AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH (CONTINUED) Psych & Neurology Drugs, CNS & Autonomic

FORMULARY PRODUCTS FORMULARY PRODUCTS DRUG NAME DRUG NAME 3.9.2.3 MAO INHIBITORS 3.9.3 ANTIPSYCHOTICS GENERICS 3.9.3.1 PHENOTHIAZINES Phenelzine Sulfate (Nardil) GENERICS Tranylcypromine Sulfate (Parnate) Chlorpromazine HCl (Thorazine)

Fluphenazine HCl (Prolixin) 3.9.2.4 SELECTIVE SEROTONIN REUPTAKE INHIBITORS Perphenazine (Trilafon) GENERICS [QL] Thioridazine HCl (Mellaril) Citalopram Hydrobromide (Celexa) Trifluoperazine HCl (Stelazine) Escitalopram Oxalate (Lexapro) Fluoxetine HCl (Prozac) 3.9.3.2 BUTYROPHENONES [QL] Fluoxetine HCl (Prozac Weekly) GENERICS Fluvoxamine Maleate (Luvox) Haloperidol (Haldol) Paroxetine HCl Tablet (Paxil) Haloperidol Lactate Concentrate, Oral (Haldol) Paroxetine HCl Tablet (Paxil CR) Sertraline HCl (Zoloft) 3.9.3.3 MISCELLANEOUS ANTIPSYCHOTICS BRANDS GENERICS [QL] Fluoxetine 60mg Clozapine (Clozaril) Clozapine ODT (Fazaclo) Loxapine Succinate (Loxitane) COMMONLY PRESCRIBED NONFORMULARY PRODUCTS DRUG NAME Olanzapine Orally Disintegrating Tablets (Zyprexa Zydis) Olanzapine Tablets (Zyprexa) [PA] [QL] Brisdelle Quetiapine Fumarate (Seroquel) [PA] Pexeva

Sarafem Risperidone Tablets (Risperdal) Risperidone Tablets, Oral Disintegrating (Risperdal M-tab) [PA] [QL] Viibryd Thiothixene (Navane) Ziprasidone HCl (Geodon) BRANDS [PA] Abilify (Aripiprazole) Moban (Molindone HCl) Orap (Pimozide)

COMMONLY PRESCRIBED NONFORMULARY PRODUCTS DRUG NAME [PA] Abilify Discmelt [PA] Fanapt Fazaclo (150mg, 200mg) [PA] [QL] Invega [PA] Latuda [PA] [QL] Saphris [PA] [QL] Seroquel XR [PA] Versacloz

3.9.5 3.9.4 Cardiovascular, Hypertension & Lipids 4 (Trental) (Trental) (Heparin (Heparin Lock Flush) (Ticlid) (Ticlid) (Arixtra) PRODUCTS FORMULARY PRODUCTS FORMULARY PRODUCTS FORMULARY PRODUCTS FORMULARY PRODUCTS FORMULARY PRODUCTS FORMULARY (Plavix) (Plavix) (Persantine) (Persantine) (Amicar) (Coumadin) (Pletal) (Pletal) detailed description, see Drug List Medication Coverage. Coverage. Medication List Drug see description, detailed (Lovenox) (Lovenox) (Phytonadione Tablet) Tablet) (Phytonadione (Aspirin/Dipyridamole (Aspirin/Dipyridamole Capsule, Release) Multiphasic (Eltrombopag (Eltrombopag Olamine) (Dalteparin Sodium, Porcine) (Dalteparin Sodium, Porcine) (Dabigatran) (Dabigatran) (Ticagrelor) (Ticagrelor) (Rivaroxaban) (Rivaroxaban) (Apixaban) (Apixaban) (Prasugrel HCl) (Prasugrel HEPARIN GENERICS K VITAMIN BRANDS HEMOSTATICS GENERICS AGENTS MISCELLANEOUS COAGULATION GENERICS ANTICOAGULANTS GENERICS DRUGS ANTIPLATELET GENERICS DRUG NAME BRANDS DRUG NAME DRUG NAME BRANDS DRUG NAME DRUG NAME BRANDS DRUG NAME BRANDS Pentoxifylline Tablet, Sustained Action Tablet, Pentoxifylline Enoxaparin Sodium Fondaparinux Heparin Sodium, Porcine Fragmin Mephyton Aminocaproic Acid Promacta Warfarin Sodium Warfarin Eliquis Pradaxa Xarelto Tablet Cilostazol Clopidogrel Bisulfate Tablet Dipyridamole Tablet HCl Ticlopidine Aggrenox Brilinta Effient [PREVENT] Prevent drugs may be covered at $0 if criteria are met. For a For met. are criteria if $0 at covered be may drugs Prevent [PREVENT] IPIDS [PA] [PA] [QL] [QL] [QL] [QL]

4.4Therapy Coagulation 4.4.3 4.4.4 4.4.5 4.4.6 4.4.1 4.4.2 18 & L (Imdur) (Imdur) (Norpace CR) (Norpace YPERTENSION (Quinaglute) (Quinaglute) (Nitroglycerin) (Nitroglycerin) (Quinidex) (Quinidex) (Mexitil) (Mexitil) , H (Nitroglycerin) (Nitroglycerin) (Nitro-Time) (Nitrostat) (Nitrostat) (Nitro-Bid) (Nitro-Bid) (Quinidine (Quinidine Sulfate) (Norpace) (Norpace) (Rythmol) (Rythmol) (Cordarone) (Cordarone) PRODUCTS FORMULARY PRODUCTS FORMULARY PRODUCTS FORMULARY PRODUCTS FORMULARY (Isordil) (Isordil) (Betapace) (Betapace) (Tambocor) (Tambocor) (Rythmol SR) (Rythmol (Lanoxin) (Lanoxin) (Lanoxin) (Lanoxin) (Isosorbide Dinitrate (Isosorbide Capsule, Dinitrate Sustained Action) (Nitromist Lingual (Nitromist Spray) (Nitroglycerin) (Nitroglycerin) (Betapace (Betapace AF) (Nitroglycerin Patch, Transdermal 24 Hours) Transdermal Patch, (Nitroglycerin (Nitroglycerin) (Nitroglycerin) ARDIOVASCULAR (Dofetilide) (Dofetilide) (Dronedarone (Dronedarone HCl) individual plan design. design. plan individual individual plan design. plan individual PRESCRIBED PRODUCTS NONFORMULARY COMMONLY PRESCRIBED PRODUCTS NONFORMULARY COMMONLY [PA] upon based apply, may authorization prior circumstances, limited In LONG ACTING ACTING NITRATES LONG GENERICS RAPID ACTING ACTING NITRATES RAPID GENERICS DRUG NAME BRANDS DRUG NAME BRANDS DRUG NAME DRUG NAME DRUG NAME GENERICS BRANDS DRUG NAME GENERICS Minitran Patch, Transdermal 24 Hours Transdermal Minitran Patch, Dilatrate-SR Nitro-Dur Nitroglycerin Capsule, Nitroglycerin Sustained Action Ointment(gm) Nitroglycerin 24 Hours Transdermal Patch, Nitroglycerin Isosorbide Isosorbide Dinitrate Sustained Release 24hr Tablet, Isosorbide Mononitrate Capsule, Nitroglycerin Sustained Action Nitrolingual Nitrostat Nitroglycerin Tablet 0.4mg Nitroglycerin Sublingual Lanoxin Lanoxin 62.5mcg & 187.5mcg Digoxin Tablet Digoxin Digoxin Digoxin Solution Sotalol Tablet HCl Multaq Tikosyn Quinidine Sulfate Tablet Quinidine Sulfate Sustained Action Tablet, Quinidine Sulfate Sotalol HCl Mexiletine Mexiletine HCl Capsule Soft, (Hard, Etc.) HCl Propafenone Tablet HCl Propafenone Sustained Action Tablet, Quinidine Gluconate Amiodarone Tablet Amiodarone HCl Phosphate Disopyramide Phosphate Disopyramide Capsule, Sustained Action Flecainide Acetate [QL] upon based apply, may limits quantity circumstances, limited In [QL] 4. C

4.3 Nitrates

4.2 Cardiac Glycosides

4.1Agents Antiarrhythmic 4.3.2 4.3.1 Cardiovascular, Hypertension & Lipids 4 (Verelan) (Verelan) PM) (Verelan (Procardia XL) (Procardia (Cardizem (Cardizem CD) (Cardizem (Cardizem LA) (Tiazac) (Tiazac) (Calan SR) (Isoptin S.R.) (Procardia) (Procardia) (Adalat (Adalat CC) ) (Monopril) (Monopril) (Caduet) (Accupril) (Accupril) (Aceon) (Aceon) PRODUCTS FORMULARY PRODUCTS FORMULARY PRODUCTS FORMULARY (Norvasc) (Norvasc) (Sular) (Sular) (Vasotec) (Lotensin) (Calan) (Cardizem) (Cardizem) (Univasc) (Univasc) (Plendil) (Plendil) (Mavik) (Mavik) (Nimotop) (Nimotop) (Verapamil HCl Tablet, Sustained Release Osmotic Push) Tablet, HCl (Verapamil ONTINUED detailed description, see Drug List Medication Coverage. Coverage. Medication List Drug see description, detailed (DynaCirc) (DynaCirc) (Prinivil) (Prinivil) (Zestril) (Capoten) (Altace) PRESCRIBED PRODUCTS NONFORMULARY COMMONLY PRESCRIBED PRODUCTS NONFORMULARY COMMONLY CALCIUM CHANNEL BLOCKERS/DIHYDROPYRIDINES GENERICS ACE INHIBITORS GENERICS CALCIUM CHANNEL BLOCKERS CALCIUM CHANNEL BLOCKERS/NON-DIHYDROPYRIDINES GENERICS DRUG NAME BRANDS DRUG NAME DRUG NAME DRUG NAME DRUG NAME Epaned Amlodipine Amlodipine Besylate ER Felodipine Isradipine Nifedipine Capsule Soft, (Hard, Etc.) Sustained Action Tablet, Nifedipine Sustained Release Osmotic Push Tablet, Nifedipine Tablet Nisoldipine Benazepril HCl Captopril Enalapril Maleate Tablet Sodium Fosinopril Lisinopril Lisinopril Moexipril HCl Erbumine Perindopril Tablet Quinapril HCl Ramipril Trandolapril Amlodipine/Atorvastatin Diltiazem Extended Release (excluding 120mg) Diltiazem HCl Diltiazem HCl Capsule, Sustained Action Diltiazem HCl Capsule, Sustained Release 24 hr Nimodipine HCl Verapamil HCl Capsule, 24hr Sustained Release Pellets Verapamil HCl Capsule, 24hr Sustained Release Pellets Verapamil Sustained Action Tablet, HCl Verapamil Sustained Action Tablet, HCl Verapamil Covera-HS Nymalize Tekamlo [PREVENT] Prevent drugs may be covered at $0 if criteria are met. For a For met. are criteria if $0 at covered be may drugs Prevent [PREVENT] IPIDS (C [PA] [PA] [QL] [QL] [QL]

4.5.3.2 4.5.4 4.5.3 4.5.3.1 19 & L (Toprol XL) (Toprol (Inderal (Inderal LA) YPERTENSION , H (Moduretic) (Moduretic) (Aldactazide) (Maxzide) (Maxzide) (Dyazide) (Midamor) (Midamor) (Aldactone) PRODUCTS FORMULARY PRODUCTS FORMULARY (HydroDIURIL) (HydroDIURIL) (Zebeta) (Zebeta) (Lopressor) (Lopressor) (Inderal) (Inderal) (Blocadren) (Blocadren) (Sectral) (Sectral) (Hygroton) (Hygroton) (Diuril) (Diuril) (Normodyne) (Normodyne) (Trandate) (Kerlone) (Kerlone) (Bumex) (Bumex) (Lozol) (Lozol) (Zaroxolyn) (Zaroxolyn) (Lasix) (Triamterene Capsule Soft, (Hard, Etc.)) (Triamterene (Inspra) (Inspra) (Carvedilol) (Coreg) (Coreg) (Demadex) (Demadex) ARDIOVASCULAR (Visken) (Visken) (Tenormin) (Tenormin) (Ethacrynic Acid) (Corgard) (Corgard) individual plan design. design. plan individual design. plan individual PRESCRIBED PRODUCTS NONFORMULARY COMMONLY BETA-BLOCKERS GENERICS THIAZIDE & RELATED THIAZIDE DIURETICS & RELATED GENERICS DRUG NAME BRANDS DRUG NAME BRANDS DRUG NAME Hemangeol Innopran XL Sotylize Bystolic Timolol Maleate Timolol Coreg CR Nadolol Pindolol HCl Propranolol HCl Capsule, Propranolol Sustained Action 24 hr Labetalol HCl Labetalol HCl Sustained Release 24hr Tablet, Metoprolol Succinate Tartrate Metoprolol Atenolol Betaxolol HCl Bisoprolol Fumarate Carvedilol Acebutolol Acebutolol HCl Triamterene/Hydrochlorothiazide Dyrenium Edecrin Spironolactone/Hydrochlorothiazide Tablet Spironolactone Torsemide Triamterene/Hydrochlorothiazide Furosemide Hydrochlorothiazide Indapamide Metolazone Chlorothiazide Chlorthalidone Eplerenone Amiloride Amiloride HCl/Hydrochlorothiazide Tablet Amiloride HCl Bumetanide [PA] upon based apply, may authorization prior circumstances, limited In [QL] upon based apply, may limits quantity circumstances, limited In [PA] [QL] [PA] [PA] 4. C

4.5Therapy Antihypertensive 4.5.2 4.5.1 4 4. CARDIOVASCULAR, HYPERTENSION & LIPIDS (CONTINUED) Cardiovascular,Lipids & Hypertension

FORMULARY PRODUCTS FORMULARY PRODUCTS DRUG NAME DRUG NAME 4.5.5 ADRENERGIC ANTAGONISTS & RELATED DRUGS 4.5.8 OTHER ANTIHYPERTENSIVE COMBINATIONS GENERICS GENERICS Clonidine HCl (Catapres) Amlodipine Besylate/Benazepril HCl (Lotrel) Clonidine HCl Patch, Transdermal Weekly (Catapres-TTS) Amlodipine/Valsartan (Exforge) Doxazosin Mesylate (Cardura) Amlodipine/Valsartan HCTZ (Exforge HCT) [QL] Guanfacine Extended Release (Intuniv) Atenolol/Chlorthalidone (Tenoretic) Guanfacine HCl (Tenex) Benazepril HCl/Hydrochlorothiazide (Lotensin HCT) Methyldopa (Aldomet) Bisoprolol Fumarate/Hydrochlorothiazide (Ziac) Prazosin HCl (Minipress) Captopril/Hydrochlorothiazide (Capozide) Reserpine (Reserpine) Enalapril Maleate/Hydrochlorothiazide (Vaseretic) Terazosin HCl (Hytrin) Fosinopril Sodium/Hydrochlorothiazide (Monopril HCT) Lisinopril/Hydrochlorothiazide (Prinzide, Zestoretic) Methyldopa/Hydrochlorothiazide (Aldoril) FORMULARY PRODUCTS

DRUG NAME Propranolol HCl/Hydrochlorothiazide (Inderide) 4.5.6 AGENTS FOR PHEOCHROMOCYTOMA Metoprolol Tartrate/Hydrochlorothiazide (Lopressor HCT) Moexipril HCl/Hydrochlorothiazide (Uniretic) BRANDS Quinapril HCl/Hydrochlorothiazide Tablet (Accuretic) [PA] [QL] Dibenzyline (Phenoxybenzamine HCl) Telmisartan/Amlodipine (Twynsta) Trandolapril/Verapamil (Tarka) FORMULARY PRODUCTS BRANDS DRUG NAME Azor (Amlodipine Besylate/ Olmesartan Medoxomil) 4.5.7 VASODILATORS Clorpres (Clonidine HCl/Chlorthalidone Tablet) GENERICS [QL] Tribenzor (Olmesartan/Amlodipine/HCTZ) Hydralazine HCl (Apresoline) Minoxidil (Loniten) COMMONLY PRESCRIBED NONFORMULARY PRODUCTS BRANDS DRUG NAME BiDil (Hydralazine HCl/Isosorbide Dinitrate) [QL] Amturnide [QL] Edarbyclor Tarka

FORMULARY PRODUCTS DRUG NAME 4.5.9 ANGIOTENSIN II RECEPTOR BLOCKERS GENERICS Candesartan Cilexetil (Atacand) Candesartan Cilexetil/Hydrochlorothiazide (Atacand HCT) Eprosartan (Teveten 600mg) Irbesartan (Avapro) Irbesartan/Hydrochlorothiazide (Avalide) Losartan Potassium (Cozaar) Losartan Potassium/Hydrochlorothiazide (Hyzaar) Telmisartan (Micardis) Telmisartan/Hydrochlorothiazide (Micardis HCT) Valsartan (Diovan) Valsartan/Hydrochlorothiazide (Diovan HCT) BRANDS Benicar (Olmesartan Medoxomil) Benicar HCT (Olmesartan Medoxomil/Hydrochlorothiazide)

COMMONLY PRESCRIBED NONFORMULARY PRODUCTS DRUG NAME [QL] Edarbi [PA] Tekturna Teveten HCT

4.6 Agents Lipid/Cholesterol Lowering Dermatologicals/Topical Therapy 5 (Synalar (Synalar 0.01%) (Aclovate) (Aclovate) (Fluocinolone (Fluocinolone Acetonide 0.01%) (Synalar (Synalar 0.03%) (Synalar (Synalar 0.03%) (Xylocaine) (Xylocaine) (Locoid Lipocream 0.1%) (Topicort Lp 0.05%) (Topicort (Lida Mantle) (Hydrocortisone) (Hydrocortisone) (Xylocaine) (Xylocaine) (DesOwen) (DesOwen) (Lidoderm) (Fluocinolone (Fluocinolone Acetonide) (Kenalog) (Kenalog) (DesOwen) (DesOwen) (Locoid) (Westcort) (Westcort) (Betatrex) (Betatrex) (Xylocaine) (Xylocaine) (Cutivate) (Cutivate) (Flurandrenolide Tape, Medicated) Tape, (Flurandrenolide (DesOwen) (DesOwen) PRODUCTS FORMULARY PRODUCTS FORMULARY PRODUCTS FORMULARY (Elocon) (Elocon) (Emla) (Emla) (Hytone) (Hytone) (Clocortolone Pivalate Cream (Grams)) (Clocortolone Pivalate (Grams)) Cream (Luxiq Foam) (Luxiq Foam) detailed description, see Drug List Medication Coverage. Coverage. Medication List Drug see description, detailed TOPICAL TOPICAL CORTICOSTEROIDS MEDIUM POTENCY GENERICS TOPICAL CORTICOSTEROIDS LOW POTENCY GENERICS BRANDS DRUG NAME GENERICS DRUG NAME BRANDS DRUG NAME Alclometasone Alclometasone Dipropionate Ointment(gm) Desonide (Grams) Cream Desonide Lotion (ml) Desonide Ointment(gm) Fluocinolone (Grams) Acetonide Cream Fluocinolone Acetonide Solution, Non-Oral Lotion Hydrocortisone Rx (ml) Rx Hydrocortisone Capex Shampoo 0.01% Lidocaine Adhesive Patch Lidocaine HCl (Grams) Cream Lidocaine HCl (ml) Jel Lidocaine HCl Ointment(gm) Lidocaine HCl Solution, Non-Oral Lidocaine/Prilocaine Betamethasone Valerate Betamethasone Desoximetasone (Grams) Cream Fluocinolone (Grams) Acetonide Cream Fluocinolone Acetonide Ointment(gm) Fluticasone Propionate Butyrate Hydrocortisone Butyrate/Emollient Hydrocortisone Valerate Hydrocortisone Mometasone Furoate Acetonide Triamcinolone Clocortolone Pivalate Cream Cloderm 0.10% Cordran 4mcg/sq cm [PREVENT] Prevent drugs may be covered at $0 if criteria are met. For a For met. are criteria if $0 at covered be may drugs Prevent [PREVENT] [QL] 5.2Anesthetics Topical

5.1.3 5.1.4 22 HERAPY T (Taclonex) (Taclonex) OPICAL (Psorcon E) (Psorcon /T (Kenalog (Kenalog 0.50%) (Lidex-E 0.05%) (Diprolene (Diprolene 0.05%) (Betatrex (Betatrex 0.10%) (Psorcon) (Psorcon) (Psorcon) (Psorcon) (Clobex) (Topicort 0.25%) (Topicort (OLUX-E Foam) (OLUX-E Foam) (Temovate) (Clobex) (Topicort 0.25%) (Topicort (Diprosone) (Diprosone) (Diprolene) (Diprolene) (Topicort 0.05%) (Topicort (Ultravate) (Ultravate) (OLUX Foam) (OLUX Foam) (Temovate) PRODUCTS FORMULARY PRODUCTS FORMULARY (Clobetasol Propionate) (Clobetasol Propionate) (Dovonex) (Dovonex) (Lidex) (Vanos) (Cyclocort) (Cyclocort) (Vectical, Topical) Topical) (Vectical, ERMATOLOGICALS individual plan design. design. plan individual individual plan design. plan individual (Diprolene (Diprolene AF 0.05%) [PA] upon based apply, may authorization prior circumstances, limited In TOPICAL TOPICAL CORTICOSTEROIDS HIGH POTENCY GENERICS TOPICAL CORTICOSTEROIDS VERY VERY TOPICAL HIGH CORTICOSTEROIDS POTENCY GENERICS DRUG NAME BRANDS DRUG NAME Fluocinonide/Emollient Cream (Grams) Cream Fluocinonide/Emollient (Grams) Acetonide Cream Triamcinolone Diflorasone Diacetate Diflorasone (Grams) Cream (Grams) Diacetate/Emollient Diflorasone Cream Fluocinonide Fluocinonide Betamethasone Valerate Ointment(gm) Valerate Betamethasone Desoximetasone (Grams) Cream Desoximetasone Gel (gm) Desoximetasone Ointment(gm) Betamethasone Betamethasone Dipropionate Ointment (Grams) Glycol Cream Betamethasone Dipropionate/Propylene Amcinonide Betamethasone Dipropionate Diflorasone Diacetate Diflorasone Ointment(gm) Halobetasol Propionate Clobex Spray Clobetasol Propionate/Emollient Clobetasol Propionate/Emollient Clobetasol Lotion Propionate (ml) Clobetasol Shampoo Propionate Calcitriol Clobetasol Propionate Clobetasol Propionate Betamethasone Betamethasone Dipropionate Calcipotriene Calcipotriene/Bethamethasone Dipropionate Ointment [QL] upon based apply, may limits quantity circumstances, limited In 5. D

5.1 Corticosteroids Topical 5.1.2 5.1.1 Dermatologicals/Topical Therapy 5 (Nizoral) (Nizoral) (Mycolog II) (Mycolog (Mycostatin) (Mycostatin) PRODUCTS FORMULARY PRODUCTS FORMULARY PRODUCTS FORMULARY PRODUCTS FORMULARY (Zovirax) (Zovirax) (Silvadene) (Silvadene) (Spectazole) (Spectazole) (Sulfamylon) (Sulfamylon) ) detailed description, see Drug List Medication Coverage. Coverage. Medication List Drug see description, detailed (Loprox, Penlac) (Loprox, Penlac) (Acyclovir Cream) Cream) (Acyclovir (Butenafine (Butenafine HCl) (Collagenase) (Lotrisone) PRESCRIBED PRODUCTS NONFORMULARY COMMONLY PRESCRIBED PRODUCTS NONFORMULARY COMMONLY GENERICS BRANDS DRUG NAME GENERICS BRANDS GENERICS BRANDS DRUG NAME DRUG NAME DRUG NAME DRUG NAME DRUG NAME Acyclovir Ointment Acyclovir Zovirax Denavir Mafenide Acetate Silver Sulfadiazine Santyl Ciclopirox or Clotrimazole/Betamethasone Dipropionate (Grams) Lotion Cream (ml) Econazole Nitrate Ketoconazole Shampoo Ketoconazole (Grams), Cream (Grams) Nystatin Cream Acetonide Nystatin/Triamcinolone Mentax Ecoza Exelderm Jublia Kerydin Luzu Naftin Oxistat Xolegel ONTINUED [PREVENT] Prevent drugs may be covered at $0 if criteria are met. For a For met. are criteria if $0 at covered be may drugs Prevent [PREVENT] [PA] [QL] [PA] [QL] [PA] [QL] [PA] [QL] [PA] [QL] [PA] [QL] [PA] [QL] [PA] 5.6Antivirals Topical 5.7Therapy Burn 5.8 Enzymes Topical 5.5Antifungals Topical 23 HERAPY (C T (A/T/S) (Erycette) OPICAL (Benzamycin) (Benzamycin) /T (A/T/S) (Benzaclin) (Benzaclin) (Duac) (Del-Mycin) (Del-Mycin) (Sulfacet-R) (Sulfacet-R) (Bactroban) (Bactroban) (Cleocin T) (Cleocin (Metrogel) (Metrogel) (Retin-A (Retin-A Micro) PRODUCTS FORMULARY PRODUCTS FORMULARY (Benzoyl Peroxide) (Benzoyl Peroxide) (Differin) (Differin) (Garamycin) (Garamycin) (Evoclin) (Evoclin) (Mupirocin Calcium) (Mupirocin (Metrocream) (Metrocream) (Metrolotion) (Tretinoin) (Tretinoin) (Differin (Differin 0.1% cream, gel) (Clindamycin Phosphate/Benzoyl Peroxide Pump) (Clindamycin Peroxide Phosphate/Benzoyl ERMATOLOGICALS (Retin-A) (Retin-A) (Isotrentoin) (Isotrentoin) (Tazarotene) (Tazarotene) (Azelaic Acid Gel) (Benzoyl Peroxide/Adapalene) (Benzoyl Peroxide/Adapalene) (Dapsone) (Dapsone) (Benzoyl Peroxide/Clindamycin) (Benzoyl Peroxide/Clindamycin) (Clindamycin/Tretinoin) (Clindamycin/Tretinoin) individual plan design. design. plan individual design. plan individual PRESCRIBED PRODUCTS NONFORMULARY COMMONLY PRESCRIBED PRODUCTS NONFORMULARY COMMONLY DRUG NAME BRANDS DRUG NAME GENERICS DRUG NAME BRANDS DRUG NAME GENERICS Centany Bactroban Bactroban Nasal Gentamicin Gentamicin Sulfate Calcium Mupirocin (gm) Fabior Retin-A Micro 0.08% Azelex Differin Lotion 0.1% Tazorac Veltin Benzaclin Epiduo Finacea Absorica Acanya Aczone Atralin Gel Sulfacetamide Sulfacetamide Sodium/Sulfur Tretinoin Microsphere Tretinoin Erythromycin Base/Ethyl Alcohol Swab, Medicated Erythromycin Base/Ethyl Alcohol Swab, Metronidazole Metronidazole Topical Metronidazole, Erythromycin Base/Benzoyl Peroxide Gel (gm) Erythromycin Peroxide Base/Benzoyl Erythromycin Base/Ethyl Alcohol Gel (gm) Erythromycin Base/Ethyl Alcohol Solution, Non-Oral Clindamycin Clindamycin Phosphate Clindamycin Peroxide Phosphate/Benzoyl Clindamycin Peroxide Phosphate/Benzoyl Erythromycin Base Solution, Non-Oral Adapalene Adapalene 0.3% gel Rx Benzoyl Peroxide Clindamycin 1% [PA] upon based apply, may authorization prior circumstances, limited In [QL] upon based apply, may limits quantity circumstances, limited In [PA] [QL] [PA] [PA] [PA] 5. D

5.4Antibacterials Topical

5.3 Acne Therapy For 5 5. DERMATOLOGICALS/TOPICAL THERAPY (CONTINUED)

5.10 Antipsoriatic/Antiseborrheic 5.12 Miscellaneous Dermatologicals FORMULARY PRODUCTS FORMULARY PRODUCTS

DRUG NAME DRUG NAME Dermatologicals/TopicalTherapy GENERICS GENERICS Acitretin (Soriatane) Aluminum Chloride (Drysol) Calcitriol (Vectical, Topical) [PA] Diclofenac Sodium Gel (Solaraze) Calcipotriene (Dovonex) Fluorouracil Cream (Efudex) Calcipotriene/Betamethasone (Taclonex Ointment) Fluorouracil Solution, Non-Oral (Efudex) Selenium Sulfide (Selsun Rx) Imiquimod (Aldara) Sulfacetamide Sodium (Ovace) Methoxsalen (Oxsoralen-Ultra) Sulfacetamide Sodium/Urea (Scalp Treatment) Sulfacetamide Sodium/Urea Lotion (gm) (Carmol 10%) BRANDS Tacrolimus Ointment (Protopic) Carmol HC (Hydrocortisone Acetate/Urea) Urea (Carmol 40) Dritho-Scalp (Anthralin) BRANDS Pramosone (Hydrocortisone Acetate/Pramoxine HCl) Alphaquin HP (Oxybenzone/Octinoxate/Hydroquinone) Tazorac (Tazarotene) Condylox (Podofilox Solution, Non-Oral) Elidel (Pimecrolimus Cream (Grams)) Oxsoralen (Methoxsalen) COMMONLY PRESCRIBED NONFORMULARY PRODUCTS Panretin (Alitretinoin) DRUG NAME Taclonex Topical Suspension

COMMONLY PRESCRIBED NONFORMULARY PRODUCTS DRUG NAME 5.11 Topical Scabicides/Pediculicides [PA] [QL] Picato FORMULARY PRODUCTS [QL] Zyclara DRUG NAME GENERICS Lindane (Lindane) Malathion (Ovide) Permethrin (Elimite) BRANDS Eurax Cream (Crotamiton) Eurax Lotion (Crotamiton) Ulesfia (Benzyl Alcohol)

COMMONLY PRESCRIBED NONFORMULARY PRODUCTS DRUG NAME [QL] Sklice

6.3 Otic Steroid/Antibiotic

6.2 Miscellaneous Otic Preparations

6.1 Intranasal Steroids Endocrine/Diabetes 7 (Delatestryl) (Depo-Testosterone) (Depo-Testosterone) (Follitropin Alpha,Recombinant) Alpha,Recombinant) (Follitropin (Testosterone Propionate) Propionate) (Testosterone PRODUCTS FORMULARY PRODUCTS FORMULARY (Clomid) (Methitest) (Methitest) detailed description, see Drug List Medication Coverage. Coverage. Medication List Drug see description, detailed (Testosterone Patch, Transdermal 24 Hours) Transdermal Patch, (Testosterone (Menotropins) (Menotropins) (Testosterone Gel in Pump (gm)) Metered-Dose (Testosterone (gm)) Gel in Packet (Testosterone (Danocrine) (Danocrine) (Testosterone) (Testosterone) (Urofollitropin (FSH)) (Urofollitropin (HCG Alpha,Recombinant) (HCG Alpha,Recombinant) (Testosterone) (Testosterone) PRESCRIBED PRODUCTS NONFORMULARY COMMONLY PRESCRIBED PRODUCTS NONFORMULARY COMMONLY OVULATORY STIMULANTS OVULATORY GENERICS ANDROGENS GENERICS DRUG NAME BRANDS DRUG NAME DRUG NAME BRANDS DRUG NAME Striant Vogelxo Clomiphene Citrate Bravelle Gonal-F RFF Gonal-F, Ovidrel Repronex AQ Follistim Danazol Methyltestosterone Vial (ml) Cypionate Testosterone Enanthate Disposable Syringe (ml) Testosterone Propionate Testosterone Androderm Androgel Androgel Fortesta Testim Anadrol-50 Axiron Nandrolone Natesto Oxandrolone [PREVENT] Prevent drugs may be covered at $0 if criteria are met. For a For met. are criteria if $0 at covered be may drugs Prevent [PREVENT] [PA] [QL] [PA] [QL] [PA] [PA] [PA] [PA] [QL] [PA] [QL] [PA] [QL] [PA] [QL] [PA] [QL] [PA] [PA] [QL] [PA] [PA] [QL] [PA] [PA]

7.4 Miscellaneous Hormones 7.4.2 7.4.1 26 (Pediapred) (Pediapred) IABETES (Decadron) (Decadron) /D (Florinef (Florinef Acetate) (Propylthiouracil) (Propylthiouracil) (Levoxyl) (Levoxyl) (Synthroid) PRODUCTS FORMULARY PRODUCTS FORMULARY PRODUCTS FORMULARY (Tapazole) (Tapazole) (Prednisolone) (Prednisolone) (Medrol) (Medrol) (Prelone) (Prelone) (Cortisone Acetate) (Cortef) (Cytomel) (Cytomel) (Orasone) (Orasone) (Prednisone) (Liotrix) (Liotrix) NDOCRINE individual plan design. design. plan individual individual plan design. plan individual PRESCRIBED PRODUCTS NONFORMULARY COMMONLY [PA] upon based apply, may authorization prior circumstances, limited In GENERICS DRUG NAME BRANDS GENERICS DRUG NAME DRUG NAME DRUG NAME GENERICS Prednisolone Syrup Prednisolone Tablet Prednisolone Prednisone Prednisone Fludrocortisone Fludrocortisone Acetate Hydrocortisone Methylprednisolone Sodium Prednisolone Phosphate Solution, Oral Cortisone Acetate Dose Pack Tablet, Dexamethasone Liothyronine Thyrolar Levothyroxine Levothyroxine Sodium Levothyroxine Sodium SSKI Methimazole Tablet Methimazole Tablet Propylthiouracil [QL] upon based apply, may limits quantity circumstances, limited In 7. E

7.3 Adrenal Hormones

7.2 Thyroid Hormones

7.1Agents Antithyroid Endocrine/Diabetes 7 (Insulin (Insulin NPH Regular Human Recombinant/Insulin (Insulin Lispro (NPL)/Insulin Lispro,Human Rec.Anlog) Rec.Anlog) (Insulin Lispro (NPL)/Insulin Lispro,Human PRODUCTS FORMULARY (Insulin (Insulin Aspart Aspart Human/Insulin Protamine (Insulin Aspart Aspart Human/Insulin Protamine (Insulin AspartVial Aspart Human/Insulin Protamine (Insulin (Insulin Regular Human Rec Disposable Syringe (ml)) (Insulin (Insulin Detemir) (Insulin Glargine,Human Recombinant Analog) (Insulin Glargine,Human (Insulin (Insulin NPH Regular Human Recombinant/Insulin Human (Insulin NPH Regular Human Recombinant/Insulin Human (Insulin NPH Regular Human Recombinant/Insulin Human (Insulin (Insulin NPH Human Recombinant) (Insulin (Insulin Regular Human Rec) (Insulin (Insulin NPH Human Recombinant Cartridge (ml)) (Insulin NPH Human Recombinant Disposable Syringe (ml)) (Insulin NPH Human Semi-Synthetic) (Insulin (Insulin Regular Human Rec) (Insulin Regular Human Rec Cartridge (ml)) (Insulin Regular Human Rec Disposable Syringe (ml)) or Additive) (ml)) Vial (SDV,MDV (Insulin Regular Human Rec detailed description, see Drug List Medication Coverage. Coverage. Medication List Drug see description, detailed (Insulin Lispro,Human Rec.Anlog) Rec.Anlog) (Insulin Lispro,Human (Insulin (Insulin Aspart) (Insulin Aspart Cartridge (ml)) (Insulin Aspart Disposable Syringe (ml)) or Additive) (ml)) Vial (Insulin Aspart(SDV,MDV (Insulin Glargine,Human Recombinant Analog) (Insulin Glargine,Human (Insulin (Insulin Glulisine) (Insulin NPH Human Recombinant Vial (SDV,MDV or Additive) (ml)) Vial (SDV,MDV (Insulin NPH Human Recombinant (Insulin NPH Human Recombinant Disposable Syringe (ml)) Cartridge (ml)) Disposable Syringe (ml)) or Additive) (ml)) (SDV,MDV (Insulin NPH Human Semi-Synthetic/Insulin Regular (Insulin NPH Human Rec) Human Semi-Synthetic/Insulin (Insulin NPH Regular Human Recombinant/Insulin Human Rec) Human Rec Disposable Syringe (ml)) Rec Rec Cartridge (ml)) Rec Disposable Syringe (ml)) or Additive) (ml)) Vial (SDV,MDV Rec PRESCRIBED PRODUCTS NONFORMULARY COMMONLY INSULIN THERAPY INSULIN BRANDS DRUG NAME DRUG NAME Novolin N Novolin N Novolin N Novolin N Novolin N InnoLet Novolin R Novolin R Novolin R Novolin R Novolin R InnoLet Novolin NovoLog NovoLog NovoLog NovoLog Mix 70/30 Novolog Mix 70/30 Novolog Mix 70/30 Novolog Afrezza Apidra Humalog Mix Humalog 75/25 50/50 Humulin 70/30 Humulin N Humulin R Humulin Lantus Lantus Solostar Levemir Nordisk 70/30 Novolin 70/30 Novolin 70/30 Novolin 70/30 InnoLet Novolin [PREVENT] Prevent drugs may be covered at $0 if criteria are met. For a For met. are criteria if $0 at covered be may drugs Prevent [PREVENT] [PA] [QL] [PA]

7.5Therapy Diabetes 7.5.1 27 ) ONTINUED (Sandostatin) (Sandostatin) (DDAVP) (DDAVP) (Rocaltrol) (Rocaltrol) IABETES (C (Miacalcin) (Miacalcin) /D (DDAVP) (DDAVP) (Rocaltrol) (Rocaltrol) (Hectorol) (Hectorol) (Buphenyl Oral Powder) (Buphenyl Oral Powder) (Rocaltrol) (Rocaltrol) PRODUCTS FORMULARY PRODUCTS FORMULARY (Lanreotide) (Lanreotide) (Sodium Phenylbutyrate) (Sodium Phenylbutyrate) (Octreotide Acetate (Octreotide Kit) (Calcitonin (Calcitonin Salmon Recombinant) (Dostinex) (Dostinex) (Zemplar) (Zemplar) (Proscar) (Proscar) (Imiglucerase) (Imiglucerase) (Cetrorelix Acetate) (Cetrorelix (Pegvisomant) (Pegvisomant) (Ganirelix Acetate) (Ganirelix (Alglucerase) (Alglucerase) (Cinacalcet (Cinacalcet HCl) NDOCRINE (Pasireotide Diaspartate) (Pasireotide (Chorionic Gonadotropin, Human) (Chorionic Gonadotropin) (Nafarelin Acetate) (Nafarelin (Tolvaptan) (Tolvaptan) (Sapropterin (Sapropterin Dihydrochloride) individual plan design. design. plan individual design. plan individual PRESCRIBED PRODUCTS NONFORMULARY COMMONLY GONADOTROPIN & RELATED AGENTS GONADOTROPIN & RELATED BRANDS MISCELLANEOUS AGENTS MISCELLANEOUS GENERICS DRUG NAME DRUG NAME BRANDS DRUG NAME Cetrotide Ganirelix Novarel Pregnyl Korlym Ravicti Signifor Somatuline Depot Somavert Synarel Samsca Sandostatin LAR Sensipar Ceredase Cerezyme Nasal Fortical Kuvan Paricalcitol Sodium Phenylbutyrate Tablets Buphenyl Desmopressin Acetate Tablet Acetate Desmopressin Capsule Doxercalciferol Finasteride or Additive) (ml) Vial (SDV,MDV Acetate Octreotide Calcitriol Calcitriol Solution, Oral Calcitonin, Salmon, Synthetic Acetate Desmopressin Solution, Non-Oral Cabergoline Calcitriol Capsule Soft, (Hard, Etc.) Calcitriol Liquid (ml) [PA] upon based apply, may authorization prior circumstances, limited In [QL] upon based apply, may limits quantity circumstances, limited In [PA] [PA] [PA] [PA] [QL] [PA] [QL] [PA] [PA] [QL] [PA] [PA] [PA] [PA] [PA] [QL] [PA] [PA] [PA] 7. E

7.4.4 7.4.3 7 7. ENDOCRINE/DIABETES (CONTINUED)

FORMULARY PRODUCTS FORMULARY PRODUCTS DRUG NAME DRUG NAME 7.5.2 NON-INSULIN HYPOGLYCEMIC AGENTS 7.5.3 GLUCOSE ELEVATING AGENTS GENERICS BRANDS Acarbose (Precose) Glucagon (Glucagon,Human Recombinant) Chlorpropamide (Diabinese) Glimepiride (Amaryl) FORMULARY PRODUCTS Endocrine/Diabetes

Glipizide (Glucotrol) DRUG NAME Glipizide/Metformin HCl (Metaglip) 7.5.4 INSULIN SYRINGES/MISCELLANEOUS DURABLE MEDICAL Glipizide Tablet, Sustained Release Osmotic Push (Glucotrol XL) Glyburide (DiaBeta) EQUIPMENT Glyburide/Metformin HCl (Glucovance) BRANDS Glyburide,Micronized (Glynase) Accu-Chek Active (Blood-Glucose Measuring Equipment Kit) Metformin HCl (Glucophage) Accu-Chek Aviva (Blood-Glucose Measuring Equipment Kit) Metformin HCl Tablet, Extended Release (Fortamet) Accu-Chek Aviva Plus (Blood-Glucose Measuring Equipment Kit) Metformin HCl Tablet, Sustained Release 24hr (Glucophage XR) Accu-Chek Comfort Curve (Blood-Glucose Measuring Equipment Kit) Nateglinide (Starlix) B-D Insulin Syringe (Syringe w-Needle, Disposable, Insulin) Pioglitazone/Glimepiride (Duetact) Novofine (Needles, Insulin Disposable) Pioglitazone HCl (Actos) One Touch Ultra System (Blood-Glucose Measuring Equipment Kit) Pioglitazone HCl/Metformin (Actoplus Met) One Touch Verio (Blood-Glucose Measuring Equipment Kit) Repaglinide (Prandin) Pen Needle (Needles, Insulin Disposable) Tolazamide (Tolinase) Tolbutamide (Orinase) COMMONLY PRESCRIBED NONFORMULARY PRODUCTS BRANDS DRUG NAME Actoplus Met XR (Pioglitazone HCl/Metformin Extended Release) Accu-Chek Compact Plus [PA] [QL] Bydureon (Exenatide) Accu-Chek Softclix [PA] [QL] Byetta (Exenatide) Lancets Janumet (Sitagliptin/Metformin HCl) One Touch Ultra 2 [QL] Janumet XR (Sitagliptin Phosphate/Metformin HCl) One Touch Ultramini [QL] Januvia (Sitagliptin Phosphate) One Touch Ultra Smart Kombiglyze XR (Saxagliptin/Metformin) Surestep Prandimet (Repaglinide/Metformin HCl) Surestep Pro [QL] Onglyza (Saxagliptin) Symlin (Pramlintide Acetate) Symlin Pen (Pramlintide Acetate) [PA] [QL] Victoza (Liraglutide)

COMMONLY PRESCRIBED NONFORMULARY PRODUCTS DRUG NAME Avandamet Avandaryl Avandia [PA] [QL] Cycloset [PA] [QL] Farxiga [PA] [QL] Invokamet [PA] [QL] Invokana [PA] [QL] Jardiance [PA] [QL] Jentadueto [PA] [QL] Kazano [PA] [QL] Nesina [PA] [QL] Oseni Riomet [PA] [QL] Tanzeum [PA] [QL] Tradjenta [PA] [QL] Trulicity [PA] Xigduo

8.3 Miscellaneous Gastrointestinal 8.2 Antidiarrheals Antispasmodics & 8.2.3 8.3.1 8.2.1 8.2.2 29 (Prevpac) (Prevpac) (Carafate) (Prevacid Solutab) (Prevacid (Tagamet) (Tagamet) (Tagamet) (Tagamet) PRODUCTS FORMULARY PRODUCTS FORMULARY PRODUCTS FORMULARY PRODUCTS FORMULARY (Protonix) (Protonix) (Zantac) (Zantac) (Zegerid (Zegerid Rx) (Prilosec OTC) OTC) (Prilosec (Carafate) (Prilosec) (Prilosec) (Pepcid) (Pepcid) (Omeprazole) (Omeprazole) (Prevacid) (Prevacid) (Aciphex) (Aciphex) (Cytotec) (Cytotec) (Axid) ASTROENTEROLOGY (Bismuth/Metronidazole/Tetracycline)) (Bismuth/Metronidazole/Tetracycline)) individual plan design. design. plan individual design. plan individual PRESCRIBED PRODUCTS NONFORMULARY COMMONLY PROTON PUMP PROTON INHIBITORS GENERICS OTHER THERAPY OTHER ULCER GENERICS PROSTAGLANDINS GENERICS H2 ANTAGONISTS H2 GENERICS DRUG NAME BRANDS DRUG NAME BRANDS DRUG NAME DRUG NAME DRUG NAME Nexium Zegerid Aciphex Aciphex Sprinkle Dexilant Esomeprazole Strontium Prilosec OTC Prilosec Pantoprazole Sodium Pantoprazole Rabeprazole Lansoprazole Tablet, Rapid Dissolve Tablet, Lansoprazole Omeprazole/Bicarb OTC Omeprazole Rx Omeprazole Lansoprazole Pylera Lansoprazole/Amoxicillin Trihydrate/Clarithromycin Lansoprazole/Amoxicillin (Final Suspension, Oral Dose Sucralfate Form) Tablet Sucralfate Misoprostol Nizatidine Ranitidine HCl Rx Cimetidine Cimetidine HCl Liquid (ml) Rx Tablet Cimetidine Rx Famotidine [PA] upon based apply, may authorization prior circumstances, limited In [QL] upon based apply, may limits quantity circumstances, limited In [PA] [PA] [PA] [QL] [PA] [PA] [QL] [PA] 8. G

8.1Therapy Ulcer 8.1.4 8.1.3 8.1.2 8.1.1 Gastroenterology 8 (Tigan) (Tigan) (Compazine) (Phenergan) (Phenergan) (Compazine) (Tigan) (Tigan) PRODUCTS FORMULARY PRODUCTS FORMULARY (Phenergan) (Phenergan) (Zofran) (Zofran) (Scopolamine Hydrobromide Patch, Transdermal 72 Hours) Transdermal (Scopolamine Patch, Hydrobromide (Kytril) (Kytril) (Antivert) detailed description, see Drug List Medication Coverage. Coverage. Medication List Drug see description, detailed (Colyte) Solution) (GoLYTELY (Zofran (Zofran ODT) (Sodium Sulfate/Sodium/Sodium Bicarbonate/Potassium (Marinol) (Marinol) (Bisacodyl/Sodium (Bisacodyl/Sodium Chloride/Sodium Bicarbonate/Potassium (Dolasetron Mesylate Tablet) Tablet) (Dolasetron Mesylate (Aprepitant) (Aprepitant) Glycols Glycols Glycols) Chloride/Polyethylene Glycol 3350) Chloride/Polyethylene PRESCRIBED PRODUCTS NONFORMULARY COMMONLY PRESCRIBED PRODUCTS NONFORMULARY COMMONLY BOWEL EVACUANTS GENERICS ANTIVERTIGO ANTIVERTIGO AGENTS ANTIEMETIC & GENERICS DRUG NAME BRANDS DRUG NAME DRUG NAME BRANDS DRUG NAME Diclegis Sancuso Zuplenz Sodium Chloride/Polyethylene Sulfate/Sodium/Sodium Bicarbonate/Potassium Sodium Chloride/Polyethylene Sulfate/Sodium/Sodium Bicarbonate/Potassium GoLYTELY Halflytely oral BC, powder, NuLytlely Prepopik Suclear Dronabinol HCl Granisetron Meclizine HCl Ondansetron Ondansetron HCl Rectal Maleate Suppository, Prochlorperazine Tablet Maleate Prochlorperazine HCl Promethazine Rectal HCl Promethazine Suppository, HCl Trimethobenzamide Rectal HCl/Benzocaine Suppository, Trimethobenzamide Anzemet Emend Transderm-Scop Akynzeo [PREVENT] Prevent drugs may be covered at $0 if criteria are met. For a For met. are criteria if $0 at covered be may drugs Prevent [PREVENT] [PA] [QL] [PA] [QL] [PA] [PA] [QL] [PA] [QL] [PA]

8.3.5 8.3.4 30 ) ONTINUED (Pramosone) (Pramosone) (Entocort EC) (Anusol-HC) (Azulfidine) (Anusol-HC) (Zenpep) (Zenpep) (Rowasa) (Rowasa) (Hydrocortisone Acetate/Pramoxine HCl) Acetate/Pramoxine (Hydrocortisone (Colazal) PRODUCTS FORMULARY PRODUCTS FORMULARY (Reglan) (Reglan) (Gastrocrom) (Gastrocrom) (Hydrocortisone/Pramoxine) (Hydrocortisone/Pramoxine) (Hydrocortisone Acetate/Pramoxine HCl) Acetate/Pramoxine (Hydrocortisone (Cortenema) (proctoCream-HC 2.50%) (Azulfidine) (Mesalamine (Mesalamine Delayed-Release) (Hydrocortisone Acetate (gm)) (Hydrocortisone Foam (Lactulose) (Pancrelipase) (Pancrelipase) ASTROENTEROLOGY (C (Cephulac) (Mesalamine) (Mesalamine) (Amylase/Lipase/Protease) (Amylase/Lipase/Protease) (Methylnatrexone Bromide) (Methylnatrexone (Pancrelipase) (Pancrelipase) (Mesalamine (Mesalamine Capsule, Sustained Action) (Mesalamine Suppository, Rectal) (Mesalamine Suppository, (Teduglutide Subcutaneous Injection) (Teduglutide (Mesalamine) (Mesalamine) individual plan design. design. plan individual individual plan design. plan individual (Amylase/Lipase/Protease) (Amylase/Lipase/Protease) (Mesalamine) (Mesalamine) PRESCRIBED PRODUCTS NONFORMULARY COMMONLY [PA] upon based apply, may authorization prior circumstances, limited In MISCELLANEOUS AGENTS GASTROINTESTINAL GENERICS DIGESTIVE DIGESTIVE ENZYMES GENERICS DRUG NAME BRANDS DRUG NAME BRANDS DRUG NAME Movantik Rectiv Uceris Uceris Rectal Foam Linzess Lotronex ODT Metozolv Amitiza Giazo Proctofoam-HC Relistor Gattex Kristalose Lialda Pentasa Asacol HD Canasa Cortifoam Delzicol Analpram-HC Analpram-HC 1%-1% Apriso Metoclopramide HCl Metoclopramide Sulfasalazine Enteric Coated Tablet, Sulfasalazine Hydrocortisone Acetate/Pramoxine HCl Rectal Cream, Acetate/Pramoxine Hydrocortisone (Grams) Cream Hydrocortisone Lactulose Mesalamine Enema (ml) Cromolyn Cromolyn Sodium Hydrocortisone Hydrocortisone Rectal Acetate Hydrocortisone Suppository, Balsalazide Balsalazide Disodium Budesonide Capsule, Sustained Release 24 hr Pancreaze Viokace Zenpep Pancrelipase 5K-17K-27K Pancrelipase Creon [QL] upon based apply, may limits quantity circumstances, limited In [PA] [QL] [PA] [QL] [QL] [PA] [PA] [PA] [QL] [PA] [QL] [PA] [PA] [QL] [PA] [QL] [PA] [PA] [QL] [PA] [PA] [QL] [PA] 8. G

8.3.3 8.3.2 Immunology, Vaccines & Biotechnology 9 (Somatropin) (Somatropin) PRODUCTS FORMULARY PRODUCTS FORMULARY (Somatropin) (Somatropin) (Somatropin) (Somatropin) detailed description, see Drug List Medication Coverage. Coverage. Medication List Drug see description, detailed (Oprelvekin) (Oprelvekin) (Somatropin) (Somatropin) (Rilonacept) PRESCRIBED PRODUCTS NONFORMULARY COMMONLY PRESCRIBED PRODUCTS NONFORMULARY COMMONLY GROWTH HORMONES BRANDS INTERLEUKINS BRANDS DRUG NAME DRUG NAME DRUG NAME DRUG NAME Arcalyst Neumega Gammagard Gammaked Gamunex-C Hizentra HyQvia Genotropin Nutropin AQ Nutropin AQ Nutropin Nuspin Humatrope Norditropin Omnitrope Saizen Serostim Tev-Tropin Zorbtive [PREVENT] Prevent drugs may be covered at $0 if criteria are met. For a For met. are criteria if $0 at covered be may drugs Prevent [PREVENT] [PA] [PA] [PA] [PA] [PA] [PA] [PA] [PA] [PA] [PA] [PA] [PA] [PA] [PA] [PA] [PA] [PA] [PA] [PA] 9.2 Immune Globulin

9.1.4 9.1.5 31 IOTECHNOLOGY & B ACCINES , V PRODUCTS FORMULARY PRODUCTS FORMULARY PRODUCTS FORMULARY (Peginterferon Alfa-2b) (Peginterferon (Peginterferon Alfa-2A) (Peginterferon (Interferon (Interferon Beta-1A) (Interferon Gamma-1b,Recombinant) (Interferon Gamma-1b,Recombinant) (Interferon (Interferon Beta-1A/Albumin Human) (Peginterferon Alfa-2b) (Peginterferon (Filgrastim) (Filgrastim) (Glatiramer Acetate) (Glatiramer (Interferon Alfa-2b,Recombinant) (Interferon Alfa-2b,Recombinant) (Pegfilgrastim (Pegfilgrastim Disposable Syringe (ml)) (Interferon (Interferon Alfacon-1) (Sargramostim) (Sargramostim) (Darbepoetin (Darbepoetin Alfa in Albumin Sol) (Interferon (Interferon Beta-1A/Albumin Human) (Peginterferon Alfa-2A) (Peginterferon (Filgrastin) (Filgrastin) (Epoetin (Epoetin Alfa) MMUNOLOGY (Interferon (Interferon Beta-1A/Albumin Human Disposable Syringe (ml)) individual plan design. design. plan individual design. plan individual PRESCRIBED PRODUCTS NONFORMULARY COMMONLY PRESCRIBED PRODUCTS NONFORMULARY COMMONLY INTERFERONS BRANDS MYELOID STIMULANTS BRANDS ERYTHROID ERYTHROID STIMULANTS BRANDS DRUG NAME DRUG NAME DRUG NAME DRUG NAME DRUG NAME Betaseron Extavia Plegridy Rebif Rebif Rebidose Pegasys Proclick Pegasys Peg-Intron Redipen Peg-Intron Rebif Copaxone Infergen Intron A Pegasys Actimmune Avonex Pen Avonex Neulasta Neupogen Granix Leukine Epogen Aranesp Procrit [PA] upon based apply, may authorization prior circumstances, limited In [QL] upon based apply, may limits quantity circumstances, limited In [PA] [PA] [PA] [QL] [QL] [QL] [QL] [PA] [PA] [PA] [PA] [PA] 9. I

9.1 Biotechnology Drugs 9.1.3 9.1.2 9.1.1 Musculoskeletal & Rheumatology 10 (Choline Mag Trisalicylate) Trisalicylate) (Choline Mag (Pediapred) (Pediapred) (Decadron) (Decadron) (Probenecid w/Colchicine) (Probenecid PRODUCTS FORMULARY PRODUCTS FORMULARY PRODUCTS FORMULARY (Prednisolone) (Prednisolone) (Medrol) (Medrol) (Prelone) (Prelone) (Cortisone Acetate) (Decadron) (Decadron) (Cortef) detailed description, see Drug List Medication Coverage. Coverage. Medication List Drug see description, detailed (Zyloprim) (Zyloprim) (Probenecid) (Probenecid) (Prednisone) (Prednisone) (Dolobid) (Dolobid) (Salflex) (Salflex) (Colchicine) (Febuxostat) (Febuxostat) PRESCRIBED PRODUCTS NONFORMULARY COMMONLY PRESCRIBED PRODUCTS NONFORMULARY COMMONLY CORTICOSTEROIDS GENERICS SALICYLATES GENERICS DRUG NAME DRUG NAME DRUG NAME DRUG NAME GENERICS BRANDS DRUG NAME Cortisone Acetate Dexamethasone Dose Pack Tablet, Dexamethasone Hydrocortisone Methylprednisolone Sodium Prednisolone Phosphate Solution, Oral Syrup Prednisolone Tablet Prednisolone Prednisone Rayos Choline Tablet Salicylate/Magnesium Salicylate Diflunisal Salsalate Allopurinol Colchicine/Probenecid Probenecid Colcrys Uloric Mitigare [PREVENT] Prevent drugs may be covered at $0 if criteria are met. For a For met. are criteria if $0 at covered be may drugs Prevent [PREVENT] [PA] [QL] [PA] [PA] [QL] [PA] 10.3 Other Rheumatologicals 10.2Therapy Gout 10.3.1 10.1.2 32 HEUMATOLOGY (Oruvail) (Oruvail) (Voltaren-XR) (Voltaren-XR) & R (Naprelan 500mg) (Naprelan (Indocin (Indocin SR) (Lodine XL) (Arthrotec) (EC-Naprosyn) (EC-Naprosyn) (Pennsaid) (Pennsaid) (Toradol) (Toradol) (Meclofenamate (Meclofenamate Sodium) (Indomethacine (Indomethacine Suppository) PRODUCTS FORMULARY PRODUCTS FORMULARY (Cataflam) (Voltaren) (Voltaren) (Anaprox) (Anaprox) (Anaprox DS) (Naproxen Sodium Tablet, Sustained Action) Tablet, Sodium (Naproxen (Tolectin) (Tolectin) (Ponstel) (Ponstel) (Indocin) (Indocin) (Relafen) (Relafen) (Ansaid) (Mobic) (Mobic) (Daypro) (Daypro) (Orudis) USCULOSKELETAL (Feldene) (Feldene) (Naprosyn) (Naprosyn) (Motrin) (Motrin) (Celebrex) (Celebrex) (Clinoril) (Lodine) individual plan design. design. plan individual individual plan design. plan individual PRESCRIBED PRODUCTS NONFORMULARY COMMONLY [PA] upon based apply, may authorization prior circumstances, limited In NSAIDS- SPECIFIC COX-II INHIBITORS GENERICS NSAIDS GENERICS NSAIDS/COX NSAIDS/COX II INHIBITORS DRUG NAME DRUG NAME BRANDS DRUG NAME Celecoxib Zipsor Sprix Vimovo Gel 1% Voltaren Flector Flector Patch Nalfon 500mg, Naprelan 750mg 2% Pennsaid Cambia Duexis Indocin Indocin Suppository 375mg Naprelan Piroxicam Sulindac Sodium Tolmetin Naproxen Sodium Naproxen Sustained Action Tablet, Sodium Naproxen Sustained Release Naproxen, Oxaprozin Nabumetone Naproxen Sodium Naproxen Ketorolac Tromethamine Ketorolac Meclofenamate Sodium Mefenamic Acid Meloxicam Indomethacin Indomethacin Capsule, Sustained Action Ketoprofen Ketoprofen Capsule, 24hr Sustained Release Pellets Etodolac Sustained Release 24hr Tablet, Etodolac Flurbiprofen Ibuprofen Diclofenac Sodium-Misoprostol Diclofenac Sodium 1.5% Sustained Release 24hr Diclofenac Tablet, Sodium Diclofenac Potassium Diclofenac Sodium [QL] upon based apply, may limits quantity circumstances, limited In [QL] [QL] [PA] [QL] [PA] [PA] [QL] [PA] [QL] [PA] [PA] [QL] [PA] [QL] [PA] [QL] [QL] 10. M

10.1Agents Nsaid 10.1.1.2 10.1.1.1 10.1.1 Musculoskeletal & Rheumatology 10 (Activella) (Activella) (Vivelle) (Vivelle) (Vivelle-Dot) (Femhrt) (Femhrt) (Climara) (Estradiol) (Boniva) (Boniva) (Miacalcin) (Miacalcin) (Actonel) (Actonel) PRODUCTS FORMULARY (Fosamax) (Fosamax) Weekly) (Fosamax (Didronel) (Didronel) [PREVENT] (Ogen) (Ogen) ) (Estradiol/Levonogestrel) (Estradiol/Levonogestrel) detailed description, see Drug List Medication Coverage. Coverage. Medication List Drug see description, detailed (Evista) (Evista) (Estrogens, Conjugated Tablet) Tablet) (Estrogens, Conjugated (Risedronate (Risedronate Sodium) (Estrogens, (Estrogens, Conjugated, Synthetic B) (Calcitonin (Calcitonin Salmon Recombinant) (Teriparatide) (Teriparatide) (Estradiol) (Estradiol) PRESCRIBED PRODUCTS NONFORMULARY COMMONLY ONTINUED DRUG NAME GENERICS BRANDS DRUG NAME Premarin Atelvia Binosto Duavee Plus Fosamax D Minivelle Alendronate Alendronate Sodium Alendronate Sodium Calcitonin, Salmon, Synthetic Acetate 1.0-0.5mg Estradiol/Norethindrone Semiweekly Transdermal Patch, Estradiol Semiweekly Transdermal Patch, Estradiol Weekly Transdermal Patch, Estradiol Weekly Transdermal Patch, Estradiol Tablet Estropipate Acetate Ethinyl Estradiol/Norethindrone Etidronate Sodium Ibandronate Sodium Tablet 150mg Raloxifene Risedronate Sodium 150mg Actonel Alora Climara Pro Enjuvia Forteo Fortical [PREVENT] Prevent drugs may be covered at $0 if criteria are met. For a For met. are criteria if $0 at covered be may drugs Prevent [PREVENT] [PA] [QL] [PA] [QL] [PA] [QL] [PA] [QL] [QL] [QL] [QL] [QL] [QL] [QL] [QL] [QL] [QL] [PA] [QL] [PA] [QL] [PA] [QL] [QL] [QL] [PA]

10.4Therapy Osteoporosis 33 HEUMATOLOGY (C (Detrol (Detrol LA) & R (Azulfidine EN-tabs) (Plaquenil) (Plaquenil) (Detrol) (Detrol) (Flexeril) (Flexeril) (Rheumatrex) (Rheumatrex) (Ditropan) (Ditropan) (Ditropan XL) PRODUCTS FORMULARY PRODUCTS FORMULARY (Soma (Soma Compound) (Dantrium) (Dantrium) (Sanctura (Sanctura XR) (Diazepam) (Diazepam) (Flexmid) (Flexmid) (Robaxin) (Robaxin) (Parafon Forte DSC) Forte (Parafon (Azulfidine) (Imuran) (Imuran) (Soma) (Soma) (Arava) (Arava) (Skelaxin) (Skelaxin) (Penicillamine) (Penicillamine) USCULOSKELETAL (Valium) (Valium) (Sanctura) (Sanctura) (Lioresal) (Lioresal) (Darifenacin Hydrobromide) (Darifenacin Hydrobromide) (Solifenacin Succinate) (Adalimumab) (Adalimumab) (Auranofin) (Auranofin) (Oxybutynin Patch, Transdermal Semiweekly) Transdermal (Oxybutynin Patch, (Methotrexate Sodium) (Methotrexate (Etanercept) (Etanercept) individual plan design. design. plan individual design. plan individual

PRESCRIBED PRODUCTS NONFORMULARY COMMONLY PRESCRIBED PRODUCTS NONFORMULARY COMMONLY MUSCLE RELAXANTS & ANTISPASMODIC THERAPY MUSCLE RELAXANTS ANTISPASMODIC & GENERICS MISCELLANEOUS RHEUMATOLOGICAL AGENTS MISCELLANEOUS RHEUMATOLOGICAL GENERICS DRUG NAME BRANDS DRUG NAME DRUG NAME BRANDS DRUG NAME Amrix Gelnique Vesicare Enablex Oxytrol Tolterodine Tartrate Capsule, Sustained Release 24 hr Tartrate Tolterodine Tablet Tartrate Tolterodine Trospium Chloride Trospium Methocarbamol Oxybutynin Chloride Oxybutynin Chloride Metaxalone Cyclobenzaprine HCl Cyclobenzaprine Dantrolene Sodium Diazepam Tablet Diazepam Carisoprodol Carisoprodol/Aspirin Chlorzoxazone Cyclobenzaprine Baclofen Rasuvo Simponi Stelara Xeljanz Kineret Orencia (syringe) Otezla Otrexup Actemra Actemra (syringe) Cimzia (syringe) Ridaura Trexall Cuprimine Enbrel Humira Methotrexate Sodium Methotrexate Enteric Coated Tablet, Sulfasalazine Leflunomide Azathioprine Sulfasalazine Sulfate Hydroxychloroquine

[PA] upon based apply, may authorization prior circumstances, limited In [QL] upon based apply, may limits quantity circumstances, limited In [PA] [PA] [QL] [QL] [PA] [QL] [PA] [QL] [PA] [QL] [PA] [QL] [PA] [PA] [QL] [PA] [QL] [PA] [QL] [PA] [QL] [PA] [PA] [QL] [PA] [PA] [PA] [PA] [PA] 10. M

10.3.3 10.3.2 1 Obstetrics & Gynecology 11 (Vivelle) (Vivelle) (Vivelle-Dot) (Climara) (Estradiol) [PREVENT] (Depo-Provera, Provera) Provera) (Depo-Provera, (Medroxyprogesterone Acet (Medroxyprogesterone vial) (Prometrium) (Prometrium) (Estradiol) (Estradiol) (Aygestin) PRODUCTS FORMULARY PRODUCTS FORMULARY (Medroxyprogesterone Acet (Medroxyprogesterone Disposable Syringe (ml)) (Estrace) (Ortho Micronor) detailed description, see Drug List Medication Coverage. Coverage. Medication List Drug see description, detailed (Progesterone, Micronized) (Progesterone, (Ogen) (Ogen) (Estradiol Patch, Transdermal Semiweekly) Transdermal Patch, (Estradiol (Estrogens,Conjugated Cream (Grams)) (Grams)) (Estrogens,Conjugated Cream Tablet) (Estrogens,Conjugated (Estrogens, Conjugated, Synthetic Tablet) Tablet) (Estrogens, Conjugated, Synthetic (Progesterone, Micronized (Progesterone, Gel) (Estradiol Vaginal Tablet) Tablet) Vaginal (Estradiol (Estrogens, (Estrogens, Conjugated Synthetic B) (Estradiol Ring, Vaginal) Vaginal) Ring, (Estradiol (Estradiol) (Estradiol) PRESCRIBED PRODUCTS NONFORMULARY COMMONLY PROGESTINS GENERICS ESTROGENS GENERICS BRANDS DRUG NAME DRUG NAME BRANDS DRUG NAME Estropipate Alora Cenestin Climara Enjuvia Cream Estrace Vaginal Estraderm Estring Premarin Premarin Vagifem Divigel Elestrin Estrasorb Estrogel Evamist Femring Menostar Minivelle Medroxyprogesterone Acetate Medroxyprogesterone Norethindrone Acetate Norethindrone Micronized Progesterone, Crinone 400mg/ml Depo-Provera Provera Depo-Subq Endometrin Semiweekly Transdermal Patch, Estradiol Semiweekly Transdermal Patch, Estradiol Weekly Transdermal Patch, Estradiol Weekly Transdermal Patch, Estradiol Tablet Estradiol [PREVENT] Prevent drugs may be covered at $0 if criteria are met. For a For met. are criteria if $0 at covered be may drugs Prevent [PREVENT] [QL] [QL] [QL] [QL] [QL] [QL] [QL] [QL] [QL] [QL] [QL] [QL] [QL] [QL]

11.3 Estrogens & Progestins 11.3.1 11.3.2 34 [PREVENT] [PREVENT] [PREVENT] [PREVENT] [PREVENT] [PREVENT] (Loseasonique) (Seasonique) [PREVENT] (Loestrin Fe) (Loestrin Fe) [PREVENT] (Mircette) (Mircette) [PREVENT] [PREVENT] [PREVENT] [PREVENT] [PREVENT] [PREVENT] [PREVENT] [PREVENT] [PREVENT] [PREVENT] YNECOLOGY [PREVENT] [PREVENT] [PREVENT] [PREVENT] [PREVENT] [PREVENT] [PREVENT] [PREVENT] [PREVENT] [PREVENT] [PREVENT] [PREVENT] [PREVENT] (Brevicon) (Brevicon) Fe) (Femcon (Modicon) (Norinyl) (Ortho-Novum) (Levlite) (Lybrel) (Nordette) (Seasonale) (Tri-Levlen) (Triphasil) (Alesse) (Levlen) & G (Demulen) (Demulen) (Yasmin) (Yasmin) (YAZ) (Ortho-Cyclen) (Ortho-Cyclen) Tri-Cyclen) (Ortho (Loestrin) (Cyclessa) (Cyclessa) (Desogen) (Ortho-Cept) (Estrostep Fe) (Estrostep Fe) (Lo/Ovral) (Ovral) (Methergine) (Methergine) (Aygestin) (Norgestimate-Ethinyl Estradiol) Estradiol) (Norgestimate-Ethinyl PRODUCTS FORMULARY PRODUCTS FORMULARY (Norethindrone A-E Estradiol/Ferrous Fumarate) Fumarate) A-E Estradiol/Ferrous (Norethindrone (Ortho Micronor) (Plan (Plan B One Step) BSTETRICS (Estradiol Valerate-Dienogest) Valerate-Dienogest) (Estradiol (Ethinyl Estradiol/Drospirenone) (Ethinyl Estradiol/Drospirenone) individual plan design. design. plan individual individual plan design. plan individual (Drospirone/Estradiol/Levomefol) (Drospirone/Estradiol/Levomefol) PRESCRIBED PRODUCTS NONFORMULARY COMMONLY [PA] upon based apply, may authorization prior circumstances, limited In PROGESTIN ONLY GENERICS MONOPHASIC/BIPHASIC/TRIPHASIC/4-PHASIC AGENTS MONOPHASIC/BIPHASIC/TRIPHASIC/4-PHASIC GENERICS DRUG NAME DRUG NAME BRANDS DRUG NAME Methylergonovine Maleate Methylergonovine Norethindrone Acetate Norethindrone Lo Minastrin FE Quartette Ella Natazia Lo Tri-Cyclen Ortho Safyral Norgestrel-Ethinyl Estradiol Norgestrel-Ethinyl Beyaz Lo Loestrin Fe Norgestimate-Ethinyl Estradiol Norgestimate-Ethinyl Estradiol Norgestimate-Ethinyl Estradiol Norgestrel-Ethinyl Estradiol Norgestrel-Ethinyl Norethindrone-Ethinyl Estradiol Norethindrone-Ethinyl Estradiol Norethindrone-Ethinyl Estradiol Norethindrone-Ethinyl Norethindrone A-E Estradiol Norethindrone Fumarate A-E Estradiol/Ferrous Norethindrone Estradiol Norethindrone-Ethinyl Estradiol Norethindrone-Ethinyl Levonorgestrel-Ethinyl Estradiol Levonorgestrel-Ethinyl Estradiol Levonorgestrel-Ethinyl Estradiol Estradiol-Ethinyl Levonorgestrel-Ethinyl Estradiol Estradiol-Ethinyl Levonorgestrel-Ethinyl Levonorgestrel-Ethinyl Estradiol Levonorgestrel-Ethinyl Estradiol Levonorgestrel-Ethinyl Estradiol Levonorgestrel-Ethinyl Estradiol Levonorgestrel-Ethinyl Ethynodiol Ethynodiol D-Ethinyl Estradiol Levonorgestrel Estradiol Levonorgestrel-Ethinyl Estradiol Levonorgestrel-Ethinyl Desogestrel-Ethinyl Estradiol/Ethinyl Estradiol Estradiol/Ethinyl Desogestrel-Ethinyl Ethinyl Estradiol/Drospirenone Ethinyl Estradiol/Drospirenone Desogestrel-Ethinyl Estradiol Desogestrel-Ethinyl Estradiol Desogestrel-Ethinyl Estradiol Desogestrel-Ethinyl [QL] upon based apply, may limits quantity circumstances, limited In [QL] [QL] [QL] [QL] 11. O

11.1 Oral Contraceptives & Agents Related 11.1.2 11.1.1 Obstetrics & Gynecology 11 [PREVENT] (Terazol) (Terazol) [PREVENT] PRODUCTS FORMULARY PRODUCTS FORMULARY PRODUCTS FORMULARY (Brethine) (Brethine) (Lysteda) (Lysteda) (Vasodilan) (Vasodilan) (Butoconazole Nitrate Cream) Cream) (Butoconazole Nitrate (Diflucan) (Diflucan) (Etonogestrel/Ethinyl Estradiol Ring, Vaginal) Vaginal) Ring, Estradiol (Etonogestrel/Ethinyl detailed description, see Drug List Medication Coverage. Coverage. Medication List Drug see description, detailed (Nystatin) (Nystatin) (Nafarelin Acetate) (Nafarelin (Ortho Evra) (Ortho Evra) PRESCRIBED PRODUCTS NONFORMULARY COMMONLY DIAPHRAGMS AND OTHER DIAPHRAGMS NON-ORAL CONTRACEPTIVES GENERICS VAGINAL ANTIFUNGALS VAGINAL GENERICS SPECIALIZED OB/GYN DRUGS GENERICS BRANDS BRANDS BRANDS DRUG NAME DRUG NAME DRUG NAME DRUG NAME Osphena Xulane NuvaRing Fluconazole Nystatin with Cream Applicator Terconazole Gynazole-1 Isoxsuprine HCl Sulfate Terbutaline Acid Tranexamic Synarel [PREVENT] Prevent drugs may be covered at $0 if criteria are met. For a For met. are criteria if $0 at covered be may drugs Prevent [PREVENT] ) [QL] [QL] [PA] [QL]

11.4.5 11.4.3 11.4.4 35 ONTINUED (Activella) (Activella) YNECOLOGY (C (Metrogel) (Metrogel) (Syntest (Syntest D.S.) (Syntest H.S.) (Profasi) (Profasi) & G PRODUCTS FORMULARY PRODUCTS FORMULARY PRODUCTS FORMULARY (Leuprolide (Leuprolide Acetate) (Clomid) (Lupron) (Lupron) (Leuprolide (Leuprolide Acetate) (Vandazole) (Vandazole) (AVC) (AVC) (Follitropin Alpha,Recombinant) Alpha,Recombinant) (Follitropin (Estradiol/Norethindrone Acetate) (Estradiol/Norethindrone (Estrogens, Conjugated/Medroxyprogesterone (Estrogens, Acet) Conjugated/Medroxyprogesterone (Menotropins) (Menotropins) (Cetrorelix Acetate) (Cetrorelix (Ganirelix Acetate) (Ganirelix BSTETRICS (Estrogens, Conjugated/Medroxyprogesterone (Estrogens, Acet) Conjugated/Medroxyprogesterone (Follitropin Alpha,Recombinant) Alpha,Recombinant) (Follitropin (Urofollitropin (FSH)) (Urofollitropin (HCG Alpha,Recombinant) (HCG Alpha,Recombinant) (Ethinyl Estradiol/Norethindrone Acetate) (Ethinyl Estradiol/Norethindrone individual plan design. design. plan individual design. plan individual

PRESCRIBED PRODUCTS NONFORMULARY COMMONLY PRESCRIBED PRODUCTS NONFORMULARY COMMONLY VAGINAL CLEANSER/ANTI-INFECTIVES VAGINAL GENERICS DRUGS TO TREAT AGENTS INFERTILITY/IVF TREAT TO DRUGS GENERICS ESTROGEN ESTROGEN COMBINATIONS GENERICS DRUG NAME DRUG NAME BRANDS DRUG NAME DRUG NAME BRANDS DRUG NAME Metronidazole 1.3% Vaginal Gel 1.3% Vaginal Metronidazole Clindesse Metronidazole Gel with Metronidazole Applicator (gm) Sulfanilamide Repronex Gonal-f Gonal-f RFF Lupron Depot Lupron Depot-Ped Ovidrel Bravelle Cetrotide Ganirelix Gonal-F Clomiphene Citrate Gonadotropin, Chorionic, Human Leuprolide Acetate Angeliq Ortho-Prefest Premphase Prempro Combipatch Femhrt Estradiol/Norethindrone Acetate 1.0-0.5mg Estradiol/Norethindrone Estrogens, Esterified/Methyltestosterone Estrogens, Esterified/Methyltestosterone

[PA] upon based apply, may authorization prior circumstances, limited In [QL] upon based apply, may limits quantity circumstances, limited In [QL] [QL] 11. O

11.4 Miscellaneous OB/GYN

11.4.2 11.4.1 11.3.3 1 Ophthalmology 12 (Diamox (Diamox Sequels) (Cyclogyl 1%) (Cyclogyl PRODUCTS FORMULARY PRODUCTS FORMULARY PRODUCTS FORMULARY PRODUCTS FORMULARY (Ocufen) (Ocufen) (Bromday) (Bromday) (Voltaren) (Voltaren) (Isopto (Isopto Homatropine) (Albalon) (Isopto (Isopto Atropine) (Neptazane) (Neptazane) (Diamox) (Diamox) detailed description, see Drug List Medication Coverage. Coverage. Medication List Drug see description, detailed (Mydriacyl) (Mydriacyl) Agents PRESCRIBED PRODUCTS NONFORMULARY COMMONLY PRESCRIBED PRODUCTS NONFORMULARY COMMONLY DRUG NAME GENERICS DRUG NAME DRUG NAME GENERICS DRUG NAME GENERICS DRUG NAME GENERICS DRUG NAME Bromfenac Bromfenac Sodium Diclofenac Sodium Flurbiprofen Sodium Acuvail Ilevro Prolensa HCl Naphazoline Acetazolamide Acetazolamide Capsules Extended Release Methazolamide Atropine Sulfate HCl Cyclopentolate Drops Homatropine HBr Tropicamide Isopto Hyoscine [PREVENT] Prevent drugs may be covered at $0 if criteria are met. For a For met. are criteria if $0 at covered be may drugs Prevent [PREVENT] 12.8 Decongestants Vasoconstrictor 12.5 Oral Drugs For Glaucoma 12.6 Cycloplegic Mydriatics 12.7Anti-inflammatory Non-steroidal 36 ) ONTINUED (Timoptic-XE) (Timoptic-XE) (Cosopt) PRODUCTS FORMULARY PRODUCTS FORMULARY PRODUCTS FORMULARY PRODUCTS FORMULARY (Echothiophate (Echothiophate Iodide) (Trusopt) (Trusopt) (Carbachol) (Carbachol) (Betagan) (Betagan) (Timoptic) (Timoptic) (Isopto (Isopto Carpine) (Betoptic) (Betoptic) (Ocupress) (Pilocarpine (Pilocarpine HCl Gel (gm)) (OptiPranolol) (OptiPranolol) (Xalatan) (Travoprost) (Travoprost) (Betaxolol (Betaxolol HCl) (Travatan) (Travatan) (Bimatoprost) (Bimatoprost) PHTHALMOLOGY (C individual plan design. design. plan individual individual plan design. plan individual (Brinzolamide) (Brinzolamide) PRESCRIBED PRODUCTS NONFORMULARY COMMONLY PRESCRIBED PRODUCTS NONFORMULARY COMMONLY [PA] upon based apply, may authorization prior circumstances, limited In DRUG NAME BRANDS GENERICS DRUG NAME BRANDS DRUG NAME GENERICS DRUG NAME BRANDS DRUG NAME BRANDS DRUG NAME GENERICS Izba Simbrinza Combigan Isopto Isopto Carbachol Lumigan Z Travatan Latanoprost Travoprost Azopt Timolol Maleate/Dorzolamide Timolol HCl Dorzolamide HCl Pilocarpine Pilocarpine HCl Pilopine HS Phospholine Phospholine Iodide Istalol Betoptic Betoptic S Timolol Maleate Timolol Solution Maleate Timolol Gel-Forming Betaxolol Betaxolol HCl Carteolol HCl Levobunolol HCl Metipranolol [QL] upon based apply, may limits quantity circumstances, limited In [QL] 12. O

12.4 Other Glaucoma Drugs

12.3 Acting Miotics Direct 12.2 Cholinesterase Inhibitor Miotics

12.1 Beta-blockers Ophthalmology 12 (Vasocidin) (Vasocidin) (Maxitrol) (Maxitrol) (TobraDex) (TobraDex) (Cortisporin) PRODUCTS FORMULARY PRODUCTS FORMULARY PRODUCTS FORMULARY (Alphagan) (Alphagan P) (Sulfacetamide Sodium/Prednisolone Acetate) (Sulfacetamide Sodium/Prednisolone (Brimonidine Tartrate) Tartrate) (Brimonidine (Tobramycin/Dexamethasone) (Tobramycin/Dexamethasone) (Sulfacetamide Sodium/Prednisolone Acetate) (Sulfacetamide Sodium/Prednisolone (Tobramycin Sulfate/Dexamethasone Ointment) (Tobramycin detailed description, see Drug List Medication Coverage. Coverage. Medication List Drug see description, detailed (Neomycin Sulfate/Polymyxin B Sulfate/Prednisolone) B Sulfate/Prednisolone) Sulfate/Polymyxin (Neomycin (Tobramycin/Loteprednol Etabonate) (Tobramycin/Loteprednol (Cortisporin) (Final Dosage Form)(ml) PRESCRIBED PRODUCTS NONFORMULARY COMMONLY GENERICS BRANDS GENERICS BRANDS GENERICS BRANDS DRUG NAME DRUG NAME DRUG NAME DRUG NAME Sulfacetamide Sodium/Prednisolone Sodium Sulfacetamide Sodium/Prednisolone Phosphate Blephamide Blephamide S.O.P. Brimonidine 0.15% Tartrate Brimonidine Alphagan P 0.1% Neomycin/Polymyxin B Sulfate/Dexamethasone Neomycin/Polymyxin Ointment(gm) B/Hydrocortisone Zinc/Polymyxin Sulfate/Bacitracin Neomycin B Suspension, Drops Sulfate/Hydrocortisone Sulfate/Polymyxin Neomycin Sulfate/Dexamethasone Tobramycin Poly-Pred TobraDex TobraDex-ST Zylet Dosage Suspension, 0.3%-1% Drops (Final Form)(ml) Pred-G [PREVENT] Prevent drugs may be covered at $0 if criteria are met. For a For met. are criteria if $0 at covered be may drugs Prevent [PREVENT] 12.14 Sympathomimetics 12.12 Steroid-antibiotic Combinations 12.13 Steroid-sulfonamide Combinations 37 ) (Neosporin) (Neosporin) (Neosporin) (Neosporin) ONTINUED (Sodium Sulamyd) (Sodium Sulamyd) (Polytrim) (Polytrim) (Decadron) (Decadron) (Inflamase Forte) (Inflamase Forte) (Ciloxan) (Ciloxan) (Bleph-10) (Bleph-10) PRODUCTS FORMULARY PRODUCTS FORMULARY PRODUCTS FORMULARY (Pred Forte) Forte) (Pred (Garamycin) (Garamycin) (Tobrex) (Tobrex) (Ilotycin) (Ilotycin) (FML) (Ocuflox) (Ocuflox) (Fluorometholone) (Fluorometholone) (Quixin) (Quixin) (Zymaxid) (Zymaxid) (Fluorometholone) (Fluorometholone) (Prednisolone Acetate) (Prednisolone (Besifloxacin) (Besifloxacin) (Moxifloxacin HCl) (Moxifloxacin PHTHALMOLOGY (C (Loteprednol (Loteprednol Etabonate) (Natamycin) (Natamycin) (Difluprednate) (Difluprednate) (Ciprofloxacin (Ciprofloxacin HCl Ointment(gm)) (Moxifloxacin HCl) (Moxifloxacin (Rimexolone) (Rimexolone) (Loteprednol (Loteprednol Etabonate) individual plan design. design. plan individual design. plan individual

BRANDS DRUG NAME GENERICS DRUG NAME GENERICS BRANDS DRUG NAME GENERICS Vexol FML Forte FML S.O.P. Lotemax Mild Pred Prednisolone Sodium Prednisolone Phosphate Alrex Durezol Dexamethasone Dexamethasone Sodium Phosphate Fluorometholone Acetate Prednisolone Sulfacetamide Sulfacetamide Sodium Sulfacetamide Sodium Ointment(gm) Vigamox Besivance Ciloxan Moxeza Natacyn Polymyxin B Polymyxin Sulfate/Trimethoprim Sulfate Tobramycin Levofloxacin B Ointment(gm) Sulfate/Bacitracin/Polymyxin Neomycin B D/Polymyxin Drops Sulfate/Gramicidin Neomycin Ofloxacin Drops Ciprofloxacin Ciprofloxacin HCl Drops Erythromycin Base Gatifloxacin Gentamicin Sulfate

[PA] upon based apply, may authorization prior circumstances, limited In [QL] upon based apply, may limits quantity circumstances, limited In 12. O

12.11 Steroids

12.10 Sulfonamides

12.9 Antibiotics 1 12 12. OPHTHALMOLOGY (CONTINUED)

12.15 Miscellaneous Ophthalmologics FORMULARY PRODUCTS DRUG NAME GENERICS Azelastine HCl (Optivar) Cromolyn Sodium (Opticrom) BRANDS Alocril (Nedocromil Sodium) Alomide (Lodoxamide Tromethamine)

[PA] [QL] Cystaran (Cysteamine HCl) Ophthalmology Lacrisert (Hydroxypropyl Cellulose Insert) Pataday (Olopatadine HCl 0.2%) Patanol (Olopatadine HCl 0.1%) Restasis (Cyclosporine) Zirgan (Ganciclovir)

COMMONLY PRESCRIBED NONFORMULARY PRODUCTS DRUG NAME Bepreve Emadine

12.16 Antivirals FORMULARY PRODUCTS DRUG NAME GENERICS Trifluridine (Viroptic)

13.2 Cough & Therapy Cold 13.2.2 13.2.3 13.2.1 OLD 39 & C OUGH , C (Pediapred) (Pediapred) LLERGY , A (Dexchlorpheniramine (Dexchlorpheniramine Maleate) (Benadryl) (Vistaril) (Vistaril) (Tavist) (Tavist) PRODUCTS FORMULARY PRODUCTS FORMULARY PRODUCTS FORMULARY (Periactin) (Periactin) (Prednisolone) (Prednisolone) (Medrol) (Medrol) (Prelone) (Prelone) (Phenergan) (Phenergan) (Allegra) (Atarax) (Atarax) (Cortisone Acetate) (Claritin OTC) (Claritin OTC) (Decadron) (Decadron) (Zyrtec OTC) OTC) (Zyrtec (Cortef) (Xyzal) (Xyzal) (Clarinex) (Prednisone) (Prednisone) (Epinephrine) (Epinephrine) (Cetirizine (Cetirizine Rx) (Astepro) (Astepro) (Astelin) ESPIRATORY (Epinephrine) (Epinephrine) Agents individual plan design. design. plan individual design. plan individual PRESCRIBED PRODUCTS NONFORMULARY COMMONLY PRESCRIBED PRODUCTS NONFORMULARY COMMONLY CORTICOSTEROIDS GENERICS ADRENERGICS GENERICS ANTIHISTAMINES GENERICS DRUG NAME DRUG NAME BRANDS DRUG NAME DRUG NAME BRANDS DRUG NAME Prednisolone Syrup Prednisolone Tablet Prednisolone Prednisone Dexamethasone Hydrocortisone Methylprednisolone Sodium Prednisolone Phosphate Solution, Oral Cortisone Acetate Auvi-Q Epinephrine Epinephrine 0.15mg/0.15ml and 0.3mg/0.3ml Auto Injection EpiPen Jr. EpiPen Karbinal ER Clarinex Syrup Promethazine HCl Promethazine Rx Zyrtec Hydroxyzine Pamoate Hydroxyzine HCl Hydroxyzine Levocetirizine OTC Loratadine Desloratadine Maleate Dexchlorpheniramine HCl Diphenhydramine HCl Fexofenadine Azelastine Cetirizine HCl Clemastine Fumarate HCl Cyproheptadine Azelastine [PA] upon based apply, may authorization prior circumstances, limited In [QL] upon based apply, may limits quantity circumstances, limited In [QL] [QL] [QL] [PA] [QL] [PA] [PA] [QL] [PA] [QL] [QL] [QL] 13. R

13.1 Antihistamine Antiallergenic & 13.1.3 13.1.2 13.1.1 Respiratory, Allergy, Cough & Cold 13 (Nasacort (Nasacort AQ) (Pulmicort) (Pulmicort) (Flonase) (Flonase) PRODUCTS FORMULARY PRODUCTS FORMULARY ) (Rhinocort Aqua) (Fluticasone Propionate (Fluticasone Disk, Propionate with Inhalation Device) (Mometasone Furoate) (Mometasone Furoate) (Fluticasone Propionate) (Fluticasone Propionate) detailed description, see Drug List Medication Coverage. Coverage. Medication List Drug see description, detailed (Nasalide) (Nasalide) (Nasarel) (Budesonide Aerosol Powder, Breath Activated (ea)) Breath (Budesonide Aerosol Powder, (Budesonide Ampul for (ml)) Nebulization (Mometasone (Mometasone Furoate) (Mometasone Furoate Aerosol, Spray, (gm)) Aerosol, (Mometasone Spray, Furoate (Ciclesonide) (Ciclesonide) (Beclomethasone (Beclomethasone Dipropionate) ONTINUED PRESCRIBED PRODUCTS NONFORMULARY COMMONLY PRESCRIBED PRODUCTS NONFORMULARY COMMONLY INTRANASAL STEROIDS GENERICS INHALED CORTICOSTEROIDS GENERICS BRANDS DRUG NAME DRUG NAME BRANDS DRUG NAME DRUG NAME Budesonide Budesonide Spray Flunisolide Flunisolide Fluticasone Propionate (gm) Acetonide Aerosol, Spray, Triamcinolone Nasonex Beconase AQ Dymista Omnaris Qnasl Veramyst Zetonna Budesonide Budesonide Respules 0.25mg & 0.5mg Alvesco Asmanex Asmanex HFA Diskus Flovent HFA Flovent Pulmicort Pulmicort Qvar Aerospan HFA Arnuity Ellipta [PREVENT] Prevent drugs may be covered at $0 if criteria are met. For a For met. are criteria if $0 at covered be may drugs Prevent [PREVENT]

[PA] [QL] [PA] [QL] [QL] [QL] [QL] [QL] [PA] [QL] [PA] [QL] [PA] [QL] [PA] [QL] [PA] [QL] [PA] [QL] [PA] [QL] [QL] [QL] [QL] [QL] [QL] [QL] [QL] [QL]

13.3.5 13.3.4 OLD (C 40 & C OUGH (Theo-Dur) (Theo-Dur) , C (Xopenex) (Alupent) LLERGY (Proventil) (Proventil) , A (Accuneb) (Accuneb) (Alupent) PRODUCTS FORMULARY PRODUCTS FORMULARY PRODUCTS FORMULARY (Brethine) (Brethine) (Ephedrine (Ephedrine Sulfate) (Proventil) (Proventil) (Salmeterol (Salmeterol Xinafoate Disk, with Inhalation Device) (Albuterol (Albuterol Aerosol) (Albuterol (Albuterol Sulfate) (Aminophylline) (Albuterol (Albuterol Aerosol) (Formoterol Fumarate) Fumarate) (Formoterol (Theophylline Anhydrous) (Theophylline Anhydrous) ESPIRATORY (Formoterol Fumarate) Fumarate) (Formoterol individual plan design. design. plan individual individual plan design. plan individual PRESCRIBED PRODUCTS NONFORMULARY COMMONLY PRESCRIBED PRODUCTS NONFORMULARY COMMONLY [PA] upon based apply, may authorization prior circumstances, limited In BETA AGONISTS AGONISTS INHALERS BETA GENERICS BETA AGONISTS AGONISTS ORAL BETA GENERICS XANTHINES GENERICS DRUG NAME BRANDS DRUG NAME DRUG NAME DRUG NAME BRANDS DRUG NAME Proventil HFA Proventil Xopenex HFA Arcapta Arcapta Neohaler Brovana Serevent Diskus Serevent HFA Ventolin Foradil Perforomist HFA ProAir Albuterol Albuterol Solution, Non-Oral Albuterol Sulfate Solution, Non-Oral Levalbuterol HCl 1.25mg/5ml Solution, Non-Oral Sulfate Solution, Metaproterenol Non-Oral Metaproterenol Sulfate Metaproterenol Sulfate Terbutaline Albuterol Albuterol Sulfate Ephedrine Sulfate Lufyllin Theo-24 HFA Ventolin Aminophylline Sustained Release 12hr Tablet, Theophylline Anhydrous [QL] upon based apply, may limits quantity circumstances, limited In [QL] [QL] [QL] [QL] [QL] [QL] [QL] [QL] [QL] [QL] [QL] 13. R

13.3Agents Pulmonary 13.3.3 13.3.2 13.3.1 Respiratory, Allergy, Cough & Cold 13 ) detailed description, see Drug List Medication Coverage. Coverage. Medication List Drug see description, detailed ONTINUED [PREVENT] Prevent drugs may be covered at $0 if criteria are met. For a For met. are criteria if $0 at covered be may drugs Prevent [PREVENT] OLD (C 41 & C OUGH , C (Mucomyst) (Mucomyst) (Intal) (Intal) (Atrovent) (Atrovent) LLERGY (Duoneb) (Duoneb) , A (Revatio) (Revatio) PRODUCTS FORMULARY (Singulair) (Singulair) (Tiotropium Bromide) (Tiotropium (Aclidinium (Aclidinium Bromide) (Ipratropium Bromide Aerosol w/Adapter (Ipratropium (gm)) (Fluticasone Propionate/Salmeterol Xinafoate (Fluticasone Propionate/Salmeterol Disk, with (Umeclidinium/Vilanterol) (Umeclidinium/Vilanterol) (Fluticasone Propionate/Salmeterol Xinafoate) (Fluticasone Propionate/Salmeterol (Fluticasone Furoate/Vilanterol) (Fluticasone Furoate/Vilanterol) (Dornase Alfa Solution, Non-Oral) (Dornase Alfa Solution, Non-Oral) (Accolate) (Accolate) (Budesonide/Formoterol Fumarate Dihydtrate) Dihydtrate) Fumarate (Budesonide/Formoterol (Ivacaftor) (Ivacaftor) ESPIRATORY (Iloprost) (Iloprost) (Bosentan) (Sildenafil Citrate Suspension, Oral) (Sildenafil Suspension, Oral) Citrate (Ambrisentan) (Ambrisentan) (Mometasone Furoate/Formoterol Fumarate Dihydrate) Dihydrate) Fumarate (Mometasone Furoate/Formoterol (Tiotropium Bromide) (Tiotropium (Albuterol Sulfate/Ipratropium Bromide Aerosol w/Adapter) (Albuterol Sulfate/Ipratropium Inhalation Inhalation Device) individual plan design. design. plan individual design. plan individual

PRESCRIBED PRODUCTS NONFORMULARY COMMONLY MISCELLANEOUS PULMONARY AGENTS MISCELLANEOUS PULMONARY GENERICS DRUG NAME BRANDS DRUG NAME Zyflo CR Zyflo Opsumit Orenitram ER Respimat Striverdi Zyflo Daliresp Esbriet Incruse Ellipta Ofev Adcirca Adempas Tudorza Pressair Tudorza Ventavis Spiriva Respimat Spiriva Symbicort Tracleer Letairis Pulmozyme Revatio Combivent Combivent Respimat Dulera Kalydeco Advair Advair HFA Anoro Ellipta HFA Atrovent Breo Ellipta Zafirlukast Advair Diskus Ipratropium Bromide Solution, Ipratropium Non-Oral Montelukast Sodium Tablet Sildenafil Citrate Acetylcysteine Vial (SDV,MDV or Additive) (ml) Vial (SDV,MDV Acetylcysteine Bromide Albuterol Sulfate/Ipratropium Cromolyn Sodium Ampul for (ml) Nebulization

[PA] upon based apply, may authorization prior circumstances, limited In [QL] upon based apply, may limits quantity circumstances, limited In [QL] [PA] [QL] [PA] [PA] [QL] [QL] [PA] [QL] [PA] [PA] [QL] [PA] [PA] [QL] [PA] [QL] [PA] [QL] [QL] [QL] [QL] [PA] [QL] [PA] [QL] [QL] [QL] [PA] [QL] [QL] [QL] [QL] [QL] [QL] [QL] [QL] [QL] [PA] 13. R

13.3.6 1 Urologicals 14 PRODUCTS FORMULARY (Cardura) (Cardura) (Hytrin) (Hytrin) (Uroxatral) (Uroxatral) detailed description, see Drug List Medication Coverage. Coverage. Medication List Drug see description, detailed (Flomax) (Flomax) (Proscar) (Proscar) (Dutasteride) (Tadalafil) (Tadalafil) Therapy (Dutasteride/Tamsulosin HCl) (Dutasteride/Tamsulosin PRESCRIBED PRODUCTS NONFORMULARY COMMONLY DRUG NAME GENERICS BRANDS DRUG NAME Alfuzosin Alfuzosin HCl Doxazosin Mesylate Finasteride Tamsulosin HCl Terazosin Avodart Cialis Jalyn Rapaflo [PREVENT] Prevent drugs may be covered at $0 if criteria are met. For a For met. are criteria if $0 at covered be may drugs Prevent [PREVENT]

[PA] [QL] [PA] [QL] [QL] 14.5 Benign Prostatic Hyperplasia (BPH) 42 (Detrol (Detrol LA) (Nulev) (Nulev) (Urocit-K) (Urocit-K) (Detrol) (Detrol) (Bentyl) (Bentyl) (Urecholine) (Urecholine) (Ditropan) (Ditropan) (Ditropan XL) PRODUCTS FORMULARY PRODUCTS FORMULARY PRODUCTS FORMULARY (Levsin) (Sanctura (Sanctura XR) (Bentyl) (Bentyl) (Urispas) (Urispas) (Cystospaz) (Cystospaz) (Magnesium (Magnesium Carbonate/Citric Solution, Acid/Gluconolactone (Alprostadil) (Alprostadil) (Cysteamine Bitartrate) (Cysteamine Bitartrate) ROLOGICALS (Pentosan Polysulfate Sodium) Polysulfate (Pentosan (Boceprevir) (Boceprevir) (Oxybutynin Patch, Transdermal Semiweekly) Transdermal (Oxybutynin Patch, (Sildenafil Citrate) (Sildenafil Citrate) (Fesoterodine Fumarate) Fumarate) (Fesoterodine individual plan design. design. plan individual individual plan design. plan individual (Tadalafil) (Tadalafil) (Alprostadil Suppository, Urethral) Urethral) (Alprostadil Suppository, Irrigation) Irrigation) PRESCRIBED PRODUCTS NONFORMULARY COMMONLY PRESCRIBED PRODUCTS NONFORMULARY COMMONLY [PA] upon based apply, may authorization prior circumstances, limited In DRUG NAME BRANDS DRUG NAME GENERICS DRUG NAME BRANDS DRUG NAME GENERICS DRUG NAME GENERICS Procysbi Staxyn Stendra Edex Levitra Viagra Cystagon Elmiron Muse Renacidin Caverject Cialis Potassium Citrate Tablet, Sustained Action Tablet, Citrate Potassium Myrbetriq Oxytrol Toviaz Vesicare Tolterodine Tartrate Capsule, Sustained Release 24 hr Tartrate Tolterodine Tablet Tartrate Tolterodine Chloride Trospium Hyoscyamine Sulfate Hyoscyamine Rapid Dissolve Tablet, Sulfate Hyoscyamine Oxybutynin Chloride Oxybutynin Chloride Dicyclomine Dicyclomine HCl Dicyclomine HCl Syrup HCl Flavoxate Hyoscyamine Bethanechol Bethanechol Chloride [QL] upon based apply, may limits quantity circumstances, limited In [PA] [QL] [PA] [QL] [QL] [QL] [QL] [QL] [QL] [QL] [QL] [PA] [PA] [QL] [PA] [QL] [QL] 14. U

14.4 Miscellaneous Urologicals

14.2 Anticholinergics Antispasmodics & 14.1 Cholinergic Stimulants Vitamins, Hematinics & Electrolytes 15 (Micro-K) (Micro-K) (Slow-K (Slow-K 8mEq) (Trental) (Trental) (K-Lyte) (K-Lyte) (Kay Ciel) (K-Lor) (Heparin (Heparin Lock Flush) (Lugol’s) (Lugol’s) (Arixtra) PRODUCTS FORMULARY PRODUCTS FORMULARY PRODUCTS FORMULARY PRODUCTS FORMULARY PRODUCTS FORMULARY PRODUCTS FORMULARY (Lovenox) (Lovenox) (Micro-K (Micro-K 8mEq) (Amicar) (Phoslo) (Phoslo) (Potassium Chloride Tablet, Sustained Action) Tablet, Chloride (Potassium (Zinc (Zinc Sulfate) (Phytonadione Tablet) Tablet) (Phytonadione detailed description, see Drug List Medication Coverage. Coverage. Medication List Drug see description, detailed (Eltrombopag (Eltrombopag Olamine) (Dalteparin Sodium ,Porcine) (Dalteparin Sodium ,Porcine) (K-Lyte/Cl 25mEq) (K-Lyte/Cl MISCELLANEOUS COAGULATION AGENTS MISCELLANEOUS COAGULATION GENERICS POTASSIUM GENERICS OTHER ELECTROLYTES GENERICS HEPARIN GENERICS K VITAMIN BRANDS HEMOSTATICS GENERICS BRANDS BRANDS BRANDS DRUG NAME DRUG NAME DRUG NAME DRUG NAME DRUG NAME DRUG NAME Calcium Calcium Acetate Iodide/Iodine Potassium Zinc Sulfate Promacta Sustained Action Tablet, Pentoxifylline Bicarbonate/Citric Acid Potassium Chloride Potassium Chloride Potassium Capsule, Sustained Action Chloride Potassium Liquid (ml) Chloride Potassium Packet Effervescent Tablet, Bicarbonate/Citric Acid Chloride/Potassium Potassium Sustained Action Tablet, Chloride Potassium 10mEq K-Tab Enoxaparin Enoxaparin Sodium Sodium Fondaparinux Heparin Sodium, Porcine Fragmin Mephyton Aminocaproic Acid [PREVENT] Prevent drugs may be covered at $0 if criteria are met. For a For met. are criteria if $0 at covered be may drugs Prevent [PREVENT] [PA] [PA]

15.3 Electrolytes

15.2.6 15.3.1 15.3.2 15.2.3 15.2.4 15.2.5 43 (Natafort) (Natafort) LECTROLYTES (Strongstart) (Strongstart) & E [PREVENT] (Nestabs fa) (Nestabs [PREVENT] (Hemocyte (Hemocyte Plus Capsule) (Vitamin (Vitamin D 50000 Unit) (Tri-Vi-Flor w/Iron) (Tri-Vi-Flor (Poly-Vi-Flor w/Iron) (Poly-Vi-Flor (Tri-Vi-Flor) (Tri-Vi-Flor) (Nephrocaps) (Nephrocaps) EMATINICS (Hemocyte-F) (Hemocyte-F) (Poly-Vi-Flor) (Poly-Vi-Flor) (Foltrate) (Foltrate) , H (Vitafol) (Vitafol) PRODUCTS FORMULARY PRODUCTS FORMULARY PRODUCTS FORMULARY (Plavix) (Plavix) (Coumadin) (Ticlid) (Ticlid) (Persantine) (Persantine) (Prenatal Vit #36/Iron/Fa CMB#6) Vit #36/Iron/Fa (Prenatal (Folvite) (Folvite) (Aspirin/Dipyridamole) (Aspirin/Dipyridamole) (Pletal) (Pletal) ITAMINS (Dabigatran) (Dabigatran) (Ticagrelor) (Ticagrelor) (Rivaroxaban) (Rivaroxaban) (Apixaban) (Apixaban) (Prasugrel HCl) (Prasugrel individual plan design. design. plan individual design. plan individual

PRESCRIBED PRODUCTS NONFORMULARY COMMONLY PRESCRIBED PRODUCTS NONFORMULARY COMMONLY ANTIPLATELET DRUGS ANTIPLATELET GENERICS ANTICOAGULANTS GENERICS DRUG NAME BRANDS DRUG NAME BRANDS DRUG NAME DRUG NAME BRANDS DRUG NAME GENERICS Zontivity Aggrenox Brilinta Effient Clopidogrel Clopidogrel Bisulfate Dipyridamole HCl Ticlopidine Cilostazol Xarelto Eliquis Pradaxa Warfarin Sodium Warfarin Chromagen Chromagen fa Nascobal fa Nephron Sodium Fluoride 0.25MG and 0.5MG chewable tablet Sodium Fluoride 0.25MG and 0.5MG drops Elite Prenate Nephro-Vite Rx Nephro-Vite Acid Vitamin Sulfate/Folic w-o Carbonyl-Fe Calcium/Fe Prenatal Acid Fumarate/Docusate/Folic Vitamins/Ferrous Prenatal Acid Fumarate/Folic Vitamins/Ferrous Prenatal Fluoride Ion/Vitamins A,C,and Fluoride Ion/Vitamins D Acid Folic B Acid/Vitamin Folic Comp w-C Ferrous Fumarate/Folic Acid/Multivitamins Fumarate/Folic Ferrous A,C,and Fluoride D Ion/Iron/Vitamins Fluoride Ion/Multivitamins w-Iron Fluoride Ion/Multivitamins Cyanocobalamin/Folic Acid Cyanocobalamin/Folic Ergocalciferol Capsule Soft, (Hard, Etc.) Fumarate/Cal/E/Fa Fe Acid Fumarate/Folic Ferrous

[PA] upon based apply, may authorization prior circumstances, limited In [QL] upon based apply, may limits quantity circumstances, limited In [PA] [QL] [PA] [QL] [QL] [QL] [QL] 15. V

15.2Therapy Coagulation

15.1 Vitamins & Hematinics 15.2.2 15.2.1 1 16 16. DIAGNOSTICS & MISCELLANEOUS AGENTS

16.1 Miscellaneous Agents 16.2 Smoking Deterrents Diagnostics & Miscellaneous Agents Miscellaneous & Diagnostics FORMULARY PRODUCTS FORMULARY PRODUCTS DRUG NAME DRUG NAME GENERICS GENERICS Acamprosate Calcium (Campral) [QL] Bupropion HCl, Sustained Action (Zyban) [PREVENT] Anagrelide HCl (Agrylin) [QL] Nicotine Polacrilex (Nicotine Gum) [PREVENT] Cevimeline HCl (Evoxac) [QL] Nicotine Polacrilex (Nicotine Lozenge, OTC) [PREVENT] Disulfiram (Antabuse) [QL] Nicotine Polacrilex (Nicotine Patch) [PREVENT] Levocarnitine (Carnitor) BRANDS Pilocarpine HCl (Salagen) [PA] [QL] Chantix (Varenicline Tartrate) [PREVENT] Riluzole (Rilutek) Sevelamer Carbonate 800mg Tablet (Renvela) Sodium Polystyrene Sulfonate (Kayexalate) COMMONLY PRESCRIBED NONFORMULARY PRODUCTS Sodium Polystyrene Sulfonate Enema (ml) (Sodium Polystyrene Sulfonate) DRUG NAME [PA] [QL] Nicotrol Inhaler [PREVENT] BRANDS [PA] [QL] Nicotrol Nasal Spray [PREVENT] [PA] Carbaglu (Carglumic Acid) Chemet (Succimer) [PA] Fosrenol (Lanthanum Carbonate) 16.3 Anorexiants Kuvan (Sapropterin Dihydrochloride) Numoisyn (Calcium Phosphate/Saliva Stimulant Agents Combin/Malic Acid/ FORMULARY PRODUCTS Sorbitol Lozenge) DRUG NAME Renagel (Sevelamer HCl) GENERICS Thalomid (Thalidomide) Benzphetamine HCl (Didrex)

Diethylpropion HCl Tablet (Tenuate) Phendimetrazine Tartrate (Bontril PDM) COMMONLY PRESCRIBED NONFORMULARY PRODUCTS Phendimetrazine Tartrate Capsule, Sustained Action (Prelu-2) DRUG NAME Phentermine HCl (Fastin) [PA] Auryxia BRANDS [PA] Cerdelga Xenical (Orlistat) [PA] [QL] Egrifta

Exjade [PA] [QL] Ferriprox COMMONLY PRESCRIBED NONFORMULARY PRODUCTS [PA] [QL] Firazyr DRUG NAME [PA] Fosrenol Oral Powder [PA] [QL] Belviq [PA] [QL] Grastek [PA] [QL] Contrave [PA] [QL] Hetlioz [PA] [QL] Qsymia [PA] Increlex [PA] [QL] Suprenza [PA] [QL] Myalept [PA] [QL] Oralair [PA] [QL] Ragwitek Renvela powder, oral [PA] [QL] Ruconest [PA] [QL] Velphoro [PA] [QL] Zavesca

[PA] In limited circumstances, prior authorization may apply, based upon [PREVENT] Prevent drugs may be covered at $0 if criteria are met. For a individual plan design. detailed description, see Drug List Medication Coverage. [QL] In limited circumstances, quantity limits may apply, based upon individual plan design. 44 INDEX Index A Albuterol Sulfate/Ipratropium Bromide Androgens, Estrogens, Hormones & Related A/T/S ...... 23 Aerosol w/Adapter ...... 41 Drugs ...... 9 Abacavir Sulfate ...... 7 Alclometasone Dipropionate Ointment(gm) ...... 22 Anexsia ...... 11 Abacavir Sulfate Tablet ...... 7 Aldactazide ...... 19 Angeliq ...... 35 Abacavir Sulfate/Lamivudine ...... 7 Aldactone ...... 19 Angiotensin II Receptor Blockers ...... 20 Abacavir Sulfate/Lamivudine/Zidovudine ...... 7 Aldara ...... 24 Anorexiants...... 44 Abacavir/Dolutegravir/Lamivudine ...... 7 Aldomet ...... 20 Anoro Ellipta ...... 41 Abilify...... 16 Aldoril ...... 20 Ansaid ...... 12,32 Abilify Discmelt ...... 16 Alendronate Sodium ...... 33 Antabuse...... 44 Alesse ...... 34 Antara...... 21 Abiraterone Acetate ...... 9 ...... 24 Absorica ...... 23 Alfuzosin HCl ...... 42 Anthralin Alglucerase ...... 27 Antiandrogens ...... 9 Abstral ...... 11 Antiarrhythmic Agents ...... 18 ...... 44 Alinia ...... 8 Acamprosate Calcium ...... 24 Antibiotics ...... 37 Acanya ...... 23 Alitretinoin Alkeran ...... 9 Anticholinergics & Antispasmodics ...... 42 Acarbose ...... 28 Alkylating Agents ...... 9 Anticoagulants ...... 18,43 Accolate ...... 41 Allegra ...... 39 Anticonvulsants ...... 14 Accu-Chek Active ...... 28 Allegra-D 12 Hr ...... 39 Antidepressant Agents ...... 15 Accu-Chek Aviva ...... 28 Allegra-D 24 Hr ...... 39 Antidiarrheals ...... 29 Accu-Chek Aviva Plus...... 28 Allopurinol ...... 32 Antidiarrheals & Antispasmodics ...... 29 Accu-Chek Comfort Curve...... 28 Alocril...... 38 Antiestrogens ...... 9 Accu-Chek Compact Plus...... 28 Alomide ...... 38 Antifungal Agents ...... 7 Accu-Chek Softclix ...... 28 Alora ...... 33,34 Antihistamine & Antiallergenic Agents...... 39 Accuneb ...... 40 Alphagan ...... 37 Antihistamines ...... 39 Accupril ...... 19 Alphagan P ...... 37 Antihypertensive Therapy ...... 19 Accuretic...... 20 Alphagan P 0.1% ...... 37 Antimalarials ...... 8 Ace Inhibitors ...... 19 Alphaquin HP ...... 24 Antimetabolites ...... 9 Acebutolol HCl ...... 19 Alprazolam ...... 17 Antimycobacterials ...... 8 Aceon ...... 19 Alprazolam Tablets, Oral Disintegrating ...... 17 Antineoplastic & Immunosuppressant Drugs . . . . . 9 Acetaminophen With Codeine ...... 13 Alprazolam, Sustained Release 24hr ...... 17 Antiparasitics ...... 8 Acetaminophen/Butalbital ...... 11,13 Alprostadil ...... 42 Antiparkinsonism Agents ...... 13 Acetaminophen/Caffeine/Butalbital ...... 11,13 Alprostadil Suppository, Urethral ...... 42 Antiplatelet Drugs ...... 18,43 Acetazolamide ...... 14,36 Alrex ...... 37 Antipsoriatic/Antiseborrheic ...... 24 Acetazolamide Capsules Extended Release ...... 36 Alsuma ...... 13 Antipsychotics ...... 16 Acetic Acid/Hydrocortisone ...... 25 Altace ...... 19 Antipyrine/Benzocaine/Glycerin ...... 25 Acetylcysteine Vial (SDV,MDV or Additive) Altoprev ...... 21 Antispasmodics ...... 29 (ml) ...... 41 Altretamine ...... 10 Antithyroid Agents ...... 26 Achromycin V...... 5 Aluminum Chloride ...... 24 Antitussive Combinations ...... 39 Aciphex...... 29 Alupent...... 40 Antivert ...... 13,30 Aciphex Sprinkle...... 29 Alvesco ...... 40 Antivertigo & Antiemetic Agents ...... 30 Acitretin ...... 24 Amantadine HCl ...... 6 Antivertigo & Antiemetic Drugs ...... 13 Aclidinium Bromide ...... 41 Amantadine HCl Tablet ...... 13 Antivirals ...... 6,38 Aclovate ...... 22 Amaryl ...... 28 Anusol-HC ...... 30 Actemra (syringe) ...... 33 Ambien...... 15 Anxiolytics ...... 17 Acticlate ...... 5 Ambien CR ...... 15 Anzemet...... 13,30 Actigall ...... 29 Ambrisentan ...... 41 Apidra...... 27 Actimmune...... 31 Amcinonide ...... 22 Apixaban ...... 18,43 Actiq...... 11 Amerge ...... 13 Aplenzin ...... 15 Activella...... 33,35 Amicar...... 18,43 Apokyn...... 13 Actonel ...... 33 Amiloride HCl Tablet ...... 19 Apomorphine HCl Cartridge (ml) ...... 13 Actoplus Met ...... 28 Amiloride HCl/Hydrochlorothiazide ...... 19 Aprepitant ...... 13,30 Actoplus Met XR ...... 28 Aminocaproic Acid ...... 18,43 Apresoline...... 20 Actos...... 28 Aminophylline ...... 40 Apriso ...... 30 Acuvail ...... 36 Aminophylline ...... 40 Aptiom ...... 14 Acyclovir ...... 6 Amiodarone HCl Tablet ...... 18 Aptivus ...... 7 Acyclovir Cream ...... 23 Amitiza ...... 30 Aptivus Oral Solution...... 7 Acyclovir Ointment ...... 23 Amitriptyline HCl ...... 15 Aralen ...... 8 Aczone ...... 23 Amlodipine Besylate ...... 19 Aranesp ...... 10,31 Adalat CC...... 19 Amlodipine Besylate/ Olmesartan Medoxomil . . . . . 20 Arava ...... 33 Adalimumab ...... 33 Amlodipine Besylate/Benazepril HCl ...... 20 Arcalyst...... 31 Adapalene ...... 23 Amlodipine/Atorvastatin ...... 19,21 Arcapta Neohaler ...... 40 Adapalene 0.3% gel ...... 23 Amlodipine/Valsartan ...... 20 Aricept ...... 14 Adcirca ...... 41 Amlodipine/Valsartan HCTZ ...... 20 Aricept 23mg ...... 14 Adderall ...... 17 Amoxapine ...... 15 Aricept ODT ...... 14 Adderall XR ...... 17 Amoxicillin ...... 5 Arimidex...... 9 Adefovir Dipivoxil ...... 6 Amoxicillin Trihydrate/Potassium Aripiprazole ...... 16 Adempas ...... 41 Clavulanate ...... 5 Arixtra ...... 18,43 Adjunctive Agents...... 10 Amoxicillin/Potassium Clavulanate ...... 5 Arnuity Ellipta ...... 40 Adoxa ...... 5 Amoxil ...... 5 Aromasin ...... 9 Adrenal Hormones ...... 26 Amphetamine Aspartate/Amphetamine Sulfate/ Artane...... 13 Adrenergic Antagonists & Related Drugs ...... 20 Dextroamphetamine Capsules, Sustained Artemether/Lumefantrine ...... 8 Adrenergics ...... 39 Release ...... 17 Arthrotec ...... 12,32 Advair Diskus ...... 41 Amphetamine Aspartate/Amphetamine Sulfate/ Asacol HD ...... 30 Advair HFA ...... 41 Dextroamphetamine ...... 17 Asendin...... 15 Advicor ...... 21 Ampicillin Trihydrate ...... 5 Asmanex ...... 40 Aerospan HFA ...... 40 Ampyra...... 14 Asmanex HFA ...... 40 Afatinib ...... 10 Amrix ...... 14,33 Aspirin/Caffeine/Butalbital ...... 11,13 Afinitor...... 10 Amturnide ...... 20 Aspirin/Dipyridamole ...... 43 Afinitor Disperz ...... 10 Amylase/Lipase/Protease ...... 30 Aspirin/Dipyridamole Capsule, Multiphasic Afrezza ...... 27 Anadrol-50 ...... 26 Release ...... 18 Agents For Pheochromocytoma ...... 20 Anafranil...... 15 Astagraf XL...... 9 Aggrenox ...... 18,43 Anagrelide HCl ...... 44 Astelin ...... 25,39 Agrylin ...... 44 Analpram-HC...... 30 Astepro ...... 25,39 Akynzeo ...... 30 Analpram-HC 1%-1% ...... 30 Atacand...... 20 Albalon ...... 36 Anaprox...... 12,32 Atacand HCT...... 20 Albenza...... 8 Anaprox DS...... 12,32 Atarax ...... 39 Albuterol Aerosol ...... 40 Anastrozole ...... 9 Atazanavir Sulfate ...... 7 Albuterol Solution, Non-Oral ...... 40 Ancobon...... 7 Atelvia...... 33 Albuterol Sulfate ...... 40 Androderm ...... 26 Atenolol ...... 19 Albuterol Sulfate Solution, Non-Oral ...... 40 Androgel...... 26 Atenolol/Chlorthalidone ...... 20 Albuterol Sulfate/Ipratropium Bromide ...... 41 Androgens ...... 26 Ativan ...... 17

45 Atomoxetine HCl Capsule (Hard, Soft, Etc.) ...... 17 Betagan...... 36 Bydureon ...... 28 Atorvastatin Calcium ...... 21 Betamethasone ...... 22 Byetta ...... 28 Atovaquone ...... 8 Betamethasone Dipropionate ...... 22 Bystolic...... 19 Atovaquone/Proguanil HCl ...... 8 Betamethasone Dipropionate Ointment ...... 22 Atralin Gel ...... 23 Betamethasone Dipropionate/Propylene Atripla ...... 7 Glycol Cream (Grams) ...... 22 C Atropine Sulfate ...... 36 Betamethasone Valerate ...... 22 Cabergoline ...... 27 Atrovent...... 25,41 Betamethasone Valerate Ointment(gm) ...... 22 Cabozantinib ...... 10 Atrovent HFA...... 41 Betapace ...... 18 Caduet...... 19,21 Aubagio ...... 14 Betapace AF ...... 18 Cafergot ...... 13 Augmentin ...... 5 Betaseron ...... 31 Calan ...... 19 Augmentin ES ...... 5 Betatrex...... 22 Calan SR ...... 19 Augmentin Suspension, Reconstituted Betatrex 0.10% ...... 22 Calcipotriene ...... 22,24 125-31.25mg/5ml ...... 5 Betaxolol HCl ...... 19,36 Calcipotriene/Betamethasone ...... 24 Augmentin XR ...... 5 Bethanechol Chloride ...... 42 Calcipotriene/Bethamethasone Dipropionate Auralgan ...... 25 Bethkis ...... 8 Ointment ...... 22 Auranofin ...... 33 Betoptic ...... 36 Calcitonin Salmon Recombinant ...... 27,33 Auryxia ...... 44 Betoptic S ...... 36 Calcitonin, Salmon, Synthetic ...... 27,33 Auvi-Q ...... 39 Beyaz ...... 34 Calcitriol ...... 22,24 Avalide ...... 20 Biaxin ...... 5 Calcitriol Capsule (Hard, Soft, Etc.) ...... 27 Avandamet ...... 28 Biaxin XL ...... 5 Calcitriol Liquid (ml) ...... 27 Avandaryl ...... 28 Bicalutamide ...... 9 Calcitriol Solution, Oral ...... 27 Avandia...... 28 BiDil...... 20 Calcium Acetate ...... 43 Avapro ...... 20 Bile Acids ...... 29 Calcium Channel Blockers ...... 19 AVC ...... 35 Biltricide...... 8 Calcium Channel Blockers/Dihydropyridines. . . . 19 Avelox...... 6 Bimatoprost ...... 36 Calcium Channel Blockers/Non- Avinza...... 11 Binosto ...... 33 Dihydropyridines ...... 19 Avodart...... 42 Biohist-LA ...... 39 Calcium Phosphate/Saliva Stimulant Agents Avonex ...... 31 Biotechnology Drugs ...... 31 Combin/Malic Acid/Sorbitol Lozenge ...... 44 Avonex Pen ...... 31 Bisacodyl/Sodium Chloride/Sodium Cambia ...... 12,32 Axert...... 13 Bicarbonate/Potassium Chloride/ Campral ...... 44 Axid ...... 29 Polyethylene Glycol 3350 ...... 30 Canasa ...... 30 Axiron...... 26 Bismuth/Metronidazole/Tetracycline) ...... 29 Candesartan Cilexetil ...... 20 Axitinib ...... 10 Bisoprolol Fumarate ...... 19 Candesartan Cilexetil/Hydrochlorothiazide ...... 20 Aygestin ...... 34 Bisoprolol Fumarate/Hydrochlorothiazide ...... 20 Cantil ...... 29 Azasan...... 9 Bleph-10...... 37 Capecitabine ...... 9 Azathioprine ...... 9,33 Blephamide...... 37 Capex Shampoo 0.01% ...... 22 Azelaic Acid Gel ...... 23 Blephamide S.O.P...... 37 Capoten ...... 19 Azelastine ...... 25,39 Blocadren ...... 19 Capozide...... 20 Azelastine HCl ...... 38 Blood-Glucose Measuring Equipment Kit ...... 28 Caprelsa ...... 10 Azelex ...... 23 Boceprevir ...... 6,42 Captopril ...... 19 Azilect...... 13 Boniva ...... 33 Captopril/Hydrochlorothiazide ...... 20 Azithromycin Suspension, Reconstituted, Bontril PDM ...... 44 Carafate ...... 29 Oral (ml) ...... 5 Bosentan ...... 41 Carbachol ...... 36 Azithromycin Tablet ...... 5 Bosulif ...... 10 Carbaglu...... 44 Azopt ...... 36 Bosutinib ...... 10 Carbamazepine ...... 14 Azor ...... 20 Bowel Evacuants ...... 30 Carbamazepine Tablet, Sustained Release Azulfidine ...... 30,33 Bravelle ...... 26,35 12hr ...... 14 Azulfidine EN-tabs ...... 33 Breo Ellipta...... 41 Carbatrol ...... 14 Brethine...... 35,40 Carbatuss ...... 39 Brevicon ...... 34 Carbidopa ...... 13 B Brilinta ...... 18,43 Carbidopa/Levodopa ...... 13 B-D Insulin Syringe ...... 28 Brimonidine 0.15% ...... 37 Carbidopa/Levodopa Tablet, Sustained Baclofen ...... 33 Brimonidine Tartrate ...... 37 Action ...... 13 Baclofen Tablet ...... 14 Brintellix...... 15 Carbidopa/Levodopa/Entacapone ...... 13 Bactrim DS...... 6 Brinzolamide ...... 36 Cardiac Glycosides ...... 18 Bactroban ...... 23 Brisdelle ...... 16 Cardizem ...... 19 Bactroban Nasal ...... 23 Bromday...... 36 Cardizem CD ...... 19 Balsalazide Disodium ...... 30 Bromfed ...... 39 Cardizem LA ...... 19 Banzel ...... 14 Bromfed-DM ...... 39 Cardura ...... 20,42 Baraclude ...... 6 Bromfenac Sodium ...... 36 Carglumic Acid ...... 44 Baraclude Oral Solution ...... 6 Bromocriptine Mesylate ...... 13 Carisoprodol ...... 33 BC, powder, oral...... 30 Brovana...... 40 Carisoprodol Tablet ...... 14 Beclomethasone Dipropionate ...... 40 Budesonide ...... 25 Carisoprodol/Aspirin ...... 14,33 Beconase AQ ...... 25,40 Budesonide Aerosol Powder, Breath Carmol 10%...... 24 Bedaquiline ...... 8 Activated (ea) ...... 40 Carmol 40 ...... 24 Belladonna Alkaloids/Phenobarbital ...... 29 Budesonide Ampul for Nebulization (ml) ...... 40 Carmol HC ...... 24 Belsomra...... 15 Budesonide Capsule, Sustained Release 24 hr . . . . . 30 Carnitor ...... 44 Belviq ...... 44 Budesonide Respules 0.25mg & 0.5mg ...... 40 Carteolol HCl ...... 36 Benadryl ...... 13,39 Budesonide Spray ...... 40 Carvedilol ...... 19 Benazepril HCl ...... 19 Budesonide/Formoterol Fumarate Dihydtrate ...... 41 Casodex ...... 9 Benazepril HCl/Hydrochlorothiazide ...... 20 Bumetanide ...... 19 Cataflam ...... 12,32 Benicar ...... 20 Bumex ...... 19 Catapres ...... 20 Benicar HCT ...... 20 Bunavail ...... 12 Catapres-TTS ...... 20 Benign Prostatic Hyperplasia (BPH) Therapy. . . . 42 Buphenyl Oral Powder ...... 27 Caverject...... 42 Bentyl ...... 29,42 Buphenyl Tablets ...... 27 Cayston ...... 8 Benzaclin ...... 23 Buprenorphine HCl/Naloxone HCl ...... 12 Ceclor...... 5 Benzamycin ...... 23 Bupropion HCl Tablet ...... 15 Cedax ...... 5 Benzoyl Peroxide...... 23 Bupropion HCl Tablet, Sustained Action ...... 15 Cedax (90mg/5mL oral suspension) ...... 5 Benzoyl Peroxide Rx ...... 23 Bupropion HCl Tablet, Sustained Release 24 hr . . . 15 Cefaclor ...... 5 Benzoyl Peroxide/Adapalene ...... 23 Bupropion HCl, Sustained Action ...... 44 Cefadroxil Hydrate ...... 5 Benzoyl Peroxide/Clindamycin ...... 23 Burn Therapy ...... 23 Cefdinir ...... 5 Benzphetamine HCl ...... 44 Buspar ...... 17 Cefditoren 400mg only ...... 5 Benztropine Mesylate ...... 13 Buspirone HCl ...... 17 Cefixime ...... 5 Benzyl Alcohol ...... 24 Busulfan ...... 9 Cefpodoxime Proxetil Tablet ...... 5 Bepreve...... 38 Butalbial/Acetaminophen/Caffeine ...... 11 Cefprozil ...... 5 Besifloxacin ...... 37 Butenafine HCl ...... 23 Cefprozil Suspension, Reconstituted, Oral ...... 5 Besivance ...... 37 Butisol Sodium ...... 15 Ceftibuten ...... 5 Beta Agonists Inhalers ...... 40 Butoconazole Nitrate Cream ...... 35 Ceftibuten, Reconstituted 180mg/5ml ...... 5 Beta Agonists Oral ...... 40 Butrans ...... 11 Ceftin ...... 5 Beta-Blockers ...... 19,36 Butyrophenones ...... 16 Ceftin Suspension...... 5

46 Cefuroxime Axetil ...... 5 Clobetasol Propionate Lotion (ml) ...... 22 Cromolyn Sodium ...... 30,38 Cefuroxime Axetil Suspension, Clobetasol Propionate Shampoo ...... 22 Cromolyn Sodium Ampul for Nebulization Reconstituted, Oral (ml) ...... 5 Clobetasol Propionate/Emollient ...... 22 (ml) ...... 41 Cefzil ...... 5 Clobex ...... 22 Crotamiton ...... 24 Celebrex...... 12,32 Clobex Spray ...... 22 Cuprimine ...... 33 Celecoxib ...... 12,32 Clocortolone Pivalate Cream ...... 22 Cutivate ...... 22 Celexa...... 16 Clocortolone Pivalate Cream (Grams) ...... 22 Cyanocobalamin/Folic Acid ...... 43 CellCept ...... 9 Cloderm 0.10% ...... 22 Cyclessa ...... 34 Cenestin ...... 34 Clomid ...... 26,35 Cyclobenzaprine ...... 33 Centany ...... 23 Clomiphene Citrate ...... 26,35 Cyclobenzaprine HCl ...... 14,33 Cephalexin Monohydrate ...... 5 Clomipramine HCl ...... 15 Cyclocort ...... 22 Cephalosporins ...... 5 Clonazepam ...... 14 Cyclogyl 1% ...... 36 Cephulac ...... 30 Clonazepam Tablet, Rapid Dissolve ...... 14 Cyclopentolate HCl Drops ...... 36 Cerdelga ...... 44 Clonidine HCl ...... 20 Cyclophosphamide Capsule ...... 9 Ceredase ...... 27 Clonidine HCl Extended-Release ...... 17 Cyclophosphamide Tablet ...... 9 Cerezyme ...... 27 Clonidine HCl Patch, Transdermal Weekly ...... 20 Cycloplegic Mydriatics ...... 36 Ceritinib ...... 10 Clonidine HCl/Chlorthalidone Tablet ...... 20 Cycloserine ...... 8 Cetirizine HCl ...... 39 Clopidogrel Bisulfate ...... 18,43 Cycloserine ...... 8 Cetirizine Rx ...... 39 Clorazepate Dipotassium Tablet ...... 17 Cycloset ...... 28 Cetraxal ...... 25 Clorpres ...... 20 Cyclosporine ...... 9,38 Cetrorelix Acetate ...... 27,35 Clotrimazole Troche ...... 7 Cyclosporine, Modified Capsule (Hard, Soft, Cetrotide ...... 27,35 Clotrimazole/Betamethasone Dipropionate Etc.) ...... 9 Cevimeline HCl ...... 44 Cream (Grams) or Lotion (ml) ...... 23 Cymbalta ...... 15 Chantix...... 44 Clozapine ...... 16 Cyproheptadine HCl ...... 39 Chemet...... 44 Clozapine ODT ...... 16 Cystagon...... 42 Chenodal ...... 29 Clozaril...... 16 Cystaran ...... 38 Chloral Hydrate ...... 15 Coagulation Therapy ...... 18,43 Cysteamine Bitartrate ...... 42 Chloral Hydrate ...... 15 Coartem ...... 8 Cysteamine HCl ...... 38 Chlorambucil ...... 9 Cobicistat ...... 7 Cystospaz ...... 42 Chlordiazepoxide HCl ...... 17 Cocet ...... 13 Cytomel ...... 26 Chloroquine Phosphate ...... 8 Codal-DM ...... 39 Cytotec ...... 29 Chlorothiazide ...... 19 Codeine Phosphate/Acetaminophen ...... 11 Cytoxan ...... 9 Chlorpromazine HCl ...... 16 Codeine Phosphate/Acetaminophen/Caffeine/ Chlorpropamide ...... 28 Butalbital ...... 11 Chlorthalidone ...... 19 Codeine Phosphate/Aspirin/Caffeine/ D Chlorzoxazone ...... 14,33 Butalbital ...... 11 D-Amphetamine Sulfate ...... 17 Choline Mag Trisalicylate...... 12,32 Codeine Sulfate...... 11 D-Amphetamine Sulfate Capsule, Sustained Choline Salicylate/Magnesium Salicylate ...... 12 Codeine Sulfate ...... 11 Action ...... 17 Choline Salicylate/Magnesium Salicylate Codeine/Promethazine HCl ...... 39 D.H.E.45 ...... 13 Tablet ...... 32 Cogentin...... 13 Dabigatran ...... 18,43 Cholinergic Stimulants ...... 42 Colazal ...... 30 Dabrafenib ...... 10 Cholinesterase Inhibitor Miotics...... 36 Colchicine ...... 32 Daliresp ...... 41 Chorionic Gonadotropin ...... 27 Colchicine/Probenecid ...... 32 Dallergy ...... 39 Chorionic Gonadotropin, Human ...... 27 Colcrys ...... 32 Dalmane ...... 15 Chromagen fa...... 43 Colesevelam HCl ...... 21 Dalteparin Sodium, Porcine ...... 18,43 Cialis ...... 42 Colestid ...... 21 Danazol ...... 26 Ciclesonide ...... 40 Colestipol ...... 21 Danocrine...... 26 Ciclopirox ...... 23 Collagenase ...... 23 Dantrium...... 14,33 Cilostazol ...... 43 Coly-Mycin S ...... 25 Dantrolene Sodium ...... 14,33 Cilostazol Tablet ...... 18 Colyte...... 30 Dapsone ...... 8 Ciloxan...... 37 Combigan...... 36 Dapsone ...... 8,23 Cimetidine HCl Liquid (ml) ...... 29 Combination Anticholinergics ...... 29 Daraprim ...... 8 Cimetidine Tablet Rx ...... 29 Combination Narcotic/Analgesics ...... 11 Darbepoetin Alfa in Albumin Sol ...... 10,31 Cimzia (syringe) ...... 33 Combipatch ...... 35 Darifenacin Hydrobromide ...... 14,33 Cinacalcet HCl ...... 27 Combivent Respimat ...... 41 Darunavir Ethanolate ...... 7 Cipro ...... 6 Combivir ...... 7 Dasatinib ...... 10 Cipro HC...... 25 Combunox ...... 11 Daypro ...... 12,32 Cipro XR ...... 6 Cometriq ...... 10 Daytrana...... 17 Ciprodex...... 25 Compazine ...... 13,30 DDAVP ...... 27 Ciprofloxacin HCl - Betaine Combination Compazine 25mg ...... 13 Decadron...... 26,32,37,39 Tablet, Sustained Release 24hr ...... 6 Complera ...... 7 Deconamine ...... 39 Ciprofloxacin HCl Drops ...... 25,37 Comtan ...... 13 Deconamine SR ...... 39 Ciprofloxacin HCl Ointment(gm) ...... 37 Concerta...... 17 Decongestant/Antihistamines ...... 39 Ciprofloxacin HCl Tablet ...... 6 Condylox ...... 24 Del-Mycin ...... 23 Ciprofloxacin HCl/Dexamethasone Suspension, Contrave...... 44 Delatestryl ...... 26 Drops (Final Dosage Form)(ml) ...... 25 Copaxone ...... 14,31 Delavirdine Mesylate ...... 7 Ciprofloxacin HCl/Hydrocortisone ...... 25 Copegus ...... 6 Deltuss ...... 39 Ciprofloxacin Suspension ...... 6 Cordarone...... 18 Delzicol ...... 30 Citalopram Hydrobromide ...... 16 Cordran 4mcg/sq cm ...... 22 Demadex ...... 19 Clarinex ...... 39 Coreg ...... 19 Demerol ...... 11 Clarinex Syrup ...... 39 Coreg CR ...... 19 Demulen...... 34 Clarinex-D ...... 39 Corgard ...... 19 Denavir...... 23 Clarithromycin ...... 5 Cortef ...... 26,32,39 Depakene ...... 14 Claritin OTC ...... 39 Cortenema ...... 30 Depakote ...... 14 Claritin-D...... 39 Corticosteroids ...... 32,39 Depakote ER ...... 14 Clemastine Fumarate ...... 39 Cortifoam...... 30 Depakote Sprinkle ...... 14 Cleocin HCl ...... 8 Cortisone Acetate ...... 26,32,39 Depo-Provera ...... 10 Cleocin T ...... 23 Cortisone Acetate ...... 26,32,39 Depo-Provera 400mg/ml ...... 34 Clidinium Bromide/Chlordiazepoxide ...... 29 Cortisporin ...... 25,37 Depo-Provera, Provera ...... 34 Climara ...... 33,34 Cortisporin-TC...... 25 Depo-Subq Provera ...... 10,34 Climara Pro ...... 33 Cosopt ...... 36 Depo-Testosterone ...... 26 Clindamycin 1% ...... 23 Cough & Cold Therapy ...... 39 Desipramine HCl ...... 15 Clindamycin HCl ...... 8 Coumadin ...... 18,43 Desloratadine ...... 39 Clindamycin Phosphate ...... 23 Covera-HS ...... 19 Desmopressin Acetate Solution, Non-Oral ...... 27 Clindamycin Phosphate/Benzoyl Peroxide ...... 23 Cozaar ...... 20 Desmopressin Acetate Tablet ...... 27 Clindamycin Phosphate/Benzoyl Peroxide Creon ...... 30 Desogen ...... 34 Pump ...... 23 Crestor ...... 21 Desogestrel-Ethinyl Estradiol ...... 34 Clindamycin/Tretinoin ...... 23 Crinone ...... 34 Desogestrel-Ethinyl Estradiol/Ethinyl Clindesse ...... 35 Crixivan ...... 7 Estradiol ...... 34 Clinoril ...... 12,32 Crizotinib ...... 10 Desonide Cream (Grams) ...... 22 Clobetasol Propionate ...... 22 Crofelemer Delayed Release Capsule ...... 29 Desonide Lotion (ml) ...... 22

47 Desonide Ointment(gm) ...... 22 Diprosone...... 22 Electrolytes ...... 43 DesOwen ...... 22 Dipyridamole ...... 43 Elestrin ...... 34 Desoximetasone Cream (Grams) ...... 22 Dipyridamole Tablet ...... 18 Elidel ...... 24 Desoximetasone Gel (gm) ...... 22 Direct Acting Miotics ...... 36 Elimite ...... 24 Desoximetasone Ointment(gm) ...... 22 Disopyramide Phosphate ...... 18 Eliquis ...... 18,43 Desoxyn ...... 17 Disopyramide Phosphate Capsule, Sustained Ella ...... 34 Desvenlafaxine ER ...... 15 Action ...... 18 Elmiron ...... 42 Desvenlafaxine Fumarate ...... 15 Disulfiram ...... 44 Elocon ...... 22 Desyrel ...... 15 Ditropan...... 14,33,42 Eltrombopag Olamine ...... 18,43 Detrol ...... 14,33,42 Ditropan XL...... 14,33,42 Elvitegravir ...... 7 Detrol LA ...... 14,33,42 Diuril ...... 19 Elvitegravir/Cobicistat/Emtricitabine/ Dexamethasone ...... 32,39 Divalproex Sodium ...... 14 Tenofovir Disoproxil Fumerate ...... 7 Dexamethasone Sodium Phosphate ...... 37 Divalproex Sodium Sprinkle Capsules ...... 14 Emadine ...... 38 Dexamethasone Tablet, Dose Pack ...... 26,32 Divalproex Sodium Tablets, Delayed Release ...... 14 Embeda ...... 11 Dexchlorpheniramine Maleate ...... 39 Divigel ...... 34 Emcyt ...... 10 Dexchlorpheniramine Maleate ...... 39 Dofetilide ...... 18 Emend...... 13,30 Dexedrine ...... 17 Dolasetron Mesylate Tablet ...... 13,30 Emla ...... 22 Dexilant ...... 29 Dolobid ...... 12,32 Emtricitab/Rilpivirine/Tenofov ...... 7 Dexmethylphenidate HCl ...... 17 Dolophine HCl ...... 11 Emtricitabine ...... 7 Dexmethylphenidate HCl Extended-Release ...... 17 Dolutegravir ...... 7 Emtricitabine/Tenofovir Disoproxil Dextromethorphan HBr/Phenylephrine HCl/ Donatussin ...... 39 Fumarate ...... 7 Pyrilamine ...... 39 Donepezil HCl ...... 14 Emtriva...... 7 Dextromethorphan HBr/Pseudoephedrine HCl/ Donepezil HCl Tablet, Rapid Dissolve ...... 14 Enablex ...... 14,33 Brompheniramine ...... 39 Donnatal...... 29 Enalapril Maleate ...... 19 Dextromethorphan HBr/Pseudoephedrine HCl/ Doral ...... 15 Enalapril Maleate/Hydrochlorothiazide ...... 20 Chlorpheniramine ...... 39 Dornase Alfa Solution, Non-Oral ...... 41 Enbrel...... 33 Dextromethorphan HBR/Quinidine ...... 14 Doryx ...... 5 Endometrin ...... 34 DiaBeta...... 28 Doryx 200mg ...... 5 Enfuvirtide ...... 7 Diabetes Therapy ...... 27 Dorzolamide HCl ...... 36 Enjuvia ...... 33,34 Diabinese ...... 28 Dostinex ...... 27 Enoxaparin ...... 18 Diamox ...... 14,36 Dovonex ...... 22,24 Enoxaparin Sodium ...... 43 Diamox Sequels ...... 36 Doxazosin Mesylate ...... 20,42 Entacapone ...... 13 Diaphragms And Other Non-Oral Doxepin HCl ...... 15 Entecavir ...... 6 Contraceptives ...... 35 Doxercalciferol Capsule ...... 27 Entex PSE...... 39 Diastat ...... 14 Doxycycline Calcium Syrup ...... 5 Entocort EC ...... 30 Diastat Acudial ...... 14 Doxycycline Hyclate Capsule (Hard, Soft, Etc.) . . . . . 5 Enzalutamide ...... 9 Diazepam ...... 33 Doxycycline Hyclate Tablet ...... 5 Epaned ...... 19 Diazepam ...... 14,17,33 Doxycycline Hyclate Tablet, Enteric Coated ...... 5 Epanova ...... 21 Diazepam Tablet ...... 33 Doxycycline Monohydrate ...... 5 Ephedrine Sulfate ...... 40 Dibenzyline ...... 20 Doxycycline Monohydrate Suspension, Ephedrine Sulfate ...... 40 Diclegis...... 30 Reconstituted, Oral (ml) ...... 5 Epiduo ...... 23 Diclofenac Potassium ...... 12,32 Dritho-Scalp ...... 24 Epinephrine ...... 39 Diclofenac Sodium ...... 12,32,36 Dronabinol ...... 13,30 Epinephrine 0.15mg/0.15ml and 0.3mg/0.3ml Diclofenac Sodium 1.5% ...... 12,32 Dronedarone HCl ...... 18 Auto Injection ...... 39 Diclofenac Sodium Gel ...... 24 Drospirone/Estradiol/Levomefol ...... 34 EpiPen ...... 39 Diclofenac Sodium Tablet, Sustained Droxia...... 10 EpiPen Jr...... 39 Release 24hr ...... 12,32 Drugs To Treat Infertility/IVF Agents ...... 35 Epivir ...... 7 Diclofenac Sodium-Misoprostol ...... 12,32 Drysol...... 24 Epivir Solution ...... 7 Dicloxacillin Sodium ...... 5 Duac...... 23 Epivir-HBV ...... 7 Dicyclomine HCl ...... 29,42 Duavee ...... 33 Epivir-HBV Solution ...... 7 Dicyclomine HCl Syrup ...... 42 Duetact...... 28 Eplerenone ...... 19 Didanosine Capsule,Delayed Release Duexis ...... 12,32 Epoetin Alfa ...... 31 (Enteric Coated) ...... 7 Dulera...... 41 Epoetin Alfa Vial (mL) ...... 10 Didanosine Solution, Reconstituted, Oral ...... 7 Duloxetine ...... 15 Epogen ...... 10,31 Didrex ...... 44 Duoneb ...... 41 Eprosartan ...... 20 Didronel ...... 33 Duragesic ...... 11 Epzicom ...... 7 Diethylpropion HCl Tablet ...... 44 Duratuss DM ...... 39 Equetro...... 14 Difenoxin HCl/Atropine Sulfate ...... 29 Durezol...... 37 Ergocalciferol Capsule (Hard, Soft, Etc.) ...... 43 Differin...... 23 Duricef ...... 5 Ergomar ...... 13 Differin 0.1% cream, gel ...... 23 Dutasteride ...... 42 Ergotamine Tartrate Tablet, Sublingual ...... 13 Differin Lotion 0.1% ...... 23 Dutasteride/Tamsulosin HCl ...... 42 Ergotamine Tartrate/Caffeine ...... 13 Dificid ...... 5 Dyazide...... 19 Ergotamine Tartrate/Caffeine Suppository, Diflorasone Diacetate Cream (Grams) ...... 22 Dymista...... 25,40 Rectal ...... 13 Diflorasone Diacetate Ointment(gm) ...... 22 Dynacin ...... 5 Ergotamine Tartrate/Caffeine Tablet ...... 13 Diflorasone Diacetate/Emollient Cream DynaCirc ...... 19 Erivedge ...... 10 (Grams) ...... 22 Dynapen...... 5 Erlotinib HCl ...... 10 Diflucan...... 7,35 Dyrenium ...... 19 Ery-Tab 500mg...... 5 Diflunisal ...... 12,32 Eryc ...... 5 Difluprednate ...... 37 Erycette...... 23 Digestive Enzymes ...... 30 E EryPed Suspension, Reconstituted, Oral Digoxin Solution ...... 18 E.E.S...... 5 (ml) 400mg/5ml ...... 5 Digoxin Tablet ...... 18 EC-Naprosyn...... 12,32 Erythrocin Stearate ...... 5 Dihydroergotamine Mesylate ...... 13 Echothiophate Iodide ...... 36 Erythroid Stimulants ...... 31 Dilantin ...... 14 Econazole Nitrate ...... 23 Erythromycin Base ...... 5,37 Dilantin 30mg ...... 14 Ecoza ...... 23 Erythromycin Base Solution, Non-Oral ...... 23 Dilatrate-SR ...... 18 Edarbi...... 20 Erythromycin Base/Benzoyl Peroxide Gel Dilaudid ...... 11 Edarbyclor ...... 20 (gm) ...... 23 Diltiazem Extended Release (excluding Edecrin ...... 19 Erythromycin Base/Ethyl Alcohol Gel (gm)...... 23 120mg) ...... 19 Edex ...... 42 Erythromycin Base/Ethyl Alcohol Solution, Diltiazem HCl ...... 19 Edluar...... 15 Non-Oral ...... 23 Diltiazem HCl Capsule, Sustained Action ...... 19 Edurant...... 7 Erythromycin Base/Ethyl Alcohol Swab, Diltiazem HCl Capsule, Sustained Release Efavirenz ...... 7 Medicated ...... 23 24 hr ...... 19 Efavirenz/Emtricitabine/Tenofovir Erythromycin Ethylsuccinate ...... 5 Dimethyl Fumarate ...... 14 Disoproxil Fumarate ...... 7 Erythromycin Ethylsuccinate/Sulfisoxazole Diovan ...... 20 Effexor ...... 15 Acetyl ...... 5,6 Diovan HCT ...... 20 Effexor XR ...... 15 Erythromycin Stearate ...... 5 Diphenhydramine HCl ...... 13,39 Effient ...... 18,43 Erythromycins & Other Macrolides ...... 5 Diphenoxylate HCl/Atropine Sulfate ...... 29 Efudex ...... 24 Esbriet ...... 41 Diprolene ...... 22 Egrifta...... 44 Escitalopram Oxalate ...... 16 Diprolene 0.05% ...... 22 Elavil...... 15 Esgic ...... 11 Diprolene AF 0.05% ...... 22 Eldepryl ...... 13 Esgic-Plus ...... 11

48 Eskalith...... 17 Fazaclo (150mg, 200mg) ...... 16 FML ...... 37 Eskalith CR ...... 17 Fe Fumarate/Cal/E/Fa ...... 43 FML Forte ...... 37 Esomeprazole Strontium...... 29 Febuxostat ...... 32 FML S.O.P...... 37 Estazolam ...... 15 Felbamate ...... 14 Focalin ...... 17 Estrace ...... 34 Felbatol...... 14 Focalin XR 5mg, 15mg, 30mg, 40mg...... 17 Estrace Vaginal Cream ...... 34 Feldene ...... 12,32 Focalin XR Capsule, Multiphasic Release 50-50 . . 17 Estraderm ...... 34 Felodipine ER ...... 19 Folic Acid ...... 43 Estradiol ...... 33,34 Femara ...... 9 Folic Acid/Vitamin B Comp w-C ...... 43 Estradiol ...... 33,34 Femcon Fe ...... 34 Follistim AQ...... 26 Estradiol Patch, Transdermal Semiweekly . . . . . 33,34 Femhrt...... 33,35 Follitropin Alpha,Recombinant ...... 26,35 Estradiol Patch, Transdermal Weekly ...... 33,34 Femring ...... 34 Foltrate ...... 43 Estradiol Ring, Vaginal ...... 34 Fenofibrate ...... 21 Folvite...... 43 Estradiol Tablet ...... 34 Fenofibrate ...... 21 Fondaparinux Sodium ...... 18,43 Estradiol Vaginal Tablet ...... 34 Fenofibrate, Micronized ...... 21 Foradil ...... 40 Estradiol Valerate-Dienogest ...... 34 Fenofibric Acid ...... 21 Forfivo XL ...... 15 Estradiol/Levonogestrel ...... 33 Fenofibric Acid Delayed Release ...... 21 Formoterol Fumarate ...... 40 Estradiol/Norethindrone Acetate ...... 35 Fenoglide ...... 21 Fortamet ...... 28 Estradiol/Norethindrone Acetate 1.0-0.5mg . . . . 33,35 Fentanyl ...... 11 Forteo ...... 33 Estramustine Phosphate Sodium ...... 10 Fentanyl Citrate ...... 11 Fortesta...... 26 Estrasorb...... 34 Fentora ...... 11 Fortical ...... 33 Estring ...... 34 Ferriprox...... 44 Fortical Nasal ...... 27 Estrogel...... 34 Ferrous Fumarate/Folic Acid ...... 43 Fosamax ...... 33 Estrogen Combinations ...... 35 Ferrous Fumarate/Folic Acid/Multivitamins...... 43 Fosamax Plus D ...... 33 Estrogens ...... 34 Fesoterodine Fumarate ...... 42 Fosamax Weekly ...... 33 Estrogens & Progestins ...... 34 Fetzima ...... 15 Fosamprenavir Calcium Tablet ...... 7 Estrogens, Conjugated Synthetic B ...... 34 Fexofenadine HCl ...... 39 Fosinopril Sodium Tablet ...... 19 Estrogens, Conjugated Tablet ...... 33 Fexofenadine/Pseudoephedrine ...... 39 Fosinopril Sodium/Hydrochlorothiazide ...... 20 Estrogens, Conjugated, Synthetic B ...... 33 Fibricor...... 21 Fosrenol ...... 44 Estrogens, Conjugated, Synthetic Tablet ...... 34 Filgrastim ...... 10,31 Fosrenol Oral Powder ...... 44 Estrogens, Conjugated/Medroxyprogesterone Filgrastin ...... 31 Fragmin ...... 18,43 Acet ...... 35 Finacea ...... 23 Frova...... 13 Estrogens, Esterified/Methyltestosterone...... 35 Finasteride ...... 27,42 Fulyzaq ...... 29 Estrogens,Conjugated Cream (Grams) ...... 34 Fingolimod ...... 14 Furosemide ...... 19 Estrogens,Conjugated Tablet ...... 34 Fioricet ...... 11,13 Fuzeon ...... 7 Estropipate ...... 34 Fioricet w/Codeine ...... 11 Fycompa ...... 14 Estropipate Tablet ...... 33 Fiorinal ...... 11,13 Estrostep Fe ...... 34 Fiorinal w/Codeine ...... 11 Eszopiclone ...... 15 Firazyr...... 44 G Etanercept ...... 33 First Generation Cephalosporins ...... 5 Gabapentin ...... 14 Ethacrynic Acid ...... 19 Flagyl ...... 8 Gabitril 12mg, 16mg ...... 14 Ethinyl Estradiol/Drospirenone ...... 34 Flagyl ER ...... 8 Gabitril 2mg, 4mg ...... 14 Ethinyl Estradiol/Norethindrone Acetate ...... 33,35 Flavoxate HCl ...... 42 Galantamine Hydrobromide ...... 14 Ethosuximide ...... 14 Flecainide Acetate ...... 18 Galantamine Hydrobromide Extended-Release Ethosuximide Capsule (Hard, Soft, Etc.) ...... 14 Flector Patch ...... 12,32 Capsules ...... 14 Ethotoin ...... 14 Flexeril...... 14,33 Gammagard ...... 31 Ethynodiol D-Ethinyl Estradiol ...... 34 Flexmid...... 33 Gammaked ...... 31 Etidronate Sodium ...... 33 Flomax ...... 42 Gamunex-C ...... 31 Etodolac ...... 12,32 Flonase...... 25,40 Ganciclovir ...... 38 Etodolac Tablet, Sustained Release 24hr ...... 12,32 Florinef Acetate...... 26 Ganirelix ...... 27,35 Etonogestrel/Ethinyl Estradiol Ring, Flovent Diskus ...... 40 Ganirelix Acetate ...... 27,35 Vaginal ...... 35 Flovent HFA...... 40 Garamycin ...... 23,37 Etoposide ...... 10 Floxin ...... 6,25 Gastrocrom...... 30 Etravirine ...... 7 Fluconazole ...... 35 Gatifloxacin ...... 37 Eulexin ...... 9 Fluconazole Tablet ...... 7 Gattex...... 30 Eurax Cream...... 24 Flucytosine ...... 7 Gefitinib Tablet ...... 10 Eurax Lotion...... 24 Fludrocortisone Acetate ...... 26 Gel-Kam...... 25 Evamist...... 34 Flumadine...... 6 Gelnique...... 33 Everolimus ...... 10 Flunisolide ...... 25,40 Genotropin...... 31 Everolimus Tablet for Oral Suspension ...... 10 Fluocinolone Acetonide ...... 22 Gentamicin Sulfate ...... 23,37 Evista ...... 33 Fluocinolone Acetonide 0.01%...... 22 Geodon...... 16 Evoclin ...... 23 Fluocinolone Acetonide Cream (Grams) ...... 22 Giazo ...... 30 Evoxac ...... 44 Fluocinolone Acetonide Ointment(gm) ...... 22 Gilenya ...... 14 Evzio...... 12 Fluocinolone Acetonide Solution, Non-Oral...... 22 Gilotrif ...... 10 Exalgo...... 11 Fluocinonide ...... 22 Giltuss ...... 39 Exelderm...... 23 Fluocinonide/Emollient Cream (Grams) ...... 22 Glatiramer Acetate ...... 31 Exelon...... 14 Fluoride Ion/Iron/Vitamins A,C,and D ...... 43 Glatiramer Acetate Kit ...... 14 Exelon Patch...... 14 Fluoride Ion/Multivitamins ...... 43 Gleevec ...... 10 Exelon Solution ...... 14 Fluoride Ion/Multivitamins w-Iron ...... 43 Glimepiride ...... 28 Exemestane ...... 9 Fluoride Ion/Vitamins A,C,and D ...... 43 Glipizide ...... 28 Exenatide ...... 28 Fluorometholone ...... 37 Glipizide Tablet, Sustained Release Exforge ...... 20 Fluoroquinolones ...... 6 Osmotic Push ...... 28 Exforge HCT ...... 20 Fluorouracil Cream ...... 24 Glipizide/Metformin HCl ...... 28 Exjade...... 44 Fluorouracil Solution, Non-Oral ...... 24 Glucagon ...... 28 Expectorant Combinations ...... 39 Fluoxetine 60mg...... 16 Glucagon,Human Recombinant ...... 28 Extavia ...... 31 Fluoxetine HCl ...... 16 Glucophage...... 28 Ezetimibe ...... 21 Fluphenazine HCl ...... 16 Glucophage XR ...... 28 Ezetimibe/Simvastatin ...... 21 Flurandrenolide Tape, Medicated ...... 22 Glucose Elevating Agents ...... 28 Ezogabine ...... 14 Flurazepam HCl ...... 15 Glucotrol ...... 28 Flurbiprofen ...... 12,32 Glucotrol XL ...... 28 Flurbiprofen Sodium ...... 36 Glucovance ...... 28 F Flutamide ...... 9 Glyburide ...... 28 Fabior ...... 23 Fluticasone Furoate/Vilanterol ...... 41 Glyburide,Micronized ...... 28 Factive ...... 6 Fluticasone Propionate ...... 22,25,40 Glyburide/Metformin HCl ...... 28 Famciclovir ...... 6 Fluticasone Propionate Disk, with Glycopyrrolate ...... 29 Famotidine Rx ...... 29 Inhalation Device ...... 40 Glynase...... 28 Famvir ...... 6 Fluticasone Propionate/Salmeterol GoLYTELY...... 30 Fanapt...... 16 Xinafoate ...... 41 GoLYTELY Solution...... 30 Fareston ...... 9 Fluticasone Propionate/Salmeterol Gonadotropin & Related Agents ...... 27 Farxiga ...... 28 Xinafoate Disk, with Inhalation Device ...... 41 Gonadotropin, Chorionic, Human ...... 35 Fastin ...... 44 Fluvastatin Sodium ...... 21 Gonal-F ...... 26,35 Fazaclo ...... 16 Fluvoxamine Maleate ...... 15,16 Gonal-F RFF ...... 26,35

49 Goserelin Acetate ...... 10 Hydroxychloroquine Sulfate ...... 8,33 Insulin NPH Human Recombinant/Insulin Gout Therapy ...... 32 Hydroxypropyl Cellulose Insert ...... 38 Regular Human Rec Vial (SDV,MDV or Gralise ...... 14 Hydroxyurea ...... 10 Additive) (ml) ...... 27 Granisetron HCl ...... 13,30 Hydroxyzine HCl ...... 39 Insulin NPH Human Recombinant/Insulin Granix ...... 10,31 Hydroxyzine Pamoate ...... 39 Regular Human Rec Disposable Syringe (ml) . . . . 27 Grastek ...... 44 Hygroton ...... 19 Insulin NPH Human Semi-Synthetic ...... 27 Grifulvin V ...... 7 Hyoscyamine ...... 42 Insulin NPH Human Semi-Synthetic/Insulin Gris-Peg ...... 7 Hyoscyamine Sulfate ...... 42 Regular Human Rec ...... 27 Griseofulvin Ultramicrosize Tablet ...... 7 Hyoscyamine Sulfate Tablet, Rapid Dissolve . . . . 29,42 Insulin Regular Human Rec ...... 27 Griseofulvin, Microsize Suspension, Oral Hyoscyamine Sulfate Tablet, Sublingual ...... 29 Insulin Regular Human Rec Cartridge (ml)...... 27 (Final Dose Form) ...... 7 Hyoscyamine Sulfate Tablet, Sustained Insulin Regular Human Rec Disposable Griseofulvin, Microsize Tablet ...... 7 Release 12hr ...... 29 Syringe (ml) ...... 27 Growth Hormones ...... 31 Hypnotic Agents ...... 15 Insulin Regular Human Rec Vial (SDV,MDV or Guaifenesin/Carbetapentane Citrate/ HyQvia...... 31 Additive) (ml) ...... 27 Phenylephrine ...... 39 Hysingla ER ...... 11 Insulin Syringes/Miscellaneous Durable Guaifenesin/Dextromethorphan HBr ...... 39 Hytone ...... 22 Medical Equipment ...... 28 Guaifenesin/Dextromethorphan HBr/ Hytrin ...... 20,42 Insulin Therapy ...... 27 Phenylephrine ...... 39 Hyzaar ...... 20 Intal ...... 41 Guaifenesin/Dextromethorphan HBr/ Intelence ...... 7 Phenylephrine/Chlorpheniramine ...... 39 Interferon Alfa-2b,Recombinant ...... 31 Guaifenesin/Pseudoephedrine HCl ...... 39 I Interferon Alfacon-1 ...... 31 Guanfacine Extended Release ...... 20 Ibandronate Sodium 150mg Tablet ...... 33 Interferon Beta-1A ...... 31 Guanfacine HCl ...... 20 Ibuprofen ...... 12,32 Interferon Beta-1A/Albumin Human ...... 31 Gynazole-1 ...... 35 Ibuprofen/Oxycodone HCl ...... 11 Interferon Beta-1A/Albumin Human Iclusig ...... 10 Disposable Syringe (ml) ...... 31 Idelalisib ...... 10 Interferon Gamma-1b,Recombinant ...... 31 H Ilevro ...... 36 Interferons ...... 31 H2 Antagonists ...... 29 Iloprost ...... 41 Interleukins ...... 31 Halcion...... 15 Ilotycin ...... 37 Intermezzo ...... 15 Haldol ...... 16 Imatinib Mesylate ...... 10 Intranasal Steroids ...... 25,40 Halflytely ...... 30 Imbruvica ...... 10 Intron A ...... 31 Halobetasol Propionate ...... 22 Imdur ...... 18 Intuniv ...... 20 Haloperidol ...... 16 Imiglucerase ...... 27 Invega ...... 16 Haloperidol Lactate Concentrate, Oral ...... 16 Imipramine HCl ...... 15 Invirase ...... 7 Harvoni ...... 6 Imipramine Pamoate ...... 15 Invokamet...... 28 HCG Alpha,Recombinant ...... 26,35 Imiquimod ...... 24 Invokana...... 28 Headache Therapy ...... 13 Imitrex ...... 13 Iodoquinol ...... 8 Hectorol ...... 27 Imitrex Nasal Spray...... 13 Ipratropium Bromide Aerosol w/Adapter (gm) . . . . . 41 Hemangeol ...... 19 Immune Globulin...... 31 Ipratropium Bromide Aerosol, Spray (ml) ...... 25 Immunosuppressant Drugs ...... 9 Hemocyte Plus Capsule ...... 43 Ipratropium Bromide Solution, Non-Oral ...... 41 Hemocyte-F ...... 43 Imodium 2mg ...... 29 Irbesartan ...... 20 Hemostatics ...... 18,43 Impavido ...... 8 Irbesartan/Hydrochlorothiazide ...... 20 Heparin ...... 18,43 Imuran...... 9,33 Iressa 250mg...... 10 Heparin Lock Flush...... 18,43 Incivek ...... 6 Isentress ...... 7 Heparin Sodium, Porcine ...... 18,43 Increlex...... 44 Hepsera...... 6 Incruse Ellipta...... 41 Isometheptene Mucate/Acetaminophen/ ...... 13 Hetlioz ...... 44 Indapamide ...... 19 Caffeine Hexalen ...... 10 Inderal ...... 19 Isometheptene Mucate/Acetaminophen/ Hiprex ...... 6 Inderal LA ...... 19 Dichloralphenazone ...... 13 Hiv/Aids Therapy ...... 7 Inderide ...... 20 Isoniazid ...... 8 Hizentra ...... 31 Indinavir Sulfate ...... 7 Isoniazid ...... 8 Homatropine HBr ...... 36 Indocin ...... 12,32 Isoptin S.R...... 19 Horizant ...... 14 Indocin SR ...... 12,32 Isopto Atropine...... 36 Hormones ...... 9 Indocin Suppository ...... 32 Isopto Carbachol ...... 36 Humalog...... 27 Indomethacin ...... 12,32 Isopto Carpine ...... 36 Humalog Mix 75/25...... 27 Indomethacin Capsule, Sustained Action ...... 12,32 Isopto Homatropine ...... 36 Humatin...... 8 Indomethacine Suppository ...... 32 Isopto Hyoscine ...... 36 Humatrope ...... 31 Infergen ...... 31 Isordil ...... 18 Humira...... 33 Inflamase Forte ...... 37 Isosorbide Dinitrate ...... 18 Humulin 50/50 ...... 27 Inhaled Corticosteroids ...... 40 Isosorbide Dinitrate Capsule, Sustained Humulin 70/30 ...... 27 Inlyta ...... 10 Action ...... 18 Humulin N ...... 27 Innopran XL...... 19 Isosorbide Mononitrate Tablet, Sustained Humulin R ...... 27 Inspra ...... 19 Release 24hr ...... 18 Hycamtin ...... 10 Insulin Aspart ...... 27 Isotrentoin ...... 23 Hydralazine HCl ...... 20 Insulin Aspart Cartridge (ml) ...... 27 Isoxsuprine HCl ...... 35 Hydralazine HCl/Isosorbide Dinitrate ...... 20 Insulin Aspart Disposable Syringe (ml) ...... 27 Isradipine ...... 19 Hydrea ...... 10 Insulin Aspart Protamine Human/Insulin Istalol ...... 36 Hydrochlorothiazide ...... 19 Aspart Cartridge (ml) ...... 27 Itraconazole ...... 7 Hydrocodone Bit/Acetaminophen ...... 11 Insulin Aspart Protamine Human/Insulin Ivacaftor ...... 41 Hydrocodone Bit/Ibuprofen ...... 11 Aspart Disposable Syringe (ml) ...... 27 Ivermectin ...... 8 Hydrocodone Polistrx/Chlorpheniramine Insulin Aspart Protamine Human/Insulin Izba...... 36 Polistirex ...... 39 Aspart Vial (SDV,MDV or Additive) (ml) ...... 27 Hydrocodone/Pseudoephed/CPM ...... 39 Insulin Aspart Vial (SDV,MDV or Additive) J Hydrocortisone...... 22 (ml) ...... 27 Jakafi...... 10 Hydrocortisone ...... 26,30,32,39 Insulin Detemir ...... 27 Jalyn ...... 42 Hydrocortisone Acetate Foam (gm) ...... 30 Insulin Glargine,Human Recombinant Analog . . . . 27 Janumet ...... 28 Hydrocortisone Acetate Suppository, Rectal ...... 30 Insulin Glulisine ...... 27 Janumet XR ...... 28 Hydrocortisone Acetate/Pramoxine HCl ...... 24,30 Insulin Lispro (NPL)/Insulin Lispro,Human Januvia ...... 28 Hydrocortisone Acetate/Pramoxine HCl Cream, Rec.Anlog ...... 27 Jardiance ...... 28 Rectal ...... 30 Insulin Lispro,Human Rec.Anlog ...... 27 Jentadueto...... 28 Hydrocortisone Acetate/Urea ...... 24 Insulin NPH Human Recombinant ...... 27 Jublia ...... 23 Hydrocortisone Butyrate ...... 22 Insulin NPH Human Recombinant Cartridge Juxtapid ...... 21 Hydrocortisone Butyrate/Emollient ...... 22 (ml) ...... 27 Hydrocortisone Cream (Grams) ...... 30 Insulin NPH Human Recombinant Disposable Hydrocortisone Lotion Rx (ml) ...... 22 Syringe (ml) ...... 27 K Hydrocortisone Rx ...... 22 Insulin NPH Human Recombinant Vial (SDV, K-Lor ...... 43 Hydrocortisone Valerate ...... 22 MDV or Additive) (ml) ...... 27 K-Lyte...... 43 Hydrocortisone/Pramoxine ...... 30 Insulin NPH Human Recombinant/Insulin K-Lyte/Cl 25mEq...... 43 HydroDIURIL ...... 19 Regular Human Rec ...... 27 K-Tab 10mEq...... 43 Hydromorphone ER ...... 11 Insulin NPH Human Recombinant/Insulin Kadian ...... 11 Hydromorphone HCl ...... 11 Regular Human Rec Cartridge (ml) ...... 27 Kadian (40mg, 200mg) ...... 11

50 Kaletra ...... 7 Levonorgestrel ...... 34 Lupron Depot ...... 10,35 Kalydeco...... 41 Levonorgestrel-Ethinyl Estradiol ...... 34 Lupron Depot-3 Month ...... 10 Kapvay ...... 17 Levonorgestrel-Ethinyl Estradiol-Ethinyl Lupron Depot-Ped...... 10,35 Karbinal ER ...... 39 Estradiol ...... 34 Luvox ...... 16 Kay Ciel ...... 43 Levothyroxine Sodium ...... 26 Luvox CR ...... 15 Kayexalate...... 44 Levoxyl ...... 26 Luxiq Foam ...... 22 Kazano ...... 28 Levsin ...... 42 Luzu ...... 23 Keflex ...... 5 Levsin/SL ...... 29 Lybrel ...... 34 Kenalog ...... 22 Lexapro...... 16 Lyrica ...... 14 Kenalog 0.50%...... 22 Lexiva ...... 7 Lysodren ...... 10 Kenalog in Orabase...... 25 Lialda ...... 30 Lysteda ...... 35 Keppra ...... 14 Librax ...... 29 Kerlone...... 19 Librium ...... 17 Kerydin...... 23 Lida Mantle ...... 22 M Ketoconazole ...... 7 Lidex...... 22 Macrodantin...... 6 Ketoconazole Cream (Grams), Ketoconazole Lidex-E 0.05% ...... 22 Macrodantin 25mg...... 6 Shampoo ...... 23 Lidocaine Adhesive Patch ...... 22 Mafenide Acetate ...... 23 Ketoprofen ...... 12,32 Lidocaine HCl ...... 25 Magnesium Carbonate/Citric Acid/ Ketoprofen Capsule, 24hr Sustained Release Lidocaine HCl ...... 25 Gluconolactone Solution, Irrigation ...... 42 Pellets ...... 12,32 Lidocaine HCl Cream (Grams) ...... 22 Malarone ...... 8 Ketorolac Tromethamine ...... 12,32 Lidocaine HCl Jel (ml) ...... 22,25 Malathion ...... 24 Khedezla ...... 15 Lidocaine HCl Ointment(gm) ...... 22 Mandelamine ...... 6 Kineret ...... 33 Lidocaine HCl Solution, Non-Oral ...... 22,25 MAO Inhibitors ...... 16 Klonopin ...... 14 Lidocaine/Prilocaine ...... 22 Maprotiline HCl ...... 15 Kombiglyze XR...... 28 Lidoderm ...... 22 Marinol ...... 13,30 Korlym ...... 27 Lindane...... 24 Matulane ...... 10 Kristalose ...... 30 Lindane ...... 24 Mavik ...... 19 Kuvan ...... 27,44 Linezolid ...... 8 Maxalt ...... 13 Kynamro...... 21 Linzess ...... 30 Maxalt MLT ...... 13 Kytril ...... 13,30 Lioresal ...... 14,33 Maxitrol ...... 37 Liothyronine ...... 26 Maxzide ...... 19 Liotrix ...... 26 Meclizine HCl ...... 13,30 L Lipid/Cholesterol Lowering Agents...... 21 Meclofenamate Sodium ...... 12,32 L-Dopa ...... 13 Lipitor ...... 21 Meclofenamate Sodium ...... 12,32 Labetalol HCl ...... 19 Lipofen ...... 21 Medrol ...... 26,32,39 Lacosamide ...... 14 Liptruzet...... 21 Medroxyprogesterone Acet Disposable Lacrisert ...... 38 Liraglutide ...... 28 Syringe (ml) ...... 10,34 Lactulose ...... 30 Lisinopril ...... 19 Medroxyprogesterone Acet vial ...... 34 Lamictal ...... 14 Lisinopril/Hydrochlorothiazide ...... 20 Medroxyprogesterone Acetate ...... 10,34 Lamictal ODT ...... 14 Lithium Carbonate ...... 17 Mefenamic Acid ...... 12,32 Lamictal XR ...... 14 Lithium Carbonate Tablet, Sustained Action ...... 17 Mefloquine HCl ...... 8 Lamisil ...... 7 Lithium Citrate...... 17 Megace ...... 9 Lamisil, Oral Granules ...... 7 Lithium Citrate ...... 17 Megestrol Acetate ...... 9 Lamivudine ...... 7 Lithobid ...... 17 Mekinist ...... 10 Lamivudine/Zidovudine ...... 7 Livalo ...... 21 Mellaril ...... 16 Lamotrigine ...... 14 Lo Loestrin Fe...... 34 Meloxicam ...... 12,32 Lamotrigine Orally Disintegrating ...... 14 Lo Minastrin FE ...... 34 Melphalan ...... 9 Lamotrigine Sustained Release ...... 14 Lo/Ovral...... 34 Memantine HCl, Memantine HCl Solution, Lamotrigine Tablet, Dispersible ...... 14 Locoid ...... 22 Oral ...... 14 Lamotrigine Tablet, Dose Pack ...... 14 Locoid Lipocream 0.1% ...... 22 Menostar...... 34 Lancets ...... 28 Lodine ...... 12,32 Menotropins ...... 26,35 Lanoxin ...... 18 Lodine XL ...... 12,32 Mentax ...... 23 Lanoxin 62.5mcg & 187.5mcg...... 18 Lodosyn ...... 13 Meperidine HCl ...... 11 Lanreotide ...... 27 Lodoxamide Tromethamine ...... 38 Mephyton ...... 18,43 Lansoprazole ...... 29 Loestrin ...... 34 Mepron...... 8 Lansoprazole Tablet, Rapid Dissolve ...... 29 Loestrin Fe ...... 34 Mercaptopurine ...... 9 Lansoprazole/Amoxicillin Trihydrate/ Lomotil...... 29 Mesalamine ...... 30 Clarithromycin ...... 29 Lomustine ...... 9 Mesalamine Capsule, Sustained Action ...... 30 Lanthanum Carbonate ...... 44 Long Acting Nitrates ...... 18 Mesalamine Delayed-Release ...... 30 Lantus...... 27 Loniten...... 20 Mesalamine Enema (ml) ...... 30 Lantus Solostar ...... 27 Loperamide HCl Capsule (Hard, Soft, Etc.) ...... 29 Mesalamine Suppository, Rectal ...... 30 Lapatinib Ditosylate ...... 10 Lopressor ...... 19 Mesna Tablet ...... 10 Lariam ...... 8 Lopressor HCT...... 20 Mesnex ...... 10 Lasix ...... 19 Loprox ...... 23 Mestinon ...... 15 Latanoprost ...... 36 Loratadine OTC ...... 39 Metadate CD ...... 17 Latuda ...... 16 Lorazepam ...... 17 Metadate ER 20mg...... 17 Lazanda ...... 11 Lorcet 10/650...... 11 Metaglip ...... 28 Leflunomide ...... 33 Lorcet Plus ...... 11 Metaproterenol Sulfate ...... 40 Lescol ...... 21 Lortab...... 11 Metaproterenol Sulfate Solution, Non-Oral ...... 40 Lescol XL ...... 21 Losartan Potassium ...... 20 Metaxalone ...... 14,33 Letairis ...... 41 Losartan Potassium/Hydrochlorothiazide ...... 20 Metformin HCl ...... 28 Letrozole ...... 9 Loseasonique...... 34 Metformin HCl Tablet, Extended Release ...... 28 Leucovorin Calcium ...... 10 Lotemax ...... 37 Metformin HCl Tablet, Sustained Release Leucovorin Calcium ...... 10 Lotensin ...... 19 24hr ...... 28 Leukeran...... 9 Lotensin HCT ...... 20 Methadone HCl ...... 11 Leukine ...... 10,31 Loteprednol Etabonate ...... 37 Methamphetamine HCl ...... 17 Leuprolide Acetate ...... 10,35 Lotrel ...... 20 Methazolamide ...... 36 Levalbuterol HCl Solution, Non-Oral 1.25mg/ Lotrisone...... 23 Methenamine Hippurate ...... 6 5ml ...... 40 Lotronex ...... 30 Methenamine Mandelate ...... 6 Levaquin...... 6 Lovastatin ...... 21 Methergine ...... 34 Levbid...... 29 Lovaza...... 21 Methimazole Tablet ...... 26 Levetiracetam ...... 14 Lovenox ...... 18,43 Methitest ...... 26 Levitra ...... 42 Loxapine Succinate ...... 16 Methocarbamol ...... 33 Levlen...... 34 Loxitane ...... 16 Methotrexate Sodium ...... 9,33 Levlite...... 34 Lozol...... 19 Methoxsalen ...... 24 Levobunolol HCl ...... 36 Ludiomil...... 15 Methyldopa ...... 20 Levocarnitine ...... 44 Lufyllin...... 40 Methyldopa/Hydrochlorothiazide ...... 20 Levocetirizine ...... 39 Lugol’s ...... 43 Methylergonovine Maleate ...... 34 Levodopa ...... 13 Lumigan ...... 36 Methylin...... 17 Levofloxacin ...... 6,37 Lunesta ...... 15 Methylin Solution, Oral ...... 17 Levofloxacin Solution, Oral ...... 6 Lupron...... 10,35 Methylnatrexone Bromide ...... 30

51 Methylphenidate HCl ...... 17 Monopril HCT...... 20 Neomycin Sulfate/Gramicidin D/Polymyxin B Methylphenidate HCl Tablet ...... 17 Montelukast Sodium ...... 41 Drops ...... 37 Methylphenidate HCl Tablet, Sustained Monurol ...... 6 Neomycin Sulfate/Polymyxin B Sulfate/ Action ...... 17 Morphine Sulfate ...... 11 Hydrocortisone ...... 25 Methylphenidate Solution ...... 17 Morphine Sulfate ...... 11 Neomycin Sulfate/Polymyxin B Sulfate/ Methylphenidate, Patch, Transdermal 24 hr ...... 17 Morphine Sulfate Capsule, Multiphasic Hydrocortisone Suspension, Drops (Final Methylprednisolone ...... 26,32,39 Release ...... 11 Dosage Form)(ml) ...... 37 Methyltestosterone ...... 26 Morphine Sulfate Solution, Oral ...... 11 Neomycin Sulfate/Polymyxin B Sulfate/ Metipranolol ...... 36 Morphine Sulfate Tablet, Sustained Action ...... 11 Prednisolone ...... 37 Metoclopramide HCl ...... 30 Morphine Sulfate/Naltrexone ...... 11 Neomycin/Polymyxin B Sulfate/Dexamethasone . . . . 37 Metolazone ...... 19 Motofen ...... 29 Neoral...... 9 Metoprolol Succinate Tablet, Sustained Motrin...... 12,32 Neosporin...... 37 Release 24hr ...... 19 Movantik ...... 30 Neostigmine Bromide ...... 15 Metoprolol Tartrate ...... 19 Moxatag ...... 5 Nephro-Vite Rx ...... 43 Metoprolol Tartrate/Hydrochlorothiazide ...... 20 Moxeza ...... 37 Nephrocaps...... 43 Metozolv ODT...... 30 Moxifloxacin HCl ...... 6,37 Nephron fa ...... 43 Metrocream ...... 23 MS Contin ...... 11 Neptazane...... 36 Metrogel ...... 23,35 MSIR ...... 11 Nesina...... 28 Metrolotion ...... 23 Mucomyst...... 41 Nestabs fa ...... 43 Metronidazole ...... 8,23,35 Multaq ...... 18 Neulasta...... 10,31 Metronidazole 1.3% Vaginal Gel ...... 35 Mupirocin Calcium ...... 23 Neumega ...... 31 Metronidazole Gel with Applicator (gm) ...... 35 Mupirocin Calcium (gm) ...... 23 Neupogen ...... 10,31 Metronidazole, Topical ...... 23 Muscle Relaxants & Antispasmodic Agents . . . . . 14 Neupro ...... 13 Mevacor ...... 21 Muscle Relaxants & Antispasmodic Therapy . . 14,33 Neurontin...... 14 Mexiletine HCl Capsule (Hard, Soft, Etc.) ...... 18 Muse...... 42 Nevirapine ...... 7 Mexitil ...... 18 Myalept ...... 44 Nexavar...... 10 Miacalcin...... 27,33 Myasthenia Gravis ...... 15 Nexium...... 29 Micardis ...... 20 Mycelex ...... 7 Niacin Tablet, Sustained Action Sequential ...... 21 Micardis HCT ...... 20 Mycobutin ...... 8 Niaspan ...... 21 Micro-K ...... 43 Mycolog II ...... 23 Nicotine Gum ...... 44 Micro-K 8mEq ...... 43 Mycophenolate ...... 9 Nicotine Lozenge, OTC ...... 44 Midamor ...... 19 Mycophenolate Mofetil Oral Suspension ...... 9 Nicotine Patch ...... 44 Midazolam HCl ...... 17 Mycophenolic Acid ...... 9 Nicotine Polacrilex ...... 44 Midazolam HCl Syrup ...... 17 Mycostatin...... 7,23 Nicotrol Inhaler ...... 44 ...... 21 Nicotrol Nasal Spray...... 44 Midodrine HCl Mydriacyl ...... 36 Midrin ...... 13 Nifedipine Capsule (Hard, Soft, Etc.) ...... 19 Migergot...... 13 Myeloid Stimulants ...... 31 Nifedipine Tablet, Sustained Action ...... 19 Migraine & Cluster Headache Therapy ...... 13 Myfortic ...... 9 Nifedipine Tablet, Sustained Release Migranal ...... 13 Myleran ...... 9 Osmotic Push ...... 19 Minipress ...... 20 Myrbetriq ...... 42 Nilandron ...... 9 Minitran Patch, Transdermal 24 Hours ...... 18 Mysoline...... 14 Nilotinib Hydrochloride ...... 10 Minivelle ...... 33,34 Nilutamide ...... 9 Minocin ...... 5 N Nimodipine ...... 19 Minocycline HCl ...... 5 Nabumetone ...... 12,32 Nimotop...... 19 Minocycline HCl, Extended Release ...... 5 Nadolol ...... 19 Niravam ...... 17 Minoxidil ...... 20 Nafarelin Acetate ...... 27,35 Nisoldipine Tablet ...... 19 Mipomersen Subcutaneous Injection ...... 21 Naftin ...... 23 Nitazoxanide ...... 8 Mirapex ...... 13 Nalfon ...... 12,32 Nitazoxanide Suspension, Reconstituted, Mirapex ER ...... 13 Naloxone HCl ...... 12 Oral (ml) ...... 8 Mircette ...... 34 Naltrexone HCl ...... 12 Nitrates...... 18 Mirtazapine Tablet ...... 15 Namenda ...... 14 Nitro-Bid ...... 18 Mirtazapine Tablet, Rapid Dissolve ...... 15 Namenda XR ...... 14 Nitro-Dur...... 18 Miscellaneous Agents ...... 25,27,44 Nandrolone...... 26 Nitro-Time ...... 18 Miscellaneous Analgesics ...... 12 Naphazoline HCl ...... 36 Nitrofurantoin Macrocrystal ...... 6 Miscellaneous Anti-infectives ...... 8 Naprelan 375mg ...... 12,32 Nitroglycerin...... 18 Miscellaneous Antidepressants ...... 15 Naprelan 500mg ...... 12,32 Nitroglycerin ...... 18 Miscellaneous Antineoplastic Drugs ...... 10 ...... 18 Naprelan 500mg, 750mg...... 12,32 Nitroglycerin 0.4mg Sublingual Tablet Miscellaneous Antipsychotics ...... 16 Nitroglycerin Capsule, Sustained Action ...... 18 Miscellaneous Antivirals ...... 6 Naprosyn ...... 12,32 Nitroglycerin Ointment(gm) ...... 18 Miscellaneous Cardiovascular Agents ...... 21 Naproxen ...... 12,32 Nitroglycerin Patch, Transdermal 24 Hours ...... 18 Miscellaneous Coagulation Agents ...... 18,43 Naproxen Sodium ...... 12,32 Nitrolingual ...... 18 Miscellaneous Dermatologicals ...... 24 Naproxen Sodium Tablet, Sustained Action . . . . 12,32 Nitromist Lingual Spray ...... 18 Miscellaneous Gastrointestinal Agents ...... 29,30 Naproxen, Sustained Release ...... 12,32 Nitrostat ...... 18 Miscellaneous Hormones ...... 26 Naratriptan ...... 13 Nizatidine ...... 29 Miscellaneous Neurological Therapy...... 14 Narcotic Analgesics...... 11 Nizoral...... 7,23 Miscellaneous OB/GYN ...... 35 Narcotic Antagonists ...... 12 Nolvadex...... 9 Miscellaneous Ophthalmologics ...... 38 Narcotics ...... 11 Non-Insulin Hypoglycemic Agents ...... 28 Miscellaneous Otic Preparations ...... 25 Nardil ...... 16 Non-narcotic Analgesics ...... 12 Miscellaneous Psychotherapeutic Agents ...... 17 Nasacort AQ ...... 25,40 Non-steroidal Anti-inflammatory Agents ...... 36 Miscellaneous Pulmonary Agents ...... 41 Nasalide...... 25,40 Nordette ...... 34 Miscellaneous Rheumatological Agents ...... 33 Nasarel ...... 40 Nordisk Levemir...... 27 Miscellaneous Urologicals ...... 42 Nascobal ...... 43 Norditropin ...... 31 Misoprostol ...... 29 Nasonex...... 25,40 Norethindrone ...... 34 Mitigare ...... 32 Natacyn ...... 37 Norethindrone A-E Estradiol ...... 34 Mitotane ...... 10 Natafort ...... 43 Norethindrone A-E Estradiol/Ferrous Moban ...... 16 Natamycin ...... 37 Fumarate ...... 34 Mobic ...... 12,32 Natazia ...... 34 Norethindrone Acetate ...... 34 Modafinil ...... 17 Nateglinide ...... 28 Norethindrone-Ethinyl Estradiol ...... 34 Modicon...... 34 Natesto ...... 26 Norfloxacin ...... 6 Moduretic...... 19 Navane ...... 16 Norgestimate-Ethinyl Estradiol ...... 34 Moexipril HCl ...... 19 NebuPent ...... 8 Norgestrel-Ethinyl Estradiol ...... 34 Moexipril HCl/Hydrochlorothiazide ...... 20 Nedocromil Sodium ...... 38 Norinyl ...... 34 Molindone HCl ...... 16 Needles, Insulin Disposable ...... 28 Normodyne ...... 19 Mometasone Furoate ...... 22,25,40 Nelfinavir Mesylate ...... 7 Noroxin ...... 6 Mometasone Furoate Aerosol, Spray, (gm) ...... 40 Nembutal Sodium ...... 15 Norpace ...... 18 Mometasone Furoate/Formoterol Fumarate Neomycin Sulfate ...... 8 Norpace CR ...... 18 Dihydrate ...... 41 Neomycin Sulfate ...... 8 Norpramin ...... 15 Monodox ...... 5 Neomycin Sulfate/Bacitracin Zinc/Polymyxin B/ Northera ...... 21 Monophasic/Biphasic/Triphasic/4-Phasic Hydrocortisone Ointment(gm) ...... 37 Nortriptyline HCl ...... 15 Agents ...... 34 Neomycin Sulfate/Bacitracin/Polymyxin B Norvasc...... 19 Monopril ...... 19 Ointment(gm) ...... 37 Norvir...... 7

52 Novarel ...... 27 Orencia (syringe) ...... 33 Penicillin V Potassium ...... 5 Novofine...... 28 Orenitram ER...... 41 Penicillins ...... 5 Novolin 70/30 ...... 27 Orinase ...... 28 Penlac ...... 23 Novolin 70/30 InnoLet...... 27 Orlistat ...... 44 Pennsaid ...... 12,32 Novolin N ...... 27 Ortho Evra ...... 35 Pennsaid 2% ...... 12,32 Novolin N InnoLet...... 27 Ortho Micronor ...... 34 Pentamidine Isethionate ...... 8 Novolin R...... 27 Ortho Tri-Cyclen ...... 34 Pentasa ...... 30 Novolin R InnoLet ...... 27 Ortho Tri-Cyclen Lo...... 34 Pentazocine HCl/Acetaminophen ...... 12 NovoLog...... 27 Ortho-Cept...... 34 Pentazocine HCl/Naloxone HCl ...... 12 Novolog Mix 70/30 ...... 27 Ortho-Cyclen ...... 34 Pentosan Polysulfate Sodium ...... 42 Noxafil ...... 7 Ortho-Novum ...... 34 Pentoxifylline Tablet, Sustained Action ...... 18,43 NSAID Agents ...... 32 Ortho-Prefest ...... 35 Pepcid...... 29 NSAIDS ...... 12,32 Orudis ...... 12,32 Percocet ...... 11 NSAIDS- Specific COX-II Inhibitors ...... 12,32 Oruvail ...... 12,32 Percodan...... 11 NSAIDS/COX II Inhibitors ...... 12,32 Oseltamivir Phosphate ...... 6 Perforomist ...... 40 Nucynta ...... 12 Oseni ...... 28 Periactin ...... 39 Nucynta ER ...... 12 Osphena ...... 35 Perindopril Erbumine ...... 19 Nuedexta ...... 14 Osteoporosis Therapy ...... 33 Permethrin ...... 24 Nulev...... 29,42 Otezla ...... 33 Perphenazine ...... 16 NuLytlely ...... 30 Other Antihypertensive Combinations ...... 20 Persantine ...... 18,43 Numoisyn...... 44 Other Electrolytes ...... 43 Pexeva ...... 15,16 Nutropin ...... 31 Other Glaucoma Drugs ...... 36 Phendimetrazine Tartrate ...... 44 Nutropin AQ ...... 31 Other Rheumatologicals ...... 32 Phendimetrazine Tartrate Capsule, Nutropin AQ Nuspin ...... 31 Other Ulcer Therapy ...... 29 Sustained Action ...... 44 NuvaRing ...... 35 Otic Steroid/Antibiotic ...... 25 Phenelzine Sulfate ...... 16 Nuvigil ...... 17 Otrexup ...... 33 Phenergan...... 13,30,39 Nymalize...... 19 Ovace ...... 24 Phenergan w/Codeine...... 39 Nystatin ...... 35 Ovide ...... 24 Phenobarbital ...... 14 Nystatin ...... 7,35 Ovidrel ...... 26,35 Phenobarbital ...... 14 Nystatin Cream (Grams) ...... 23 Ovral ...... 34 Phenothiazines ...... 16 Nystatin/Triamcinolone Acetonide ...... 23 Ovulatory Stimulants ...... 26 Phenoxybenzamine HCl ...... 20 Oxandrolone...... 26 Phentermine HCl ...... 44 Oxaprozin ...... 12,32 Phenylephrine HCl/Brompheniramine Maleate . . . . 39 O Oxazepam ...... 17 Phenytek...... 14 Octreotide Acetate Kit ...... 10,27 Oxcarbazepine ...... 14 Phenytoin Sodium Extended ...... 14 Octreotide Acetate Vial (SDV,MDV or Oxecta ...... 11 Phenytoin Sodium Extended Capsule ...... 14 Additive) (ml) ...... 10,27 Oxistat ...... 23 Phenytoin Suspension, Oral (Final Dose Ocufen ...... 36 Oxsoralen ...... 24 Form) ...... 14 Ocuflox...... 37 Oxsoralen-Ultra ...... 24 Phoslo...... 43 Ocupress...... 36 Oxtellar XR ...... 14 Phospholine Iodide...... 36 Ofev ...... 41 Oxybenzone/Octinoxate/Hydroquinone ...... 24 Phrenilin ...... 11,13 Ofloxacin ...... 6,25 Oxybutynin Chloride ...... 14,33,42 Phrenilin Forte...... 11,13 Ofloxacin Drops ...... 37 Oxybutynin Patch, Transdermal Semiweekly. . 14,33,42 Phytonadione Tablet ...... 18,43 Ogen ...... 33,34 Oxycodone HCl ...... 11 Picato ...... 24 Olanzapine Orally Disintegrating Tablets ...... 16 Oxycodone HCl/Acetaminophen ...... 11 Pilocarpine HCl ...... 36,44 Olanzapine Tablets ...... 16 Oxycodone/Aspirin ...... 11 Pilocarpine HCl Gel (gm) ...... 36 Oleptro ER...... 15 OxyContin ...... 11 Pilopine HS ...... 36 Olmesartan Medoxomil ...... 20 Oxymorphone ...... 11 Pimecrolimus Cream (Grams) ...... 24 Olmesartan Medoxomil/Hydrochlorothiazide ...... 20 Oxymorphone HCl, Extended Release ...... 11 Pimozide ...... 16 Olmesartan/Amlodipine/HCTZ ...... 20 Oxytrol ...... 14,33,42 Pindolol ...... 19 Olopatadine ...... 25 Pioglitazone HCl ...... 28 Olopatadine HCl 0.1% ...... 38 Pioglitazone HCl/Metformin ...... 28 Olopatadine HCl 0.2% ...... 38 P Pioglitazone HCl/Metformin Extended OLUX Foam ...... 22 Pamelor...... 15 Release ...... 28 OLUX-E Foam...... 22 Pancreaze ...... 30 Pioglitazone/Glimepiride ...... 28 Olysio ...... 6 Pancrelipase ...... 30 Piroxicam ...... 12,32 Omega-3 Acid Ethyl Est ...... 21 Pancrelipase 5K-17K-27K ...... 30 Plan B One Step ...... 34 Omeprazole ...... 29 Panretin ...... 24 Plaquenil ...... 8,33 Omeprazole OTC ...... 29 Pantoprazole Sodium ...... 29 Plavix...... 18,43 Omeprazole Rx ...... 29 Parafon Forte DSC ...... 14,33 Plegridy...... 31 Omeprazole/Bicarb ...... 29 Parcopa ...... 13 Plendil ...... 19 Omnaris...... 25,40 Paregoric...... 29 Pletal ...... 18,43 Omnicef ...... 5 Paregoric ...... 29 Podofilox Solution, Non-Oral ...... 24 Omnitrope ...... 31 Paricalcitol ...... 27 Poly-Pred ...... 37 Omtryg...... 21 Parlodel...... 13 Poly-Vi-Flor ...... 43 Ondansetron ...... 13,30 Parnate ...... 16 Poly-Vi-Flor w/Iron ...... 43 Ondansetron HCl ...... 13,30 Paromomycin Sulfate ...... 8 Polymyxin B Sulfate/Trimethoprim ...... 37 One Touch Ultra 2 ...... 28 Paroxetine HCl Tablet ...... 16 Polytrim ...... 37 One Touch Ultra Smart ...... 28 Pasireotide Diaspartate ...... 27 Pomalyst ...... 10 One Touch Ultra System ...... 28 Pataday ...... 38 Ponatinib ...... 10 One Touch Ultramini ...... 28 Patanase ...... 25 Ponstel ...... 12,32 One Touch Verio ...... 28 Patanol ...... 38 Posaconazole ...... 7 Onfi ...... 14 Paxil ...... 16 Potassium ...... 43 Onglyza ...... 28 Paxil CR ...... 16 Potassium Bicarbonate/Citric Acid ...... 43 Onmel ...... 7 Pazopanib ...... 10 Potassium Chloride ...... 43 Onsolis ...... 11 PCE ...... 5 Potassium Chloride Capsule, Sustained Opana...... 11 Pediapred ...... 26,32,39 Action ...... 43 Opana ER...... 11 Pediazole ...... 5,6 Potassium Chloride Liquid (ml) ...... 43 Opium Tincture ...... 29 Peg-Intron...... 31 Potassium Chloride Packet ...... 43 Oprelvekin ...... 31 Peg-Intron Redipen...... 31 Potassium Chloride Tablet, Sustained Opsumit ...... 41 Peganone ...... 14 Action ...... 43 Opticrom ...... 38 Pegasys ...... 31 Potassium Chloride/Potassium Bicarbonate/ OptiPranolol...... 36 Pegasys Proclick ...... 31 Citric Acid Tablet, Effervescent ...... 43 Optivar ...... 38 Pegfilgrastim ...... 10 Potassium Citrate Tablet, Sustained Action ...... 42 Oracea ...... 5 Pegfilgrastim Disposable Syringe (ml) ...... 31 Potassium Guaiacolsulfonate/ Oral Contraceptives & Related Agents ...... 34 Peginterferon Alfa-2A ...... 31 Dextromethorphan HBr ...... 39 Oral Drugs For Glaucoma ...... 36 Peginterferon Alfa-2b ...... 31 Potassium Iodide/Iodine ...... 43 Oralair ...... 44 Pegvisomant ...... 27 Potiga ...... 14 Orap ...... 16 Pen Needle ...... 28 Pradaxa ...... 18,43 Orasone ...... 26 Pen-Vee K...... 5 Pramipexol ...... 13 Oravig...... 7 Penicillamine ...... 33 Pramlintide Acetate ...... 28

53 Pramosone ...... 24,30 Propranolol HCl/Hydrochlorothiazide ...... 20 Regorafenib ...... 10 Prandimet ...... 28 Propylthiouracil ...... 26 Relafen...... 12,32 Prandin...... 28 Propylthiouracil Tablet ...... 26 Relenza ...... 6 Prasugrel HCl ...... 18,43 Proscar ...... 27,42 Relistor ...... 30 Pravachol ...... 21 ProSom...... 15 Relpax...... 13 Pravastatin Sodium ...... 21 Prostaglandins ...... 29 Remeron...... 15 Praziquantel ...... 8 Prostigmin ...... 15 Renacidin ...... 42 Prazosin HCl ...... 20 Proton Pump Inhibitors ...... 29 Renagel...... 44 Precose ...... 28 Protonix ...... 29 Renvela ...... 44 Pred Forte...... 37 Protopic ...... 24 Renvela powder, oral...... 44 Pred Mild ...... 37 Protriptyline HCl ...... 15 Repaglinide ...... 28 Pred-G Suspension, Drops (Final Dosage Proventil ...... 40 Repaglinide/Metformin HCl ...... 28 Form)(ml) 0.3%-1% ...... 37 Proventil HFA ...... 40 Repronex ...... 26,35 Prednisolone ...... 26,32,39 Provigil ...... 17 Requip ...... 13 Prednisolone Acetate ...... 37 Prozac ...... 16 Requip XL ...... 13 Prednisolone Sodium Phosphate ...... 37 Prozac Weekly...... 16 Rescriptor ...... 7 Prednisolone Sodium Phosphate Solution, Pseudoephedrine HCl/Brompheniramine Reserpine ...... 20 Oral ...... 26,32,39 Maleate ...... 39 Reserpine ...... 20 Prednisolone Syrup ...... 26,32,39 Pseudoephedrine HCl/Cetrizine HCl OTC ...... 39 Restasis ...... 38 Prednisolone Tablet ...... 26,32,39 Pseudoephedrine HCl/Chlorpheniramine Restoril ...... 15 Prednisone ...... 26,32,39 Maleate ...... 39 Retin-A...... 23 Prednisone ...... 26,32,39 Pseudoephedrine HCl/Chlorpheniramine Retin-A Micro ...... 23 Pregnyl ...... 27 Maleate Capsule, Sustained Release 12 hr ...... 39 Retin-A Micro 0.08%...... 23 Prelone ...... 26,32,39 Pseudoephedrine HCl/Loratadine OTC ...... 39 Retrovir...... 7 Prelu-2 ...... 44 Psorcon...... 22 Revatio ...... 41 Premarin ...... 33,34 Psorcon E ...... 22 ReVia ...... 12 Premphase...... 35 Psychotherapeutic Drugs...... 15 Revlimid ...... 14 Prempro ...... 35 Pulmicort ...... 40 Reyataz ...... 7 Prenatal Vit #36/Iron/Fa CMB#6 ...... 43 Pulmonary Agents...... 40 Rezira ...... 39 Prenatal Vitamin w-o Calcium/Fe Carbonyl- Pulmozyme...... 41 Rheumatrex ...... 9,33 Fe Sulfate/Folic Acid ...... 43 Purinethol...... 9 Rhinocort Aqua ...... 25,40 Prenatal Vitamins/Ferrous Fumarate/ Purixan ...... 9 Ribavirin ...... 6 Docusate/Folic Acid ...... 43 Pylera ...... 29 Ridaura...... 33 Prenatal Vitamins/Ferrous Fumarate/Folic Pyrazinamide ...... 8 Rifabutin ...... 8 Acid ...... 43 Pyrazinamide ...... 8 Rifadin ...... 8 Prenate Elite ...... 43 Pyridostigmine Bromide Syrup ...... 15 Rifampin ...... 8 Prepopik ...... 30 Pyridostigmine Bromide Tablet ...... 15 Rifaximin ...... 8 Prevacid ...... 29 Pyridostigmine Bromide Tablet, Sustained Rilonacept ...... 31 Prevacid Solutab ...... 29 Action ...... 15 Rilpivirine ...... 7 Prevpac ...... 29 Pyrimethamine ...... 8 Rilutek ...... 44 Prezista ...... 7 Riluzole ...... 44 Priftin ...... 8 Rimantadine HCl ...... 6 Prilosec ...... 29 Q Rimexolone ...... 37 Prilosec OTC ...... 29 Qnasl...... 25,40 Riomet ...... 28 Primaquine ...... 8 Qsymia ...... 44 Risedronate Sodium ...... 33 Primaquine Phosphate ...... 8 Qualaquin...... 8 Risedronate Sodium 150mg ...... 33 Primidone Tablet ...... 14 Quartette ...... 34 Risperdal...... 16 Primsol ...... 6 Qudexy XR...... 14 Risperdal M-tab ...... 16 Principen ...... 5 Quetiapine Fumarate ...... 16 Risperidone Tablets ...... 16 Prinivil ...... 19 Quillivant XR ...... 17 Risperidone Tablets, Oral Disintegrating ...... 16 Prinzide, Zestoretic ...... 20 Quinaglute ...... 18 Ritalin...... 17 Pristiq ER ...... 15 Quinapril HCl Tablet ...... 19 Ritalin LA 10mg...... 17 ProAir HFA ...... 40 Quinapril HCl/Hydrochlorothiazide Tablet ...... 20 Ritalin LA 20mg, 30mg, 40mg...... 17 ProAmantine...... 21 Quinidex ...... 18 Ritalin-SR...... 17 Probenecid ...... 32 Quinidine Gluconate Tablet, Sustained Ritonavir ...... 7 Probenecid ...... 32 Action ...... 18 Ritonavir/Lopinavir ...... 7 Probenecid w/Colchicine ...... 32 Quinidine Sulfate ...... 18 Rivaroxaban ...... 18,43 Procarbazine HCl ...... 10 Quinidine Sulfate Tablet ...... 18 Rivastigmine ...... 14 Procardia...... 19 Quinidine Sulfate Tablet, Sustained Action ...... 18 Rivastigmine Solution ...... 14 Procardia XL...... 19 Quinine Sulfate ...... 8 Rivastigmine Transdermal System ...... 14 Prochlorperazine Maleate ...... 13 Quinolones...... 6 Rizatriptan Benzoate Tablet ...... 13 Prochlorperazine Maleate Suppository, Quixin ...... 37 Rizatriptan Benzoate Tablet, Rapid Rectal ...... 13,30 Qvar ...... 40 Dissolve ...... 13 Prochlorperazine Maleate Tablet ...... 30 Rms-Suppository ...... 11 Procrit ...... 10,31 Robaxin ...... 33 proctoCream-HC 2.50% ...... 30 R Robinul...... 29 Proctofoam-HC ...... 30 Rabeprazole ...... 29 Rocaltrol ...... 27 Procysbi ...... 42 Ragwitek...... 44 Ropinirole HCl ...... 13 Prodrin ...... 13 Raloxifene ...... 33 Ropinirole HCl Sustained Release ...... 13 Profasi...... 35 Raltegravir Potassium ...... 7 Rosuvastatin Calcium ...... 21 Progesterone, Micronized ...... 34 Raltegravir Potassium Tablet, Chewable ...... 7 Rowasa ...... 30 Progesterone, Micronized Gel ...... 34 Ramipril ...... 19 Roxicodone...... 11 Progestin Only ...... 34 Ranexa ...... 21 Rozerem ...... 15 Progestins ...... 34 Ranitidine HCl Rx ...... 29 Ruconest...... 44 Prograf ...... 9 Ranolazine ...... 21 Rufinamide ...... 14 Prolensa ...... 36 Rapaflo ...... 42 Ruxolitinib ...... 10 Prolex DM ...... 39 Rapamune ...... 9 Rythmol ...... 18 Prolixin...... 16 Rapamune Oral Solution ...... 9 Rythmol SR ...... 18 Proloprim ...... 6 Rapid Acting Nitrates ...... 18 Ryzolt ...... 12 Promacta ...... 18,43 Rasagiline Mesylate ...... 13 Promethazine HCl ...... 30,39 Rasuvo ...... 33 Promethazine HCl Suppository, Rectal ...... 13,30 Ravicti ...... 27 S Promethazine HCl Tablet ...... 13 Rayos ...... 32 Sabril ...... 14 Prometrium ...... 34 Razadyne ...... 14 Safyral...... 34 Propafenone HCl ...... 18 Razadyne ER ...... 14 Saizen ...... 31 Propafenone HCl Tablet ...... 18 Rebetol ...... 6 Salagen ...... 44 Propantheline Bromide ...... 29 Rebetol Solution ...... 6 Salflex ...... 12,32 Propantheline Bromide ...... 29 Rebif...... 31 Salicylates ...... 12,32 Propranolol HCl ...... 19 Rebif Rebidose ...... 31 Salmeterol Xinafoate Disk, with Inhalation Propranolol HCl Capsule, Sustained Action Rectiv ...... 30 Device ...... 40 24 hr ...... 19 Reglan...... 30 Salsalate ...... 12,32

54 Samsca ...... 27 Sotylize ...... 19 Taclonex ...... 22 Sanctura ...... 33 Sovaldi ...... 6 Taclonex Ointment...... 24 Sanctura XR ...... 33,42 Specialized OB/GYN Drugs ...... 35 Taclonex Topical Suspension...... 24 Sancuso...... 30 Spectazole ...... 23 Tacrolimus ...... 9 Sandimmune ...... 9 Spectracef ...... 5 Tacrolimus Ointment ...... 24 Sandostatin ...... 10,27 Spectracef (200mg)...... 5 Tadalafil ...... 42 Sandostatin LAR ...... 10,27 Spiriva...... 41 Tafinlar...... 10 Santyl ...... 23 Spiriva Respimat ...... 41 Tagamet ...... 29 Saphris ...... 16 Spironolactone Tablet ...... 19 Talacen ...... 12 Sapropterin Dihydrochloride ...... 27,44 Spironolactone/Hydrochlorothiazide ...... 19 Talwin NX ...... 12 Saquinavir Mesylate ...... 7 Sporanox...... 7 Tambocor ...... 18 Sarafem...... 16 Sporanox Solution ...... 7 Tamiflu...... 6 Sargramostim ...... 10,31 Sprix ...... 12,32 Tamoxifen Citrate ...... 9 Savella...... 14 Sprycel ...... 10 Tamsulosin ...... 42 Saxagliptin ...... 28 SSKI ...... 26 Tanzeum...... 28 Saxagliptin/Metformin ...... 28 Stalevo ...... 13 Tapazole ...... 26 Scalp Treatment ...... 24 Stannous Fluoride Solution, Non-Oral ...... 25 Tapentadol ...... 12 Scopolamine Hydrobromide Patch, Starlix ...... 28 Tarceva ...... 10 Transdermal 72 Hours ...... 13,30 Stavudine Capsule ...... 7 Targiniq ER ...... 11 Seasonale...... 34 Staxyn...... 42 Targretin capsules ...... 10 Seasonique ...... 34 Stelara...... 33 Tarka...... 20 Seconal Sodium ...... 15 Stelazine ...... 16 Tasigna ...... 10 Second Generation Cephalosporins ...... 5 Stendra ...... 42 Tasmar ...... 13 Sectral...... 19 Steroid-antibiotic Combinations...... 37 Tavist ...... 39 Selective Serotonin Reuptake Inhibitors ...... 16 Steroid-sulfonamide Combinations...... 37 Tazarotene ...... 23,24 Selegiline HCl ...... 13 Steroids...... 37 Tazorac ...... 23,24 Selenium Sulfide ...... 24 Stivarga...... 10 Tecfidera...... 14 Selsun Rx ...... 24 Strattera ...... 17 Teduglutide Subcutaneous Injection ...... 30 Semprex-D ...... 39 Striant...... 26 Tegretol...... 14 Sensipar ...... 27 Stribild ...... 7 Tegretol XR ...... 14 Septra DS ...... 6 Striverdi Respimat...... 41 Tekamlo ...... 19 Serax...... 17 Stromectol ...... 8 Tekturna...... 20 Serevent Diskus ...... 40 Strongstart ...... 43 Telaprevir ...... 6 Seroquel ...... 16 Suboxone Film ...... 12 Telmisartan ...... 20 Seroquel XR ...... 16 Suboxone SL Tab ...... 12 Telmisartan/Amlodipine ...... 20 Serostim ...... 31 Subsys...... 11 Telmisartan/Hydrochlorothiazide ...... 20 Sertraline HCl ...... 16 Succimer ...... 44 Temazepam ...... 15 Sevelamer Carbonate 800mg Tablet ...... 44 Suclear ...... 30 Temodar ...... 9 Sevelamer HCl ...... 44 Sucralfate Suspension, Oral (Final Dose Temovate ...... 22 Signifor...... 27 Form) ...... 29 Temozolomide ...... 9 Sildenafil Citrate ...... 42 Sucralfate Tablet ...... 29 Tenex ...... 20 Sildenafil Citrate Suspension, Oral ...... 41 Sular ...... 19 Tenofovir Disoproxil Fumarate ...... 7 Sildenafil Citrate Tablet ...... 41 Sulfacet-R ...... 23 Tenofovir Disoproxil Fumarate 400mg ...... 7 Silenor ...... 15 Sulfacetamide Sodium ...... 24,37 Tenoretic...... 20 Silvadene...... 23 Sulfacetamide Sodium Ointment(gm) ...... 37 Tenormin ...... 19 Silver Sulfadiazine ...... 23 Sulfacetamide Sodium/Prednisolone Acetate ...... 37 Tenuate...... 44 Simbrinza ...... 36 Sulfacetamide Sodium/Prednisolone Sodium Terazol ...... 35 Simcor ...... 21 Phosphate ...... 37 Terazosin HCl ...... 20,42 Simepevir Sodium ...... 6 Sulfacetamide Sodium/Sulfur ...... 23 Terbinafine HCl Tablet ...... 7 Simponi ...... 33 Sulfacetamide Sodium/Urea ...... 24 Terbutaline Sulfate ...... 35,40 Simvastatin ...... 21 Sulfacetamide Sodium/Urea Lotion (gm) ...... 24 Terconazole Cream with Applicator ...... 35 Sinemet...... 13 Sulfadiazine...... 6 Teriparatide ...... 33 Sinemet CR ...... 13 Sulfadiazine ...... 6 Testim...... 26 Sinequan...... 15 Sulfamethoxazole/Trimethoprim ...... 6 Testosterone ...... 26 Singulair ...... 41 Sulfamylon ...... 23 Testosterone Cypionate Vial (ml) ...... 26 Sirolimus ...... 9 Sulfanilamide ...... 35 Testosterone Enanthate Disposable Syringe Sirturo ...... 8 Sulfas & Related Agents ...... 6 (ml) ...... 26 Sitagliptin Phosphate ...... 28 Sulfasalazine ...... 30,33 Testosterone Gel in Metered-Dose Pump (gm) . . . . . 26 Sitagliptin Phosphate/Metformin HCl ...... 28 Sulfasalazine Tablet, Enteric Coated ...... 30,33 Testosterone Gel in Packet (gm) ...... 26 Sitagliptin/Metformin HCl ...... 28 Sulfonamides ...... 37 Testosterone Patch, Transdermal 24 Hours ...... 26 Sitavig...... 6 Sulindac ...... 12,32 Testosterone Propionate ...... 26 Sivextro Tablet ...... 8 Sumatriptan Intranasal Solution ...... 13 Testosterone Propionate ...... 26 Skelaxin ...... 14,33 Sumatriptan Succinate Kit ...... 13 Tetrabenazine ...... 14 Sklice ...... 24 Sumatriptan Succinate Tablet ...... 13 Tetracycline HCl ...... 5 Slow-K 8mEq ...... 43 Sumatriptan Succinatet ...... 13 Tetracyclines ...... 5 Smoking Deterrents ...... 44 Sumavel Dose Pro...... 13 Tev-Tropin ...... 31 Sodium Fluoride 0.25MG and 0.5MG chewable Sunitinib Malate ...... 10 Teveten 600mg ...... 20 tablet ...... 43 Suprax...... 5 Teveten HCT ...... 20 Sodium Fluoride 0.25MG and 0.5MG drops . . . . . 43 Suprenza ...... 44 Thalidomide ...... 44 Sodium Phenylbutyrate ...... 27 Surestep ...... 28 Thalomid ...... 44 Sodium Polystyrene Sulfonate...... 44 Surestep Pro ...... 28 Theo-24 ...... 40 Sodium Polystyrene Sulfonate ...... 44 Surmontil ...... 15 Theo-Dur ...... 40 Sodium Polystyrene Sulfonate Enema (ml) ...... 44 Sustiva ...... 7 Theophylline Anhydrous ...... 40 Sodium Sulamyd...... 37 Sutent ...... 10 Theophylline Anhydrous Tablet, Sustained Sodium Sulfate/Sodium/Sodium Bicarbonate/ Symbicort ...... 41 Release 12hr ...... 40 Potassium Chloride/Polyethylene Glycols ...... 30 Symlin ...... 28 Therapy For Acne...... 23 Sofosbuvir ...... 6 Symlin Pen ...... 28 Thiazide & Related Diuretics ...... 19 Solaraze...... 24 Symmetrel ...... 6,13 Thioguanine ...... 9 Solifenacin Succinate ...... 14,33 Sympathomimetics ...... 37 Thioridazine HCl ...... 16 Solodyn...... 5 Synalar 0.01% ...... 22 Thiothixene ...... 16 Solodyn 45mg, 90mg, 135mg ...... 5 Synalar 0.03% ...... 22 Third Generation Cephalosporins ...... 5 Soma ...... 14,33 Synalgos-DC...... 11 Thorazine ...... 16 Soma Compound ...... 14,33 Synarel...... 27,35 Thyroid Hormones...... 26 Somatropin ...... 31 Syntest D.S...... 35 Thyrolar ...... 26 Somatuline Depot...... 27 Syntest H.S...... 35 Tiagabine HCl ...... 14 Somavert...... 27 Synthroid ...... 26 Tiazac ...... 19 Sonata...... 15 Syringe w-Needle, Disposable, Insulin ...... 28 Ticagrelor ...... 18,43 Sorafenib Tosylate ...... 10 Ticlid ...... 18,43 Soriatane...... 24 Ticlopidine HCl ...... 43 Sotalol HCl ...... 18 T Ticlopidine HCl Tablet ...... 18 Sotalol HCl Tablet ...... 18 Tabloid ...... 9 Tigan ...... 13,30

55 Tikosyn...... 18 Triamcinolone Acetonide Cream (Grams) ...... 22 Vascepa...... 21 Timolol Maleate ...... 19,36 Triamcinolone Acetonide Paste (gm) ...... 25 Vaseretic ...... 20 Timolol Maleate Gel-Forming Solution ...... 36 Triamterene Capsule (Hard, Soft, Etc.) ...... 19 Vasocidin ...... 37 Timolol Maleate/Dorzolamide HCl ...... 36 Triamterene/Hydrochlorothiazide ...... 19 Vasoconstrictor Decongestants ...... 36 Timoptic...... 36 Triazolam ...... 15 Vasodilan ...... 35 Timoptic-XE...... 36 Tribenzor ...... 20 Vasodilators ...... 20 Tindamax ...... 8 Tricor ...... 21 Vasotec ...... 19 Tinidazole ...... 8 Tricyclics ...... 15 Vecamyl ...... 21 Tiotropium Bromide ...... 41 Trifluoperazine HCl ...... 16 Vectical, Topical...... 22,24 Tipranavir ...... 7 Trifluridine ...... 38 Velphoro ...... 44 Tipranavir/Vitamin ...... 7 Triglide ...... 21 Veltin ...... 23 Tivicay ...... 7 Trihexyphenidyl HCl ...... 13 Vemurafenib ...... 10 Tivorbex ...... 12 Trilafon...... 16 Venlafaxine HCl ...... 15 Tobi ...... 8 Trileptal ...... 14 Venlafaxine HCl ER ...... 15 Tobi Podhaler ...... 8 Trilipix ...... 21 Venlafaxine XR ...... 15 TobraDex ...... 37 Trimethobenzamide HCl ...... 13,30 Venlafaxine XR Tablet ...... 15 TobraDex-ST ...... 37 Trimethobenzamide HCl/Benzocaine Ventavis ...... 41 Tobramycin Sulfate ...... 37 Suppository, Rectal ...... 30 Ventolin HFA ...... 40 Tobramycin Sulfate/Dexamethasone ...... 37 Trimethoprim ...... 6 VePesid ...... 10 Tobramycin Sulfate/Dexamethasone Ointment. . . . . 37 Trimipramine Maleate ...... 15 Veramyst...... 40 Tobramycin/0.25 Normal Saline Ampul for Triphasil ...... 34 Nebulization (mL) ...... 8 Verapamil HCl ...... 19 Triptorelin Pamoate ...... 10 Verapamil HCl Capsule, 24hr Sustained Tobramycin/Dexamethasone ...... 37 Triumeq ...... 7 Tobramycin/Loteprednol Etabonate ...... 37 Release Pellets ...... 19 Trizivir ...... 7 Verapamil HCl Tablet, Sustained Action ...... 19 Tobrex ...... 37 Trokendi XR...... 14 Verapamil HCl Tablet, Sustained Release Tofranil...... 15 Tropicamide ...... 36 Tofranil-PM ...... 15 Trospium ...... 33 Osmotic Push ...... 19 Tolazamide ...... 28 Trospium Chloride ...... 33,42 Verelan ...... 19 Tolbutamide ...... 28 Trulicity ...... 28 Verelan PM...... 19 Tolectin ...... 12,32 Trusopt ...... 36 Versacloz...... 16 Tolinase ...... 28 Truvada...... 7 Versed...... 17 Tolmetin Sodium ...... 12,32 Tudorza Pressair ...... 41 Vesanoid ...... 10 Tolterodine Tartrate ...... 14 Tussicaps...... 39 Vesicare...... 14,33,42 Tolterodine Tartrate Capsule, Sustained Twynsta ...... 20 Vexol...... 37 Release 24 hr ...... 14,33,42 Tybost...... 7 Vfend ...... 7 Tolterodine Tartrate Tablet ...... 33,42 Tykerb ...... 10 Vfend Suspension, Reconstituted, Oral (mL) . . . . . 7 Tolvaptan ...... 27 Tylenol w/Codeine ...... 11 Viagra ...... 42 Topamax...... 14 Tylox...... 11 Vibra-Tabs ...... 5 Topamax Tablets...... 14 Tyvaso...... 21 Vibramycin...... 5 Topical Anesthetics ...... 22 Tyzeka...... 6 Vicodin...... 11 Topical Antibacterials ...... 23 Vicodin ES ...... 11 Topical Antifungals...... 23 Vicoprofen ...... 11 Topical Antivirals ...... 23 U Victoza ...... 28 Topical Corticosteroids ...... 22 Uceris ...... 30 Victrelis ...... 6 Topical Corticosteroids High Potency ...... 22 Uceris Rectal Foam...... 30 Videx ...... 7 Topical Corticosteroids Low Potency ...... 22 Ulcer Therapy...... 29 Videx EC ...... 7 Topical Corticosteroids Medium Potency ...... 22 Ulesfia...... 24 Vigabatrin ...... 14 Topical Corticosteroids Very High Potency...... 22 Uloric ...... 32 Vigamox ...... 37 Topical Enzymes ...... 23 Ultracet...... 12 Viibryd ...... 15,16 Topical Scabicides/Pediculicides ...... 24 Ultram ...... 12 Vimovo ...... 12,32 Topicort 0.05% ...... 22 Ultram ER ...... 12 Vimpat ...... 14 Topicort 0.25% ...... 22 Ultravate...... 22 Viokace...... 30 Topicort Lp 0.05% ...... 22 Umeclidinium/Vilanterol ...... 41 Viracept ...... 7 Topiramate ...... 14 Uniretic ...... 20 Viramune ...... 7 Topiramate Sprinkle Capsules ...... 14 Univasc...... 19 Viramune XR ...... 7 ...... 10 Topotecan HCl Urea ...... 24 Viread...... 7 Toprol XL...... 19 Urecholine ...... 42 Toradol ...... 12,32 Viroptic ...... 38 Urinary Tract Agents...... 6 Visken...... 19 Toremifene Citrate ...... 9 Urispas ...... 42 Torsemide ...... 19 Vismodegib ...... 10 Urocit-K ...... 42 Vistaril ...... 39 Toviaz ...... 42 Urofollitropin (FSH) ...... 26,35 Tracleer...... 41 Uroxatral...... 42 Vitafol...... 43 Tradjenta...... 28 Urso ...... 29 Vitamin D 50000 Unit...... 43 Tramadol ER ...... 12 Urso Forte...... 29 Vitamin K ...... 18,43 Tramadol HCl ...... 12 Ursodiol ...... 29 Vitamins & Hematinics ...... 43 Tramadol HCl/Acetaminophen ...... 12 Vitekta ...... 7 Trametinib ...... 10 Vituz...... 39 Trandate ...... 19 V Vivactil ...... 15 Trandolapril ...... 19 Vagifem...... 34 Vivelle ...... 33,34 Trandolapril/Verapamil ...... 20 Vaginal Antifungals ...... 35 Vivelle-Dot ...... 33,34 Tranexamic Acid ...... 35 Vaginal Cleanser/Antiinfectives ...... 35 Vogelxo...... 26 Transderm-Scop...... 13,30 Valacyclovir HCl ...... 6 Voltaren ...... 12,32,36 Tranxene T-Tab...... 17 Valchlor ...... 9 Voltaren Gel 1% ...... 12,32 Tranylcypromine Sulfate ...... 16 Valcyte ...... 6 Voltaren-XR...... 12,32 Travatan ...... 36 Valganciclovir Hydrochloride Solution, Voriconazole ...... 7 Travatan Z ...... 36 Reconstituted ...... 6 Voriconazole Suspension ...... 7 Travoprost ...... 36 Valganciclovir Hydrochloride Tablet ...... 6 Voriconazole Tablet ...... 7 Trazodone HCl ...... 15 Valium ...... 14,17,33 Vorinostat ...... 10 Trelstar ...... 10 Valproate Sodium Syrup ...... 14 VoSol HC...... 25 Trental ...... 18,43 Valproic Acid Capsule (Hard, Soft, Etc.) ...... 14 Votrient ...... 10 Treprostinil ...... 21 Valsartan ...... 20 Vytorin ...... 21 Tretinoin ...... 10,23 Valsartan/Hydrochlorothiazide ...... 20 Vyvanse...... 17 Tretinoin Microsphere ...... 23 Valtrex ...... 6 Trexall ...... 9,33 Vancocin...... 7 Treximet ...... 13 Vancomycin ...... 7 W Tri-Levlen...... 34 Vancomycin HCl Capsule ...... 7 Warfarin Sodium ...... 18,43 Tri-Vi-Flor ...... 43 Vandazole ...... 35 Welchol ...... 21 Tri-Vi-Flor w/Iron ...... 43 Vandetanib ...... 10 Wellbutrin ...... 15 Triamcinolone Acetonide ...... 22,25 Vanos ...... 22 Wellbutrin SR...... 15 Triamcinolone Acetonide Aerosol, Spray, Vantin...... 5 Wellbutrin XL ...... 15 (gm) ...... 40 Varenicline Tartrate ...... 44 Westcort ...... 22

56 X Zykadia...... 10 Xalatan ...... 36 Zylet ...... 37 Xalkori ...... 10 Zyloprim...... 32 Xanax ...... 17 Zymaxid ...... 37 Xanax XR ...... 17 Zyprexa...... 16 Xanthines ...... 40 Zyprexa Zydis ...... 16 Xarelto...... 18,43 Zyrtec OTC ...... 39 Xartemis XR ...... 11 Zyrtec Rx ...... 39 Xeljanz ...... 33 Zyrtec-D OTC ...... 39 Xeloda ...... 9 Zytiga ...... 9 Xenazine ...... 14 Zyvox ...... 8 Xenical ...... 44 Xifaxan ...... 8 Xigduo ...... 28 Xolegel ...... 23 Xopenex ...... 40 Xopenex HFA...... 40 Xtandi...... 9 Xulane ...... 35 Xylocaine ...... 22,25 Xylocaine 2% ...... 25 Xyrem...... 14 Xyzal...... 39 Y Yasmin ...... 34 YAZ ...... 34 Yodoxin...... 8 Z Zafirlukast ...... 41 Zaleplon ...... 15 Zanamivir ...... 6 Zantac ...... 29 Zarontin ...... 14 Zaroxolyn ...... 19 Zavesca ...... 44 Zebeta...... 19 Zegerid ...... 29 Zegerid Rx ...... 29 Zelboraf ...... 10 Zemplar ...... 27 Zenpep ...... 30 Zerit ...... 7 Zestril ...... 19 Zetia ...... 21 Zetonna ...... 25,40 Ziac ...... 20 Ziagen...... 7 Ziagen Solution ...... 7 Zidovudine Capsule (Hard, Soft, Etc.) ...... 7 Zidovudine Syrup ...... 7 Zinc Sulfate ...... 43 Zinc Sulfate ...... 43 Ziprasidone HCl ...... 16 Zipsor ...... 12,32 Zirgan...... 38 Zithromax...... 5 Zmax ...... 5 Zocor ...... 21 Zofran ...... 13,30 Zofran ODT ...... 13,30 Zohydro ER ...... 11 Zoladex...... 10 Zolinza ...... 10 Zolmitriptan Tablet ...... 13 Zolmitriptan Tablet, Orally Disintegrating ...... 13 Zoloft ...... 16 Zolpidem Tartrate ...... 15 Zolpidem Tartrate Controlled Release ...... 15 Zolpimist ...... 15 Zomig...... 13 Zomig Spray ...... 13 Zomig ZMT...... 13 Zonegran ...... 14 Zonisamide ...... 14 Zontivity...... 43 Zorbtive ...... 31 Zortress...... 10 Zorvolex ...... 12 Zovirax ...... 6,23 Zubsolv...... 12 Zuplenz ...... 30 Zutripro ...... 39 Zyban ...... 44 Zyclara ...... 24 Zydelig ...... 10 Zyflo...... 41 Zyflo CR ...... 41

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