2015 FORMULARY (Commercial)

EFFECTIVE 01/01/15

Introduction

This formulary is a list of generic and brand medications covered by your prescription drug benefit. It is designed to offer you and your doctor cost-effective choices for safe and clinically effective prescription drugs.

Coverage for the drugs included on the 2015 PreferredOne Formulary is determined by your benefit plan design. It is important to note that this formulary is not a complete list of medications and not all listed drugs may be covered by your plan. Please refer to the benefit documents provided by your employer or health plan for information on your specific benefit coverage. You may also contact the PreferredOne Customer Service Department at 1-800- 997-1750 or visit PreferredOne.com for more information.

How is the formulary developed?

This formulary was developed based on the recommendations of an independent Pharmacy and Therapeutics (P&T) Committee comprised of doctors and pharmacists. This committee meets several times a year to review and select safe, clinically sound, cost-effective drugs for the formulary. Ongoing review of clinical literature is conducted to evaluate safety, effectiveness and current use in therapy to determine whether a drug should be included in the formulary.

Does the formulary change throughout the year?

The 2015 PreferredOne Formulary may change throughout the year as new drugs or clinical information becomes available. Drugs may be added as they are introduced to the marketplace and other drugs may change tier status as generics become available.

Please contact the PreferredOne Customer Service Department at 1-800-997-1750 or visit PreferredOne.com for the most current formulary information.

What are formulary tiers?

This formulary is made up of different cost levels or tiers. Your health plan or employer determines your out-of-pocket costs for each tier. Check your plan’s benefit documents to understand your benefit structure and out-of-pocket costs. If you are prescribed a drug on a higher tier, discuss the alternative lower tier options with your doctor to help save money on your out of pocket costs.

Are generic drugs different than brand drugs?

Generic drugs are approved by the U.S. Food and Drug Administration (FDA) to be just as safe and effective as brand drugs. Although they have the same active ingredients, generic drugs generally cost significantly less than brand drugs. You can lower your out-of-pocket expenses by asking your doctor if a generic medication is right for you. How do I fill my specialty medication?

Specialty medications are typically used to treat rare or chronic conditions and often require special handling.

To ensure the safest, most clinically appropriate and cost-effective dispensing of these medications, your plan may require you to fill your prescriptions at a designated specialty pharmacy. Specialty pharmacies provide personalized care and offer convenient delivery to your home or other approved location.

Please contact the PreferredOne Customer Service Department at 1-800-997-1750 or visit PreferredOne.com for the most current formulary information.

Are there any restrictions on my coverage?

Some medications on the formulary may have additional requirements or limits on coverage. These requirements or limits may include:

Prior Authorization — Your benefit plan may require that the medication you have been prescribed receive prior authorization. This means that you will need to get approval from your plan before you fill your prescription. If you don’t get approval, the medication may not be covered by your drug benefit.

Quantity Limits — For some drugs, your plan may limit the amount of the drug that is covered by your benefit for a certain time period. Quantities that exceed this limit must be reviewed and approved by your plan before coverage will apply.

Step Therapy — In some cases, your plan may require you to first try certain drugs to treat your medical condition before another drug for that condition will be covered. For example, if two drugs are used to treat the same medical condition, you may be required to first try one drug before the second drug is covered.

Your doctor can request a prior authorization, a quantity limit override, or a step therapy override approval by submitting the appropriate request form to PreferredOne on your behalf. PreferredOne will review the request and make a determination of coverage for the drug.

For more information about the 2015 PreferredOne Formulary: Call the PreferredOne Customer Service Department at 1-800-997-1750 Or, visit PreferredOne.com LEGEND TIER DESCRIPTION

1 Generics

2 Preferred Brands

3 Non-Preferred Brands

4 Specialty Generics

5 Specialty Preferred Brands

6 Specialty Non-Preferred Brands

Non-Specialty Injectable 7 Generics

Non-Specialty Injectable 8 Preferred Brands

Non-Specialty Injectable Non 9 Preferred Brands

TYPE DESCRIPTION There is a limit on the amount of this drug that is covered per QL Quantity Limit prescription, or within a specific time frame.

You (or your physician) are required to get prior authorization before PA Prior Authorization you fill your prescription for this drug. Without prior approval, we may not cover this drug. In some cases, you may be required to first try certain drugs to treat ST Step Therapy your medical condition before we will cover another drug for that condition. This medication is preferred by 2015 PREFERRED ONE HEALTH Preferred Drug PLAN over other medications in the same Tier that are used to treat the same condition(s)

PAGE 4 LAST UPDATED 10/2014 LIST OF COVERED PRESCRIPTION MEDICATIONS

PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS Analgesics

Nonsteroidal Anti-inflammatory Drugs

ANAPROX 275 MG TABLET 3 naproxen sodium ANAPROX DS 550 MG TABLET 3 naproxen sodium ANSAID 100 MG TABLET 3 flurbiprofen ARTHROTEC 50 MG-200 MCG TAB 3 diclofenac sodium/misoprostol ARTHROTEC 75 MG-200 MCG TAB 3 diclofenac sodium/misoprostol

aspirin ec 975 mg tablet 1

CALDOLOR 400 MG/4 ML VIAL 9 QL 960 / 30 days ibuprofen CALDOLOR 800 MG/8 ML VIAL 9 QL 960 / 30 days ibuprofen CAMBIA 50 MG POWDER PACKET 3 diclofenac potassium CATAFLAM 50 MG TABLET 3 diclofenac potassium

CELEBREX 100 MG CAPSULE QL 90 / 30 days 2 celecoxib ST

CELEBREX 200 MG CAPSULE QL 120 / 30 days 2 celecoxib ST

CELEBREX 400 MG CAPSULE QL 60 / 30 days 2 celecoxib ST

CELEBREX 50 MG CAPSULE QL 150 / 30 days 2 celecoxib ST

choline mag trisal liquid 1

COMFORT PAC-MELOXICAM KIT 3 meloxicam/irritants counter-irritants combination no.2 COMFORT PAC-NAPROXEN KIT 3 naproxen/irritants counter-irritants combination #2

PAGE 5 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS DAYPRO 600 MG CAPLET 3 oxaprozin

diclofenac pot 50 mg tablet 1

diclofenac sod dr 25 mg tab 1

diclofenac sod dr 50 mg tab 1

diclofenac sod dr 75 mg tab 1

diclofenac sod ec 25 mg tab 1

diclofenac sod ec 50 mg tab 1

diclofenac sod ec 75 mg tab 1

diclofenac sod er 100 mg tab 1

diclofenac-misoprost 50-0.2 tb 1

diclofenac-misoprost 50-200 tb 1

diclofenac-misoprost 75-0.2 tb 1

diclofenac-misoprost 75-200 tb 1

diflunisal 500 mg tablet 1

DUEXIS 800-26.6 MG TABLET 3 ibuprofen/famotidine EC-NAPROSYN EC 375 MG TABLET 3 naproxen

etodolac 200 mg capsule 1

etodolac 300 mg capsule 1

etodolac 400 mg tablet 1

etodolac 500 mg tablet 1

etodolac er 400 mg tablet 1

PAGE 6 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

etodolac er 400 mg tablet 1

etodolac er 500 mg tablet 1

etodolac er 600 mg tablet 1

FELDENE 10 MG CAPSULE 3 piroxicam FELDENE 20 MG CAPSULE 3 piroxicam

fenoprofen 600 mg tablet 1

fenoprofen calcium 400 mg cap 1

FLECTOR 1.3% PATCH 3 diclofenac epolamine

flurbiprofen 100 mg tablet 1

flurbiprofen 50 mg tablet 1

ibuprofen 100 mg/5 ml susp 1

ibuprofen 400 mg tablet 1

ibuprofen 600 mg tablet 1

ibuprofen 800 mg tablet 1

INDOCIN 25 MG/5 ML SUSPENSION 3 indomethacin INDOCIN 50 MG SUPPOSITORY 3 indomethacin INDOCIN I.V. 1 MG VIAL 9 indomethacin sodium

indomethacin 1 mg vial 7

indomethacin 25 mg capsule 1

PAGE 7 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

indomethacin 50 mg capsule 1

indomethacin er 75 mg capsule 1

ketoprofen 50 mg capsule 1

ketoprofen 75 mg capsule 1

ketoprofen er 200 mg capsule 1

ketorolac 10 mg tablet 1 QL 20 / 30 days

ketorolac 15 mg/ml carpuject 7

ketorolac 15 mg/ml isecure syr 7

ketorolac 15 mg/ml vial 7

ketorolac 30 mg/ml carpuject 7

ketorolac 30 mg/ml isecure syr 7

ketorolac 30 mg/ml vial 7

ketorolac 300 mg/10 ml vial 7

ketorolac 60 mg/2 ml vial 7

LEVACET CAPLET 3 aspirin/salicylamide/acetaminophen/caffeine

meclofenamate 100 mg capsule 1

meclofenamate 50 mg capsule 1

mefenamic acid 250 mg capsule 1

meloxicam 15 mg tablet 1

meloxicam 7.5 mg tablet 1

meloxicam 7.5 mg/5 ml susp 3

MOBIC 15 MG TABLET 3

PAGE 8 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS meloxicam MOBIC 7.5 MG TABLET 3 meloxicam MOBIC 7.5 MG/5 ML SUSPENSION 3 meloxicam

nabumetone 500 mg tablet 1

nabumetone 750 mg tablet 1

NALFON 400 MG CAPSULE 3 fenoprofen calcium NAPRELAN CR 375 MG TABLET 3 naproxen sodium NAPRELAN CR 375 MG TABLET 3 naproxen sodium NAPRELAN CR 500 MG TABLET 3 naproxen sodium NAPRELAN CR 750 MG TABLET 3 naproxen sodium NAPROSYN 125 MG/5 ML SUSPEN 3 naproxen NAPROSYN 250 MG TABLET 3 naproxen NAPROSYN 375 MG TABLET 3 naproxen NAPROSYN 500 MG TABLET 3 naproxen NAPROSYN EC 500 MG TABLET 3 naproxen

naproxen 125 mg/5 ml suspen 1

naproxen 250 mg tablet 1

naproxen 375 mg tablet 1

naproxen 500 mg kit 1

naproxen 500 mg tablet 1

naproxen dr 375 mg tablet 1

PAGE 9 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

naproxen dr 500 mg tablet 1

naproxen ec 375 mg tablet 1

naproxen ec 500 mg tablet 1

naproxen sodium 275 mg tab 1

naproxen sodium 550 mg tab 1

oxaprozin 600 mg caplet 1

oxaprozin 600 mg tablet 1

oxycodone-ibuprofen 5-400 tab 1

piroxicam 10 mg capsule 1

piroxicam 20 mg capsule 1

PONSTEL 250 MG KAPSEALS 3 mefenamic acid

salsalate 500 mg tablet 1

salsalate 750 mg caplet 1

salsalate 750 mg tablet 1

sulindac 150 mg tablet 1

sulindac 200 mg tablet 1

tolmetin sodium 200 mg tab 1

tolmetin sodium 400 mg cap 1

tolmetin sodium 600 mg tab 1

VIMOVO DR 375-20 MG TABLET 3 QL 60 / 30 days naproxen/esomeprazole magnesium VIMOVO DR 375-20 MG TABLET 3 QL 60 / 30 days naproxen/esomeprazole magnesium VIMOVO DR 500-20 MG TABLET 3 QL 60 / 30 days naproxen/esomeprazole magnesium

PAGE 10 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS VIMOVO DR 500-20 MG TABLET 3 QL 60 / 30 days naproxen/esomeprazole magnesium VOLTAREN-XR 100 MG TABLET 3 diclofenac sodium ZIPSOR 25 MG CAPSULE 3 QL 120 / 30 days diclofenac potassium ZORVOLEX 18 MG CAPSULE 3 diclofenac submicronized ZORVOLEX 35 MG CAPSULE 3 diclofenac submicronized Opioid Analgesics, Long-acting

ACTIQ 1,200 MCG LOZENGE 3 QL 120 / 30 days fentanyl citrate ACTIQ 1,600 MCG LOZENGE 3 QL 120 / 30 days fentanyl citrate ACTIQ 200 MCG LOZENGE 3 QL 120 / 30 days fentanyl citrate ACTIQ 400 MCG LOZENGE 3 QL 120 / 30 days fentanyl citrate ACTIQ 600 MCG LOZENGE 3 QL 120 / 30 days fentanyl citrate ACTIQ 800 MCG LOZENGE 3 QL 120 / 30 days fentanyl citrate AVINZA 120 MG CAPSULE 3 QL 30 / 30 days morphine sulfate AVINZA 30 MG CAPSULE 3 QL 30 / 30 days morphine sulfate AVINZA 45 MG CAPSULE 3 QL 30 / 30 days morphine sulfate AVINZA 60 MG CAPSULE 3 QL 30 / 30 days morphine sulfate AVINZA 75 MG CAPSULE 3 QL 30 / 30 days morphine sulfate AVINZA 90 MG CAPSULE 3 QL 30 / 30 days morphine sulfate BUTRANS 10 MCG/HR PATCH 3 QL 4 / 28 days buprenorphine BUTRANS 15 MCG/HR PATCH 3 QL 4 / 28 days buprenorphine

BUTRANS 20 MCG/HR PATCH 3 QL 4 / 28 days

PAGE 11 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS buprenorphine BUTRANS 5 MCG/HR PATCH 3 QL 4 / 28 days buprenorphine BUTRANS 7.5 MCG/HR PATCH 3 QL 4 / 28 days buprenorphine CONZIP 100 MG CAPSULE 3 tramadol hcl CONZIP 100 MG CAPSULE 3 tramadol hcl CONZIP 200 MG CAPSULE 3 tramadol hcl CONZIP 200 MG CAPSULE 3 tramadol hcl CONZIP 300 MG CAPSULE 3 tramadol hcl CONZIP 300 MG CAPSULE 3 tramadol hcl DISKETS 40 MG TABLET DISPR 1 methadone hcl DOLOPHINE HCL 10 MG TABLET 3 methadone hcl DOLOPHINE HCL 5 MG TABLET 3 methadone hcl DURAGESIC 100 MCG/HR PATCH 3 QL 10 / 30 days fentanyl DURAGESIC 12 MCG/HR PATCH 3 QL 10 / 30 days fentanyl DURAGESIC 25 MCG/HR PATCH 3 QL 10 / 30 days fentanyl DURAGESIC 50 MCG/HR PATCH 3 QL 10 / 30 days fentanyl DURAGESIC 75 MCG/HR PATCH 3 QL 10 / 30 days fentanyl EXALGO ER 12 MG TABLET 3 QL 60 / 30 days hydromorphone hcl EXALGO ER 16 MG TABLET 3 QL 60 / 30 days hydromorphone hcl EXALGO ER 32 MG TABLET 3 QL 60 / 30 days hydromorphone hcl

EXALGO ER 8 MG TABLET 3 QL 180 / 30 days

PAGE 12 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS hydromorphone hcl

fentanyl 0.05 mg/ml ampul 7

fentanyl 0.05 mg/ml syringe 7

fentanyl 0.05 mg/ml vial 7

fentanyl 1 mg/20 ml vial 7

fentanyl 1,000 mcg/20 ml ampul 7

fentanyl 1,000 mcg/20 ml vial 7

fentanyl 100 mcg/2 ml ampul 7

fentanyl 100 mcg/2 ml vial 7

fentanyl 100 mcg/hr patch 1 QL 10 / 30 days

fentanyl 12 mcg/hr patch 1 QL 10 / 30 days

fentanyl 2,500 mcg/50 ml vial 7

fentanyl 25 mcg/hr patch 1 QL 10 / 30 days

fentanyl 250 mcg/5 ml ampul 7

fentanyl 250 mcg/5 ml vial 7

fentanyl 50 mcg/hr patch 1 QL 10 / 30 days

fentanyl 75 mcg/hr patch 1 QL 10 / 30 days

fentanyl cit otfc 1,200 mcg 1 QL 120 / 30 days

fentanyl cit otfc 1,600 mcg 1 QL 120 / 30 days

fentanyl citrate otfc 200 mcg 1 QL 120 / 30 days

fentanyl citrate otfc 400 mcg 1 QL 120 / 30 days

fentanyl citrate otfc 600 mcg 1 QL 120 / 30 days

fentanyl citrate otfc 800 mcg 1 QL 120 / 30 days

PAGE 13 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS FENTORA 100 MCG BUCCAL TABLET 3 QL 120 / 30 days fentanyl citrate FENTORA 200 MCG BUCCAL TABLET 3 QL 120 / 30 days fentanyl citrate FENTORA 400 MCG BUCCAL TABLET 3 QL 120 / 30 days fentanyl citrate FENTORA 600 MCG BUCCAL TABLET 3 QL 120 / 30 days fentanyl citrate FENTORA 800 MCG BUCCAL TABLET 3 QL 120 / 30 days fentanyl citrate

hydromorphone hcl er 12 mg tab 1 QL 60 / 30 days

hydromorphone hcl er 16 mg tab 1 QL 60 / 30 days

hydromorphone hcl er 32 mg tab 1 QL 60 / 30 days

hydromorphone hcl er 8 mg tab 1 QL 180 / 30 days

KADIAN ER 10 MG CAPSULE 3 QL 60 / 30 days morphine sulfate KADIAN ER 10 MG CAPSULE 3 QL 60 / 30 days morphine sulfate KADIAN ER 100 MG CAPSULE 3 QL 60 / 30 days morphine sulfate KADIAN ER 100 MG CAPSULE 3 QL 60 / 30 days morphine sulfate KADIAN ER 130 MG CAPSULE 3 QL 60 / 30 days morphine sulfate KADIAN ER 150 MG CAPSULE 3 QL 60 / 30 days morphine sulfate KADIAN ER 20 MG CAPSULE 3 QL 60 / 30 days morphine sulfate KADIAN ER 20 MG CAPSULE 3 QL 60 / 30 days morphine sulfate KADIAN ER 200 MG CAPSULE 3 QL 60 / 30 days morphine sulfate KADIAN ER 200 MG CAPSULE 3 QL 60 / 30 days morphine sulfate KADIAN ER 30 MG CAPSULE 3 QL 60 / 30 days morphine sulfate KADIAN ER 30 MG CAPSULE 3 QL 60 / 30 days morphine sulfate

PAGE 14 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS KADIAN ER 40 MG CAPSULE QL 60 / 30 days morphine sulfate KADIAN ER 40 MG CAPSULE 3 QL 60 / 30 days morphine sulfate KADIAN ER 50 MG CAPSULE 3 QL 60 / 30 days morphine sulfate KADIAN ER 50 MG CAPSULE 3 QL 60 / 30 days morphine sulfate KADIAN ER 60 MG CAPSULE 3 QL 60 / 30 days morphine sulfate KADIAN ER 60 MG CAPSULE 3 QL 60 / 30 days morphine sulfate KADIAN ER 70 MG CAPSULE 3 QL 60 / 30 days morphine sulfate KADIAN ER 80 MG CAPSULE 3 QL 60 / 30 days morphine sulfate KADIAN ER 80 MG CAPSULE 3 QL 60 / 30 days morphine sulfate LAZANDA 100 MCG NASAL SPRAY 3 fentanyl citrate LAZANDA 100 MCG NASAL SPRAY 3 fentanyl citrate LAZANDA 400 MCG NASAL SPRAY 3 fentanyl citrate LAZANDA 400 MCG NASAL SPRAY 3 fentanyl citrate

levorphanol 2 mg tablet 1

methadone 10 mg/5 ml solution 1

methadone 10 mg/ml oral conc 1

methadone 40 mg tablet dispr 1

methadone 5 mg/5 ml solution 1

methadone hcl 10 mg tablet 1

methadone hcl 10 mg/ml vial 9

methadone hcl 5 mg tablet 1

methadone intensol 10 mg/ml 1

PAGE 15 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS METHADOSE 10 MG/ML ORAL CONC 3 methadone hcl

methadose 40 mg tablet dispr 1

morphine sulf er 100 mg tablet 1

morphine sulf er 15 mg tablet 1

morphine sulf er 200 mg tablet 1

morphine sulf er 30 mg tablet 1

morphine sulf er 60 mg tablet 1

morphine sulfate er 10 mg cap 1 QL 60 / 30 days

morphine sulfate er 100 mg cap 1 QL 60 / 30 days

morphine sulfate er 120 mg cap 1 QL 30 / 30 days

morphine sulfate er 20 mg cap 1 QL 60 / 30 days

morphine sulfate er 30 mg cap 1 QL 30 / 30 days

morphine sulfate er 45 mg cap 1 QL 30 / 30 days

morphine sulfate er 50 mg cap 1 QL 60 / 30 days

morphine sulfate er 60 mg cap 1 QL 30 / 30 days

morphine sulfate er 75 mg cap 1 QL 30 / 30 days

morphine sulfate er 80 mg cap 1 QL 60 / 30 days

morphine sulfate er 90 mg cap 1 QL 30 / 30 days

MS CONTIN 100 MG TABLET 3 morphine sulfate MS CONTIN 15 MG TABLET 3 morphine sulfate MS CONTIN 200 MG TABLET 3 morphine sulfate

PAGE 16 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS MS CONTIN 60 MG TABLET 3 morphine sulfate MS CONTIN CR 30 MG TABLET 3 morphine sulfate NUCYNTA ER 100 MG TABLET 3 QL 60 / 30 days tapentadol hcl NUCYNTA ER 150 MG TABLET 3 QL 60 / 30 days tapentadol hcl NUCYNTA ER 200 MG TABLET 3 QL 60 / 30 days tapentadol hcl NUCYNTA ER 250 MG TABLET 3 QL 60 / 30 days tapentadol hcl NUCYNTA ER 50 MG TABLET 3 QL 60 / 30 days tapentadol hcl ONSOLIS 1,200 MCG SOLUBLE FILM 5 PA fentanyl citrate ONSOLIS 200 MCG SOLUBLE FILM 5 PA fentanyl citrate ONSOLIS 400 MCG SOLUBLE FILM 5 PA fentanyl citrate ONSOLIS 600 MCG SOLUBLE FILM 5 PA fentanyl citrate ONSOLIS 800 MCG SOLUBLE FILM 5 PA fentanyl citrate OPANA ER 10 MG TABLET 3 oxymorphone hcl OPANA ER 15 MG TABLET 3 oxymorphone hcl OPANA ER 20 MG TABLET 3 oxymorphone hcl OPANA ER 30 MG TABLET 3 oxymorphone hcl OPANA ER 40 MG TABLET 3 oxymorphone hcl OPANA ER 5 MG TABLET 3 oxymorphone hcl OPANA ER 7.5 MG TABLET 3 oxymorphone hcl

oxycodone hcl er 10 mg tablet 1 QL 120 / 30 days

oxycodone hcl er 20 mg tablet 1 QL 120 / 30 days

PAGE 17 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

oxycodone hcl er 40 mg tablet 1 QL 120 / 30 days

oxycodone hcl er 80 mg tablet 1 QL 120 / 30 days

OXYCONTIN 10 MG TABLET 2 QL 120 / 30 days oxycodone hcl OXYCONTIN 15 MG TABLET 2 QL 120 / 30 days oxycodone hcl OXYCONTIN 20 MG TABLET 2 QL 120 / 30 days oxycodone hcl OXYCONTIN 30 MG TABLET 2 QL 120 / 30 days oxycodone hcl OXYCONTIN 40 MG TABLET 2 QL 120 / 30 days oxycodone hcl OXYCONTIN 60 MG TABLET 2 QL 120 / 30 days oxycodone hcl OXYCONTIN 80 MG TABLET 2 QL 120 / 30 days oxycodone hcl

oxymorphone hcl er 10 mg tab 1

oxymorphone hcl er 15 mg tab 1

oxymorphone hcl er 20 mg tab 1

oxymorphone hcl er 30 mg tab 1

oxymorphone hcl er 40 mg tab 1

oxymorphone hcl er 5 mg tablet 1

oxymorphone hcl er 7.5 mg tab 1

RYZOLT ER 100 MG TABLET 3 QL 30 / 30 days tramadol hcl

PAGE 18 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS RYZOLT ER 200 MG TABLET QL 30 / 30 days tramadol hcl RYZOLT ER 300 MG TABLET 3 QL 30 / 30 days tramadol hcl SUBLIMAZE 50 MCG/ML AMPULE 9 fentanyl citrate/pf SUBSYS 1,200 MCG SPRAY 3 fentanyl SUBSYS 1,600 MCG SPRAY 3 fentanyl SUBSYS 100 MCG SPRAY 3 fentanyl SUBSYS 200 MCG SPRAY 3 fentanyl SUBSYS 400 MCG SPRAY 3 fentanyl SUBSYS 600 MCG SPRAY 3 fentanyl SUBSYS 800 MCG SPRAY 3 fentanyl

tramadol er 100 mg tablet 1 QL 30 / 30 days

tramadol er 200 mg tablet 1 QL 30 / 30 days

tramadol er 300 mg tablet 1 QL 30 / 30 days

tramadol hcl er 100 mg tablet 1

tramadol hcl er 150 mg capsule 1

tramadol hcl er 200 mg tablet 1

tramadol hcl er 300 mg tablet 1

ULTRAM ER 100 MG TABLET 3 tramadol hcl ULTRAM ER 200 MG TABLET 3 tramadol hcl ULTRAM ER 300 MG TABLET 3 tramadol hcl

PAGE 19 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS XARTEMIS XR 7.5-325 MG TABLET 3 oxycodone hcl/acetaminophen ZOHYDRO ER 10 MG CAPSULE 3 hydrocodone bitartrate ZOHYDRO ER 15 MG CAPSULE 3 hydrocodone bitartrate ZOHYDRO ER 20 MG CAPSULE 3 hydrocodone bitartrate ZOHYDRO ER 30 MG CAPSULE 3 hydrocodone bitartrate ZOHYDRO ER 40 MG CAPSULE 3 hydrocodone bitartrate ZOHYDRO ER 50 MG CAPSULE 3 hydrocodone bitartrate Opioid Analgesics, Short-acting

ABSTRAL 100 MCG TAB SUBLINGUAL 3 fentanyl citrate ABSTRAL 200 MCG TAB SUBLINGUAL 3 fentanyl citrate ABSTRAL 300 MCG TAB SUBLINGUAL 3 fentanyl citrate ABSTRAL 400 MCG TAB SUBLINGUAL 3 fentanyl citrate ABSTRAL 600 MCG TAB SUBLINGUAL 3 fentanyl citrate ABSTRAL 800 MCG TAB SUBLINGUAL 3 fentanyl citrate

acetaminoph-caff-dihydrocodein 1

acetaminophen-cod #2 tablet 1

acetaminophen-cod #3 tablet 1

acetaminophen-cod #4 tablet 1

acetaminophen-codeine solution 1

ACTIQ 1,200 MCG LOZENGE 3 QL 120 / 30 days

PAGE 20 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS fentanyl citrate ACTIQ 1,600 MCG LOZENGE 3 QL 120 / 30 days fentanyl citrate ACTIQ 200 MCG LOZENGE 3 QL 120 / 30 days fentanyl citrate ACTIQ 400 MCG LOZENGE 3 QL 120 / 30 days fentanyl citrate ACTIQ 600 MCG LOZENGE 3 QL 120 / 30 days fentanyl citrate ACTIQ 800 MCG LOZENGE 3 QL 120 / 30 days fentanyl citrate ALFENTA 500 MCG/ML AMPUL 9 alfentanil hcl

alfentanil 500 mcg/ml ampul 7

aspirin-caff-dihydrocodein cap 3

astramorph-pf 0.5 mg/ml amp 7

astramorph-pf 1 mg/ml ampul 7

ASTRAMORPH-PF 10 MG/10 ML VIAL 7 morphine sulfate/pf ASTRAMORPH-PF 5 MG/10 ML VIAL 7 morphine sulfate/pf BUPRENEX 0.3 MG/ML AMPUL 9 buprenorphine hcl

buprenorphine 0.3 mg/ml syrn 7

buprenorphine 0.3 mg/ml vial 7

butalb-acetaminoph-caff-codein 1

butorphanol 1 mg/ml vial 7

butorphanol 10 mg/ml spray 1 QL 15 / 90 days

butorphanol 2 mg/ml vial 7

CAPITAL WITH CODEINE SUSP 3 acetaminophen with codeine phosphate

carisoprodol cpd-codeine tab 1 QL 120 / 30 days

carisoprodol-aspirin-codein tb 1 QL 120 / 30 days

co-gesic 5-500 tablet 1

PAGE 21 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

codeine sulfate 15 mg tablet 3

codeine sulfate 30 mg tablet 3

codeine sulfate 30 mg/5 ml sol 1

codeine sulfate 60 mg tablet 3

DEMEROL 100 MG TABLET 3 meperidine hcl DEMEROL 100 MG/ML AMPUL 9 meperidine hcl/pf DEMEROL 100 MG/ML SYRINGE 9 meperidine hcl/pf DEMEROL 100 MG/ML VIAL 9 meperidine hcl DEMEROL 25 MG/ML SYRINGE 9 meperidine hcl/pf DEMEROL 50 MG TABLET 3 meperidine hcl DEMEROL 50 MG/ML AMPUL 9 meperidine hcl/pf DEMEROL 50 MG/ML SYRINGE 9 meperidine hcl/pf DEMEROL 50 MG/ML VIAL 9 meperidine hcl DEMEROL 75 MG/1.5 ML AMPUL 9 meperidine hcl/pf DEMEROL 75 MG/ML SYRINGE 9 meperidine hcl/pf DEPODUR 10 MG/ML VIAL 9 morphine sulfate liposomal/pf DEPODUR 15 MG/1.5 ML VIAL 9 morphine sulfate liposomal/pf DILAUDID 1 MG/ML AMPUL 9 hydromorphone hcl/pf DILAUDID 1 MG/ML LIQUID 3 hydromorphone hcl DILAUDID 2 MG TABLET 3 hydromorphone hcl DILAUDID 2 MG/ML AMPUL 9 hydromorphone hcl/pf

PAGE 22 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS DILAUDID 4 MG TABLET hydromorphone hcl DILAUDID 4 MG/ML AMPUL 9 hydromorphone hcl/pf DILAUDID 8 MG TABLET 3 hydromorphone hcl DILAUDID-HP 10 MG/ML AMPUL 9 hydromorphone hcl/pf DILAUDID-HP 10 MG/ML VIAL 9 hydromorphone hcl/pf DILAUDID-HP 250 MG VIAL 9 hydromorphone hcl/pf DISKETS 40 MG TABLET DISPR 1 methadone hcl DOLOPHINE HCL 10 MG TABLET 3 methadone hcl DOLOPHINE HCL 5 MG TABLET 3 methadone hcl DURAGESIC 100 MCG/HR PATCH 3 QL 10 / 30 days fentanyl DURAGESIC 12 MCG/HR PATCH 3 QL 10 / 30 days fentanyl DURAGESIC 25 MCG/HR PATCH 3 QL 10 / 30 days fentanyl DURAGESIC 50 MCG/HR PATCH 3 QL 10 / 30 days fentanyl DURAGESIC 75 MCG/HR PATCH 3 QL 10 / 30 days fentanyl DURAMORPH 10 MG/10 ML AMPUL 7 morphine sulfate/pf DURAMORPH 5 MG/10 ML AMPUL 7 morphine sulfate/pf

endocet 10-325 mg tablet 1

endocet 10-650 mg tablet 1

endocet 2.5-325 mg tablet 1

endocet 5-325 tablet 1

endocet 7.5-325 mg tablet 1

endocet 7.5-500 mg tablet 1

PAGE 23 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

endodan 4.83-325 mg tablet 1

fentanyl 100 mcg/hr patch 1 QL 10 / 30 days

fentanyl 12 mcg/hr patch 1 QL 10 / 30 days

fentanyl 25 mcg/hr patch 1 QL 10 / 30 days

fentanyl 50 mcg/hr patch 1 QL 10 / 30 days

fentanyl 75 mcg/hr patch 1 QL 10 / 30 days

fentanyl cit otfc 1,200 mcg 1 QL 120 / 30 days

fentanyl cit otfc 1,600 mcg 1 QL 120 / 30 days

fentanyl citrate otfc 200 mcg 1 QL 120 / 30 days

fentanyl citrate otfc 400 mcg 1 QL 120 / 30 days

fentanyl citrate otfc 600 mcg 1 QL 120 / 30 days

fentanyl citrate otfc 800 mcg 1 QL 120 / 30 days

FENTORA 100 MCG BUCCAL TABLET 3 QL 120 / 30 days fentanyl citrate FENTORA 200 MCG BUCCAL TABLET 3 QL 120 / 30 days fentanyl citrate FENTORA 400 MCG BUCCAL TABLET 3 QL 120 / 30 days fentanyl citrate FENTORA 600 MCG BUCCAL TABLET 3 QL 120 / 30 days fentanyl citrate FENTORA 800 MCG BUCCAL TABLET 3 QL 120 / 30 days fentanyl citrate FIORICET-COD 50-300-40-30 CAP 3 butalbital/acetaminophen/caffeine/codeine phosphate HYCET 7.5 MG-325 MG/15 ML SOLN 3 hydrocodone bitartrate/acetaminophen HYCET 7.5 MG-325 MG/15 ML SOLN 3 hydrocodone bitartrate/acetaminophen

hydrocodon-acetamin 7.5-325/15 1

hydrocodon-acetamin 7.5-500/15 1

hydrocodon-acetaminoph 2.5-325 1

PAGE 24 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

hydrocodon-acetaminoph 2.5-325

hydrocodon-acetaminoph 2.5-500 1

hydrocodon-acetaminoph 7.5-300 1

hydrocodon-acetaminoph 7.5-325 1

hydrocodon-acetaminoph 7.5-500 1

hydrocodon-acetaminoph 7.5-650 1

hydrocodon-acetaminoph 7.5-750 1

hydrocodon-acetaminophen 5-300 1

hydrocodon-acetaminophen 5-325 1

hydrocodon-acetaminophen 5-500 1

hydrocodon-acetaminophn 10-300 1

hydrocodon-acetaminophn 10-325 1

hydrocodon-acetaminophn 10-500 1

hydrocodon-acetaminophn 10-650 1

hydrocodon-acetaminophn 10-660 1

hydrocodon-acetaminophn 10-750 1

hydrocodone-acetamin 10-325/15 1

hydrocodone-acetamin 2.5-108/5 1

hydrocodone-acetamin 2.5-167/5 1

hydrocodone-acetamin 5-163/7.5 1

hydrocodone-acetamin 5-217/10 1

hydrocodone-acetamin 5-334/10 1

PAGE 25 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

hydrocodone-ibuprofen 10-200 1

hydrocodone-ibuprofen 2.5-200 1

hydrocodone-ibuprofen 5-200 mg 1

hydrocodone-ibuprofen 7.5-200 1

hydromorphone 0.5 mg/0.5 ml 7

hydromorphone 1 mg/ml solution 1

hydromorphone 1 mg/ml syringe 7

hydromorphone 10 mg/ml vial 7

hydromorphone 2 mg tablet 1

hydromorphone 2 mg/ml syringe 7

hydromorphone 2 mg/ml vial 7

hydromorphone 3 mg suppos 1

hydromorphone 4 mg tablet 1

hydromorphone 4 mg/ml syrin 7

hydromorphone 5 mg/5 ml soln 1

hydromorphone 50 mg/5 ml vial 7

hydromorphone 500 mg/50 ml via 7

hydromorphone 8 mg tablet 1

hydromorphone hcl 1 mg/ml amp 7

hydromorphone hcl 10 mg/ml amp 7

hydromorphone hcl 10 mg/ml vl 7

hydromorphone hcl 2 mg/ml amp 7

hydromorphone hcl 4 mg/ml amp 7

IBUDONE 10-200 MG TABLET 3 hydrocodone/ibuprofen

ibudone 5-200 mg tablet 1

PAGE 26 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS INFUMORPH 200 MG/20 ML AMPUL 8 morphine sulfate/pf INFUMORPH 500 MG/20 ML AMPUL 8 morphine sulfate/pf J-MAX DHC LIQUID 3 dihydrocodeine bitartrate/guaifenesin LAZANDA 100 MCG NASAL SPRAY 3 fentanyl citrate LAZANDA 400 MCG NASAL SPRAY 3 fentanyl citrate LORCET 10-650 TABLET 3 hydrocodone bitartrate/acetaminophen

lorcet 5-325 mg tablet 1

lorcet hd 10-325 mg tablet 1

lorcet plus 7.5-325 mg tablet 1

LORCET PLUS TABLET 3 hydrocodone bitartrate/acetaminophen

lortab 10 mg-300 mg/15 ml elxr 1

lortab 10-325 mg tablet 1

LORTAB 10-500 TABLET 3 hydrocodone bitartrate/acetaminophen

lortab 5-325 mg tablet 1

lortab 5-500 tablet 3

lortab 7.5-325 mg tablet 1

LORTAB 7.5-500 MG/15 ML ELIXIR 3 hydrocodone bitartrate/acetaminophen LORTAB 7.5-500 TABLET 3 hydrocodone bitartrate/acetaminophen MAGNACET 10 MG-400 MG TABLET 3 oxycodone hcl/acetaminophen MAGNACET 5 MG-400 MG TABLET 3 oxycodone hcl/acetaminophen MAGNACET 7.5 MG-400 MG TABLET 3 oxycodone hcl/acetaminophen MAXIDONE 10-750 MG TABLET 3 hydrocodone bitartrate/acetaminophen

PAGE 27 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

meperidine 10 mg/ml cartrdge

meperidine 100 mg tablet 1

meperidine 100 mg/ml vial 7

meperidine 25 mg/ml vial 7

meperidine 50 mg tablet 1

meperidine 50 mg/5 ml solution 1

meperidine 50 mg/ml vial 7

meperitab 100 mg tablet 1

methadone 10 mg/5 ml solution 1

methadone 10 mg/ml oral conc 1

methadone 40 mg tablet dispr 1

methadone 5 mg/5 ml solution 1

methadone hcl 10 mg tablet 1

methadone hcl 10 mg/ml vial 9

methadone hcl 5 mg tablet 1

methadone intensol 10 mg/ml 1

METHADOSE 10 MG/ML ORAL CONC 3 methadone hcl

methadose 40 mg tablet dispr 1

morphine 0.5 mg/ml vial 7

morphine 1 mg/ml syringe 7

morphine 1 mg/ml vial p-f 7

morphine 1 mg/ml-d5w 100 ml 9

morphine 10 mg/ml carpuject 8

morphine 10 mg/ml isecure syr 7

morphine 10 mg/ml syringe 7

morphine 10 mg/ml vial 7

PAGE 28 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

morphine 100 mg/10 ml vial 7

morphine 15 mg/ml carpuject 8

morphine 15 mg/ml syringe 7

morphine 15 mg/ml vial 7

morphine 2 mg/ml carpuject 8

morphine 2 mg/ml isecure syr 7

morphine 2 mg/ml syringe 8

morphine 30 mg/30 ml syringe 7

morphine 300 mg/20 ml vial 7

morphine 4 mg/ml carpuject 9

morphine 4 mg/ml isecure syr 7

morphine 4 mg/ml syringe 7

morphine 5 mg/ml syringe 7

morphine 5 mg/ml vial 8

morphine 8 mg/ml isecure syr 7

morphine 8 mg/ml syringe 7

morphine 8 mg/ml vial 7

morphine sulf 10 mg suppos 2

morphine sulf 10 mg/0.7 ml syr 8

morphine sulf 10 mg/5 ml soln 1

morphine sulf 100 mg/5 ml soln 1

morphine sulf 20 mg suppos 2

PAGE 29 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

morphine sulf 20 mg/5 ml soln 1

morphine sulf 30 mg suppos 2

morphine sulf 5 mg suppos 2

morphine sulfate 1 mg/ml vial 7

morphine sulfate 25 mg/ml vial 8

morphine sulfate 25 mg/ml vl 8

morphine sulfate 50 mg/ml vial 8

morphine sulfate ir 15 mg tab 1

morphine sulfate ir 30 mg tab 1

nalbuphine 10 mg/ml ampul 7

nalbuphine 100 mg/10 ml vial 7

nalbuphine 20 mg/ml ampul 7

nalbuphine 200 mg/10 ml vial 7

NORCO 10-325 TABLET 3 hydrocodone bitartrate/acetaminophen NORCO 5-325 TABLET 3 hydrocodone bitartrate/acetaminophen NORCO 7.5-325 TABLET 3 hydrocodone bitartrate/acetaminophen NUCYNTA 100 MG TABLET 3 QL 180 / 30 days tapentadol hcl NUCYNTA 50 MG TABLET 3 QL 180 / 30 days tapentadol hcl NUCYNTA 75 MG TABLET 3 QL 180 / 30 days tapentadol hcl ONSOLIS 1,200 MCG SOLUBLE FILM 5 PA fentanyl citrate ONSOLIS 200 MCG SOLUBLE FILM 5 PA fentanyl citrate ONSOLIS 400 MCG SOLUBLE FILM 5 PA fentanyl citrate ONSOLIS 600 MCG SOLUBLE FILM 5 PA fentanyl citrate

ONSOLIS 800 MCG SOLUBLE FILM 5 PA

PAGE 30 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS fentanyl citrate OPANA 1 MG/ML INJ AMPULE 9 oxymorphone hcl OPANA 10 MG TABLET 3 oxymorphone hcl OPANA 5 MG TABLET 3 oxymorphone hcl OXECTA 5 MG TABLET 3 oxycodone hcl OXECTA 7.5 MG TABLET 3 oxycodone hcl

oxycodon-acetaminophen 2.5-325 1

oxycodon-acetaminophen 7.5-325 1

oxycodon-acetaminophen 7.5-500 1

oxycodone hcl 10 mg tablet 1

oxycodone hcl 100 mg/5 ml soln 1

oxycodone hcl 15 mg tablet 1

oxycodone hcl 20 mg tablet 1

oxycodone hcl 30 mg tablet 1

oxycodone hcl 5 mg capsule 1

oxycodone hcl 5 mg tablet 1

oxycodone hcl 5 mg/5 ml soln 1

oxycodone-acetaminophen 10-325 1

PAGE 31 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

oxycodone-acetaminophen 10-325 1

oxycodone-acetaminophen 10-650 1

oxycodone-acetaminophen 5-325 1

oxycodone-acetaminophen 5-500 1

oxycodone-aspirin 4.83-325 mg 1

oxycodone-ibuprofen 5-400 tab 1

oxymorphone hcl 10 mg tablet 1

oxymorphone hcl 5 mg tablet 1

pentazocin-acetaminophn 25-650 1

pentazocine-naloxone tablet 1

PERCOCET 10-325 MG TABLET 3 oxycodone hcl/acetaminophen PERCOCET 10-650 MG TABLET 3 oxycodone hcl/acetaminophen PERCOCET 2.5-325 MG TABLET 3 oxycodone hcl/acetaminophen PERCOCET 5-325 MG TABLET 3 oxycodone hcl/acetaminophen PERCOCET 7.5-325 MG TABLET 3 oxycodone hcl/acetaminophen PERCOCET 7.5-500 MG TABLET 3 oxycodone hcl/acetaminophen PERCODAN TABLET 3 oxycodone hcl/aspirin

reprexain 10-200 mg tablet 1

REPREXAIN 2.5-200 MG TABLET 3 hydrocodone/ibuprofen REPREXAIN 5-200 MG TABLET 3 hydrocodone/ibuprofen ROXICET 5-325 ORAL SOLUTION 3 oxycodone hcl/acetaminophen

roxicet 5-325 tablet 1

PAGE 32 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ROXICODONE 15 MG TABLET 3 oxycodone hcl ROXICODONE 30 MG TABLET 3 oxycodone hcl ROXICODONE 5 MG TABLET 3 oxycodone hcl ROXICODONE 5 MG TABLET 3 oxycodone hcl RYBIX ODT 50 MG TABLET 3 QL 240 / 30 days tramadol hcl

stagesic 5-500 capsule 1

SUBLIMAZE 50 MCG/ML AMPULE 9 fentanyl citrate/pf SUBSYS 1,200 MCG SPRAY 3 fentanyl SUBSYS 1,600 MCG SPRAY 3 fentanyl SUBSYS 100 MCG SPRAY 3 fentanyl SUBSYS 200 MCG SPRAY 3 fentanyl SUBSYS 400 MCG SPRAY 3 fentanyl SUBSYS 600 MCG SPRAY 3 fentanyl SUBSYS 800 MCG SPRAY 3 fentanyl SUFENTA 100 MCG/2 ML AMPUL 9 sufentanil citrate SUFENTA 250 MCG/5 ML AMPULE 9 sufentanil citrate SUFENTA 50 MCG/ML AMPUL 9 sufentanil citrate

sufentanil 100 mcg/2 ml ampul 7

sufentanil 250 mcg/5 ml ampul 7

sufentanil 50 mcg/ml ampul 7

sufentanil 50 mcg/ml vial 7

SYNALGOS-DC CAPSULE 3

PAGE 33 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS dihydrocodeine bitartrate/aspirin/caffeine TALWIN 30 MG/ML AMPUL 9 pentazocine lactate TALWIN 30 MG/ML VIAL 9 pentazocine lactate

tramadol hcl 50 mg tablet 1 QL 240 / 30 days

tramadol-acetaminophn 37.5-325 1 QL 240 / 30 days

trezix capsule 2

TYLENOL WITH CODEINE #3 TABLET 3 acetaminophen with codeine phosphate TYLENOL WITH CODEINE #4 TABLET 3 acetaminophen with codeine phosphate TYLOX 5-500 MG CAPSULE 3 oxycodone hcl/acetaminophen ULTIVA 1 MG VIAL 9 remifentanil hcl ULTIVA 1 MG VIAL 9 remifentanil hcl ULTIVA 2 MG VIAL 9 remifentanil hcl ULTIVA 5 MG VIAL 9 remifentanil hcl ULTRACET TABLET 3 QL 240 / 30 days tramadol hcl/acetaminophen ULTRAM 50 MG TABLET 3 QL 240 / 30 days tramadol hcl

verdrocet 2.5-325 mg tablet 1

vicodin 5-300 mg tablet 1

vicodin es 7.5-300 mg tablet 1

vicodin hp 10-300 mg tablet 1

VICOPROFEN 200-7.5 MG TAB 3 hydrocodone/ibuprofen VITUZ SOLUTION 3 hydrocodone bitartrate/chlorpheniramine maleate

PAGE 34 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS XODOL 10-300 TABLET 3 hydrocodone bitartrate/acetaminophen XODOL 5-300 TABLET 3 hydrocodone bitartrate/acetaminophen XODOL 7.5-300 MG TABLET 3 hydrocodone bitartrate/acetaminophen

xylon 10-200 mg tablet 1

ZAMICET 10-325 MG/15 ML SOLN 3 hydrocodone bitartrate/acetaminophen ZOLVIT 10 MG-300 MG/15 ML SOLN 3 hydrocodone bitartrate/acetaminophen ZYDONE 10-400 MG TABLET 3 hydrocodone bitartrate/acetaminophen ZYDONE 5-400 MG TABLET 3 hydrocodone bitartrate/acetaminophen ZYDONE 7.5-400 MG TABLET 3 hydrocodone bitartrate/acetaminophen Anesthetics

Local Anesthetics

ALCAINE 0.5% EYE DROPS 3 proparacaine hcl AMIDATE 2 MG/ML ABBOJECT 9 etomidate AMIDATE 2 MG/ML AMPUL 9 etomidate AMIDATE 20 MG/10 ML VIAL 9 etomidate AMIDATE 40 MG/20 ML VIAL 9 etomidate ANACAINE OINTMENT 3 benzocaine ARTICADENT DENTAL 4%-1:100,000 9 articaine hcl/epinephrine bitartrate ARTICADENT DENTAL 4%-1:200,000 9 articaine hcl/epinephrine bitartrate BREVITAL SODIUM 2.5 GM VIAL 9 methohexital sodium BREVITAL SODIUM 200 MG VIAL 9 methohexital sodium

PAGE 35 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS BREVITAL SODIUM 500 MG VIAL 9 methohexital sodium BUCALSEP SOLUTION 3 benzocaine/zinc chloride/pine tar/cetylpyridinium chloride BUCALSEP SPRAY 3 benzocaine/zinc chloride/pine tar/cetylpyridinium chloride

bupivacaine 0.25% ampul 7

bupivacaine 0.25% vial 7

bupivacaine 0.5% ampul 7

bupivacaine 0.5% vial 7

bupivacaine 0.75% ampul 7

bupivacaine 0.75% vial 7

bupivacaine-dextr 0.75% amp 7

bupivacaine-epi 0.25%-0.0005 7

bupivacaine-epi 0.5%-0.0005 7

bupivacaine-epi 0.5%-1:200,000 7

CARBOCAINE 1% VIAL 9 mepivacaine hcl CARBOCAINE 1% VIAL 9 mepivacaine hcl/pf CARBOCAINE 1.5% VIAL 9 mepivacaine hcl/pf

PAGE 36 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS CARBOCAINE 2% VIAL 9 mepivacaine hcl CARBOCAINE 2% VIAL 9 mepivacaine hcl/pf CETACAINE ANESTHETIC LIQUID 3 tetracaine/benzocaine/butamben CETACAINE MEDICAL KIT E 3 tetracaine/benzocaine/butamben CETACAINE SPRAY 3 tetracaine/benzocaine/butamben

chloroprocaine 2% vial 7

chloroprocaine 3% vial 7

CITANEST PLAIN DENTAL 4% CART 9 prilocaine hcl

cocaine 10% solution 1

cocaine 4% solution 1

compound 347 inhalation 1

DIPRIVAN 1,000 MG/100 ML VIAL 9 propofol DIPRIVAN 1,000 MG/100 ML VIAL 9 propofol DIPRIVAN 10 MG/ML VIAL 9 propofol DIPRIVAN 100 MG/10 ML VIAL 9 propofol DIPRIVAN 200 MG/20 ML VIAL 9 propofol DIPRIVAN 200 MG/20 ML VIAL 9 propofol DIPRIVAN 500 MG/50 ML VIAL 9 propofol DIPRIVAN 500 MG/50 ML VIAL 9 propofol DNA MEDICATED COLLECTION KIT 3 lidocaine hcl/glycerin EMLA CREAM 3 lidocaine/prilocaine

ETHRANE INHALATION 3

PAGE 37 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS enflurane

ethyl chloride spray 3

etomidate 20 mg/10 ml vial 7

etomidate 40 mg/20 ml vial 7

EXACTACAIN SPRAY 3 tetracaine/benzocaine/butamben EXPAREL 266 MG/20 ML VIAL 9 bupivacaine liposome/pf FORANE LIQUID 3 isoflurane

glydo 2% jelly syringe 1

isoflurane liquid 1

KETALAR 200 MG/20 ML VIAL 9 ketamine hcl KETALAR 500 MG/10 ML VIAL 9 ketamine hcl KETALAR 500 MG/5 ML VIAL 9 ketamine hcl

ketamine 100 mg/ml vial 7

ketamine 200 mg/20 ml vial 7

ketamine 500 mg/10 ml vial 7

ketamine 500 mg/5 ml vial 7

lidocaine 0.4% in d5w soln 7

lidocaine 0.5%-epi 1:200,000 7

lidocaine 0.8% in d5w soln 7

lidocaine 1%-epi 1:100,000 7

lidocaine 1.5%-epi 1:200,000 7

lidocaine 2% - epi 1:100,000 7

lidocaine 2% - epi 1:50,000 7

PAGE 38 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

lidocaine 2% viscous soln 1

lidocaine 2%-epi 1:100,000 7

lidocaine 2%-epi 1:200,000 7

lidocaine 3% cream 1

lidocaine 5% in d7.5w ampul 1

lidocaine 5% ointment 1

lidocaine 5% patch 1

lidocaine hcl 0.5% vial 7

lidocaine hcl 1% 20 mg/2 ml 7

lidocaine hcl 1% 20 mg/2 ml vl 7

lidocaine hcl 1% 300 mg/30 ml 7

lidocaine hcl 1% 50 mg/5 ml 7

lidocaine hcl 1% 50 mg/5 ml vl 7

lidocaine hcl 1% ampul 7

lidocaine hcl 1% syringe 7

lidocaine hcl 1% vial 7

lidocaine hcl 1.5% ampul 7

lidocaine hcl 2% 100 mg/5 ml 7

lidocaine hcl 2% 40 mg/2 ml 7

lidocaine hcl 2% 40 mg/2 ml vl 7

lidocaine hcl 2% ampul 7

lidocaine hcl 2% jelly 1

PAGE 39 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

lidocaine hcl 2% jelly 1

lidocaine hcl 2% syringe 7

lidocaine hcl 2% vial 7

lidocaine hcl 3% lotion 1

lidocaine hcl 4% ampul 7

lidocaine hcl 4% solution 1

lidocaine-prilocaine cream 1

LIDODERM 5% PATCH 3 lidocaine LIDORX 3% GEL 3 lidocaine hcl MARCAINE 0.25% VIAL 9 bupivacaine hcl MARCAINE 0.25% VIAL 9 bupivacaine hcl/pf MARCAINE 0.25%-EPI 0.0005 VIAL 9 bupivacaine hcl/epinephrine MARCAINE 0.5% VIAL 9 bupivacaine hcl MARCAINE 0.5% VIAL 9 bupivacaine hcl/pf MARCAINE 0.5%-EPI 0.0005 VIAL 9 bupivacaine hcl/epinephrine MARCAINE 0.5%-EPI 0.0005 VIAL 9 bupivacaine hcl/epinephrine/pf MARCAINE 0.75% VIAL 9 bupivacaine hcl/pf MARCAINE SPINAL AMPUL 9 bupivacaine hcl/dextrose-water/pf MARCAINE-EPI 0.25%-0.0005 VIAL 9 bupivacaine hcl/epinephrine/pf NAROPIN 0.2% 20 MG/10 ML AMP 9 ropivacaine hcl/pf

PAGE 40 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS NAROPIN 0.2% 20 MG/10 ML VIAL 9 ropivacaine hcl/pf NAROPIN 0.2% 40 MG/20 ML AMP 9 ropivacaine hcl/pf NAROPIN 0.2% 40 MG/20 ML VIAL 9 ropivacaine hcl/pf NAROPIN 0.2% 400 MG/200 ML BTL 9 ropivacaine hcl/pf NAROPIN 0.5% 100 MG/20 ML AMP 9 ropivacaine hcl/pf NAROPIN 0.5% 100 MG/20 ML VIAL 9 ropivacaine hcl/pf NAROPIN 0.5% 100 MG/20 ML VIAL 9 ropivacaine hcl/pf NAROPIN 0.5% 150 MG/30 ML VIAL 9 ropivacaine hcl/pf NAROPIN 0.5% 150 MG/30 ML VIAL 9 ropivacaine hcl/pf NAROPIN 0.5% 50 MG/10 ML AMP 9 ropivacaine hcl/pf NAROPIN 0.75% 150 MG/20 ML AMP 9 ropivacaine hcl/pf NAROPIN 0.75% 150 MG/20 ML VL 9 ropivacaine hcl/pf NAROPIN 1% 100 MG/10 ML AMPULE 9 ropivacaine hcl/pf NAROPIN 1% 100 MG/10 ML VIAL 9 ropivacaine hcl/pf NAROPIN 1% 200 MG/20 ML AMPULE 9 ropivacaine hcl/pf NAROPIN 1% 200 MG/20 ML VIAL 9 ropivacaine hcl/pf NAROPIN 2 MG/ML INFUSION BTL 9 ropivacaine hcl/pf NAROPIN 200 MG/100 ML INF BTL 9 ropivacaine hcl/pf NAROPIN 5 MG/ML INFUSION BTL 9 ropivacaine hcl/pf NESACAINE 1% VIAL 9 chloroprocaine hcl

PAGE 41 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS NESACAINE 2% VIAL chloroprocaine hcl NESACAINE-MPF 2% VIAL 9 chloroprocaine hcl/pf NESACAINE-MPF 3% VIAL 9 chloroprocaine hcl/pf ORASEP SOLUTION 3 benzocaine/tannic acid/menthol/cetylpyridinium chloride PAIN EASE SPRAY 3 norflurane/hfc 245fa

parcaine 0.5% eye drops 1

PLIAGLIS 7%-7% CREAM 3 lidocaine/tetracaine

polocaine 1% vial 7

polocaine 1.5% vial 7

polocaine 2% vial 7

polocaine-mpf 1% vial 7

polocaine-mpf 1.5% vial 7

polocaine-mpf 2% vial 7

PONTOCAINE 1% AMPUL 9 tetracaine hcl/pf PONTOCAINE 2% SOLUTION 3 tetracaine hcl PONTOCAINE 20 MG AMPUL 9 tetracaine hcl/pf PRE-ATTACHED LTA KIT 3 lidocaine hcl

proparacaine 0.5% eye drops 1

propofol 1% emulsion vial 7

propofol 1,000 mg/100 ml vial 7

propofol 10 mg/ml vial 7

propofol 200 mg/20 ml vial 7

PAGE 42 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS PROPOVEN 1,000 MG/100 ML VIAL 7 propofol/pf PROPOVEN 200 MG/20 ML AMPUL 7 propofol/pf PROPOVEN 200 MG/20 ML VIAL 7 propofol/pf PROPOVEN 500 MG/50 ML VIAL 7 propofol/pf REGENECARE 2% WOUND GEL 3 lidocaine hcl/collagen REGENECARE 2% WOUND GEL 3 vitamin e/lidocaine/aloe vera/collagen

ropivacaine 0.2% 20 mg/10 ml 7

ropivacaine 0.2% 40 mg/20 ml 7

ropivacaine 0.5% 150 mg/30 ml 7

ropivacaine 0.75% 150 mg/20 ml 7

ropivacaine 1% 100 mg/10 ml vl 7

ropivacaine 1% 200 mg/20 ml vl 7

SENSORCAIN-MPF EPI 0.5%-0.0005 7 bupivacaine hcl/epinephrine/pf SENSORCAINE 0.25% VIAL 7 bupivacaine hcl

sensorcaine 0.5% vial 7

sensorcaine-dextr 0.75% amp 7

sensorcaine-epi 0.25%-0.0005 7

sensorcaine-epi 0.5%-0.0005 7

SENSORCAINE-EPI 0.75%-0.0005 7 bupivacaine hcl/epinephrine/pf SENSORCAINE-MPF 0.25% AMPUL 7 bupivacaine hcl/pf SENSORCAINE-MPF 0.25% VIAL 7 bupivacaine hcl/pf SENSORCAINE-MPF 0.5% AMPUL 7 bupivacaine hcl/pf

PAGE 43 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

sensorcaine-mpf 0.5% vial 7

sensorcaine-mpf 0.75% ampul 7

sensorcaine-mpf 0.75% vial 7

sevoflurane inhalation liquid 1

sojourn inhalation liquid 1

SPRAY AND STRETCH SPRAY 3 norflurane/hfc 245fa SUPRANE INHALATION LIQUID 3 desflurane SYNERA PATCH 3 lidocaine/tetracaine SYNERA PATCH 3 lidocaine/tetracaine

terrell liquid 1

tetracaine hcl 1% ampul 7

ULTANE 250 ML PEN BOTTLE 3 sevoflurane VEXA PATCH 3 lidocaine/allantoin/petrolatum,white XYLOCAIN 1.5-EPI 1:200,000-MPF 9 lidocaine hcl/epinephrine/pf XYLOCAINE 0.5% VIAL 9 lidocaine hcl XYLOCAINE 0.5%-EPI 1:200,000 9 lidocaine hcl/epinephrine XYLOCAINE 1% VIAL 9 lidocaine hcl XYLOCAINE 1%-EPI 1:100,000 9 lidocaine hcl/epinephrine XYLOCAINE 2% VIAL 9 lidocaine hcl XYLOCAINE 2%-EPI 1:100,000 9 lidocaine hcl/epinephrine XYLOCAINE 2%-EPI 1:200,000 9 lidocaine hcl/epinephrine/pf XYLOCAINE 4% SOLUTION 3 lidocaine hcl

PAGE 44 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS XYLOCAINE IV 2% AMPUL 9 lidocaine hcl/pf XYLOCAINE-MPF 0.5% VIAL 9 lidocaine hcl/pf XYLOCAINE-MPF 1% AMPUL 9 lidocaine hcl/pf XYLOCAINE-MPF 1% VIAL 9 lidocaine hcl/pf XYLOCAINE-MPF 1%-EPI 1:200,000 9 lidocaine hcl/epinephrine/pf XYLOCAINE-MPF 1.5% AMPUL 9 lidocaine hcl XYLOCAINE-MPF 2% AMPUL 9 lidocaine hcl/pf XYLOCAINE-MPF 2% VIAL 9 lidocaine hcl/pf XYLOCAINE-MPF 4% AMPUL 9 lidocaine hcl/pf Anti-Addiction/Substance Abuse Treatment Agents

Alcohol Deterrents/Anti-craving

acamprosate calc dr 333 mg tab 1

ANTABUSE 250 MG TABLET 3 disulfiram ANTABUSE 500 MG TABLET 3 disulfiram CAMPRAL DR 333 MG TABLET 3 acamprosate calcium

depade 50 mg tablet 1

disulfiram 250 mg tablet 1

disulfiram 500 mg tablet 1

EVZIO 0.4 MG AUTO-INJECTOR 8 naloxone hcl

naltrexone 50 mg tablet 1

PAGE 45 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

revia 50 mg tablet 3

VIVITROL 380 MG VIAL 9 naltrexone microspheres VIVITROL 380 MG VIAL + DILUENT 9 naltrexone microspheres Opioid Antagonists

BUNAVAIL 2.1-0.3 MG FILM 3 buprenorphine hcl/naloxone hcl BUNAVAIL 4.2-0.7 MG FILM 3 buprenorphine hcl/naloxone hcl BUNAVAIL 6.3-1 MG FILM 3 buprenorphine hcl/naloxone hcl BUPRENEX 0.3 MG/ML AMPUL 9 buprenorphine hcl

buprenorphin-naloxon 8-2 mg sl 1

buprenorphine 0.3 mg/ml syrn 7

buprenorphine 0.3 mg/ml vial 7

buprenorphine 2 mg tablet sl 1

buprenorphine 8 mg tablet sl 1

buprenorphn-naloxn 2-0.5 mg sl 1

depade 50 mg tablet 1

naloxone 0.4 mg/ml syringe 7

naloxone 0.4 mg/ml vial 7

naloxone 2 mg/2 ml syringe 7

naloxone 4 mg/10 ml vial 7

naltrexone 50 mg tablet 1

revia 50 mg tablet 3

SUBOXONE 12 MG-3 MG SL FILM 3 buprenorphine hcl/naloxone hcl

PAGE 46 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS SUBOXONE 2 MG-0.5 MG SL FILM 3 buprenorphine hcl/naloxone hcl SUBOXONE 2 MG-0.5 MG TABLET SL 3 buprenorphine hcl/naloxone hcl SUBOXONE 4 MG-1 MG SL FILM 3 buprenorphine hcl/naloxone hcl SUBOXONE 8 MG-2 MG SL FILM 3 buprenorphine hcl/naloxone hcl SUBOXONE 8 MG-2 MG TABLET SL 3 buprenorphine hcl/naloxone hcl VIVITROL 380 MG VIAL 9 naltrexone microspheres VIVITROL 380 MG VIAL + DILUENT 9 naltrexone microspheres ZUBSOLV 1.4-0.36 MG TABLET SL 3 buprenorphine hcl/naloxone hcl ZUBSOLV 5.7-1.4 MG TABLET SL 3 buprenorphine hcl/naloxone hcl Smoking Cessation Agents

buproban 150 mg tablet 1

CHANTIX 0.5 MG TABLET 3 QL 60 / 30 days varenicline tartrate CHANTIX 1 MG CONT MONTH BOX 3 QL 90 / 30 days varenicline tartrate CHANTIX 1 MG TABLET 3 QL 90 / 30 days varenicline tartrate CHANTIX STARTING MONTH BOX 3 QL 120 / 30 days varenicline tartrate NICOTROL CARTRIDGE INHALER 3 nicotine NICOTROL NS 10 MG/ML SPRAY 3 nicotine ZYBAN SR 150 MG TABLET 3 ST bupropion hcl Anti-inflammatory Agents

Glucocorticoids

a-methapred 125 mg vial 7

a-methapred 40 mg univial 7

PAGE 47 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ALA-CORT 1% CREAM 1 hydrocortisone ALA-SCALP 2% LOTION 3 hydrocortisone

alclometasone dipr 0.05% oint 1

alclometasone dipro 0.05% crm 1

amcinonide 0.1% cream 1

amcinonide 0.1% lotion 1

amcinonide 0.1% ointment 1

ANUSOL-HC 2.5% CREAM 3 hydrocortisone

betamethasone dp 0.05% crm 1

betamethasone dp 0.05% lot 1

betamethasone dp 0.05% oint 1

betamethasone dp aug 0.05% crm 1

betamethasone dp aug 0.05% gel 1

betamethasone dp aug 0.05% lot 1

betamethasone dp aug 0.05% oin 1

betamethasone va 0.1% cream 1

betamethasone va 0.1% lotion 1

betamethasone valer 0.1% ointm 1

betamethasone valer 0.12% foam 1

CAPEX SHAMPOO 2 fluocinolone acetonide CARMOL HC 1% CREAM 3 hydrocortisone acetate/urea

clobetasol 0.05% cream 1

clobetasol 0.05% gel 1

clobetasol 0.05% ointment 1

clobetasol 0.05% shampoo 1

PAGE 48 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

clobetasol 0.05% solution

clobetasol 0.05% topical lotn 1

clobetasol emollient 0.05% crm 1

clobetasol emollnt 0.05% foam 1

clobetasol emulsion 0.05% foam 1

clobetasol prop 0.05% foam 1

CLOBEX 0.05% SHAMPOO 3 clobetasol propionate CLOBEX 0.05% SPRAY 3 clobetasol propionate CLOBEX 0.05% TOPICAL LOTION 3 clobetasol propionate

clocortolone 0.1% cream pump 1

clocortolone pivalate 0.1% crm 1

clodan 0.05% shampoo 1

CLODERM 0.1% CREAM 3 clocortolone pivalate CLODERM 0.1% CREAM PUMP 3 clocortolone pivalate CORDRAN 0.05% CREAM 3 flurandrenolide CORDRAN 0.05% LOTION 3 flurandrenolide CORDRAN 4 MCG/SQ CM TAPE LARGE 3 QL 6 / 90 days flurandrenolide CORDRAN 4 MCG/SQ CM TAPE SMALL 3 QL 6 / 90 days flurandrenolide

cormax 0.05% ointment 1

cormax 0.05% solution 1

cortisone 25 mg tablet 1

CORTISPORIN CREAM 2 neomycin sulfate/polymyxin b sulfate/hydrocortisone

PAGE 49 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS CORTISPORIN EAR SOLUTION 3 neomycin sulfate/polymyxin b sulfate/hydrocortisone CUTIVATE 0.05% CREAM 3 fluticasone propionate CUTIVATE 0.05% LOTION 3 fluticasone propionate DEPO-MEDROL 20 MG/ML VIAL 9 methylprednisolone acetate DEPO-MEDROL 40 MG/ML VIAL 9 methylprednisolone acetate DEPO-MEDROL 80 MG/ML VIAL 9 methylprednisolone acetate DERMA-SMOOTHE-FS BODY OIL 3 fluocinolone acetonide DERMA-SMOOTHE-FS SCALP OIL 3 fluocinolone acetonide/shower cap DESONATE 0.05% GEL 3 desonide

desonide 0.05% cream 1

desonide 0.05% lotion 1

desonide 0.05% ointment 1

DESOWEN 0.05% CREAM 3 desonide DESOWEN 0.05% LOTION 3 desonide

desoximetasone 0.05% cream 1

desoximetasone 0.05% gel 1

desoximetasone 0.05% ointment 1

desoximetasone 0.25% cream 1

desoximetasone 0.25% ointment 1

dexamethasone 10 mg/ml vial 7

dexamethasone 100 mg/10 ml vl 7

dexamethasone 120 mg/30 ml vl 7

PAGE 50 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

dexamethasone 120 mg/30 ml vl

dexamethasone 20 mg/5 ml vial 7

dexamethasone 4 mg/ml vial 7

diflorasone 0.05% cream 1

diflorasone 0.05% ointment 1

fludrocortisone 0.1 mg tablet 1

fluocinolone 0.01% body oil 1

fluocinolone 0.01% scalp oil 1

fluocinolone 0.01% solution 1

fluocinolone 0.025% cream 1

fluocinolone 0.025% ointment 1

fluocinonide 0.05% cream 1

fluocinonide 0.05% gel 1

fluocinonide 0.05% ointment 1

fluocinonide 0.05% solution 1

fluocinonide 0.1% cream 1

fluocinonide-e 0.05% cream 1

fluocinonide-emol 0.05% cream 1

PAGE 51 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

fluticasone prop 0.005% oint 1

fluticasone prop 0.05% cream 1

fluticasone prop 0.05% lotion 1

halobetasol prop 0.05% cream 1

halobetasol prop 0.05% ointmnt 1

HALOG 0.1% CREAM 3 halcinonide HALOG 0.1% OINTMENT 3 halcinonide

hydrocort buty 0.1% lipid crm 3

hydrocort buty 0.1% lipo cream 1

hydrocortisone 1% cream 1

hydrocortisone 2.5% cream 1

hydrocortisone 2.5% lotion 1

hydrocortisone 2.5% ointment 1

hydrocortisone buty 0.1% cream 1

KENALOG AEROSOL SPRAY 2 ST triamcinolone acetonide

lokara 0.05% lotion 1

LUXIQ 0.12% FOAM 3 betamethasone valerate LUXIQ 0.12% FOAM 3 betamethasone valerate MEDROL 16 MG TABLET 3 methylprednisolone MEDROL 32 MG TABLET 3 methylprednisolone MEDROL 4 MG DOSEPAK 3 methylprednisolone MEDROL 4 MG TABLET 3 methylprednisolone MEDROL 8 MG TABLET 3 methylprednisolone

methylprednisolone 125 mg vial 7

PAGE 52 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

methylprednisolone 16 mg tab 1

methylprednisolone 32 mg tab 1

methylprednisolone 4 mg dosepk 1

methylprednisolone 40 mg vial 7

methylprednisolone 8 mg tab 1

methylprednisolone ss 1 gm vl 7

MILLIPRED 10 MG/5 ML SOLUTION 3 prednisolone sod phosphate MILLIPRED 10 MG/5 ML SOLUTION 3 prednisolone sod phosphate

millipred dp 5 mg dose pack tb 1

neomycin-polymyxin-hc ear soln 1

neomycin-polymyxin-hc ear susp 1

nystatin-triamcinolone cream 1

nystatin-triamcinolone ointm 1

OLUX 0.05% FOAM 3 clobetasol propionate OLUX 0.05% FOAM 3 clobetasol propionate OLUX-E 0.05% FOAM 3 clobetasol propionate/emollient base OLUX-E 0.05% FOAM 3 clobetasol propionate/emollient base

oralone 0.1% paste 1

ORAPRED 15 MG/5 ML SOLUTION 3 prednisolone sod phosphate ORAPRED ODT 10 MG TABLET 3 prednisolone sod phosphate ORAPRED ODT 10 MG TABLET 3 prednisolone sod phosphate ORAPRED ODT 15 MG TABLET 3 prednisolone sod phosphate ORAPRED ODT 15 MG TABLET 3 prednisolone sod phosphate

PAGE 53 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ORAPRED ODT 30 MG TABLET prednisolone sod phosphate ORAPRED ODT 30 MG TABLET 3 prednisolone sod phosphate PEDIADERM HC 2% KIT 3 hydrocortisone/emollient combination no.45 PEDIAPRED 5 MG/5 ML SOLN 3 prednisolone sod phosphate

prednisolone 15 mg/5 ml soln 1

prednisolone 15 mg/5 ml syrup 1

prednisolone 5 mg/5 ml soln 1

prednisolone sod ph 25 mg/5 ml 1

prednisone 1 mg tablet 1

prednisone 10 mg tab dose pack 1

prednisone 10 mg tablet 1

prednisone 2.5 mg tablet 1

prednisone 20 mg tablet 1

prednisone 5 mg/5 ml solution 1

prednisone 5 mg/ml solution 1

prednisone 50 mg tablet 1

PRELONE 15 MG/5 ML SYRUP 3 prednisolone

procto-pak 1% cream 1

PROCTOCORT 1% CREAM 3 hydrocortisone

proctocream-hc 2.5% cream 1

proctosol-hc 2.5% cream 1

RAYOS DR 1 MG TABLET 3 prednisone

RAYOS DR 2 MG TABLET 3

PAGE 54 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS prednisone RAYOS DR 5 MG TABLET 3 prednisone

scalacort 2% lotion 1

SOLU-MEDROL 1 GM VIAL 9 methylprednisolone sodium succinate SOLU-MEDROL 1,000 MG VIAL 9 methylprednisolone sodium succinate/pf SOLU-MEDROL 125 MG VIAL 9 methylprednisolone sodium succinate SOLU-MEDROL 125 MG VIAL 9 methylprednisolone sodium succinate/pf SOLU-MEDROL 2,000 MG VIAL 9 methylprednisolone sodium succinate SOLU-MEDROL 40 MG VIAL 9 methylprednisolone sodium succinate/pf SOLU-MEDROL 500 MG VIAL 9 methylprednisolone sodium succinate SOLU-MEDROL 500 MG VIAL 9 methylprednisolone sodium succinate/pf SYNALAR 0.01% SOLUTION 3 fluocinolone acetonide SYNALAR 0.025% CREAM 1 fluocinolone acetonide SYNALAR 0.025% CREAM KIT 3 fluocinolone acetonide/emollient combination no.65 SYNALAR 0.025% OINTMENT 1 fluocinolone acetonide SYNALAR 0.025% OINTMENT KIT 3 fluocinolone acetonide/emollient combination no.65 SYNALAR TS 0.01% KIT 3 fluocinolone acetonide/skin cleanser comb no.28 TEMOVATE 0.05% CREAM 3 clobetasol propionate TEMOVATE 0.05% OINTMENT 3 clobetasol propionate TEMOVATE EMOLLIENT 0.05% CRM 3 clobetasol propionate/emollient base TEXACORT 2.5% SOLUTION 3 hydrocortisone

PAGE 55 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS TOPICORT 0.05% CREAM 3 desoximetasone TOPICORT 0.05% GEL 3 desoximetasone TOPICORT 0.05% OINTMENT 3 desoximetasone TOPICORT 0.25% CREAM 3 desoximetasone TOPICORT 0.25% OINTMENT 3 desoximetasone

triamcinolone 0.025% cream 1

triamcinolone 0.025% lotion 1

triamcinolone 0.025% oint 1

triamcinolone 0.1% lotion 1

triamcinolone 0.1% ointment 1

triamcinolone 0.1% paste 1

triamcinolone 0.5% cream 1

triamcinolone 0.5% ointment 1

triderm 0.1% cream 1

ULTRAVATE 0.05% CREAM 3 halobetasol propionate ULTRAVATE 0.05% OINTMENT 3 halobetasol propionate VANOS 0.1% CREAM 3 fluocinonide VERDESO 0.05% FOAM 3 desonide VERIPRED 20 20 MG/5 ML SOLN 3 prednisolone sod phosphate VERIPRED 20 20 MG/5 ML SOLN 3 prednisolone sod phosphate Nonsteroidal Anti-inflammatory Drugs

ANAPROX 275 MG TABLET 3 naproxen sodium ANAPROX DS 550 MG TABLET 3 naproxen sodium

PAGE 56 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ANSAID 100 MG TABLET 3 flurbiprofen CATAFLAM 50 MG TABLET 3 diclofenac potassium

CELEBREX 100 MG CAPSULE QL 90 / 30 days 2 celecoxib ST

CELEBREX 200 MG CAPSULE QL 120 / 30 days 2 celecoxib ST

CELEBREX 400 MG CAPSULE QL 60 / 30 days 2 celecoxib ST

CELEBREX 50 MG CAPSULE QL 150 / 30 days 2 celecoxib ST

COMFORT PAC-MELOXICAM KIT 3 meloxicam/irritants counter-irritants combination no.2 COMFORT PAC-NAPROXEN KIT 3 naproxen/irritants counter-irritants combination #2 DAYPRO 600 MG CAPLET 3 oxaprozin

diclofenac pot 50 mg tablet 1

diclofenac sod ec 25 mg tab 1

diclofenac sod er 100 mg tab 1

diflunisal 500 mg tablet 1

EC-NAPROSYN EC 375 MG TABLET 3 naproxen

etodolac 200 mg capsule 1

etodolac 300 mg capsule 1

etodolac 400 mg tablet 1

etodolac 500 mg tablet 1

etodolac er 400 mg tablet 1

etodolac er 500 mg tablet 1

etodolac er 600 mg tablet 1

FELDENE 10 MG CAPSULE 3 piroxicam

PAGE 57 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS FELDENE 20 MG CAPSULE 3 piroxicam

fenoprofen 600 mg tablet 1

FLECTOR 1.3% PATCH 3 diclofenac epolamine

flurbiprofen 100 mg tablet 1

flurbiprofen 50 mg tablet 1

INDOCIN 25 MG/5 ML SUSPENSION 3 indomethacin

indomethacin 25 mg capsule 1

indomethacin 50 mg capsule 1

ketoprofen 50 mg capsule 1

ketoprofen 75 mg capsule 1

ketorolac 10 mg tablet 1 QL 20 / 30 days

ketorolac 30 mg/ml isecure syr 7

ketorolac 300 mg/10 ml vial 7

meclofenamate 100 mg capsule 1

meclofenamate 50 mg capsule 1

mefenamic acid 250 mg capsule 1

meloxicam 7.5 mg tablet 1

meloxicam 7.5 mg/5 ml susp 3

MOBIC 15 MG TABLET 3 meloxicam MOBIC 7.5 MG TABLET 3 meloxicam MOBIC 7.5 MG/5 ML SUSPENSION 3 meloxicam

nabumetone 750 mg tablet 1

NALFON 400 MG CAPSULE 3 fenoprofen calcium

NAPRELAN CR 375 MG TABLET 3

PAGE 58 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS naproxen sodium NAPRELAN CR 500 MG TABLET 3 naproxen sodium NAPRELAN CR 750 MG TABLET 3 naproxen sodium NAPROSYN 125 MG/5 ML SUSPEN 3 naproxen NAPROSYN 250 MG TABLET 3 naproxen NAPROSYN 375 MG TABLET 3 naproxen NAPROSYN 500 MG TABLET 3 naproxen NAPROSYN EC 500 MG TABLET 3 naproxen

naproxen 125 mg/5 ml suspen 1

naproxen 250 mg tablet 1

naproxen 375 mg tablet 1

naproxen 500 mg kit 1

naproxen 500 mg tablet 1

naproxen dr 375 mg tablet 1

naproxen dr 500 mg tablet 1

naproxen ec 375 mg tablet 1

naproxen ec 500 mg tablet 1

naproxen sodium 275 mg tab 1

naproxen sodium 550 mg tab 1

oxaprozin 600 mg caplet 1

oxaprozin 600 mg tablet 1

oxycodone-ibuprofen 5-400 tab 1

piroxicam 10 mg capsule 1

piroxicam 20 mg capsule 1

PONSTEL 250 MG KAPSEALS 3

PAGE 59 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS mefenamic acid SPRIX 15.75 MG NASAL SPRAY 3 QL 15 / 90 days ketorolac tromethamine

sulindac 150 mg tablet 1

sulindac 200 mg tablet 1

tolmetin sodium 200 mg tab 1

tolmetin sodium 400 mg cap 1

tolmetin sodium 600 mg tab 1

VOLTAREN-XR 100 MG TABLET 3 diclofenac sodium ZIPSOR 25 MG CAPSULE 3 QL 120 / 30 days diclofenac potassium Antibacterials

Aminoglycosides

amikacin sulf 1 gram/4 ml vial 7

amikacin sulf 500 mg/2 ml vial 7

amikacin sulfate 500 mg/2 ml 7

BETHKIS 300 MG/4 ML AMPULE 3 tobramycin

garamycin 0.3% eye drops 1

GARAMYCIN 3 MG/GM EYE OINTMENT 1 gentamicin sulfate GARAMYCIN 3 MG/ML EYE DROPS 3 gentamicin sulfate

gentak 0.3 % eye ointment 1

gentak 3 mg/ml eye drops 1

gentamicin 0.1% cream 1

gentamicin 0.1% ointment 1

PAGE 60 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

gentamicin 0.3% eye drops

gentamicin 10 mg/ml vial 7

gentamicin 100 mg/ns 100 ml 7

gentamicin 20 mg/2 ml vial 7

gentamicin 3 mg/ml eye drops 1

gentamicin 40 mg/ml vial 7

gentamicin 60 mg/ns 50 ml pb 7

gentamicin 70 mg/ns 50 ml pb 1

gentamicin 80 mg/2 ml vial 7

gentamicin 80 mg/ns 100 ml pb 7

gentamicin 80 mg/ns 50 ml pb 7

gentamicin 800 mg/20 ml vial 7

gentamicin 90 mg/ns 100 ml pb 1

gentamicin ped 20 mg/2 ml vial 7

iso gentamicin 100 mg/100 ml 7

iso gentamicin 120 mg/100 ml 7

isoton gentamicin 100 mg/50 ml 1

isoton gentamicin 60 mg/50 ml 7

isoton gentamicin 80 mg/100 ml 7

isoton gentamicin 80 mg/50 ml 7

neomycin 500 mg tablet 1

paromomycin 250 mg capsule 1

streptomycin sulf 1 gm vial 1

TOBI 300 MG/5 ML SOLUTION QL 300 / 30 days 3 tobramycin in 0.225 % sodium chloride PA

TOBI PODHALER 28 MG INHALE CAP 5 PA tobramycin

PAGE 61 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS TOBRADEX EYE OINTMENT 2 tobramycin/dexamethasone

tobramycin 0.3% eye drops 1

tobramycin 1.2 gm vial 7

tobramycin 1.2 gram/30 ml vial 7

tobramycin 10 mg/ml vial 7

QL 300 / 30 days tobramycin 300 mg/5 ml ampule 1 PA

tobramycin 40 mg/ml vial 7

tobramycin 60 mg/50 ml ns 1

tobramycin 80 mg/100 ml ns 1

tobramycin 80 mg/2 ml vial 7

TOBREX 0.3% EYE DROPS 3 tobramycin TOBREX 0.3% EYE OINTMENT 2 tobramycin Antibacterials, Other

acetasol hc ear drops 1

acetic acid 2% ear solution 1

acetic acid-aluminum drops 1

ALTABAX 1% OINTMENT 3 retapamulin AMINOACETIC ACID 1.5% IRRIG 7 glycine urologic solution

baciim strl 50,000 units vial 7

bacitracin 50,000 units vial 7

PAGE 62 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

bacitracin 50,000 units vial 7

bacitracin 500 unit/gm ophth 1

BACTROBAN 2% CREAM 3 mupirocin calcium BACTROBAN 2% OINTMENT 3 mupirocin BACTROBAN NASAL 2% OINTMENT 2 mupirocin calcium CENTANY 2% OINTMENT 3 mupirocin CENTANY AT 2% OINTMENT KIT 3 mupirocin

chloramphen na succ 1 gm vl 1

chlorhexidine 0.12% rinse 1

CLEOCIN 100 MG VAGINAL OVULE 2 clindamycin phosphate CLEOCIN 150 MG/ML ADDVN VIAL 9 clindamycin phosphate CLEOCIN 2% VAGINAL CREAM 3 clindamycin phosphate CLEOCIN 300 MG-D5W-GALAXY 9 clindamycin phosphate/dextrose 5 % in water CLEOCIN 600 MG-D5W-GALAXY 9 clindamycin phosphate/dextrose 5 % in water CLEOCIN 600 MG-D5W-GALAXY 9 clindamycin phosphate/dextrose 5 % in water CLEOCIN 75 MG/5 ML GRANULES 3 clindamycin palmitate hcl CLEOCIN 900 MG-D5W-GALAXY 9 clindamycin phosphate/dextrose 5 % in water CLEOCIN 900 MG-D5W-GALAXY 9 clindamycin phosphate/dextrose 5 % in water CLEOCIN HCL 150 MG CAPSULE 3 clindamycin hcl CLEOCIN HCL 300 MG CAPSULE 3 clindamycin hcl

CLEOCIN HCL 75 MG CAPSULE 3

PAGE 63 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS clindamycin hcl CLEOCIN PHOS 150 MG/ML VIAL 9 clindamycin phosphate CLEOCIN PHOS 300 MG/2 ML VIAL 9 clindamycin phosphate CLEOCIN PHOS 600 MG/4 ML VIAL 9 clindamycin phosphate CLEOCIN PHOS 900 MG/6 ML VIAL 9 clindamycin phosphate CLEOCIN T 1% GEL 3 clindamycin phosphate CLEOCIN T 1% LOTION 3 clindamycin phosphate CLEOCIN T 1% PLEDGETS 3 clindamycin phosphate CLEOCIN T 1% SOLUTION 3 clindamycin phosphate

clinda-derm 1% solution 3

clindacin etz 1% pledget 3

CLINDACIN ETZ KIT 3 clindamycin phosphate/skin cleanser comb no.19

clindacin p 1% pledgets 1

CLINDACIN PAC KIT 3 clindamycin phosphate/skin cleanser comb no.19

clindamycin 150 mg/ml addvan 7

clindamycin 2% vaginal cream 1

clindamycin 75 mg/5 ml soln 1

clindamycin hcl 150 mg capsule 1

clindamycin hcl 300 mg capsule 1

clindamycin hcl 75 mg capsule 1

clindamycin pediatr 75 mg/5 ml 1

clindamycin ph 1% gel 1

PAGE 64 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

clindamycin ph 1% solution 1

clindamycin ph 300 mg/2 ml vl 7

clindamycin ph 600 mg/4 ml vl 7

clindamycin ph 9 g/60 ml vial 7

clindamycin ph 900 mg/6 ml vl 7

clindamycin phos 1% pledget 1

clindamycin phosp 1% lotion 1

clindamycin phosphate 1% foam 1

clindamycin-d5w 300 mg/50 ml 7

clindamycin-d5w 600 mg/50 ml 7

clindamycin-d5w 900 mg/50 ml 7

CLINDESSE 2% VAGINAL CREAM 3 clindamycin phosphate

colistimethate 150 mg vial 7

COLY-MYCIN M 150 MG VIAL 9 colistin (as colistimethate sodium) CUBICIN 500 MG VIAL 9 daptomycin

cycloserine 250 mg capsule 1

DALVANCE 500 MG VIAL 9 dalbavancin hcl

erythromycin-sulfisox susp 1

EVOCLIN 1% FOAM 3 clindamycin phosphate EVOCLIN 1% FOAM 3 clindamycin phosphate FEM PH VAGINAL JELLY 3 acetic acid/oxyquinoline sulfate

FLAGYL 250 MG TABLET 3

PAGE 65 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS metronidazole FLAGYL 375 CAPSULE 3 metronidazole FLAGYL 500 MG TABLET 3 metronidazole FLAGYL ER 750 MG TABLET 3 metronidazole FURADANTIN 25 MG/5 ML SUSP 3 nitrofurantoin

glutaraldehyde 25% aq solution 3

glycine 1.5% irrigation 7

HIPREX 1 GM TABLET 3 methenamine hippurate

hydrocortison-acetic acid soln 1

hyophen tablet 1

LINCOCIN 300 MG/ML VIAL 9 lincomycin hcl MACROBID 100 MG CAPSULE 3 nitrofurantoin monohydrate/macrocrystals MACRODANTIN 100 MG CAPSULE 3 nitrofurantoin macrocrystal MACRODANTIN 25 MG CAPSULE 3 nitrofurantoin macrocrystal MACRODANTIN 50 MG CAPSULE 3 nitrofurantoin macrocrystal

mafenide acetate 50 gm powd pk 1

methenamine hipp 1 gm tablet 1

methenamine md 1 gm tablet 1

methenamine md 500 mg tablet 3

METRO IV 500 MG/100 ML 9 metronidazole in sodium chloride METROCREAM 0.75% CREAM 3 metronidazole METROGEL TOPICAL 1% GEL 2 metronidazole

PAGE 66 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS METROGEL TOPICAL 1% PUMP 2 metronidazole METROGEL-VAGINAL 0.75% GEL 3 metronidazole METROLOTION TOPICAL 0.75% 3 metronidazole

metronidazole 0.75% cream 1

metronidazole 0.75% lotion 1

metronidazole 250 mg tablet 1

metronidazole 375 mg capsule 1

metronidazole 500 mg tablet 1

metronidazole 500 mg/100 ml 7

metronidazole topical 0.75% gl 1

metronidazole topical 1% gel 1

metronidazole vaginal 0.75% gl 1

MONUROL 3 GM SACHET 3 fosfomycin tromethamine

mupirocin 2% cream 1

mupirocin 2% ointment 1

neomy-polymyxin b 40 mg/ml amp 7

neomy-polymyxin b 40 mg/ml vl 7

NEOSPORIN GU IRR 40 MG/ML AMP 9 neomycin sulfate/polymyxin b sulfate

PAGE 67 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS NEOSPORIN GU IRR 40 MG/ML VIAL neomycin sulfate/polymyxin b sulfate

nitrofurantoin 25 mg/5 ml susp 1

nitrofurantoin mcr 100 mg cap 1

nitrofurantoin mcr 50 mg cap 1

nitrofurantoin mono-mcr 100 mg 1

NORITATE 1% CREAM 3 metronidazole ORBACTIV 400 MG VIAL 9 oritavancin diphosphate

paroex 0.12% oral rinse 1

PERIDEX 0.12% ORAL RINSE 3 chlorhexidine gluconate PERIDEX 0.12% ORAL RINSE 3 chlorhexidine gluconate

periogard 0.12% oral rinse 1

phosphasal tablet 1

polymyxin b sulfate vial 7

PRIMSOL 50 MG/5 ML ORAL SOLN 3 trimethoprim PROSED-DS TABLET methenamine/methylene blue/benzoic 3 acid/salicylate/hyoscy

relagard vaginal gel 3

rosadan 0.75% cream 1

ROSADAN 0.75% CREAM KIT 3 metronidazole/skin cleanser combination no.23

rosadan 0.75% gel 1

PAGE 68 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ROSADAN 0.75% GEL KIT 3 metronidazole/skin cleanser combination no.23 SEROMYCIN 250 MG CAPSULE 3 cycloserine SIVEXTRO 200 MG TABLET 3 tedizolid phosphate SIVEXTRO 200 MG VIAL 9 tedizolid phosphate SULFAMYLON 8.5% CREAM 3 mafenide acetate SULFAMYLON POWDER PACKET 3 mafenide acetate SYNERCID 500 MG VIAL 9 quinupristin/dalfopristin TINDAMAX 250 MG TABLET 3 tinidazole TINDAMAX 500 MG TABLET 3 tinidazole

tinidazole 250 mg tablet 1

tinidazole 500 mg tablet 1

trimethoprim 100 mg tablet 1

TYGACIL 50 MG VIAL 9 tigecycline

ur n-c tablet 1

URELLE TABLET methenamine/methylene blue/salicylate/sodium 3 phos/hyoscy URETRON D-S TABLET methenamine/methylene blue/salicylate/sodium 3 phos/hyoscy URETRON D-S TABLET methenamine/methylene blue/sodium phos/pnyl sal/hyosc 3 sul URIBEL CAPSULE methenamine/methylene blue/sodium phos/pnyl sal/hyosc 3 sul

PAGE 69 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

urimar-t tablet

urin d.s. tablet 1

UROGESIC-BLUE TABLET methenamine/sodium phosphate,monobasic/meth 3 blue/hyosc sul UROQID-ACID NO.2 500-500 TB methenamine mandelate/sodium phosphate,m-basic m- 3 hyd

uryl tablet 1

ustell capsule 1

UTA CAPSULE methenamine/methylene blue/salicylate/sodium 3 phos/hyoscy UTA CAPSULE methenamine/sodium phosphate,monobasic/meth 3 blue/hyosc sul

utira-c tablet 1

VANCOCIN HCL 125 MG PULVULE 3 vancomycin hcl VANCOCIN HCL 250 MG PULVULE 3 vancomycin hcl

vancomycin 1 gm add-van vial 7

vancomycin 1 gm vial 7

vancomycin 500 mg a-v vial 7

vancomycin 500 mg vial 7

vancomycin 750 mg vial 1

vancomycin 750 mg/150 ml bag 9

vancomycin hcl 10 gm vial 7

vancomycin hcl 125 mg capsule 1

PAGE 70 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

vancomycin hcl 1g/200 ml bag 9

vancomycin hcl 250 mg capsule 1

vancomycin hcl 5 gm vial 7

vancomycin hcl 750 mg vial 1

vancomycin-d5w 500 mg/100 ml 9

VANDAZOLE VAGINAL 0.75% GEL 1 metronidazole VIBATIV 250 MG VIAL 9 telavancin hcl VIBATIV 250 MG VIAL 9 telavancin hcl VIBATIV 750 MG VIAL 9 telavancin hcl

vitazol 0.75% cream 1

VOSOL HC EAR DROPS 3 acetic acid/hydrocortisone XIFAXAN 200 MG TABLET 3 rifaximin XIFAXAN 550 MG TABLET 3 rifaximin ZYVOX 100 MG/5 ML SUSPENSION 3 linezolid ZYVOX 200 MG/100 ML IV SOLN 9 linezolid ZYVOX 600 MG TABLET 3 QL 60 / 30 days linezolid ZYVOX 600 MG/300 ML IV SOLN 9 linezolid Beta-lactam, Cephalosporins

CEDAX 180 MG/5 ML SUSPENSION 3 ceftibuten dihydrate CEDAX 400 MG CAPSULE 3 ceftibuten dihydrate

CEDAX 90 MG/5 ML SUSPENSION 3

PAGE 71 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ceftibuten dihydrate

cefaclor 125 mg/5 ml susp 1

cefaclor 250 mg capsule 1

cefaclor 250 mg/5 ml susp 1

cefaclor 375 mg/5 ml suspen 1

cefaclor 500 mg capsule 1

cefaclor er 500 mg tablet 1

cefadroxil 1 gm tablet 1

cefadroxil 250 mg/5 ml susp 1

cefadroxil 500 mg capsule 1

cefadroxil 500 mg/5 ml susp 1

cefazolin 1 gm add-van vial 1

cefazolin 1 gm vial 7

cefazolin 1 gm-d5w bag 9

cefazolin 10 gm vial 7

cefazolin 2 gm-d5w bag 9

cefazolin 20 gm bulk vial 7

cefazolin 500 mg vial 7

cefazolin sod 100 gm bulk bag 7

cefazolin sod 300 gm bulk bag 7

cefdinir 125 mg/5 ml susp 1

cefdinir 250 mg/5 ml susp 1

cefdinir 300 mg capsule 1

PAGE 72 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

cefditoren pivoxil 200 mg tab 1

cefditoren pivoxil 400 mg tab 3

cefepime 1 gm injection 9

cefepime 2 gm injection 9

cefepime hcl 1 gm vial 7

cefepime hcl 2 gram vial 7

cefepime-dextrose 1 gm/50 ml 9

cefepime-dextrose 2 gm/50 ml 9

cefotaxime sodium 1 gm vial 7

cefotaxime sodium 10 gm vial 7

cefotaxime sodium 2 gm vial 7

cefotaxime sodium 500 mg vial 7

cefotetan 1 gm vial 1

cefotetan 10 gm vial 1

cefotetan 2 gm vial 1

cefotetan-dextr 1 g duplex bag 1

cefotetan-dextr 2 g duplex bag 1

cefoxitin 1 gm piggyback bag 1

cefoxitin 1 gm vial 7

cefoxitin 10 gm vial 7

cefoxitin 2 gm piggyback bag 1

cefoxitin 2 gm vial 7

cefpodoxime 100 mg tablet 1

cefpodoxime 100 mg/5 ml susp 1

cefpodoxime 200 mg tablet 1

cefpodoxime 50 mg/5 ml susp 1

PAGE 73 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

cefprozil 125 mg/5 ml susp 1

cefprozil 250 mg tablet 1

cefprozil 250 mg/5 ml susp 1

cefprozil 500 mg tablet 1

ceftazidime 1 gm piggyback 9

ceftazidime 1 gm vial 7

ceftazidime 2 gm piggyback 9

ceftazidime 2 gm vial 7

ceftazidime 6 gm vial 7

ceftibuten 180 mg/5 ml susp 1

ceftibuten 400 mg capsule 1

CEFTIN 125 MG/5 ML ORAL SUSP 3 cefuroxime axetil CEFTIN 250 MG TABLET 3 cefuroxime axetil CEFTIN 250 MG/5 ML ORAL SUSP 3 cefuroxime axetil CEFTIN 500 MG TABLET 3 cefuroxime axetil

ceftriaxone 1 gm piggyback 7

ceftriaxone 1 gm vial 7

ceftriaxone 1 gm-d5w bag 9

ceftriaxone 10 gm vial 7

ceftriaxone 2 gm add vial 7

PAGE 74 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

ceftriaxone 2 gm piggyback 7

ceftriaxone 2 gm vial 7

ceftriaxone 2 gm-d5w bag 9

ceftriaxone 250 mg vial 7

ceftriaxone 500 mg vial 7

cefuroxime 1.5g/50 ml bag 9

cefuroxime 750 mg/50 ml bag 9

cefuroxime axetil 250 mg tab 1

cefuroxime axetil 500 mg tab 1

cefuroxime sod 1.5 gm vial 7

cefuroxime sod 7.5 gm vial 7

cefuroxime sod 75 gm bulk bag 7

cefuroxime sod 750 mg vial 7

cephalexin 125 mg/5 ml susp 1

cephalexin 250 mg capsule 1

cephalexin 250 mg tablet 1

cephalexin 250 mg/5 ml susp 1

cephalexin 500 mg capsule 1

cephalexin 500 mg tablet 1

cephalexin 750 mg capsule 1

CLAFORAN 1 GM ADD-VANTAGE VL 3 cefotaxime sodium

CLAFORAN 1 GM VIAL 9

PAGE 75 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS cefotaxime sodium CLAFORAN 10 GM VIAL 9 cefotaxime sodium CLAFORAN 2 GM ADD-VANTAGE VL 3 cefotaxime sodium CLAFORAN 2 GM VIAL 9 cefotaxime sodium CLAFORAN 500 MG VIAL 9 cefotaxime sodium FORTAZ 1 GM ADD-VANTAGE VIAL 9 ceftazidime pentahydrate FORTAZ 1 GM TWISTVIAL 9 ceftazidime pentahydrate FORTAZ 1 GM VIAL 9 ceftazidime pentahydrate FORTAZ 2 GM ADD-VANTAGE VIAL 9 ceftazidime pentahydrate FORTAZ 2 GM TWISTVIAL 9 ceftazidime pentahydrate FORTAZ 2 GM VIAL 9 ceftazidime pentahydrate FORTAZ 500 MG VIAL 9 ceftazidime pentahydrate FORTAZ 6 GM VIAL 9 ceftazidime pentahydrate FORTAZ-ISO-OSMOT 2 GM/50 ML 9 ceftazidime sodium/dextrose, iso-osmotic FORTAZ-ISO-OSMOTIC 1 GM/50 ML 9 ceftazidime sodium/dextrose, iso-osmotic KEFLEX 250 MG CAPSULE 3 cephalexin KEFLEX 500 MG CAPSULE 3 cephalexin KEFLEX 750 MG CAPSULE 3 cephalexin MAXIPIME 1 GM ADD-VANTAGE VL 3 cefepime hcl MAXIPIME 1 GRAM VIAL 3 cefepime hcl

MAXIPIME 2 GM ADD-VANTAGE VL 3

PAGE 76 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS cefepime hcl MAXIPIME 2 GRAM VIAL 3 cefepime hcl MEFOXIN 1 GM/50 ML PIGGYBACK 3 cefoxitin sodium/dextrose 5 % in water MEFOXIN 2 GM/50 ML PIGGYBACK 3 cefoxitin sodium/dextrose 5 % in water ROCEPHIN 1 GM VIAL 9 ceftriaxone sodium ROCEPHIN 500 MG VIAL 9 ceftriaxone sodium SPECTRACEF 200 MG DOSE PACK TB 3 cefditoren pivoxil SPECTRACEF 400 MG DOSE PACK TB 3 cefditoren pivoxil SUPRAX 100 MG TABLET CHEWABLE 3 cefixime SUPRAX 100 MG/5 ML SUSPENSION 3 cefixime SUPRAX 200 MG TABLET CHEWABLE 3 cefixime SUPRAX 200 MG/5 ML SUSPENSION 3 cefixime SUPRAX 400 MG CAPSULE 3 cefixime SUPRAX 400 MG CAPSULE 3 cefixime SUPRAX 400 MG TABLET 3 cefixime SUPRAX 500 MG/5 ML SUSPENSION 3 cefixime

tazicef 1 gm add-vantage vial 7

tazicef 1 gram vial 7

tazicef 2 gm add-vantage 7

tazicef 2 gram vial 7

tazicef 6 gram vial 7

TEFLARO 400 MG VIAL 9 QL 30 / 30 days ceftaroline fosamil acetate

PAGE 77 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS TEFLARO 600 MG VIAL 9 QL 30 / 30 days ceftaroline fosamil acetate ZINACEF 1.5 GM ADD-VANT VIAL 9 cefuroxime sodium ZINACEF 1.5 GM TWISTVIAL 9 cefuroxime sodium ZINACEF 1.5 GM VIAL 9 cefuroxime sodium ZINACEF 1.5 GM VIAL 9 cefuroxime sodium ZINACEF 1.5 GRAM/50 ML 9 cefuroxime sodium/water for injection,sterile ZINACEF 7.5 GM VIAL 9 cefuroxime sodium ZINACEF 750 MG ADD-VANT VIAL 9 cefuroxime sodium ZINACEF 750 MG TWISTVIAL 9 cefuroxime sodium ZINACEF 750 MG VIAL 9 cefuroxime sodium ZINACEF-DEXTROSE 750 MG/50 ML 9 cefuroxime sodium/dextrose, iso-osmotic Beta-lactam, Other

AZACTAM 1 GM VIAL 9 aztreonam AZACTAM 2 GM VIAL 9 aztreonam AZACTAM-ISO-OSMOT 1 GM/50 ML 9 aztreonam/dextrose-water AZACTAM-ISO-OSMOT 2 GM/50 ML 9 aztreonam/dextrose-water

aztreonam 1 gm vial 7

aztreonam 2 gm vial 7

CAYSTON 75 MG INHAL SOLUTION 5 QL 84 / 56 days aztreonam lysine

DORIBAX 250 MG VIAL 9

PAGE 78 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS doripenem DORIBAX 500 MG VIAL 9 doripenem

imipenem-cilastatin 250 mg vl 7

imipenem-cilastatin 500 mg vl 7

INVANZ 1 GM ADD-VANTAGE VIAL 9 ertapenem sodium INVANZ 1 GM VIAL 9 ertapenem sodium

meropenem iv 1 gm vial 7

meropenem iv 500 mg vial 7

MERREM IV 1 GM VIAL 9 meropenem MERREM IV 500 MG VIAL 9 meropenem PRIMAXIN 250 MG VIAL 9 imipenem/cilastatin sodium PRIMAXIN 500 MG VIAL 9 imipenem/cilastatin sodium Beta-lactam, Penicillins

amox tr-k clv 200-28.5 tab chw 1

amox tr-k clv 200-28.5/5 susp 1

amox tr-k clv 250-125 mg tab 1

amox tr-k clv 250-62.5/5 susp 1

amox tr-k clv 400-57 tab chew 1

amox tr-k clv 400-57/5 susp 1

amox tr-k clv 500-125 mg tab 1

amox tr-k clv 600-42.9/5 susp 1

PAGE 79 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

amox tr-k clv 600-42.9/5 susp 1

amox tr-k clv 875-125 mg tab 1

amoxicillin 125 mg tab chew 1

amoxicillin 125 mg/5 ml susp 1

amoxicillin 200 mg/5 ml susp 1

amoxicillin 250 mg capsule 1

amoxicillin 250 mg tab chew 1

amoxicillin 250 mg/5 ml susp 1

amoxicillin 400 mg/5 ml susp 1

amoxicillin 500 mg capsule 1

amoxicillin 500 mg tablet 1

amoxicillin 875 mg tablet 1

amoxicillin er 775 mg tablet 1

amoxicillin-clav er 1,000-62.5 1

ampicillin 1 gm a-v vial 1

ampicillin 1 gm vial 7

ampicillin 10 gm vial 7

ampicillin 125 mg vial 7

ampicillin 125 mg/5 ml susp 1

ampicillin 2 gm a-v vial 1

PAGE 80 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

ampicillin 2 gm vial 7

ampicillin 250 mg capsule 1

ampicillin 250 mg vial 7

ampicillin 250 mg/5 ml susp 1

ampicillin 500 mg capsule 1

ampicillin 500 mg vial 7

ampicillin-sulb 3 gm add vial 7

ampicillin-sulbactam 1.5 gm vl 7

ampicillin-sulbactam 15 gm vl 7

ampicillin-sulbactam 3 gm vial 7

AUGMENTIN 125-31.25 MG/5 ML 3 amoxicillin/potassium clavulanate AUGMENTIN 250-62.5 MG/5 ML 3 amoxicillin/potassium clavulanate AUGMENTIN 500-125 TABLET 3 amoxicillin/potassium clavulanate AUGMENTIN 875-125 TABLET 3 amoxicillin/potassium clavulanate AUGMENTIN ES-600 SUSPENSION 3 amoxicillin/potassium clavulanate AUGMENTIN XR 1,000-62.5 TAB 3 amoxicillin/potassium clavulanate BICILLIN C-R 1.2 MILLION UNIT 9 penicillin g benzathine/penicillin g procaine BICILLIN C-R 900-300 SYRINGE 9 penicillin g benzathine/penicillin g procaine BICILLIN C-R 900-300 SYRINGE 9 penicillin g benzathine/penicillin g procaine BICILLIN L-A 1,200,000 UNITS 9 penicillin g benzathine BICILLIN L-A 2,400,000 UNITS 9 penicillin g benzathine BICILLIN L-A 2,400,000 UNITS 9 penicillin g benzathine

PAGE 81 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS BICILLIN L-A 600,000 UNIT/ML 9 penicillin g benzathine

dicloxacillin 250 mg capsule 1

dicloxacillin 500 mg capsule 1

MOXATAG ER 775 MG TABLET 3 amoxicillin MOXATAG ER 775 MG TABLET 3 amoxicillin

nafcillin 1 gm add-van vial 1

nafcillin 1 gm vial 7

nafcillin 1 gm/ 50 ml inj 8

nafcillin 10 gm bulk vial 7

nafcillin 10 gm vial 7

nafcillin 2 gm add-vant vial 1

nafcillin 2 gm vial 7

nafcillin 2 gm/ 100 ml inj 8

oxacillin 1 gm add-vantage vl 7

oxacillin 1 gm vial 7

oxacillin 1 gm/ 50 ml inj 7

oxacillin 10 gm vial 7

oxacillin 2 gm add-vantage vl 7

oxacillin 2 gm vial 7

oxacillin 2 gm/ 50 ml inj 7

pen g 1.2 million unit/2 ml 1

pen g k 1 million unit/50 ml 9

pen g k 2 million unit/50 ml 9

PAGE 82 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

pen g k 3 million unit/50 ml 9

penicillin g 600,000 unit/1 ml 1

penicillin g k 5 million unit 7

penicillin gk 20 million unit 7

penicillin vk 125 mg/5 ml soln 1

penicillin vk 250 mg tablet 1

penicillin vk 250 mg/5 ml soln 1

penicillin vk 500 mg tablet 1

pfizerpen 20 million unit vial 9

piperacil-tazo 2.25 gm add vl 7

piperacil-tazobact 2.25 gm vl 7

piperacil-tazobact 3.375 gm vl 7

piperacil-tazobact 4.5 gm vial 7

piperacil-tazobact 40.5 gram 7

TIMENTIN 3.1 GM VIAL 9 ticarcillin disodium/potassium clavulanate TIMENTIN 3.1 GM/100 ML ISO 9 ticarcillin disodium/potassium clavulanate TIMENTIN 31 GM BULK VIAL 9 ticarcillin disodium/potassium clavulanate UNASYN 1.5 GM PIGGYBACK BOTTLE 9 ampicillin sodium/sulbactam sodium UNASYN 1.5 GM VIAL 9 ampicillin sodium/sulbactam sodium UNASYN 15 GM VIAL 9 ampicillin sodium/sulbactam sodium UNASYN 3 GM VIAL 9 ampicillin sodium/sulbactam sodium

ZOSYN 2.25 GM/50 ML GALAXY BAG 9

PAGE 83 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS piperacillin and tazobactam in dextrose, iso-osmotic ZOSYN 2.25 GRAM VIAL 9 piperacillin sodium/tazobactam sodium ZOSYN 2.25 GRAM VIAL 9 piperacillin sodium/tazobactam sodium ZOSYN 3.375 GM/50 ML GALAXY 9 piperacillin and tazobactam in dextrose, iso-osmotic ZOSYN 3.375 GRAM VIAL 9 piperacillin sodium/tazobactam sodium ZOSYN 3.375 GRAM VIAL 9 piperacillin sodium/tazobactam sodium ZOSYN 4.5 GM/100 ML GALAXY BAG 9 piperacillin and tazobactam in dextrose, iso-osmotic ZOSYN 4.5 GRAM VIAL 9 piperacillin sodium/tazobactam sodium ZOSYN 4.5 GRAM VIAL 9 piperacillin sodium/tazobactam sodium ZOSYN 40.5 GRAM BULK VIAL 9 piperacillin sodium/tazobactam sodium ZOSYN 40.5 GRAM BULK VIAL 9 piperacillin sodium/tazobactam sodium Macrolides

AKNE-MYCIN 2% OINTMENT 2 erythromycin base AZASITE 1% EYE DROPS 3 azithromycin AZASITE 1% EYE DROPS 3 azithromycin

azithromycin 1 gm pwd packet 3

azithromycin 100 mg/5 ml susp 1

azithromycin 200 mg/5 ml susp 1

azithromycin 250 mg tablet 1

azithromycin 500 mg tablet 1

azithromycin 600 mg tablet 1

PAGE 84 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

azithromycin i.v. 500 mg vial 7

BIAXIN 250 MG TABLET 3 clarithromycin BIAXIN 250 MG/5 ML SUSPENSION 3 clarithromycin BIAXIN 500 MG TABLET 3 clarithromycin BIAXIN XL 500 MG TABLET 3 clarithromycin

clarithromycin 125 mg/5 ml sus 1

clarithromycin 250 mg tablet 1

clarithromycin 250 mg/5 ml sus 1

clarithromycin 500 mg tablet 1

clarithromycin er 500 mg tab 1

DIFICID 200 MG TABLET 5 fidaxomicin E.E.S. 200 MG/5 ML GRANULES 3 erythromycin ethylsuccinate E.E.S. 400 FILMTAB 1 erythromycin ethylsuccinate

ery 2% pads 1

ERY-TAB EC 250 MG TABLET 3 erythromycin base ERY-TAB EC 333 MG TABLET 3 erythromycin base ERY-TAB EC 500 MG TABLET 3 erythromycin base ERYPED 200 MG/5 ML SUSPENSION 3 erythromycin ethylsuccinate ERYPED 400 MG/5 ML SUSPENSION 3 erythromycin ethylsuccinate

PAGE 85 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ERYTHROCIN 1 GM ADDVANT VIAL 9 erythromycin lactobionate ERYTHROCIN 250 MG FILMTAB 3 erythromycin stearate ERYTHROCIN 500 MG ADDVNT VL 9 erythromycin lactobionate ERYTHROCIN 500 MG VIAL 9 erythromycin lactobionate

erythromycin 0.5% eye ointment 1

erythromycin 2% gel 1

erythromycin 2% pledgets 1

erythromycin 2% solution 1

erythromycin 250 mg filmtab 1

erythromycin 500 mg filmtab 1

erythromycin dr 250 mg cap 1

erythromycin ec 250 mg cap 1

erythromycin es 400 mg tab 1

erythromycin eye ointment 1

ILOTYCIN 0.5% EYE OINTMENT 3 erythromycin base ILOTYCIN 0.5% EYE OINTMENT 3 erythromycin base KETEK 300 MG TABLET 2 telithromycin KETEK 400 MG TABLET 2 telithromycin PCE 333 MG TABLET 3 erythromycin base PCE 500 MG TABLET 3 erythromycin base ZITHROMAX 1 GM POWDER PACKET 3 azithromycin ZITHROMAX 100 MG/5 ML SUSP 3 azithromycin

PAGE 86 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ZITHROMAX 200 MG/5 ML SUSP 3 azithromycin ZITHROMAX 250 MG TABLET 3 azithromycin ZITHROMAX 250 MG Z-PAK TABLET 3 azithromycin ZITHROMAX 500 MG TABLET 3 azithromycin ZITHROMAX 600 MG TABLET 3 azithromycin ZITHROMAX I.V. 500 MG VIAL 9 azithromycin ZITHROMAX I.V. 500 MG VIAL 9 azithromycin ZITHROMAX TRI-PAK 500 MG TAB 3 azithromycin ZMAX 2 G/60 ML ORAL SUSPENSION 2 azithromycin Quinolones

AVELOX 400 MG TABLET 3 moxifloxacin hcl AVELOX ABC PACK 400 MG TAB 3 moxifloxacin hcl AVELOX IV 400 MG/250 ML 9 moxifloxacin hcl/sodium chloride, iso-osmotic BESIVANCE 0.6% SUSP 3 besifloxacin hcl CILOXAN 0.3% EYE DROPS 3 ciprofloxacin hcl CILOXAN 0.3% OINTMENT 3 ciprofloxacin hcl CIPRO 10% SUSPENSION 3 ciprofloxacin CIPRO 250 MG TABLET 3 ciprofloxacin hcl CIPRO 5% SUSPENSION 3 ciprofloxacin CIPRO 500 MG TABLET 3 ciprofloxacin hcl

CIPRO I.V. 200 MG/100 ML D5W 9

PAGE 87 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ciprofloxacin lactate/dextrose 5 % in water CIPRO I.V. 400 MG/200 ML D5W 9 ciprofloxacin lactate/dextrose 5 % in water CIPRO XR 1,000 MG TABLET 3 ciprofloxacin/ciprofloxacin hcl CIPRO XR 500 MG TABLET 3 ciprofloxacin/ciprofloxacin hcl

ciprofloxacin 0.3% eye drop 1

ciprofloxacin 200 mg/20 ml vl 7

ciprofloxacin 250 mg/5 ml susp 1

ciprofloxacin 400 mg/40 ml vl 7

ciprofloxacin 500 mg/5 ml susp 1

ciprofloxacin er 1,000 mg tab 1

ciprofloxacin er 500 mg tablet 1

ciprofloxacin hcl 100 mg tab 1

ciprofloxacin hcl 250 mg tab 1

ciprofloxacin hcl 500 mg tab 1

ciprofloxacin hcl 750 mg tab 1

ciprofloxacn-d5w 200 mg/100 ml 7

ciprofloxacn-d5w 400 mg/200 ml 7

FACTIVE 320 MG TABLET 3 QL 7 / 30 days gemifloxacin mesylate FACTIVE 320 MG TABLET 3 QL 7 / 30 days gemifloxacin mesylate

gatifloxacin 0.5% eye drops 1 QL 2 / 30 days

LEVAQUIN 25 MG/ML SOLUTION 3 levofloxacin LEVAQUIN 250 MG TABLET 3 levofloxacin LEVAQUIN 500 MG TABLET 3 levofloxacin

LEVAQUIN 750 MG TABLET 3

PAGE 88 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

levofloxacin

LEVAQUIN-D5W 250 MG/50 ML BAG 9 levofloxacin/dextrose 5 % in water LEVAQUIN-D5W 500 MG/100 ML BAG 9 levofloxacin/dextrose 5 % in water LEVAQUIN-D5W 750 MG/150 ML BAG 9 levofloxacin/dextrose 5 % in water

levofloxacin 0.5% eye drops 1

levofloxacin 25 mg/ml solution 1

levofloxacin 250 mg tablet 1

levofloxacin 250 mg/10 ml soln 1

levofloxacin 500 mg tablet 1

levofloxacin 500 mg/20 ml soln 1

levofloxacin 500 mg/20 ml vial 7

levofloxacin 750 mg tablet 1

levofloxacin 750 mg/30 ml vial 7

levofloxacin-d5w 250 mg/50 ml 7

levofloxacin-d5w 500 mg/100 ml 7

levofloxacin-d5w 750 mg/150 ml 7

MOXEZA 0.5% EYE DROPS 3 QL 9 / 90 days moxifloxacin hcl

moxifloxacin hcl 400 mg tablet 1

NOROXIN 400 MG TABLET 3

PAGE 89 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS norfloxacin OCUFLOX 0.3% EYE DROPS 3 ofloxacin

ofloxacin 0.3% ear drops 1

ofloxacin 0.3% eye drops 1

ofloxacin 200 mg tablet 1

ofloxacin 300 mg tablet 1

ofloxacin 400 mg tablet 1

VIGAMOX 0.5% EYE DROPS 3 moxifloxacin hcl ZYMAXID 0.5% EYE DROPS 3 QL 2 / 30 days gatifloxacin Sulfonamides

AVC 15% CREAM 3 sulfanilamide BACTRIM 400-80 MG TABLET 3 sulfamethoxazole/trimethoprim BACTRIM 400-80 MG TABLET 3 sulfamethoxazole/trimethoprim BACTRIM DS TABLET 3 sulfamethoxazole/trimethoprim BACTRIM DS TABLET 3 sulfamethoxazole/trimethoprim BLEPH-10 10% EYE DROPS 3 sulfacetamide sodium KLARON 10% LOTION 3 sulfacetamide sodium OVACE PLUS 9.8% LOTION 3 sulfacetamide sodium SILVADENE 1% CREAM 3 silver sulfadiazine

silver sulfadiazine 1% cream 1

sodium sulfacetamide 10% lot 1

SSD 1% CREAM 1 silver sulfadiazine

PAGE 90 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

sulfacetamide 10% eye drops 1

sulfacetamide sod 10% top susp 1

sulfadiazine 500 mg tablet 1

sulfamethoxazole-tmp ds tablet 1

sulfamethoxazole-tmp ss tablet 1

sulfamethoxazole-tmp susp 1

sulfamethoxazole-tmp vial 1

sulfamide 10% eye drops 1

SULFATRIM PEDIATRIC SUSPENSION 1 sulfamethoxazole/trimethoprim THERMAZENE 1% CREAM 1 silver sulfadiazine Tetracyclines

ACTICLATE 150 MG TABLET 3 doxycycline hyclate ACTICLATE 75 MG TABLET 3 doxycycline hyclate ADOXA 150 MG CAPSULE 3 doxycycline monohydrate ALODOX CONVENIENCE KIT 3 doxycycline hyclate/eyelid clns no2/eyelid clns no3

avidoxy 100 mg tablet 1

AVIDOXY DK KIT doxycycline monohydrate/salicylic acid/octinoxate/zinc 3 oxide BENOXYLDOXY 30 KIT 3 doxycycline monohydrate/benzoyl peroxide BENOXYLDOXY 60 KIT 3 doxycycline monohydrate/benzoyl peroxide

demeclocycline 150 mg tablet 1

demeclocycline 300 mg tablet 1

DORYX DR 150 MG TABLET 3 doxycycline hyclate

PAGE 91 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS DORYX DR 200 MG TABLET doxycycline hyclate

doxy 100 vial 7

doxycycline 25 mg/5 ml susp 1

doxycycline hyc 100 mg vial 7

doxycycline hyc dr 100 mg tab 1

doxycycline hyc dr 150 mg tab 1

doxycycline hyc dr 75 mg tab 1

doxycycline hyclate 100 mg cap 1

doxycycline hyclate 100 mg tab 1

doxycycline hyclate 20 mg tab 1

doxycycline hyclate 50 mg cap 1

doxycycline mono 100 mg cap 1

doxycycline mono 100 mg tablet 1

doxycycline mono 150 mg cap 1

doxycycline mono 150 mg tablet 1

doxycycline mono 50 mg cap 1

doxycycline mono 50 mg tablet 1

doxycycline mono 75 mg capsule 1

doxycycline mono 75 mg tablet 1

PAGE 92 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

dynacin 100 mg tablet 3

dynacin 50 mg tablet 3

DYNACIN 75 MG TABLET 3 minocycline hcl MINOCIN 100 MG PELLETIZED CAP 3 minocycline hcl MINOCIN 100 MG VIAL 9 minocycline hcl MINOCIN 50 MG PELLETIZED CAP 3 minocycline hcl MINOCIN 75 MG PELLETIZED CAP 3 minocycline hcl MINOCIN KIT 100 MG COMBO 3 minocycline hcl/skin cleanser combination no.4 MINOCIN KIT 50 MG COMBO 3 minocycline hcl/skin cleanser combination no.4

minocycline 100 mg capsule 1

minocycline 50 mg capsule 1

minocycline 75 mg capsule 1

minocycline er 135 mg tablet 1

minocycline er 45 mg tablet 1

minocycline er 90 mg tablet 1

minocycline hcl 100 mg tablet 1

minocycline hcl 50 mg tablet 1

minocycline hcl 75 mg tablet 1

MONODOX 100 MG CAPSULE 3 doxycycline monohydrate MONODOX 50 MG CAPSULE 3 doxycycline monohydrate MONODOX 75 MG CAPSULE 3 doxycycline monohydrate

morgidox 100 mg capsule 1

MORGIDOX 1X100 MG KIT 3 doxycycline hyclate/skin cleanser comb no.19

PAGE 93 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS MORGIDOX 2X100 MG KIT doxycycline hyclate/skin cleanser comb no.19 OCUDOX CONVENIENCE KIT 3 doxycycline hyclate/eyelid clns no.3/eyelid emollient no.1 ORACEA 40 MG CAPSULE 3 doxycycline monohydrate SOLODYN ER 105 MG TABLET 3 minocycline hcl SOLODYN ER 115 MG TABLET 3 minocycline hcl SOLODYN ER 135 MG TABLET 3 minocycline hcl SOLODYN ER 45 MG TABLET 3 minocycline hcl SOLODYN ER 55 MG TABLET 3 minocycline hcl SOLODYN ER 65 MG TABLET 3 minocycline hcl SOLODYN ER 80 MG TABLET 3 minocycline hcl SOLODYN ER 90 MG TABLET 3 minocycline hcl

tetracycline 250 mg capsule 1

tetracycline 500 mg capsule 1

VIBRAMYCIN 100 MG CAPSULE 3 doxycycline hyclate VIBRAMYCIN 25 MG/5 ML SUSP 2 doxycycline monohydrate VIBRAMYCIN 50 MG/5 ML SYRUP 3 doxycycline calcium Anticonvulsants

Anticonvulsants, Other

acetazolamide 125 mg tablet 1

acetazolamide 250 mg tablet 1

acetazolamide sod 500 mg vial 7

FYCOMPA 10 MG TABLET 3 perampanel

PAGE 94 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS FYCOMPA 12 MG TABLET 3 perampanel FYCOMPA 2 MG TABLET 3 perampanel FYCOMPA 4 MG TABLET 3 perampanel FYCOMPA 6 MG TABLET 3 perampanel FYCOMPA 8 MG TABLET 3 perampanel KEPPRA 1,000 MG TABLET 3 levetiracetam KEPPRA 100 MG/ML ORAL SOLN 3 levetiracetam KEPPRA 250 MG TABLET 3 levetiracetam KEPPRA 500 MG TABLET 3 levetiracetam KEPPRA 500 MG/5 ML VIAL 9 levetiracetam KEPPRA 750 MG TABLET 3 levetiracetam KEPPRA XR 500 MG TABLET 3 QL 30 / 30 days levetiracetam KEPPRA XR 750 MG TABLET 3 QL 30 / 30 days levetiracetam

levetiracetam 1,000 mg tablet 1

levetiracetam 100 mg/ml soln 1

levetiracetam 250 mg tablet 1

levetiracetam 500 mg tablet 1

levetiracetam 500 mg/5 ml soln 1

levetiracetam 500 mg/5 ml vial 7

levetiracetam 750 mg tablet 1

PAGE 95 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

levetiracetam 750 mg tablet 1

levetiracetam er 500 mg tablet 1 QL 30 / 30 days

levetiracetam er 750 mg tablet 1 QL 30 / 30 days

levetiracetam-nacl 1,000mg/100 9

levetiracetam-nacl 1,500mg/100 9

levetiracetam-nacl 500 mg/100 9

MYSOLINE 250 MG TABLET 3 primidone MYSOLINE 50 MG TABLET 3 primidone POTIGA 200 MG TABLET 3 ezogabine POTIGA 300 MG TABLET 3 ezogabine POTIGA 400 MG TABLET 3 ezogabine POTIGA 50 MG TABLET 3 ezogabine

primidone 250 mg tablet 1

primidone 50 mg tablet 1

Calcium Channel Modifying Agents

CELONTIN 300 MG KAPSEAL 2 methsuximide

ethosuximide 250 mg capsule 1

ethosuximide 250 mg/5 ml soln 1

LYRICA 100 MG CAPSULE QL 120 / 30 days 2 pregabalin ST

LYRICA 150 MG CAPSULE QL 120 / 30 days 2 pregabalin ST

LYRICA 20 MG/ML ORAL SOLUTION 2 pregabalin

PAGE 96 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

LYRICA 200 MG CAPSULE QL 120 / 30 days 2 pregabalin ST

LYRICA 225 MG CAPSULE QL 120 / 30 days 2 pregabalin ST

LYRICA 25 MG CAPSULE QL 120 / 30 days 2 pregabalin ST

LYRICA 300 MG CAPSULE QL 120 / 30 days 2 pregabalin ST

LYRICA 50 MG CAPSULE QL 120 / 30 days 2 pregabalin ST

LYRICA 75 MG CAPSULE QL 120 / 30 days 2 pregabalin ST

ZARONTIN 250 MG CAPSULE 3 ethosuximide ZARONTIN 250 MG/5 ML SOLUTION 3 ethosuximide ZONEGRAN 100 MG CAPSULE 3 zonisamide ZONEGRAN 25 MG CAPSULE 3 zonisamide

zonisamide 100 mg capsule 1

zonisamide 25 mg capsule 1

zonisamide 50 mg capsule 1

Gamma-aminobutyric Acid (GABA) Augmenting Agents

DEPACON 500 MG VIAL 9 valproic acid (as sodium salt) (valproate sodium) DEPAKENE 250 MG CAPSULE 3 valproic acid DEPAKENE 250 MG/5 ML SOLUTION 3 valproic acid (as sodium salt) (valproate sodium)

PAGE 97 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS DEPAKOTE 125 MG SPRINKLE CAP divalproex sodium DEPAKOTE DR 125 MG TABLET 3 divalproex sodium DEPAKOTE DR 250 MG TABLET 3 divalproex sodium DEPAKOTE DR 500 MG TABLET 3 divalproex sodium DEPAKOTE ER 250 MG TABLET 3 divalproex sodium DEPAKOTE ER 500 MG TABLET 3 divalproex sodium DIASTAT 2.5 MG PEDI SYSTEM 3 diazepam DIASTAT ACUDIAL 12.5-15-20 MG 3 diazepam DIASTAT ACUDIAL 5-7.5-10 MG KT 3 diazepam

diazepam 10 mg rectal gel syst 1

diazepam 2.5 mg rectal gel sys 1

diazepam 20 mg rectal gel syst 1

divalproex sod dr 125 mg tab 1

divalproex sod dr 250 mg tab 1

divalproex sod dr 500 mg tab 1

divalproex sod er 250 mg tab 1

divalproex sod er 500 mg tab 1

divalproex sodium 125 mg cap 1

FANATREX ORAL SUSPENSION 3 gabapentin

PAGE 98 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

gabapentin 100 mg capsule 1

gabapentin 250 mg/5 ml soln 1

gabapentin 300 mg capsule 1

gabapentin 300 mg/6 ml soln 1

gabapentin 400 mg capsule 1

gabapentin 600 mg tablet 1

gabapentin 800 mg tablet 1

GABITRIL 12 MG TABLET 2 tiagabine hcl GABITRIL 16 MG TABLET 2 tiagabine hcl GABITRIL 2 MG TABLET 3 tiagabine hcl GABITRIL 4 MG TABLET 3 tiagabine hcl GRALISE 30-DAY STARTER PACK 3 ST gabapentin GRALISE ER 300 MG TABLET 3 ST gabapentin GRALISE ER 600 MG TABLET 3 ST gabapentin HORIZANT ER 600 MG TABLET 3 ST gabapentin enacarbil

luminal 130 mg/ml carpuject 9 PA

NEURONTIN 100 MG CAPSULE 3 ST gabapentin NEURONTIN 250 MG/5 ML SOLN 3 ST gabapentin NEURONTIN 300 MG CAPSULE 3 ST gabapentin

PAGE 99 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS NEURONTIN 400 MG CAPSULE ST gabapentin NEURONTIN 600 MG TABLET 3 ST gabapentin NEURONTIN 800 MG TABLET 3 ST gabapentin ONFI 10 MG TABLET 3 clobazam ONFI 2.5 MG/ML SUSPENSION 3 clobazam ONFI 20 MG TABLET 3 clobazam ONFI 5 MG TABLET 3 clobazam

phenobarbital 100 mg tablet 1

phenobarbital 130 mg/ml vial 7 PA

phenobarbital 15 mg tablet 1

phenobarbital 16.2 mg tablet 1

phenobarbital 20 mg/5 ml elix 1

phenobarbital 20 mg/5 ml soln 1

phenobarbital 30 mg tablet 1

phenobarbital 32.4 mg tablet 1

phenobarbital 60 mg tablet 1

phenobarbital 64.8 mg tablet 2

phenobarbital 65 mg/ml vial 9 PA

phenobarbital 97.2 mg tablet 2

SABRIL 500 MG POWDER PACKET QL 180 / 30 days 9 vigabatrin PA

SABRIL 500 MG TABLET QL 180 / 30 days 9 vigabatrin PA

STAVZOR DR 125 MG CAPSULE 3 valproic acid

PAGE 100 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS STAVZOR DR 250 MG CAPSULE 3 valproic acid STAVZOR DR 500 MG CAPSULE 3 valproic acid

tiagabine hcl 2 mg tablet 1

tiagabine hcl 4 mg tablet 1

TROKENDI XR 100 MG CAPSULE 3 topiramate TROKENDI XR 200 MG CAPSULE 3 topiramate TROKENDI XR 25 MG CAPSULE 3 topiramate TROKENDI XR 50 MG CAPSULE 3 topiramate

valproate sod 500 mg/5 ml vl 7

valproic acid 250 mg capsule 1

valproic acid 250 mg/5 ml soln 1

valproic acid 500 mg/10 ml sol 1

Glutamate Reducing Agents

felbamate 400 mg tablet 1

felbamate 600 mg tablet 1

felbamate 600 mg/5 ml susp 1

FELBATOL 400 MG TABLET 3 felbamate FELBATOL 600 MG TABLET 3 felbamate FELBATOL 600 MG/5 ML SUSP 2 felbamate LAMICTAL 100 MG TABLET 3 lamotrigine

LAMICTAL 150 MG TABLET 3

PAGE 101 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS lamotrigine LAMICTAL 2 MG DISPER TABLET 3 lamotrigine LAMICTAL 200 MG TABLET 3 lamotrigine LAMICTAL 25 MG DISPER TABLET 3 lamotrigine LAMICTAL 25 MG TABLET 3 lamotrigine LAMICTAL 5 MG DISPER TABLET 3 lamotrigine LAMICTAL ODT 100 MG TABLET 3 lamotrigine LAMICTAL ODT 200 MG TABLET 3 lamotrigine LAMICTAL ODT 25 MG TABLET 3 lamotrigine LAMICTAL ODT 50 MG TABLET 3 lamotrigine LAMICTAL ODT START KIT (BLUE) 3 lamotrigine LAMICTAL ODT START KIT (GREEN) 3 lamotrigine LAMICTAL ODT START KT (ORANGE) 3 lamotrigine LAMICTAL TAB START KIT (BLUE) 3 lamotrigine LAMICTAL TAB START KIT (GREEN) 3 lamotrigine LAMICTAL TB START KIT (ORANGE) 3 lamotrigine LAMICTAL XR 100 MG TABLET 3 lamotrigine LAMICTAL XR 200 MG TABLET 3 lamotrigine LAMICTAL XR 25 MG TABLET 3 lamotrigine LAMICTAL XR 250 MG TABLET 3 lamotrigine

LAMICTAL XR 300 MG TABLET 3

PAGE 102 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS lamotrigine LAMICTAL XR 50 MG TABLET 3 lamotrigine LAMICTAL XR START KIT (BLUE) 3 lamotrigine LAMICTAL XR START KIT (GREEN) 3 lamotrigine LAMICTAL XR START KIT (ORANGE) 3 lamotrigine

lamotrigine 100 mg tablet 1

lamotrigine 150 mg tablet 1

lamotrigine 200 mg tablet 1

lamotrigine 25 mg disper tab 1

lamotrigine 25 mg tablet 1

lamotrigine 25 mg tb start kit 1

lamotrigine 5 mg disper tablet 1

lamotrigine er 100 mg tablet 1

lamotrigine er 200 mg tablet 1

lamotrigine er 25 mg tablet 1

lamotrigine er 250 mg tablet 1

lamotrigine er 300 mg tablet 1

lamotrigine er 50 mg tablet 1

PAGE 103 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QUDEXY XR 100 MG CAPSULE 3 topiramate QUDEXY XR 150 MG CAPSULE 3 topiramate QUDEXY XR 200 MG CAPSULE 3 topiramate QUDEXY XR 25 MG CAPSULE 3 topiramate QUDEXY XR 50 MG CAPSULE 3 topiramate TOPAMAX 100 MG TABLET 3 topiramate TOPAMAX 15 MG SPRINKLE CAP 3 topiramate TOPAMAX 200 MG TABLET 3 topiramate TOPAMAX 25 MG SPRINKLE CAP 3 topiramate TOPAMAX 25 MG TABLET 3 topiramate TOPAMAX 50 MG TABLET 3 topiramate

topiragen 100 mg tablet 1

topiragen 200 mg tablet 1

topiragen 25 mg tablet 1

topiragen 50 mg tablet 1

topiramate 100 mg tablet 1

topiramate 15 mg sprinkle cap 1

topiramate 200 mg tablet 1

topiramate 25 mg sprinkle cap 1

topiramate 25 mg tablet 1

PAGE 104 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

topiramate 50 mg tablet

topiramate 50 mg tablet 1

topiramate er 100 mg capsule 1

topiramate er 150 mg capsule 1

topiramate er 200 mg capsule 1

topiramate er 25 mg capsule 1

topiramate er 50 mg capsule 1

TROKENDI XR 100 MG CAPSULE 3 topiramate TROKENDI XR 200 MG CAPSULE 3 topiramate TROKENDI XR 25 MG CAPSULE 3 topiramate TROKENDI XR 50 MG CAPSULE 3 topiramate Sodium Channel Agents

APTIOM 200 MG TABLET 3 eslicarbazepine acetate APTIOM 400 MG TABLET 3 eslicarbazepine acetate APTIOM 600 MG TABLET 3 eslicarbazepine acetate APTIOM 800 MG TABLET 3 eslicarbazepine acetate BANZEL 200 MG TABLET 3 QL 240 / 30 days rufinamide BANZEL 40 MG/ML SUSPENSION 3 rufinamide BANZEL 400 MG TABLET 3 QL 240 / 30 days rufinamide

carbamazepine 100 mg tab chew 1

carbamazepine 100 mg/5 ml susp 1

carbamazepine 200 mg tablet 1

PAGE 105 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

carbamazepine er 100 mg cap

carbamazepine er 200 mg cap 1

carbamazepine er 200 mg tablet 1

carbamazepine er 300 mg cap 1

carbamazepine er 400 mg tablet 1

carbamazepine xr 200 mg tablet 1

carbamazepine xr 400 mg tablet 1

CARBATROL ER 100 MG CAPSULE 3 carbamazepine CARBATROL ER 200 MG CAPSULE 3 carbamazepine CARBATROL ER 300 MG CAPSULE 3 carbamazepine CEREBYX 100 MG PE/2 ML VIAL 9 fosphenytoin sodium CEREBYX 500 MG PE/10 ML VIAL 9 fosphenytoin sodium DILANTIN 100 MG CAPSULE 2 phenytoin sodium extended DILANTIN 125 MG/5 ML SUSP 2 phenytoin DILANTIN 30 MG CAPSULE 2 phenytoin sodium extended DILANTIN 50 MG INFATAB 2 phenytoin

epitol 200 mg tablet 1

EQUETRO 100 MG CAPSULE 3 carbamazepine EQUETRO 200 MG CAPSULE 3 carbamazepine EQUETRO 300 MG CAPSULE 3 carbamazepine

fosphenytoin 100 mg pe/2 ml vl 7

fosphenytoin 500 mg pe/10 ml 7

oxcarbazepine 150 mg tablet 1

PAGE 106 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

oxcarbazepine 300 mg tablet 1

oxcarbazepine 300 mg/5 ml susp 1

oxcarbazepine 600 mg tablet 1

OXTELLAR XR 150 MG TABLET 3 QL 120 / 30 days oxcarbazepine OXTELLAR XR 300 MG TABLET 3 QL 120 / 30 days oxcarbazepine OXTELLAR XR 600 MG TABLET 3 QL 120 / 30 days oxcarbazepine PEGANONE 250 MG TABLET 3 ethotoin PHENYTEK 200 MG CAPSULE 1 phenytoin sodium extended PHENYTEK 300 MG CAPSULE 3 phenytoin sodium extended

phenytoin 100 mg/2 ml vial 7

phenytoin 100 mg/4 ml susp 1

phenytoin 125 mg/5 ml susp 1

phenytoin 250 mg/5 ml vial 7

phenytoin 50 mg infatab 1

phenytoin 50 mg tablet chew 1

phenytoin 50 mg/ml ampul 7

phenytoin 50 mg/ml syringe 7

phenytoin 50 mg/ml vial 7

phenytoin sod ext 100 mg cap 1

phenytoin sod ext 200 mg cap 1

phenytoin sod ext 300 mg cap 1

TEGRETOL 100 MG/5 ML SUSP 2 carbamazepine

TEGRETOL 200 MG TABLET 2

PAGE 107 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS carbamazepine TEGRETOL XR 100 MG TABLET 2 carbamazepine TEGRETOL XR 200 MG TABLET 2 carbamazepine TEGRETOL XR 400 MG TABLET 2 carbamazepine TRILEPTAL 150 MG TABLET 2 oxcarbazepine TRILEPTAL 300 MG TABLET 2 oxcarbazepine TRILEPTAL 300 MG/5 ML SUSP 3 oxcarbazepine TRILEPTAL 600 MG TABLET 2 oxcarbazepine VIMPAT 10 MG/ML SOLUTION 3 lacosamide VIMPAT 100 MG TABLET 3 QL 60 / 30 days lacosamide VIMPAT 150 MG TABLET 3 QL 60 / 30 days lacosamide VIMPAT 200 MG TABLET 3 QL 60 / 30 days lacosamide VIMPAT 200 MG/20 ML VIAL 9 lacosamide VIMPAT 50 MG TABLET 3 QL 60 / 30 days lacosamide VIMPAT STARTER KIT 3 QL 28 / 180 days lacosamide

ziprasidone hcl 20 mg capsule 1 QL 60 / 30 days

ZONEGRAN 100 MG CAPSULE 3 zonisamide ZONEGRAN 25 MG CAPSULE 3 zonisamide

zonisamide 100 mg capsule 1

zonisamide 25 mg capsule 1

zonisamide 50 mg capsule 1

PAGE 108 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS Antidementia Agents

Antidementia Agents, Other

ergoloid mesylates 1 mg tab 1

Cholinesterase Inhibitors

ARICEPT 10 MG TABLET 3 QL 30 / 30 days donepezil hcl ARICEPT 23 MG TABLET 3 QL 30 / 30 days donepezil hcl ARICEPT 5 MG TABLET 3 QL 30 / 30 days donepezil hcl ARICEPT ODT 10 MG TABLET 3 QL 30 / 30 days donepezil hcl ARICEPT ODT 5 MG TABLET 3 QL 30 / 30 days donepezil hcl

donepezil hcl 10 mg tablet 1 QL 30 / 30 days

donepezil hcl 23 mg tablet 1 QL 30 / 30 days

donepezil hcl 5 mg tablet 1 QL 30 / 30 days

donepezil hcl odt 10 mg tablet 1 QL 30 / 30 days

donepezil hcl odt 5 mg tablet 1 QL 30 / 30 days

EXELON 1.5 MG CAPSULE 3 QL 60 / 30 days rivastigmine tartrate EXELON 13.3 MG/24HR PATCH 2 QL 30 / 30 days rivastigmine EXELON 2 MG/ML ORAL SOLUTION 2 rivastigmine tartrate EXELON 3 MG CAPSULE 3 QL 60 / 30 days rivastigmine tartrate EXELON 4.5 MG CAPSULE 3 QL 60 / 30 days rivastigmine tartrate

PAGE 109 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS EXELON 4.6 MG/24HR PATCH 2 QL 30 / 30 days rivastigmine EXELON 6 MG CAPSULE 3 QL 60 / 30 days rivastigmine tartrate EXELON 9.5 MG/24HR PATCH 2 QL 30 / 30 days rivastigmine

galantamine 4 mg/ml oral soln 1

galantamine er 16 mg capsule 1 QL 30 / 30 days

galantamine er 24 mg capsule 1 QL 30 / 30 days

galantamine er 8 mg capsule 1 QL 30 / 30 days

galantamine hbr 12 mg tablet 1

galantamine hbr 4 mg tablet 1

galantamine hbr 8 mg tablet 1

RAZADYNE 12 MG TABLET 3 galantamine hbr RAZADYNE 4 MG TABLET 3 galantamine hbr RAZADYNE 4 MG/ML ORAL SOLUTION 3 galantamine hbr RAZADYNE 8 MG TABLET 3 galantamine hbr RAZADYNE ER 16 MG CAPSULE 3 QL 30 / 30 days galantamine hbr RAZADYNE ER 24 MG CAPSULE 3 QL 30 / 30 days galantamine hbr RAZADYNE ER 8 MG CAPSULE 3 QL 30 / 30 days galantamine hbr

rivastigmine 1.5 mg capsule 1 QL 60 / 30 days

rivastigmine 3 mg capsule 1 QL 60 / 30 days

rivastigmine 4.5 mg capsule 1 QL 60 / 30 days

rivastigmine 6 mg capsule 1 QL 60 / 30 days

PAGE 110 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS N-methyl-D-aspartate (NMDA) Receptor Antagonist

NAMENDA 10 MG TABLET 2 memantine hcl NAMENDA 10 MG/5 ML SOLUTION 2 memantine hcl NAMENDA 5 MG TABLET 2 memantine hcl NAMENDA 5-10 MG TITRATION PK 2 memantine hcl NAMENDA XR 14 MG CAPSULE 3 memantine hcl NAMENDA XR 21 MG CAPSULE 3 memantine hcl NAMENDA XR 28 MG CAPSULE 3 memantine hcl NAMENDA XR 7 MG CAPSULE 3 memantine hcl NAMENDA XR TITRATION PACK 3 memantine hcl Antidepressants

Antidepressants, Other

ABILIFY 1 MG/ML SOLUTION 3 aripiprazole ABILIFY 10 MG TABLET 3 QL 30 / 30 days aripiprazole ABILIFY 15 MG TABLET 3 QL 30 / 30 days aripiprazole ABILIFY 2 MG TABLET 3 QL 30 / 30 days aripiprazole ABILIFY 20 MG TABLET 3 QL 30 / 30 days aripiprazole ABILIFY 30 MG TABLET 3 QL 30 / 30 days aripiprazole ABILIFY 5 MG TABLET 3 QL 30 / 30 days aripiprazole ABILIFY 9.7 MG/1.3 ML VIAL 9 aripiprazole ABILIFY DISCMELT 10 MG TABLET 3 QL 30 / 30 days aripiprazole

PAGE 111 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ABILIFY DISCMELT 15 MG TABLET QL 30 / 30 days aripiprazole ABILIFY MAINTENA ER 300 MG VL 3 aripiprazole ABILIFY MAINTENA ER 300 MG VL 3 aripiprazole ABILIFY MAINTENA ER 400 MG VL 3 aripiprazole ABILIFY MAINTENA ER 400 MG VL 3 aripiprazole

APLENZIN ER 174 MG TABLET QL 30 / 30 days 3 bupropion hbr ST

APLENZIN ER 348 MG TABLET QL 30 / 30 days 3 bupropion hbr ST

APLENZIN ER 522 MG TABLET QL 30 / 30 days 3 bupropion hbr ST

budeprion sr 100 mg tablet 1

budeprion sr 150 mg tablet 1

budeprion xl 300 mg tablet 1 QL 30 / 30 days

bupropion hcl 100 mg tablet 1

bupropion hcl 75 mg tablet 1

bupropion hcl sr 100 mg tablet 1

bupropion hcl sr 150 mg tablet 1

bupropion hcl sr 200 mg tab 1

bupropion hcl xl 150 mg tablet 1 QL 90 / 30 days

bupropion hcl xl 300 mg tablet 1 QL 30 / 30 days

FORFIVO XL 450 MG TABLET 3 bupropion hcl

PAGE 112 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

maprotiline 25 mg tablet 1

maprotiline 50 mg tablet 1

maprotiline 75 mg tablet 1

mirtazapine 15 mg odt 1 QL 30 / 30 days

mirtazapine 15 mg tablet 1 QL 30 / 30 days

mirtazapine 30 mg odt 1 QL 30 / 30 days

mirtazapine 30 mg tablet 1 QL 30 / 30 days

mirtazapine 45 mg odt 1 QL 30 / 30 days

mirtazapine 45 mg tablet 1 QL 30 / 30 days

mirtazapine 7.5 mg tablet 1 QL 30 / 30 days

nefazodone hcl 100 mg tablet 1

nefazodone hcl 150 mg tablet 1

nefazodone hcl 200 mg tablet 1

nefazodone hcl 250 mg tablet 1

nefazodone hcl 50 mg tablet 1

olanzapine-fluoxetine 12-25 mg 1 QL 30 / 30 days

olanzapine-fluoxetine 12-50 mg 1 QL 30 / 30 days

olanzapine-fluoxetine 3-25 mg 1 QL 30 / 30 days

olanzapine-fluoxetine 6-25 mg 1 QL 30 / 30 days

olanzapine-fluoxetine 6-50 mg 1 QL 30 / 30 days

PAGE 113 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

OLEPTRO ER 150 MG TABLET QL 30 / 30 days 3 trazodone hcl ST

OLEPTRO ER 300 MG TABLET QL 30 / 30 days 3 trazodone hcl ST

perphen-amitrip 2 mg-10 mg tab 1

perphen-amitrip 2 mg-25 mg tab 1

perphen-amitrip 4 mg-10 mg tab 1

perphen-amitrip 4 mg-25 mg tab 1

perphen-amitrip 4 mg-50 mg tab 1

REMERON 15 MG SOLTAB QL 30 / 30 days 3 mirtazapine ST

REMERON 15 MG TABLET QL 30 / 30 days 3 mirtazapine ST

REMERON 30 MG SOLTAB QL 30 / 30 days 3 mirtazapine ST

REMERON 30 MG TABLET QL 30 / 30 days 3 mirtazapine ST

REMERON 45 MG SOLTAB QL 30 / 30 days 3 mirtazapine ST

REMERON 45 MG TABLET QL 30 / 30 days 3 mirtazapine ST

SEROQUEL XR 150 MG TABLET 2 QL 30 / 30 days quetiapine fumarate SEROQUEL XR 200 MG TABLET 2 QL 30 / 30 days quetiapine fumarate SEROQUEL XR 300 MG TABLET 2 QL 60 / 30 days quetiapine fumarate SEROQUEL XR 400 MG TABLET 2 QL 60 / 30 days quetiapine fumarate SEROQUEL XR 50 MG TABLET 2 QL 30 / 30 days quetiapine fumarate SYMBYAX 12-25 MG CAPSULE 3 QL 30 / 30 days olanzapine/fluoxetine hcl

PAGE 114 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS SYMBYAX 12-50 MG CAPSULE 3 QL 30 / 30 days olanzapine/fluoxetine hcl SYMBYAX 3-25 MG CAPSULE 3 QL 30 / 30 days olanzapine/fluoxetine hcl SYMBYAX 6-25 MG CAPSULE 3 QL 30 / 30 days olanzapine/fluoxetine hcl SYMBYAX 6-50 MG CAPSULE 3 QL 30 / 30 days olanzapine/fluoxetine hcl

trazodone 100 mg tablet 1

trazodone 150 mg tablet 1

trazodone 300 mg tablet 1

trazodone 50 mg tablet 1

VIIBRYD 10 MG TABLET QL 30 / 30 days 3 vilazodone hydrochloride ST

VIIBRYD 20 MG TABLET QL 30 / 30 days 3 vilazodone hydrochloride ST

VIIBRYD 40 MG TABLET QL 30 / 30 days 3 vilazodone hydrochloride ST

VIIBRYD TITRATION PACK 3 QL 30 / 30 days vilazodone hydrochloride WELLBUTRIN 100 MG TABLET 3 ST bupropion hcl WELLBUTRIN 75 MG TABLET 3 ST bupropion hcl WELLBUTRIN SR 100 MG TABLET 3 ST bupropion hcl WELLBUTRIN SR 150 MG TABLET 3 ST bupropion hcl WELLBUTRIN SR 200 MG TABLET 3 ST bupropion hcl

3 QL

PAGE 115 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

WELLBUTRIN XL 150 MG TABLET 90 / 30 days bupropion hcl ST

WELLBUTRIN XL 300 MG TABLET QL 30 / 30 days 3 bupropion hcl ST

Monoamine Oxidase Inhibitors

EMSAM 12 MG/24 HOURS PATCH 3 QL 30 / 30 days selegiline EMSAM 6 MG/24 HOURS PATCH 3 QL 30 / 30 days selegiline EMSAM 9 MG/24 HOURS PATCH 3 QL 30 / 30 days selegiline MARPLAN 10 MG TABLET 3 isocarboxazid NARDIL 15 MG TABLET 3 phenelzine sulfate PARNATE 10 MG TABLET 3 tranylcypromine sulfate

phenelzine sulfate 15 mg tab 1

tranylcypromine sulf 10 mg tab 1

Serotonin/Norepinephrine Reuptake Inhibitors

BRINTELLIX 10 MG TABLET 3 vortioxetine hydrobromide BRINTELLIX 20 MG TABLET 3 vortioxetine hydrobromide BRINTELLIX 5 MG TABLET 3 vortioxetine hydrobromide BRISDELLE 7.5 MG CAPSULE 3 paroxetine mesylate CELEXA 10 MG TABLET 3 ST citalopram hydrobromide CELEXA 20 MG TABLET 3 ST citalopram hydrobromide CELEXA 40 MG TABLET 3 ST citalopram hydrobromide

citalopram hbr 10 mg tablet 1

PAGE 116 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

citalopram hbr 10 mg/5 ml soln

citalopram hbr 20 mg tablet 1

citalopram hbr 40 mg tablet 1

CYMBALTA 20 MG CAPSULE QL 90 / 30 days 2 duloxetine hcl ST

CYMBALTA 30 MG CAPSULE QL 30 / 30 days 2 duloxetine hcl ST

CYMBALTA 60 MG CAPSULE QL 30 / 30 days 2 duloxetine hcl ST

desvenlafaxine er 100 mg tab 1

desvenlafaxine er 50 mg tab 1

desvenlafaxine er 50 mg tablet 1

desvenlafaxine fum er 100 mg 1

desvenlafaxine fum er 50 mg 1

duloxetine hcl dr 20 mg cap 1 QL 90 / 30 days

duloxetine hcl dr 30 mg cap 1 QL 30 / 30 days

duloxetine hcl dr 60 mg cap 1 QL 30 / 30 days

EFFEXOR XR 150 MG CAPSULE QL 60 / 30 days 3 venlafaxine hcl ST

EFFEXOR XR 37.5 MG CAPSULE QL 60 / 30 days 3 venlafaxine hcl ST

EFFEXOR XR 75 MG CAPSULE QL 90 / 30 days 3 venlafaxine hcl ST

PAGE 117 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

escitalopram 10 mg tablet 1 QL 30 / 30 days

escitalopram 20 mg tablet 1 QL 30 / 30 days

escitalopram 5 mg tablet 1 QL 30 / 30 days

escitalopram oxalate 5 mg/5 ml 1 QL 620 / 30 days

FETZIMA 20-40 MG TITRATION PAK 3 ST levomilnacipran hydrochloride FETZIMA ER 120 MG CAPSULE 3 ST levomilnacipran hydrochloride FETZIMA ER 20 MG CAPSULE 3 ST levomilnacipran hydrochloride FETZIMA ER 40 MG CAPSULE 3 ST levomilnacipran hydrochloride FETZIMA ER 80 MG CAPSULE 3 ST levomilnacipran hydrochloride

fluoxetine 20 mg/5 ml solution 1

fluoxetine dr 90 mg capsule 1

fluoxetine hcl 10 mg capsule 1

fluoxetine hcl 10 mg tablet 1

fluoxetine hcl 20 mg capsule 1

fluoxetine hcl 20 mg tablet 1

fluoxetine hcl 40 mg capsule 1

fluoxetine hcl 60 mg tablet 1

fluvoxamine er 100 mg capsule 1 QL 30 / 30 days

fluvoxamine er 150 mg capsule 1 QL 30 / 30 days

PAGE 118 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

fluvoxamine er 150 mg capsule QL 30 / 30 days

fluvoxamine maleate 100 mg tab 1

fluvoxamine maleate 25 mg tab 1

fluvoxamine maleate 50 mg tab 1

KHEDEZLA ER 100 MG TABLET 3 desvenlafaxine KHEDEZLA ER 100 MG TABLET 3 desvenlafaxine KHEDEZLA ER 50 MG TABLET 3 desvenlafaxine KHEDEZLA ER 50 MG TABLET 3 desvenlafaxine

LEXAPRO 10 MG TABLET QL 30 / 30 days 3 escitalopram oxalate ST

LEXAPRO 20 MG TABLET QL 30 / 30 days 3 escitalopram oxalate ST

LEXAPRO 5 MG TABLET QL 30 / 30 days 3 escitalopram oxalate ST

LEXAPRO 5 MG/5 ML SOLUTION QL 620 / 30 days 3 escitalopram oxalate ST

LUVOX CR 100 MG CAPSULE QL 30 / 30 days 3 fluvoxamine maleate ST

LUVOX CR 150 MG CAPSULE QL 30 / 30 days 3 fluvoxamine maleate ST

nefazodone hcl 100 mg tablet 1

nefazodone hcl 150 mg tablet 1

nefazodone hcl 200 mg tablet 1

nefazodone hcl 250 mg tablet 1

nefazodone hcl 50 mg tablet 1

paroxetine cr 12.5 mg tablet 1 QL 60 / 30 days

PAGE 119 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

paroxetine cr 25 mg tablet 1 QL 60 / 30 days

paroxetine cr 37.5 mg tablet 1 QL 60 / 30 days

paroxetine er 37.5 mg tablet 1 QL 60 / 30 days

paroxetine hcl 10 mg tablet 1

paroxetine hcl 20 mg tablet 1

paroxetine hcl 30 mg tablet 1

paroxetine hcl 40 mg tablet 1

PAXIL 10 MG TABLET 3 ST paroxetine hcl PAXIL 10 MG/5 ML SUSPENSION 3 ST paroxetine hcl PAXIL 20 MG TABLET 3 ST paroxetine hcl PAXIL 30 MG TABLET 3 ST paroxetine hcl PAXIL 40 MG TABLET 3 ST paroxetine hcl

PAXIL CR 12.5 MG TABLET QL 60 / 30 days 3 paroxetine hcl ST

PAXIL CR 25 MG TABLET QL 60 / 30 days 3 paroxetine hcl ST

PAXIL CR 37.5 MG TABLET QL 60 / 30 days 3 paroxetine hcl ST

PEXEVA 10 MG TABLET QL 30 / 30 days 3 paroxetine mesylate ST

PEXEVA 20 MG TABLET QL 30 / 30 days 3 paroxetine mesylate ST

PEXEVA 30 MG TABLET 3 QL 30 / 30 days

PAGE 120 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

paroxetine mesylate ST

PEXEVA 40 MG TABLET QL 30 / 30 days 3 paroxetine mesylate ST

PRISTIQ ER 100 MG TABLET QL 30 / 30 days 3 desvenlafaxine succinate ST

PRISTIQ ER 50 MG TABLET QL 30 / 30 days 3 desvenlafaxine succinate ST

PROZAC 10 MG PULVULE 3 ST fluoxetine hcl PROZAC 20 MG PULVULE 3 ST fluoxetine hcl PROZAC 40 MG PULVULE 3 ST fluoxetine hcl PROZAC WEEKLY 90 MG CAPSULE 3 ST fluoxetine hcl SARAFEM 10 MG TABLET 3 fluoxetine hcl SARAFEM 20 MG TABLET 3 fluoxetine hcl

sertraline 20 mg/ml oral conc 1

sertraline hcl 100 mg tablet 1

sertraline hcl 25 mg tablet 1

sertraline hcl 50 mg tablet 1

venlafaxine hcl 100 mg tablet 1

venlafaxine hcl 25 mg tablet 1

venlafaxine hcl 37.5 mg tablet 1

PAGE 121 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

venlafaxine hcl 37.5 mg tablet 1

venlafaxine hcl 50 mg tablet 1

venlafaxine hcl 75 mg tablet 1

venlafaxine hcl er 150 mg cap 1 QL 60 / 30 days

venlafaxine hcl er 150 mg tab 1 QL 60 / 30 days

VENLAFAXINE HCL ER 150 MG TAB 1 QL 60 / 30 days venlafaxine hcl VENLAFAXINE HCL ER 225 MG TAB 2 venlafaxine hcl

venlafaxine hcl er 37.5 mg cap 1 QL 60 / 30 days

venlafaxine hcl er 37.5 mg tab 1 QL 60 / 30 days

VENLAFAXINE HCL ER 37.5 MG TAB 1 QL 60 / 30 days venlafaxine hcl

venlafaxine hcl er 75 mg cap 1 QL 90 / 30 days

venlafaxine hcl er 75 mg tab 1 QL 90 / 30 days

VENLAFAXINE HCL ER 75 MG TAB 1 QL 90 / 30 days venlafaxine hcl ZOLOFT 100 MG TABLET 3 ST sertraline hcl ZOLOFT 20 MG/ML ORAL CONC 3 ST sertraline hcl ZOLOFT 25 MG TABLET 3 ST sertraline hcl ZOLOFT 50 MG TABLET 3 ST sertraline hcl Tricyclics

amitriptyline hcl 10 mg tab 1

PAGE 122 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

amitriptyline hcl 100 mg tab

amitriptyline hcl 150 mg tab 1

amitriptyline hcl 25 mg tab 1

amitriptyline hcl 50 mg tab 1

amitriptyline hcl 75 mg tab 1

amoxapine 100 mg tablet 1

amoxapine 150 mg tablet 1

amoxapine 25 mg tablet 1

amoxapine 50 mg tablet 1

ANAFRANIL 25 MG CAPSULE 3 clomipramine hcl ANAFRANIL 50 MG CAPSULE 3 clomipramine hcl ANAFRANIL 75 MG CAPSULE 3 clomipramine hcl

clomipramine 25 mg capsule 1

clomipramine 50 mg capsule 1

clomipramine 75 mg capsule 1

desipramine 10 mg tablet 1

desipramine 100 mg tablet 1

desipramine 150 mg tablet 1

desipramine 25 mg tablet 1

desipramine 50 mg tablet 1

PAGE 123 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

desipramine 50 mg tablet 1

desipramine 75 mg tablet 1

doxepin 10 mg capsule 1

doxepin 10 mg/ml oral conc 1

doxepin 100 mg capsule 1

doxepin 150 mg capsule 1

doxepin 25 mg capsule 1

doxepin 50 mg capsule 1

doxepin 75 mg capsule 1

imipramine hcl 10 mg tablet 1

imipramine hcl 25 mg tablet 1

imipramine hcl 50 mg tablet 1

imipramine pamoate 100 mg cap 1

imipramine pamoate 125 mg cap 1

imipramine pamoate 150 mg cap 1

imipramine pamoate 75 mg cap 1

NORPRAMIN 10 MG TABLET 3 desipramine hcl NORPRAMIN 100 MG TABLET 3 desipramine hcl NORPRAMIN 150 MG TABLET 3 desipramine hcl NORPRAMIN 25 MG TABLET 3 desipramine hcl NORPRAMIN 50 MG TABLET 3 desipramine hcl NORPRAMIN 75 MG TABLET 3 desipramine hcl

nortriptyline 10 mg/5 ml sol 1

nortriptyline hcl 10 mg cap 1

PAGE 124 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

nortriptyline hcl 25 mg cap 1

nortriptyline hcl 50 mg cap 1

nortriptyline hcl 75 mg cap 1

PAMELOR 10 MG CAPSULE 3 nortriptyline hcl PAMELOR 25 MG CAPSULE 3 nortriptyline hcl PAMELOR 50 MG CAPSULE 3 nortriptyline hcl PAMELOR 75 MG CAPSULE 3 nortriptyline hcl

protriptyline hcl 10 mg tablet 1

protriptyline hcl 5 mg tablet 1

SURMONTIL 100 MG CAPSULE 3 trimipramine maleate SURMONTIL 25 MG CAPSULE 3 trimipramine maleate SURMONTIL 50 MG CAPSULE 3 trimipramine maleate TOFRANIL 10 MG TABLET 3 imipramine hcl TOFRANIL 25 MG TABLET 3 imipramine hcl TOFRANIL 50 MG TABLET 3 imipramine hcl TOFRANIL-PM 100 MG CAPSULE 3 imipramine pamoate TOFRANIL-PM 125 MG CAPSULE 3 imipramine pamoate TOFRANIL-PM 150 MG CAPSULE 3 imipramine pamoate TOFRANIL-PM 75 MG CAPSULE 3 imipramine pamoate

trimipramine maleate 100 mg cp 1

trimipramine maleate 25 mg cap 1

PAGE 125 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

trimipramine maleate 50 mg cap

VIVACTIL 10 MG TABLET 3 protriptyline hcl VIVACTIL 5 MG TABLET 3 protriptyline hcl Antiemetics

Antiemetics, Other

ALOXI 0.25 MG/5 ML VIAL 9 palonosetron hcl ANTIVERT 12.5 MG TABLET 3 meclizine hcl ANTIVERT 25 MG TABLET 3 meclizine hcl ANTIVERT 50 MG TABLET 3 meclizine hcl

chlorpromazine 10 mg tablet 1

chlorpromazine 100 mg tablet 1

chlorpromazine 200 mg tablet 1

chlorpromazine 25 mg tablet 1

chlorpromazine 25 mg/ml amp 1

chlorpromazine 50 mg tablet 1

COMPAZINE 10 MG TABLET 3 prochlorperazine maleate COMPAZINE 25 MG SUPPOSITORY 1 prochlorperazine maleate COMPAZINE 5 MG TABLET 3 prochlorperazine maleate

compro 25 mg suppository 1

DICLEGIS DR 10-10 MG TABLET 3 doxylamine succinate/pyridoxine hcl

diphenhydramine 50 mg/ml syrng 7

diphenhydramine 50 mg/ml vial 7

diphenhydramine hcl 50 mg/ml 7

droperidol 2.5 mg/ml ampul 7 PA

PAGE 126 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

droperidol 2.5 mg/ml vial 7 PA

hydroxyzine 10 mg/5 ml syrup 1

hydroxyzine 25 mg/ml vial 1

hydroxyzine 50 mg/ml vial 7 PA

hydroxyzine hcl 10 mg tablet 1

hydroxyzine hcl 25 mg tablet 1

hydroxyzine hcl 50 mg tablet 1

hydroxyzine pam 100 mg cap 1

hydroxyzine pam 25 mg cap 1

hydroxyzine pam 50 mg cap 1

meclizine 12.5 mg tablet 1

meclizine 25 mg tablet 1

metoclopramide 10 mg tablet 1

metoclopramide 10 mg/10 ml sol 1

metoclopramide 10 mg/2 ml syr 7

metoclopramide 10 mg/2 ml vial 7

metoclopramide 5 mg tablet 1

metoclopramide 5 mg/5 ml soln 1

metoclopramide 5 mg/5 ml syrup 1

metoclopramide 5 mg/ml vial 7

PAGE 127 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS METOZOLV ODT 10 MG TABLET 3 QL 120 / 30 days metoclopramide hcl METOZOLV ODT 5 MG TABLET 3 QL 120 / 30 days metoclopramide hcl

perphenazine 16 mg tablet 1

perphenazine 2 mg tablet 1

perphenazine 4 mg tablet 1

perphenazine 8 mg tablet 1

phenadoz 12.5 mg suppository 1

phenadoz 25 mg suppository 1

PHENERGAN 12.5 MG SUPPOSITORY 1 promethazine hcl PHENERGAN 25 MG SUPPOSITORY 1 promethazine hcl

phenergan 25 mg/ml ampul 9

PHENERGAN 25 MG/ML AMPUL 9 promethazine hcl

phenergan 25 mg/ml vial 9

PHENERGAN 25 MG/ML VIAL 9 promethazine hcl PHENERGAN 50 MG SUPPOSITORY 1 promethazine hcl

phenergan 50 mg/ml ampul 7

PHENERGAN 50 MG/ML AMPUL 9 promethazine hcl

phenergan 50 mg/ml vial 7

PHENERGAN 50 MG/ML VIAL 9 promethazine hcl

prochlorperazine 10 mg tab 1

prochlorperazine 25 mg supp 1

PAGE 128 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

prochlorperazine 5 mg tablet 1

promethazine 12.5 mg suppos 1

promethazine 12.5 mg tablet 1

promethazine 25 mg suppository 1

promethazine 25 mg/ml ampul 7

promethazine 25 mg/ml syringe 7

promethazine 25 mg/ml vial 7

promethazine 50 mg suppository 1

promethazine 50 mg tablet 1

promethazine 50 mg/ml ampul 7

promethazine 50 mg/ml vial 7

promethazine 6.25 mg/5 ml syrp 1

promethegan 12.5 mg suppos 1

promethegan 25 mg supp 1

promethegan 50 mg suppository 1

REGLAN 10 MG TABLET 3 metoclopramide hcl REGLAN 5 MG TABLET 3 metoclopramide hcl TIGAN 100 MG/ML VIAL 9 trimethobenzamide hcl TIGAN 300 MG CAPSULE 3 trimethobenzamide hcl TRANSDERM-SCOP 1.5 MG/72HR 3 QL 10 / 30 days scopolamine

trimethobenzamide 2,000 mg/20 7

PAGE 129 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

trimethobenzamide 200 mg/2 ml

trimethobenzamide 300 mg cap 1

VISTARIL 25 MG CAPSULE 3 hydroxyzine pamoate VISTARIL 50 MG CAPSULE 3 hydroxyzine pamoate Emetogenic Therapy Adjuncts

AKYNZEO 300-0.5 MG CAPSULE 3 netupitant/palonosetron hcl ALOXI 0.25 MG/5 ML VIAL 9 palonosetron hcl ANZEMET 100 MG TABLET 3 dolasetron mesylate ANZEMET 20 MG/ML VIAL 9 dolasetron mesylate ANZEMET 50 MG TABLET 3 dolasetron mesylate CESAMET 1 MG CAPSULE 3 nabilone

dronabinol 10 mg capsule 1

dronabinol 2.5 mg capsule 1

dronabinol 5 mg capsule 1

EMEND 125 MG CAPSULE 3 aprepitant EMEND 150 MG VIAL 9 fosaprepitant dimeglumine EMEND 40 MG CAPSULE 3 aprepitant EMEND 80 MG CAPSULE 3 aprepitant EMEND TRIFOLD PACK 3 aprepitant

granisetron hcl 0.1 mg/ml vial 7

granisetron hcl 1 mg tablet 1

granisetron hcl 1 mg/ml vial 7

PAGE 130 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

granisetron hcl 4 mg/4 ml vial 7

MARINOL 10 MG CAPSULE 3 dronabinol MARINOL 2.5 MG CAPSULE 3 dronabinol MARINOL 5 MG CAPSULE 3 dronabinol

ondansetron 4 mg/2 ml ampule 7

ondansetron 4 mg/5 ml solution 1

ondansetron 40 mg/20 ml vial 7

ondansetron hcl 24 mg tablet 1

ondansetron hcl 32 mg/50 ml bg 7

ondansetron hcl 4 mg tablet 1

ondansetron hcl 4 mg/2 ml syr 7

ondansetron hcl 4 mg/2 ml vial 7

ondansetron hcl 8 mg tablet 1

ondansetron odt 4 mg tablet 1

ondansetron odt 8 mg tablet 1

SANCUSO 3.1 MG/24 HR PATCH 3 QL 4 / 30 days granisetron ZOFRAN 2 MG/ML VIAL 9 ondansetron hcl ZOFRAN 4 MG TABLET 3 ondansetron hcl ZOFRAN 4 MG/5 ML ORAL SOLN 3 ondansetron hcl ZOFRAN 8 MG TABLET 3 ondansetron hcl

PAGE 131 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ZOFRAN ODT 4 MG TABLET ondansetron ZOFRAN ODT 8 MG TABLET 3 ondansetron ZUPLENZ 4 MG SOLUBLE FILM 3 ondansetron ZUPLENZ 8 MG SOLUBLE FILM 3 ondansetron Antifungals

ABELCET 100 MG/20 ML VIAL 9 amphotericin b lipid complex AMBISOME 50 MG VIAL 9 amphotericin b liposome ANCOBON 250 MG CAPSULE 3 flucytosine ANCOBON 500 MG CAPSULE 3 flucytosine CANCIDAS IV 50 MG VIAL 9 caspofungin acetate CANCIDAS IV 70 MG VIAL 9 caspofungin acetate

ciclodan 0.77% cream 1

CICLODAN 0.77% CREAM KIT 3 ciclopirox olamine/skin cleanser combination no.28 CICLODAN 8% KIT 3 ciclopirox/urea/camphor/menthol/eucalyptol

ciclodan 8% solution 1

ciclopirox 0.77% cream 1

ciclopirox 0.77% gel 1

ciclopirox 0.77% topical susp 1

ciclopirox 1% shampoo 1

ciclopirox 8 % kit 1

ciclopirox 8% solution 1

ciclopirox 8% treatment kit 1

clotrimazole 1% cream 1

PAGE 132 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

clotrimazole 1% solution 1

clotrimazole 10 mg troche 1

CNL 8 NAIL KIT 3 ciclopirox & nail lacquer remover, non-acetone DIFLUCAN 10 MG/ML SUSPENSION 3 fluconazole DIFLUCAN 100 MG TABLET 3 fluconazole DIFLUCAN 150 MG TABLET 3 fluconazole DIFLUCAN 200 MG TABLET 3 fluconazole DIFLUCAN 40 MG/ML SUSPENSION 3 fluconazole DIFLUCAN 50 MG TABLET 3 fluconazole

econazole nitrate 1% cream 1

ECOZA 1% FOAM 3 econazole nitrate ERAXIS(WATER DIL) 100 MG VIAL 9 anidulafungin ERAXIS(WATER DIL) 50 MG VIAL 9 anidulafungin ERTACZO 2% CREAM 3 sertaconazole nitrate EXELDERM 1% CREAM 3 sulconazole nitrate EXELDERM 1% SOLUTION 3 sulconazole nitrate EXTINA 2% FOAM 3 ketoconazole

fluconazole 10 mg/ml susp 1

fluconazole 100 mg tablet 1

fluconazole 150 mg tablet 1

PAGE 133 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

fluconazole 200 mg tablet

fluconazole 200 mg tablet 1

fluconazole 40 mg/ml susp 1

fluconazole 50 mg tablet 1

fluconazole-dext 200 mg/100 ml 7

fluconazole-dext 400 mg/200 ml 7

fluconazole-nacl 200 mg/100 ml 7

fluconazole-nacl 400 mg/200 ml 7

fluconazole-ns 100 mg/50 ml 7

fluconazole-ns 200 mg/100 ml 7

fluconazole-ns 400 mg/200 ml 7

flucytosine 250 mg capsule 1

flucytosine 500 mg capsule 1

GRIFULVIN V 500 MG TABLET 3 griseofulvin, microsize GRIS-PEG 125 MG TABLET 3 griseofulvin ultramicrosize GRIS-PEG 250 MG TABLET 3 griseofulvin ultramicrosize

griseofulvin 125 mg/5 ml susp 1

griseofulvin micro 500 mg tab 1

griseofulvin ultra 125 mg tab 1

griseofulvin ultra 250 mg tab 1

GYNAZOLE-1 CREAM 3 butoconazole nitrate

itraconazole 100 mg capsule 1 QL 90 / 365 days

JUBLIA 10% TOPICAL SOLUTION 3

PAGE 134 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS efinaconazole KERYDIN 5% TOPICAL SOLUTION 3 tavaborole

ketoconazole 2% cream 1

ketoconazole 2% foam 1

ketoconazole 2% shampoo 1

ketoconazole 200 mg tablet 1

ketodan 2% foam 1

KETODAN 2% FOAM KIT 3 ketoconazole/skin cleanser combination no.28 LAMISIL 125 MG GRANULES PACKET 3 terbinafine hcl LAMISIL 187.5 MG GRANULES PACK 3 terbinafine hcl LAMISIL 250 MG TABLET 3 QL 90 / 365 days terbinafine hcl LOPROX 0.77% GEL 3 ciclopirox LOPROX 1% SHAMPOO 3 ciclopirox LUZU 1% CREAM 3 luliconazole MENTAX 1% CREAM 3 butenafine hcl

miconazole 3 200 mg vag supp 1

MYCAMINE 100 MG VIAL 9 micafungin sodium MYCAMINE 50 MG VIAL 9 micafungin sodium NAFTIN 1% CREAM 3 naftifine hcl NAFTIN 1% GEL 3 naftifine hcl NAFTIN 2% CREAM 3 naftifine hcl NAFTIN 2% CREAM 3 naftifine hcl

PAGE 135 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS NAFTIN 2% GEL 3 naftifine hcl NAFTIN 2% GEL 3 naftifine hcl NATACYN EYE DROPS 3 natamycin NIZORAL 2% SHAMPOO 3 ketoconazole NOXAFIL 300 MG/16.7 ML VIAL 3 posaconazole NOXAFIL 40 MG/ML SUSPENSION 3 posaconazole NOXAFIL DR 100 MG TABLET 3 posaconazole

nyamyc 100,000 units/gm powder 1

nystatin 100,000 unit/gm cream 1

nystatin 100,000 unit/gm powd 1

nystatin 100,000 units/gm oint 1

nystatin 100,000 units/ml susp 1

nystatin 150,000,000 units pwd 1

nystatin 50,000,000 units pwd 1

nystatin 500,000 unit oral tab 1

nystatin 500,000 units/5 ml 1

nystatin 500,000,000 units pwd 1

nystatin vaginal tablet 1

nystop 100,000 units/gm powder 1

ONMEL 200 MG TABLET 3 itraconazole ORAVIG 50 MG BUCCAL TABLET 3 miconazole

PAGE 136 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS OXISTAT 1% CREAM 3 oxiconazole nitrate OXISTAT 1% LOTION 3 oxiconazole nitrate

pedi-dri topical powder 1

PEDIADERM AF KIT 3 nystatin/emollient combination no.54 PEDIPIROX-4 NAIL KIT ciclopirox/nail lacquer remover, non-acet/foot 3 deodorant#4 PENLAC 8% SOLUTION 3 ciclopirox SPORANOX 10 MG/ML SOLUTION 3 itraconazole SPORANOX 100 MG CAPSULE 3 QL 90 / 365 days itraconazole TERAZOL 3 80 MG SUPPOSITORY 3 terconazole TERAZOL 3 CREAM 3 QL 45 / 30 days terconazole TERAZOL 7 CREAM 3 QL 45 / 30 days terconazole

terbinafine hcl 250 mg tablet 1 QL 90 / 365 days

TERBINEX KIT 3 terbinafine hcl/hydroxypropyl chitosan

terconazole 0.4% cream 1 QL 45 / 30 days

terconazole 0.8% cream 1 QL 45 / 30 days

terconazole 80 mg suppository 1

triacetin liquid 1

VFEND 200 MG TABLET 3 voriconazole VFEND 40 MG/ML SUSPENSION 3 voriconazole VFEND 50 MG TABLET 3 voriconazole

VFEND IV 200 MG VIAL 9

PAGE 137 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS voriconazole

voriconazole 200 mg tablet 1

voriconazole 200 mg vial 7

voriconazole 40 mg/ml susp 1

voriconazole 50 mg tablet 1

XOLEGEL 2% GEL 3 ketoconazole

zazole vaginal 0.4% cream 1 QL 45 / 30 days

Antigout Agents

allopurinol 100 mg tablet 1

allopurinol 300 mg tablet 1

allopurinol sodium 500 mg vial 7

ALOPRIM 500 MG VIAL 9 allopurinol sodium COLCRYS 0.6 MG TABLET 3 colchicine KRYSTEXXA 8 MG/ML VIAL 5 pegloticase KRYSTEXXA 8 MG/ML VIAL 5 pegloticase MITIGARE 0.6 MG CAPSULE 3 colchicine

probenecid 500 mg tablet 1

probenecid-colchicine tabs 1

sulindac 150 mg tablet 1

sulindac 200 mg tablet 1

ULORIC 40 MG TABLET 3 QL 30 / 30 days febuxostat ULORIC 80 MG TABLET 3 QL 30 / 30 days febuxostat

ZYLOPRIM 100 MG TABLET 3

PAGE 138 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

allopurinol

ZYLOPRIM 300 MG TABLET 3 allopurinol Antimigraine Agents

Ergot Alkaloids

CAFERGOT TABLET 3 ergotamine tartrate/caffeine D.H.E.45 1 MG/ML AMPUL 9 dihydroergotamine mesylate

dihydroergotamine 1 mg/ml am 7

dihydroergotamine 1 mg/ml vl 7

dihydroergotamine 4 mg/ml spry 3 QL 48 / 90 days

ERGOMAR 2 MG TABLET SL 3 ergotamine tartrate

ergotamine-caffeine tablet 1

MIGRANAL NASAL SPRAY 3 QL 48 / 90 days dihydroergotamine mesylate Prophylactic

BOTOX 100 UNITS VIAL 9 onabotulinumtoxina BOTOX 200 UNITS VIAL 9 onabotulinumtoxina BOTOX COSMETIC 100 UNITS VIAL 9 onabotulinumtoxina BOTOX COSMETIC 50 UNITS VIAL 9 onabotulinumtoxina DEPAKENE 250 MG CAPSULE 3 valproic acid DEPAKENE 250 MG/5 ML SOLUTION 3 valproic acid (as sodium salt) (valproate sodium) DEPAKOTE 125 MG SPRINKLE CAP 3 divalproex sodium DEPAKOTE DR 125 MG TABLET 3 divalproex sodium DEPAKOTE DR 250 MG TABLET 3 divalproex sodium

DEPAKOTE DR 500 MG TABLET 3

PAGE 139 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

divalproex sodium

DEPAKOTE ER 250 MG TABLET 3 divalproex sodium DEPAKOTE ER 500 MG TABLET 3 divalproex sodium

divalproex sod dr 125 mg tab 1

divalproex sodium 125 mg cap 1

STAVZOR DR 125 MG CAPSULE 3 valproic acid STAVZOR DR 250 MG CAPSULE 3 valproic acid STAVZOR DR 500 MG CAPSULE 3 valproic acid

timolol maleate 10 mg tablet 1

timolol maleate 20 mg tablet 1

timolol maleate 5 mg tablet 1

TOPAMAX 100 MG TABLET 3 topiramate TOPAMAX 15 MG SPRINKLE CAP 3 topiramate TOPAMAX 200 MG TABLET 3 topiramate TOPAMAX 25 MG SPRINKLE CAP 3 topiramate TOPAMAX 25 MG TABLET 3 topiramate TOPAMAX 50 MG TABLET 3 topiramate

topiramate 100 mg tablet 1

topiramate 15 mg sprinkle cap 1

topiramate 200 mg tablet 1

PAGE 140 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

topiramate 25 mg sprinkle cap

topiramate 25 mg tablet 1

topiramate 50 mg tablet 1

TROKENDI XR 100 MG CAPSULE 3 topiramate TROKENDI XR 200 MG CAPSULE 3 topiramate TROKENDI XR 25 MG CAPSULE 3 topiramate TROKENDI XR 50 MG CAPSULE 3 topiramate

valproic acid 250 mg capsule 1

valproic acid 250 mg/5 ml soln 1

valproic acid 500 mg/10 ml sol 1

Serotonin (5-HT) 1b/1d Receptor Agonists

ALSUMA 6 MG/0.5 ML AUTO-INJECT 3 QL 9 / 90 days sumatriptan succinate AMERGE 1 MG TABLET 3 QL 54 / 90 days naratriptan hcl AMERGE 2.5 MG TABLET 3 QL 27 / 90 days naratriptan hcl AXERT 12.5 MG TABLET 3 QL 36 / 90 days almotriptan malate AXERT 6.25 MG TABLET 3 QL 54 / 90 days almotriptan malate FROVA 2.5 MG TABLET 3 QL 54 / 90 days frovatriptan succinate IMITREX 100 MG TABLET 3 QL 27 / 90 days sumatriptan succinate IMITREX 20 MG NASAL SPRAY 3 QL 36 / 90 days sumatriptan IMITREX 25 MG TABLET 3 QL 54 / 90 days sumatriptan succinate

PAGE 141 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS IMITREX 4 MG/0.5 ML CARTRIDGES 9 QL 9 / 90 days sumatriptan succinate IMITREX 4 MG/0.5 ML PEN INJECT 9 QL 9 / 90 days sumatriptan succinate IMITREX 5 MG NASAL SPRAY 3 QL 36 / 90 days sumatriptan IMITREX 50 MG TABLET 3 QL 54 / 90 days sumatriptan succinate IMITREX 6 MG/0.5 ML CARTRIDGES 9 QL 9 / 90 days sumatriptan succinate IMITREX 6 MG/0.5 ML PEN INJECT 9 QL 9 / 90 days sumatriptan succinate IMITREX 6 MG/0.5 ML VIAL 9 QL 9 / 90 days sumatriptan succinate MAXALT 10 MG TABLET 3 QL 36 / 90 days rizatriptan benzoate MAXALT 5 MG TABLET 3 QL 72 / 90 days rizatriptan benzoate MAXALT MLT 10 MG TABLET 3 QL 36 / 90 days rizatriptan benzoate MAXALT MLT 5 MG TABLET 3 QL 72 / 90 days rizatriptan benzoate

naratriptan 1 mg tablet 1 QL 54 / 90 days

naratriptan 2.5 mg tablet 1 QL 27 / 90 days

naratriptan hcl 1 mg tablet 1 QL 54 / 90 days

naratriptan hcl 2.5 mg tablet 1 QL 27 / 90 days

RELPAX 20 MG TABLET 2 QL 36 / 90 days eletriptan hbr RELPAX 40 MG TABLET 2 QL 18 / 90 days eletriptan hbr

rizatriptan 10 mg odt 1 QL 36 / 90 days

rizatriptan 10 mg tablet 1 QL 36 / 90 days

rizatriptan 5 mg odt 1 QL 72 / 90 days

PAGE 142 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

rizatriptan 5 mg tablet 1 QL 72 / 90 days

sumatriptan 20 mg nasal spray 1 QL 36 / 90 days

sumatriptan 4 mg/0.5 ml cart 7 QL 9 / 90 days

sumatriptan 4 mg/0.5 ml inject 7 QL 9 / 90 days

sumatriptan 5 mg nasal spray 1 QL 36 / 90 days

sumatriptan 6 mg/0.5 ml inject 7 QL 9 / 90 days

sumatriptan 6 mg/0.5 ml refill 7 QL 9 / 90 days

sumatriptan 6 mg/0.5 ml syrng 7 QL 9 / 90 days

sumatriptan 6 mg/0.5 ml vial 7 QL 9 / 90 days

sumatriptan succ 100 mg tablet 1 QL 27 / 90 days

sumatriptan succ 25 mg tablet 1 QL 54 / 90 days

sumatriptan succ 50 mg tablet 1 QL 54 / 90 days

SUMAVEL DOSEPRO 4 MG/0.5 ML 9 sumatriptan succinate SUMAVEL DOSEPRO 6 MG/0.5 ML 9 sumatriptan succinate TREXIMET 85-500 MG TABLET 3 sumatriptan succinate/naproxen sodium

zolmitriptan 2.5 mg odt 1 QL 36 / 90 days

zolmitriptan 2.5 mg tablet 1 QL 36 / 90 days

zolmitriptan 5 mg odt 1 QL 18 / 90 days

zolmitriptan 5 mg tablet 1 QL 18 / 90 days

PAGE 143 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

zolmitriptan 5 mg tablet 1 QL 18 / 90 days

ZOMIG 2.5 MG NASAL SPRAY 3 QL 36 / 90 days zolmitriptan ZOMIG 2.5 MG TABLET 3 QL 36 / 90 days zolmitriptan ZOMIG 5 MG NASAL SPRAY 3 QL 36 / 90 days zolmitriptan ZOMIG 5 MG TABLET 3 QL 18 / 90 days zolmitriptan ZOMIG ZMT 2.5 MG TABLET 3 QL 36 / 90 days zolmitriptan ZOMIG ZMT 5 MG TABLET 3 QL 18 / 90 days zolmitriptan Antimyasthenic Agents

Parasympathomimetics

BLOXIVERZ 10 MG/10 ML VIAL 3 neostigmine methylsulfate BLOXIVERZ 5 MG/10 ML VIAL 3 neostigmine methylsulfate ENLON-PLUS AMPUL 9 edrophonium chloride/atropine sulfate

guanidine hcl 125 mg tablet 2

MESTINON 180 MG TIMESPAN 2 pyridostigmine bromide MESTINON 60 MG TABLET 2 pyridostigmine bromide MESTINON 60 MG/5 ML SYRUP 2 pyridostigmine bromide

neostigmine 1:1,000 vial 7

neostigmine 1:2,000 vial 7

physostigmine 1 mg/ml ampul 8

PROSTIGMIN 15 MG TABLET 2 neostigmine bromide

pyridostigmine br 60 mg tablet 1

REGONOL 10 MG/2 ML AMPUL 8 pyridostigmine bromide

PAGE 144 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS Antimycobacterials

Antimycobacterials, Other

dapsone 100 mg tablet 1

dapsone 25 mg tablet 1

MYCOBUTIN 150 MG CAPSULE 3 rifabutin

rifabutin 150 mg capsule 1

Antituberculars

CAPASTAT SULFATE 1 GM VIAL 9 capreomycin sulfate

cycloserine 250 mg capsule 1

ethambutol hcl 100 mg tablet 1

ethambutol hcl 400 mg tablet 1

isonarif capsule 1

isoniazid 100 mg tablet 1

isoniazid 100 mg/ml vial 1

isoniazid 300 mg tablet 1

isoniazid 50 mg/5 ml solution 1

MYAMBUTOL 100 MG TABLET 3 ethambutol hcl MYAMBUTOL 400 MG TABLET 3 ethambutol hcl PASER GRANULES 4 GM PACKET 3 aminosalicylic acid PRIFTIN 150 MG TABLET 3 rifapentine

pyrazinamide 500 mg tablet 1

RIFADIN 150 MG CAPSULE 3 rifampin RIFADIN 300 MG CAPSULE 3 rifampin RIFADIN IV 600 MG VIAL 9 rifampin

PAGE 145 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS RIFAMATE CAPSULE rifampin/isoniazid

rifampin 150 mg capsule 1

rifampin 300 mg capsule 1

rifampin iv 600 mg vial 7

RIFATER TABLET 3 rifampin/isoniazid/pyrazinamide SEROMYCIN 250 MG CAPSULE 3 cycloserine SIRTURO 100 MG TABLET 5 bedaquiline fumarate

streptomycin sulf 1 gm vial 1

TRECATOR 250 MG TABLET 3 ethionamide Antineoplastics

Alkylating Agents

ALKERAN 2 MG TABLET 2 melphalan ALKERAN 50 MG VIAL 9 melphalan hcl BICNU 100 MG VIAL 9 carmustine BUSULFEX 60 MG/10 ML VIAL 9 busulfan

carboplatin 150 mg vial 7

carboplatin 150 mg/15 ml vial 7

carboplatin 450 mg/45 ml vial 7

carboplatin 50 mg/5 ml vial 7

PAGE 146 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

carboplatin 50 mg/5 ml vial 7

carboplatin 600 mg/60 ml vial 7

CEENU 10 MG CAPSULE 5 PA lomustine CEENU 100 MG CAPSULE 5 PA lomustine CEENU 40 MG CAPSULE 5 PA lomustine

cisplatin 100 mg/100 ml vial 7

cisplatin 200 mg/200 ml vial 7

cisplatin 50 mg/50 ml vial 7

cyclophosphamide 1 gm vial 1

cyclophosphamide 2 gm vial 1

cyclophosphamide 25 mg capsule 1

cyclophosphamide 25 mg tab 1

cyclophosphamide 50 mg capsule 1

cyclophosphamide 50 mg tablet 1

cyclophosphamide 500 mg vial 1

dacarbazine 100 mg vial 1

dacarbazine 200 mg vial 7

ELOXATIN 100 MG/20 ML VIAL 9 PA oxaliplatin ELOXATIN 200 MG/40 ML VIAL 9 PA oxaliplatin ELOXATIN 50 MG/10 ML VIAL 9 PA oxaliplatin GLIADEL WAFER 3 carmustine in polifeprosan 20

IFEX 1 GM VIAL 9

PAGE 147 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ifosfamide IFEX 3 GM VIAL 9 ifosfamide

ifosfamide 1 gm vial 7

ifosfamide 1 gm/20 ml vial 7

ifosfamide 3 gm vial 9

ifosfamide 3 gm/ 60 ml vial 7

ifosfamide-mesna kit 1

LEUKERAN 2 MG TABLET 2 chlorambucil LOMUSTINE 10 MG CAPSULE 1 PA lomustine LOMUSTINE 100 MG CAPSULE 1 PA lomustine LOMUSTINE 40 MG CAPSULE 1 PA lomustine MATULANE 50 MG CAPSULE 5 PA procarbazine hcl

melphalan hcl 50 mg vial 7

MUSTARGEN 10 MG VIAL 9 mechlorethamine hcl MYLERAN 2 MG TABLET 2 busulfan

oxaliplatin 100 mg vial 7 PA

oxaliplatin 100 mg/20 ml vial 7 PA

oxaliplatin 50 mg vial 7 PA

oxaliplatin 50 mg/10 ml vial 7 PA

TEMODAR 100 MG CAPSULE 5 PA temozolomide

PAGE 148 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS TEMODAR 100 MG CAPSULE 5 PA temozolomide TEMODAR 100 MG VIAL 5 PA temozolomide TEMODAR 140 MG CAPSULE 5 PA temozolomide TEMODAR 180 MG CAPSULE 5 PA temozolomide TEMODAR 20 MG CAPSULE 5 PA temozolomide TEMODAR 250 MG CAPSULE 5 PA temozolomide TEMODAR 5 MG CAPSULE 5 PA temozolomide

temozolomide 100 mg capsule 4 PA

temozolomide 140 mg capsule 4 PA

temozolomide 180 mg capsule 4 PA

temozolomide 20 mg capsule 4 PA

temozolomide 250 mg capsule 4 PA

temozolomide 5 mg capsule 4 PA

TREANDA 100 MG VIAL 9 bendamustine hcl TREANDA 25 MG VIAL 9 bendamustine hcl VALCHLOR 0.016% GEL 3 mechlorethamine hcl ZANOSAR 1 GM POWDER VIAL 9 streptozocin

PAGE 149 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS Antiangiogenic Agents

POMALYST 1 MG CAPSULE QL 22 / 30 days 5 pomalidomide PA

POMALYST 2 MG CAPSULE QL 22 / 30 days 5 pomalidomide PA

POMALYST 3 MG CAPSULE QL 22 / 30 days 5 pomalidomide PA

POMALYST 4 MG CAPSULE QL 22 / 30 days 5 pomalidomide PA

REVLIMID 10 MG CAPSULE 5 PA lenalidomide REVLIMID 15 MG CAPSULE 5 PA lenalidomide REVLIMID 2.5 MG CAPSULE 5 PA lenalidomide REVLIMID 20 MG CAPSULE 5 PA lenalidomide REVLIMID 25 MG CAPSULE 5 PA lenalidomide REVLIMID 5 MG CAPSULE 5 PA lenalidomide THALOMID 100 MG CAPSULE 5 PA thalidomide THALOMID 150 MG CAPSULE 5 PA thalidomide THALOMID 200 MG CAPSULE 5 PA thalidomide THALOMID 50 MG CAPSULE 5 PA thalidomide Antiestrogens/Modifiers

EMCYT 140 MG CAPSULE 2 estramustine phosphate sodium FARESTON 60 MG TABLET 2 toremifene citrate FASLODEX 250 MG/5 ML SYRINGE 5 PA fulvestrant

SOLTAMOX 10 MG/5 ML SOLN 3

PAGE 150 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS tamoxifen citrate

tamoxifen 10 mg tablet 1

tamoxifen 20 mg tablet 1

Antimetabolites

adrucil 5 gram/100 ml vial 7

adrucil 50 mg/ml vial 7

ALIMTA 100 MG VIAL 9 pemetrexed disodium ALIMTA 500 MG VIAL 9 pemetrexed disodium ARRANON 250 MG VIAL 9 nelarabine

azacitidine 100 mg vial 7

capecitabine 150 mg tablet 4 PA

capecitabine 500 mg tablet 4 PA

cladribine 10 mg/10 ml vial 7

CLOLAR 20 MG/20 ML VIAL 9 clofarabine

cytarabine 1 gm vial 7

cytarabine 100 mg vial 7

cytarabine 100 mg/5 ml vial 7

cytarabine 1000 mg/50 ml vial 7

cytarabine 2 g/20 ml vial 7

cytarabine 20 mg/ml vial 7

cytarabine 500 mg vial 7

cytarabine 500 mg/25 ml vial 7

PAGE 151 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS DACOGEN 50 MG VIAL 9 decitabine

decitabine 50 mg vial 7

DEPOCYT 50 MG/5 ML VIAL 9 cytarabine liposome/pf DROXIA 200 MG CAPSULE 3 hydroxyurea DROXIA 300 MG CAPSULE 3 hydroxyurea DROXIA 400 MG CAPSULE 3 hydroxyurea

floxuridine 500 mg vial 7

FLUDARA 50 MG VIAL 9 fludarabine phosphate

fludarabine 50 mg vial 7

fludarabine 50 mg/2 ml vial 7

fluorouracil 1,000 mg/20 ml vl 7

fluorouracil 2,500 mg/50 ml vl 7

fluorouracil 5,000 mg/100 ml 7

fluorouracil 500 mg/10 ml vial 7

FOLOTYN 20 MG/ML VIAL 9 pralatrexate FOLOTYN 40 MG/2 ML VIAL 9 pralatrexate

gemcitabine 1 gram/26.3 ml vl 9 PA

gemcitabine 2 gram/52.6 ml vl 9 PA

PAGE 152 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

gemcitabine 2 gram/52.6 ml vl PA

gemcitabine 200 mg/5.26 ml vl 9 PA

gemcitabine hcl 1 gram vial 7 PA

gemcitabine hcl 2 gram vial 7 PA

gemcitabine hcl 200 mg vial 7 PA

GEMZAR 1 GRAM VIAL 9 PA gemcitabine hcl GEMZAR 200 MG VIAL 9 PA gemcitabine hcl HYDREA 500 MG CAPSULE 3 hydroxyurea

hydroxyurea 500 mg capsule 1

mercaptopurine 50 mg tablet 1

methotrexate 1 gm vial 7

methotrexate 2.5 mg tablet 1

methotrexate 25 mg/ml vial 7

NIPENT 10 MG VIAL 9 pentostatin NIPENT 10 MG VIAL 9 pentostatin

pentostatin 10 mg vial 7

PURINETHOL 50 MG TABLET 3 mercaptopurine PURIXAN 20 MG/ML ORAL SUSP 3 mercaptopurine TABLOID 40 MG TABLET 2 thioguanine

PAGE 153 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS TREXALL 10 MG TABLET methotrexate sodium TREXALL 15 MG TABLET 3 methotrexate sodium TREXALL 5 MG TABLET 3 methotrexate sodium TREXALL 7.5 MG TABLET 3 methotrexate sodium VIDAZA 100 MG VIAL 9 azacitidine XELODA 150 MG TABLET 5 PA capecitabine XELODA 500 MG TABLET 5 PA capecitabine Antineoplastics, Other

ABRAXANE 100 MG VIAL 9 paclitaxel protein-bound

adriamycin 10 mg vial 7

adriamycin 2 mg/ml vial 7

adriamycin 20 mg vial 7

adriamycin 200 mg/100 ml vial 7

ADRIAMYCIN 50 MG VIAL 7 doxorubicin hcl ALDARA 5% CREAM 3 imiquimod ALFERON N 5 MILLION UNITS VIAL 5 interferon alfa-n3

amifostine 500 mg vial 7

BCG VACCINE (TICE STRAIN) VIAL 9 bcg live BELEODAQ 500 MG VIAL 5 belinostat

bleomycin sulfate 15 unit vial 7

bleomycin sulfate 30 unit vial 7

calcium folinate 10 mg/ml vial 9

CERUBIDINE 20 MG VIAL 9

PAGE 154 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS daunorubicin hcl COSMEGEN 0.5 MG VIAL 9 dactinomycin

dactinomycin 0.5 mg vial 7

daunorubicin 20 mg vial 7

daunorubicin 20 mg/4 ml vial 7

daunorubicin 50 mg/10 ml vial 7

DAUNOXOME 50 MG (2 MG/ML) VIAL 9 daunorubicin citrate liposomal

dexrazoxane 250 mg vial 7

dexrazoxane 500 mg vial 7

DOCEFREZ 20 MG VIAL 9 docetaxel DOCEFREZ 80 MG VIAL 9 docetaxel

docetaxel 140 mg/7 ml vial 1

docetaxel 160 mg/16 ml vial 7

docetaxel 160 mg/8 ml vial 7

docetaxel 20 mg/0.5 ml vial 7

docetaxel 20 mg/2 ml vial 7

docetaxel 20 mg/ml vial 7

docetaxel 80 mg/2 ml vial 7

docetaxel 80 mg/4 ml vial 7

docetaxel 80 mg/8 ml vial 7

DOXIL 2 MG/ML VIAL 9 doxorubicin hcl pegylated liposomal

doxorubicin 10 mg vial 7

PAGE 155 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

doxorubicin 10 mg/5 ml vial 7

doxorubicin 150 mg/75 ml vial 7

doxorubicin 20 mg/10 ml vial 7

doxorubicin 200 mg/100 ml vial 7

doxorubicin 50 mg vial 7

doxorubicin 50 mg/25 ml vial 7

doxorubicin liposome 20mg/10ml 7

doxorubicin liposome 50mg/25ml 7

ELLENCE 2 MG/ML VIAL 9 epirubicin hcl ELSPAR 10,000 UNITS VIAL 9 asparaginase

epirubicin 200 mg/100 ml vial 7

epirubicin 50 mg/25 ml vial 7

epirubicin hcl 200 mg vial 1

epirubicin hcl 50 mg vial 9

ERWINAZE 10,000 UNITS VIAL 3 asparaginase (erwinia chrysanthemi) ETHYOL 500 MG VIAL 9 amifostine crystalline

flutamide 125 mg capsule 1

FUSILEV I.V. 50 MG VIAL 9 levoleucovorin calcium HALAVEN 1 MG/2 ML VIAL 3 eribulin mesylate

PAGE 156 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS HEXALEN 50 MG CAPSULE 2 altretamine IDAMYCIN PFS 1 MG/ML VIAL 9 idarubicin hcl

idarubicin hcl 10 mg/10 ml vl 7

idarubicin hcl 20 mg/20 ml vl 7

idarubicin hcl 5 mg/5 ml vial 7

idarubicin pfs 10 mg/10 ml vl 7

imiquimod 5% cream packet 1

INTRON A 10 MILLION UNIT/ML 5 PA interferon alfa-2b,recomb. INTRON A 10 MILLION UNITS VIAL 5 PA interferon alfa-2b,recomb. INTRON A 18 MILLION UNITS VIAL 5 PA interferon alfa-2b,recomb. INTRON A 50 MILLION UNITS VIAL 5 PA interferon alfa-2b,recomb. INTRON A 6 MILLION UNIT/ML VL 5 PA interferon alfa-2b,recomb. IXEMPRA 15 MG KIT 9 ixabepilone IXEMPRA 45 MG KIT 9 ixabepilone JEVTANA 60 MG/1.5 ML KIT 5 PA cabazitaxel

leucovorin cal 500 mg/50 ml vl 7

leucovorin calcium 10 mg tab 1

leucovorin calcium 100 mg vial 7

leucovorin calcium 15 mg tab 1

leucovorin calcium 200 mg vial 7

leucovorin calcium 25 mg tab 1

leucovorin calcium 350 mg vial 7

PAGE 157 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

leucovorin calcium 5 mg tab 1

leucovorin calcium 50 mg vial 7

leucovorin calcium 500 mg vl 7

lipodox 2 mg/ml vial 7

lipodox 50 2 mg/ml vial 7

MARQIBO KIT 3 vincristine sulfate liposomal

mesna 1 gram/10 ml vial 7

mesna 100 mg/ml vial 7

MESNEX 1 GRAM/10 ML VIAL 9 mesna MESNEX 400 MG TABLET 3 mesna

mitomycin 20 mg vial 7

mitomycin 40 mg vial 7

mitomycin 5 mg vial 7

mitoxantrone 20 mg/10 ml vial 1

mitoxantrone 25 mg/12.5 ml vl 1

mitoxantrone 30 mg/15 ml vial 1

NAVELBINE 10 MG/ML VIAL 9 vinorelbine tartrate NAVELBINE 50 MG/5 ML VIAL 9 vinorelbine tartrate ONCASPAR 750 UNIT/ML VIAL 9 pegaspargase ONTAK 150 MCG/ML VIAL 9 denileukin diftitox

onxol 30 mg/5 ml vial 7 PA

paclitaxel 100 mg/16.7 ml vial 7 PA

paclitaxel 150 mg/25 ml vial 7 PA

paclitaxel 30 mg/5 ml vial 7 PA

PAGE 158 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

paclitaxel 30 mg/5 ml vial 7 PA

paclitaxel 300 mg/50 ml vial 7 PA

PHOTOFRIN 75 MG VIAL 7 porfimer sodium PROLEUKIN 22 MILLION UNIT VIAL 9 aldesleukin PROVENGE INFUSION BAG 5 PA sipuleucel-t/lactated ringers solution

SYLATRON 296 MCG 4-PACK QL 4 / 30 days 5 peginterferon alfa-2b PA

SYLATRON 296 MCG KIT QL 1 / 30 days 5 peginterferon alfa-2b PA

SYLATRON 444 MCG 4-PACK QL 1 / 30 days 5 peginterferon alfa-2b PA

SYLATRON 444 MCG KIT QL 4 / 30 days 5 peginterferon alfa-2b PA

SYLATRON 888 MCG 4-PACK QL 1 / 30 days 5 peginterferon alfa-2b PA

SYLATRON 888 MCG KIT QL 4 / 30 days 5 peginterferon alfa-2b PA

SYNRIBO 3.5 MG/ML VIAL 5 omacetaxine mepesuccinate TAXOTERE 20 MG/ML VIAL 9 docetaxel TAXOTERE 80 MG/2 ML VIAL 9 docetaxel TAXOTERE 80 MG/4 ML VIAL 9 docetaxel

teniposide 50 mg/5 ml ampule 9

THERACYS 81 MG VIAL 9 bcg live TOTECT 500 MG VIAL 9 dexrazoxane

TRELSTAR 11.25 MG SYRINGE 3

PAGE 159 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

triptorelin pamoate

TRELSTAR 22.5 MG SYRINGE 3 triptorelin pamoate TRELSTAR 22.5 MG VIAL 3 triptorelin pamoate TRELSTAR 3.75 MG SYRINGE 3 triptorelin pamoate TRELSTAR DEPOT 3.75 MG VIAL 3 triptorelin pamoate TRELSTAR LA 11.25 MG VIAL 3 triptorelin pamoate TRISENOX 10 MG/10 ML AMPULE 9 arsenic trioxide VALSTAR 40 MG/ML VIAL 8 valrubicin

vinblastine 1 mg/ml vial 1

vinblastine sulf 10 mg vial 1

vincasar pfs 1 mg/ml vial 7

vincasar pfs 2 mg/2 ml vial 7

vincristine 1 mg/ml vial 7

vincristine 2 mg/2 ml vial 7

vinorelbine 10 mg/ml vial 7

vinorelbine 50 mg/5 ml vial 7

VORAXAZE 1,000 UNIT VIAL 3 glucarpidase VUMON 50 MG/5 ML AMPULE 9 teniposide XOFIGO 1,000 KBQ/ML VIAL 3 radium-223 dichloride ZINECARD 250 MG VIAL 9 dexrazoxane

PAGE 160 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ZINECARD 500 MG VIAL dexrazoxane ZYCLARA 2.5% CREAM PUMP 3 imiquimod ZYCLARA 3.75% CREAM 3 imiquimod ZYCLARA 3.75% CREAM PUMP 3 imiquimod Aromatase Inhibitors, 3rd Generation

anastrozole 1 mg tablet 1 QL 30 / 30 days

ARIMIDEX 1 MG TABLET 3 QL 30 / 30 days anastrozole AROMASIN 25 MG TABLET 3 exemestane

exemestane 25 mg tablet 1

FEMARA 2.5 MG TABLET 3 letrozole

letrozole 2.5 mg tablet 1

Enzyme Inhibitors

BOSULIF 100 MG TABLET QL 60 / 30 days 5 bosutinib PA

BOSULIF 500 MG TABLET QL 30 / 30 days 5 bosutinib PA

CAMPTOSAR 100 MG/5 ML VIAL 9 irinotecan hcl CAMPTOSAR 300 MG/15 ML VIAL 9 irinotecan hcl CAMPTOSAR 40 MG/2 ML VIAL 9 irinotecan hcl ETOPOPHOS 100 MG VIAL 9 etoposide phosphate

etoposide 1,000 mg/50 ml vial 7

PAGE 161 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

etoposide 100 mg/5 ml vial 7

etoposide 50 mg capsule 1

etoposide 500 mg/25 ml vial 7

GILOTRIF 20 MG TABLET 3 afatinib dimaleate GILOTRIF 30 MG TABLET 3 afatinib dimaleate GILOTRIF 40 MG TABLET 3 afatinib dimaleate HYCAMTIN 0.25 MG CAPSULE 5 PA topotecan hcl HYCAMTIN 1 MG CAPSULE 5 PA topotecan hcl HYCAMTIN 4 MG VIAL 9 topotecan hcl IMBRUVICA 140 MG CAPSULE 3 ibrutinib

INLYTA 1 MG TABLET QL 120 / 30 days 5 axitinib PA

INLYTA 5 MG TABLET QL 120 / 30 days 5 axitinib PA

irinotecan hcl 100 mg/5 ml vl 7

irinotecan hcl 40 mg/2 ml vial 7

irinotecan hcl 500 mg/25 ml vl 7

JAKAFI 10 MG TABLET 5 QL 60 / 30 days ruxolitinib phosphate JAKAFI 15 MG TABLET 5 QL 60 / 30 days ruxolitinib phosphate JAKAFI 20 MG TABLET 5 QL 60 / 30 days ruxolitinib phosphate JAKAFI 25 MG TABLET 5 QL 60 / 30 days ruxolitinib phosphate

JAKAFI 5 MG TABLET 5 QL 60 / 30 days

PAGE 162 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ruxolitinib phosphate MEKINIST 0.5 MG TABLET 3 trametinib dimethyl sulfoxide MEKINIST 2 MG TABLET 3 trametinib dimethyl sulfoxide TAFINLAR 50 MG CAPSULE 3 dabrafenib mesylate TAFINLAR 75 MG CAPSULE 3 dabrafenib mesylate

toposar 1,000 mg/50 ml vial 7

toposar 100 mg/5 ml vial 7

toposar 500 mg/25 ml vial 7

topotecan hcl 4 mg vial 7

topotecan hcl 4 mg/4 ml vial 9

VOTRIENT 200 MG TABLET 5 pazopanib hcl

ZELBORAF 240 MG TABLET QL 240 / 30 days 5 vemurafenib PA

ZYTIGA 250 MG TABLET QL 120 / 30 days 5 abiraterone acetate PA

Molecular Target Inhibitors

AFINITOR 10 MG TABLET QL 30 / 30 days 5 everolimus PA

AFINITOR 2.5 MG TABLET QL 30 / 30 days 5 everolimus PA

AFINITOR 5 MG TABLET QL 30 / 30 days 5 everolimus PA

AFINITOR 7.5 MG TABLET QL 30 / 30 days 5 everolimus PA

AFINITOR DISPERZ 2 MG TABLET QL 30 / 30 days 5 everolimus

PAGE 163 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

AFINITOR DISPERZ 3 MG TABLET QL 30 / 30 days 5 everolimus PA

AFINITOR DISPERZ 5 MG TABLET QL 30 / 30 days 5 everolimus PA

CAPRELSA 100 MG TABLET 5 QL 60 / 30 days vandetanib CAPRELSA 300 MG TABLET 5 QL 30 / 30 days vandetanib

COMETRIQ 100 MG DAILY-DOSE PK QL 60 / 30 days 5 cabozantinib s-malate PA

COMETRIQ 140 MG DAILY-DOSE PK QL 120 / 30 days 5 cabozantinib s-malate PA

COMETRIQ 60 MG DAILY-DOSE PACK QL 90 / 30 days 5 cabozantinib s-malate PA

ERIVEDGE 150 MG CAPSULE QL 30 / 30 days 5 vismodegib PA

GLEEVEC 100 MG TABLET 5 PA imatinib mesylate GLEEVEC 400 MG TABLET 5 PA imatinib mesylate HERCEPTIN 440 MG VIAL 9 PA trastuzumab ICLUSIG 15 MG TABLET 5 QL 30 / 30 days ponatinib hcl ICLUSIG 15 MG TABLET 5 QL 30 / 30 days ponatinib hcl ICLUSIG 45 MG TABLET 5 QL 30 / 30 days ponatinib hcl ISTODAX 10 MG VIAL 9 romidepsin KADCYLA 100 MG VIAL 3 ado-trastuzumab emtansine KADCYLA 160 MG VIAL 3 ado-trastuzumab emtansine

KYPROLIS 60 MG VIAL 3

PAGE 164 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS carfilzomib NEXAVAR 200 MG TABLET 5 PA sorafenib tosylate SPRYCEL 100 MG TABLET 5 PA dasatinib SPRYCEL 140 MG TABLET 5 PA dasatinib SPRYCEL 20 MG TABLET 5 PA dasatinib SPRYCEL 50 MG TABLET 5 PA dasatinib SPRYCEL 70 MG TABLET 5 PA dasatinib SPRYCEL 80 MG TABLET 5 PA dasatinib

STIVARGA 40 MG TABLET QL 252 / 84 days 5 regorafenib PA

SUTENT 12.5 MG CAPSULE 5 PA sunitinib malate SUTENT 25 MG CAPSULE 5 PA sunitinib malate SUTENT 37.5 MG CAPSULE 5 PA sunitinib malate SUTENT 50 MG CAPSULE 5 PA sunitinib malate TARCEVA 100 MG TABLET 5 PA erlotinib hcl TARCEVA 150 MG TABLET 5 PA erlotinib hcl TARCEVA 25 MG TABLET 5 PA erlotinib hcl TASIGNA 150 MG CAPSULE 5 PA nilotinib hcl TASIGNA 200 MG CAPSULE 5 PA nilotinib hcl TORISEL 25 MG KIT 3 temsirolimus TYKERB 250 MG TABLET 5 PA lapatinib ditosylate

PAGE 165 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS VECTIBIX 100 MG/5 ML VIAL panitumumab VECTIBIX 400 MG/20 ML VIAL 9 panitumumab VELCADE 3.5 MG VIAL 8 bortezomib XALKORI 200 MG CAPSULE 9 crizotinib XALKORI 250 MG CAPSULE 9 crizotinib ZALTRAP 100 MG/4 ML VIAL 3 ziv-aflibercept ZALTRAP 200 MG/8 ML VIAL 3 ziv-aflibercept ZOLINZA 100 MG CAPSULE 5 PA vorinostat ZYDELIG 100 MG TABLET 3 idelalisib ZYDELIG 150 MG TABLET 3 idelalisib ZYKADIA 150 MG CAPSULE 3 ceritinib Monoclonal Antibodies

ADCETRIS 50 MG VIAL 3 brentuximab vedotin ARZERRA 1,000 MG/50 ML VIAL 3 ofatumumab ARZERRA 100 MG/5 ML VIAL 3 ofatumumab AVASTIN 100 MG/4 ML VIAL 9 bevacizumab AVASTIN 400 MG/16 ML VIAL 9 bevacizumab BEXXAR 131 IODINE DOSIMETRIC 9 tositumomab iodine-131 (with maltose) BEXXAR 131 IODINE THERAPEUTIC 9 tositumomab iodine-131 (with maltose) BEXXAR 14 MG/ML DOSIMETRIC 9 tositumomab (with maltose)

BEXXAR 14 MG/ML THERAPEUTIC 9

PAGE 166 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS tositumomab (with maltose) CAMPATH 30 MG/ML VIAL 9 alemtuzumab CYRAMZA 100 MG/10 ML VIAL 3 ramucirumab CYRAMZA 500 MG/50 ML VIAL 3 ramucirumab ERBITUX 100 MG/50 ML VIAL 9 cetuximab ERBITUX 200 MG/100 ML VIAL 9 cetuximab GAZYVA 1,000 MG/40 ML VIAL 3 obinutuzumab KEYTRUDA 50 MG VIAL 5 pembrolizumab PERJETA 420 MG/14 ML VIAL 3 pertuzumab PROLIA 60 MG/ML SYRINGE 5 PA denosumab RITUXAN 10 MG/ML VIAL 9 PA rituximab XGEVA 120 MG/1.7 ML VIAL 9 PA denosumab YERVOY 200 MG/40 ML VIAL 3 ipilimumab YERVOY 50 MG/10 ML VIAL 3 ipilimumab ZEVALIN Y-90 VIAL kit for prep yttrium-90/ibritumomab tiuxetan/albumin 3 human Retinoids

PANRETIN 0.1% GEL 2 alitretinoin TARGRETIN 1% GEL 5 PA bexarotene TARGRETIN 75 MG CAPSULE 5 PA bexarotene TARGRETIN 75 MG SOFTGEL 5 PA bexarotene

TRETIN-X 0.075% CREAM 3 ST

PAGE 167 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS tretinoin

tretinoin 10 mg capsule 4 PA

Antiparasitics

Anthelmintics

ALBENZA 200 MG TABLET 3 albendazole BILTRICIDE 600 MG TABLET 3 praziquantel

spinosad 0.9% topical susp 1

STROMECTOL 3 MG TABLET 3 ivermectin ULESFIA 5% LOTION 2 QL 1362 / 30 days benzyl alcohol Antiprotozoals

ALINIA 100 MG/5 ML SUSPENSION 3 nitazoxanide ALINIA 500 MG TABLET 3 nitazoxanide

atovaquone 750 mg/5 ml susp 1

atovaquone-proguanil 250-100 1

atovaquone-proguanil 62.5-25 1

chloroquine ph 250 mg tablet 1

chloroquine ph 500 mg tablet 1

CLEOCIN HCL 150 MG CAPSULE 3 clindamycin hcl CLEOCIN HCL 300 MG CAPSULE 3 clindamycin hcl

clindamycin hcl 150 mg capsule 1

clindamycin hcl 300 mg capsule 1

COARTEM TABLETS 3 QL 72 / 90 days artemether/lumefantrine

PAGE 168 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS DARAPRIM 25 MG TABLET pyrimethamine

hydroxychloroquine 200 mg tab 1

MALARONE 250-100 MG TABLET 3 atovaquone/proguanil hcl MALARONE 62.5-25 MG PED TAB 3 atovaquone/proguanil hcl

mefloquine hcl 250 mg tablet 1

MEPRON 750 MG/5 ML SUSPENSION 3 atovaquone NEBUPENT 300 MG INHAL POWDER 3 QL 1 / 30 days pentamidine isethionate PENTAM 300 VIAL 9 pentamidine isethionate PLAQUENIL 200 MG TABLET 3 hydroxychloroquine sulfate PLAQUENIL 200 MG TABLET 3 hydroxychloroquine sulfate

primaquine 26.3 mg tablet 1

QUALAQUIN 324 MG CAPSULE 3 quinine sulfate QUALAQUIN 324 MG CAPSULE 3 quinine sulfate

quinine sulfate 324 mg capsule 1

YODOXIN 210 MG TABLET 3 iodoquinol YODOXIN 650 MG TABLET 3 iodoquinol Pediculicides/Scabicides

EURAX 10% CREAM 3 crotamiton EURAX 10% LOTION 3 crotamiton

lindane 1% lotion 1

lindane 1% shampoo 1

PAGE 169 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

malathion 0.5% lotion

malathion 0.5% lotion 1

OVIDE 0.5% LOTION 3 malathion OVIDE 0.5% LOTION 3 malathion

permethrin 5% cream 1

SKLICE 0.5% LOTION 3 QL 120 / 7 days ivermectin ULESFIA 5% LOTION 2 QL 1362 / 30 days benzyl alcohol Antiparkinson Agents

Anticholinergics

benztropine 2 mg/2 ml ampule 7

benztropine 2 mg/2 ml vial 7

benztropine mes 0.5 mg tab 1

benztropine mes 1 mg tablet 1

benztropine mes 2 mg tablet 1

COGENTIN 2 MG/2 ML AMPULE 9 benztropine mesylate

trihexyphenidyl 2 mg tablet 1

trihexyphenidyl 2 mg/5 ml elx 1

trihexyphenidyl 5 mg tablet 1

Antiparkinson Agents, Other

amantadine 100 mg capsule 1

amantadine 100 mg tablet 1

amantadine 50 mg/5 ml syrup 1

carbidopa-levodopa-enta 100 mg 1

PAGE 170 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

carbidopa-levodopa-enta 100 mg 1

carbidopa-levodopa-enta 125 mg 1

carbidopa-levodopa-enta 150 mg 1

carbidopa-levodopa-enta 200 mg 1

carbidopa-levodopa-enta 50 mg 1

carbidopa-levodopa-enta 75 mg 1

COMTAN 200 MG TABLET 3 entacapone

entacapone 200 mg tablet 1

STALEVO 100 TABLET 2 carbidopa/levodopa/entacapone STALEVO 125 TABLET 2 carbidopa/levodopa/entacapone STALEVO 150 TABLET 2 carbidopa/levodopa/entacapone STALEVO 200 TABLET 2 carbidopa/levodopa/entacapone STALEVO 50 TABLET 2 carbidopa/levodopa/entacapone STALEVO 75 TABLET 2 carbidopa/levodopa/entacapone TASMAR 100 MG TABLET 2 QL 90 / 30 days tolcapone Dopamine Agonists

APOKYN 30 MG/3 ML CARTRIDGE 5 apomorphine hcl

PAGE 171 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

bromocriptine 2.5 mg tablet 1

bromocriptine 5 mg capsule 1

MIRAPEX 0.125 MG TABLET 3 QL 90 / 30 days pramipexole di-hcl MIRAPEX 0.25 MG TABLET 3 QL 90 / 30 days pramipexole di-hcl MIRAPEX 0.5 MG TABLET 3 QL 90 / 30 days pramipexole di-hcl MIRAPEX 0.75 MG TABLET 3 QL 90 / 30 days pramipexole di-hcl MIRAPEX 1 MG TABLET 3 QL 90 / 30 days pramipexole di-hcl MIRAPEX 1.5 MG TABLET 3 QL 90 / 30 days pramipexole di-hcl MIRAPEX ER 0.375 MG TABLET 3 QL 30 / 30 days pramipexole di-hcl MIRAPEX ER 0.75 MG TABLET 3 QL 30 / 30 days pramipexole di-hcl MIRAPEX ER 1.5 MG TABLET 3 QL 30 / 30 days pramipexole di-hcl MIRAPEX ER 2.25 MG TABLET 3 QL 30 / 30 days pramipexole di-hcl MIRAPEX ER 3 MG TABLET 3 QL 30 / 30 days pramipexole di-hcl MIRAPEX ER 3.75 MG TABLET 3 QL 30 / 30 days pramipexole di-hcl MIRAPEX ER 4.5 MG TABLET 3 QL 30 / 30 days pramipexole di-hcl NEUPRO 1 MG/24 HR PATCH 3 QL 30 / 30 days rotigotine NEUPRO 2 MG/24 HR PATCH 3 QL 30 / 30 days rotigotine NEUPRO 3 MG/24 HR PATCH 3 QL 30 / 30 days rotigotine NEUPRO 4 MG/24 HR PATCH 3 QL 30 / 30 days rotigotine NEUPRO 6 MG/24 HR PATCH 3 QL 30 / 30 days rotigotine NEUPRO 8 MG/24 HR PATCH 3 QL 30 / 30 days rotigotine

PAGE 172 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS PARLODEL 2.5 MG TABLET 3 bromocriptine mesylate PARLODEL 5 MG CAPSULE 3 bromocriptine mesylate

pramipexole 0.125 mg tablet 1 QL 90 / 30 days

pramipexole 0.25 mg tablet 1 QL 90 / 30 days

pramipexole 0.5 mg tablet 1 QL 90 / 30 days

pramipexole 0.75 mg tablet 1 QL 90 / 30 days

pramipexole 1 mg tablet 1 QL 90 / 30 days

pramipexole 1.5 mg tablet 1 QL 90 / 30 days

REQUIP 0.25 MG TABLET 3 ropinirole hcl REQUIP 0.5 MG TABLET 3 ropinirole hcl REQUIP 1 MG TABLET 3 ropinirole hcl REQUIP 2 MG TABLET 3 ropinirole hcl REQUIP 3 MG TABLET 3 ropinirole hcl REQUIP 4 MG TABLET 3 ropinirole hcl REQUIP 5 MG TABLET 3 ropinirole hcl REQUIP XL 12 MG TABLET 3 QL 30 / 30 days ropinirole hcl REQUIP XL 2 MG TABLET 3 QL 30 / 30 days ropinirole hcl REQUIP XL 4 MG TABLET 3 QL 30 / 30 days ropinirole hcl REQUIP XL 6 MG TABLET 3 QL 30 / 30 days ropinirole hcl REQUIP XL 8 MG TABLET 3 QL 30 / 30 days ropinirole hcl

ropinirole hcl 0.25 mg tablet 1

PAGE 173 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

ropinirole hcl 0.25 mg tablet

ropinirole hcl 0.5 mg tablet 1

ropinirole hcl 1 mg tablet 1

ropinirole hcl 2 mg tablet 1

ropinirole hcl 3 mg tablet 1

ropinirole hcl 4 mg tablet 1

ropinirole hcl 5 mg tablet 1

ropinirole hcl er 12 mg tablet 1 QL 30 / 30 days

ropinirole hcl er 2 mg tablet 1 QL 30 / 30 days

ropinirole hcl er 4 mg tablet 1 QL 30 / 30 days

ropinirole hcl er 6 mg tablet 1 QL 30 / 30 days

ropinirole hcl er 8 mg tablet 1 QL 30 / 30 days

Dopamine Precursors/ L-Amino Acid Decarboxylase Inhibitors

carbidopa 25 mg tablet 1

carbidopa-levo 10-100 mg odt 1

carbidopa-levo 25-100 mg odt 1

carbidopa-levo 25-250 mg odt 1

carbidopa-levo er 25-100 tab 1

carbidopa-levo er 50-200 tab 1

carbidopa-levodopa 10-100 tab 1

carbidopa-levodopa 25-100 tab 1

carbidopa-levodopa 25-250 tab 1

PAGE 174 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS LODOSYN 25 MG TABLET 2 carbidopa PARCOPA 10 MG-100 MG ODT 3 carbidopa/levodopa PARCOPA 25 MG-100 MG ODT 3 carbidopa/levodopa PARCOPA 25 MG-250 MG ODT 3 carbidopa/levodopa SINEMET 10-100 MG TABLET 3 carbidopa/levodopa SINEMET 25-100 MG TABLET 3 carbidopa/levodopa SINEMET 25-250 MG TABLET 3 carbidopa/levodopa SINEMET CR 25-100 TABLET 3 carbidopa/levodopa SINEMET CR 50-200 TABLET 3 carbidopa/levodopa Monoamine Oxidase B (MAO-B) Inhibitors

AZILECT 0.5 MG TABLET 3 rasagiline mesylate AZILECT 1 MG TABLET 3 rasagiline mesylate ELDEPRYL 5 MG CAPSULE 3 selegiline hcl

selegiline hcl 5 mg capsule 1

selegiline hcl 5 mg tablet 1

ZELAPAR 1.25 MG ODT TABLET 3 selegiline hcl ZELAPAR 1.25 MG ODT TABLET 3 selegiline hcl Antipsychotics

1st Generation/Typical

ADASUVE 10 MG INHALATION POWD 3 loxapine

chlorpromazine 10 mg tablet 1

PAGE 175 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

chlorpromazine 100 mg tablet

chlorpromazine 200 mg tablet 1

chlorpromazine 25 mg tablet 1

chlorpromazine 25 mg/ml amp 1

chlorpromazine 50 mg tablet 1

fluphenazine 1 mg tablet 1

fluphenazine 10 mg tablet 1

fluphenazine 2.5 mg tablet 1

fluphenazine 2.5 mg/5 ml elix 1

fluphenazine 2.5 mg/ml vial 1

fluphenazine 5 mg tablet 1

fluphenazine 5 mg/ml conc 1

HALDOL 5 MG/ML AMPUL 9 haloperidol lactate HALDOL DECANOATE 100 AMPUL 9 haloperidol decanoate HALDOL DECANOATE 50 AMPUL 9 haloperidol decanoate

haloperidol 0.5 mg tablet 1

haloperidol 1 mg tablet 1

haloperidol 10 mg tablet 1

haloperidol 2 mg tablet 1

haloperidol 20 mg tablet 1

haloperidol 5 mg tablet 1

haloperidol 5 mg/ml ampul 7

haloperidol dec 100 mg/ml amp 7

haloperidol dec 100 mg/ml vial 7

PAGE 176 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

haloperidol dec 100 mg/ml vial 7

haloperidol dec 50 mg/ml vial 7

haloperidol decan 50 mg/ml amp 7

haloperidol lac 2 mg/ml conc 1

haloperidol lac 5 mg/ml vial 7

haloperidol lac 50 mg/10 ml vl 7

loxapine 10 mg capsule 1

loxapine 25 mg capsule 1

loxapine 5 mg capsule 1

loxapine 50 mg capsule 1

LOXITANE 10 MG CAPSULE 3 loxapine succinate LOXITANE 25 MG CAPSULE 3 loxapine succinate LOXITANE 5 MG CAPSULE 3 loxapine succinate LOXITANE 50 MG CAPSULE 3 loxapine succinate ORAP 1 MG TABLET 2 pimozide ORAP 2 MG TABLET 2 pimozide

perphenazine 16 mg tablet 1

perphenazine 2 mg tablet 1

perphenazine 4 mg tablet 1

perphenazine 8 mg tablet 1

prochlorperazine 10 mg tab 1

prochlorperazine 5 mg tablet 1

thioridazine 10 mg tablet 1

PAGE 177 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

thioridazine 100 mg tablet 1

thioridazine 25 mg tablet 1

thioridazine 50 mg tablet 1

thiothixene 1 mg capsule 1

thiothixene 10 mg capsule 1

thiothixene 2 mg capsule 1

thiothixene 5 mg capsule 1

trifluoperazine 1 mg tablet 1

trifluoperazine 10 mg tablet 1

trifluoperazine 2 mg tablet 1

trifluoperazine 5 mg tablet 1

2nd Generation/Atypical

3 QL

PAGE 178 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS FANAPT 10 MG TABLET 60 / 30 days iloperidone FANAPT 12 MG TABLET 3 QL 60 / 30 days iloperidone FANAPT 2 MG TABLET 3 QL 60 / 30 days iloperidone FANAPT 4 MG TABLET 3 QL 60 / 30 days iloperidone FANAPT 6 MG TABLET 3 QL 60 / 30 days iloperidone FANAPT 8 MG TABLET 3 QL 60 / 30 days iloperidone FANAPT TITRATION PACK 3 QL 60 / 30 days iloperidone GEODON 20 MG CAPSULE 3 QL 60 / 30 days ziprasidone hcl GEODON 20 MG/ML VIAL 8 ziprasidone mesylate GEODON 20 MG/ML VIAL 8 ziprasidone mesylate GEODON 40 MG CAPSULE 3 QL 60 / 30 days ziprasidone hcl GEODON 60 MG CAPSULE 3 QL 60 / 30 days ziprasidone hcl GEODON 80 MG CAPSULE 3 QL 60 / 30 days ziprasidone hcl INVEGA ER 1.5 MG TABLET 3 QL 30 / 30 days paliperidone INVEGA ER 3 MG TABLET 3 QL 30 / 30 days paliperidone INVEGA ER 6 MG TABLET 3 QL 60 / 30 days paliperidone INVEGA ER 9 MG TABLET 3 QL 30 / 30 days paliperidone INVEGA SUSTENNA 117 MG PREF SY 9 paliperidone palmitate INVEGA SUSTENNA 156 MG PREF SY 9 paliperidone palmitate INVEGA SUSTENNA 234 MG PREF SY 9 paliperidone palmitate

PAGE 179 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS INVEGA SUSTENNA 39 MG PREF SYR paliperidone palmitate INVEGA SUSTENNA 78 MG PREF SYR 9 paliperidone palmitate LATUDA 120 MG TABLET 3 QL 30 / 30 days lurasidone hcl LATUDA 20 MG TABLET 3 QL 30 / 30 days lurasidone hcl LATUDA 40 MG TABLET 3 QL 30 / 30 days lurasidone hcl LATUDA 60 MG TABLET 3 QL 30 / 30 days lurasidone hcl LATUDA 60 MG TABLET 3 QL 30 / 30 days lurasidone hcl LATUDA 80 MG TABLET 3 QL 30 / 30 days lurasidone hcl

olanzapine 10 mg tablet 1 QL 30 / 30 days

olanzapine 10 mg vial 7

olanzapine 15 mg tablet 1 QL 30 / 30 days

olanzapine 2.5 mg tablet 1 QL 30 / 30 days

olanzapine 20 mg tablet 1 QL 30 / 30 days

olanzapine 5 mg tablet 1 QL 30 / 30 days

olanzapine 7.5 mg tablet 1 QL 30 / 30 days

olanzapine odt 10 mg tablet 1 QL 30 / 30 days

olanzapine odt 15 mg tablet 1 QL 30 / 30 days

PAGE 180 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

olanzapine odt 15 mg tablet QL 30 / 30 days

olanzapine odt 20 mg tablet 1 QL 30 / 30 days

olanzapine odt 5 mg tablet 1 QL 30 / 30 days

quetiapine fumarate 100 mg tab 1 QL 60 / 30 days

quetiapine fumarate 200 mg tab 1 QL 60 / 30 days

quetiapine fumarate 25 mg tab 1 QL 60 / 30 days

quetiapine fumarate 300 mg tab 1 QL 60 / 30 days

quetiapine fumarate 400 mg tab 1 QL 60 / 30 days

quetiapine fumarate 50 mg tab 1 QL 60 / 30 days

RISPERDAL 0.25 MG TABLET 3 QL 60 / 30 days risperidone RISPERDAL 0.5 MG TABLET 3 QL 60 / 30 days risperidone RISPERDAL 1 MG TABLET 3 QL 60 / 30 days risperidone RISPERDAL 1 MG/ML SOLUTION 3 risperidone RISPERDAL 2 MG TABLET 3 QL 60 / 30 days risperidone RISPERDAL 3 MG TABLET 3 QL 60 / 30 days risperidone RISPERDAL 4 MG TABLET 3 QL 120 / 30 days risperidone

RISPERDAL CONSTA 12.5 MG SYR 9

PAGE 181 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS risperidone microspheres RISPERDAL CONSTA 25 MG SYR 9 risperidone microspheres RISPERDAL CONSTA 37.5 MG SYR 9 risperidone microspheres RISPERDAL CONSTA 50 MG SYR 9 risperidone microspheres RISPERDAL M-TAB 0.5 MG ODT 3 QL 60 / 30 days risperidone RISPERDAL M-TAB 1 MG ODT 3 QL 60 / 30 days risperidone RISPERDAL M-TAB 2 MG ODT 3 QL 60 / 30 days risperidone RISPERDAL M-TAB 3 MG ODT 3 QL 60 / 30 days risperidone RISPERDAL M-TAB 4 MG ODT 3 QL 120 / 30 days risperidone

risperidone 0.25 mg odt 1

risperidone 0.25 mg tablet 1 QL 60 / 30 days

risperidone 0.5 mg odt 1 QL 60 / 30 days

risperidone 0.5 mg tablet 1 QL 60 / 30 days

risperidone 1 mg odt 1 QL 60 / 30 days

risperidone 1 mg tablet 1 QL 60 / 30 days

risperidone 1 mg/ml solution 1

risperidone 2 mg odt 1 QL 60 / 30 days

risperidone 2 mg tablet 1 QL 60 / 30 days

risperidone 3 mg odt 1 QL 60 / 30 days

risperidone 3 mg tablet 1 QL 60 / 30 days

PAGE 182 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

risperidone 3 mg tablet 1 QL 60 / 30 days

risperidone 4 mg odt 1 QL 120 / 30 days

risperidone 4 mg tablet 1 QL 120 / 30 days

SAPHRIS 10 MG TAB SL BLK CHERY 3 QL 60 / 30 days asenapine maleate SAPHRIS 10 MG TAB SL BLK CHERY 3 QL 60 / 30 days asenapine maleate SAPHRIS 10 MG TAB SUBLINGUAL 3 QL 60 / 30 days asenapine maleate SAPHRIS 5 MG TAB SL BLK CHERRY 3 QL 60 / 30 days asenapine maleate SAPHRIS 5 MG TABLET SUBLINGUAL 3 QL 60 / 30 days asenapine maleate SEROQUEL 100 MG TABLET 3 QL 60 / 30 days quetiapine fumarate SEROQUEL 200 MG TABLET 3 QL 60 / 30 days quetiapine fumarate SEROQUEL 25 MG TABLET 3 QL 60 / 30 days quetiapine fumarate SEROQUEL 300 MG TABLET 3 QL 60 / 30 days quetiapine fumarate SEROQUEL 400 MG TABLET 3 QL 60 / 30 days quetiapine fumarate SEROQUEL 50 MG TABLET 3 QL 60 / 30 days quetiapine fumarate SEROQUEL XR 150 MG TABLET 2 QL 30 / 30 days quetiapine fumarate SEROQUEL XR 200 MG TABLET 2 QL 30 / 30 days quetiapine fumarate SEROQUEL XR 300 MG TABLET 2 QL 60 / 30 days quetiapine fumarate SEROQUEL XR 400 MG TABLET 2 QL 60 / 30 days quetiapine fumarate SEROQUEL XR 50 MG TABLET 2 QL 30 / 30 days quetiapine fumarate

ziprasidone hcl 20 mg capsule 1 QL 60 / 30 days

PAGE 183 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

ziprasidone hcl 20 mg capsule 1 QL 60 / 30 days

ziprasidone hcl 40 mg capsule 1 QL 60 / 30 days

ziprasidone hcl 60 mg capsule 1 QL 60 / 30 days

ziprasidone hcl 80 mg capsule 1 QL 60 / 30 days

ZYPREXA 10 MG TABLET 2 QL 30 / 30 days olanzapine ZYPREXA 10 MG VIAL 9 olanzapine ZYPREXA 15 MG TABLET 2 QL 30 / 30 days olanzapine ZYPREXA 2.5 MG TABLET 2 QL 30 / 30 days olanzapine ZYPREXA 20 MG TABLET 2 QL 30 / 30 days olanzapine ZYPREXA 5 MG TABLET 2 QL 30 / 30 days olanzapine ZYPREXA 7.5 MG TABLET 2 QL 30 / 30 days olanzapine

ZYPREXA RELPREVV 210 MG VIAL QL 2 / 30 days 9 olanzapine pamoate PA

ZYPREXA RELPREVV 300 MG VIAL QL 2 / 30 days 9 olanzapine pamoate PA

ZYPREXA RELPREVV 405 MG VIAL QL 1 / 30 days 9 olanzapine pamoate PA

ZYPREXA ZYDIS 10 MG TABLET 2 QL 30 / 30 days olanzapine ZYPREXA ZYDIS 15 MG TABLET 2 QL 30 / 30 days olanzapine ZYPREXA ZYDIS 20 MG TABLET 2 QL 30 / 30 days olanzapine ZYPREXA ZYDIS 5 MG TABLET 2 QL 30 / 30 days olanzapine

PAGE 184 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS Treatment-Resistant

clozapine 100 mg tablet 1 QL 120 / 30 days

clozapine 200 mg tablet 1 QL 120 / 30 days

clozapine 25 mg tablet 1 QL 120 / 30 days

clozapine 50 mg tablet 1 QL 120 / 30 days

clozapine odt 100 mg tablet 3 QL 120 / 30 days

clozapine odt 12.5 mg tablet 3 QL 120 / 30 days

clozapine odt 25 mg tablet 3 QL 120 / 30 days

CLOZARIL 100 MG TABLET 3 QL 120 / 30 days clozapine CLOZARIL 25 MG TABLET 3 QL 120 / 30 days clozapine FAZACLO 100 MG ODT 3 QL 120 / 30 days clozapine FAZACLO 12.5 MG ODT 3 QL 120 / 30 days clozapine FAZACLO 150 MG ODT 3 clozapine FAZACLO 200 MG ODT 3 clozapine FAZACLO 25 MG ODT 3 QL 120 / 30 days clozapine VERSACLOZ 50 MG/ML SUSPENSION 3 clozapine Antispasticity Agents

baclofen 10 mg tablet 1

baclofen 20 mg tablet 1

BOTOX 100 UNITS VIAL 9 onabotulinumtoxina BOTOX 200 UNITS VIAL 9 onabotulinumtoxina BOTOX COSMETIC 100 UNITS VIAL 9 onabotulinumtoxina BOTOX COSMETIC 50 UNITS VIAL 9 onabotulinumtoxina

PAGE 185 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS COMFORT PAC-TIZANIDINE KIT 3 tizanidine hcl/irritants counter-irritants combination no.2 DANTRIUM 100 MG CAPSULE 3 dantrolene sodium DANTRIUM 20 MG VIAL 9 dantrolene sodium DANTRIUM 25 MG CAPSULE 3 dantrolene sodium DANTRIUM 50 MG CAPSULE 3 dantrolene sodium

dantrolene sodium 100 mg cap 1

dantrolene sodium 25 mg cap 1

dantrolene sodium 50 mg cap 1

GABLOFEN 10,000 MCG/20 ML SYRG 5 PA baclofen GABLOFEN 10,000 MCG/20 ML VIAL 5 PA baclofen GABLOFEN 20,000 MCG/20 ML SYRG 9 PA baclofen GABLOFEN 20,000 MCG/20 ML VIAL 9 PA baclofen GABLOFEN 40,000 MCG/20 ML SYRG 5 PA baclofen GABLOFEN 40,000 MCG/20 ML VIAL 5 PA baclofen GABLOFEN 50 MCG/ML SYRINGE 5 PA baclofen LIORESAL IT 0.05 MG/1 ML AMP 9 baclofen LIORESAL IT 10 MG/20 ML KIT 9 baclofen LIORESAL IT 10 MG/5 ML KIT 9 baclofen LIORESAL IT 40 MG/20 ML KIT 9 baclofen

MYRBETRIQ ER 25 MG TABLET QL 30 / 30 days 3 mirabegron ST

MYRBETRIQ ER 50 MG TABLET 3 QL 30 / 30 days

PAGE 186 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

mirabegron ST

revonto 20 mg vial 7

tizanidine hcl 2 mg capsule 1

tizanidine hcl 2 mg tablet 1

tizanidine hcl 4 mg capsule 1

tizanidine hcl 4 mg tablet 1

tizanidine hcl 6 mg capsule 1

XEOMIN 100 UNITS VIAL 5 PA incobotulinumtoxina XEOMIN 50 UNITS VIAL 5 PA incobotulinumtoxina ZANAFLEX 2 MG CAPSULE 3 tizanidine hcl ZANAFLEX 4 MG CAPSULE 3 tizanidine hcl ZANAFLEX 4 MG TABLET 3 tizanidine hcl ZANAFLEX 6 MG CAPSULE 3 tizanidine hcl Antivirals

Anti-cytomegalovirus (CMV) Agents

cidofovir 375 mg/5 ml vial 7

CYTOVENE 500 MG VIAL 9 ganciclovir sodium

foscarnet 24 mg/ml infus bttl 9

FOSCAVIR 6,000 MG/250 ML BTTL 9 foscarnet sodium

ganciclovir 500 mg vial 7

VALCYTE 450 MG TABLET 5 PA valganciclovir hcl

PAGE 187 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS VALCYTE 50 MG/ML SOLUTION 5 PA valganciclovir hcl VISTIDE 75 MG/ML VIAL 9 cidofovir ZIRGAN 0.15% OPHTHALMIC GEL 3 ganciclovir Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors

EDURANT 25 MG TABLET 2 QL 30 / 30 days rilpivirine hcl INTELENCE 100 MG TABLET 2 QL 60 / 30 days etravirine INTELENCE 200 MG TABLET 2 QL 60 / 30 days etravirine INTELENCE 25 MG TABLET 2 QL 120 / 30 days etravirine

nevirapine 200 mg tablet 1

nevirapine 50 mg/5 ml susp 2

nevirapine er 400 mg tablet 1

RESCRIPTOR 100 MG TABLET 2 delavirdine mesylate RESCRIPTOR 200 MG TABLET 2 delavirdine mesylate SUSTIVA 200 MG CAPSULE 2 efavirenz SUSTIVA 50 MG CAPSULE 2 efavirenz SUSTIVA 600 MG TABLET 2 efavirenz VIRAMUNE 200 MG TABLET 3 nevirapine VIRAMUNE 50 MG/5 ML SUSP 2 nevirapine VIRAMUNE XR 100 MG TABLET 3 nevirapine VIRAMUNE XR 400 MG TABLET 3 nevirapine Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors

abacavir 300 mg tablet 1

PAGE 188 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

abacavir 300 mg tablet 1

abacavir-lamivudine-zidov tab 1

COMBIVIR TABLET 3 lamivudine/zidovudine COMPLERA TABLET 2 emtricitabine/rilpivirine hcl/tenofovir disoproxil fumarate

didanosine dr 125 mg capsule 1

didanosine dr 200 mg capsule 1

didanosine dr 250 mg capsule 1

didanosine dr 400 mg capsule 1

EMTRIVA 10 MG/ML SOLUTION 2 emtricitabine EMTRIVA 200 MG CAPSULE 2 emtricitabine EPIVIR 10 MG/ML ORAL SOLN 2 lamivudine EPIVIR 150 MG TABLET 2 lamivudine EPIVIR 300 MG TABLET 2 lamivudine EPZICOM TABLET 2 abacavir sulfate/lamivudine

lamivudine 150 mg tablet 1

lamivudine 300 mg tablet 1

lamivudine-zidovudine tablet 1

RETROVIR 10 MG/ML SYRUP 3 zidovudine RETROVIR 10 MG/ML VIAL 5 PA zidovudine RETROVIR 100 MG CAPSULE 3 zidovudine

PAGE 189 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS RETROVIR 300 MG TABLET zidovudine

stavudine 1 mg/ml solution 1

stavudine 15 mg capsule 1

stavudine 20 mg capsule 1

stavudine 30 mg capsule 1

stavudine 40 mg capsule 1

TRIZIVIR TABLET 2 abacavir sulfate/lamivudine/zidovudine TRUVADA 200 MG-300 MG TABLET 2 emtricitabine/tenofovir disoproxil fumarate VIDEX 2 GM PEDIATRIC SOLN 2 didanosine VIDEX 4 GM PEDIATRIC SOLN 2 didanosine VIDEX EC 125 MG CAPSULE 3 didanosine VIDEX EC 200 MG CAPSULE 3 didanosine VIDEX EC 250 MG CAPSULE 3 didanosine VIDEX EC 400 MG CAPSULE 3 didanosine VIREAD 150 MG TABLET 2 tenofovir disoproxil fumarate VIREAD 200 MG TABLET 2 tenofovir disoproxil fumarate VIREAD 250 MG TABLET 2 tenofovir disoproxil fumarate VIREAD 300 MG TABLET 2 tenofovir disoproxil fumarate VIREAD POWDER 3 tenofovir disoproxil fumarate ZERIT 1 MG/ML SOLUTION 3 stavudine ZERIT 15 MG CAPSULE 3 stavudine

ZERIT 20 MG CAPSULE 3

PAGE 190 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS stavudine ZERIT 30 MG CAPSULE 3 stavudine ZERIT 40 MG CAPSULE 3 stavudine ZIAGEN 20 MG/ML SOLUTION 2 abacavir sulfate ZIAGEN 300 MG TABLET 3 abacavir sulfate

zidovudine 100 mg capsule 1

zidovudine 300 mg tablet 1

zidovudine 50 mg/5 ml syrup 1

Anti-HIV Agents, Other

ATRIPLA TABLET 2 efavirenz/emtricitabine/tenofovir disoproxil fumarate FUZEON 90 MG VIAL 5 enfuvirtide FUZEON CONVENIENCE KIT 5 enfuvirtide ISENTRESS 100 MG POWDER PACKET 3 raltegravir potassium ISENTRESS 100 MG TABLET CHEW 2 QL 180 / 30 days raltegravir potassium ISENTRESS 25 MG TABLET CHEW 2 QL 120 / 30 days raltegravir potassium ISENTRESS 400 MG TABLET 2 raltegravir potassium SELZENTRY 150 MG TABLET 2 maraviroc SELZENTRY 300 MG TABLET 2 maraviroc STRIBILD TABLET 2 QL 30 / 30 days elvitegravir/cobicistat/emtricitabine/tenofovir TIVICAY 50 MG TABLET 3 dolutegravir sodium TRIUMEQ TABLET 3 abacavir sulfate/dolutegravir sodium/lamivudine

PAGE 191 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

TYBOST 150 MG TABLET QL 30 / 30 days 3 cobicistat PA

Anti-HIV Agents, Protease Inhibitors

APTIVUS 100 MG/ML SOLUTION 2 tipranavir/vitamin e tpgs APTIVUS 250 MG CAPSULE 2 tipranavir CRIXIVAN 200 MG CAPSULE 2 indinavir sulfate CRIXIVAN 400 MG CAPSULE 2 indinavir sulfate INVIRASE 200 MG CAPSULE 2 saquinavir mesylate INVIRASE 500 MG TABLET 2 saquinavir mesylate KALETRA 100-25 MG TABLET 2 lopinavir/ritonavir KALETRA 200-50 MG TABLET 2 lopinavir/ritonavir KALETRA 400-100/5 ML ORAL SOLU 2 lopinavir/ritonavir LEXIVA 50 MG/ML SUSPENSION 2 fosamprenavir calcium LEXIVA 700 MG TABLET 2 fosamprenavir calcium NORVIR 100 MG SOFTGEL CAP 2 ritonavir NORVIR 100 MG TABLET 2 ritonavir NORVIR 80 MG/ML SOLUTION 2 ritonavir PREZISTA 100 MG/ML SUSPENSION 2 darunavir ethanolate PREZISTA 150 MG TABLET 2 darunavir ethanolate PREZISTA 400 MG TABLET 2 darunavir ethanolate PREZISTA 600 MG TABLET 2 darunavir ethanolate

PAGE 192 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS PREZISTA 75 MG TABLET darunavir ethanolate PREZISTA 800 MG TABLET 2 darunavir ethanolate REYATAZ 100 MG CAPSULE 2 atazanavir sulfate REYATAZ 150 MG CAPSULE 2 atazanavir sulfate REYATAZ 200 MG CAPSULE 2 atazanavir sulfate REYATAZ 300 MG CAPSULE 2 atazanavir sulfate VIRACEPT 250 MG TABLET 2 nelfinavir mesylate VIRACEPT 625 MG TABLET 2 nelfinavir mesylate Anti-influenza Agents

amantadine 100 mg capsule 1

amantadine 100 mg tablet 1

amantadine 50 mg/5 ml syrup 1

FLUMADINE 100 MG TABLET 3 rimantadine hcl RELENZA 5 MG DISKHALER 3 QL 20 / 180 days zanamivir

rimantadine hcl 100 mg tablet 1

TAMIFLU 30 MG CAPSULE 2 QL 20 / 180 days oseltamivir phosphate TAMIFLU 45 MG CAPSULE 2 QL 10 / 180 days oseltamivir phosphate TAMIFLU 6 MG/ML SUSPENSION 2 oseltamivir phosphate TAMIFLU 75 MG CAPSULE 2 QL 10 / 180 days oseltamivir phosphate Antihepatitis Agents

QL 30 / 30 days adefovir dipivoxil 10 mg tab 4 PA

BARACLUDE 0.05 MG/ML SOLUTION 5 PA

PAGE 193 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS entecavir BARACLUDE 0.5 MG TABLET 5 PA entecavir BARACLUDE 1 MG TABLET 5 PA entecavir COPEGUS 200 MG TABLET 5 PA ribavirin

entecavir 0.5 mg tablet 4 PA

entecavir 1 mg tablet 4 PA

EPIVIR HBV 100 MG TABLET QL 30 / 30 days 5 lamivudine PA

EPIVIR HBV 25 MG/5 ML SOLN 5 PA lamivudine HARVONI 90-400 MG TABLET 5 PA ledipasvir/sofosbuvir

HEPSERA 10 MG TABLET QL 30 / 30 days 5 adefovir dipivoxil PA

INCIVEK 375 MG TABLET 5 PA telaprevir INFERGEN 15 MCG/0.5 ML VIAL 5 QL 6 / 30 days interferon alfacon-1 INFERGEN 9 MCG/0.3 ML VIAL 5 QL 4 / 30 days interferon alfacon-1 INTRON A 10 MILLION UNIT/ML 5 PA interferon alfa-2b,recomb. INTRON A 10 MILLION UNITS VIAL 5 PA interferon alfa-2b,recomb. INTRON A 18 MILLION UNITS VIAL 5 PA interferon alfa-2b,recomb. INTRON A 50 MILLION UNITS VIAL 5 PA interferon alfa-2b,recomb. INTRON A 6 MILLION UNIT/ML VL 5 PA interferon alfa-2b,recomb.

QL 30 / 30 days lamivudine hbv 100 mg tablet 4 PA

moderiba 200 mg tablet 4 PA

moderiba 200-400 mg dosepack 4 PA

PAGE 194 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

moderiba 400-400 mg dosepack 4 PA

moderiba 600-400 mg dosepack 4 PA

moderiba 600-600 mg dosepack 4 PA

OLYSIO 150 MG CAPSULE 5 PA simeprevir sodium PEGASYS 180 MCG/0.5 ML SYRINGE 5 PA peginterferon alfa-2a PEGASYS 180 MCG/ML VIAL 5 PA peginterferon alfa-2a PEGASYS PROCLICK 135 MCG/0.5 5 PA peginterferon alfa-2a PEGASYS PROCLICK 180 MCG/0.5 5 PA peginterferon alfa-2a

PEGINTRON 120 MCG KIT QL 4 / 30 days 5 peginterferon alfa-2b PA

PEGINTRON 150 MCG KIT QL 4 / 30 days 5 peginterferon alfa-2b PA

PEGINTRON 50 MCG KIT QL 4 / 30 days 5 peginterferon alfa-2b PA

PEGINTRON 80 MCG KIT QL 4 / 30 days 5 peginterferon alfa-2b PA

PEGINTRON REDIPEN 120 MCG QL 4 / 30 days 5 peginterferon alfa-2b PA

PEGINTRON REDIPEN 120 MCG 4PK QL 4 / 30 days 5 peginterferon alfa-2b PA

PEGINTRON REDIPEN 150 MCG QL 4 / 30 days 5 peginterferon alfa-2b PA

PEGINTRON REDIPEN 150 MCG 4PK QL 4 / 30 days 5 peginterferon alfa-2b PA

PEGINTRON REDIPEN 50 MCG QL 4 / 30 days 5 peginterferon alfa-2b PA

PEGINTRON REDIPEN 50 MCG 4PK 5 QL 4 / 30 days

PAGE 195 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

peginterferon alfa-2b PA

PEGINTRON REDIPEN 80 MCG QL 4 / 30 days 5 peginterferon alfa-2b PA

PEGINTRON REDIPEN 80 MCG 4PK QL 4 / 30 days 5 peginterferon alfa-2b PA

REBETOL 200 MG CAPSULE 5 PA ribavirin REBETOL 40 MG/ML SOLUTION 5 PA ribavirin RIBAPAK 200-400 MG DOSEPACK 3 PA ribavirin RIBAPAK 400-400 MG DOSEPACK 3 PA ribavirin RIBAPAK 600-400 MG DOSEPACK 3 PA ribavirin RIBAPAK 600-600 MG DOSEPACK 3 PA ribavirin

ribasphere 200 mg capsule 5 PA

ribasphere 200 mg tablet 4 PA

ribasphere 400 mg tablet 4

ribasphere 600 mg tablet 4

RIBATAB 400-400 MG DOSEPACK 3 PA ribavirin RIBATAB 400-600 MG DOSEPACK 3 PA ribavirin RIBATAB 600-600 MG DOSEPACK 3 ribavirin

ribavirin 200 mg capsule 4 PA

ribavirin 200 mg tablet 4 PA

SOVALDI 400 MG TABLET 5 PA sofosbuvir TYZEKA 600 MG TABLET 5 PA telbivudine VICTRELIS 200 MG CAPSULE 5 PA boceprevir

PAGE 196 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS VIRAZOLE 6 GM VIAL 3 ribavirin VIREAD 150 MG TABLET 2 tenofovir disoproxil fumarate VIREAD 200 MG TABLET 2 tenofovir disoproxil fumarate VIREAD 250 MG TABLET 2 tenofovir disoproxil fumarate VIREAD 300 MG TABLET 2 tenofovir disoproxil fumarate VIREAD POWDER 3 tenofovir disoproxil fumarate Antiherpetic Agents

acyclovir 1,000 mg/20 ml vial 7

acyclovir 200 mg capsule 1

acyclovir 200 mg/5 ml susp 1

acyclovir 400 mg tablet 1

acyclovir 5% ointment 1 QL 30 / 30 days

acyclovir 500 mg/10 ml vial 7

acyclovir 800 mg tablet 1

acyclovir sodium 1 gm vial 7

acyclovir sodium 500 mg vial 7

DENAVIR 1% CREAM 3 QL 15 / 90 days penciclovir

famciclovir 125 mg tablet 1

PAGE 197 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

famciclovir 250 mg tablet 1

famciclovir 500 mg tablet 1

FAMVIR 125 MG TABLET 3 famciclovir FAMVIR 250 MG TABLET 3 famciclovir FAMVIR 500 MG TABLET 3 famciclovir

foscarnet 24 mg/ml infus bttl 9

FOSCAVIR 6,000 MG/250 ML BTTL 9 foscarnet sodium LIDOVIR 4%-4% OINTMENT KIT 3 acyclovir/lidocaine hcl SITAVIG 50 MG BUCCAL TABLET 3 acyclovir

trifluridine 1% eye drops 1

valacyclovir hcl 1 gram tablet 1

valacyclovir hcl 500 mg tablet 1

VALTREX 1 GM CAPLET 3 valacyclovir hcl VALTREX 500 MG CAPLET 3 valacyclovir hcl VIROPTIC 1% EYE DROPS 3 trifluridine XERESE 5%-1% CREAM 3 QL 5 / 30 days acyclovir/hydrocortisone ZOVIRAX 200 MG CAPSULE 3 acyclovir ZOVIRAX 200 MG CAPSULE 3 acyclovir ZOVIRAX 200 MG/5 ML SUSP 3 acyclovir ZOVIRAX 400 MG TABLET 3 acyclovir

PAGE 198 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ZOVIRAX 400 MG TABLET acyclovir ZOVIRAX 5% CREAM 2 acyclovir ZOVIRAX 5% OINTMENT 3 QL 30 / 30 days acyclovir ZOVIRAX 800 MG TABLET 3 acyclovir Anxiolytics

Anxiolytics, Other

alprazolam 0.25 mg odt 1

alprazolam 0.25 mg tablet 1

alprazolam 0.5 mg odt 1

alprazolam 0.5 mg tablet 1

alprazolam 1 mg odt 1

alprazolam 1 mg tablet 1

alprazolam 1 mg/ml oral conc 1

alprazolam 2 mg odt 1

alprazolam 2 mg tablet 1

alprazolam er 0.5 mg tablet 1

alprazolam er 1 mg tablet 1

alprazolam er 2 mg tablet 1

alprazolam er 3 mg tablet 1

alprazolam odt 0.25 mg tab 1

alprazolam odt 0.5 mg tab 1

alprazolam odt 1 mg tab 1

alprazolam odt 2 mg tab 1

PAGE 199 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

alprazolam xr 0.5 mg tablet 1

alprazolam xr 1 mg tablet 1

alprazolam xr 2 mg tablet 1

alprazolam xr 3 mg tablet 1

ATIVAN 0.5 MG TABLET 3 lorazepam ATIVAN 0.5 MG TABLET 3 lorazepam ATIVAN 1 MG TABLET 3 lorazepam ATIVAN 1 MG TABLET 3 lorazepam ATIVAN 2 MG TABLET 3 lorazepam ATIVAN 2 MG/ML VIAL 9 PA lorazepam ATIVAN 20 MG/10 ML VIAL 9 PA lorazepam ATIVAN 4 MG/ML VIAL 9 PA lorazepam ATIVAN 40 MG/10 ML VIAL 9 PA lorazepam

buspirone hcl 10 mg tablet 1

buspirone hcl 15 mg tablet 1

buspirone hcl 30 mg tablet 1

buspirone hcl 5 mg tablet 1

buspirone hcl 7.5 mg tablet 1

BUTISOL SODIUM 30 MG TABLET 3 butabarbital sodium

BUTISOL SODIUM 30 MG/5 ML ELX 3

PAGE 200 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS butabarbital sodium BUTISOL SODIUM 50 MG TABLET 3 butabarbital sodium

chlordiazepo-amitriptyl 5-12.5 1

chlordiazepox-amitriptyl 10-25 1

chlordiazepoxide 10 mg capsule 1

chlordiazepoxide 25 mg capsule 1

chlordiazepoxide 5 mg capsule 1

clonazepam 0.125 mg dis tab 1

clonazepam 0.25 mg odt 1

clonazepam 0.5 mg dis tablet 1

clonazepam 0.5 mg tablet 1

clonazepam 1 mg dis tablet 1

clonazepam 1 mg tablet 1

clonazepam 2 mg odt 1

clonazepam 2 mg tablet 1

clorazepate 15 mg tablet 1

clorazepate 3.75 mg tablet 1

clorazepate 7.5 mg tablet 1

diazepam 10 mg tablet 1

diazepam 10 mg/2 ml syringe 9 PA

diazepam 2 mg tablet 1

diazepam 5 mg tablet 1

diazepam 5 mg/5 ml oral soln 1

PAGE 201 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

diazepam 5 mg/5 ml solution 1

diazepam 5 mg/ml oral conc 1

diazepam 5 mg/ml syringe 1 PA

diazepam 5 mg/ml vial 1

doxepin 10 mg capsule 1

doxepin 10 mg/ml oral conc 1

doxepin 100 mg capsule 1

doxepin 150 mg capsule 1

doxepin 25 mg capsule 1

doxepin 50 mg capsule 1

doxepin 75 mg capsule 1

hydroxyzine 10 mg/5 ml syrup 1

hydroxyzine 25 mg/ml vial 1

hydroxyzine 50 mg/ml vial 7 PA

hydroxyzine hcl 10 mg tablet 1

hydroxyzine hcl 25 mg tablet 1

hydroxyzine hcl 50 mg tablet 1

hydroxyzine pam 100 mg cap 1

hydroxyzine pam 25 mg cap 1

hydroxyzine pam 50 mg cap 1

KLONOPIN 0.5 MG TABLET 3 clonazepam KLONOPIN 1 MG TABLET 3 clonazepam KLONOPIN 2 MG TABLET 3 clonazepam

lorazepam 0.5 mg tablet 1

PAGE 202 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

lorazepam 1 mg tablet 1

lorazepam 2 mg tablet 1

lorazepam 2 mg/ml carpuject 7 PA

lorazepam 2 mg/ml oral concent 1

lorazepam 2 mg/ml syringe 7 PA

lorazepam 2 mg/ml vial 7 PA

lorazepam 20 mg/10 ml vial 7 PA

lorazepam 4 mg/ml carpuject 7 PA

lorazepam 4 mg/ml vial 7 PA

lorazepam 40 mg/10 ml vial 7 PA

lorazepam intensol 2 mg/ml 1

meprobamate 200 mg tablet 1

meprobamate 400 mg tablet 1

midazolam 10 mg/2 ml syringe 7

midazolam 2 mg/2 ml carpuject 7

midazolam 2 mg/2 ml isecure 7

midazolam 2 mg/2 ml syringe 7

midazolam 5 mg/ml carpuject 7

midazolam 5 mg/ml isecure syr 7

midazolam 5 mg/ml syringe 7

midazolam hcl 1 mg/ml vial 7

midazolam hcl 10 mg/10 ml vial 7

midazolam hcl 10 mg/2 ml vial 7

midazolam hcl 2 mg/2 ml vial 7

PAGE 203 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

midazolam hcl 2 mg/2 ml vial 7

midazolam hcl 2 mg/ml syrup 1

midazolam hcl 25 mg/5 ml vial 7

midazolam hcl 5 mg/5 ml vial 7

midazolam hcl 5 mg/ml vial 7

midazolam hcl 50 mg/10 ml vial 7

NIRAVAM 0.25 MG ODT 3 alprazolam NIRAVAM 0.5 MG ODT 3 alprazolam NIRAVAM 1 MG ODT 3 alprazolam NIRAVAM 2 MG ODT 3 alprazolam

oxazepam 10 mg capsule 1

oxazepam 15 mg capsule 1

oxazepam 30 mg capsule 1

TRANXENE T-TAB 15 MG 3 clorazepate dipotassium TRANXENE T-TAB 3.75 MG 3 clorazepate dipotassium TRANXENE T-TAB 7.5 MG 3 clorazepate dipotassium VALIUM 10 MG TABLET 3 diazepam VALIUM 2 MG TABLET 3 diazepam VALIUM 5 MG TABLET 3 diazepam VISTARIL 25 MG CAPSULE 3 hydroxyzine pamoate VISTARIL 50 MG CAPSULE 3 hydroxyzine pamoate

PAGE 204 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS XANAX 0.25 MG TABLET 3 alprazolam XANAX 0.5 MG TABLET 3 alprazolam XANAX 1 MG TABLET 3 alprazolam XANAX 2 MG TABLET 3 alprazolam XANAX XR 0.5 MG TABLET 3 alprazolam XANAX XR 1 MG TABLET 3 alprazolam XANAX XR 2 MG TABLET 3 alprazolam XANAX XR 3 MG TABLET 3 alprazolam SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/ Serotonin and Norepinephrine Reuptake Inhibitors)

BRISDELLE 7.5 MG CAPSULE 3 paroxetine mesylate

CYMBALTA 20 MG CAPSULE QL 90 / 30 days 2 duloxetine hcl ST

CYMBALTA 30 MG CAPSULE QL 30 / 30 days 2 duloxetine hcl ST

CYMBALTA 60 MG CAPSULE QL 30 / 30 days 2 duloxetine hcl ST

EFFEXOR XR 150 MG CAPSULE QL 60 / 30 days 3 venlafaxine hcl ST

EFFEXOR XR 37.5 MG CAPSULE QL 60 / 30 days 3 venlafaxine hcl ST

EFFEXOR XR 75 MG CAPSULE QL 90 / 30 days 3 venlafaxine hcl ST

escitalopram 20 mg tablet 1 QL 30 / 30 days

escitalopram 5 mg tablet 1 QL 30 / 30 days

PAGE 205 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

escitalopram oxalate 5 mg/5 ml 1 QL 620 / 30 days

LEXAPRO 10 MG TABLET QL 30 / 30 days 3 escitalopram oxalate ST

LEXAPRO 20 MG TABLET QL 30 / 30 days 3 escitalopram oxalate ST

LEXAPRO 5 MG TABLET QL 30 / 30 days 3 escitalopram oxalate ST

LEXAPRO 5 MG/5 ML SOLUTION QL 620 / 30 days 3 escitalopram oxalate ST

paroxetine cr 12.5 mg tablet 1 QL 60 / 30 days

paroxetine cr 25 mg tablet 1 QL 60 / 30 days

paroxetine cr 37.5 mg tablet 1 QL 60 / 30 days

paroxetine er 37.5 mg tablet 1 QL 60 / 30 days

paroxetine hcl 10 mg tablet 1

paroxetine hcl 20 mg tablet 1

paroxetine hcl 30 mg tablet 1

PAXIL CR 12.5 MG TABLET QL 60 / 30 days 3 paroxetine hcl ST

PAXIL CR 25 MG TABLET QL 60 / 30 days 3 paroxetine hcl ST

PAXIL CR 37.5 MG TABLET 3 QL 60 / 30 days

PAGE 206 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

paroxetine hcl ST

PEXEVA 10 MG TABLET QL 30 / 30 days 3 paroxetine mesylate ST

PEXEVA 20 MG TABLET QL 30 / 30 days 3 paroxetine mesylate ST

PEXEVA 30 MG TABLET QL 30 / 30 days 3 paroxetine mesylate ST

PEXEVA 40 MG TABLET QL 30 / 30 days 3 paroxetine mesylate ST

sertraline 20 mg/ml oral conc 1

sertraline hcl 100 mg tablet 1

sertraline hcl 25 mg tablet 1

sertraline hcl 50 mg tablet 1

venlafaxine hcl 100 mg tablet 1

venlafaxine hcl 25 mg tablet 1

venlafaxine hcl 50 mg tablet 1

venlafaxine hcl er 150 mg cap 1 QL 60 / 30 days

venlafaxine hcl er 150 mg tab 1 QL 60 / 30 days

VENLAFAXINE HCL ER 150 MG TAB 1 QL 60 / 30 days venlafaxine hcl VENLAFAXINE HCL ER 225 MG TAB 2 venlafaxine hcl

venlafaxine hcl er 37.5 mg tab 1 QL 60 / 30 days

VENLAFAXINE HCL ER 37.5 MG TAB 1 QL 60 / 30 days venlafaxine hcl

venlafaxine hcl er 75 mg cap 1 QL 90 / 30 days

venlafaxine hcl er 75 mg tab 1 QL 90 / 30 days

VENLAFAXINE HCL ER 75 MG TAB 1 QL 90 / 30 days venlafaxine hcl

PAGE 207 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ZOLOFT 100 MG TABLET 3 ST sertraline hcl ZOLOFT 20 MG/ML ORAL CONC 3 ST sertraline hcl ZOLOFT 25 MG TABLET 3 ST sertraline hcl ZOLOFT 50 MG TABLET 3 ST sertraline hcl Bipolar Agents

Bipolar Agents, Other

chlorpromazine 10 mg tablet 1

chlorpromazine 100 mg tablet 1

chlorpromazine 200 mg tablet 1

chlorpromazine 25 mg tablet 1

chlorpromazine 25 mg/ml amp 1

chlorpromazine 50 mg tablet 1

GEODON 20 MG CAPSULE 3 QL 60 / 30 days

PAGE 208 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

ziprasidone hcl

GEODON 20 MG/ML VIAL 8 ziprasidone mesylate GEODON 40 MG CAPSULE 3 QL 60 / 30 days ziprasidone hcl GEODON 60 MG CAPSULE 3 QL 60 / 30 days ziprasidone hcl GEODON 80 MG CAPSULE 3 QL 60 / 30 days ziprasidone hcl

olanzapine 10 mg vial 7

olanzapine 15 mg tablet 1 QL 30 / 30 days

olanzapine 2.5 mg tablet 1 QL 30 / 30 days

olanzapine 20 mg tablet 1 QL 30 / 30 days

olanzapine 7.5 mg tablet 1 QL 30 / 30 days

olanzapine odt 10 mg tablet 1 QL 30 / 30 days

olanzapine odt 15 mg tablet 1 QL 30 / 30 days

olanzapine odt 20 mg tablet 1 QL 30 / 30 days

olanzapine odt 5 mg tablet 1 QL 30 / 30 days

PAGE 209 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS RISPERDAL 4 MG TABLET 3 QL 120 / 30 days risperidone RISPERDAL CONSTA 12.5 MG SYR 9 risperidone microspheres RISPERDAL CONSTA 25 MG SYR 9 risperidone microspheres RISPERDAL CONSTA 37.5 MG SYR 9 risperidone microspheres RISPERDAL CONSTA 50 MG SYR 9 risperidone microspheres RISPERDAL M-TAB 0.5 MG ODT 3 QL 60 / 30 days risperidone RISPERDAL M-TAB 1 MG ODT 3 QL 60 / 30 days risperidone RISPERDAL M-TAB 2 MG ODT 3 QL 60 / 30 days risperidone RISPERDAL M-TAB 3 MG ODT 3 QL 60 / 30 days risperidone RISPERDAL M-TAB 4 MG ODT 3 QL 120 / 30 days risperidone

risperidone 0.25 mg odt 1

risperidone 0.25 mg tablet 1 QL 60 / 30 days

risperidone 0.5 mg odt 1 QL 60 / 30 days

risperidone 1 mg odt 1 QL 60 / 30 days

risperidone 1 mg/ml solution 1

risperidone 2 mg odt 1 QL 60 / 30 days

risperidone 2 mg tablet 1 QL 60 / 30 days

risperidone 3 mg odt 1 QL 60 / 30 days

risperidone 4 mg odt 1 QL 120 / 30 days

risperidone 4 mg tablet 1 QL 120 / 30 days

SAPHRIS 10 MG TAB SL BLK CHERY 3 QL 60 / 30 days asenapine maleate SAPHRIS 10 MG TAB SUBLINGUAL 3 QL 60 / 30 days asenapine maleate SAPHRIS 5 MG TAB SL BLK CHERRY 3 QL 60 / 30 days asenapine maleate

PAGE 210 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS SAPHRIS 5 MG TABLET SUBLINGUAL 3 QL 60 / 30 days asenapine maleate SEROQUEL 100 MG TABLET 3 QL 60 / 30 days quetiapine fumarate SEROQUEL 200 MG TABLET 3 QL 60 / 30 days quetiapine fumarate SEROQUEL 25 MG TABLET 3 QL 60 / 30 days quetiapine fumarate SEROQUEL 300 MG TABLET 3 QL 60 / 30 days quetiapine fumarate SEROQUEL 400 MG TABLET 3 QL 60 / 30 days quetiapine fumarate SEROQUEL 50 MG TABLET 3 QL 60 / 30 days quetiapine fumarate SEROQUEL XR 150 MG TABLET 2 QL 30 / 30 days quetiapine fumarate SEROQUEL XR 200 MG TABLET 2 QL 30 / 30 days quetiapine fumarate SEROQUEL XR 300 MG TABLET 2 QL 60 / 30 days quetiapine fumarate SEROQUEL XR 400 MG TABLET 2 QL 60 / 30 days quetiapine fumarate SEROQUEL XR 50 MG TABLET 2 QL 30 / 30 days quetiapine fumarate

ziprasidone hcl 20 mg capsule 1 QL 60 / 30 days

ziprasidone hcl 40 mg capsule 1 QL 60 / 30 days

ziprasidone hcl 60 mg capsule 1 QL 60 / 30 days

ziprasidone hcl 80 mg capsule 1 QL 60 / 30 days

ZYPREXA 10 MG TABLET 2 QL 30 / 30 days olanzapine ZYPREXA 10 MG VIAL 9 olanzapine

PAGE 211 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ZYPREXA 15 MG TABLET QL 30 / 30 days olanzapine ZYPREXA 2.5 MG TABLET 2 QL 30 / 30 days olanzapine ZYPREXA 20 MG TABLET 2 QL 30 / 30 days olanzapine ZYPREXA 5 MG TABLET 2 QL 30 / 30 days olanzapine ZYPREXA 7.5 MG TABLET 2 QL 30 / 30 days olanzapine ZYPREXA ZYDIS 10 MG TABLET 2 QL 30 / 30 days olanzapine ZYPREXA ZYDIS 15 MG TABLET 2 QL 30 / 30 days olanzapine ZYPREXA ZYDIS 20 MG TABLET 2 QL 30 / 30 days olanzapine ZYPREXA ZYDIS 5 MG TABLET 2 QL 30 / 30 days olanzapine Mood Stabilizers

carbamazepine 100 mg tab chew 1

carbamazepine 100 mg/5 ml susp 1

carbamazepine er 100 mg cap 1

carbamazepine er 200 mg cap 1

carbamazepine er 200 mg tablet 1

carbamazepine er 300 mg cap 1

carbamazepine er 400 mg tablet 1

carbamazepine xr 200 mg tablet 1

carbamazepine xr 400 mg tablet 1

CARBATROL ER 100 MG CAPSULE 3 carbamazepine CARBATROL ER 200 MG CAPSULE 3 carbamazepine CARBATROL ER 300 MG CAPSULE 3 carbamazepine DEPAKENE 250 MG CAPSULE 3 valproic acid

PAGE 212 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS DEPAKENE 250 MG/5 ML SOLUTION 3 valproic acid (as sodium salt) (valproate sodium) DEPAKOTE 125 MG SPRINKLE CAP 3 divalproex sodium DEPAKOTE DR 125 MG TABLET 3 divalproex sodium DEPAKOTE DR 250 MG TABLET 3 divalproex sodium DEPAKOTE DR 500 MG TABLET 3 divalproex sodium DEPAKOTE ER 250 MG TABLET 3 divalproex sodium DEPAKOTE ER 500 MG TABLET 3 divalproex sodium

divalproex sod dr 125 mg tab 1

divalproex sodium 125 mg cap 1

epitol 200 mg tablet 1

EQUETRO 100 MG CAPSULE 3 carbamazepine EQUETRO 200 MG CAPSULE 3 carbamazepine EQUETRO 300 MG CAPSULE 3 carbamazepine LAMICTAL 100 MG TABLET 3 lamotrigine LAMICTAL 150 MG TABLET 3 lamotrigine LAMICTAL 2 MG DISPER TABLET 3 lamotrigine LAMICTAL 200 MG TABLET 3 lamotrigine LAMICTAL 25 MG DISPER TABLET 3 lamotrigine LAMICTAL 25 MG TABLET 3 lamotrigine LAMICTAL 5 MG DISPER TABLET 3 lamotrigine

PAGE 213 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS LAMICTAL ODT 100 MG TABLET lamotrigine LAMICTAL ODT 200 MG TABLET 3 lamotrigine LAMICTAL ODT 25 MG TABLET 3 lamotrigine LAMICTAL ODT 50 MG TABLET 3 lamotrigine LAMICTAL ODT START KIT (BLUE) 3 lamotrigine LAMICTAL ODT START KIT (GREEN) 3 lamotrigine LAMICTAL ODT START KT (ORANGE) 3 lamotrigine LAMICTAL TAB START KIT (BLUE) 3 lamotrigine LAMICTAL TAB START KIT (GREEN) 3 lamotrigine LAMICTAL TB START KIT (ORANGE) 3 lamotrigine LAMICTAL XR 100 MG TABLET 3 lamotrigine LAMICTAL XR 200 MG TABLET 3 lamotrigine LAMICTAL XR 25 MG TABLET 3 lamotrigine LAMICTAL XR 250 MG TABLET 3 lamotrigine LAMICTAL XR 300 MG TABLET 3 lamotrigine LAMICTAL XR 50 MG TABLET 3 lamotrigine LAMICTAL XR START KIT (BLUE) 3 lamotrigine LAMICTAL XR START KIT (GREEN) 3 lamotrigine LAMICTAL XR START KIT (ORANGE) 3 lamotrigine

lamotrigine 100 mg tablet 1

PAGE 214 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

lamotrigine 150 mg tablet 1

lamotrigine 200 mg tablet 1

lamotrigine 25 mg disper tab 1

lamotrigine 25 mg tb start kit 1

lamotrigine 5 mg disper tablet 1

lithium 8 meq/5 ml solution 2

lithium carbonate 150 mg cap 1

lithium carbonate 300 mg cap 1

lithium carbonate 300 mg tab 1

lithium carbonate 600 mg cap 1

lithium carbonate er 300 mg tb 1

lithium carbonate er 450 mg tb 1

LITHOBID ER 300 MG TABLET 3 lithium carbonate LITHOBID ER 300 MG TABLET 3 lithium carbonate STAVZOR DR 125 MG CAPSULE 3 valproic acid STAVZOR DR 250 MG CAPSULE 3 valproic acid STAVZOR DR 500 MG CAPSULE 3 valproic acid TEGRETOL 100 MG/5 ML SUSP 2 carbamazepine TEGRETOL 200 MG TABLET 2 carbamazepine TEGRETOL XR 100 MG TABLET 2 carbamazepine

PAGE 215 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS TEGRETOL XR 200 MG TABLET carbamazepine TEGRETOL XR 400 MG TABLET 2 carbamazepine

valproic acid 250 mg capsule 1

valproic acid 250 mg/5 ml soln 1

valproic acid 500 mg/10 ml sol 1

Blood Glucose Regulators

Antidiabetic Agents

acarbose 100 mg tablet 1

acarbose 25 mg tablet 1

acarbose 50 mg tablet 1

ACTOPLUS MET 15 MG-500 MG TAB QL 60 / 30 days 3 pioglitazone hcl/metformin hcl ST

ACTOPLUS MET 15 MG-850 MG TAB QL 60 / 30 days 3 pioglitazone hcl/metformin hcl ST

ACTOPLUS MET XR 15-1,000 MG TB 2 ST pioglitazone hcl/metformin hcl ACTOPLUS MET XR 30-1,000 MG TB 2 ST pioglitazone hcl/metformin hcl

ACTOS 15 MG TABLET QL 30 / 30 days 3 pioglitazone hcl ST

ACTOS 30 MG TABLET QL 30 / 30 days 3 pioglitazone hcl ST

ACTOS 45 MG TABLET QL 30 / 30 days 3 pioglitazone hcl ST

AMARYL 1 MG TABLET 3 glimepiride

PAGE 216 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS AMARYL 2 MG TABLET 3 glimepiride AMARYL 4 MG TABLET 3 glimepiride

AVANDAMET 2 MG-1,000 MG TAB QL 60 / 30 days 2 rosiglitazone maleate/metformin hcl ST

AVANDAMET 2 MG-500 MG TABLET QL 60 / 30 days 2 rosiglitazone maleate/metformin hcl ST

AVANDAMET 4 MG-1,000 MG TABLET QL 60 / 30 days 2 rosiglitazone maleate/metformin hcl ST

AVANDAMET 4 MG-500 MG TABLET QL 60 / 30 days 2 rosiglitazone maleate/metformin hcl ST

AVANDARYL 4 MG-1 MG TABLET QL 60 / 30 days 2 rosiglitazone maleate/glimepiride ST

AVANDARYL 4 MG-2 MG TABLET QL 60 / 30 days 2 rosiglitazone maleate/glimepiride ST

AVANDARYL 4 MG-4 MG TABLET QL 60 / 30 days 2 rosiglitazone maleate/glimepiride ST

AVANDARYL 8 MG-2 MG TABLET QL 60 / 30 days 2 rosiglitazone maleate/glimepiride ST

AVANDARYL 8 MG-4 MG TABLET QL 60 / 30 days 2 rosiglitazone maleate/glimepiride ST

AVANDIA 2 MG TABLET 2 ST rosiglitazone maleate AVANDIA 2 MG TABLET 2 ST rosiglitazone maleate AVANDIA 4 MG TABLET 2 ST rosiglitazone maleate AVANDIA 4 MG TABLET 2 ST rosiglitazone maleate AVANDIA 8 MG TABLET 2 ST rosiglitazone maleate AVANDIA 8 MG TABLET 2 ST rosiglitazone maleate

BYDUREON 2 MG PEN INJECT 9 QL 4 / 28 days

PAGE 217 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

exenatide microspheres

BYDUREON 2 MG VIAL 9 QL 4 / 30 days exenatide microspheres BYETTA 10 MCG DOSE PEN INJ 9 QL 2 / 30 days exenatide BYETTA 5 MCG DOSE PEN INJ 9 QL 2 / 30 days exenatide

chlorpropamide 100 mg tablet 1

chlorpropamide 250 mg tablet 1

CYCLOSET 0.8 MG TABLET 3 bromocriptine mesylate DIABETA 1.25 MG TABLET 3 glyburide DIABETA 2.5 MG TABLET 3 glyburide DIABETA 5 MG TABLET 3 glyburide DUETACT 30-2 MG TABLET 3 ST pioglitazone hcl/glimepiride DUETACT 30-4 MG TABLET 3 ST pioglitazone hcl/glimepiride FARXIGA 10 MG TABLET 3 dapagliflozin propanediol FARXIGA 5 MG TABLET 3 dapagliflozin propanediol FORTAMET ER 1,000 MG TABLET 3 ST metformin hcl FORTAMET ER 500 MG TABLET 3 ST metformin hcl

glimepiride 1 mg tablet 1

glimepiride 2 mg tablet 1

glimepiride 4 mg tablet 1

glipizide 10 mg tablet 1

PAGE 218 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

glipizide 5 mg tablet 1

glipizide er 10 mg tablet 1

glipizide er 2.5 mg tablet 1

glipizide er 5 mg tablet 1

glipizide xl 10 mg tablet 1

glipizide xl 2.5 mg tablet 1

glipizide xl 5 mg tablet 1

glipizide-metformin 2.5-250 mg 1

glipizide-metformin 2.5-500 mg 1

glipizide-metformin 5-500 mg 1

GLUCOPHAGE 1,000 MG TABLET 3 ST metformin hcl GLUCOPHAGE 500 MG TABLET 3 ST metformin hcl GLUCOPHAGE 850 MG TABLET 3 ST metformin hcl GLUCOPHAGE XR 500 MG TAB 3 ST metformin hcl GLUCOPHAGE XR 750 MG TAB 3 ST metformin hcl GLUCOTROL 10 MG TABLET 3 glipizide GLUCOTROL 5 MG TABLET 3 glipizide GLUCOTROL XL 10 MG TABLET 3 glipizide GLUCOTROL XL 2.5 MG TABLET 3 glipizide GLUCOTROL XL 5 MG TABLET 3 glipizide GLUCOVANCE 2.5-500 MG TABLET 3 ST glyburide/metformin hcl GLUCOVANCE 5-500 MG TABLET 3 ST glyburide/metformin hcl GLUMETZA ER 1,000 MG TABLET 3 ST metformin hcl

PAGE 219 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS GLUMETZA ER 500 MG TABLET 3 ST metformin hcl

glyburid-metformin 1.25-250 mg 1

glyburide 1.25 mg tablet 1

glyburide 2.5 mg tablet 1

glyburide 5 mg tablet 1

glyburide micro 1.5 mg tab 1

glyburide micro 3 mg tablet 1

glyburide micro 6 mg tablet 1

glyburide-metformin 2.5-500 mg 1

glyburide-metformin 5-500 mg 1

GLYNASE 1.5 MG PRESTAB 3 glyburide,micronized GLYNASE 3 MG PRESTAB 3 glyburide,micronized GLYNASE 6 MG PRESTAB 3 glyburide,micronized GLYSET 100 MG TABLET 2 miglitol GLYSET 25 MG TABLET 2 miglitol GLYSET 50 MG TABLET 2 miglitol INVOKAMET 150-1,000 MG TABLET 3 canagliflozin/metformin hcl INVOKAMET 150-500 MG TABLET 3 canagliflozin/metformin hcl

PAGE 220 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS INVOKAMET 50-1,000 MG TABLET 3 canagliflozin/metformin hcl INVOKAMET 50-500 MG TABLET 3 canagliflozin/metformin hcl

INVOKANA 100 MG TABLET QL 60 / 30 days 3 canagliflozin ST

INVOKANA 300 MG TABLET QL 30 / 30 days 3 canagliflozin ST

JANUMET 50-1,000 MG TABLET 2 ST sitagliptin phosphate/metformin hcl JANUMET 50-500 MG TABLET 2 ST sitagliptin phosphate/metformin hcl

JANUMET XR 100-1,000 MG TABLET QL 30 / 30 days 3 sitagliptin phosphate/metformin hcl ST

JANUMET XR 50-1,000 MG TABLET QL 30 / 30 days 3 sitagliptin phosphate/metformin hcl ST

JANUMET XR 50-500 MG TABLET QL 30 / 30 days 3 sitagliptin phosphate/metformin hcl ST

JANUVIA 100 MG TABLET QL 30 / 30 days 2 sitagliptin phosphate ST

JANUVIA 25 MG TABLET QL 30 / 30 days 2 sitagliptin phosphate ST

JANUVIA 50 MG TABLET QL 30 / 30 days 2 sitagliptin phosphate ST

JARDIANCE 10 MG TABLET 3 empagliflozin JARDIANCE 25 MG TABLET 3 empagliflozin

JENTADUETO 2.5 MG-1000 MG TAB QL 60 / 30 days 3 linagliptin/metformin hcl ST

JENTADUETO 2.5 MG-500 MG TAB QL 60 / 30 days 3 linagliptin/metformin hcl ST

JENTADUETO 2.5 MG-850 MG TAB QL 60 / 30 days 3 linagliptin/metformin hcl ST

PAGE 221 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS JUVISYNC 100-10 MG TABLET 3 sitagliptin phosphate/simvastatin JUVISYNC 100-20 MG TABLET 3 sitagliptin phosphate/simvastatin JUVISYNC 100-40 MG TABLET 3 sitagliptin phosphate/simvastatin JUVISYNC 50-10 MG TABLET 3 sitagliptin phosphate/simvastatin JUVISYNC 50-20 MG TABLET 3 sitagliptin phosphate/simvastatin JUVISYNC 50-40 MG TABLET 3 sitagliptin phosphate/simvastatin

KAZANO 12.5-1,000 MG TABLET QL 60 / 30 days 3 alogliptin benzoate/metformin hcl ST

KAZANO 12.5-500 MG TABLET QL 60 / 30 days 3 alogliptin benzoate/metformin hcl ST

KOMBIGLYZE XR 2.5-1,000 MG TAB QL 60 / 30 days 3 saxagliptin hcl/metformin hcl ST

KOMBIGLYZE XR 5-1,000 MG TAB QL 60 / 30 days 3 saxagliptin hcl/metformin hcl ST

KOMBIGLYZE XR 5-500 MG TABLET QL 60 / 30 days 3 saxagliptin hcl/metformin hcl ST

metformin er 1,000 mg osm-tab 1

metformin hcl 1,000 mg tablet 1

metformin hcl 500 mg tablet 1

metformin hcl 850 mg tablet 1

metformin hcl er 500 mg osm-tb 1

metformin hcl er 500 mg tablet 1

PAGE 222 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

metformin hcl er 750 mg tablet

nateglinide 120 mg tablet 1 QL 90 / 30 days

nateglinide 60 mg tablet 1 QL 90 / 30 days

NESINA 12.5 MG TABLET QL 30 / 30 days 3 alogliptin benzoate ST

NESINA 25 MG TABLET QL 30 / 30 days 3 alogliptin benzoate ST

NESINA 6.25 MG TABLET QL 30 / 30 days 3 alogliptin benzoate ST

ONGLYZA 2.5 MG TABLET QL 30 / 30 days 3 saxagliptin hcl ST

ONGLYZA 5 MG TABLET QL 30 / 30 days 3 saxagliptin hcl ST

OSENI 12.5-15 MG TABLET 3 alogliptin benzoate/pioglitazone hcl OSENI 12.5-30 MG TABLET 3 alogliptin benzoate/pioglitazone hcl OSENI 12.5-45 MG TABLET 3 alogliptin benzoate/pioglitazone hcl OSENI 25-15 MG TABLET 3 alogliptin benzoate/pioglitazone hcl OSENI 25-30 MG TABLET 3 alogliptin benzoate/pioglitazone hcl OSENI 25-45 MG TABLET 3 alogliptin benzoate/pioglitazone hcl

pioglitaz-glimepir 30-2 mg tab 1 ST

pioglitaz-glimepir 30-4 mg tab 1 ST

pioglitazone hcl 15 mg tablet 1 QL 30 / 30 days

pioglitazone hcl 30 mg tablet 1 QL 30 / 30 days

pioglitazone hcl 45 mg tablet 1 QL 30 / 30 days

PAGE 223 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

pioglitazone hcl 45 mg tablet QL 30 / 30 days

QL 60 / 30 days pioglitazone-metformin 15-500 1 ST

QL 60 / 30 days pioglitazone-metformin 15-850 1 ST

PRANDIMET 1 MG-500 MG TABLET QL 60 / 30 days 3 repaglinide/metformin hcl ST

PRANDIMET 2 MG-500 MG TABLET QL 60 / 30 days 3 repaglinide/metformin hcl ST

PRANDIN 0.5 MG TABLET 3 QL 240 / 30 days repaglinide PRANDIN 1 MG TABLET 3 QL 240 / 30 days repaglinide PRANDIN 2 MG TABLET 3 QL 240 / 30 days repaglinide PRECOSE 100 MG TABLET 3 acarbose PRECOSE 25 MG TABLET 3 acarbose PRECOSE 50 MG TABLET 3 acarbose

repaglinide 0.5 mg tablet 1 QL 240 / 30 days

repaglinide 1 mg tablet 1 QL 240 / 30 days

repaglinide 2 mg tablet 1 QL 240 / 30 days

RIOMET 500 MG/5 ML SOLUTION 3 ST metformin hcl STARLIX 120 MG TABLET 3 QL 90 / 30 days nateglinide STARLIX 60 MG TABLET 3 QL 90 / 30 days nateglinide SYMLINPEN 120 PEN INJECTOR 3 pramlintide acetate

PAGE 224 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS SYMLINPEN 60 PEN INJECTOR 3 pramlintide acetate TANZEUM 30 MG PEN INJECT 9 QL 4 / 28 days albiglutide TANZEUM 50 MG PEN INJECT 9 QL 4 / 28 days albiglutide

tolazamide 250 mg tablet 1

tolazamide 500 mg tablet 1

tolbutamide 500 mg tablet 1

TRADJENTA 5 MG TABLET QL 30 / 30 days 3 linagliptin ST

TRULICITY 0.75 MG/0.5 ML PEN 3 QL 2 / 28 days dulaglutide TRULICITY 1.5 MG/0.5 ML PEN 3 QL 2 / 28 days dulaglutide VICTOZA 2-PAK 18 MG/3 ML PEN 9 QL 10 / 30 days liraglutide VICTOZA 3-PAK 18 MG/3 ML PEN 9 QL 10 / 30 days liraglutide WELCHOL 3.75G PACKET 3 colesevelam hcl WELCHOL 625 MG TABLET 3 colesevelam hcl Glycemic Agents

GLUCAGEN 1 MG HYPOKIT 8 glucagon,human recombinant GLUCAGEN 1 MG HYPOKIT 2-PACK 8 glucagon,human recombinant GLUCAGEN 1 MG VIAL 8 glucagon,human recombinant GLUCAGON 1 MG EMERGENCY KIT 8 glucagon,human recombinant PROGLYCEM 50 MG/ML ORAL SUSP 3 diazoxide Insulins

APIDRA 100 UNITS/ML VIAL 2 insulin glulisine

PAGE 225 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS APIDRA SOLOSTAR 100 UNITS/ML insulin glulisine HUMALOG 100 UNITS/ML CARTRIDGE 2 insulin lispro HUMALOG 100 UNITS/ML KWIKPEN 2 insulin lispro HUMALOG 100 UNITS/ML VIAL 2 insulin lispro HUMALOG MIX 50-50 KWIKPEN 2 insulin lispro protamine & insulin lispro HUMALOG MIX 50-50 VIAL 2 insulin lispro protamine & insulin lispro HUMALOG MIX 75-25 KWIKPEN 2 insulin lispro protamine & insulin lispro HUMALOG MIX 75-25 VIAL 2 insulin lispro protamine & insulin lispro HUMULIN R 500 UNITS/ML VIAL 2 insulin regular, human LANTUS 100 UNITS/ML VIAL 2 insulin glargine, human recombinant analog LANTUS SOLOSTAR 100 UNITS/ML 2 insulin glargine, human recombinant analog LEVEMIR 100 UNITS/ML VIAL 2 insulin detemir LEVEMIR FLEXPEN 100 UNITS/ML 2 insulin detemir LEVEMIR FLEXTOUCH 100 UNITS/ML 2 insulin detemir NOVOLOG 100 UNIT/ML CARTRIDGE 3 insulin aspart NOVOLOG 100 UNIT/ML VIAL 3 insulin aspart NOVOLOG FLEXPEN SYRINGE 3 insulin aspart NOVOLOG MIX 70-30 FLEXPEN SYRN 3 insulin aspart protamine human/insulin aspart NOVOLOG MIX 70-30 VIAL 3 insulin aspart protamine human/insulin aspart Blood Products/Modifiers/ Volume Expanders

Anticoagulants

PAGE 226 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ACD INJECTION SOLUTION 3 dextrose-water/sodium citrate/citric acid ACD-A SOLUTION 3 citrate dextrose solution ACTIVASE 100 MG VIAL 9 alteplase ACTIVASE 50 MG VIAL 9 alteplase ANGIOMAX 250 MG VIAL 9 bivalirudin

argatroban 250 mg/2.5 ml vial 1

argatroban-nacl 125 mg/125 ml 9

argatroban-nacl 50 mg/50 ml vl 9

ARIXTRA 10 MG SYRINGE 5 fondaparinux sodium ARIXTRA 2.5 MG SYRINGE 5 fondaparinux sodium ARIXTRA 5 MG SYRINGE 5 fondaparinux sodium ARIXTRA 7.5 MG SYRINGE 5 fondaparinux sodium CATHFLO ACTIVASE 2 MG VIAL 9 alteplase CEPROTIN 400-600 UNITS VIAL 5 PA protein c concentrate, human CEPROTIN 800-1,200 UNITS VIAL 5 PA protein c concentrate, human

citrate phos dextrose soln 3

COUMADIN 1 MG TABLET 2 warfarin sodium COUMADIN 10 MG TABLET 2 warfarin sodium COUMADIN 2 MG TABLET 2 warfarin sodium COUMADIN 2.5 MG TABLET 2 warfarin sodium

COUMADIN 3 MG TABLET 2

PAGE 227 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS warfarin sodium COUMADIN 4 MG TABLET 2 warfarin sodium COUMADIN 5 MG TABLET 2 warfarin sodium COUMADIN 5 MG VIAL 9 warfarin sodium COUMADIN 6 MG TABLET 2 warfarin sodium COUMADIN 7.5 MG TABLET 2 warfarin sodium ELIQUIS 2.5 MG TABLET 3 QL 30 / 30 days apixaban ELIQUIS 5 MG TABLET 3 QL 30 / 30 days apixaban

enoxaparin 100 mg/ml syringe 4 QL 60 / 30 days

enoxaparin 120 mg/0.8 ml syr 4 QL 48 / 30 days

enoxaparin 150 mg/ml syringe 4 QL 60 / 30 days

enoxaparin 30 mg/0.3 ml syr 4 QL 18 / 30 days

enoxaparin 300 mg/3 ml vial 4 QL 180 / 30 days

enoxaparin 40 mg/0.4 ml syr 4 QL 24 / 30 days

enoxaparin 60 mg/0.6 ml syr 4 QL 36 / 30 days

enoxaparin 80 mg/0.8 ml syr 4 QL 48 / 30 days

fondaparinux 10 mg/0.8 ml syr 4

fondaparinux 2.5 mg/0.5 ml syr 4

fondaparinux 5 mg/0.4 ml syr 4

fondaparinux 7.5 mg/0.6 ml syr 4

FRAGMIN 10,000 UNITS SYRINGE 5 dalteparin sodium,porcine FRAGMIN 12,500 UNITS SYRINGE 5 dalteparin sodium,porcine FRAGMIN 15,000 UNITS SYRINGE 5 dalteparin sodium,porcine

FRAGMIN 18,000 UNITS SYRINGE 5

PAGE 228 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS dalteparin sodium,porcine FRAGMIN 2,500 UNITS SYRINGE 5 dalteparin sodium,porcine FRAGMIN 25,000 UNITS/ML VIAL 5 dalteparin sodium,porcine FRAGMIN 5,000 UNITS SYRINGE 5 dalteparin sodium,porcine FRAGMIN 7,500 UNITS SYRINGE 5 dalteparin sodium,porcine

hep-lock flush 10 units/ml kit 7

hep-lock flush 100 unit/ml kit 7

heparin 1,000 unit/10 (100/ml) 7

heparin 10 unit/10 ml (1/ml) 7

heparin 10,000 unit/10 ml vial 7

heparin 100 unit/10 ml (10/ml) 7

heparin 2 unit/2 ml (1/ml) syr 7

heparin 2,000 unit/2 ml vial 7

heparin 20 units/2 ml (10/ml) 7

heparin 200 unit/2 ml (100/ml) 7

heparin 3 unit/3 ml (1/ml) syr 7

heparin 3,000 unit/30 (100/ml) 7

heparin 30 unit/3 ml (10/ml) 7

heparin 30 units/3 ml (10/ml) 7

heparin 30,000 unit/30 ml vial 7

PAGE 229 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

heparin 30,000 unit/30 ml vial 7

heparin 300 unit/3 ml (100/ml) 7

heparin 40,000 units/4 ml vial 7

heparin 5 unit/5 ml (1/ml) syr 7

heparin 50 units/5 ml (10/ml) 7

heparin 50,000 unit/10 ml vial 7

heparin 50,000 units/10 ml vl 7

heparin 50,000 units/5 ml vial 7

heparin 500 unit/5 ml (100/ml) 7

heparin 60 units/6 ml (10/ml) 7

heparin iv flush 1 unit/ml syr 7

heparin iv flush 10 unit/ml sy 7

heparin iv flush 100 units/ml 7

heparin lock flush 10 units/ml 7

heparin lock flush 100 unit/ml 7

heparin sod 1,000 unit/ml vial 7

heparin sod 10,000 unit/ml vl 7

heparin sod 20,000 unit/ml vl 7

PAGE 230 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

heparin sod 5,000 unit/ 0.5 ml 7

heparin sod 5,000 unit/0.5 ml 7

heparin sod 5,000 unit/ml syr 7

heparin sod 5,000 unit/ml vial 7

heparin-1/2ns 12,500 units/250 7

heparin-1/2ns 25,000 units/250 7

heparin-1/2ns 25,000 units/500 7

heparin-d5w 12,500 unit/250 ml 7

heparin-d5w 20,000 unit/500 ml 7

heparin-d5w 25,000 unit/250 ml 7

heparin-d5w 25,000 unit/500 ml 7

heparin-ns 1,000 units/500 ml 7

heparin-ns 2,000 unit/1,000 ml 7

IPRIVASK 15 MG VIAL 9 desirudin IPRIVASK 15 MG VIAL 9 desirudin

jantoven 1 mg tablet 1

jantoven 10 mg tablet 1

jantoven 2 mg tablet 1

jantoven 2.5 mg tablet 1

jantoven 3 mg tablet 1

jantoven 4 mg tablet 1

jantoven 5 mg tablet 1

jantoven 6 mg tablet 1

jantoven 7.5 mg tablet 1

LOVENOX 100 MG/ML SYRINGE 5 QL 60 / 30 days enoxaparin sodium

PAGE 231 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS LOVENOX 120 MG/0.8 ML SYRINGE 5 QL 48 / 30 days enoxaparin sodium LOVENOX 150 MG/ML SYRINGE 5 QL 60 / 30 days enoxaparin sodium LOVENOX 30 MG/0.3 ML SYRINGE 5 QL 18 / 30 days enoxaparin sodium LOVENOX 300 MG/3 ML VIAL 5 QL 180 / 30 days enoxaparin sodium LOVENOX 40 MG/0.4 ML SYRINGE 5 QL 24 / 30 days enoxaparin sodium LOVENOX 60 MG/0.6 ML SYRINGE 5 QL 36 / 30 days enoxaparin sodium LOVENOX 80 MG/0.8 ML SYRINGE 5 QL 48 / 30 days enoxaparin sodium PRADAXA 150 MG CAPSULE 2 QL 60 / 30 days dabigatran etexilate mesylate PRADAXA 75 MG CAPSULE 2 QL 60 / 30 days dabigatran etexilate mesylate REFLUDAN 50 MG VIAL 3 lepirudin,recombinant RETAVASE VIAL HALF-KIT 9 reteplase RETAVASE VIAL KIT 9 reteplase TNKASE 50 MG KIT 9 tenecteplase TRICITRASOL 46.7% VIAL 3 sodium citrate dihydrate

warfarin sodium 1 mg tablet 1

warfarin sodium 10 mg tablet 1

warfarin sodium 2 mg tablet 1

warfarin sodium 2.5 mg tablet 1

warfarin sodium 3 mg tablet 1

warfarin sodium 4 mg tablet 1

warfarin sodium 5 mg tablet 1

warfarin sodium 6 mg tablet 1

PAGE 232 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

warfarin sodium 7.5 mg tablet

XARELTO 10 MG TABLET 2 QL 30 / 30 days rivaroxaban XARELTO 15 MG TABLET 2 QL 30 / 30 days rivaroxaban XARELTO 20 MG TABLET 2 QL 30 / 30 days rivaroxaban XARELTO STARTER PACK 3 rivaroxaban Blood Formation Modifiers

AGRYLIN 0.5 MG CAPSULE 3 anagrelide hcl ALBUKED-25 VIAL 5 PA albumin human ALBUKED-5 VIAL 5 PA albumin human

albumin (human) 5% iv solution 4 PA

ALBUMINAR-25 IV SOLUTION 5 PA albumin human ALBUMINAR-25 IV SOLUTION 5 PA albumin human ALBUMINAR-5 IV SOLUTION 5 PA albumin human ALBUMINAR-5 IV SOLUTION 5 PA albumin human ALBURX (HUMAN) 25% VIAL 5 PA albumin human ALBURX (HUMAN) 5% VIAL 5 PA albumin human ALBUTEIN 25% VIAL 5 PA albumin human ALBUTEIN 5% VIAL 5 PA albumin human ALBUTEIN 5% VIAL 5 PA albumin human

anagrelide hcl 0.5 mg capsule 1

anagrelide hcl 1 mg capsule 1

ARANESP 100 MCG/0.5 ML SYRINGE 5

PAGE 233 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS darbepoetin alfa in polysorbate 80 ARANESP 100 MCG/ML VIAL 5 darbepoetin alfa in polysorbate 80 ARANESP 150 MCG/0.3 ML SYRINGE 5 darbepoetin alfa in polysorbate 80 ARANESP 150 MCG/0.75 ML VIAL 5 darbepoetin alfa in polysorbate 80 ARANESP 200 MCG/0.4 ML SYRINGE 5 darbepoetin alfa in polysorbate 80 ARANESP 200 MCG/ML VIAL 5 darbepoetin alfa in polysorbate 80 ARANESP 25 MCG/0.42 ML SYRING 5 darbepoetin alfa in polysorbate 80 ARANESP 25 MCG/ML VIAL 5 darbepoetin alfa in polysorbate 80 ARANESP 300 MCG/0.6 ML SYRINGE 5 darbepoetin alfa in polysorbate 80 ARANESP 300 MCG/ML VIAL 5 darbepoetin alfa in polysorbate 80 ARANESP 40 MCG/0.4 ML SYRINGE 5 darbepoetin alfa in polysorbate 80 ARANESP 40 MCG/ML VIAL 5 darbepoetin alfa in polysorbate 80 ARANESP 500 MCG/1 ML SYRINGE 5 darbepoetin alfa in polysorbate 80 ARANESP 60 MCG/0.3 ML SYRINGE 5 darbepoetin alfa in polysorbate 80 ARANESP 60 MCG/ML VIAL 5 darbepoetin alfa in polysorbate 80 ATRYN 1,750 UNIT VIAL 5 antithrombin iii, human recombinant BERINERT 500 UNIT KIT 5 PA c1 esterase inhibitor BERINERT 500 UNIT VIAL 3 c1 esterase inhibitor BUMINATE 25% IV SOLUTION 5 PA albumin human BUMINATE 5% IV SOLUTION 5 PA albumin human

CINRYZE 500 UNIT VIAL 5

PAGE 234 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS c1 esterase inhibitor EPOGEN 10,000 UNITS/ML VIAL 5 QL 13 / 30 days epoetin alfa EPOGEN 2,000 UNITS/ML VIAL 5 QL 13 / 30 days epoetin alfa EPOGEN 20,000 UNITS/2 ML VIAL 5 QL 13 / 30 days epoetin alfa EPOGEN 20,000 UNITS/ML VIAL 5 QL 13 / 30 days epoetin alfa EPOGEN 3,000 UNITS/ML VIAL 5 QL 13 / 30 days epoetin alfa EPOGEN 4,000 UNITS/ML VIAL 5 QL 13 / 30 days epoetin alfa FLEXBUMIN 25% IV SOLUTION 5 PA albumin human FLEXBUMIN 5% IV SOLUTION 5 PA albumin human GRANIX 300 MCG/0.5 ML SYRINGE 3 tbo-filgrastim GRANIX 480 MCG/0.8 ML SYRINGE 3 tbo-filgrastim HESPAN 6%-NS INFUSION BAG 9 hetastarch in 0.9 % sodium chloride

hetastarch 6% in ns 7

HEXTEND 6%-LACT ELEC BAG 3 hetastarch/electrolyte solution,lactated

human albumin 25% iv solution 4 PA

KEDBUMIN 25% VIAL 5 PA albumin human LEUKINE 250 MCG VIAL 9 sargramostim LEUKINE 250 MCG VIAL 9 sargramostim LEUKINE 500 MCG/ML VIAL 9 sargramostim MOZOBIL 20 MG/ML VIAL 9 plerixafor

MOZOBIL 24 MG/1.2 ML VIAL 9

PAGE 235 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

plerixafor

NEULASTA 6 MG/0.6 ML SYRINGE 5 QL 1 / 30 days pegfilgrastim

NEUMEGA 5 MG VIAL QL 21 / 30 days 5 oprelvekin PA

NEUPOGEN 300 MCG/0.5 ML SYR 5 filgrastim NEUPOGEN 300 MCG/ML VIAL 5 filgrastim NEUPOGEN 480 MCG/0.8 ML SYR 5 filgrastim NEUPOGEN 480 MCG/1.6 ML VIAL 5 filgrastim NPLATE 250 MCG VIAL 9 romiplostim NPLATE 500 MCG VIAL 9 romiplostim OCTAPLAS BLOOD GROUP A IV BAG 5 PA plasma human, blood group a OCTAPLAS BLOOD GROUP AB IV BAG 5 PA plasma human, blood group ab OCTAPLAS BLOOD GROUP B IV BAG 5 PA plasma human, blood group b OCTAPLAS BLOOD GROUP O IV BAG 5 PA plasma human, blood group o PLASBUMIN-25 IV SOLUTION 5 PA albumin human PLASBUMIN-5 IV SOLUTION 5 PA albumin human PLASBUMIN-5 IV SOLUTION 5 PA albumin human PLASMANATE 5% IV SOLUTION 5 PA plasma protein fraction PROCRIT 10,000 UNITS/ML VIAL 5 QL 13 / 30 days epoetin alfa PROCRIT 10,000 UNITS/ML VIAL 5 QL 13 / 30 days epoetin alfa PROCRIT 2,000 UNITS/ML VIAL 5 QL 13 / 30 days epoetin alfa

PAGE 236 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS PROCRIT 20,000 UNITS/ML VIAL QL 13 / 30 days epoetin alfa PROCRIT 3,000 UNITS/ML VIAL 5 QL 13 / 30 days epoetin alfa PROCRIT 4,000 UNITS/ML VIAL 5 QL 13 / 30 days epoetin alfa PROCRIT 40,000 UNITS/ML VIAL 5 QL 13 / 30 days epoetin alfa PROMACTA 12.5 MG TABLET 3 QL 30 / 30 days eltrombopag olamine PROMACTA 25 MG TABLET 3 QL 30 / 30 days eltrombopag olamine PROMACTA 50 MG TABLET 3 QL 30 / 30 days eltrombopag olamine PROMACTA 75 MG TABLET 3 QL 30 / 30 days eltrombopag olamine SOLIRIS 300 MG/30 ML VIAL 9 eculizumab THROMBATE III 1,000 UNITS VIAL 5 PA antithrombin iii (human plasma derived) THROMBATE III 500 UNITS VIAL 5 PA antithrombin iii (human plasma derived) VOLUVEN INJECTION 9 hydroxyethyl starch 130/0.4 in 0.9 % sodium chloride Coagulants

ADVATE 1,201-1,800 UNITS VIAL 5 PA antihemophilic factor viii (plasma/albumin-free) ADVATE 1,201-1,800 UNITS VIAL 5 PA antihemophilic factor viii (plasma/albumin-free) ADVATE 1,201-1,800 UNITS VIAL 5 PA antihemophilic factor viii (plasma/albumin-free) ADVATE 1,801-2,400 UNITS VIAL 5 PA antihemophilic factor viii (plasma/albumin-free) ADVATE 1,801-2,400 UNITS VIAL 5 PA antihemophilic factor viii (plasma/albumin-free) ADVATE 1,801-2,400 UNITS VIAL 5 PA antihemophilic factor viii (plasma/albumin-free) ADVATE 2,401-3,600 UNITS VIAL 5 PA antihemophilic factor viii (plasma/albumin-free)

ADVATE 2,401-3,600 UNITS VIAL 5 PA

PAGE 237 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS antihemophilic factor viii (plasma/albumin-free) ADVATE 200-400 UNITS VIAL 5 PA antihemophilic factor viii (plasma/albumin-free) ADVATE 200-400 UNITS VIAL 5 PA antihemophilic factor viii (plasma/albumin-free) ADVATE 200-400 UNITS VIAL 5 PA antihemophilic factor viii (plasma/albumin-free) ADVATE 3,601-4,800 UNITS VIAL 5 PA antihemophilic factor viii (plasma/albumin-free) ADVATE 3,601-4,800 UNITS VIAL 5 PA antihemophilic factor viii (plasma/albumin-free) ADVATE 401-800 UNITS VIAL 5 PA antihemophilic factor viii (plasma/albumin-free) ADVATE 401-800 UNITS VIAL 5 PA antihemophilic factor viii (plasma/albumin-free) ADVATE 401-800 UNITS VIAL 5 PA antihemophilic factor viii (plasma/albumin-free) ADVATE 801-1,200 UNITS VIAL 5 PA antihemophilic factor viii (plasma/albumin-free) ADVATE 801-1,200 UNITS VIAL 5 PA antihemophilic factor viii (plasma/albumin-free) ADVATE 801-1,200 UNITS VIAL 5 PA antihemophilic factor viii (plasma/albumin-free) ALPHANATE 1,000-400 UNIT VIAL 5 PA antihemophilic factor, human/von willebrand factor,human ALPHANATE 1,500-600 UNIT VIAL 5 PA antihemophilic factor, human/von willebrand factor,human ALPHANATE 250-100 UNIT VIAL 5 PA antihemophilic factor, human/von willebrand factor,human ALPHANATE 500-200 UNIT VIAL 5 PA antihemophilic factor, human/von willebrand factor,human ALPHANINE SD 1,000 UNITS VIAL 5 PA factor ix ALPHANINE SD 1,000 UNITS VIAL 5 PA factor ix ALPHANINE SD 1,500 UNITS VIAL 5 PA factor ix ALPHANINE SD 1,500 UNITS VIAL 5 PA factor ix

ALPHANINE SD 500 UNITS VIAL 5 PA

PAGE 238 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS factor ix ALPHANINE SD 500 UNITS VIAL 5 PA factor ix ALPROLIX 1,000 UNIT NOMINAL 3 factor ix recombinant, fc fusion protein ALPROLIX 2,000 UNIT NOMINAL 3 factor ix recombinant, fc fusion protein ALPROLIX 3,000 UNIT NOMINAL 3 factor ix recombinant, fc fusion protein ALPROLIX 500 UNIT NOMINAL 3 factor ix recombinant, fc fusion protein

aminocaproic acid 1,000 mg tab 4 PA

aminocaproic acid 25% solution 4 PA

aminocaproic acid 250 mg/ml 4 PA

aminocaproic acid 500 mg tab 4 PA

BEBULIN 200-1,200 UNITS VIAL 5 PA factor ix complex human BEBULIN VH IMMU 200-1,200 UNIT 5 PA factor ix complex human BENEFIX 1,000 UNIT KIT 5 PA factor ix human recombinant BENEFIX 2,000 UNIT KIT 5 PA factor ix human recombinant BENEFIX 250 UNIT KIT 5 PA factor ix human recombinant BENEFIX 3,000 UNIT KIT 5 PA factor ix human recombinant BENEFIX 500 UNIT KIT 5 PA factor ix human recombinant CORIFACT KIT 5 PA factor xiii CYKLOKAPRON 100 MG/ML AMPUL 9 PA tranexamic acid FEIBA NF 1,000 UNIT (NOMINAL) 5 PA anti-inhibitor coagulant complex FEIBA NF 1,750-3,250 UNIT VIAL 5 PA anti-inhibitor coagulant complex

FEIBA NF 2,500 UNIT (NOMINAL) 5 PA

PAGE 239 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS anti-inhibitor coagulant complex FEIBA NF 400-650 UNIT VIAL 5 PA anti-inhibitor coagulant complex FEIBA NF 500 UNIT (NOMINAL) 5 PA anti-inhibitor coagulant complex FEIBA NF 651-1,200 UNIT VIAL 5 PA anti-inhibitor coagulant complex FEIBA VH IMMUNO 651-1,200 UNIT 5 PA anti-inhibitor coagulant complex HELIXATE FS 1,000 UNIT VIAL 5 PA antihemophilic factor viii, human recombinant HELIXATE FS 2,000 UNIT VIAL 5 PA antihemophilic factor viii, human recombinant HELIXATE FS 250 UNIT VIAL 5 PA antihemophilic factor viii, human recombinant HELIXATE FS 3,000 UNITS VIAL 5 PA antihemophilic factor viii, human recombinant HELIXATE FS 500 UNIT VIAL 5 PA antihemophilic factor viii, human recombinant HEMOFIL M 1,000 UNIT NOMINAL 5 PA antihemophilic factor, human HEMOFIL M 1,700 UNIT NOMINAL 5 PA antihemophilic factor, human HEMOFIL M 250 UNIT NOMINAL 5 PA antihemophilic factor, human HEMOFIL M 500 UNIT NOMINAL 5 PA antihemophilic factor, human HUMATE-P 1,200 UNIT VWF:RCO 5 PA antihemophilic factor, human/von willebrand factor,human HUMATE-P 2,400 UNIT VWF:RCO 5 PA antihemophilic factor, human/von willebrand factor,human HUMATE-P 600 UNIT VWF:RCO 5 PA antihemophilic factor, human/von willebrand factor,human KCENTRA 1,000 UNIT KIT 3 human prothrombin complex concentrate (pcc) KCENTRA 500 UNIT KIT 3 human prothrombin complex concentrate (pcc) KCENTRA 500 UNIT VIAL 3 human prothrombin complex concentrate (pcc)

KOATE-DVI 1,000 UNITS VIAL 5 PA

PAGE 240 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS antihemophilic factor, human KOATE-DVI 250 UNITS VIAL 5 PA antihemophilic factor, human KOATE-DVI 500 UNITS KIT 5 PA antihemophilic factor, human KOATE-DVI 500 UNITS VIAL 5 PA antihemophilic factor, human KOGENATE FS 1,000 UNIT VIAL 5 PA antihemophilic factor viii, human recombinant KOGENATE FS 1,000 UNITS VIAL 5 PA antihemophilic factor viii, human recombinant KOGENATE FS 2,000 UNIT VIAL 5 PA antihemophilic factor viii, human recombinant KOGENATE FS 250 UNIT VIAL 5 PA antihemophilic factor viii, human recombinant KOGENATE FS 3,000 UNIT VIAL 5 PA antihemophilic factor viii, human recombinant KOGENATE FS 3,000 UNITS VIAL 5 PA antihemophilic factor viii, human recombinant KOGENATE FS 500 UNIT VIAL 5 PA antihemophilic factor viii, human recombinant LYSTEDA 650 MG TABLET 3 QL 30 / 30 days tranexamic acid LYSTEDA 650 MG TABLET 3 QL 30 / 30 days tranexamic acid MONOCLATE-P 1,000 UNITS KIT 5 PA antihemophilic factor, human MONOCLATE-P 1,500 UNITS KIT 5 PA antihemophilic factor, human MONONINE 1,000 UNITS KIT 5 PA factor ix NOVOSEVEN RT 1 MG VIAL 5 PA coagulation factor viia (recombinant) NOVOSEVEN RT 2 MG VIAL 5 PA coagulation factor viia (recombinant) NOVOSEVEN RT 5 MG VIAL 5 PA coagulation factor viia (recombinant) NOVOSEVEN RT 8 MG VIAL 5 PA coagulation factor viia (recombinant)

PROFILNINE 1,000 UNITS VIAL 5 PA

PAGE 241 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS factor ix complex human PROFILNINE 1,000 UNITS VIAL 5 PA factor ix complex human PROFILNINE 1,500 UNITS VIAL 5 PA factor ix complex human PROFILNINE 1,500 UNITS VIAL 5 PA factor ix complex human PROFILNINE 500 UNITS VIAL 5 PA factor ix complex human PROFILNINE 500 UNITS VIAL 5 PA factor ix complex human

protamine 10 mg/ml vial 1

protamine 250 mg/25 ml vial 1

protamine 50 mg/5 ml vial 1

RECOMBINATE 1,241-1,800 UNIT V 5 PA antihemophilic factor viii, human recombinant RECOMBINATE 1,801-2,400 UNIT V 5 PA antihemophilic factor viii, human recombinant RECOMBINATE 220-400 UNIT VIAL 5 PA antihemophilic factor viii, human recombinant RECOMBINATE 401-800 UNIT VIAL 5 PA antihemophilic factor viii, human recombinant RECOMBINATE 801-1,240 UNIT VL 5 PA antihemophilic factor viii, human recombinant RIASTAP VIAL 5 PA fibrinogen RIXUBIS 1,000 UNIT NOMINAL 5 PA factor ix human recombinant RIXUBIS 2,000 UNIT NOMINAL 5 PA factor ix human recombinant RIXUBIS 250 UNIT NOMINAL 5 PA factor ix human recombinant RIXUBIS 3,000 UNIT NOMINAL 5 PA factor ix human recombinant RIXUBIS 500 UNIT NOMINAL 5 PA factor ix human recombinant

tranexamic acid 1,000 mg/10 ml 7 PA

PAGE 242 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

tranexamic acid 650 mg tablet 1 QL 30 / 30 days

TRETTEN 2,500 UNIT VIAL 3 factor xiii a-subunit, recombinant WILATE 1,000-1,000 UNIT KIT 5 PA antihemophilic factor, human/von willebrand factor,human WILATE 450-450 UNIT KIT 5 PA antihemophilic factor, human/von willebrand factor,human WILATE 500-500 UNIT KIT 5 PA antihemophilic factor, human/von willebrand factor,human WILATE 900-900 UNIT KIT 5 PA antihemophilic factor, human/von willebrand factor,human XYNTHA 1,000 UNIT KIT 5 PA antihemophilic factor viii (plasma/albumin-free) XYNTHA 2,000 UNIT KIT 5 PA antihemophilic factor viii (plasma/albumin-free) XYNTHA 250 UNIT KIT 5 PA antihemophilic factor viii (plasma/albumin-free) XYNTHA 3,000 UNIT SYRINGE KIT 5 PA antihemophilic factor viii (plasma/albumin-free) XYNTHA 500 UNIT KIT 5 PA antihemophilic factor viii (plasma/albumin-free) XYNTHA SOLOFUSE 1,000 UNIT KIT 5 PA antihemophilic factor viii (plasma/albumin-free) XYNTHA SOLOFUSE 2,000 UNIT KIT 5 PA antihemophilic factor viii (plasma/albumin-free) XYNTHA SOLOFUSE 250 UNIT KIT 5 PA antihemophilic factor viii (plasma/albumin-free) XYNTHA SOLOFUSE 500 UNIT KIT 5 PA antihemophilic factor viii (plasma/albumin-free) Platelet Modifying Agents

AGGRASTAT 12.5 MG/250 ML 9 tirofiban hcl monohydrate in 0.9 % sodium chloride AGGRASTAT 5 MG/100 ML IV SOLN 9 tirofiban hcl monohydrate in 0.9 % sodium chloride AGGRENOX 25 MG-200 MG CAPSULE 2 aspirin/dipyridamole AGRYLIN 0.5 MG CAPSULE 3 anagrelide hcl

PAGE 243 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

anagrelide hcl 0.5 mg capsule 1

anagrelide hcl 1 mg capsule 1

BRILINTA 90 MG TABLET 3 ticagrelor

cilostazol 100 mg tablet 1

cilostazol 50 mg tablet 1

clopidogrel 300 mg tablet 1 QL 30 / 30 days

clopidogrel 75 mg tablet 1 QL 30 / 30 days

dipyridamole 25 mg tablet 1

dipyridamole 5 mg/ml vial 7

dipyridamole 50 mg tablet 1

dipyridamole 75 mg tablet 1

EFFIENT 10 MG TABLET 2 QL 30 / 30 days prasugrel hcl EFFIENT 5 MG TABLET 2 QL 30 / 30 days prasugrel hcl INTEGRILIN 20 MG/10 ML VIAL 9 eptifibatide INTEGRILIN 200 MG/100 ML VIAL 9 eptifibatide INTEGRILIN 75 MG/100 ML VIAL 9 eptifibatide INTEGRILIN 75 MG/100 ML VIAL 9 eptifibatide PERSANTINE 25 MG TABLET 3 dipyridamole PERSANTINE 50 MG TABLET 3 dipyridamole PERSANTINE 75 MG TABLET 3 dipyridamole

PLAVIX 300 MG TABLET 3 QL 30 / 30 days

PAGE 244 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS clopidogrel bisulfate PLAVIX 75 MG TABLET 3 QL 30 / 30 days clopidogrel bisulfate PLETAL 100 MG TABLET 3 cilostazol PLETAL 50 MG TABLET 3 cilostazol REOPRO 2 MG/ML VIAL 9 abciximab

ticlopidine 250 mg tablet 1

ZONTIVITY 2.08 MG TABLET 3 vorapaxar sulfate Cardiovascular Agents

Alpha-adrenergic Agonists

CATAPRES 0.1 MG TABLET 3 clonidine hcl CATAPRES 0.2 MG TABLET 3 clonidine hcl CATAPRES 0.3 MG TABLET 3 clonidine hcl CATAPRES-TTS 1 PATCH 3 clonidine CATAPRES-TTS 2 PATCH 3 clonidine CATAPRES-TTS 3 PATCH 3 clonidine

clonidine 0.1 mg/day patch 1

clonidine 0.2 mg/day patch 1

clonidine 0.3 mg/day patch 1

clonidine 1,000 mcg/10 ml vial 7

clonidine 5,000 mcg/10 ml vial 7

PAGE 245 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

clonidine 5,000 mcg/10 ml vial 7

clonidine hcl 0.1 mg tablet 1

clonidine hcl 0.2 mg tablet 1

clonidine hcl 0.3 mg tablet 1

DURACLON 100 MCG/ML VIAL 9 clonidine hcl/pf DURACLON 500 MCG/ML VIAL 9 clonidine hcl/pf

guanfacine 1 mg tablet 1

guanfacine 2 mg tablet 1

methyldopa 250 mg tablet 1

methyldopa 500 mg tablet 1

methyldopate 250 mg/5 ml vial 1

midodrine hcl 10 mg tablet 1

midodrine hcl 2.5 mg tablet 1

midodrine hcl 5 mg tablet 1

TENEX 1 MG TABLET 3 guanfacine hcl TENEX 2 MG TABLET 3 guanfacine hcl Alpha-adrenergic Blocking Agents

CARDURA 1 MG TABLET 3 ST doxazosin mesylate CARDURA 2 MG TABLET 3 ST doxazosin mesylate CARDURA 4 MG TABLET 3 ST doxazosin mesylate

PAGE 246 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS CARDURA 8 MG TABLET 3 ST doxazosin mesylate CARDURA XL 4 MG TABLET 3 ST doxazosin mesylate CARDURA XL 8 MG TABLET 3 ST doxazosin mesylate DIBENZYLINE 10 MG CAPSULE 3 phenoxybenzamine hcl

doxazosin mesylate 1 mg tab 1

doxazosin mesylate 2 mg tab 1

doxazosin mesylate 4 mg tab 1

doxazosin mesylate 8 mg tab 1

MINIPRESS 1 MG CAPSULE 3 prazosin hcl MINIPRESS 2 MG CAPSULE 3 prazosin hcl MINIPRESS 5 MG CAPSULE 3 prazosin hcl

phentolamine 5 mg/ml vial 9

prazosin 1 mg capsule 1

prazosin 2 mg capsule 1

prazosin 5 mg capsule 1

reserpine 0.1 mg tablet 2

reserpine 0.25 mg tablet 2

terazosin 1 mg capsule 1

terazosin 10 mg capsule 1

terazosin 2 mg capsule 1

terazosin 5 mg capsule 1

PAGE 247 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS Angiotensin II Receptor Antagonists

ATACAND 16 MG TABLET QL 30 / 30 days 3 candesartan cilexetil ST

ATACAND 32 MG TABLET QL 30 / 30 days 3 candesartan cilexetil ST

ATACAND 4 MG TABLET QL 30 / 30 days 3 candesartan cilexetil ST

ATACAND 8 MG TABLET QL 30 / 30 days 3 candesartan cilexetil ST

AVAPRO 150 MG TABLET QL 30 / 30 days 3 irbesartan ST

AVAPRO 300 MG TABLET QL 30 / 30 days 3 irbesartan ST

AVAPRO 75 MG TABLET QL 30 / 30 days 3 irbesartan ST

BENICAR 20 MG TABLET QL 30 / 30 days 3 olmesartan medoxomil ST

BENICAR 40 MG TABLET QL 30 / 30 days 3 olmesartan medoxomil ST

BENICAR 5 MG TABLET QL 30 / 30 days 3 olmesartan medoxomil ST

candesartan cilexetil 16 mg tb 1 QL 30 / 30 days

candesartan cilexetil 32 mg tb 1 QL 30 / 30 days

candesartan cilexetil 4 mg tab 1 QL 30 / 30 days

PAGE 248 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

candesartan cilexetil 4 mg tab 1 QL 30 / 30 days

candesartan cilexetil 8 mg tab 1 QL 30 / 30 days

COZAAR 100 MG TABLET QL 30 / 30 days 3 losartan potassium ST

COZAAR 25 MG TABLET QL 30 / 30 days 3 losartan potassium ST

COZAAR 50 MG TABLET QL 30 / 30 days 3 losartan potassium ST

DIOVAN 160 MG TABLET QL 30 / 30 days 2 valsartan ST

DIOVAN 320 MG TABLET QL 30 / 30 days 2 valsartan ST

DIOVAN 40 MG TABLET QL 30 / 30 days 2 valsartan ST

DIOVAN 80 MG TABLET QL 30 / 30 days 2 valsartan ST

EDARBI 40 MG TABLET QL 30 / 30 days 3 azilsartan medoxomil ST

EDARBI 80 MG TABLET QL 30 / 30 days 3 azilsartan medoxomil ST

eprosartan mesylate 600 mg tab 1

irbesartan 150 mg tablet 1 QL 30 / 30 days

irbesartan 300 mg tablet 1 QL 30 / 30 days

irbesartan 75 mg tablet 1 QL 30 / 30 days

losartan potassium 100 mg tab 1 QL 30 / 30 days

losartan potassium 25 mg tab 1 QL 30 / 30 days

PAGE 249 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

losartan potassium 25 mg tab QL 30 / 30 days

losartan potassium 50 mg tab 1 QL 30 / 30 days

MICARDIS 20 MG TABLET QL 30 / 30 days 3 telmisartan ST

MICARDIS 40 MG TABLET QL 30 / 30 days 3 telmisartan ST

MICARDIS 80 MG TABLET QL 30 / 30 days 3 telmisartan ST

telmisartan 20 mg tablet 1 QL 30 / 30 days

telmisartan 40 mg tablet 1 QL 30 / 30 days

telmisartan 80 mg tablet 1 QL 30 / 30 days

TEVETEN 400 MG TABLET 3 ST eprosartan mesylate TEVETEN 600 MG TABLET 3 ST eprosartan mesylate

valsartan 160 mg tablet 1 QL 30 / 30 days

valsartan 320 mg tablet 1 QL 30 / 30 days

valsartan 40 mg tablet 1 QL 30 / 30 days

valsartan 80 mg tablet 1 QL 30 / 30 days

Angiotensin-converting Enzyme (ACE) Inhibitors

ACCUPRIL 10 MG TABLET 3 quinapril hcl ACCUPRIL 20 MG TABLET 3 quinapril hcl ACCUPRIL 40 MG TABLET 3 quinapril hcl ACCUPRIL 5 MG TABLET 3 quinapril hcl ACEON 4 MG TABLET 3 perindopril erbumine ACEON 8 MG TABLET 3 perindopril erbumine

PAGE 250 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ALTACE 1.25 MG CAPSULE 3 ramipril ALTACE 10 MG CAPSULE 3 ramipril ALTACE 2.5 MG CAPSULE 3 ramipril ALTACE 5 MG CAPSULE 3 ramipril

benazepril hcl 10 mg tablet 1

benazepril hcl 20 mg tablet 1

benazepril hcl 40 mg tablet 1

benazepril hcl 5 mg tablet 1

captopril 100 mg tablet 1

captopril 12.5 mg tablet 1

captopril 25 mg tablet 1

captopril 50 mg tablet 1

enalapril maleate 10 mg tab 1

enalapril maleate 2.5 mg tab 1

enalapril maleate 20 mg tab 1

enalapril maleate 5 mg tablet 1

enalaprilat 1.25 mg/ml vial 7

enalaprilat 2.5 mg/2 ml vial 7

EPANED 1 MG/ML SOLUTION 3 enalapril maleate

PAGE 251 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

fosinopril sodium 10 mg tab

fosinopril sodium 20 mg tab 1

fosinopril sodium 40 mg tab 1

lisinopril 10 mg tablet 1

lisinopril 2.5 mg tablet 1

lisinopril 20 mg tablet 1

lisinopril 30 mg tablet 1

lisinopril 40 mg tablet 1

lisinopril 5 mg tablet 1

LOTENSIN 10 MG TABLET 3 benazepril hcl LOTENSIN 20 MG TABLET 3 benazepril hcl LOTENSIN 40 MG TABLET 3 benazepril hcl MAVIK 1 MG TABLET 3 trandolapril MAVIK 2 MG TABLET 3 trandolapril MAVIK 4 MG TABLET 3 trandolapril

moexipril hcl 15 mg tablet 1

moexipril hcl 7.5 mg tablet 1

perindopril erbumine 2 mg tab 1

perindopril erbumine 4 mg tab 1

PAGE 252 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

perindopril erbumine 4 mg tab 1

perindopril erbumine 8 mg tab 1

PRINIVIL 10 MG TABLET 3 lisinopril PRINIVIL 20 MG TABLET 3 lisinopril PRINIVIL 5 MG TABLET 3 lisinopril

quinapril 10 mg tablet 1

quinapril 20 mg tablet 1

quinapril 40 mg tablet 1

quinapril 5 mg tablet 1

ramipril 1.25 mg capsule 1

ramipril 10 mg capsule 1

ramipril 2.5 mg capsule 1

ramipril 5 mg capsule 1

trandolapril 1 mg tablet 1

trandolapril 2 mg tablet 1

trandolapril 4 mg tablet 1

UNIVASC 15 MG TABLET 3 moexipril hcl

PAGE 253 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS UNIVASC 7.5 MG TABLET 3 moexipril hcl VASOTEC 10 MG TABLET 3 enalapril maleate VASOTEC 2.5 MG TABLET 3 enalapril maleate VASOTEC 20 MG TABLET 3 enalapril maleate VASOTEC 5 MG TABLET 3 enalapril maleate ZESTRIL 10 MG TABLET 3 lisinopril ZESTRIL 2.5 MG TABLET 3 lisinopril ZESTRIL 20 MG TABLET 3 lisinopril ZESTRIL 30 MG TABLET 3 lisinopril ZESTRIL 40 MG TABLET 3 lisinopril ZESTRIL 5 MG TABLET 3 lisinopril Antiarrhythmics

ADENOCARD 12 MG/4 ML SYRINGE 9 adenosine ADENOCARD 6 MG/2 ML SYRINGE 9 adenosine

adenosine 12 mg/4 ml syringe 7

adenosine 12 mg/4 ml vial 7

adenosine 6 mg/2 ml syringe 7

adenosine 6 mg/2 ml vial 7

amiodarone 150 mg/3 ml amp 7

amiodarone 150 mg/3 ml syringe 7

amiodarone 150 mg/3 ml vial 7

PAGE 254 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

amiodarone 450 mg/9 ml vial 7

amiodarone 900 mg/18 ml vial 1

amiodarone hcl 100 mg tablet 1

amiodarone hcl 200 mg tablet 1

amiodarone hcl 400 mg tablet 1

ATROPEN 0.5 MG/0.7 ML SYRINGE 9 atropine sulfate ATROPEN 1 MG/0.7 ML SYRINGE 9 atropine sulfate ATROPEN 2 MG/0.7 ML SYRINGE 9 atropine sulfate

atropine 0.05 mg/ml syringe 9

atropine 0.1 mg/ml abboject 7

atropine 0.1 mg/ml syringe 7

atropine 0.4 mg/ml vial 7

atropine 1 mg/ml vial 7

atropine 8 mg/20 ml vial 7

BETAPACE 120 MG TABLET 3 ST sotalol hcl BETAPACE 160 MG TABLET 3 ST sotalol hcl BETAPACE 240 MG TABLET 3 ST sotalol hcl BETAPACE 80 MG TABLET 3 ST sotalol hcl BETAPACE AF 120 MG TABLET 3 ST sotalol hcl BETAPACE AF 160 MG TABLET 3 ST sotalol hcl BETAPACE AF 80 MG TABLET 3 ST sotalol hcl CALAN 120 MG TABLET 3 ST verapamil hcl CALAN 80 MG TABLET 3 ST verapamil hcl

PAGE 255 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS CORDARONE 200 MG TABLET 3 amiodarone hcl CORVERT 1 MG/10 ML VIAL 9 ibutilide fumarate

diltiazem 125 mg/25 ml vial 7

diltiazem 25 mg/5 ml vial 7

diltiazem 50 mg/10 ml vial 7

diltiazem hcl 100 mg vial 1

disopyramide 100 mg capsule 1

disopyramide 150 mg capsule 1

flecainide acetate 100 mg tab 1

flecainide acetate 150 mg tab 1

flecainide acetate 50 mg tab 1

glycopyrrolate 0.2 mg/ml vial 7

glycopyrrolate 0.4 mg/2 ml vl 7

glycopyrrolate 1 mg/5 ml vial 7

glycopyrrolate 4 mg/20 ml vial 7

ibutilide fum 1 mg/10 ml vial 7

lidocaine hcl 1% abboject 7

lidocaine hcl 1% syringe 7

lidocaine hcl 2% abboject 7

lidocaine hcl 2% luer-jet 7

lidocaine hcl 2% syringe 7

mexiletine 150 mg capsule 1

mexiletine 200 mg capsule 1

mexiletine 250 mg capsule 1

MULTAQ 400 MG TABLET 3 QL 60 / 30 days dronedarone hcl

PAGE 256 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS NEXTERONE 150 MG/100 ML BAG 9 amiodarone in dextrose, iso-osmotic NEXTERONE 360 MG/200 ML BAG 9 amiodarone in dextrose, iso-osmotic NORPACE 100 MG CAPSULE 3 disopyramide phosphate NORPACE 150 MG CAPSULE 3 disopyramide phosphate NORPACE CR 100 MG CAPSULE 3 disopyramide phosphate NORPACE CR 150 MG CAPSULE 3 disopyramide phosphate PACERONE 100 MG TABLET 1 amiodarone hcl

pacerone 200 mg tablet 1

PACERONE 400 MG TABLET 1 amiodarone hcl

procainamide 100 mg/ml vial 7

procainamide 500 mg/ml vial 7

propafenone hcl 150 mg tablet 1

propafenone hcl 225 mg tab 1

propafenone hcl 300 mg tab 1

propafenone hcl er 225 mg cap 1

propafenone hcl sr 325 mg cap 1

propafenone hcl sr 425 mg cap 1

quinidine gluc 80 mg/ml vial 9

quinidine gluc er 324 mg tab 1

quinidine sulf er 300 mg tab 1

quinidine sulfate 200 mg tab 1

quinidine sulfate 300 mg tab 1

ROBINUL 0.2 MG/ML VIAL 9 glycopyrrolate ROBINUL 0.4 MG/2 ML VIAL 9 glycopyrrolate

PAGE 257 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ROBINUL 1 MG/5 ML VIAL 9 glycopyrrolate ROBINUL 4 MG/20 ML VIAL 9 glycopyrrolate RYTHMOL 150 MG TABLET 3 propafenone hcl RYTHMOL 225 MG TABLET 3 propafenone hcl RYTHMOL SR 225 MG CAPSULE 3 propafenone hcl RYTHMOL SR 325 MG CAPSULE 3 propafenone hcl RYTHMOL SR 425 MG CAPSULE 3 propafenone hcl

sorine 120 mg tablet 1

sorine 160 mg tablet 1

sorine 240 mg tablet 1

sorine 80 mg tablet 1

sotalol 120 mg tablet 1

sotalol 160 mg tablet 1

sotalol 240 mg tablet 1

sotalol 80 mg tablet 1

sotalol af 120 mg tablet 1

sotalol af 160 mg tablet 1

sotalol af 80 mg tablet 1

sotalol hcl 150 mg/10 ml vial 9

TAMBOCOR 100 MG TABLET 3 flecainide acetate TAMBOCOR 150 MG TABLET 3 flecainide acetate TAMBOCOR 50 MG TABLET 3 flecainide acetate

TIKOSYN 125 MCG CAPSULE 5

PAGE 258 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS dofetilide TIKOSYN 250 MCG CAPSULE 5 dofetilide TIKOSYN 500 MCG CAPSULE 5 dofetilide

verapamil 120 mg tablet 1

verapamil 40 mg tablet 1

verapamil 80 mg tablet 1

Beta-adrenergic Blocking Agents

acebutolol 200 mg capsule 1

acebutolol 400 mg capsule 1

atenolol 100 mg tablet 1

atenolol 25 mg tablet 1

atenolol 50 mg tablet 1

betaxolol 10 mg tablet 1

betaxolol 20 mg tablet 1

bisoprolol fumarate 10 mg tab 1

bisoprolol fumarate 5 mg tab 1

BREVIBLOC 10 MG/ML IV BAG 9 ST esmolol hcl in sodium chloride, iso-osmotic BREVIBLOC 10 MG/ML VIAL 9 ST esmolol hcl BREVIBLOC 20 MG/ML IV BAG 9 ST esmolol hcl in sodium chloride, iso-osmotic

BYSTOLIC 10 MG TABLET QL 120 / 30 days 3 nebivolol hcl ST

BYSTOLIC 2.5 MG TABLET QL 60 / 30 days 3 nebivolol hcl ST

PAGE 259 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

BYSTOLIC 20 MG TABLET QL 60 / 30 days 3 nebivolol hcl ST

BYSTOLIC 5 MG TABLET QL 60 / 30 days 3 nebivolol hcl ST

carvedilol 12.5 mg tablet 1

carvedilol 25 mg tablet 1

carvedilol 3.125 mg tablet 1

carvedilol 6.25 mg tablet 1

COREG 12.5 MG TABLET 3 ST carvedilol COREG 25 MG TABLET 3 ST carvedilol COREG 3.125 MG TABLET 3 ST carvedilol COREG 6.25 MG TABLET 3 ST carvedilol

COREG CR 10 MG CAPSULE QL 30 / 30 days 2 carvedilol phosphate ST

COREG CR 20 MG CAPSULE QL 30 / 30 days 2 carvedilol phosphate ST

COREG CR 40 MG CAPSULE QL 30 / 30 days 2 carvedilol phosphate ST

COREG CR 80 MG CAPSULE QL 30 / 30 days 2 carvedilol phosphate ST

CORGARD 20 MG TABLET 3 ST nadolol

PAGE 260 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS CORGARD 40 MG TABLET 3 ST nadolol CORGARD 80 MG TABLET 3 ST nadolol

esmolol hcl 100 mg/10 ml vial 7

HEMANGEOL 4.28 MG/ML ORAL SOLN 3 propranolol hcl INDERAL LA 120 MG CAPSULE 3 ST propranolol hcl INDERAL LA 160 MG CAPSULE 3 ST propranolol hcl INDERAL LA 60 MG CAPSULE 3 ST propranolol hcl INDERAL LA 80 MG CAPSULE 3 ST propranolol hcl INDERAL XL 120 MG CAPSULE 3 ST propranolol hcl INDERAL XL 80 MG CAPSULE 3 ST propranolol hcl INNOPRAN XL 120 MG CAPSULE 3 ST propranolol hcl INNOPRAN XL 120 MG CAPSULE 3 ST propranolol hcl INNOPRAN XL 80 MG CAPSULE 3 ST propranolol hcl INNOPRAN XL 80 MG CAPSULE 3 ST propranolol hcl KERLONE 10 MG TABLET 3 ST betaxolol hcl KERLONE 20 MG TABLET 3 ST betaxolol hcl

labetalol hcl 100 mg tablet 1

labetalol hcl 100 mg/20 ml vl 7

labetalol hcl 20 mg/4 ml crpj 7

labetalol hcl 200 mg tablet 1

PAGE 261 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

labetalol hcl 200 mg tablet 1

labetalol hcl 200 mg/40 ml vl 7

labetalol hcl 300 mg tablet 1

LEVATOL 20 MG TABLET 3 ST penbutolol sulfate LOPRESSOR 100 MG TABLET 3 ST metoprolol tartrate LOPRESSOR 5 MG/5 ML AMPUL 9 metoprolol tartrate LOPRESSOR 50 MG TABLET 3 ST metoprolol tartrate LOPRESSOR 50 MG TABLET 3 ST metoprolol tartrate

metoprolol 1 mg/ml carpuject 7

metoprolol succ er 100 mg tab 1

metoprolol succ er 200 mg tab 1

metoprolol succ er 25 mg tab 1

metoprolol succ er 50 mg tab 1

metoprolol tart 5 mg/5 ml amp 7

metoprolol tart 5 mg/5 ml vial 7

metoprolol tartrate 100 mg tab 1

metoprolol tartrate 25 mg tab 1

PAGE 262 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

metoprolol tartrate 50 mg tab

metoprolol tartrate 50 mg tab 1

nadolol 20 mg tablet 1

nadolol 40 mg tablet 1

nadolol 80 mg tablet 1

pindolol 10 mg tablet 1

pindolol 5 mg tablet 1

propranolol 1 mg/ml vial 7

propranolol 10 mg tablet 1

propranolol 20 mg tablet 1

propranolol 20 mg/5 ml soln 1

propranolol 40 mg tablet 1

propranolol 40 mg/5 ml soln 1

propranolol 60 mg tablet 1

propranolol 80 mg tablet 1

propranolol er 120 mg capsule 1

propranolol er 160 mg capsule 1

propranolol er 60 mg capsule 1

propranolol er 80 mg capsule 1

SECTRAL 200 MG CAPSULE 3 ST acebutolol hcl SECTRAL 400 MG CAPSULE 3 ST acebutolol hcl

PAGE 263 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS TENORMIN 100 MG TABLET ST atenolol TENORMIN 25 MG TABLET 3 ST atenolol TENORMIN 50 MG TABLET 3 ST atenolol

timolol maleate 10 mg tablet 1

timolol maleate 20 mg tablet 1

timolol maleate 5 mg tablet 1

TOPROL XL 100 MG TABLET 3 ST metoprolol succinate TOPROL XL 200 MG TABLET 3 ST metoprolol succinate TOPROL XL 25 MG TABLET 3 ST metoprolol succinate TOPROL XL 50 MG TABLET 3 ST metoprolol succinate TRANDATE 100 MG TABLET 3 ST labetalol hcl TRANDATE 200 MG TABLET 3 ST labetalol hcl TRANDATE 300 MG TABLET 3 ST labetalol hcl ZEBETA 10 MG TABLET 3 ST bisoprolol fumarate ZEBETA 5 MG TABLET 3 ST bisoprolol fumarate Calcium Channel Blocking Agents

ADALAT CC 30 MG TABLET 3 ST nifedipine ADALAT CC 60 MG TABLET 3 ST nifedipine ADALAT CC 90 MG TABLET 3 ST nifedipine

afeditab cr 30 mg tablet 1

afeditab cr 60 mg tablet 1

amlodipine besylate 10 mg tab 1 QL 30 / 30 days

PAGE 264 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

amlodipine besylate 10 mg tab 1 QL 30 / 30 days

amlodipine besylate 2.5 mg tab 1 QL 30 / 30 days

amlodipine besylate 5 mg tab 1 QL 30 / 30 days

CALAN 120 MG TABLET 3 ST verapamil hcl CALAN 80 MG TABLET 3 ST verapamil hcl CALAN SR 120 MG CAPLET 3 ST verapamil hcl CALAN SR 180 MG CAPLET 3 ST verapamil hcl CALAN SR 240 MG CAPLET 3 ST verapamil hcl CARDENE I.V. 25 MG/10 ML AMPUL 9 ST nicardipine hcl CARDENE SR 30 MG CAPSULE 3 ST nicardipine hcl CARDENE SR 45 MG CAPSULE 3 ST nicardipine hcl CARDENE SR 60 MG CAPSULE 3 ST nicardipine hcl CARDENE-DEX 20 MG/200 ML SOLN 9 ST nicardipine in dextrose, iso-osmotic CARDENE-DEX 20 MG/200 ML SOLN 9 ST nicardipine in dextrose, iso-osmotic CARDENE-DEX 40 MG/200 ML IV 9 ST nicardipine in dextrose, iso-osmotic CARDENE-DEX 40 MG/200 ML IV 9 ST nicardipine in dextrose, iso-osmotic CARDENE-NACL 20 MG/200 ML SOLN 9 ST nicardipine in sodium chloride, iso-osmotic CARDENE-NACL 20 MG/200 ML SOLN 9 ST nicardipine in sodium chloride, iso-osmotic CARDENE-NACL 40 MG/200 ML IV 9 ST nicardipine in sodium chloride, iso-osmotic

CARDENE-NACL 40 MG/200 ML IV 9 ST

PAGE 265 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS nicardipine in sodium chloride, iso-osmotic CARDIZEM 120 MG TABLET 3 ST diltiazem hcl CARDIZEM 30 MG TABLET 3 ST diltiazem hcl CARDIZEM 30 MG TABLET 3 ST diltiazem hcl CARDIZEM 60 MG TABLET 3 ST diltiazem hcl CARDIZEM 90 MG TABLET 3 ST diltiazem hcl CARDIZEM CD 120 MG CAPSULE 3 ST diltiazem hcl CARDIZEM CD 180 MG CAPSULE 3 ST diltiazem hcl CARDIZEM CD 240 MG CAPSULE 3 ST diltiazem hcl CARDIZEM CD 300 MG CAPSULE 3 ST diltiazem hcl CARDIZEM CD 360 MG CAPSULE 3 ST diltiazem hcl CARDIZEM LA 120 MG TABLET 3 ST diltiazem hcl CARDIZEM LA 120 MG TABLET 3 ST diltiazem hcl CARDIZEM LA 180 MG TABLET 3 ST diltiazem hcl CARDIZEM LA 180 MG TABLET 3 ST diltiazem hcl CARDIZEM LA 240 MG TABLET 3 ST diltiazem hcl CARDIZEM LA 240 MG TABLET 3 ST diltiazem hcl CARDIZEM LA 300 MG TABLET 3 ST diltiazem hcl CARDIZEM LA 360 MG TABLET 3 ST diltiazem hcl CARDIZEM LA 360 MG TABLET 3 ST diltiazem hcl

CARDIZEM LA 420 MG TABLET 3 ST

PAGE 266 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS diltiazem hcl

cartia xt 120 mg capsule 1

cartia xt 180 mg capsule 1

cartia xt 240 mg capsule 1

cartia xt 300 mg capsule 1

CLEVIPREX 25 MG/50 ML VIAL 9 ST clevidipine butyrate CLEVIPREX 50 MG/100 ML VIAL 9 ST clevidipine butyrate DILACOR XR 240 MG CAPSULE 3 ST diltiazem hcl

dilt xr 120 mg capsule 1

dilt xr 180 mg capsule 1

dilt xr 240 mg capsule 1

dilt-cd 120 mg capsule 1

dilt-cd 180 mg capsule 1

dilt-cd 240 mg capsule 1

dilt-cd er 300 mg capsule 1

diltia xt 240 mg capsule 1

diltiazem 120 mg tablet 1

diltiazem 125 mg/25 ml vial 7

diltiazem 24hr cd 120 mg cap 1

diltiazem 24hr cd 180 mg cap 1

diltiazem 24hr cd 240 mg cap 1

diltiazem 24hr cd 300 mg cap 1

diltiazem 24hr cd 360 mg cap 1

diltiazem 24hr er 120 mg cap 1

diltiazem 24hr er 180 mg cap 1

PAGE 267 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

diltiazem 24hr er 240 mg cap 1

diltiazem 24hr er 300 mg cap 1

diltiazem 24hr er 360 mg cap 1

diltiazem 25 mg/5 ml vial 7

diltiazem 30 mg tablet 1

diltiazem 50 mg/10 ml vial 7

diltiazem 60 mg tablet 1

diltiazem 90 mg tablet 1

diltiazem er 120 mg 12-hr cap 1

diltiazem er 120 mg capsule 1

diltiazem er 180 mg capsule 1

diltiazem er 180 mg tablet 1

diltiazem er 240 mg capsule 1

diltiazem er 240 mg tablet 1

diltiazem er 300 mg tablet 1

diltiazem er 360 mg tablet 1

diltiazem er 420 mg tablet 1

diltiazem er 60 mg 12-hr cap 1

diltiazem er 90 mg 12-hr cap 1

diltiazem hcl 100 mg vial 1

diltiazem hcl er 120 mg cap 1

diltiazem hcl er 180 mg cap 1

PAGE 268 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

diltiazem hcl er 240 mg cap 1

diltiazem hcl er 300 mg cap 1

diltiazem hcl er 360 mg cap 1

diltiazem hcl er 420 mg cap 1

diltzac er 120 mg capsule 1

diltzac er 180 mg capsule 1

diltzac er 240 mg capsule 1

diltzac er 300 mg capsule 1

diltzac er 360 mg capsule 1

DYNACIRC CR 10 MG TABLET 3 ST isradipine DYNACIRC CR 5 MG TABLET 3 ST isradipine

felodipine er 10 mg tablet 1

felodipine er 2.5 mg tablet 1

felodipine er 5 mg tablet 1

isradipine 2.5 mg capsule 1

isradipine 5 mg capsule 1

matzim la 180 mg tablet 1

matzim la 240 mg tablet 1

matzim la 300 mg tablet 1

PAGE 269 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

matzim la 360 mg tablet

matzim la 420 mg tablet 1

nicardipine 20 mg capsule 1

nicardipine 25 mg/10 ml ampule 7

nicardipine 25 mg/10 ml vial 7

nicardipine 30 mg capsule 1

nifediac cc 30 mg tablet 1

nifediac cc 60 mg tablet 1

nifediac cc 90 mg tablet 1

nifedical xl 30 mg tablet 1

nifedical xl 60 mg tablet 1

nifedipine 10 mg capsule 1

nifedipine 20 mg capsule 1

nifedipine er 30 mg tablet 1

nifedipine er 60 mg tablet 1

nifedipine er 90 mg tablet 1

nimodipine 30 mg capsule 1

nisoldipine er 17 mg tablet 1

nisoldipine er 20 mg tablet 1

nisoldipine er 25.5 mg tablet 1

nisoldipine er 30 mg tablet 1

nisoldipine er 34 mg tablet 2

nisoldipine er 40 mg tablet 1

nisoldipine er 8.5 mg tablet 1

NORVASC 10 MG TABLET QL 30 / 30 days 3 amlodipine besylate ST

NORVASC 2.5 MG TABLET QL 30 / 30 days 3 amlodipine besylate ST

PAGE 270 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

NORVASC 5 MG TABLET QL 30 / 30 days 3 amlodipine besylate ST

NYMALIZE 60 MG/20 ML SOLUTION 3 ST nimodipine PROCARDIA 10 MG CAPSULE 3 ST nifedipine PROCARDIA XL 30 MG TABLET 3 ST nifedipine PROCARDIA XL 60 MG TABLET 3 ST nifedipine PROCARDIA XL 90 MG TABLET 3 ST nifedipine SULAR ER 17 MG TABLET 3 ST nisoldipine SULAR ER 34 MG TABLET 3 ST nisoldipine SULAR ER 8.5 MG TABLET 3 ST nisoldipine

taztia xt 120 mg capsule 1

taztia xt 180 mg capsule 1

taztia xt 240 mg capsule 1

taztia xt 300 mg capsule 1

taztia xt 360 mg capsule 1

TIAZAC ER 120 MG CAPSULE 3 ST diltiazem hcl TIAZAC ER 120 MG CAPSULE 3 ST diltiazem hcl TIAZAC ER 180 MG CAPSULE 3 ST diltiazem hcl TIAZAC ER 180 MG CAPSULE 3 ST diltiazem hcl TIAZAC ER 240 MG CAPSULE 3 ST diltiazem hcl TIAZAC ER 240 MG CAPSULE 3 ST diltiazem hcl

TIAZAC ER 300 MG CAPSULE 3 ST

PAGE 271 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

diltiazem hcl

TIAZAC ER 300 MG CAPSULE 3 ST diltiazem hcl TIAZAC ER 360 MG CAPSULE 3 ST diltiazem hcl TIAZAC ER 360 MG CAPSULE 3 ST diltiazem hcl TIAZAC ER 420 MG CAPSULE 3 ST diltiazem hcl TIAZAC ER 420 MG CAPSULE 3 ST diltiazem hcl

verapamil 120 mg tablet 1

verapamil 2.5 mg/ml ampul 7

verapamil 2.5 mg/ml syringe 7

verapamil 2.5 mg/ml vial 7

verapamil 360 mg cap pellet 1

verapamil 40 mg tablet 1

verapamil 80 mg tablet 1

verapamil er 120 mg capsule 1

verapamil er 120 mg tablet 1

verapamil er 180 mg capsule 1

verapamil er 180 mg tablet 1

verapamil er 240 mg capsule 1

verapamil er 240 mg tablet 1

verapamil er pm 100 mg capsule 1

verapamil er pm 200 mg capsule 1

verapamil er pm 300 mg capsule 1

PAGE 272 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

verapamil sr 120 mg capsule

verapamil sr 180 mg capsule 1

verapamil sr 240 mg capsule 1

VERELAN 120 MG CAP PELLET 3 ST verapamil hcl VERELAN 120 MG CAP PELLET 3 ST verapamil hcl VERELAN 180 MG CAP PELLET 3 ST verapamil hcl VERELAN 180 MG CAP PELLET 3 ST verapamil hcl VERELAN 240 MG CAP PELLET 3 ST verapamil hcl VERELAN 240 MG CAP PELLET 3 ST verapamil hcl VERELAN 360 MG CAP PELLET 3 ST verapamil hcl VERELAN 360 MG CAP PELLET 3 ST verapamil hcl VERELAN PM 100 MG CAP PELLET 3 ST verapamil hcl VERELAN PM 100 MG CAP PELLET 3 ST verapamil hcl VERELAN PM 200 MG CAP PELLET 3 ST verapamil hcl VERELAN PM 200 MG CAP PELLET 3 ST verapamil hcl VERELAN PM 300 MG CAP PELLET 3 ST verapamil hcl VERELAN PM 300 MG CAP PELLET 3 ST verapamil hcl Cardiovascular Agents, Other

ACCURETIC 10-12.5 MG TABLET 3 quinapril hcl/hydrochlorothiazide ACCURETIC 20-12.5 MG TABLET 3 quinapril hcl/hydrochlorothiazide ACCURETIC 20-25 MG TABLET 3 quinapril hcl/hydrochlorothiazide

PAGE 273 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ALDACTAZIDE 25-25 TABLET spironolactone/hydrochlorothiazide ALDACTAZIDE 50-50 TABLET 3 spironolactone/hydrochlorothiazide

alprostadil 500 mcg/ml vial 7

amiloride hcl-hctz 5-50 mg tab 1

QL 30 / 30 days amlodipine-atorvast 10-10 mg 1 ST

QL 30 / 30 days amlodipine-atorvast 10-20 mg 1 ST

QL 30 / 30 days amlodipine-atorvast 10-40 mg 1 ST

QL 30 / 30 days amlodipine-atorvast 10-80 mg 1 ST

QL 30 / 30 days amlodipine-atorvast 2.5-10 mg 1 ST

QL 30 / 30 days amlodipine-atorvast 2.5-20 mg 1 ST

QL 30 / 30 days amlodipine-atorvast 2.5-40 mg 1 ST

PAGE 274 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 30 / 30 days amlodipine-atorvast 2.5-40 mg 1 ST

QL 30 / 30 days amlodipine-atorvast 5-10 mg 1 ST

QL 30 / 30 days amlodipine-atorvast 5-20 mg 1 ST

QL 30 / 30 days amlodipine-atorvast 5-40 mg 1 ST

QL 30 / 30 days amlodipine-atorvast 5-80 mg 1 ST

amlodipine-benazepril 10-20 mg 1 QL 30 / 30 days

amlodipine-benazepril 10-40 mg 1 QL 30 / 30 days

amlodipine-benazepril 2.5-10 1 QL 30 / 30 days

amlodipine-benazepril 5-10 mg 1 QL 30 / 30 days

amlodipine-benazepril 5-20 mg 1 QL 30 / 30 days

PAGE 275 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

amlodipine-benazepril 5-40 mg QL 30 / 30 days

amlodipine-benazepril 5-40 mg 1 QL 30 / 30 days

amlodipine-valsartan 10-160 mg 1 QL 30 / 30 days

amlodipine-valsartan 10-320 mg 1 QL 30 / 30 days

amlodipine-valsartan 5-160 mg 1 QL 30 / 30 days

amlodipine-valsartan 5-320 mg 1 QL 30 / 30 days

AMTURNIDE 150-5-12.5 MG TAB 3 QL 30 / 30 days aliskiren hemifumarate/amlodipine/hydrochlorothiazide AMTURNIDE 300-10-12.5 MG TAB 3 QL 30 / 30 days aliskiren hemifumarate/amlodipine/hydrochlorothiazide AMTURNIDE 300-10-25 MG TAB 3 QL 30 / 30 days aliskiren hemifumarate/amlodipine/hydrochlorothiazide AMTURNIDE 300-5-12.5 MG TAB 3 QL 30 / 30 days aliskiren hemifumarate/amlodipine/hydrochlorothiazide AMTURNIDE 300-5-25 MG TAB 3 QL 30 / 30 days aliskiren hemifumarate/amlodipine/hydrochlorothiazide

ATACAND HCT 16-12.5 MG TAB QL 30 / 30 days 3 candesartan cilexetil/hydrochlorothiazide ST

ATACAND HCT 32-12.5 MG TAB QL 30 / 30 days 3 candesartan cilexetil/hydrochlorothiazide ST

ATACAND HCT 32-25 MG TABLET QL 30 / 30 days 3 candesartan cilexetil/hydrochlorothiazide ST

atenolol-chlorthal 50-25 tb 1

atenolol-chlorthalidone 100-25 1

AVALIDE 150-12.5 MG TABLET QL 30 / 30 days 3 irbesartan/hydrochlorothiazide ST

AVALIDE 300-12.5 MG TABLET QL 30 / 30 days 3 irbesartan/hydrochlorothiazide ST

AZOR 10-20 MG TABLET 3 amlodipine besylate/olmesartan medoxomil AZOR 10-40 MG TABLET 3 amlodipine besylate/olmesartan medoxomil

AZOR 5-20 MG TABLET 3

PAGE 276 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS amlodipine besylate/olmesartan medoxomil AZOR 5-40 MG TABLET 3 amlodipine besylate/olmesartan medoxomil

benazepril-hctz 10-12.5 mg tab 1

benazepril-hctz 20-12.5 mg tab 1

benazepril-hctz 20-25 mg tab 1

benazepril-hctz 5-6.25 mg tab 1

BENICAR HCT 20-12.5 MG TABLET QL 30 / 30 days 3 olmesartan medoxomil/hydrochlorothiazide ST

BENICAR HCT 40-12.5 MG TABLET QL 30 / 30 days 3 olmesartan medoxomil/hydrochlorothiazide ST

BENICAR HCT 40-25 MG TABLET QL 30 / 30 days 3 olmesartan medoxomil/hydrochlorothiazide ST

BIDIL TABLET 3 isosorbide dinitrate/hydralazine hcl

bisoprolol-hctz 10-6.25 mg tab 1

bisoprolol-hctz 2.5-6.25 mg tb 1

bisoprolol-hctz 5-6.25 mg tab 1

CADUET 10 MG-10 MG TABLET QL 30 / 30 days 3 amlodipine besylate/atorvastatin calcium ST

CADUET 10 MG-20 MG TABLET QL 30 / 30 days 3 amlodipine besylate/atorvastatin calcium ST

CADUET 10 MG-40 MG TABLET QL 30 / 30 days 3 amlodipine besylate/atorvastatin calcium ST

CADUET 10 MG-80 MG TABLET QL 30 / 30 days 3 amlodipine besylate/atorvastatin calcium ST

CADUET 2.5 MG-10 MG TABLET QL 30 / 30 days 3 amlodipine besylate/atorvastatin calcium ST

PAGE 277 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

CADUET 2.5 MG-20 MG TABLET QL 30 / 30 days 3 amlodipine besylate/atorvastatin calcium ST

CADUET 2.5 MG-40 MG TABLET QL 30 / 30 days 3 amlodipine besylate/atorvastatin calcium ST

CADUET 5 MG-10 MG TABLET QL 30 / 30 days 3 amlodipine besylate/atorvastatin calcium ST

CADUET 5 MG-20 MG TABLET QL 30 / 30 days 3 amlodipine besylate/atorvastatin calcium ST

CADUET 5 MG-40 MG TABLET QL 30 / 30 days 3 amlodipine besylate/atorvastatin calcium ST

CADUET 5 MG-80 MG TABLET QL 30 / 30 days 3 amlodipine besylate/atorvastatin calcium ST

candesartan-hctz 16-12.5 mg tb 1 QL 30 / 30 days

candesartan-hctz 32-12.5 mg tb 1 QL 30 / 30 days

candesartan-hctz 32-25 mg tab 1 QL 30 / 30 days

captopril-hctz 25-15 mg tablet 1

captopril-hctz 25-25 mg tablet 1

captopril-hctz 50-15 mg tablet 1

captopril-hctz 50-25 mg tablet 1

cardioplegic solution 7

CORZIDE 40-5 TABLET 3 ST nadolol/bendroflumethiazide CORZIDE 80-5 TABLET 3 ST nadolol/bendroflumethiazide CYANOKIT 5G KIT 9 hydroxocobalamin DEMSER 250 MG CAPSULE 2 metyrosine DIGIFAB 40 MG VIAL 9 digoxin immune fab

digox 125 mcg tablet 1

PAGE 278 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

digox 250 mcg tablet 1

digoxin 0.25 mg/ml ampul 7

digoxin 0.25 mg/ml syringe 7

digoxin 125 mcg tablet 1

digoxin 250 mcg tablet 1

digoxin 50 mcg/ml solution 2

DIOVAN HCT 160-12.5 MG TAB QL 30 / 30 days 3 valsartan/hydrochlorothiazide ST

DIOVAN HCT 160-25 MG TABLET QL 30 / 30 days 3 valsartan/hydrochlorothiazide ST

DIOVAN HCT 320-12.5 MG TAB QL 30 / 30 days 3 valsartan/hydrochlorothiazide ST

DIOVAN HCT 320-25 MG TABLET QL 30 / 30 days 3 valsartan/hydrochlorothiazide ST

DIOVAN HCT 80-12.5 MG TABLET QL 30 / 30 days 3 valsartan/hydrochlorothiazide ST

dobutamine 1 gm-d5w 250 ml 7

dobutamine 12.5 mg/ml vial 7

dobutamine 250 mg-d5w 250 ml 7

dobutamine 500 mg-d5w 250 ml 7

dobutamine 500 mg-d5w 500 ml 7

dopamine 160 mg/ml vial 1

dopamine 200 mg-d5w 250 ml 7

dopamine 40 mg/ml vial 7

dopamine 400 mg-d5w 250 ml 7

dopamine 400 mg-d5w 500 ml 7

PAGE 279 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

dopamine 80 mg/ml vial

dopamine 800 mg-d5w 250 ml 7

dopamine 800 mg-d5w 500 ml 7

DUTOPROL 100-12.5 MG TABLET 3 metoprolol succinate/hydrochlorothiazide DUTOPROL 100-12.5 MG TABLET 3 metoprolol succinate/hydrochlorothiazide DUTOPROL 25-12.5 MG TABLET 3 metoprolol succinate/hydrochlorothiazide DUTOPROL 25-12.5 MG TABLET 3 metoprolol succinate/hydrochlorothiazide DUTOPROL 50-12.5 MG TABLET 3 metoprolol succinate/hydrochlorothiazide DUTOPROL 50-12.5 MG TABLET 3 metoprolol succinate/hydrochlorothiazide DYAZIDE 37.5-25 CAPSULE 3 triamterene/hydrochlorothiazide

EDARBYCLOR 40-12.5 MG TABLET QL 30 / 30 days 3 azilsartan medoxomil/chlorthalidone ST

EDARBYCLOR 40-25 MG TABLET QL 30 / 30 days 3 azilsartan medoxomil/chlorthalidone ST

enalapril-hctz 10-25 mg tablet 1

enalapril-hctz 5-12.5 mg tab 1

EXFORGE 10-160 MG TABLET 3 QL 30 / 30 days amlodipine besylate/valsartan EXFORGE 10-320 MG TABLET 3 QL 30 / 30 days amlodipine besylate/valsartan EXFORGE 5-160 MG TABLET 3 QL 30 / 30 days amlodipine besylate/valsartan EXFORGE 5-320 MG TABLET 3 QL 30 / 30 days amlodipine besylate/valsartan EXFORGE HCT 10-160-12.5 MG TAB 3 amlodipine besylate/valsartan/hydrochlorothiazide EXFORGE HCT 10-160-25 MG TAB 3 amlodipine besylate/valsartan/hydrochlorothiazide EXFORGE HCT 10-320-25 MG TAB 3 amlodipine besylate/valsartan/hydrochlorothiazide

PAGE 280 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS EXFORGE HCT 5-160-12.5 MG TAB 3 amlodipine besylate/valsartan/hydrochlorothiazide EXFORGE HCT 5-160-25 MG TAB 3 amlodipine besylate/valsartan/hydrochlorothiazide

fomepizole 1.5 gm/1.5 ml vial 7

fosinopril-hctz 10-12.5 mg tab 1

fosinopril-hctz 20-12.5 mg tab 1

HYZAAR 100-12.5 TABLET QL 30 / 30 days 3 losartan potassium/hydrochlorothiazide ST

HYZAAR 100-25 TABLET QL 30 / 30 days 3 losartan potassium/hydrochlorothiazide ST

HYZAAR 50-12.5 TABLET QL 30 / 30 days 3 losartan potassium/hydrochlorothiazide ST

irbesartan-hctz 150-12.5 mg tb 1 QL 30 / 30 days

irbesartan-hctz 300-12.5 mg tb 1 QL 30 / 30 days

isoxsuprine 10 mg tablet 2

isoxsuprine 20 mg tablet 3

ISUPREL 0.2 MG/ML AMPUL 9 isoproterenol hcl ISUPREL 0.2 MG/ML AMPUL 9 isoproterenol hcl ISUPREL 1 MG/5 ML AMPUL 9 isoproterenol hcl LANOXIN 125 MCG TABLET 2 digoxin LANOXIN 187.5 MCG TABLET 2 digoxin LANOXIN 250 MCG TABLET 2 digoxin

PAGE 281 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS LANOXIN 500 MCG/2 ML AMPULE 9 digoxin LANOXIN 62.5 MCG TABLET 2 digoxin LANOXIN PED 0.1 MG/ML AMPUL 9 digoxin LANOXIN PED 100 MCG/ML AMPUL 9 digoxin LEVOPHED 1 MG/ML AMPUL 9 norepinephrine bitartrate LEVOPHED 1 MG/ML VIAL 9 norepinephrine bitartrate LEVOPHED 4 MG/4 ML AMPUL 9 norepinephrine bitartrate LEVOPHED 4 MG/4 ML VIAL 9 norepinephrine bitartrate

lisinopril-hctz 10-12.5 mg tab 1

lisinopril-hctz 20-12.5 mg tab 1

lisinopril-hctz 20-25 mg tab 1

LOPRESSOR HCT 100-25 TABLET 3 ST metoprolol tartrate/hydrochlorothiazide LOPRESSOR HCT 50-25 TABLET 3 ST metoprolol tartrate/hydrochlorothiazide

losartan-hctz 100-12.5 mg tab 1 QL 30 / 30 days

losartan-hctz 100-25 mg tab 1 QL 30 / 30 days

losartan-hctz 50-12.5 mg tab 1 QL 30 / 30 days

LOTENSIN HCT 10-12.5 MG TABLET 3 benazepril hcl/hydrochlorothiazide LOTENSIN HCT 10-12.5 TABLET 3 benazepril hcl/hydrochlorothiazide LOTENSIN HCT 20-12.5 MG TABLET 3 benazepril hcl/hydrochlorothiazide

LOTENSIN HCT 20-12.5 TABLET 3

PAGE 282 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS benazepril hcl/hydrochlorothiazide LOTENSIN HCT 20-25 MG TABLET 3 benazepril hcl/hydrochlorothiazide LOTENSIN HCT 20-25 TABLET 3 benazepril hcl/hydrochlorothiazide

LOTREL 10-20 MG CAPSULE QL 30 / 30 days 3 amlodipine besylate/benazepril hcl ST

LOTREL 10-40 MG CAPSULE QL 30 / 30 days 3 amlodipine besylate/benazepril hcl ST

LOTREL 2.5-10 MG CAPSULE QL 30 / 30 days 3 amlodipine besylate/benazepril hcl ST

LOTREL 5-10 MG CAPSULE QL 30 / 30 days 3 amlodipine besylate/benazepril hcl ST

LOTREL 5-20 MG CAPSULE QL 30 / 30 days 3 amlodipine besylate/benazepril hcl ST

LOTREL 5-40 MG CAPSULE QL 30 / 30 days 3 amlodipine besylate/benazepril hcl ST

mannitol 10% iv solution 7

mannitol 20% iv solution 7

mannitol 25% vial 7

mannitol 5% iv solution 7

MAXZIDE 37.5 MG-25 MG TABLET 3 triamterene/hydrochlorothiazide MAXZIDE 75 MG-50 MG TABLET 3 triamterene/hydrochlorothiazide

methyldopa-hctz 250-15 mg tab 1

methyldopa-hctz 250-25 mg tab 1

metoprolol-hctz 100-25 mg tab 1

metoprolol-hctz 100-50 mg tab 1

PAGE 283 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

metoprolol-hctz 50-25 mg tab

metoprolol-hctz 50-25 mg tab 1

MICARDIS HCT 40-12.5 MG TABLET QL 30 / 30 days 3 telmisartan/hydrochlorothiazide ST

MICARDIS HCT 80-12.5 MG TABLET QL 30 / 30 days 3 telmisartan/hydrochlorothiazide ST

MICARDIS HCT 80-25 MG TABLET QL 30 / 30 days 3 telmisartan/hydrochlorothiazide ST

milrinone lact 10 mg/10 ml vl 7

milrinone lact 20 mg/20 ml vl 7

milrinone lact 50 mg/50 ml vl 7

milrinone-d5w 20 mg/100 ml 7

milrinone-d5w 40 mg/200 ml 7

moexipril-hctz 15-12.5 mg tab 1

moexipril-hctz 15-25 mg tablet 1

moexipril-hctz 7.5-12.5 mg tab 1

nadolol-bendroflu 40-5 mg tab 1

nadolol-bendroflu 80-5 mg tab 1

NATRECOR 1.5 MG VIAL 9 nesiritide NEO-SYNEPHRINE 10 MG/ML AMP 9 phenylephrine hcl NEOPROFEN 20 MG/2 ML VIAL 9 ibuprofen lysine/pf

norepinephrine 1 mg/ml vial 7

norepinephrine 4 mg/4 ml ampul 7

NORTHERA 100 MG CAPSULE 3 droxidopa NORTHERA 200 MG CAPSULE 3 droxidopa

PAGE 284 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS NORTHERA 300 MG CAPSULE 3 droxidopa OSMITROL 10% IV SOLUTION 7 mannitol OSMITROL 15% IV SOLUTION 7 mannitol OSMITROL 20% IV SOLUTION 7 mannitol OSMITROL 5% IV SOLUTION 7 mannitol

papaverine 150 mg capsule sa 1

papaverine 300 mg/10 ml vial 7

papaverine 60 mg/2 ml vial 7

pentoxifylline er 400 mg tab 1

phenylephrine 10 mg/ml vial 7

PLEGISOL SOLUTION 9 cardioplegic solution no.1 PRINZIDE 10-12.5 MG TABLET 3 lisinopril/hydrochlorothiazide PRINZIDE 20-12.5 MG TABLET 3 lisinopril/hydrochlorothiazide

propranolol-hctz 40-25 mg tab 1

propranolol-hctz 80-25 mg tab 1

PROSTIN VR PEDI 500 MCG/ML AMP 9 alprostadil

quinapril-hctz 10-12.5 mg tab 1

quinapril-hctz 20-12.5 mg tab 1

quinapril-hctz 20-25 mg tab 1

RANEXA ER 1,000 MG TABLET 2 QL 120 / 30 days ranolazine

PAGE 285 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS RANEXA ER 500 MG TABLET 2 QL 120 / 30 days ranolazine

sodium nitrite 300 mg/10 ml vl 9

spironolactone-hctz 25-25 tab 1

TARKA ER 1-240 MG TABLET 2 QL 30 / 30 days trandolapril/verapamil hcl TARKA ER 2-180 MG TABLET 2 QL 30 / 30 days trandolapril/verapamil hcl TARKA ER 2-240 MG TABLET 2 QL 30 / 30 days trandolapril/verapamil hcl TARKA ER 4-240 MG TABLET 2 QL 30 / 30 days trandolapril/verapamil hcl TEKAMLO 150 MG-10 MG TABLET 2 QL 30 / 30 days aliskiren hemifumarate/amlodipine besylate TEKAMLO 150 MG-5 MG TABLET 2 QL 30 / 30 days aliskiren hemifumarate/amlodipine besylate TEKAMLO 300 MG-10 MG TABLET 2 QL 30 / 30 days aliskiren hemifumarate/amlodipine besylate TEKAMLO 300 MG-5 MG TABLET 2 QL 30 / 30 days aliskiren hemifumarate/amlodipine besylate TEKTURNA 150 MG TABLET 2 QL 30 / 30 days aliskiren hemifumarate TEKTURNA 300 MG TABLET 2 QL 30 / 30 days aliskiren hemifumarate TEKTURNA HCT 150-12.5 MG TAB 2 QL 30 / 30 days aliskiren hemifumarate/hydrochlorothiazide TEKTURNA HCT 150-25 MG TABLET 2 QL 30 / 30 days aliskiren hemifumarate/hydrochlorothiazide TEKTURNA HCT 300-12.5 MG TAB 2 QL 30 / 30 days aliskiren hemifumarate/hydrochlorothiazide TEKTURNA HCT 300-25 MG TABLET 2 QL 30 / 30 days aliskiren hemifumarate/hydrochlorothiazide

telmisartan-amlodipine 40-10 1 QL 30 / 30 days

telmisartan-amlodipine 40-5 mg 1 QL 30 / 30 days

telmisartan-amlodipine 80-10 1 QL 30 / 30 days

telmisartan-amlodipine 80-5 mg 1 QL 30 / 30 days

telmisartan-hctz 40-12.5 mg tb 1 QL 30 / 30 days

PAGE 286 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

telmisartan-hctz 80-12.5 mg tb 1 QL 30 / 30 days

telmisartan-hctz 80-25 mg tab 1 QL 30 / 30 days

TENORETIC 100 TABLET 3 ST atenolol/chlorthalidone TENORETIC 50 TABLET 3 ST atenolol/chlorthalidone TEVETEN HCT 600-12.5 MG TAB 3 ST eprosartan mesylate/hydrochlorothiazide TEVETEN HCT 600-25 MG TAB 3 ST eprosartan mesylate/hydrochlorothiazide TRENTAL ER 400 MG TABLET 3 pentoxifylline

triamterene-hctz 37.5-25 mg cp 1

triamterene-hctz 37.5-25 mg tb 1

triamterene-hctz 75-50 mg tab 1

TRIBENZOR 20-5-12.5 MG TABLET olmesartan medoxomil/amlodipine 3 besylate/hydrochlorothiazide TRIBENZOR 40-10-12.5 MG TABLET olmesartan medoxomil/amlodipine 3 besylate/hydrochlorothiazide TRIBENZOR 40-10-25 MG TABLET olmesartan medoxomil/amlodipine 3 besylate/hydrochlorothiazide TRIBENZOR 40-5-12.5 MG TABLET olmesartan medoxomil/amlodipine 3 besylate/hydrochlorothiazide TRIBENZOR 40-5-25 MG TABLET olmesartan medoxomil/amlodipine 3 besylate/hydrochlorothiazide TWYNSTA 40-10 MG TABLET 3 QL 30 / 30 days telmisartan/amlodipine besylate TWYNSTA 40-5 MG TABLET 3 QL 30 / 30 days telmisartan/amlodipine besylate TWYNSTA 80-10 MG TABLET 3 QL 30 / 30 days telmisartan/amlodipine besylate

PAGE 287 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS TWYNSTA 80-5 MG TABLET 3 QL 30 / 30 days telmisartan/amlodipine besylate UNIRETIC 15-12.5 TABLET 3 moexipril hcl/hydrochlorothiazide UNIRETIC 15-25 MG TABLET 3 moexipril hcl/hydrochlorothiazide UNIRETIC 7.5-12.5 MG TABLET 3 moexipril hcl/hydrochlorothiazide

valsartan-hctz 160-12.5 mg tab 1 QL 30 / 30 days

valsartan-hctz 160-25 mg tab 1 QL 30 / 30 days

valsartan-hctz 320-12.5 mg tab 1 QL 30 / 30 days

valsartan-hctz 320-25 mg tab 1 QL 30 / 30 days

valsartan-hctz 80-12.5 mg tab 1 QL 30 / 30 days

VASERETIC 10-25 MG TABLET 3 enalapril maleate/hydrochlorothiazide VAZCULEP 10 MG/ML VIAL 9 phenylephrine hcl VAZCULEP 100 MG/10 ML VIAL 9 phenylephrine hcl VAZCULEP 50 MG/5 ML VIAL 9 phenylephrine hcl ZESTORETIC 10-12.5 MG TABLET 3 lisinopril/hydrochlorothiazide ZESTORETIC 20-12.5 MG TABLET 3 lisinopril/hydrochlorothiazide ZESTORETIC 20-25 MG TABLET 3 lisinopril/hydrochlorothiazide ZIAC 10-6.25 MG TABLET 3 ST bisoprolol fumarate/hydrochlorothiazide ZIAC 2.5-6.25 MG TABLET 3 ST bisoprolol fumarate/hydrochlorothiazide

PAGE 288 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ZIAC 5-6.25 MG TABLET 3 ST bisoprolol fumarate/hydrochlorothiazide Diuretics, Carbonic Anhydrase Inhibitors

acetazolamide 125 mg tablet 1

acetazolamide 250 mg tablet 1

acetazolamide er 500 mg cap 1

acetazolamide sod 500 mg vial 7

DIAMOX SEQUELS ER 500 MG CAP 3 acetazolamide

methazolamide 25 mg tablet 1

methazolamide 50 mg tablet 1

NEPTAZANE 25 MG TABLET 3 methazolamide NEPTAZANE 50 MG TABLET 3 methazolamide Diuretics, Loop

bumetanide 0.25 mg/ml vial 7

bumetanide 0.5 mg tablet 1

bumetanide 1 mg tablet 1

bumetanide 1 mg/4 ml vial 7

bumetanide 2 mg tablet 1

bumetanide 2.5 mg/10 ml vial 7

DEMADEX 10 MG TABLET 3 torsemide DEMADEX 100 MG TABLET 3 torsemide DEMADEX 20 MG TABLET 3 torsemide DEMADEX 5 MG TABLET 3 torsemide EDECRIN 25 MG TABLET 3 ethacrynic acid

PAGE 289 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

furosemide 10 mg/ml solution 1

furosemide 10 mg/ml syringe 7

furosemide 100 mg/10 ml vial 7

furosemide 20 mg tablet 1

furosemide 20 mg/2 ml vial 7

furosemide 40 mg tablet 1

furosemide 40 mg/4 ml vial 7

furosemide 40 mg/5 ml soln 1

furosemide 80 mg tablet 1

LASIX 20 MG TABLET 3 furosemide LASIX 40 MG TABLET 3 furosemide LASIX 80 MG TABLET 3 furosemide SODIUM EDECRIN 50 MG VIAL 9 ethacrynate sodium

torsemide 10 mg tablet 1

torsemide 100 mg tablet 1

torsemide 20 mg tablet 1

torsemide 20 mg/2 ml vial 1

torsemide 5 mg tablet 1

torsemide 50 mg/5 ml vial 1

Diuretics, Potassium-sparing

ALDACTONE 100 MG TABLET 3 spironolactone ALDACTONE 25 MG TABLET 3 spironolactone

PAGE 290 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ALDACTONE 50 MG TABLET 3 spironolactone

amiloride hcl 5 mg tablet 1

DYRENIUM 100 MG CAPSULE 3 triamterene DYRENIUM 50 MG CAPSULE 3 triamterene

eplerenone 25 mg tablet 1 QL 60 / 30 days

eplerenone 50 mg tablet 1 QL 60 / 30 days

INSPRA 25 MG TABLET 3 QL 60 / 30 days eplerenone INSPRA 50 MG TABLET 3 QL 60 / 30 days eplerenone

spironolactone 100 mg tablet 1

spironolactone 25 mg tablet 1

spironolactone 50 mg tablet 1

Diuretics, Thiazide

chlorothiazide 250 mg tablet 1

chlorothiazide 500 mg tablet 1

chlorothiazide sod 500 mg vial 7

chlorthalidone 25 mg tablet 1

chlorthalidone 50 mg tablet 1

DIURIL 250 MG/5 ML ORAL SUSP 3 chlorothiazide

hydrochlorothiazide 12.5 mg cp 1

hydrochlorothiazide 12.5 mg tb 1

hydrochlorothiazide 25 mg tab 1

PAGE 291 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

hydrochlorothiazide 50 mg tab 1

indapamide 1.25 mg tablet 1

indapamide 2.5 mg tablet 1

methyclothiazide 5 mg tablet 1

metolazone 10 mg tablet 1

metolazone 2.5 mg tablet 1

metolazone 5 mg tablet 1

MICROZIDE 12.5 MG CAPSULE 3 hydrochlorothiazide SODIUM DIURIL 0.5 GRAM VIAL 9 chlorothiazide sodium ZAROXOLYN 2.5 MG TABLET 3 metolazone ZAROXOLYN 5 MG TABLET 3 metolazone Dyslipidemics, Fibric Acid Derivatives

ANTARA 130 MG CAPSULE QL 30 / 30 days 3 fenofibrate,micronized ST

ANTARA 30 MG CAPSULE QL 60 / 30 days 3 fenofibrate,micronized ST

ANTARA 43 MG CAPSULE QL 60 / 30 days 3 fenofibrate,micronized ST

ANTARA 90 MG CAPSULE QL 60 / 30 days 3 fenofibrate,micronized ST

fenofibrate 130 mg capsule 1 QL 30 / 30 days

fenofibrate 134 mg capsule 1 QL 30 / 30 days

fenofibrate 145 mg tablet 1 QL 30 / 30 days

fenofibrate 150 mg capsule 1

PAGE 292 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

fenofibrate 160 mg tablet 1 QL 30 / 30 days

fenofibrate 200 mg capsule 1 QL 30 / 30 days

fenofibrate 43 mg capsule 1 QL 60 / 30 days

fenofibrate 48 mg tablet 1 QL 30 / 30 days

fenofibrate 50 mg capsule 1

fenofibrate 54 mg tablet 1 QL 30 / 30 days

fenofibrate 67 mg capsule 1 QL 30 / 30 days

QL 30 / 30 days fenofibric acid 105 mg tablet 1 ST

QL 30 / 30 days fenofibric acid 35 mg tablet 1 ST

fenofibric acid dr 135 mg cap 1 QL 30 / 30 days

fenofibric acid dr 45 mg cap 1 QL 30 / 30 days

FENOGLIDE 120 MG TABLET 3 ST fenofibrate FENOGLIDE 40 MG TABLET 3 ST fenofibrate

FIBRICOR 105 MG TABLET QL 30 / 30 days 3 fenofibric acid ST

FIBRICOR 35 MG TABLET QL 30 / 30 days 3 fenofibric acid ST

gemfibrozil 600 mg tablet 1

PAGE 293 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS LIPOFEN 150 MG CAPSULE 3 ST fenofibrate LIPOFEN 50 MG CAPSULE 3 ST fenofibrate

lofibra 134 mg capsule 3 QL 30 / 30 days

lofibra 160 mg tablet 3 QL 30 / 30 days

lofibra 200 mg capsule 3 QL 30 / 30 days

lofibra 54 mg tablet 3 QL 30 / 30 days

lofibra 67 mg capsule 3 QL 30 / 30 days

LOPID 600 MG TABLET 3 gemfibrozil

TRICOR 145 MG TABLET QL 30 / 30 days 3 fenofibrate nanocrystallized ST

TRICOR 48 MG TABLET QL 30 / 30 days 3 fenofibrate nanocrystallized ST

TRIGLIDE 160 MG TABLET 2 ST fenofibrate nanocrystallized TRIGLIDE 50 MG TABLET 2 ST fenofibrate nanocrystallized

TRILIPIX DR 135 MG CAPSULE QL 30 / 30 days 2 fenofibric acid (choline) ST

TRILIPIX DR 45 MG CAPSULE QL 30 / 30 days 2 fenofibric acid (choline) ST

Dyslipidemics, HMG CoA Reductase Inhibitors

ALTOPREV 20 MG TABLET 3 QL 30 / 30 days lovastatin ALTOPREV 40 MG TABLET 3 QL 30 / 30 days lovastatin ALTOPREV 60 MG TABLET 3 QL 30 / 30 days lovastatin

atorvastatin 10 mg tablet 1 QL 30 / 30 days

atorvastatin 20 mg tablet 1 QL 30 / 30 days

1 QL

PAGE 294 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

atorvastatin 20 mg tablet 30 / 30 days

atorvastatin 40 mg tablet 1 QL 30 / 30 days

atorvastatin 80 mg tablet 1 QL 30 / 30 days

CRESTOR 10 MG TABLET 2 QL 30 / 30 days rosuvastatin calcium CRESTOR 20 MG TABLET 2 QL 30 / 30 days rosuvastatin calcium CRESTOR 40 MG TABLET 2 QL 30 / 30 days rosuvastatin calcium CRESTOR 5 MG TABLET 2 QL 30 / 30 days rosuvastatin calcium

fluvastatin sodium 20 mg cap 1 QL 60 / 30 days

fluvastatin sodium 40 mg cap 1 QL 60 / 30 days

LESCOL 20 MG CAPSULE 3 QL 60 / 30 days fluvastatin sodium LESCOL 40 MG CAPSULE 3 QL 60 / 30 days fluvastatin sodium LESCOL XL 80 MG TABLET 3 fluvastatin sodium LIPITOR 10 MG TABLET 3 QL 30 / 30 days atorvastatin calcium LIPITOR 20 MG TABLET 3 QL 30 / 30 days atorvastatin calcium LIPITOR 40 MG TABLET 3 QL 30 / 30 days atorvastatin calcium LIPITOR 80 MG TABLET 3 QL 30 / 30 days atorvastatin calcium LIVALO 1 MG TABLET 3 pitavastatin calcium LIVALO 2 MG TABLET 3 pitavastatin calcium LIVALO 4 MG TABLET 3 pitavastatin calcium

lovastatin 10 mg tablet 1

PAGE 295 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

lovastatin 10 mg tablet

lovastatin 20 mg tablet 1

lovastatin 40 mg tablet 1

MEVACOR 20 MG TABLET 3 lovastatin MEVACOR 40 MG TABLET 3 lovastatin PRAVACHOL 20 MG TABLET 3 QL 30 / 30 days pravastatin sodium PRAVACHOL 40 MG TABLET 3 QL 30 / 30 days pravastatin sodium PRAVACHOL 80 MG TABLET 3 QL 30 / 30 days pravastatin sodium

pravastatin sodium 10 mg tab 1 QL 30 / 30 days

pravastatin sodium 20 mg tab 1 QL 30 / 30 days

pravastatin sodium 40 mg tab 1 QL 30 / 30 days

pravastatin sodium 80 mg tab 1 QL 30 / 30 days

simvastatin 10 mg tablet 1 QL 30 / 30 days

simvastatin 20 mg tablet 1 QL 30 / 30 days

simvastatin 40 mg tablet 1 QL 30 / 30 days

simvastatin 5 mg tablet 1 QL 30 / 30 days

simvastatin 80 mg tablet 1 QL 30 / 30 days

ZOCOR 10 MG TABLET 3 QL 30 / 30 days simvastatin ZOCOR 20 MG TABLET 3 QL 30 / 30 days simvastatin

PAGE 296 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ZOCOR 40 MG TABLET 3 QL 30 / 30 days simvastatin ZOCOR 5 MG TABLET 3 QL 30 / 30 days simvastatin ZOCOR 80 MG TABLET 3 QL 30 / 30 days simvastatin Dyslipidemics, Other

ADVICOR 1,000 MG-20 MG TABLET 3 niacin/lovastatin ADVICOR 1,000 MG-40 MG TABLET 3 niacin/lovastatin ADVICOR 500 MG-20 MG TABLET 3 niacin/lovastatin ADVICOR 750 MG-20 MG TABLET 3 niacin/lovastatin

cholestyramine light packet 1

cholestyramine light powder 1

cholestyramine packet 1

cholestyramine powder 1

COLESTID 1 GM TABLET 3 colestipol hcl COLESTID FLAVORED GRANULES 3 colestipol hcl COLESTID GRANULES 3 colestipol hcl COLESTID GRANULES PACKET 3 colestipol hcl

colestipol hcl 1 gm tablet 1

colestipol hcl granules 1

colestipol hcl granules packet 1

colestipol micronized 1 gm tab 1

JUXTAPID 10 MG CAPSULE QL 90 / 30 days 5 lomitapide mesylate PA

JUXTAPID 20 MG CAPSULE 5 QL 90 / 30 days

PAGE 297 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

lomitapide mesylate PA

JUXTAPID 5 MG CAPSULE QL 90 / 30 days 5 lomitapide mesylate PA

KYNAMRO 200 MG/ML SYRINGE QL 4 / 30 days 5 mipomersen sodium PA

LIPOCHOL PLUS TABLET 3 methionine/inositol/choline/folic acid LIPTRUZET 10-10 MG TABLET 3 ezetimibe/atorvastatin calcium LIPTRUZET 10-20 MG TABLET 3 ezetimibe/atorvastatin calcium LIPTRUZET 10-40 MG TABLET 3 ezetimibe/atorvastatin calcium LIPTRUZET 10-80 MG TABLET 3 ezetimibe/atorvastatin calcium LOVAZA 1 GM CAPSULE 2 omega-3 acid ethyl esters

niacin er 1,000 mg tablet 1 QL 60 / 30 days

niacin er 500 mg tablet 1 QL 60 / 30 days

niacin er 750 mg tablet 1 QL 60 / 30 days

NIASPAN ER 1,000 MG TABLET 3 QL 60 / 30 days niacin NIASPAN ER 500 MG TABLET 3 QL 60 / 30 days niacin NIASPAN ER 750 MG TABLET 3 QL 60 / 30 days niacin

omega-3 ethyl esters 1 gm cap 1

prevalite packet 1

prevalite powder 1

QUESTRAN LIGHT PACKET 3 cholestyramine/aspartame

PAGE 298 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QUESTRAN LIGHT POWDER 3 cholestyramine/aspartame SIMCOR 1,000-20 MG TABLET 3 niacin/simvastatin SIMCOR 1,000-40 MG TABLET 3 niacin/simvastatin SIMCOR 500-20 MG TABLET 3 niacin/simvastatin SIMCOR 500-40 MG TABLET 3 niacin/simvastatin SIMCOR 750-20 MG TABLET 3 niacin/simvastatin VASCEPA 1 GM CAPSULE 3 QL 120 / 30 days icosapent ethyl VAYAROL CAPSULES 3 phytosterol/omega-3 fatty acids/dha/epa/fish oil VYTORIN 10-10 MG TABLET 3 QL 30 / 30 days ezetimibe/simvastatin VYTORIN 10-20 MG TABLET 3 QL 30 / 30 days ezetimibe/simvastatin VYTORIN 10-40 MG TABLET 3 QL 30 / 30 days ezetimibe/simvastatin VYTORIN 10-80 MG TABLET 3 QL 30 / 30 days ezetimibe/simvastatin WELCHOL 3.75G PACKET 3 colesevelam hcl WELCHOL 625 MG TABLET 3 colesevelam hcl ZETIA 10 MG TABLET 3 QL 30 / 30 days ezetimibe Vasodilators, Direct-acting Arterial

CORLOPAM 10 MG/ML AMPUL 9 fenoldopam mesylate CORLOPAM 10 MG/ML VIAL 9 fenoldopam mesylate

hydralazine 10 mg tablet 1

hydralazine 100 mg tablet 1

PAGE 299 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

hydralazine 20 mg/ml vial

hydralazine 25 mg tablet 1

hydralazine 50 mg tablet 1

minoxidil 10 mg tablet 1

minoxidil 2.5 mg tablet 1

NITROPRESS 50 MG/2 ML VIAL 3 nitroprusside sodium NITROPRESS 50 MG/2 ML VIAL 3 nitroprusside sodium RECTIV 0.4% OINTMENT 3 nitroglycerin Vasodilators, Direct-acting Arterial/Venous

DILATRATE-SR 40 MG CAPSULE 3 isosorbide dinitrate IMDUR ER 120 MG TABLET 3 isosorbide mononitrate

isochron 40 mg tablet sa 1

ISORDIL 40 MG TABLET 3 isosorbide dinitrate ISORDIL TITRADOSE 5 MG TAB 3 isosorbide dinitrate

isosorbide dn 10 mg tablet 1

isosorbide dn 2.5 mg tab sl 1

isosorbide dn 20 mg tablet 1

isosorbide dn 30 mg tablet 1

isosorbide dn 5 mg tablet 1

isosorbide dn 5 mg tablet sl 1

PAGE 300 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

isosorbide dn er 40 mg tablet 1

isosorbide mn 10 mg tablet 1

isosorbide mn 20 mg tablet 1

isosorbide mn er 120 mg tab 1

isosorbide mn er 30 mg tablet 1

isosorbide mn er 60 mg tablet 1

minitran 0.1 mg/hr patch 1

minitran 0.2 mg/hr patch 1

minitran 0.4 mg/hr patch 1

minitran 0.6 mg/hr patch 1

MONOKET 10 MG TABLET 3 isosorbide mononitrate MONOKET 20 MG TABLET 3 isosorbide mononitrate NITRO-BID 2% OINTMENT 3 nitroglycerin NITRO-DUR 0.1 MG/HR PATCH 3 nitroglycerin NITRO-DUR 0.2 MG/HR PATCH 3 nitroglycerin NITRO-DUR 0.3 MG/HR PATCH 3 nitroglycerin NITRO-DUR 0.3 MG/HR PATCH 3 nitroglycerin NITRO-DUR 0.4 MG/HR PATCH 3 nitroglycerin NITRO-DUR 0.6 MG/HR PATCH 3 nitroglycerin NITRO-DUR 0.8 MG/HR PATCH 3 nitroglycerin

nitro-time er 2.5 mg capsule 1

PAGE 301 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

nitro-time er 6.5 mg capsule 1

nitro-time er 9 mg capsule 1

nitroglycerin 0.1 mg/hr patch 1

nitroglycerin 0.2 mg/hr patch 1

nitroglycerin 0.4 mg/hr patch 1

nitroglycerin 0.6 mg/hr patch 1

nitroglycerin 400 mcg spray 3

nitroglycerin 5 mg/ml vial 1

nitroglycerin er 2.5 mg cap 1

nitroglycerin er 6.5 mg cap 1

nitroglycerin er 9 mg capsule 1

nitroglycerin lingual 0.4 mg 1

NITROLINGUAL 0.4 MG SPRAY 3 nitroglycerin NITROMIST 400 MCG SPRAY 3 nitroglycerin NITRONAL 25 MG/25 ML AMPULE 3 nitroglycerin NITRONAL 50 MG/50 ML VIAL 3 nitroglycerin NITROSTAT 0.3 MG TABLET SL 2 nitroglycerin NITROSTAT 0.4 MG TABLET SL 2 nitroglycerin NITROSTAT 0.6 MG TABLET SL 2 nitroglycerin

ntg 0.2 mg/ml in d5w 7

ntg 100 mg/250 ml in d5w 7

ntg 200 mg/500 ml in d5w 7

ntg 25 mg/250 ml in d5w 7

ntg 50 mg/500 ml in d5w 7

Central Nervous System Agents

PAGE 302 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS Attention Deficit Hyperactivity Disorder Agents, Amphetamines

ADDERALL 10 MG TABLET dextroamphetamine sulf-saccharate/amphetamine sulf- 3 aspartate ADDERALL 10 MG TABLET dextroamphetamine sulf-saccharate/amphetamine sulf- 3 aspartate ADDERALL 12.5 MG TABLET dextroamphetamine sulf-saccharate/amphetamine sulf- 3 aspartate ADDERALL 12.5 MG TABLET dextroamphetamine sulf-saccharate/amphetamine sulf- 3 aspartate ADDERALL 15 MG TABLET dextroamphetamine sulf-saccharate/amphetamine sulf- 3 aspartate ADDERALL 15 MG TABLET dextroamphetamine sulf-saccharate/amphetamine sulf- 3 aspartate ADDERALL 20 MG TABLET dextroamphetamine sulf-saccharate/amphetamine sulf- 3 aspartate ADDERALL 20 MG TABLET dextroamphetamine sulf-saccharate/amphetamine sulf- 3 aspartate ADDERALL 30 MG TABLET dextroamphetamine sulf-saccharate/amphetamine sulf- 3 aspartate ADDERALL 30 MG TABLET dextroamphetamine sulf-saccharate/amphetamine sulf- 3 aspartate ADDERALL 5 MG TABLET dextroamphetamine sulf-saccharate/amphetamine sulf- 3 aspartate ADDERALL 7.5 MG TABLET dextroamphetamine sulf-saccharate/amphetamine sulf- 3 aspartate ADDERALL XR 10 MG CAPSULE dextroamphetamine sulf-saccharate/amphetamine sulf- 3 aspartate ADDERALL XR 15 MG CAPSULE dextroamphetamine sulf-saccharate/amphetamine sulf- 3 aspartate

PAGE 303 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ADDERALL XR 20 MG CAPSULE dextroamphetamine sulf-saccharate/amphetamine sulf- aspartate ADDERALL XR 25 MG CAPSULE dextroamphetamine sulf-saccharate/amphetamine sulf- 3 aspartate ADDERALL XR 30 MG CAPSULE dextroamphetamine sulf-saccharate/amphetamine sulf- 3 aspartate ADDERALL XR 5 MG CAPSULE dextroamphetamine sulf-saccharate/amphetamine sulf- 3 aspartate

amphetamine salts 10 mg tablet 1

amphetamine salts 12.5 mg tab 1

amphetamine salts 15 mg tablet 1

amphetamine salts 20 mg tablet 1

amphetamine salts 30 mg tablet 1

amphetamine salts 5 mg tablet 1

amphetamine salts 7.5 mg tab 1

d-amphetamine er 10 mg capsule 1

d-amphetamine er 15 mg capsule 1

d-amphetamine er 5 mg capsule 1

DESOXYN 5 MG TABLET 3 methamphetamine hcl

PAGE 304 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS DEXEDRINE 10 MG TABLET dextroamphetamine sulfate DEXEDRINE 5 MG TABLET 3 dextroamphetamine sulfate DEXEDRINE SPANSULE 10 MG 3 dextroamphetamine sulfate DEXEDRINE SPANSULE 15 MG 3 dextroamphetamine sulfate DEXEDRINE SPANSULE 5 MG 3 dextroamphetamine sulfate

dextroamp-amphet er 10 mg cap 1

dextroamp-amphet er 15 mg cap 1

dextroamp-amphet er 20 mg cap 1

dextroamp-amphet er 25 mg cap 1

dextroamp-amphet er 30 mg cap 1

dextroamp-amphet er 5 mg cap 1

dextroamphetamine 10 mg tab 1

dextroamphetamine 5 mg tab 1

dextroamphetamine 5 mg/5 ml 1

methamphetamine 5 mg tablet 1

procentra 5 mg/5 ml solution 1

VYVANSE 20 MG CAPSULE 3 lisdexamfetamine dimesylate VYVANSE 30 MG CAPSULE 3 lisdexamfetamine dimesylate

PAGE 305 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS VYVANSE 40 MG CAPSULE 3 lisdexamfetamine dimesylate VYVANSE 50 MG CAPSULE 3 lisdexamfetamine dimesylate VYVANSE 60 MG CAPSULE 3 lisdexamfetamine dimesylate VYVANSE 70 MG CAPSULE 3 lisdexamfetamine dimesylate

zenzedi 10 mg tablet 1

ZENZEDI 15 MG TABLET 3 dextroamphetamine sulfate ZENZEDI 2.5 MG TABLET 3 dextroamphetamine sulfate ZENZEDI 20 MG TABLET 3 dextroamphetamine sulfate ZENZEDI 30 MG TABLET 3 dextroamphetamine sulfate

zenzedi 5 mg tablet 1

ZENZEDI 7.5 MG TABLET 3 dextroamphetamine sulfate Attention Deficit Hyperactivity Disorder Agents, Non-amphetamines

clonidine hcl er 0.1 mg tablet 1 QL 60 / 30 days

CONCERTA ER 18 MG TABLET 3 QL 30 / 30 days methylphenidate hcl CONCERTA ER 27 MG TABLET 3 QL 30 / 30 days methylphenidate hcl CONCERTA ER 36 MG TABLET 3 QL 60 / 30 days methylphenidate hcl CONCERTA ER 54 MG TABLET 3 QL 30 / 30 days methylphenidate hcl DAYTRANA 10 MG/9 HR PATCH 3 QL 30 / 30 days methylphenidate DAYTRANA 15 MG/9 HR PATCH 3 QL 30 / 30 days methylphenidate DAYTRANA 20 MG/9 HOUR PATCH 3 QL 30 / 30 days methylphenidate DAYTRANA 30 MG/9 HOUR PATCH 3 QL 30 / 30 days methylphenidate

PAGE 306 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

dexmethylphenidate 10 mg tab

dexmethylphenidate 2.5 mg tab 1

dexmethylphenidate 5 mg tab 1

dexmethylphenidate er 15 mg cp 1

dexmethylphenidate er 30 mg cp 1

dexmethylphenidate er 40 mg cp 1

FOCALIN 10 MG TABLET 3 dexmethylphenidate hcl FOCALIN 2.5 MG TABLET 3 dexmethylphenidate hcl FOCALIN 5 MG TABLET 3 dexmethylphenidate hcl FOCALIN XR 10 MG CAPSULE 3 dexmethylphenidate hcl FOCALIN XR 15 MG CAPSULE 3 dexmethylphenidate hcl FOCALIN XR 20 MG CAPSULE 3 dexmethylphenidate hcl FOCALIN XR 25 MG CAPSULE 3 dexmethylphenidate hcl FOCALIN XR 30 MG CAPSULE 3 dexmethylphenidate hcl FOCALIN XR 35 MG CAPSULE 3 dexmethylphenidate hcl FOCALIN XR 40 MG CAPSULE 3 dexmethylphenidate hcl FOCALIN XR 5 MG CAPSULE 3 dexmethylphenidate hcl INTUNIV ER 1 MG TABLET 3 QL 30 / 30 days guanfacine hcl INTUNIV ER 2 MG TABLET 3 QL 30 / 30 days guanfacine hcl

INTUNIV ER 3 MG TABLET 3 QL 30 / 30 days

PAGE 307 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS guanfacine hcl INTUNIV ER 4 MG TABLET 3 QL 30 / 30 days guanfacine hcl KAPVAY 0.1-0.2 MG DOSEPACK 3 QL 60 / 30 days clonidine hcl KAPVAY ER 0.1 MG TABLET 3 QL 60 / 30 days clonidine hcl KAPVAY ER 0.1 MG TABLET 3 QL 60 / 30 days clonidine hcl METADATE CD 10 MG CAPSULE 3 QL 60 / 30 days methylphenidate hcl METADATE CD 20 MG CAPSULE 3 QL 60 / 30 days methylphenidate hcl METADATE CD 30 MG CAPSULE 3 QL 60 / 30 days methylphenidate hcl METADATE CD 40 MG CAPSULE 3 QL 60 / 30 days methylphenidate hcl METADATE CD 50 MG CAPSULE 3 QL 30 / 30 days methylphenidate hcl METADATE CD 60 MG CAPSULE 3 QL 30 / 30 days methylphenidate hcl

metadate er 20 mg tablet 1

METHYLIN 10 MG CHEWABLE TABLET 3 methylphenidate hcl METHYLIN 10 MG/5 ML SOLUTION 3 methylphenidate hcl METHYLIN 2.5 MG CHEWABLE TAB 3 methylphenidate hcl METHYLIN 5 MG CHEWABLE TABLET 3 methylphenidate hcl METHYLIN 5 MG/5 ML SOLUTION 3 methylphenidate hcl

methylphenidate 10 mg tablet 1

methylphenidate 10 mg/5 ml sol 1

methylphenidate 20 mg tablet 1

PAGE 308 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

methylphenidate 20 mg tablet 1

methylphenidate 5 mg tablet 1

methylphenidate 5 mg/5 ml soln 1

methylphenidate cd 10 mg cap 1 QL 60 / 30 days

methylphenidate cd 20 mg cap 1 QL 60 / 30 days

methylphenidate cd 30 mg cap 1 QL 60 / 30 days

methylphenidate cd 40 mg cap 1 QL 60 / 30 days

methylphenidate cd 50 mg cap 1 QL 30 / 30 days

methylphenidate cd 60 mg cap 1 QL 30 / 30 days

methylphenidate er 10 mg tab 1

methylphenidate er 18 mg tab 1 QL 30 / 30 days

methylphenidate er 20 mg cap 1

methylphenidate er 20 mg tab 1

methylphenidate er 27 mg tab 1 QL 30 / 30 days

methylphenidate er 30 mg cap 1

methylphenidate er 36 mg tab 1 QL 60 / 30 days

methylphenidate er 40 mg cap 1

methylphenidate er 54 mg tab 1 QL 30 / 30 days

methylphenidate la 20 mg cap 1

methylphenidate la 30 mg cap 1

methylphenidate la 40 mg cap 1

methylphenidate sr 20 mg tab 1

PAGE 309 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QUILLIVANT XR 25 MG/5 ML SUSP 3 QL 360 / 30 days methylphenidate hcl RITALIN 10 MG TABLET 3 methylphenidate hcl RITALIN 20 MG TABLET 3 methylphenidate hcl RITALIN 5 MG TABLET 3 methylphenidate hcl RITALIN LA 10 MG CAPSULE 3 methylphenidate hcl RITALIN LA 20 MG CAPSULE 3 methylphenidate hcl RITALIN LA 30 MG CAPSULE 3 methylphenidate hcl RITALIN LA 40 MG CAPSULE 3 methylphenidate hcl RITALIN SR 20 MG TABLET 3 methylphenidate hcl STRATTERA 10 MG CAPSULE 2 QL 60 / 30 days atomoxetine hcl STRATTERA 100 MG CAPSULE 2 QL 60 / 30 days atomoxetine hcl STRATTERA 18 MG CAPSULE 2 QL 60 / 30 days atomoxetine hcl STRATTERA 25 MG CAPSULE 2 QL 60 / 30 days atomoxetine hcl STRATTERA 40 MG CAPSULE 2 QL 60 / 30 days atomoxetine hcl STRATTERA 60 MG CAPSULE 2 QL 60 / 30 days atomoxetine hcl STRATTERA 80 MG CAPSULE 2 QL 60 / 30 days atomoxetine hcl Central Nervous System Agents, Other

acetaminophn-butalbital 325-50 1

adipex-p 37.5 mg capsule 3

ADIPEX-P 37.5 MG TABLET 3 phentermine hcl ANECTINE 20 MG/ML VIAL 7 succinylcholine chloride

PAGE 310 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

ascomp with codeine capsule 1 QL 180 / 30 days

atracurium 100 mg/10 ml vial 7

atracurium 50 mg/5 ml vial 7

BELVIQ 10 MG TABLET 3 lorcaserin hcl

benzphetamine hcl 50 mg tablet 1

BONTRIL PDM 35 MG TABLET 3 phendimetrazine tartrate

bupap 50 mg-300 mg tablet 3

bupap tablet 1

butalb-acetamin-caff 50-300-40 1

butalb-acetamin-caff 50-325-40 1

butalb-acetamin-caff 50-500-40 1

butalb-acetaminoph-caff-codein 1

butalb-caff-acetaminoph-codein 1

butalbit-acetaminophen-caff cp 1

butalbital comp-codeine #3 cap 1 QL 180 / 30 days

butalbital compound tablet 1

butalbital-asa-caffeine cap 1

butalbital-asa-caffeine tablet 1

CAFCIT 20 MG/ML ORAL SOLN 3 caffeine citrated CAFCIT 20 MG/ML VIAL 9 caffeine citrated

caff-sod benzoate 500 mg vl 8

caffeine cit 60 mg/3 ml oral 1

caffeine cit 60 mg/3 ml vial 7

PAGE 311 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

capacet capsule 1

cevimeline hcl 30 mg capsule 1

cisatracurium 10 mg/5 ml vial 7

cisatracurium 10 mg/5ml vial 7

cisatracurium 20 mg/10 ml vial 7

cisatracurium 200 mg/20 ml vl 7

DIDREX 50 MG TABLET 3 benzphetamine hcl

diethylpropion 25 mg tablet 1

diethylpropion er 75 mg tablet 1

DOLGIC PLUS TABLET 3 butalbital/acetaminophen/caffeine

dronabinol 10 mg capsule 1

dronabinol 2.5 mg capsule 1

dronabinol 5 mg capsule 1

DYSPORT 300 UNIT VIAL 9 abobotulinumtoxina DYSPORT 500 UNITS VIAL 9 abobotulinumtoxina ESGIC 50-325-40 MG TABLET 3 butalbital/acetaminophen/caffeine ESGIC 50-325-40 MG TABLET 3 butalbital/acetaminophen/caffeine ESGIC CAPSULE 3 butalbital/acetaminophen/caffeine ESGIC CAPSULE 3 butalbital/acetaminophen/caffeine ESGIC PLUS CAPSULE 3 butalbital/acetaminophen/caffeine ESGIC-PLUS 50-500-40 MG TABLET 3 butalbital/acetaminophen/caffeine

PAGE 312 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS EVOXAC 30 MG CAPSULE 3 cevimeline hcl

fioricet 50-300-40 mg capsule 3

fioricet 50-325-40 mg tablet 1

FIORICET-COD 30-50-325-40 CAP 3 butalbital/acetaminophen/caffeine/codeine phosphate FIORICET-COD 50-300-40-30 CAP 3 butalbital/acetaminophen/caffeine/codeine phosphate FIORINAL 50-325-40 MG CAPSULE 3 butalbital/aspirin/caffeine FIORINAL-COD 30-50-325-40 CAP 3 QL 180 / 30 days codeine phosphate/butalbital/aspirin/caffeine

gabapentin 250 mg/5 ml soln 1

gabapentin 300 mg/6 ml soln 1

gabapentin 600 mg tablet 1

gabapentin 800 mg tablet 1

GRALISE 30-DAY STARTER PACK 3 ST gabapentin GRALISE ER 300 MG TABLET 3 ST gabapentin GRALISE ER 600 MG TABLET 3 ST gabapentin HORIZANT ER 300 MG TABLET 3 ST gabapentin enacarbil HORIZANT ER 600 MG TABLET 3 ST gabapentin enacarbil

isomethept-caff-acetaminoph tb 1

isomethept-caff-acetaminophen 1

isomethept-dichloralp-acetamin 1

MARGESIC CAPSULE 1 butalbital/acetaminophen/caffeine MARINOL 10 MG CAPSULE 3 dronabinol MARINOL 2.5 MG CAPSULE 3 dronabinol

PAGE 313 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS MARINOL 5 MG CAPSULE 3 dronabinol MARTEN-TAB 325-50 TABLET 1 butalbital/acetaminophen

migragesic ida capsule 1

MYOBLOC 10,000 UNITS/2 ML VIAL 9 rimabotulinumtoxinb MYOBLOC 2,500 UNIT/0.5 ML VIAL 9 rimabotulinumtoxinb MYOBLOC 5,000 UNITS/1 ML VIAL 9 rimabotulinumtoxinb NEURONTIN 100 MG CAPSULE 3 ST gabapentin NEURONTIN 250 MG/5 ML SOLN 3 ST gabapentin NEURONTIN 300 MG CAPSULE 3 ST gabapentin NEURONTIN 400 MG CAPSULE 3 ST gabapentin NEURONTIN 600 MG TABLET 3 ST gabapentin NEURONTIN 800 MG TABLET 3 ST gabapentin NIMBEX 10 MG/ML VIAL 9 cisatracurium besylate NIMBEX 2 MG/ML VIAL 9 cisatracurium besylate

nodolor capsule 1

NUCYNTA 100 MG TABLET 3 QL 180 / 30 days tapentadol hcl NUCYNTA 50 MG TABLET 3 QL 180 / 30 days tapentadol hcl NUCYNTA 75 MG TABLET 3 QL 180 / 30 days tapentadol hcl NUCYNTA ER 100 MG TABLET 3 QL 60 / 30 days tapentadol hcl NUCYNTA ER 150 MG TABLET 3 QL 60 / 30 days tapentadol hcl NUCYNTA ER 200 MG TABLET 3 QL 60 / 30 days tapentadol hcl

PAGE 314 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS NUCYNTA ER 250 MG TABLET 3 QL 60 / 30 days tapentadol hcl NUCYNTA ER 50 MG TABLET 3 QL 60 / 30 days tapentadol hcl NUEDEXTA 20-10 MG CAPSULE 3 dextromethorphan hbr/quinidine sulfate ORBIVAN CAPSULE 3 butalbital/acetaminophen/caffeine ORBIVAN CF TABLET 3 butalbital/acetaminophen

pancuronium 1 mg/ml vial 7

phendimetrazine 35 mg tablet 1

phendimetrazine er 105 mg cap 1

phentermine 15 mg capsule 1

phentermine 30 mg capsule 1

phentermine 37.5 mg capsule 1

phentermine 37.5 mg tablet 1

PHRENILIN FORTE CAPSULE 3 butalbital/acetaminophen PRIALT 100 MCG/ML VIAL 9 ziconotide acetate PRIALT 25 MCG/ML VIAL 9 ziconotide acetate PRODRIN CAPLET 3 isometheptene mucate/caffeine/acetaminophen PRODRIN CAPLET 3 isometheptene mucate/caffeine/acetaminophen

promacet 50-650 mg tablet 1

QSYMIA 11.25 MG-69 MG CAPSULE 3 phentermine hcl/topiramate QSYMIA 15 MG-92 MG CAPSULE 3 phentermine hcl/topiramate QSYMIA 3.75 MG-23 MG CAPSULE 3 phentermine hcl/topiramate

QSYMIA 7.5 MG-46 MG CAPSULE 3

PAGE 315 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS phentermine hcl/topiramate QUELICIN 100 MG/ML VIAL 7 succinylcholine chloride QUELICIN 200 MG/10 ML VIAL 7 succinylcholine chloride QUELICIN 200 MG/10 ML VIAL 7 succinylcholine chloride REGIMEX 25 MG TABLET 3 benzphetamine hcl REPAN 50-325-40 MG TABLET 1 butalbital/acetaminophen/caffeine RILUTEK 50 MG TABLET 3 riluzole

riluzole 50 mg tablet 1

rocuronium 100 mg/10 ml vial 7

rocuronium 50 mg/5 ml vial 7

SUPRENZA ODT 15 MG TABLET 3 phentermine hcl SUPRENZA ODT 30 MG TABLET 3 phentermine hcl SUPRENZA ODT 37.5 MG TABLET 3 phentermine hcl

tencon 50-325 mg tablet 1

tencon tablet 1

vecuronium 10 mg vial 7

vecuronium 20 mg vial 7

XENAZINE 12.5 MG TABLET 5 tetrabenazine XENAZINE 25 MG TABLET 5 tetrabenazine

ZEBUTAL 50-325-40 MG CAPSULE 1

PAGE 316 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

butalbital/acetaminophen/caffeine

zebutal capsule 1

ZEMURON 10 MG/ML VIAL 9 rocuronium bromide Fibromyalgia Agents

CYMBALTA 20 MG CAPSULE QL 90 / 30 days 2 duloxetine hcl ST

CYMBALTA 30 MG CAPSULE QL 30 / 30 days 2 duloxetine hcl ST

CYMBALTA 60 MG CAPSULE QL 30 / 30 days 2 duloxetine hcl ST

LYRICA 100 MG CAPSULE QL 120 / 30 days 2 pregabalin ST

LYRICA 150 MG CAPSULE QL 120 / 30 days 2 pregabalin ST

LYRICA 20 MG/ML ORAL SOLUTION 2 pregabalin

LYRICA 200 MG CAPSULE QL 120 / 30 days 2 pregabalin ST

LYRICA 225 MG CAPSULE QL 120 / 30 days 2 pregabalin ST

LYRICA 25 MG CAPSULE QL 120 / 30 days 2 pregabalin ST

LYRICA 300 MG CAPSULE QL 120 / 30 days 2 pregabalin ST

LYRICA 50 MG CAPSULE QL 120 / 30 days 2 pregabalin ST

LYRICA 75 MG CAPSULE QL 120 / 30 days 2 pregabalin ST

SAVELLA 100 MG TABLET QL 60 / 30 days 3 milnacipran hcl ST

3 QL

PAGE 317 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

SAVELLA 12.5 MG TABLET 60 / 30 days milnacipran hcl ST

SAVELLA 25 MG TABLET QL 60 / 30 days 3 milnacipran hcl ST

SAVELLA 50 MG TABLET QL 60 / 30 days 3 milnacipran hcl ST

SAVELLA TITRATION PACK QL 55 / 365 days 3 milnacipran hcl ST

Multiple Sclerosis Agents

AMPYRA ER 10 MG TABLET 5 QL 30 / 30 days dalfampridine

AUBAGIO 14 MG TABLET QL 30 / 30 days 9 teriflunomide PA

AUBAGIO 7 MG TABLET QL 30 / 30 days 9 teriflunomide PA

AVONEX ADMIN PACK 30 MCG VL QL 4 / 30 days 5 interferon beta-1a/albumin human PA

AVONEX PEN 30 MCG/0.5 ML 5 QL 2 / 30 days interferon beta-1a

AVONEX PEN 30 MCG/0.5 ML QL 1 / 30 days 5 interferon beta-1a PA

AVONEX PREFILLED SYR 30 MCG QL 2 / 30 days 5 interferon beta-1a PA

AVONEX PREFILLED SYR 30 MCG KT QL 1 / 30 days 5 interferon beta-1a PA

BETASERON 0.3 MG KIT QL 15 / 30 days 5 interferon beta-1b PA

BETASERON 0.3 MG VIAL QL 45 / 30 days 3 interferon beta-1b PA

COPAXONE 20 MG/ML SYRINGE QL 1 / 30 days 5 glatiramer acetate PA

COPAXONE 40 MG/ML SYRINGE 5 QL 12 / 28 days

PAGE 318 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

glatiramer acetate PA

EXTAVIA 0.3 MG KIT QL 15 / 30 days 5 interferon beta-1b PA

EXTAVIA 0.3 MG VIAL QL 45 / 30 days 5 interferon beta-1b PA

GILENYA 0.5 MG CAPSULE QL 30 / 30 days 5 fingolimod hcl PA

mitoxantrone 20 mg/10 ml vial 1

mitoxantrone 25 mg/12.5 ml vl 1

mitoxantrone 30 mg/15 ml vial 1

PLEGRIDY 125 MCG/0.5 ML PEN QL 1 / 28 days 6 peginterferon beta-1a PA

PLEGRIDY 125 MCG/0.5 ML SYRING QL 1 / 28 days 6 peginterferon beta-1a PA

PLEGRIDY PEN INJ STARTER PACK QL 1 / 28 days 6 peginterferon beta-1a PA

PLEGRIDY SYRINGE STARTER PACK QL 1 / 28 days 6 peginterferon beta-1a PA

REBIF 22 MCG/0.5 ML SYRINGE QL 13 / 30 days 5 interferon beta-1a/albumin human PA

REBIF 44 MCG/0.5 ML SYRINGE QL 13 / 30 days 5 interferon beta-1a/albumin human PA

REBIF REBIDOSE 22 MCG/0.5 ML QL 13 / 30 days 5 interferon beta-1a/albumin human PA

REBIF REBIDOSE 44 MCG/0.5 ML QL 13 / 30 days 5 interferon beta-1a/albumin human PA

REBIF REBIDOSE TITRATION PACK QL 13 / 30 days 5 interferon beta-1a/albumin human PA

PAGE 319 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

REBIF TITRATION PACK QL 13 / 30 days interferon beta-1a/albumin human PA

TECFIDERA DR 120 MG CAPSULE QL 60 / 30 days 5 dimethyl fumarate PA

TECFIDERA DR 240 MG CAPSULE QL 60 / 30 days 5 dimethyl fumarate PA

TECFIDERA STARTER PACK QL 60 / 30 days 5 dimethyl fumarate PA

TYSABRI 300 MG/15 ML VIAL 5 PA natalizumab Dental and Oral Agents

ADOXA 150 MG CAPSULE 3 doxycycline monohydrate ALODOX CONVENIENCE KIT 3 doxycycline hyclate/eyelid clns no2/eyelid clns no3 AQUORAL SPRAY 2 saliva substitution combo no.3 ARESTIN 1 MG MICROSPHERE 3 minocycline hcl microspheres

avidoxy 100 mg tablet 1

CAPHOSOL SOLUTION 2 saliva substitution combo no.2

cevimeline hcl 30 mg capsule 1

chlorhexidine 0.12% rinse 1

CLINPRO 5000 1.1% TOOTHPASTE 1 sodium fluoride

clotrimazole 10 mg troche 1

DEBACTEROL SOLUTION 3 sulfuric acid/sulfonated phenol DEBACTEROL SWABSTICK 3 sulfuric acid/sulfonated phenol

denta 5000 plus cream 1

dentagel 1.1% gel 1

PAGE 320 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS DORYX DR 150 MG TABLET 3 doxycycline hyclate

doxycycline 25 mg/5 ml susp 1

doxycycline hyc dr 100 mg tab 1

doxycycline hyc dr 150 mg tab 1

doxycycline hyc dr 75 mg tab 1

doxycycline hyclate 20 mg tab 1

doxycycline hyclate 50 mg cap 1

doxycycline mono 100 mg cap 1

doxycycline mono 100 mg tablet 1

doxycycline mono 150 mg cap 1

doxycycline mono 150 mg tablet 1

doxycycline mono 50 mg cap 1

doxycycline mono 50 mg tablet 1

doxycycline mono 75 mg capsule 1

doxycycline mono 75 mg tablet 1

dynacin 100 mg tablet 3

dynacin 50 mg tablet 3

DYNACIN 75 MG TABLET 3 minocycline hcl EPISIL LIQUID oral mucositis & stomatitis anti-inflammatory agent comb 3 2 EVOXAC 30 MG CAPSULE 3 cevimeline hcl FIRST-BXN MOUTHWASH 3 nystatin/lidocaine hcl/diphenhydramine hcl FIRST-DUKE'S MOUTHWASH 3 nystatin/hydrocortisone/diphenhydramine hcl FIRST-MARY'S MOUTHWASH nystatin/tetracycline hcl/hydrocortisone/diphenhydramine 3 hcl

PAGE 321 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS FIRST-MOUTHWASH BLM SUSPENSION mag hydroxide/al 3 hydroxide/simeth/diphenhydramine/lidocaine FLUOR-A-DAY 0.25 MG TAB CHEW 2 sodium fluoride/xylitol FLUOR-A-DAY 0.5 MG TAB CHEW 2 sodium fluoride/xylitol FLUOR-A-DAY 1 MG TABLET CHEW 2 sodium fluoride/xylitol

fluoridex defense 1.1% gel 1

GELCLAIR ORAL GEL PACKET potassium sorbate/hydroxyethylcellulose/povidone/hyalur 3 ac GELX ORAL GEL 3 povidone/taurine/zinc gluconate/peg-40 castor oil KEPIVANCE 6.25 MG VIAL 9 palifermin MINOCIN 100 MG PELLETIZED CAP 3 minocycline hcl MINOCIN 50 MG PELLETIZED CAP 3 minocycline hcl MINOCIN KIT 100 MG COMBO 3 minocycline hcl/skin cleanser combination no.4 MINOCIN KIT 50 MG COMBO 3 minocycline hcl/skin cleanser combination no.4

minocycline 100 mg capsule 1

minocycline 50 mg capsule 1

minocycline 75 mg capsule 1

minocycline er 135 mg tablet 1

minocycline er 45 mg tablet 1

minocycline er 90 mg tablet 1

minocycline hcl 100 mg tablet 1

minocycline hcl 50 mg tablet 1

minocycline hcl 75 mg tablet 1

MONODOX 100 MG CAPSULE 3 doxycycline monohydrate

PAGE 322 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS MONODOX 50 MG CAPSULE 3 doxycycline monohydrate MONODOX 75 MG CAPSULE 3 doxycycline monohydrate

morgidox 100 mg capsule 1

MORGIDOX 1X100 MG KIT 3 doxycycline hyclate/skin cleanser comb no.19 MORGIDOX 2X100 MG KIT 3 doxycycline hyclate/skin cleanser comb no.19 MUCOTROL GEL WAFER 3 mucositis & stomatitis combo 1 MUGARD ORAL WOUND RINSE glycerin/carbomer homopolymer type a/potassium 3 hydroxide NAFRINSE DAILY-NEUTRAL RINSE 3 sodium fluoride

neutral sodium fluoride 1

NEUTRASAL 538 MG POWDER PACKET 3 saliva substitution combo no.5 NUMOISYN LIQUID 2 flaxseed NUMOISYN LOZENGE 3 sorbitol/saliva stimulant comb no. 1/malic acid/cal phos OCUDOX CONVENIENCE KIT 3 doxycycline hyclate/eyelid clns no.3/eyelid emollient no.1 ORACEA 40 MG CAPSULE 3 doxycycline monohydrate

oralone 0.1% paste 1

ORAMAGICRX ORAL RINSE 3 potassium sorbate/maltodextrin/aloe vera/mann ps

paroex 0.12% oral rinse 1

PERIDEX 0.12% ORAL RINSE 3 chlorhexidine gluconate PERIDEX 0.12% ORAL RINSE 3 chlorhexidine gluconate

periogard 0.12% oral rinse 1

phos-flur 1.1% gel 1

pilocarpine hcl 5 mg tablet 1

PAGE 323 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

pilocarpine hcl 7.5 mg tablet 1

prevident 1.1% gel 1

PREVIDENT 5000 1.1% DRY MOUTH 3 sodium fluoride PREVIDENT 5000 BOOSTER PASTE 3 sodium fluoride PREVIDENT 5000 BOOSTER PLUS 3 sodium fluoride PREVIDENT 5000 ENAMEL PROTECT 3 sodium fluoride/potassium nitrate PREVIDENT 5000 PLUS CREAM 3 sodium fluoride PREVIDENT 5000 SENSITIVE PASTE 3 sodium fluoride/potassium nitrate PREVIDENT DENTAL RINSE 3 sodium fluoride SALAGEN 5 MG TABLET 3 pilocarpine hcl SALAGEN 7.5 MG TABLET 3 pilocarpine hcl

sf 1.1% gel 1

sf 5000 plus cream 1

SOLODYN ER 105 MG TABLET 3 minocycline hcl SOLODYN ER 115 MG TABLET 3 minocycline hcl SOLODYN ER 135 MG TABLET 3 minocycline hcl SOLODYN ER 45 MG TABLET 3 minocycline hcl SOLODYN ER 55 MG TABLET 3 minocycline hcl SOLODYN ER 65 MG TABLET 3 minocycline hcl SOLODYN ER 80 MG TABLET 3 minocycline hcl

SOLODYN ER 90 MG TABLET 3

PAGE 324 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS minocycline hcl

stannous fluor 0.63% rinse 1

triamcinolone 0.1% paste 1

VIBRAMYCIN 100 MG CAPSULE 3 doxycycline hyclate VIBRAMYCIN 25 MG/5 ML SUSP 2 doxycycline monohydrate VIBRAMYCIN 50 MG/5 ML SYRUP 3 doxycycline calcium Dermatological Agents

APOP 10 %-0.5 % GEL 3 sulfacetamide sodium/bakuchiol 8-MOP 10 MG CAPSULE 2 methoxsalen ABSORICA 10 MG CAPSULE 2 QL 150 / 365 days isotretinoin ABSORICA 20 MG CAPSULE 2 QL 150 / 365 days isotretinoin ABSORICA 25 MG CAPSULE 2 QL 150 / 365 days isotretinoin ABSORICA 30 MG CAPSULE 2 QL 150 / 365 days isotretinoin ABSORICA 35 MG CAPSULE 2 QL 150 / 365 days isotretinoin ABSORICA 40 MG CAPSULE 2 QL 150 / 365 days isotretinoin ACANYA GEL PUMP 3 clindamycin phosphate/benzoyl peroxide

acitretin 10 mg capsule 1

acitretin 17.5 mg capsule 1

acitretin 25 mg capsule 1

ACLARO 4% EMULSION 3 hydroquinone/avobenzone/octinoxate ACLARO PD 4% EMULSION 3 hydroquinone/avobenzone/octinoxate

acyclovir 5% ointment 1 QL 30 / 30 days

PAGE 325 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

ACZONE 5% GEL 3 dapsone

adapalene 0.1% cream 1

adapalene 0.1% gel 1

adapalene 0.3% gel 1

adapalene 0.3% gel pump 1

AKNE-MYCIN 2% OINTMENT 2 erythromycin base ALA-CORT 1% CREAM 1 hydrocortisone ALA-QUIN 3-0.5% CREAM 2 clioquinol/hydrocortisone ALA-SCALP 2% LOTION 3 hydrocortisone

alclometasone dipr 0.05% oint 1

alclometasone dipro 0.05% crm 1

ALCORTIN A GEL hydrocortisone acetate/iodoquinol/aloe polysaccharides 3 #2 ALCORTIN A GEL hydrocortisone acetate/iodoquinol/aloe polysaccharides 3 #2 ALDARA 5% CREAM 3 imiquimod ALOQUIN GEL 3 iodoquinol/aloe polysaccharides #1 ALPHAQUIN HP 4% CREAM 1 oxybenzone/octinoxate/hydroquinone

aluminum acetate solution 1

ALUVEA 39% CREAM 3 urea

amcinonide 0.1% cream 1

amcinonide 0.1% lotion 1

amcinonide 0.1% ointment 1

PAGE 326 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

ammonium lactate 12% cream

ammonium lactate 12% cream 1

ammonium lactate 12% lotion 1

amnesteem 10 mg capsule 1 QL 150 / 365 days

amnesteem 20 mg capsule 1 QL 150 / 365 days

amnesteem 40 mg capsule 1 QL 150 / 365 days

ATOPICLAIR CREAM 3 vitamin e acet (dl,tocopheryl)/grape/hyaluronic acid ATRALIN 0.05% GEL 3 ST tretinoin ATRAPRO CP COMBO PACK 3 emollient combination no.47/emollient combination no.60 ATRAPRO DERMAL SPRAY electrolyzed water/sod chlor/sod hypochlorite/hypochlorus 3 ac ATRAPRO HYDROGEL 2 emollient combination no.60 AURSTAT ANTI-ITCH HYDROGEL sod mag fluorosilic/cyclometh/phosph ac/sod bicarb/sod 3 chlor AURSTAT ANTI-ITCH HYDROGEL KIT emol#53/na mg fluorosilicate/cyclometh/phosph 3 PA ac/nahco3/nacl AURSTAT KIT emol53/e.water/namgfs/naphos/nacl/hypochlorous 3 PA acid/nahypocl AVAGE 0.1% CREAM 3 tazarotene AVAR 9.5-5% CLEANSING PADS 3 sulfacetamide sodium/sulfur

avar cleanser 1

AVAR LS 10-2% CLEANSING PADS 3 sulfacetamide sodium/sulfur AVAR LS CLEANSER 3 sulfacetamide sodium/sulfur

avar-e emollient cream 1

avar-e green emollient cream 1

PAGE 327 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS AVAR-E LS CREAM 3 sulfacetamide sodium/sulfur AVITA 0.025% CREAM 3 ST tretinoin AVITA 0.025% GEL 3 ST tretinoin

avo cream topical emulsion 1

AZELEX 20% CREAM 3 azelaic acid BACTROBAN 2% CREAM 3 mupirocin calcium BACTROBAN 2% OINTMENT 3 mupirocin BACTROBAN NASAL 2% OINTMENT 2 mupirocin calcium

bensal hp 3% ointment 3

bensal hp ointment 3

BENZAC AC 5% GEL 3 benzoyl peroxide

benzac ac wash 10% liquid 3

benzac w wash 10% liquid 3

BENZACLIN GEL 3 clindamycin phosphate/benzoyl peroxide BENZACLIN GEL 35G PUMP 3 clindamycin phosphate/benzoyl peroxide BENZACLIN GEL 50G PUMP 3 clindamycin phosphate/benzoyl peroxide

benzalkonium cl 17% solution 3

BENZAMYCIN GEL 3 erythromycin base/benzoyl peroxide BENZAMYCINPAK GEL 2 erythromycin base/benzoyl peroxide BENZEFOAM 5.3% EMOLLIENT FOAM 3 benzoyl peroxide BENZEFOAM ULTRA 9.8% FOAM 3 benzoyl peroxide

benzepro 5.3% emollient foam 1

PAGE 328 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

benzepro 9.8% foam 1

benzoyl peroxide 5.3% foam 1

benzoyl peroxide 6% cleanser 1

benzoyl peroxide 9% cleanser 1

benzoyl peroxide 9.8% foam 1

betamethasone dp 0.05% crm 1

betamethasone dp 0.05% lot 1

betamethasone dp 0.05% oint 1

betamethasone dp aug 0.05% crm 1

betamethasone dp aug 0.05% gel 1

betamethasone dp aug 0.05% lot 1

betamethasone dp aug 0.05% oin 1

betamethasone va 0.1% cream 1

betamethasone va 0.1% lotion 1

betamethasone valer 0.1% ointm 1

BIAFINE EMULSION 1 emollient combination no.10 BIONECT 0.2% CREAM 3 hyaluronate sodium BIONECT 0.2% GEL 3 hyaluronate sodium BIONECT 0.2% SPRAY 3 hyaluronate sodium

bp 10-1 wash 1

bp 5.3% foam 1

bp 9.8% foam 1

bp cleansing wash 1

bp-50% urea emulsion 1

bpo 3% foaming cloths 1

bpo 4% creamy wash pack 1

PAGE 329 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

bpo 4% gel 3

bpo 6% foaming cloths 1

bpo 8% gel 3

bpo 9% foaming cloths 1

calcipotriene 0.005% cream 1

calcipotriene 0.005% ointment 1

calcipotriene 0.005% solution 1

calcipotriene-betameth dp oint 1

calcitrene 0.005% ointment 1

calcitriol 3 mcg/g ointment 3

CAPEX SHAMPOO 2 fluocinolone acetonide CARAC 0.5% CREAM 2 fluorouracil CARAC CREAM 2 fluorouracil CARMOL HC 1% CREAM 3 hydrocortisone acetate/urea

cem-urea 45% pre-filled appl 3

CENTANY 2% OINTMENT 3 mupirocin CENTANY AT 2% OINTMENT KIT 3 mupirocin

cerisa wash 1

ciclodan 0.77% cream 1

CICLODAN 0.77% CREAM KIT 3 ciclopirox olamine/skin cleanser combination no.28 CICLODAN 8% KIT 3 ciclopirox/urea/camphor/menthol/eucalyptol

ciclodan 8% solution 1

ciclopirox 0.77% cream 1

ciclopirox 0.77% gel 1

PAGE 330 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

ciclopirox 0.77% topical susp

ciclopirox 1% shampoo 1

ciclopirox 8 % kit 1

ciclopirox 8% solution 1

ciclopirox 8% treatment kit 1

claravis 10 mg capsule 1 QL 150 / 365 days

claravis 20 mg capsule 1 QL 150 / 365 days

claravis 30 mg capsule 1 QL 150 / 365 days

claravis 40 mg capsule 1 QL 150 / 365 days

CLARIFOAM EF EMOLLIENT FOAM 3 sulfacetamide sodium/sulfur

claris clarifying wash 1

CLENIA EMOLLIENT CREAM 1 sulfacetamide sodium/sulfur CLEOCIN 100 MG VAGINAL OVULE 2 clindamycin phosphate CLEOCIN 2% VAGINAL CREAM 3 clindamycin phosphate CLEOCIN T 1% GEL 3 clindamycin phosphate CLEOCIN T 1% LOTION 3 clindamycin phosphate CLEOCIN T 1% PLEDGETS 3 clindamycin phosphate CLEOCIN T 1% SOLUTION 3 clindamycin phosphate

clind ph-benzoyl perox 1.2-5% 1

clinda-derm 1% solution 3

clindacin etz 1% pledget 3

CLINDACIN ETZ KIT 3 clindamycin phosphate/skin cleanser comb no.19

clindacin p 1% pledgets 1

CLINDACIN PAC KIT 3 clindamycin phosphate/skin cleanser comb no.19

PAGE 331 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS CLINDAGEL 1% GEL 3 clindamycin phosphate CLINDAGEL 1% GEL 3 clindamycin phosphate

clindamycin 2% vaginal cream 1

clindamycin ph 1% gel 1

clindamycin ph 1% solution 1

clindamycin phos 1% pledget 1

clindamycin phosp 1% lotion 1

clindamycin phosphate 1% foam 1

clindamycin-benzoyl perox gel 1

CLINDESSE 2% VAGINAL CREAM 3 clindamycin phosphate

clobetasol 0.05% cream 1

clobetasol 0.05% gel 1

clobetasol 0.05% ointment 1

clobetasol 0.05% shampoo 1

clobetasol 0.05% solution 1

clobetasol 0.05% topical lotn 1

clobetasol emollient 0.05% crm 1

clobetasol emollnt 0.05% foam 1

clobetasol emulsion 0.05% foam 1

clobetasol prop 0.05% foam 1

CLOBEX 0.05% SHAMPOO 3 clobetasol propionate CLOBEX 0.05% SPRAY 3 clobetasol propionate CLOBEX 0.05% TOPICAL LOTION 3 clobetasol propionate CLODERM 0.1% CREAM 3 clocortolone pivalate

CLODERM 0.1% CREAM PUMP 3

PAGE 332 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS clocortolone pivalate

clotrimazole-betamethasone crm 1

clotrimazole-betamethasone lot 1

CNL 8 NAIL KIT 3 ciclopirox & nail lacquer remover, non-acetone

coal tar topical solution 1

CONDYLOX 0.5% GEL 3 podofilox CONDYLOX 0.5% TOPICAL SOLN 3 podofilox CORDRAN 0.05% CREAM 3 flurandrenolide CORDRAN 0.05% LOTION 3 flurandrenolide CORDRAN 4 MCG/SQ CM TAPE LARGE 3 QL 6 / 90 days flurandrenolide CORDRAN 4 MCG/SQ CM TAPE SMALL 3 QL 6 / 90 days flurandrenolide

cormax 0.05% ointment 1

cormax 0.05% solution 1

CORTISPORIN CREAM 2 neomycin sulfate/polymyxin b sulfate/hydrocortisone CORTISPORIN OINTMENT 2 neomycin/bacitracin/polymyxin b/hydrocortisone CUTIVATE 0.05% CREAM 3 fluticasone propionate CUTIVATE 0.05% LOTION 3 fluticasone propionate

cyclosporine 100 mg/ml soln 1

cyclosporine modified 25 mg 1

cyclosporine modified 50 mg 1

dapsone 100 mg tablet 1

dapsone 25 mg tablet 1

DELOS 3.5% LOTION 3

PAGE 333 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

benzoyl peroxide

DERMA-SMOOTHE-FS BODY OIL 3 fluocinolone acetonide DERMA-SMOOTHE-FS SCALP OIL 3 fluocinolone acetonide/shower cap DERMASORB AF COMPLETE KIT 3 clioquinol/hydrocortisone/emollient combination no.88 DERMASORB XM 39% COMPLETE KIT 3 urea/emollient combination no. 18 DERMATOP 0.1% CREAM 3 prednicarbate DERMATOP 0.1% OINTMENT 3 prednicarbate

dermazene cream 1

DESONATE 0.05% GEL 3 desonide

desonide 0.05% cream 1

desonide 0.05% lotion 1

desonide 0.05% ointment 1

DESOWEN 0.05% CREAM 3 desonide DESOWEN 0.05% LOTION 3 desonide

desoximetasone 0.05% cream 1

desoximetasone 0.05% gel 1

desoximetasone 0.05% ointment 1

desoximetasone 0.25% cream 1

desoximetasone 0.25% ointment 1

desquam-x 5% wash 1

diclofenac sodium 1.5% soln 1

diclofenac sodium 3% gel 1

DIFFERIN 0.1% CREAM 3 ST adapalene

DIFFERIN 0.1% GEL 3 ST

PAGE 334 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS adapalene DIFFERIN 0.1% LOTION 3 ST adapalene DIFFERIN 0.3% GEL 3 ST adapalene DIFFERIN 0.3% GEL PUMP 3 ST adapalene

diflorasone 0.05% cream 1

diflorasone 0.05% ointment 1

DIPROLENE 0.05% LOTION 3 betamethasone dipropionate/propylene glycol DIPROLENE 0.05% OINTMENT 3 betamethasone dipropionate/propylene glycol DIPROLENE AF 0.05% CREAM 3 betamethasone dipropionate/propylene glycol DOVONEX 0.005% CREAM 3 calcipotriene DRITHOCREME HP 1% CREAM 3 anthralin DRYSOL SOLUTION 3 aluminum chloride DUAC 1.2-5% GEL 3 clindamycin phosphate/benzoyl peroxide

econazole nitrate 1% cream 1

EFUDEX 5% CREAM 3 fluorouracil ELDOPAQUE FORTE 4% CREAM 3 hydroquinone/ferric oxide

eldoquin forte 4% cream 1

ELETONE CREAM 3 emollient combination no. 25 ELETONE CREAM TWIN PACK 3 emollient combination no. 25 ELIDEL 1% CREAM 3 pimecrolimus ELOCON 0.1% CREAM 3 ST mometasone furoate

ELOCON 0.1% CREAM 3 ST

PAGE 335 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS mometasone furoate ELOCON 0.1% LOTION 3 ST mometasone furoate EMLA CREAM 3 lidocaine/prilocaine EPICERAM EMULSION TWIN PACK 3 emollient combination no.32 EPICERAM SKIN BARRIER EMULSION 3 emollient combination no.32 EPICERAM SKIN BARRIER EMULSION 3 emollient combination no.32 EPIDUO GEL 3 QL 270 / 90 days adapalene/benzoyl peroxide EPIDUO GEL PUMP 3 QL 270 / 90 days adapalene/benzoyl peroxide EPIFIX 2CM X 3CM MEMBRANE 3 human regenerative tissue matrix EPIFIX 4CM X 4CM MEMBRANE 3 human regenerative tissue matrix EPIFIX 5CM X 6CM MEMBRANE 3 human regenerative tissue matrix EPIFIX 7CM X 7CM MEMBRANE 3 human regenerative tissue matrix EPIFIX AMNIOTIC 14MM MEMBRANE 3 human regenerative tissue matrix EPIQUIN MICRO 4% CREAM 3 hydroquinone microspheres ERTACZO 2% CREAM 3 sertaconazole nitrate

ery 2% pads 1

erygel 2% gel 1

erythromycin 2% gel 1

erythromycin 2% pledgets 1

erythromycin 2% solution 1

erythromycin-benzoyl gel 1

EURAX 10% CREAM 3 crotamiton

PAGE 336 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS EURAX 10% LOTION 3 crotamiton EVOCLIN 1% FOAM 3 clindamycin phosphate

exoderm lotion 1

EXTINA 2% FOAM 3 ketoconazole FABIOR 0.1% FOAM 3 tazarotene FINACEA 15% GEL 3 azelaic acid FINACEA PLUS KIT 3 azelaic acid/ceramides (1,3,6-11)

fluocinolone 0.01% body oil 1

fluocinolone 0.01% scalp oil 1

fluocinolone 0.01% solution 1

fluocinolone 0.025% cream 1

fluocinolone 0.025% ointment 1

fluocinonide 0.05% cream 1

fluocinonide 0.05% gel 1

fluocinonide 0.05% ointment 1

fluocinonide 0.05% solution 1

fluocinonide-e 0.05% cream 1

fluocinonide-emol 0.05% cream 1

FLUOROPLEX 1% CREAM 2 fluorouracil

fluorouracil 0.5% cream 1

fluorouracil 2% topical soln 1

fluorouracil 5% cream 1

fluorouracil 5% top solution 1

fluticasone prop 0.005% oint 1

fluticasone prop 0.05% cream 1

PAGE 337 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

fluticasone prop 0.05% lotion 1

FORMA-RAY 20% SOLUTION 3 formaldehyde

formadon 10% solution 1

FORMADON 10% SOLUTION 1 formaldehyde

formaldehyde 10% solution 1

GENADUR KIT biotin/carbitol/equisetum xt/ethanol/hydroxypropyl 3 chito/msm GENADUR NAIL LACQUER carbitol/equisetum ext/ethanol/hydroxypropyl 3 chitosan/msm

gengraf 100 mg capsule 1

gengraf 100 mg/ml solution 1

gengraf 25 mg capsule 1

gentamicin 0.1% cream 1

gentamicin 0.1% ointment 1

GORDO-UREA 22% OINTMENT 3 urea GORDO-UREA 40% OINTMENT 3 urea

grafco silver nit applicator 1

GRAFIX CORE 2CM X 2CM MATRIX 3 human regenerative tissue matrix GRAFIX CORE 2CM X 3CM MATRIX 3 human regenerative tissue matrix GRAFIX CORE 5CM X 5CM MATRIX 3 human regenerative tissue matrix GRAFIX CORE 5CM X 5CM MATRIX 3 human regenerative tissue matrix GRAFIX PRIME 2CM X 2CM MATRIX 3 human regenerative tissue matrix GRAFIX PRIME 2CM X 3CM MATRIX 3 human regenerative tissue matrix GRAFIX PRIME 5CM X 5CM MATRIX 3 human regenerative tissue matrix

PAGE 338 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS GRAFIX PRIME 5CM X 5CM MATRIX 3 human regenerative tissue matrix GRANULEX SPRAY 3 trypsin/balsam peru/castor oil GYNAZOLE-1 CREAM 3 butoconazole nitrate

halobetasol prop 0.05% cream 1

halobetasol prop 0.05% ointmnt 1

HALOG 0.1% CREAM 3 halcinonide HALOG 0.1% OINTMENT 3 halcinonide

hpr emollient foam 1

hpr plus cream 3

hpr plus emollient foam 1

hpr plus-mb hydrogel kit 3 PA

HYDRO 35 FOAM 3 urea HYDRO 40 FOAM 3 urea

hydrocort buty 0.1% lipid crm 3

hydrocortisone 1% cream 1

hydrocortisone 2.5% cream 1

hydrocortisone 2.5% lotion 1

hydrocortisone 2.5% ointment 1

hydrocortisone buty 0.1% cream 1

hydrocortisone-iodoquinol crm 1

hydrogen peroxide 35% solution 3

hydroquinone 4% cream 1

hydroquinone tr 4% cream 1

HYLASE WOUND GEL 3

PAGE 339 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS hyaluronate sodium/hydroxyethylcellulose/polyethylene glycol HYLATOPIC EMOLLIENT FOAM 3 emollient combination no.44 HYLATOPIC PLUS CREAM 3 emollient combination no.53 HYLATOPIC PLUS EMOLLIENT FOAM 3 emollient combination no.53

hypercare 20% solution 1

imiquimod 5% cream packet 1

INOVA 4% EASY PAD 3 benzoyl peroxide/vitamin e mixed INOVA 4-1 EASY PAD 3 salicylic acid/benzoyl peroxide/vitamin e mixed INOVA 8% EASY PAD 3 benzoyl peroxide/vitamin e mixed INOVA 8-2 EASY PAD 3 salicylic acid/benzoyl peroxide/vitamin e mixed IODOFLEX PAD 3 cadexomer iodine IODOSORB GEL 3 cadexomer iodine KENALOG AEROSOL SPRAY 2 ST triamcinolone acetonide KERAFOAM 30% FOAM 3 urea KERAFOAM 42% FOAM 3 urea KERALAC 47% CREAM 3 urea KERALYT 6% GEL 3 salicylic acid KERALYT SCALP COMPLETE KIT 3 salicylic acid KEROL 50% SUSPENSION 3 urea/lactic acid/salicylic acid

ketoconazole 2% cream 1

PAGE 340 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

ketoconazole 2% foam

ketoconazole 2% shampoo 1

ketoconazole 200 mg tablet 1

ketodan 2% foam 1

KETODAN 2% FOAM KIT 3 ketoconazole/skin cleanser combination no.28 KLARON 10% LOTION 3 sulfacetamide sodium LAC-HYDRIN 12% CREAM 3 ammonium lactate LAC-HYDRIN 12% LOTION 3 ammonium lactate

laclotion 12% lotion 1

lactic acid 10% e cream 1

lactic acid 10% lotion 1

LATISSE 0.03% EYELASH SOLUTION 3 QL 9 / 90 days bimatoprost

latrix 50% topical suspension 1

latrix xm 45% emulsion 3

LEVULAN KERASTICK 3 aminolevulinic acid hcl

lidocaine 5% ointment 1

lidocaine-prilocaine cream 1

lokara 0.05% lotion 1

LOPROX 0.77% GEL 3 ciclopirox LOPROX 1% SHAMPOO 3 ciclopirox LOTRISONE CREAM 3 clotrimazole/betamethasone dipropionate LOUTREX CREAM 3 emollient combination no.85

lugol's strong iodine solution 3

PAGE 341 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

lustra 4% cream 1

LUSTRA-AF 4% CREAM 3 vitamin e acetate/avobenzone/octinoxate/hydroquinone LUSTRA-ULTRA 4% CREAM 3 vitamin a/vitamin e/avobenzone/octinoxate/hydroquinone LUXIQ 0.12% FOAM 3 betamethasone valerate LUXIQ 0.12% FOAM 3 betamethasone valerate LYCELLE HEAD LICE REMOVAL KIT 3 citric/citronellyl/hydroxypropyl/methyl salicylate

malathion 0.5% lotion 1

mb hydrogel kit 3 PA

MEDIHONEY 100% PASTE 2 honey

melpaque hp 4% cream 1

melquin hp 4% cream 1

melquin-3 solution 2

MENTAX 1% CREAM 3 butenafine hcl

methotrexate 1 gm vial 7

methotrexate 2.5 mg tablet 1

methotrexate 25 mg/ml vial 7

methoxsalen 10 mg capsule 1

methyl salicylate liquid 1

METVIXIA 16.8% CREAM 3 methyl aminolevulinate hcl MIMYX CREAM 3 emollient combination no.35 MIRVASO 0.33% GEL 3 brimonidine tartrate

mometasone furoate 0.1% cream 1 ST

mometasone furoate 0.1% oint 1 ST

mupirocin 2% ointment 1

PAGE 342 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

myorisan 10 mg capsule 1 QL 150 / 365 days

myorisan 20 mg capsule 1 QL 150 / 365 days

myorisan 40 mg capsule 1 QL 150 / 365 days

NAFTIN 1% CREAM 3 naftifine hcl NAFTIN 1% GEL 3 naftifine hcl NAFTIN 2% CREAM 3 naftifine hcl NATROBA 0.9% TOPICAL SUSP 3 spinosad NEO-SYNALAR 0.5%-0.025% CREAM 3 neomycin sulfate/fluocinolone acetonide NEO-SYNALAR 0.5-0.025% CRM KIT neomycin sulfate/fluocinolone acetonide/emollient comb 3 no.65 NEOBENZ MICRO CREAM PLUS PACK 3 benzoyl peroxide microspheres NEORAL 100 MG GELATIN CAPSULE 2 cyclosporine, modified NEORAL 100 MG/ML SOLUTION 2 cyclosporine, modified NEORAL 25 MG GELATIN CAPSULE 2 cyclosporine, modified NEOSALUS CP CREAM 3 emollient combination no.47 NEOSALUS CREAM 3 emollient combination no.47 NEOSALUS FOAM 3 emollient combination no.38 NEOSALUS LOTION 1 emollient combination no.47 NEUAC 1.2-5% KIT clindamycin phosphate/benzoyl peroxide/emollient comb 3 no.94

neuac gel 1

nivatopic plus cream 3

NUOX GEL 3 benzoyl peroxide/sulfur

PAGE 343 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

nuquin hp 4% cream 1

nuquin hp 4% gel 1

NUVAIL NAIL 16% SOLUTION 3 poly-ureaurethane

nyamyc 100,000 units/gm powder 1

nystatin 100,000 unit/gm cream 1

nystatin 100,000 unit/gm powd 1

nystatin 100,000 units/gm oint 1

nystatin-triamcinolone cream 1

nystatin-triamcinolone ointm 1

nystop 100,000 units/gm powder 1

obagi elastiderm skin 4% cream 1

obagi nu-derm blender 4% cream 1

obagi nu-derm clear 4% cream 1

OBAGI NU-DERM SUNFADER 3 oxybenzone/octinoxate/hydroquinone OBAGI-C CLARIFYING SERUM 3 hydroquinone/ascorbic acid OBAGI-C THERAPY NIGHT CREAM 3 hydroquinone/ascorbic acid/vitamin e acetate OLUX 0.05% FOAM 3 clobetasol propionate OLUX-E 0.05% FOAM 3 clobetasol propionate/emollient base OVACE 10% WASH 3 sulfacetamide sodium OVACE 10% WASH 3 sulfacetamide sodium OVACE PLUS 10% CREAM 2 sulfacetamide sodium OVACE PLUS 10% SHAMPOO 3 sulfacetamide sodium OVACE PLUS 10% WASH 3 sulfacetamide sodium

PAGE 344 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS OVACE PLUS WASH 10% CLNSNG GEL sulfacetamide sodium OXALIS OINTMENT 3 oxalic acid OXISTAT 1% CREAM 3 oxiconazole nitrate OXISTAT 1% LOTION 3 oxiconazole nitrate OXSORALEN 1% LOTION 3 methoxsalen OXSORALEN-ULTRA 10 MG CAP 2 methoxsalen, rapid PACNEX 7% WASH 1 benzoyl peroxide PACNEX HP 7% CLEANSING PADS 3 benzoyl peroxide PACNEX LP 4.25% CLEANSING PADS 3 benzoyl peroxide PACNEX MX 4.25% CLEANSER 3 benzoyl peroxide PANRETIN 0.1% GEL 2 alitretinoin

pedi-dri topical powder 1

PEDIADERM HC 2% KIT 3 hydrocortisone/emollient combination no.45 PEDIADERM TA 0.1% KIT 3 triamcinolone acetonide/emollient combination no.45 PEDIPIROX-4 NAIL KIT ciclopirox/nail lacquer remover, non-acet/foot 3 deodorant#4 PENLAC 8% SOLUTION 3 ciclopirox PENNSAID 1.5% SOLUTION 3 diclofenac sodium PENNSAID 2% PUMP 3 diclofenac sodium

phenol liquid 1

phenol liquified 1

PHISOHEX 3% CLEANSER 3

PAGE 345 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS hexachlorophene PICATO 0.015% GEL 3 QL 9 / 30 days ingenol mebutate PICATO 0.05% GEL 3 QL 4 / 30 days ingenol mebutate PLEXION 9.8-4.8% CLEANSER 3 sulfacetamide sodium/sulfur PLEXION 9.8-4.8% CLNSING CLOTH 3 sulfacetamide sodium/sulfur PLEXION 9.8-4.8% CREAM 3 sulfacetamide sodium/sulfur PLEXION 9.8-4.8% LOTION 3 sulfacetamide sodium/sulfur

podocon-25 liquid 2

podofilox 0.5% topical soln 1

potassium hydroxide 5% soln 3

pr benzoyl peroxide 7% wash 1

pr cream kit 1

prascion fc cleansing cloths 1

prascion ra cream 1

prednicarbate 0.1% cream 1

prednicarbate 0.1% ointment 1

PRESERA FOAM 3 emollient combination no.80 PROMISEB COMPLETE KIT emollient combination no.43/skin cleanser combination 3 #27 PROMISEB TOPICAL CREAM 3 emollient combination no.43 PROMISEB TOPICAL CREAM 3 emollient combination no.43 PROTOPIC 0.03% OINTMENT 2 tacrolimus PROTOPIC 0.1% OINTMENT 2 tacrolimus

pruclair nonsteroidal cream 3

PAGE 346 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS PRUDOXIN 5% CREAM 3 doxepin hcl

prumyx cream 3

prutect topical emulsion 1

PYROGALLIC ACID 25% OINTMENT 3 pyrogallol

QUTENZA 8% KIT QL 4 / 84 days 5 capsaicin/skin cleanser PA

RADIAPLEXRX GEL 2 hyaluronate sodium/allantoin/aloe vera extract RADIGEL ACEMANNAN HYDROGEL 3 acemannan/allantoin

rea lo 39 cream 1

rea lo 40 cream 1

rea lo 40 lotion 1

REGRANEX 0.01% GEL 3 becaplermin

remeven 50% cream 1

RENOVA 0.02% CREAM 3 tretinoin/emollient base RENOVA 0.02% CREAM 3 tretinoin/emollient base RENOVA PUMP 0.02% CREAM 3 tretinoin/emollient base RETIN-A 0.01% GEL 3 ST tretinoin RETIN-A 0.025% CREAM 3 ST tretinoin RETIN-A 0.025% CREAM 3 ST tretinoin RETIN-A 0.025% GEL 3 ST tretinoin RETIN-A 0.025% GEL 3 ST tretinoin

PAGE 347 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS RETIN-A 0.05% CREAM 3 ST tretinoin RETIN-A 0.05% CREAM 3 ST tretinoin RETIN-A 0.1% CREAM 3 ST tretinoin RETIN-A 0.1% CREAM 3 ST tretinoin RETIN-A MICRO 0.04% GEL 3 ST tretinoin microspheres RETIN-A MICRO 0.1% GEL 3 ST tretinoin microspheres RETIN-A MICRO PUMP 0.04% GEL 3 ST tretinoin microspheres RETIN-A MICRO PUMP 0.08% GEL 3 ST tretinoin microspheres RETIN-A MICRO PUMP 0.1% GEL 3 ST tretinoin microspheres RIAX 5.5% FOAM 3 benzoyl peroxide RIAX 9.5% FOAM 3 benzoyl peroxide

rosanil cleanser lotion 1

salacyn 6% cream 1

salacyn 6% lotion 1

SALEX 6% CREAM KIT 3 salicylic acid/ceramides 1,3,6-11 SALEX 6% LOTION KIT 3 salicylic acid/ceramides 1,3,6-11 SALEX 6% SHAMPOO 3 salicylic acid

salicylic acid 26% liquid 1

salicylic acid 27.5% liquid 1

salicylic acid 6% cream 1

salicylic acid 6% cream kit 1

PAGE 348 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

salicylic acid 6% foam

salicylic acid 6% foam 3

salicylic acid 6% gel 1

salicylic acid 6% lotion 1

salicylic acid 6% lotion kit 1

salicylic acid 6% shampoo 1

SALKERA 6% FOAM 3 salicylic acid/ammonium lactate/aloe vera SALVAX 6% FOAM 3 salicylic acid SALVAX DUO PLUS COMBO PACK 3 salicylic acid/urea SANTYL OINTMENT 3 collagenase clostridium histolyticum SANTYL OINTMENT 3 collagenase clostridium histolyticum

scalacort 2% lotion 1

se 10-5 ss cream 1

se bpo 7% wash 1

se bpo 7-5.5% wash kit 1

seb-prev 10% wash 1

selenium sulfide 2.25% shampoo 1

selenium sulfide 2.5% lotion 1

SELRX 2.3% SHAMPOO 3 selenium sulfide SILVADENE 1% CREAM 3 silver sulfadiazine

silver nitrate 0.5% soln 3

silver nitrate 10% ointment 3

silver nitrate 10% solution 3

silver nitrate 25% solution 3

silver nitrate 50% solution 3

PAGE 349 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

silver sulfadiazine 1% cream 1

SILVRSTAT DRESSING GEL 2 silver

sod sulface-sulfur 10-5% cloth 1

sod sulface-sulfur 9-4.5% kit 1

sod sulface-sulfur 9-4.5% wash 1

sod sulfacet-sulfur 10-2% clsr 1

sod sulfacet-sulfur 10-4% pad 1

sod sulfacet-sulfur 10-5% clsr 1

sod sulfacet-sulfur 10-5% gel 3

sod sulfacetam 10% clnsng gel 1

sod sulfacetamide 10% shampoo 1

sod sulfacetamide-sulfur foam 1

sod sulfacetamide-sulfur green 1

sod sulfacetamide-sulfur lotn 1

sod sulfacetamide-sulfur susp 1

sodium sulf-sulfur cleanser 1

sodium sulfacet-sulfur wash 1

sodium sulfacetamide 10% lot 1

sodium sulfacetamide 10% wash 1

sodium sulfacetamide med pads 3

SOLARAZE 3% GEL 2 diclofenac sodium

sonafine topical emulsion 1

PAGE 350 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS SORIATANE 10 MG CAPSULE acitretin SORIATANE 17.5 MG CAPSULE 2 acitretin SORIATANE 25 MG CAPSULE 2 acitretin SORILUX 0.005% FOAM 3 calcipotriene

spinosad 0.9% topical susp 1

SSD 1% CREAM 1 silver sulfadiazine

sss 10-4 foam 3

sss 10-5 cream 1

sss 10-5 foam 1

STELARA 45 MG/0.5 ML SYRINGE 5 PA ustekinumab STELARA 90 MG/ML SYRINGE 5 PA ustekinumab

sulfacetamide sod 10% top susp 1

sulfacetamide-sulfur 10-2% crm 1

sulfacetamide-sulfur 10-5% clr 1

sulfacetamide-sulfur 10-5% crm 1

sulfacetamide-sulfur 8-4% susp 1

sulfacleanse 8-4 suspension 1

SUMADAN 9%-4.5% WASH 3 sulfacetamide sodium/sulfur SUMADAN KIT 3 sulfacetamide sodium/sulfur/skin cleanser comb no.23 SUMADAN XLT KIT sulfacetamide sodium/sulfur/avobenzone/octinoxate/octyl 3 sal SUMAXIN CLEANSING PADS 3 sulfacetamide sodium/sulfur

PAGE 351 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS SUMAXIN CP KIT 3 sulfacetamide sodium/sulfur/skin cleanser comb no.23 SUMAXIN TS TOPICAL SUSPENSION 3 sulfacetamide sodium/sulfur SUMAXIN WASH 3 sulfacetamide sodium/sulfur SYNALAR 0.01% SOLUTION 3 fluocinolone acetonide SYNALAR 0.025% CREAM 1 fluocinolone acetonide SYNALAR 0.025% CREAM KIT 3 fluocinolone acetonide/emollient combination no.65 SYNALAR 0.025% OINTMENT 1 fluocinolone acetonide SYNALAR 0.025% OINTMENT KIT 3 fluocinolone acetonide/emollient combination no.65 SYNALAR TS 0.01% KIT 3 fluocinolone acetonide/skin cleanser comb no.28 TACLONEX 0.005%-0.064% SUSPENS 3 calcipotriene/betamethasone dipropionate TACLONEX OINTMENT 3 calcipotriene/betamethasone dipropionate TARGRETIN 1% GEL 5 PA bexarotene TAZORAC 0.05% CREAM 3 tazarotene TAZORAC 0.05% GEL 3 tazarotene TAZORAC 0.1% CREAM 3 tazarotene TAZORAC 0.1% GEL 3 tazarotene TEMOVATE 0.05% CREAM 3 clobetasol propionate TEMOVATE 0.05% OINTMENT 3 clobetasol propionate TEMOVATE EMOLLIENT 0.05% CRM 3 clobetasol propionate/emollient base TERSI 2.25% FOAM 3 selenium sulfide

PAGE 352 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS TETRIX CREAM KIT protectives combination no.2/ceramides 1,3,6-11 TEXACORT 2.5% SOLUTION 3 hydrocortisone THERMAZENE 1% CREAM 1 silver sulfadiazine

tl 45% urea lotion 1

tl hydroquinone 4% cream 1

tl triseb cream 3

TOPICORT 0.05% CREAM 3 desoximetasone TOPICORT 0.05% GEL 3 desoximetasone TOPICORT 0.05% OINTMENT 3 desoximetasone TOPICORT 0.25% CREAM 3 desoximetasone TOPICORT 0.25% OINTMENT 3 desoximetasone TOPICORT 0.25% SPRAY 3 desoximetasone TRETIN-X 0.01% COMBO PACK 3 ST tretinoin/emollient combination no. 9/skin cln1/gel TRETIN-X 0.025% CREAM COMB PCK 3 ST tretinoin/emollient combination no. 9/skin cln1 TRETIN-X 0.025% GEL COMBO PACK 3 ST tretinoin/emollient combination no. 9/skin cln1/gel TRETIN-X 0.0375% CREAM 3 ST tretinoin TRETIN-X 0.05% COMBO PACK 3 ST tretinoin/emollient combination no. 9/skin cln1 TRETIN-X 0.05% COMBO PACK 3 ST tretinoin/emollient combination no. 9/skin cln1 TRETIN-X 0.075% CREAM 3 ST tretinoin TRETIN-X 0.1% COMBO PACK 3 ST tretinoin/emollient combination no. 9/skin cln1

tretinoin 0.01% gel 1

PAGE 353 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

tretinoin 0.025% cream

tretinoin 0.025% gel 1

tretinoin 0.05% cream 1

tretinoin 0.05% emollient crm 1

tretinoin 0.1% cream 1

tretinoin gel micro 0.04% pump 1

tretinoin gel micro 0.04% tube 1

tretinoin gel micro 0.1% pump 1

tretinoin gel micro 0.1% tube 1

TREXALL 10 MG TABLET 3 methotrexate sodium TREXALL 15 MG TABLET 3 methotrexate sodium TREXALL 5 MG TABLET 3 methotrexate sodium TREXALL 7.5 MG TABLET 3 methotrexate sodium TRI-CHLOR 80% SOLUTION 3 trichloroacetic acid TRI-LUMA CREAM 3 fluocinolone acetonide/tretinoin/hydroquinone

triamcinolone 0.025% cream 1

triamcinolone 0.025% lotion 1

triamcinolone 0.025% oint 1

triamcinolone 0.1% lotion 1

triamcinolone 0.1% ointment 1

triamcinolone 0.5% cream 1

PAGE 354 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

triamcinolone 0.5% ointment 1

trichloroacetic acid 25% 3

trichloroacetic acid 70% 3

trichloroacetic acid 75% 3

triderm 0.1% cream 1

TRIPLE DYE APPLICATORS 2 gentian violet/brilliant green/proflavine

triple dye swab 3

TROPAZONE CREAM 1 emollient combination no.57 TROPAZONE LOTION 1 emollient combination no.48 ULESFIA 5% LOTION 2 QL 1362 / 30 days benzyl alcohol ULTRASAL-ER 28.5% SOLUTION 3 salicylic acid ULTRAVATE 0.05% CREAM 3 halobetasol propionate ULTRAVATE 0.05% OINTMENT 3 halobetasol propionate UMECTA 40% EMULSION 3 urea

umecta 40% mousse 1

UMECTA 40% NAIL FILM PEN 3 urea UMECTA 40% NAIL FILM SUSP 3 urea UMECTA 40% SUSPENSION 3 urea UMECTA PD 40% EMULSION 3 urea UMECTA PD 40% SUSPENSION 3 urea URAMAXIN 20% FOAM 3 urea URAMAXIN 45% LOTION 3 urea

PAGE 355 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS URAMAXIN 45% NAIL GEL 3 urea URAMAXIN 45% UREA CREAM 3 urea URAMAXIN GT 45% KIT 3 urea/emollient combination no.65 URAMAXIN GT 45% PRE-FILLED APP 3 urea

urea 35% foam 1

urea 39% cream 1

urea 40% cream 1

urea 40% gel 1

urea 40% lotion 1

urea 40% nail film susp 1

urea 40% nail kit 1

urea 45% cream 1

urea 45% lotion 1

urea 45% nail gel 1

urea 50% cream 1

urea 50% emulsion 1

urea 50% nail stick 1

urea 50% topical suspension 1

UTOPIC 41% CREAM 3 urea UVADEX 20 MCG/ML VIAL 9 methoxsalen VANIQA 13.9% CREAM 3 eflornithine hcl

VANIQA 13.9% CREAM 3

PAGE 356 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS eflornithine hcl VANOS 0.1% CREAM 3 fluocinonide VANOXIDE-HC LOTION 3 benzoyl peroxide/hydrocortisone

vasolex ointment 1

VECTICAL 3 MCG/G OINTMENT 3 calcitriol VELTIN GEL 3 clindamycin phosphate/tretinoin VENELEX OINTMENT 3 balsam peru/castor oil VERDESO 0.05% FOAM 3 desonide VEREGEN 15% OINTMENT 3 QL 90 / 90 days sinecatechins VIRASAL ANTIVIRAL WART REMOVER 3 salicylic acid

virti-sulf emollient cream 1

VOLTAREN 1% GEL 3 diclofenac sodium VUSION OINTMENT 3 miconazole nitrate/zinc oxide/petrolatum,white VUSION OINTMENT 3 miconazole nitrate/zinc oxide/petrolatum,white VYTONE CREAM PACKET 3 hydrocortisone acetate/iodoquinol/aloe vera

x-viate 40% cream 1

x-viate 40% gel 1

x-viate 40% lotion 1

XCLAIR CREAM hyaluronate sodium/vite ac/emol cmb12/allantoin/shea 3 tree XENADERM OINTMENT 3 trypsin/balsam peru/castor oil XERAC AC 6.25% SOLUTION 3 aluminum chloride

zenatane 10 mg capsule 1 QL 150 / 365 days

PAGE 357 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

zenatane 20 mg capsule 1 QL 150 / 365 days

zenatane 40 mg capsule 1 QL 150 / 365 days

zencia wash 1

ZIANA GEL 3 clindamycin phosphate/tretinoin ZITHRANOL 1% SHAMPOO 3 anthralin micronized ZITHRANOL-RR 1.2% CREAM 3 anthralin ZONALON 5% CREAM 3 doxepin hcl ZOVIRAX 5% CREAM 2 acyclovir ZOVIRAX 5% OINTMENT 3 QL 30 / 30 days acyclovir ZYCLARA 2.5% CREAM PUMP 3 imiquimod ZYCLARA 3.75% CREAM 3 imiquimod ZYCLARA 3.75% CREAM PUMP 3 imiquimod Enzyme Replacement/ Modifiers

ADAGEN 250 UNITS/ML VIAL 9 pegademase bovine ALDURAZYME 2.9 MG/5 ML VIAL 9 laronidase AMMONUL 10%-10% VIAL 9 sodium benzoate/sodium phenylacetate BUPHENYL 500 MG TABLET 2 sodium phenylbutyrate BUPHENYL 500 MG TABLET 2 sodium phenylbutyrate BUPHENYL POWDER 3 sodium phenylbutyrate BUPHENYL POWDER 3 sodium phenylbutyrate CARBAGLU 200 MG DISPER TABLET 5 carglumic acid

PAGE 358 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS CERDELGA 84 MG CAPSULE eliglustat tartrate CEREZYME 400 UNITS VIAL 9 imiglucerase CREON DR 12,000 UNITS CAPSULE 2 lipase/protease/amylase CREON DR 24,000 UNITS CAPSULE 2 lipase/protease/amylase CREON DR 3,000 UNITS CAPSULE 2 lipase/protease/amylase CREON DR 36,000 UNITS CAPSULE 2 lipase/protease/amylase CREON DR 6,000 UNITS CAPSULE 2 lipase/protease/amylase CYSTADANE POWDER 3 betaine ELAPRASE 6 MG/3 ML VIAL 9 idursulfase ELELYSO 200 UNITS VIAL 3 taliglucerase alfa ELITEK 1.5 MG VIAL 9 rasburicase ELITEK 1.5 MG VIAL 9 rasburicase ELITEK 7.5 MG VIAL 9 rasburicase FABRAZYME 35 MG VIAL 5 PA agalsidase beta FABRAZYME 5 MG VIAL 5 PA agalsidase beta KUVAN 100 MG POWDER PACKET 5 PA sapropterin dihydrochloride KUVAN 100 MG TABLET 5 PA sapropterin dihydrochloride LUMIZYME 50 MG VIAL 9 PA alglucosidase alfa LUMIZYME 50 MG VIAL 9 PA alglucosidase alfa MYOZYME 50 MG VIAL 9 PA alglucosidase alfa

PAGE 359 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS NAGLAZYME 5 MG/5 ML VIAL PA galsulfase ORFADIN 10 MG CAPSULE 5 nitisinone ORFADIN 10 MG CAPSULE 5 nitisinone ORFADIN 2 MG CAPSULE 5 nitisinone ORFADIN 2 MG CAPSULE 5 nitisinone ORFADIN 5 MG CAPSULE 5 nitisinone ORFADIN 5 MG CAPSULE 5 nitisinone PANCREAZE DR 10,500 UNIT CAP 3 lipase/protease/amylase PANCREAZE DR 16,800 UNIT CAP 3 lipase/protease/amylase PANCREAZE DR 21,000 UNIT CAP 3 lipase/protease/amylase PANCREAZE DR 4,200 UNIT CAP 3 lipase/protease/amylase

pancrelipase dr 5,000 unit cap 3

PERTZYE DR 16,000 UNITS CAPS 2 lipase/protease/amylase PERTZYE DR 8,000 UNITS CAPSULE 2 lipase/protease/amylase RAVICTI 1.1 GRAM/ML LIQUID 3 glycerol phenylbutyrate

sodium phenylbutyrate powder 1

SUCRAID 8,500 UNITS/ML SOLN 5 PA sacrosidase ULTRESA DR 13,800 UNIT CAPSULE 3 lipase/protease/amylase ULTRESA DR 20,700 UNIT CAPSULE 3 lipase/protease/amylase ULTRESA DR 23,000 UNIT CAPSULE 3 lipase/protease/amylase VIMIZIM 5 MG/5 ML VIAL 3 elosulfase alfa

PAGE 360 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS VIOKACE 10,440-39,150 UNITS TB 3 lipase/protease/amylase VIOKACE 20,880-78,300 UNITS TB 3 lipase/protease/amylase VPRIV 400 UNITS VIAL 9 velaglucerase alfa ZAVESCA 100 MG CAPSULE 9 PA miglustat ZENPEP DR 10,000 UNITS CAPSULE 3 lipase/protease/amylase ZENPEP DR 15,000 UNITS CAPSULE 3 lipase/protease/amylase ZENPEP DR 20,000 UNITS CAPSULE 3 lipase/protease/amylase ZENPEP DR 25,000 UNITS CAPSULE 3 lipase/protease/amylase ZENPEP DR 25,000 UNITS CAPSULE 3 lipase/protease/amylase ZENPEP DR 3,000 UNITS CAPSULE 3 lipase/protease/amylase ZENPEP DR 5,000 UNITS CAPSULE 3 lipase/protease/amylase Gastrointestinal Agents

Antispasmodics, Gastrointestinal

ANASPAZ 0.125 MG TABLET ODT 3 hyoscyamine sulfate ATROPEN 0.5 MG/0.7 ML SYRINGE 9 atropine sulfate ATROPEN 1 MG/0.7 ML SYRINGE 9 atropine sulfate ATROPEN 2 MG/0.7 ML SYRINGE 9 atropine sulfate

atropine 0.05 mg/ml syringe 9

BENTYL 10 MG CAPSULE 3 dicyclomine hcl BENTYL 10 MG/5 ML SYRUP 3 dicyclomine hcl BENTYL 10 MG/ML AMPUL 9 dicyclomine hcl

PAGE 361 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS BENTYL 20 MG TABLET 3 dicyclomine hcl CANTIL 25 MG TABLET 3 mepenzolate bromide

chlordiazepoxide-clidinium cap 1

CUVPOSA 1 MG/5 ML SOLUTION 3 QL 1419 / 30 days glycopyrrolate

dicyclomine 10 mg capsule 1

dicyclomine 10 mg/5 ml soln 1

dicyclomine 20 mg tablet 1

DIGEX NF CAPSULE 3 hyoscyamine sulfate/phenyltoloxamine citrate

ed-spaz 0.125 mg odt 1

gastrinex nf capsule 1

GLYCATE 1.5 MG TABLET 3 glycopyrrolate

glycopyrrolate 0.2 mg/ml vial 7

glycopyrrolate 0.4 mg/2 ml vl 7

glycopyrrolate 1 mg tablet 1

glycopyrrolate 1 mg/5 ml vial 7

glycopyrrolate 2 mg tablet 1

glycopyrrolate 4 mg/20 ml vial 7

hyomax-sl 0.125 mg tablet sl 1

hyoscyamine 0.125 mg odt 1

hyoscyamine 0.125 mg tab sl 1

hyoscyamine 0.125 mg/5 ml elix 1

hyoscyamine 0.125 mg/ml drop 1

hyoscyamine 125 mcg/5 ml elix 1

PAGE 362 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

hyoscyamine er 0.375 mg tab

hyoscyamine sr 0.375 mg tab 1

hyoscyamine sulf 0.125 mg tab 1

hyosyne 0.125 mg/ml drop 1

hyosyne 125 mcg/5 ml elixir 1

LEVBID ER 0.375 MG TABLET 3 hyoscyamine sulfate LEVSIN 0.125 MG TABLET 3 hyoscyamine sulfate LEVSIN 0.5 MG/ML AMPUL 9 hyoscyamine sulfate LEVSIN-SL 0.125 MG TABLET SL 3 hyoscyamine sulfate LIBRAX CAPSULE 3 chlordiazepoxide/clidinium bromide

methscopolamine brom 2.5 mg tb 1

methscopolamine brom 5 mg tab 1

nulev 0.125 mg chewable melt 1

oscimin 0.125 mg odt 1

oscimin 0.125 mg tablet 1

oscimin sl 0.125 mg tablet 1

oscimin sr 0.375 mg tablet 1

PAMINE 2.5 MG TABLET 3 methscopolamine bromide PAMINE FORTE 5 MG TABLET 3 methscopolamine bromide PAMINE FQ DOSE PACK KIT methscopolm 3 br/l.acidophilus/s.thermophl/l.paracasei/bifido ROBINUL 0.2 MG/ML VIAL 9 glycopyrrolate ROBINUL 0.4 MG/2 ML VIAL 9 glycopyrrolate

PAGE 363 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ROBINUL 1 MG TABLET 3 glycopyrrolate ROBINUL 1 MG/5 ML VIAL 9 glycopyrrolate ROBINUL 4 MG/20 ML VIAL 9 glycopyrrolate ROBINUL FORTE 2 MG TABLET 3 glycopyrrolate

scopolamine 0.4 mg/ml vial 9

SYMAX DUOTAB 3 hyoscyamine sulfate

symax fastabs 0.125 mg tablet 1

symax-sl 0.125 mg tablet sl 1

symax-sr 0.375 mg tablet 1

Gastrointestinal Agents, Other

ACTIGALL 300 MG CAPSULE 3 ursodiol ANALPRAM ADVANCED 1 OZ KIT hc acetate/pramoxine hcl/diosmin#1/aloe 3 polysacch#1/policos ANALPRAM ADVANCED 30 X 4G KIT hc acetate/pramoxine hcl/diosmin#1/aloe 3 polysacch#1/policos ANALPRAM E 2.5% CREAM KIT hydrocortisone acetate/pramoxine/emollient/pramoxine 3 comb#1 ANALPRAM HC 1% CREAM 3 hydrocortisone acetate/pramoxine hcl ANALPRAM HC 1% CREAM SINGLES 3 hydrocortisone acetate/pramoxine hcl ANALPRAM HC 2.5% CREAM 3 hydrocortisone acetate/pramoxine hcl ANALPRAM HC 2.5% CRM SINGLES 3 hydrocortisone acetate/pramoxine hcl ANALPRAM HC 2.5% LOTION 3 hydrocortisone acetate/pramoxine hcl

anucort-hc 25 mg suppository 1

anusol-hc 25 mg suppository 3

PAGE 364 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS APRISO ER 0.375 GRAM CAPSULE 3 QL 120 / 30 days mesalamine ASACOL EC 400 MG TABLET 2 mesalamine ASACOL HD DR 800 MG TABLET 2 mesalamine AZULFIDINE 500 MG TABLET 3 sulfasalazine AZULFIDINE ENTAB 500 MG 3 sulfasalazine

belladonna-opium 16.2-30 supp 2

belladonna-opium 16.2-60 supp 2

belladonna-phenobarbital tab 1

BIAXIN 250 MG TABLET 3 clarithromycin BIAXIN 500 MG TABLET 3 clarithromycin CANASA 1,000 MG SUPPOSITORY 2 mesalamine CESINEX SUSPENSION 3 albumen (albumin)/tannic acid CHENODAL 250 MG TABLET 3 chenodiol

clarithromycin 250 mg tablet 1

clarithromycin 500 mg tablet 1

CORTIFOAM 10% AEROSOL 3 hydrocortisone acetate DELZICOL DR 400 MG CAPSULE 3 QL 180 / 30 days mesalamine

dexpanthenol 250 mg/ml vial 8

diphenoxylat-atrop 2.5-0.025/5 1

diphenoxylate-atrop 2.5-0.025 1

DONNATAL ELIXIR phenobarbital/hyoscyamine sulf/atropine sulf/scopolamine 3 hb

DONNATAL EXTENTABS 3 phenobarbital/hyoscyamine sulf/atropine sulf/scopolamine

PAGE 365 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS hb DONNATAL TABLET phenobarbital/hyoscyamine sulf/atropine sulf/scopolamine 3 hb ENTEREG 12 MG CAPSULE 3 alvimopan

falessa 1 mg tablet 1

FULYZAQ 125 MG DR TABLET 3 crofelemer GATTEX 5 MG 30-VIAL KIT 5 PA teduglutide GATTEX 5 MG ONE-VIAL KIT 5 PA teduglutide

grx hicort 25 mg suppository 1

HELIDAC THERAPY 3 bismuth subsalicylate/metronidazole/tetracycline hcl

hemril-30 30 mg suppository 1

hydrocort-pram 2.5%-1% crm kit 1

hydrocort-pramoxine 1%-1% crm 1

hydrocort-pramoxine 2.5%-1% cm 1

hydrocort-pramoxine 2.5-1% crm 1

hydrocortisone 30 mg supp 1

hydrocortisone ac 25 mg supp 1

ipecac syrup 1

KINEVAC 5 MCG VIAL 9 sincalide

lansoprazol-amoxicil-clarithro 1

LIALDA DR 1.2 GM TABLET 3 mesalamine LIALDA DR 1.2 GM TABLET 3 mesalamine

lidocaine-hc 2-2% cream kit 3

lidocaine-hc 2.8-0.55% gel 2

PAGE 366 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

lidocaine-hc 3-0.5% cream 1

lidocaine-hc 3-0.5% cream kit 1

lidocaine-hc 3-1% cream 1

lidocaine-hc 3-1% cream kit 1

lidocaine-hc 3-2.5% gel kit 1

lidocaine-hydrocort 3-2.5% gel 1

LOMOTIL 2.5-0.025 MG TABLET 3 diphenoxylate hcl/atropine sulfate

loperamide 2 mg capsule 1

me-pb-hyos elixir 1

me-pb-hyos tablet 1

mesalamine 4 gm/60 ml enema 1

mesalamine 4 gm/60 ml kit 1

metoclopramide 10 mg/10 ml sol 1

metoclopramide 5 mg tablet 1

metoclopramide 5 mg/5 ml soln 1

metoclopramide 5 mg/5 ml syrup 1

METOZOLV ODT 10 MG TABLET 3 QL 120 / 30 days metoclopramide hcl METOZOLV ODT 5 MG TABLET 3 QL 120 / 30 days metoclopramide hcl MOTOFEN TABLET 3 difenoxin hcl/atropine sulfate OMECLAMOX-PAK COMBO PACK 3 QL 80 / 365 days omeprazole/clarithromycin/amoxicillin trihydrate

opium tincture 10 mg/ml 1

paregoric liquid 1

PENTASA 250 MG CAPSULE 3 mesalamine PENTASA 500 MG CAPSULE 3 mesalamine

PAGE 367 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

pramcort 1% cream 1

PREVPAC PATIENT PACK 3 ST lansoprazole/amoxicillin trihydrate/clarithromycin PROCORT 1.85%-1.15% CREAM 3 hydrocortisone acetate/pramoxine hcl PROCTOCORT 30 MG SUPPOSITORY 3 hydrocortisone acetate PROCTOFOAM-HC 1%-1% FOAM 3 hydrocortisone acetate/pramoxine hcl PROCTOFOAM-HC FOAM 3 hydrocortisone acetate/pramoxine hcl

propantheline 15 mg tablet 1

PYLERA CAPSULE 2 colloidal bismuth subcitrate/metronidazole/tetracycline hcl

quadrapax elixir 1

rectacort-hc 25 mg suppository 1

REGLAN 10 MG TABLET 3 metoclopramide hcl REGLAN 5 MG TABLET 3 metoclopramide hcl

RELISTOR 12 MG/0.6 ML KIT QL 14 / 30 days 5 methylnaltrexone bromide PA

RELISTOR 12 MG/0.6 ML SYRINGE QL 9 / 30 days 5 methylnaltrexone bromide PA

RELISTOR 12 MG/0.6 ML VIAL QL 9 / 30 days 5 methylnaltrexone bromide PA

RELISTOR 8 MG/0.4 ML SYRINGE QL 6 / 30 days 5 methylnaltrexone bromide PA

REZYST 250 MG TABLET CHEW 3 saccharomyces boulardii REZYST IM TABLET CHEW 3 lactobacillus acidophilus/bifidobact bifidum/bifido longum ROWASA 4 GM/60 ML ENEMA KIT 3 mesalamine with cleansing wipes SFROWASA 4 GM/60 ML ENEMA 3 mesalamine

PAGE 368 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

sulfasalazine 500 mg tablet 1

sulfasalazine dr 500 mg tab 1

sulfazine 500 mg tablet 1

sulfazine ec 500 mg tab 1

URSO 250 MG TABLET 3 ursodiol URSO FORTE 500 MG TABLET 3 ursodiol

ursodiol 250 mg tablet 1

ursodiol 300 mg capsule 1

ursodiol 500 mg tablet 1

VSL#3 DS PACKET 3 lactobacillus combination no.2/s.thermophl/bif cmb no.1 XENICAL 120 MG CAPSULE 3 orlistat XIFAXAN 200 MG TABLET 3 rifaximin

z-pram cream kit 3

ZYPRAM CREAM 3 hydrocortisone acetate/pramoxine hcl/skin cleanser no.16 Histamine2 (H2) Receptor Antagonists

AXID 15 MG/ML ORAL SOLUTION 3 nizatidine

cimetidine 200 mg tablet 1

cimetidine 300 mg tablet 1

cimetidine 300 mg/5 ml soln 1

cimetidine 400 mg tablet 1

cimetidine 800 mg tablet 1

DEPRIZINE ORAL SUSPENSION 3 ranitidine hcl

PAGE 369 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

famotidine 10 mg/ml vial

famotidine 20 mg piggyback 1

famotidine 20 mg tablet 1

famotidine 20 mg/2 ml vial 7

famotidine 200 mg/20 ml vial 7

famotidine 40 mg tablet 1

famotidine 40 mg/4 ml vial 7

famotidine 40 mg/5 ml susp 1

famotidine 500 mg/50 ml vial 7

nizatidine 15 mg/ml solution 1

nizatidine 150 mg capsule 1

nizatidine 300 mg capsule 1

PEPCID 20 MG TABLET 3 famotidine PEPCID 40 MG TABLET 3 famotidine PEPCID 40 MG TABLET 3 famotidine PEPCID 40 MG/5 ML ORAL SUSP 3 famotidine

ranitidine 1,000 mg/40 ml vial 7

ranitidine 15 mg/ml syrup 1

ranitidine 150 mg capsule 1

ranitidine 150 mg tablet 1

ranitidine 150 mg/10 ml syrup 1

PAGE 370 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

ranitidine 300 mg capsule 1

ranitidine 300 mg tablet 1

ranitidine hcl 150 mg/6 ml vl 7

ranitidine hcl 25 mg/ml vial 7

ranitidine hcl 50 mg/2 ml vial 7

ZANTAC 1,000 MG/40 ML VIAL 9 ranitidine hcl ZANTAC 15 MG/ML SYRUP 3 ranitidine hcl ZANTAC 150 MG TABLET 3 ranitidine hcl ZANTAC 150 MG/6 ML VIAL 9 ranitidine hcl ZANTAC 25 EFFERDOSE TABLET 3 ranitidine hcl ZANTAC 25 MG/ML VIAL 9 ranitidine hcl ZANTAC 300 MG TABLET 3 ranitidine hcl ZANTAC 50 MG/50 ML PLAST-BAG 9 ranitidine hcl in 0.45 % sodium chloride Irritable Bowel Syndrome Agents

AMITIZA 24 MCG CAPSULES 3 QL 60 / 30 days lubiprostone AMITIZA 8 MCG CAPSULE 3 QL 60 / 30 days lubiprostone LINZESS 145 MCG CAPSULE 3 QL 30 / 30 days linaclotide LINZESS 290 MCG CAPSULE 3 QL 30 / 30 days linaclotide LOTRONEX 0.5 MG TABLET 3 QL 60 / 30 days alosetron hcl LOTRONEX 1 MG TABLET 3 QL 60 / 30 days alosetron hcl Laxatives

COLYTE WITH FLAVOR PACKETS peg 3350/sod sulf/sod bicarbonate/sod 3 chloride/potassium chl

PAGE 371 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS COLYTE WITH FLAVOR PACKETS peg 3350/sod sulf/sod bicarbonate/sod 3 chloride/potassium chl COLYTE WITH FLAVOR PACKS peg 3350/sod sulf/sod bicarbonate/sod 3 chloride/potassium chl

constulose 10 gm/15 ml soln 1

enulose 10 gm/15 ml solution 1

gavilyte-c solution 1

gavilyte-g solution 1

gavilyte-n solution 1

generlac 10 gm/15 ml solution 1

GOLYTELY PACKET peg 3350/sod sulf/sod bicarbonate/sod 3 chloride/potassium chl GOLYTELY SOLUTION peg 3350/sod sulf/sod bicarbonate/sod 3 chloride/potassium chl HALFLYTELY-BISACODYL BOWEL KIT bisacodyl/sodium chlor/sodium bicarb/potassium chl/peg 3 3350 KRISTALOSE 10 GM PACKET 3 lactulose KRISTALOSE 20 GM PACKET 3 lactulose

lactulose 10 gm/15 ml solution 1

lactulose 20 gm/30 ml solution 1

MOVIPREP POWDER PACKET peg 3350/sodium sulfate/sod chloride/kcl/ascorbate 3 sod/vit c NULYTELY WITH FLAVOR PACKS SOL sodium chloride/sodium bicarbonate/potassium 3 chloride/peg

peg 3350 electrolyte soln 1

peg-3350 and electrolytes soln 1

peg-3350 solution 1

peg-3350 with flavor packs sol 1

PAGE 372 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

polyethylene glycol 3350 powd 1

PREPOPIK POWDER PACKET 3 sodium picosulfate/magnesium oxide/citric acid SUCLEAR BOWEL PREP KIT 3 polyethylene glycol 3350/bowel prep #2,two part prep SUPREP BOWEL PREP KIT 3 sodium sulfate/potassium sulfate/magnesium sulfate

trilyte with flavor packets 1

Protectants

CARAFATE 1 GM TABLET 3 sucralfate CARAFATE 1 GM/10 ML SUSP 3 sucralfate CYTOTEC 100 MCG TABLET 3 misoprostol CYTOTEC 200 MCG TABLET 3 misoprostol

misoprostol 100 mcg tablet 1

misoprostol 200 mcg tablet 1

sucralfate 1 gm tablet 1

sucralfate 1 gm/10 ml susp 3

Proton Pump Inhibitors

ACIPHEX DR 20 MG TABLET 3 QL 30 / 30 days rabeprazole sodium ACIPHEX SPRINKLE DR 10 MG CAP 3 rabeprazole sodium ACIPHEX SPRINKLE DR 5 MG CAP 3 rabeprazole sodium

DEXILANT DR 30 MG CAPSULE QL 30 / 30 days 3 dexlansoprazole ST

DEXILANT DR 60 MG CAPSULE QL 30 / 30 days 3 dexlansoprazole ST

PAGE 373 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ESOMEPRAZOLE DR 24.65 MG CAP esomeprazole strontium ESOMEPRAZOLE DR 49.3 MG CAP 1 esomeprazole strontium

esomeprazole sodium 20 mg vial 7

esomeprazole sodium 40 mg vial 7

FIRST-LANSOPRAZOLE 3 MG/ML 3 ST lansoprazole FIRST-OMEPRAZOLE 2 MG/ML SUSP 3 ST omeprazole

lansoprazole dr 15 mg capsule 1 QL 30 / 30 days

lansoprazole dr 30 mg capsule 1 QL 30 / 30 days

NEXIUM DR 10 MG PACKET 3 QL 30 / 30 days esomeprazole magnesium NEXIUM DR 2.5 MG PACKET 3 QL 30 / 30 days esomeprazole magnesium

NEXIUM DR 20 MG CAPSULE QL 30 / 30 days 2 esomeprazole magnesium ST

NEXIUM DR 20 MG PACKET 3 QL 30 / 30 days esomeprazole magnesium

NEXIUM DR 40 MG CAPSULE QL 30 / 30 days 2 esomeprazole magnesium ST

NEXIUM DR 40 MG PACKET 3 QL 30 / 30 days esomeprazole magnesium NEXIUM DR 5 MG PACKET 3 QL 30 / 30 days esomeprazole magnesium NEXIUM I.V. 20 MG VIAL 9 esomeprazole sodium NEXIUM I.V. 40 MG VIAL 9 esomeprazole sodium

omeprazole dr 10 mg capsule 1 QL 60 / 30 days

omeprazole dr 20 mg capsule 1 QL 60 / 30 days

omeprazole dr 40 mg capsule 1 QL 60 / 30 days

PAGE 374 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

omeprazole dr 40 mg capsule 1 QL 60 / 30 days

omeprazole+syrspend sf alka kt 3 ST

omeprazole-bicarb 20-1,100 cap 1 QL 30 / 30 days

omeprazole-bicarb 40-1,100 cap 1 QL 30 / 30 days

pantoprazole sod dr 20 mg tab 1 QL 30 / 30 days

pantoprazole sod dr 40 mg tab 1 QL 30 / 30 days

pantoprazole sodium 40 mg vial 7

PREVACID 15 MG SOLUTAB QL 30 / 30 days 3 lansoprazole ST

PREVACID 30 MG SOLUTAB QL 30 / 30 days 3 lansoprazole ST

PREVACID DR 15 MG CAPSULE QL 30 / 30 days 3 lansoprazole ST

PREVACID DR 30 MG CAPSULE QL 30 / 30 days 3 lansoprazole ST

PRILOSEC DR 10 MG CAPSULE QL 60 / 30 days 3 omeprazole ST

PRILOSEC DR 10 MG SUSPENSION 3 omeprazole magnesium PRILOSEC DR 2.5 MG SUSPENSION 3 omeprazole magnesium

PRILOSEC DR 20 MG CAPSULE QL 60 / 30 days 3 omeprazole ST

PRILOSEC DR 40 MG CAPSULE QL 60 / 30 days 3 omeprazole ST

PROTONIX 40 MG SUSPENSION 2 pantoprazole sodium

PROTONIX DR 20 MG TABLET QL 30 / 30 days 3 pantoprazole sodium ST

PAGE 375 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

PROTONIX DR 40 MG TABLET QL 30 / 30 days 3 pantoprazole sodium ST

PROTONIX IV 40 MG VIAL 9 pantoprazole sodium PROTONIX IV 40 MG VIAL 9 pantoprazole sodium

rabeprazole sod dr 20 mg tab 1 QL 30 / 30 days

ZEGERID 20 MG CAPSULE 3 QL 30 / 30 days omeprazole/sodium bicarbonate ZEGERID 20 MG PACKET 3 omeprazole/sodium bicarbonate ZEGERID 40 MG CAPSULE 3 QL 30 / 30 days omeprazole/sodium bicarbonate ZEGERID 40 MG PACKET 3 omeprazole/sodium bicarbonate Genitourinary Agents

Antispasmodics, Urinary

DETROL 1 MG TABLET QL 60 / 30 days 3 tolterodine tartrate ST

DETROL 2 MG TABLET QL 60 / 30 days 3 tolterodine tartrate ST

DETROL LA 2 MG CAPSULE QL 30 / 30 days 2 tolterodine tartrate ST

DETROL LA 4 MG CAPSULE QL 30 / 30 days 2 tolterodine tartrate ST

DITROPAN XL 10 MG TABLET 3 ST oxybutynin chloride DITROPAN XL 15 MG TABLET 3 ST oxybutynin chloride DITROPAN XL 5 MG TABLET 3 ST oxybutynin chloride

ENABLEX 15 MG TABLET QL 30 / 30 days 2 darifenacin hydrobromide ST

ENABLEX 7.5 MG TABLET 2 QL 30 / 30 days

PAGE 376 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

darifenacin hydrobromide ST

flavoxate hcl 100 mg tablet 1

GELNIQUE 10% GEL SACHETS QL 30 / 30 days 3 oxybutynin chloride ST

GELNIQUE 3% GEL 3 oxybutynin

oxybutynin 5 mg tablet 1

oxybutynin 5 mg/5 ml syrup 1

oxybutynin cl er 10 mg tablet 1

oxybutynin cl er 15 mg tablet 1

oxybutynin cl er 5 mg tablet 1

OXYTROL 3.9 MG/24HR PATCH QL 9 / 30 days 3 oxybutynin ST

SANCTURA 20 MG TABLET QL 60 / 30 days 3 trospium chloride ST

SANCTURA XR 60 MG CAPSULE QL 30 / 30 days 3 trospium chloride ST

tolterodine tart er 2 mg cap 1 QL 30 / 30 days

tolterodine tart er 4 mg cap 1 QL 30 / 30 days

tolterodine tartrate 1 mg tab 1 QL 60 / 30 days

tolterodine tartrate 2 mg tab 1 QL 60 / 30 days

TOVIAZ ER 4 MG TABLET QL 30 / 30 days 2 fesoterodine fumarate ST

TOVIAZ ER 8 MG TABLET QL 30 / 30 days 2 fesoterodine fumarate ST

trospium chloride 20 mg tablet 1 QL 60 / 30 days

trospium chloride er 60 mg cap 1 QL 30 / 30 days

PAGE 377 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

trospium chloride er 60 mg cap 1 QL 30 / 30 days

VESICARE 10 MG TABLET 2 ST solifenacin succinate VESICARE 5 MG TABLET 2 ST solifenacin succinate Benign Prostatic Hypertrophy Agents

alfuzosin hcl er 10 mg tablet 1 QL 30 / 30 days

AVODART 0.5 MG SOFTGEL QL 30 / 30 days 2 dutasteride ST

CARDURA 1 MG TABLET 3 ST doxazosin mesylate CARDURA 2 MG TABLET 3 ST doxazosin mesylate CARDURA 4 MG TABLET 3 ST doxazosin mesylate CARDURA 8 MG TABLET 3 ST doxazosin mesylate CARDURA XL 4 MG TABLET 3 ST doxazosin mesylate CARDURA XL 8 MG TABLET 3 ST doxazosin mesylate

CIALIS 2.5 MG TABLET QL 18 / 90 days 2 tadalafil ST

CIALIS 5 MG TABLET QL 18 / 90 days 2 tadalafil ST

doxazosin mesylate 1 mg tab 1

doxazosin mesylate 2 mg tab 1

doxazosin mesylate 4 mg tab 1

doxazosin mesylate 8 mg tab 1

PAGE 378 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

doxazosin mesylate 8 mg tab 1

finasteride 1 mg tablet 1

finasteride 5 mg tablet 1 QL 30 / 30 days

FLOMAX 0.4 MG CAPSULE QL 60 / 30 days 3 tamsulosin hcl ST

JALYN 0.5-0.4 MG CAPSULE 3 dutasteride/tamsulosin hcl MINIPRESS 1 MG CAPSULE 3 prazosin hcl MINIPRESS 2 MG CAPSULE 3 prazosin hcl MINIPRESS 5 MG CAPSULE 3 prazosin hcl

prazosin 1 mg capsule 1

prazosin 2 mg capsule 1

prazosin 5 mg capsule 1

PROPECIA 1 MG TABLET 3 finasteride

PROSCAR 5 MG TABLET QL 30 / 30 days 3 finasteride ST

RAPAFLO 4 MG CAPSULE QL 30 / 30 days 3 silodosin ST

RAPAFLO 8 MG CAPSULE QL 30 / 30 days 3 silodosin ST

tamsulosin hcl 0.4 mg capsule 1 QL 60 / 30 days

terazosin 1 mg capsule 1

terazosin 10 mg capsule 1

terazosin 2 mg capsule 1

PAGE 379 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

terazosin 5 mg capsule 1

UROXATRAL 10 MG TABLET QL 30 / 30 days 3 alfuzosin hcl ST

Genitourinary Agents, Other

acetic acid 0.25% irrig soln 7

bethanechol 10 mg tablet 1

bethanechol 25 mg tablet 1

bethanechol 5 mg tablet 1

bethanechol 50 mg tablet 1

CAVERJECT 20 MCG VIAL 9 QL 18 / 90 days alprostadil CAVERJECT 20 MCG VIAL 9 QL 18 / 90 days alprostadil CAVERJECT 40 MCG VIAL 9 QL 18 / 90 days alprostadil CAVERJECT 40 MCG/2 ML AMPUL 3 alprostadil CAVERJECT IMPULSE 10 MCG KIT 9 QL 18 / 90 days alprostadil CAVERJECT IMPULSE 20 MCG KIT 9 QL 18 / 90 days alprostadil CERVIDIL 10 MG VAGINAL INSRT 3 dinoprostone CIALIS 10 MG TABLET 2 QL 18 / 90 days tadalafil

CIALIS 2.5 MG TABLET QL 18 / 90 days 2 tadalafil ST

CIALIS 20 MG TABLET 2 QL 18 / 90 days tadalafil

CIALIS 5 MG TABLET QL 18 / 90 days 2 tadalafil ST

PAGE 380 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS CUPRIMINE 250 MG CAPSULE 3 penicillamine CYSTAGON 150 MG CAPSULE 5 PA cysteamine bitartrate CYSTAGON 50 MG CAPSULE 5 PA cysteamine bitartrate

cytra-2 oral solution 1

cytra-3 syrup 2

cytra-k crystals packet 1

cytra-k oral solution 1

DEPEN 250 MG TITRATAB 3 penicillamine EDEX 10 MCG CARTRIDGE 2-PK KIT 9 QL 18 / 90 days alprostadil EDEX 10 MCG CARTRIDGE 6-PK KIT 9 QL 18 / 90 days alprostadil EDEX 20 MCG CARTRIDGE 2-PK KIT 9 QL 18 / 90 days alprostadil EDEX 20 MCG CARTRIDGE 6-PK KIT 9 QL 18 / 90 days alprostadil EDEX 40 MCG CARTRIDGE 2-PK KIT 9 QL 18 / 90 days alprostadil EDEX 40 MCG CARTRIDGE 6-PK KIT 9 QL 18 / 90 days alprostadil ELMIRON 100 MG CAPSULE 2 pentosan polysulfate sodium K-PHOS #2 TABLET sodium phosphate,monobasic/potassium 2 phosphate,monobasic K-PHOS NEUTRAL TABLET 3 phosphorus #1 K-PHOS ORIGINAL TABLET 3 potassium phosphate,monobasic LEVITRA 10 MG TABLET 3 QL 18 / 90 days vardenafil hcl LEVITRA 2.5 MG TABLET 3 QL 18 / 90 days vardenafil hcl LEVITRA 20 MG TABLET 3 QL 18 / 90 days vardenafil hcl

PAGE 381 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS LEVITRA 5 MG TABLET 3 QL 18 / 90 days vardenafil hcl LITHOSTAT 250 MG TABLET 2 acetohydroxamic acid

methylergonovine 0.2 mg tablet 1

methylergonovine 0.2 mg/ml amp 7

methylergonovine 0.2 mg/ml vl 7

MUSE 1,000 MCG URETHRAL SUPP 3 QL 18 / 90 days alprostadil MUSE 125 MCG URETHRAL SUPPOS 3 QL 18 / 90 days alprostadil MUSE 250 MCG URETHRAL SUPPOS 3 QL 18 / 90 days alprostadil MUSE 500 MCG URETHRAL SUPPOS 3 QL 18 / 90 days alprostadil ORACIT ORAL SOLUTION 2 citric acid/sodium citrate

oxytocin 10 units/ml vial 7

oxytocin 100 units/10 ml vial 7

phenazopyridine 100 mg tab 1

phenazopyridine 200 mg tab 1

phenazopyridine plus tablet 1

phospha 250 neutral tablet 1

PITOCIN 10 UNITS/ML VIAL 9 oxytocin PREPIDIL 0.5 MG/3 GM GEL 3 dinoprostone PROCYSBI DR 25 MG CAPSULE 3 cysteamine bitartrate PROCYSBI DR 75 MG CAPSULE 3 cysteamine bitartrate

PAGE 382 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS PROSTIN E2 VAGINAL 20 MG SUP dinoprostone PYRIDIUM 100 MG TABLET 3 phenazopyridine hcl PYRIDIUM 200 MG TABLET 3 phenazopyridine hcl RECTIV 0.4% OINTMENT 3 nitroglycerin RENACIDIN IRRIGATION SOLN 8 citric acid/gluconolactone/magnesium carbonate RESECTISOL 5% SOLUTION 9 mannitol RIMSO-50 SOLUTION 3 dimethyl sulfoxide

shohl's modified solution 3

sod citrate-citric acid soln 1

sorbitol 3% urologic irrig 1

sorbitol 3.3% urologic soln 9

sorbitol-mannitol irrig 9

STAXYN 10 MG ODT 3 vardenafil hcl STENDRA 100 MG TABLET 3 avanafil STENDRA 200 MG TABLET 3 avanafil STENDRA 50 MG TABLET 3 avanafil

taron-crystals packet 1

THIOLA 100 MG TABLET 2 tiopronin

tricitrates oral solution 2

URECHOLINE 10 MG TABLET 3 bethanechol chloride URECHOLINE 25 MG TABLET 3 bethanechol chloride URECHOLINE 5 MG TABLET 3 bethanechol chloride

PAGE 383 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS URECHOLINE 50 MG TABLET 3 bethanechol chloride VIAGRA 100 MG TABLET 2 QL 18 / 90 days sildenafil citrate VIAGRA 25 MG TABLET 2 QL 18 / 90 days sildenafil citrate VIAGRA 50 MG TABLET 2 QL 18 / 90 days sildenafil citrate

virt-phos 250 neutral tablet 1

yohimbine 5.4 mg tablet 1

Phosphate Binders

calcium acetate 667 mg capsule 1

calcium acetate 667 mg gelcap 1

calcium acetate 667 mg tablet 1

ferric citrate 210 mg tablet 1

FOSRENOL 1,000 MG TABLET CHEW 3 lanthanum carbonate FOSRENOL 500 MG TABLET CHEW 3 lanthanum carbonate FOSRENOL 750 MG TABLET CHEW 3 lanthanum carbonate PHOSLO 667 MG GELCAP 3 calcium acetate PHOSLYRA 667 MG/5 ML SOLUTION 3 calcium acetate RENAGEL 400 MG TABLET 3 sevelamer hcl RENAGEL 800 MG TABLET 3 sevelamer hcl RENVELA 0.8 GM POWDER PACKET 3 sevelamer carbonate RENVELA 2.4 GM POWDER PACKET 3 sevelamer carbonate RENVELA 800 MG TABLET 3 sevelamer carbonate

PAGE 384 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

sevelamer carbonate 800 mg tab

VELPHORO 500 MG CHEWABLE TAB 3 sucroferric oxyhydroxide Hormonal Agents, Stimulant/ Replacement/ Modifying (Adrenal)

Glucocorticoids/Mineralocorticoids

a-hydrocort 100 mg vial 7

a-methapred 125 mg vial 7

a-methapred 40 mg univial 7

ALA-CORT 1% CREAM 1 hydrocortisone ALA-SCALP 2% LOTION 3 hydrocortisone

alclometasone dipr 0.05% oint 1

alclometasone dipro 0.05% crm 1

amcinonide 0.1% cream 1

amcinonide 0.1% lotion 1

amcinonide 0.1% ointment 1

ANUSOL-HC 2.5% CREAM 3 hydrocortisone AQUA GLYCOLIC HC 2% KIT 3 hydrocortisone/skin cleanser combination no.25 ARISTOSPAN 20 MG/ML VIAL 9 triamcinolone hexacetonide ARISTOSPAN 5 MG/ML VIAL 9 triamcinolone hexacetonide

betamethasone ac-sp 6 mg/ml vl 7

betamethasone dp 0.05% crm 1

betamethasone dp 0.05% lot 1

betamethasone dp 0.05% oint 1

betamethasone dp aug 0.05% crm 1

betamethasone dp aug 0.05% gel 1

betamethasone dp aug 0.05% lot 1

PAGE 385 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

betamethasone dp aug 0.05% oin 1

betamethasone va 0.1% cream 1

betamethasone va 0.1% lotion 1

betamethasone valer 0.1% ointm 1

budesonide ec 3 mg capsule 1

CAPEX SHAMPOO 2 fluocinolone acetonide CARMOL HC 1% CREAM 3 hydrocortisone acetate/urea CELESTONE 0.6 MG/5 ML SOLUTION 2 betamethasone CELESTONE SOLUSPAN 6 MG/ML betamethasone acetate/betamethasone sodium 9 phosphate

clobetasol 0.05% cream 1

clobetasol 0.05% gel 1

clobetasol 0.05% ointment 1

clobetasol 0.05% shampoo 1

clobetasol 0.05% solution 1

clobetasol 0.05% topical lotn 1

clobetasol emollient 0.05% crm 1

clobetasol emollnt 0.05% foam 1

clobetasol emulsion 0.05% foam 1

clobetasol prop 0.05% foam 1

CLOBEX 0.05% SHAMPOO 3 clobetasol propionate CLOBEX 0.05% SPRAY 3 clobetasol propionate CLOBEX 0.05% TOPICAL LOTION 3 clobetasol propionate CLODAN 0.05% KIT 3 clobetasol propionate/skin cleanser comb no.28

CLODERM 0.1% CREAM 3

PAGE 386 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS clocortolone pivalate CLODERM 0.1% CREAM PUMP 3 clocortolone pivalate CORDRAN 0.05% CREAM 3 flurandrenolide CORDRAN 0.05% LOTION 3 flurandrenolide CORDRAN 0.05% OINTMENT 3 flurandrenolide CORDRAN 4 MCG/SQ CM TAPE LARGE 3 QL 6 / 90 days flurandrenolide CORDRAN 4 MCG/SQ CM TAPE SMALL 3 QL 6 / 90 days flurandrenolide

cormax 0.05% ointment 1

cormax 0.05% solution 1

CORTANE-B LOTION 2 hydrocortisone/pramoxine hcl/chloroxylenol CORTEF 10 MG TABLET 3 hydrocortisone CORTEF 20 MG TABLET 3 hydrocortisone CORTEF 5 MG TABLET 3 hydrocortisone

cortisone 25 mg tablet 1

CORTISPORIN CREAM 2 neomycin sulfate/polymyxin b sulfate/hydrocortisone CORTISPORIN EAR SOLUTION 3 neomycin sulfate/polymyxin b sulfate/hydrocortisone CUTIVATE 0.05% CREAM 3 fluticasone propionate CUTIVATE 0.05% LOTION 3 fluticasone propionate DEPO-MEDROL 20 MG/ML VIAL 9 methylprednisolone acetate DEPO-MEDROL 40 MG/ML VIAL 9 methylprednisolone acetate DEPO-MEDROL 80 MG/ML VIAL 9 methylprednisolone acetate

DERMA-SMOOTHE-FS BODY OIL 3

PAGE 387 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

fluocinolone acetonide

DERMA-SMOOTHE-FS SCALP OIL 3 fluocinolone acetonide/shower cap DERMASORB HC 2% COMPLETE KIT 3 hydrocortisone/skin cleanser combination no.35 DERMASORB TA 0.1% COMPLETE KIT 3 triamcinolone acetonide/emollient combination no.86 DERMOTIC OIL 0.01% EAR DROPS 3 fluocinolone acetonide oil DESONATE 0.05% GEL 3 desonide

desonide 0.05% cream 1

desonide 0.05% lotion 1

desonide 0.05% ointment 1

DESOWEN 0.05% CREAM 3 desonide DESOWEN 0.05% LOTION 3 desonide

desoximetasone 0.05% cream 1

desoximetasone 0.05% gel 1

desoximetasone 0.05% ointment 1

desoximetasone 0.25% cream 1

desoximetasone 0.25% ointment 1

dexamethasone 0.1% eye drop 1

dexamethasone 0.5 mg tablet 1

dexamethasone 0.5 mg/5 ml elx 1

dexamethasone 0.5 mg/5 ml liq 1

dexamethasone 0.75 mg tablet 1

dexamethasone 1 mg tablet 1

dexamethasone 1.5 mg tablet 1

dexamethasone 10 mg/ml vial 7

PAGE 388 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

dexamethasone 100 mg/10 ml vl 7

dexamethasone 120 mg/30 ml vl 7

dexamethasone 2 mg tablet 1

dexamethasone 20 mg/5 ml vial 7

dexamethasone 4 mg tablet 1

dexamethasone 4 mg/ml vial 7

dexamethasone 6 mg tablet 1

dexamethasone intensol 1mg/1ml 1

DEXPAK 10 DAY 1.5 MG TABLET 3 dexamethasone DEXPAK 13 DAY 1.5 MG TABLET 3 dexamethasone DEXPAK 6 DAY 1.5 MG TABLET 3 dexamethasone

diclofenac 0.1% eye drops 1

diflorasone 0.05% cream 1

diflorasone 0.05% ointment 1

DIPROLENE 0.05% LOTION 3 betamethasone dipropionate/propylene glycol DIPROLENE 0.05% OINTMENT 3 betamethasone dipropionate/propylene glycol DIPROLENE AF 0.05% CREAM 3 betamethasone dipropionate/propylene glycol DUREZOL 0.05% EYE DROPS 3 QL 10 / 30 days difluprednate ELOCON 0.1% CREAM 3 ST mometasone furoate ELOCON 0.1% CREAM 3 ST mometasone furoate ELOCON 0.1% LOTION 3 ST mometasone furoate ELOCON 0.1% OINTMENT 3 ST mometasone furoate

PAGE 389 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ENTOCORT EC 3 MG CAPSULE budesonide EPIFOAM FOAM 3 hydrocortisone acetate/pramoxine hcl EPIFOAM FOAM 3 hydrocortisone acetate/pramoxine hcl EZ USE JOINT-TUNNEL-TRIGGER KT 9 triamcinolone acetonide/lidocaine hcl FIRST HYDROCORT 10% GEL 3 hydrocortisone FLAREX 0.1% EYE DROPS 2 fluorometholone acetate FLONASE 0.05% NASAL SPRAY 3 ST fluticasone propionate FLOVENT 100 MCG DISKUS 2 fluticasone propionate FLOVENT 250 MCG DISKUS 2 fluticasone propionate FLOVENT 50 MCG DISKUS 2 fluticasone propionate FLOVENT HFA 110 MCG INHALER 2 fluticasone propionate FLOVENT HFA 220 MCG INHALER 2 fluticasone propionate FLOVENT HFA 44 MCG INHALER 2 fluticasone propionate

fludrocortisone 0.1 mg tablet 1

fluocinolone 0.01% body oil 1

fluocinolone 0.01% cream 1

fluocinolone 0.01% scalp oil 1

fluocinolone 0.01% solution 1

fluocinolone 0.025% cream 1

fluocinolone 0.025% ointment 1

fluocinolone oil 0.01% ear drp 1

fluocinonide 0.05% cream 1

PAGE 390 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

fluocinonide 0.05% gel 1

fluocinonide 0.05% ointment 1

fluocinonide 0.05% solution 1

fluocinonide 0.1% cream 1

fluocinonide-e 0.05% cream 1

fluocinonide-emol 0.05% cream 1

fluorometholone 0.1% drops 1

fluticasone prop 0.005% oint 1

fluticasone prop 0.05% cream 1

fluticasone prop 0.05% lotion 1

fluticasone prop 50 mcg spray 1

FML FORTE 0.25% EYE DROPS 2 fluorometholone FML LIQUIFILM 0.1% EYE DROP 3 fluorometholone FML S.O.P. 0.1% OINTMENT 2 fluorometholone

halobetasol prop 0.05% cream 1

halobetasol prop 0.05% ointmnt 1

HALOG 0.1% CREAM 3 halcinonide HALOG 0.1% OINTMENT 3 halcinonide

halonate combo pack 1

halonate pac combo pack 1

hydrocort buty 0.1% lipid crm 3

hydrocortisone 0.1% soln 1

hydrocortisone 1% absorbase 1

hydrocortisone 1% cream 1

hydrocortisone 1% ointment 1

PAGE 391 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

hydrocortisone 10 mg tablet

hydrocortisone 2.5% cream 1

hydrocortisone 2.5% lotion 1

hydrocortisone 2.5% ointment 1

hydrocortisone 20 mg tablet 1

hydrocortisone 5 mg tablet 1

hydrocortisone acetate 2% gel 1

hydrocortisone buty 0.1% cream 1

hydrocortisone butyr 0.1% oint 1

hydrocortisone val 0.2% cream 1

hydrocortisone val 0.2% ointmt 1

hydrocortisone-pramoxine cream 1

KENALOG AEROSOL SPRAY 2 ST triamcinolone acetonide KENALOG-10 10 MG/ML VIAL 9 ST triamcinolone acetonide KENALOG-40 40 MG/ML VIAL 9 ST triamcinolone acetonide LOCOID 0.1% CREAM 3 hydrocortisone butyrate LOCOID 0.1% LIPOCREAM 3 hydrocortisone butyrate/emollient base LOCOID 0.1% LOTION 3 hydrocortisone butyrate LOCOID 0.1% LOTION 3 hydrocortisone butyrate LOCOID 0.1% OINTMENT 3 hydrocortisone butyrate LOCOID 0.1% SOLUTION 3 hydrocortisone butyrate

lokara 0.05% lotion 1

LUXIQ 0.12% FOAM 3 betamethasone valerate

PAGE 392 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS LUXIQ 0.12% FOAM 3 betamethasone valerate MAXIDEX 0.1% EYE DROPS 3 dexamethasone MEDROL 16 MG TABLET 3 methylprednisolone MEDROL 2 MG TABLET 3 methylprednisolone MEDROL 32 MG TABLET 3 methylprednisolone MEDROL 4 MG DOSEPAK 3 methylprednisolone MEDROL 4 MG TABLET 3 methylprednisolone MEDROL 8 MG TABLET 3 methylprednisolone

methylprednisolone 125 mg vial 7

methylprednisolone 16 mg tab 1

methylprednisolone 32 mg tab 1

methylprednisolone 4 mg dosepk 1

methylprednisolone 4 mg tablet 1

methylprednisolone 40 mg vial 7

methylprednisolone 40 mg/ml vl 7

methylprednisolone 8 mg tab 1

methylprednisolone 80 mg/ml vl 7

methylprednisolone ss 1 gm vl 7

MILLIPRED 10 MG/5 ML SOLUTION 3 prednisolone sod phosphate

millipred dp 5 mg dose pack tb 1

mometasone furoate 0.1% cream 1 ST

mometasone furoate 0.1% oint 1 ST

mometasone furoate 0.1% soln 1 ST

PAGE 393 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS MOMEXIN COMBO PACK 3 mometasone furoate/ammonium lactate NASACORT AQ NASAL SPRAY 3 ST triamcinolone acetonide

neomycin-polymyxin-hc ear soln 1

neomycin-polymyxin-hc ear susp 1

NOVACORT GEL 3 hydrocortisone acetate/pramoxine hcl/aloe polysaccharide NUCORT LOTION 3 hydrocortisone acetate/aloe vera OLUX 0.05% FOAM 3 clobetasol propionate OLUX-E 0.05% FOAM 3 clobetasol propionate/emollient base ORAPRED 15 MG/5 ML SOLUTION 3 prednisolone sod phosphate ORAPRED ODT 10 MG TABLET 3 prednisolone sod phosphate ORAPRED ODT 15 MG TABLET 3 prednisolone sod phosphate ORAPRED ODT 15 MG TABLET 3 prednisolone sod phosphate ORAPRED ODT 30 MG TABLET 3 prednisolone sod phosphate ORAPRED ODT 30 MG TABLET 3 prednisolone sod phosphate PANDEL 0.1% CREAM 3 hydrocortisone probutate PEDIADERM HC 2% KIT 3 hydrocortisone/emollient combination no.45 PEDIADERM TA 0.1% KIT 3 triamcinolone acetonide/emollient combination no.45 PEDIAPRED 5 MG/5 ML SOLN 3 prednisolone sod phosphate PHYSICIANS EZ USE M-PRED KIT 9 methylprednisolone acetate/bupivacaine hcl PRAMOSONE 1% CREAM 3 hydrocortisone acetate/pramoxine hcl PRAMOSONE 1% LOTION 3 hydrocortisone acetate/pramoxine hcl

PAGE 394 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS PRAMOSONE 1% OINTMENT 3 hydrocortisone acetate/pramoxine hcl PRAMOSONE 2.5% CREAM 3 hydrocortisone acetate/pramoxine hcl PRAMOSONE 2.5% LOTION 3 hydrocortisone acetate/pramoxine hcl PRAMOSONE 2.5% OINTMENT 3 hydrocortisone acetate/pramoxine hcl PRAMOSONE E 2.5% CREAM 3 hydrocortisone acetate/pramoxine hcl/emollient base

prednisolone 15 mg/5 ml soln 1

prednisolone 15 mg/5 ml syrup 1

prednisolone 5 mg/5 ml soln 1

prednisolone sod ph 25 mg/5 ml 1

prednisone 1 mg tablet 1

prednisone 10 mg tab dose pack 1

prednisone 10 mg tablet 1

prednisone 2.5 mg tablet 1

prednisone 20 mg tablet 1

prednisone 5 mg tablet 1

prednisone 5 mg/5 ml solution 1

prednisone 5 mg/ml solution 1

prednisone 50 mg tablet 1

PRELONE 15 MG/5 ML SYRUP 3 prednisolone

procto-pak 1% cream 1

proctocream-hc 2.5% cream 1

proctosol-hc 2.5% cream 1

RAYOS DR 1 MG TABLET 3 prednisone

PAGE 395 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS RAYOS DR 2 MG TABLET 3 prednisone RAYOS DR 5 MG TABLET 3 prednisone

scalacort 2% lotion 1

SCALACORT DK 2% KIT 3 hydrocortisone/salicylic acid/sulfur/shampoo cmb 1 SOLARAZE 3% GEL 2 diclofenac sodium SOLU-CORTEF 1,000 MG VIAL 9 hydrocortisone sodium succinate/pf SOLU-CORTEF 100 MG VIAL 9 hydrocortisone sod succinate SOLU-CORTEF 100 MG VIAL 9 hydrocortisone sodium succinate/pf SOLU-CORTEF 250 MG VIAL 9 hydrocortisone sodium succinate/pf SOLU-CORTEF 500 MG VIAL 9 hydrocortisone sodium succinate/pf SOLU-MEDROL 1 GM VIAL 9 methylprednisolone sodium succinate SOLU-MEDROL 1,000 MG VIAL 9 methylprednisolone sodium succinate/pf SOLU-MEDROL 125 MG VIAL 9 methylprednisolone sodium succinate SOLU-MEDROL 125 MG VIAL 9 methylprednisolone sodium succinate/pf SOLU-MEDROL 2,000 MG VIAL 9 methylprednisolone sodium succinate SOLU-MEDROL 40 MG VIAL 9 methylprednisolone sodium succinate/pf SOLU-MEDROL 500 MG VIAL 9 methylprednisolone sodium succinate SOLU-MEDROL 500 MG VIAL 9 methylprednisolone sodium succinate/pf SYNALAR 0.01% SOLUTION 3 fluocinolone acetonide SYNALAR 0.025% CREAM 1 fluocinolone acetonide

SYNALAR 0.025% CREAM KIT 3

PAGE 396 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS fluocinolone acetonide/emollient combination no.65 SYNALAR 0.025% OINTMENT 1 fluocinolone acetonide SYNALAR 0.025% OINTMENT KIT 3 fluocinolone acetonide/emollient combination no.65 SYNALAR TS 0.01% KIT 3 fluocinolone acetonide/skin cleanser comb no.28 TEMOVATE 0.05% CREAM 3 clobetasol propionate TEMOVATE 0.05% OINTMENT 3 clobetasol propionate TEMOVATE EMOLLIENT 0.05% CRM 3 clobetasol propionate/emollient base TEXACORT 2.5% SOLUTION 3 hydrocortisone TOPICORT 0.05% CREAM 3 desoximetasone TOPICORT 0.05% GEL 3 desoximetasone TOPICORT 0.05% OINTMENT 3 desoximetasone TOPICORT 0.25% CREAM 3 desoximetasone TOPICORT 0.25% OINTMENT 3 desoximetasone TOPICORT 0.25% SPRAY 3 desoximetasone

triamcinolone 0.025% cream 1

triamcinolone 0.025% lotion 1

triamcinolone 0.025% oint 1

triamcinolone 0.1% cream 1

triamcinolone 0.1% lotion 1

triamcinolone 0.1% ointment 1

triamcinolone 0.5% cream 1

triamcinolone 0.5% ointment 1

PAGE 397 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

triamcinolone 55 mcg nasal spr 1

triderm 0.1% cream 1

u-cort 1% cream 1

ULTRAVATE 0.05% CREAM 3 halobetasol propionate ULTRAVATE 0.05% OINTMENT 3 halobetasol propionate ULTRAVATE PAC CREAM KIT 3 halobetasol propionate/ammonium lactate ULTRAVATE PAC OINTMENT KIT 3 halobetasol propionate/ammonium lactate ULTRAVATE X CREAM COMBO PACK 3 halobetasol propionate/lactic acid ULTRAVATE X OINTMENT COMBO PAC 3 halobetasol propionate/lactic acid VANOS 0.1% CREAM 3 fluocinonide VERAMYST 27.5 MCG NASAL SPRAY 2 ST fluticasone furoate VERDESO 0.05% FOAM 3 desonide VERIPRED 20 20 MG/5 ML SOLN 3 prednisolone sod phosphate VOLTAREN 1% GEL 3 diclofenac sodium WESTCORT 0.2% OINTMENT 3 hydrocortisone valerate Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)

chorionic gonad 10,000 unit vl 7 QL 3 / 30 days

DDAVP 0.01% NASAL SPRAY 3 desmopressin acetate (non-refrigerated) DDAVP 0.01% SOLUTION 3 desmopressin acetate DDAVP 0.1 MG TABLET 3 desmopressin acetate DDAVP 0.2 MG TABLET 3 desmopressin acetate

DDAVP 4 MCG/ML AMPUL 9

PAGE 398 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS desmopressin acetate DDAVP 4 MCG/ML VIAL 9 desmopressin acetate

demeclocycline 150 mg tablet 1

demeclocycline 300 mg tablet 1

desmopressin 0.01% solution 1

desmopressin 0.01% spray 1

desmopressin 0.1 mg/ml sol 1

desmopressin 0.1 mg/ml spray 1

desmopressin 10 mcg/0.1 ml spr 1

desmopressin 40 mcg/10 ml vial 7

desmopressin ac 4 mcg/ml ampul 7

desmopressin ac 4 mcg/ml vial 7

desmopressin acetate 0.1 mg tb 1

desmopressin acetate 0.2 mg tb 1

EGRIFTA 1 MG VIAL 5 PA tesamorelin acetate EGRIFTA 1 MG VIAL 5 PA tesamorelin acetate EGRIFTA 2 MG VIAL 5 PA tesamorelin acetate EGRIFTA 2 MG VIAL 5 PA tesamorelin acetate GENOTROPIN 12 MG CARTRIDGE 5 PA somatropin GENOTROPIN 5 MG CARTRIDGE 5 PA somatropin GENOTROPIN MINIQUICK 0.2 MG 5 PA somatropin

GENOTROPIN MINIQUICK 0.4 MG 5 PA

PAGE 399 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

somatropin

GENOTROPIN MINIQUICK 0.6 MG 5 PA somatropin GENOTROPIN MINIQUICK 0.8 MG 5 PA somatropin GENOTROPIN MINIQUICK 1 MG 5 PA somatropin GENOTROPIN MINIQUICK 1.2 MG 5 PA somatropin GENOTROPIN MINIQUICK 1.4 MG 5 PA somatropin GENOTROPIN MINIQUICK 1.6 MG 5 PA somatropin GENOTROPIN MINIQUICK 1.8 MG 5 PA somatropin GENOTROPIN MINIQUICK 2 MG 5 PA somatropin HP ACTHAR GEL 80 UNIT/ML VIAL 9 PA corticotropin HUMATROPE 12 MG CARTRIDGE 5 PA somatropin HUMATROPE 24 MG CARTRIDGE 5 PA somatropin HUMATROPE 5 MG VIAL 5 PA somatropin HUMATROPE 6 MG CARTRIDGE 5 PA somatropin INCRELEX 40 MG/4 ML VIAL 5 PA mecasermin NORDITROPIN FLEXPRO 10 MG/1.5 5 PA somatropin NORDITROPIN FLEXPRO 15 MG/1.5 5 PA somatropin NORDITROPIN FLEXPRO 5 MG/1.5 5 PA somatropin NORDITROPIN NORDIFLEX 30 MG/3 5 PA somatropin NOVAREL 10,000 UNITS VIAL 7 QL 3 / 30 days chorionic gonadotropin, human

NUTROPIN 10 MG VIAL 5 PA

PAGE 400 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS somatropin NUTROPIN AQ 20 MG/2ML PEN CART 5 PA somatropin NUTROPIN AQ 5 MG/ML VIAL 5 PA somatropin NUTROPIN AQ NUSPIN 10 PEN CART 5 PA somatropin NUTROPIN AQ NUSPIN 20 PEN CART 5 PA somatropin NUTROPIN AQ NUSPIN 5 PEN CART 5 PA somatropin NUTROPIN AQ PEN CARTRIDGE 5 PA somatropin OMNITROPE 10 MG/1.5 ML CRTG 5 PA somatropin OMNITROPE 5 MG/1.5 ML CRTG 5 PA somatropin OMNITROPE 5.8 MG VIAL 5 PA somatropin PITRESSIN 20 UNITS/ML VIAL 9 vasopressin PREGNYL 10,000 UNITS VIAL 7 QL 3 / 30 days chorionic gonadotropin, human SAIZEN 5 MG VIAL 5 PA somatropin SAIZEN 8.8 MG CLICK.EASY CARTG 5 PA somatropin SAIZEN 8.8 MG VIAL 5 PA somatropin SEROSTIM 4 MG VIAL 5 PA somatropin SEROSTIM 5 MG VIAL 5 PA somatropin SEROSTIM 6 MG VIAL 5 PA somatropin STIMATE 1.5 MG/ML NASAL SPRAY 5 desmopressin acetate TEV-TROPIN 5 MG VIAL 5 PA somatropin

vasopressin 10 unit/0.5 ml vl 7

PAGE 401 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

vasopressin 20 units/ml vial 7

ZORBTIVE 8.8 MG VIAL 5 PA somatropin Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins)

CYTOTEC 100 MCG TABLET 3 misoprostol CYTOTEC 200 MCG TABLET 3 misoprostol HEMABATE 250 MCG/ML AMPUL 9 carboprost tromethamine

misoprostol 100 mcg tablet 1

misoprostol 200 mcg tablet 1

Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers)

Anabolic Steroids

ANADROL-50 TABLET 3 oxymetholone OXANDRIN 10 MG TABLET 3 oxandrolone OXANDRIN 2.5 MG TABLET 3 oxandrolone

oxandrolone 10 mg tablet 1

oxandrolone 2.5 mg tablet 1

Androgens

ANDRODERM 2 MG/24HR PATCH 3 testosterone ANDRODERM 4 MG/24HR PATCH 3 testosterone ANDROGEL 1% GEL PUMP 2 testosterone ANDROGEL 1%(2.5G) GEL PACKET 2 testosterone ANDROGEL 1%(5G) GEL PACKET 2 testosterone ANDROGEL 1.62% GEL PUMP 2 testosterone

PAGE 402 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ANDROGEL 1.62%(1.25G) GEL PCKT 2 testosterone ANDROGEL 1.62%(2.5G) GEL PCKT 2 testosterone ANDROID 10 MG CAPSULE 3 methyltestosterone

androxy 10 mg tablet 2

AVEED 750 MG/3 ML VIAL 9 testosterone undecanoate AXIRON 30 MG/ACTUATION SOLN 2 QL 180 / 30 days testosterone

danazol 100 mg capsule 1

danazol 200 mg capsule 1

danazol 50 mg capsule 1

DELATESTRYL 200 MG/ML VIAL 9 testosterone enanthate DEPO-TESTOSTERONE 100 MG/ML VL 9 testosterone cypionate DEPO-TESTOSTERONE 100 MG/ML VL 9 testosterone cypionate DEPO-TESTOSTERONE 200 MG/ML 9 testosterone cypionate DEPO-TESTOSTERONE 200 MG/ML 9 testosterone cypionate DEPO-TESTOSTERONE 200 MG/ML VL 9 testosterone cypionate FIRST 2% TESTOSTERONE OINT 3 testosterone propionate FIRST-TESTOSTERONE MC 2% CR 3 testosterone propionate FORTESTA 10 MG GEL PUMP 3 QL 120 / 30 days testosterone METHITEST 10 MG TABLET 3 methyltestosterone STRIANT 30 MG MUCOADHESIVE 3 testosterone TESTIM 1% (50MG) GEL 2 testosterone

PAGE 403 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS TESTOPEL 75 MG PELLETS testosterone TESTOPEL 75 MG PELLETS 3 testosterone

testosteron cyp 1,000 mg/10 ml 1

testosteron cyp 2,000 mg/10 ml 7

testosteron enan 1,000 mg/5 ml 7

testosterone 10 mg gel pump 1 QL 120 / 30 days

testosterone 12.5 mg/1.25 gram 1

testosterone 50 mg/5 gram gel 1

testosterone 50 mg/5 gram pkt 1

testosterone cyp 100 mg/ml 7

testosterone cyp 200 mg/ml 7

testosterone enan 200 mg/ml 7

TESTRED 10 MG CAPSULE 3 methyltestosterone VOGELXO 12.5 MG/1.25 GRAM PUMP 3 testosterone VOGELXO 50 MG/5 GRAM GEL 3 testosterone VOGELXO 50 MG/5 GRAM GEL PACKT 3 testosterone Estrogens

ACTIVELLA 0.5-0.1 MG TABLET 3 estradiol/norethindrone acetate ACTIVELLA 1 MG-0.5 MG TABLET 3 estradiol/norethindrone acetate ALORA 0.025 MG PATCH 2 QL 8 / 28 days estradiol ALORA 0.05 MG PATCH 2 QL 8 / 28 days estradiol

ALORA 0.075 MG PATCH 2 QL 8 / 28 days

PAGE 404 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS estradiol ALORA 0.1 MG PATCH 2 QL 8 / 28 days estradiol

altavera-28 tablet 1

alyacen 1-35-28 tablet 1

alyacen 7-7-7-28 tablet 1

amethia 0.15-0.03-0.01 mg tab 1

amethia lo tablet 1

amethyst 90-20 mcg tablet 1

ANGELIQ 0.25 MG-0.5 MG TABLET 3 drospirenone/estradiol ANGELIQ 0.5 MG-1 MG TABLET 3 drospirenone/estradiol

apri 28 day tablet 1

aranelle 28 tablet 1

aubra-28 tablet 1

aviane-28 tablet 1

azurette 28 day tablet 1

balziva 28 tablet 1

BEYAZ 28 TABLET 3 QL 30 / 30 days drospirenone/ethinyl estradiol/levomefolate calcium BREVICON 28 TABLET 3 norethindrone-ethinyl estradiol

briellyn tablet 1

camrese 0.15-0.03-0.01 mg tab 1

camrese lo tablet 1

CAMRESE LO TABLET 3 levonorgestrel-eth estra/ethinyl estradiol

caziant 28 day tablet 1

CENESTIN 0.3 MG TABLET 2 estrogens,conj.,synthetic a

CENESTIN 0.45 MG TABLET 2

PAGE 405 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS estrogens,conj.,synthetic a CENESTIN 0.625 MG TABLET 2 estrogens,conj.,synthetic a CENESTIN 0.9 MG TABLET 2 estrogens,conj.,synthetic a CENESTIN 1.25 MG TABLET 2 estrogens,conj.,synthetic a

chateal-28 tablet 1

CLIMARA 0.025 MG/DAY PATCH 3 QL 4 / 28 days estradiol CLIMARA 0.0375 MG/DAY PATCH 3 QL 4 / 28 days estradiol CLIMARA 0.05 MG/DAY PATCH 3 QL 4 / 28 days estradiol CLIMARA 0.06/MG DAY PATCH 3 QL 4 / 28 days estradiol CLIMARA 0.075 MG/DAY PATCH 3 QL 4 / 28 days estradiol CLIMARA 0.1 MG/DAY PATCH 3 QL 4 / 28 days estradiol CLIMARA PRO PATCH 3 QL 4 / 28 days estradiol/levonorgestrel COMBIPATCH 0.05-0.14 MG PTCH 2 estradiol/norethindrone acetate COMBIPATCH 0.05-0.14 MG PTCH 2 estradiol/norethindrone acetate COMBIPATCH 0.05-0.25 MG PTCH 2 estradiol/norethindrone acetate COMBIPATCH 0.05-0.25 MG PTCH 2 estradiol/norethindrone acetate

covaryx h.s. tablet 1

covaryx tablet 1

cryselle-28 tablet 1

cyclafem 1-35-28 tablet 1

cyclafem 7-7-7-28 tablet 1

CYCLESSA 28 DAY TABLET 1 desogestrel-ethinyl estradiol

PAGE 406 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS CYCLESSA 28 DAY TABLET 1 desogestrel-ethinyl estradiol

dasetta 1-35-28 tablet 1

dasetta 7/7/7-28 tablet 1

daysee 0.15-0.03-0.01 mg tab 1

DELESTROGEN 10 MG/ML VIAL 9 estradiol valerate DELESTROGEN 20 MG/ML VIAL 9 estradiol valerate DELESTROGEN 40 MG/ML VIAL 9 estradiol valerate

delyla-28 tablet 1

DEPO-ESTRADIOL 5 MG/ML VIAL 3 estradiol cypionate DESOGEN 28 DAY TABLET 3 desogestrel-ethinyl estradiol

desogestr-eth estrad eth estra 1

desogestrel-ethinyl estrad tab 1

DIVIGEL 0.25 MG GEL PACKET 3 estradiol DIVIGEL 0.5 MG GEL PACKET 3 estradiol DIVIGEL 1 MG GEL PACKET 3 estradiol

drospirenone-eth estradiol tab 1

DUAVEE 0.45-20 MG TABLET 3 estrogens, conjugated/bazedoxifene acetate

eemt ds 1.25-2.5 mg tablet 1

eemt hs 0.625-1.25 mg tablet 1

ELESTRIN 0.06% GEL 3 estradiol

elinest-28 tablet 1

emoquette 28 day tablet 1

ENJUVIA 0.3 MG TABLET 3 estrogens,conj.,synthetic b

PAGE 407 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ENJUVIA 0.45 MG TABLET 3 estrogens,conj.,synthetic b ENJUVIA 0.625 MG TABLET 3 estrogens,conj.,synthetic b ENJUVIA 0.9 MG TABLET 3 estrogens,conj.,synthetic b ENJUVIA 1.25 MG TABLET 3 estrogens,conj.,synthetic b

enpresse-28 tablet 1

enskyce 28 tablet 1

estarylla 0.25-0.035 mg tablet 1

ESTRACE 0.01% CREAM 3 estradiol ESTRACE 0.5 MG TABLET 3 estradiol ESTRACE 1 MG TABLET 3 estradiol ESTRACE 2 MG TABLET 3 estradiol

estradiol 0.025 mg/day patch 1 QL 4 / 28 days

estradiol 0.0375 mg/day patch 1 QL 4 / 28 days

estradiol 0.05 mg/day patch 1 QL 4 / 28 days

estradiol 0.06 mg/day patch 1 QL 4 / 28 days

estradiol 0.075 mg/day patch 1 QL 4 / 28 days

estradiol 0.1 mg/day patch 1 QL 4 / 28 days

estradiol 0.5 mg tablet 1

estradiol 1 mg tablet 1

estradiol 10 mg/ml vial 7

estradiol 2 mg tablet 1

estradiol tds 0.025 mg/day 1 QL 4 / 28 days

estradiol tds 0.0375 mg/day 1 QL 4 / 28 days

PAGE 408 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

estradiol tds 0.05 mg/day QL 4 / 28 days

estradiol tds 0.06 mg/day 1 QL 4 / 28 days

estradiol tds 0.075 mg/day 1 QL 4 / 28 days

estradiol tds 0.1 mg/day 1 QL 4 / 28 days

estradiol valerate 20 mg/ml vl 7

estradiol valerate 40 mg/ml vl 7

estradiol-noreth 0.5-0.1 mg tb 1

estradiol-noreth 1-0.5 mg tab 1

ESTRASORB PACKET 3 estradiol ESTRING 2 MG VAGINAL RING 2 QL 1 / 90 days estradiol ESTROGEL 0.06% GEL 3 estradiol

estrogen-methyltestos f.s. tab 1

estrogen-methyltestos h.s. tab 1

estrogen-methyltestosterone tb 1

estropipate 0.625(0.75 mg) tab 1

estropipate 1.25(1.5 mg) tab 1

estropipate 2.5(3 mg) tab 1

ESTROSTEP FE-28 TABLET 3 norethindrone acetate-ethinyl estradiol/ferrous fumarate EVAMIST 1.53 MG/SPRAY 3 QL 16 / 30 days estradiol

falmina-28 tablet 1

FEMCON FE TABLET 3 norethindrone-ethinyl estradiol/ferrous fumarate FEMHRT 0.5 MG-2.5 MCG TABLET 2 norethindrone acetate-ethinyl estradiol

FEMRING 0.05 MG VAGINAL RING 3

PAGE 409 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS estradiol acetate FEMRING 0.10 MG VAGINAL RING 3 estradiol acetate FEMTRACE 0.45 MG TABLET 3 estradiol acetate FEMTRACE 0.9 MG TABLET 3 estradiol acetate GENERESS FE CHEWABLE TABLET 3 norethindrone-ethinyl estradiol/ferrous fumarate

gianvi 3 mg-0.02 mg tablet 1

gildagia 0.4 mg-0.035 mg tab 1

gildess 1 mg-20 mcg tablet 1

gildess 1.5 mg-30 mcg tablet 1

gildess fe 1-20 tablet 1

gildess fe 1.5-30 tablet 1

introvale 0.15-0.03 mg tablet 1

jinteli 1 mg-5 mcg tablet 1

jolessa 0.15 mg-0.03 mg tablet 1

junel 1 mg-20 mcg tablet 1

junel 1.5 mg-30 mcg tablet 1

junel fe 1 mg-20 mcg tablet 1

junel fe 1.5 mg-30 mcg tablet 1

kariva 28 day tablet 1

kelnor 1-35 28 tablet 1

kurvelo tablet 1

larin 1.5 mg-30 mcg tablet 1

larin 21 1-20 tablet 1

larin fe 1-20 tablet 1

larin fe 1.5-30 tablet 1

leena 28 tablet 1

PAGE 410 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

lessina-28 tablet 1

levonest-28 tablet 1

levonor-eth estrad 0.1-0.02 mg 1

levonor-eth estrad 0.15-0.03 1

levonorg-eth estrad eth estrad 1

levora-28 tablet 1

LO LOESTRIN FE 1-10 TABLET 3 norethindrone acetate-ethinyl estradiol/ferrous fumarate LO MINASTRIN FE TABLET CHEW 3 norethindrone acetate-ethinyl estradiol/ferrous fumarate LOESTRIN 21 1-20 TABLET 3 norethindrone acetate-ethinyl estradiol LOESTRIN 21 1.5-30 TABLET 3 norethindrone acetate-ethinyl estradiol LOESTRIN 24 FE TABLET 2 norethindrone acetate-ethinyl estradiol/ferrous fumarate LOESTRIN FE 1-20 TABLET 3 norethindrone acetate-ethinyl estradiol/ferrous fumarate LOESTRIN FE 1.5-30 TABLET 3 norethindrone acetate-ethinyl estradiol/ferrous fumarate

lomedia 24 fe tablet 1

loryna 3 mg-0.02 mg tablet 1

LOSEASONIQUE TABLET 3 levonorgestrel-eth estra/ethinyl estradiol

low-ogestrel-28 tablet 1

lutera-28 tablet 1

MAKENA 250 MG/ML VIAL 3 hydroxyprogesterone caproate

marlissa-28 tablet 1

MENEST 0.3 MG TABLET 3 estrogens,esterified MENEST 0.625 MG TABLET 3 estrogens,esterified

PAGE 411 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS MENEST 1.25 MG TABLET estrogens,esterified MENEST 2.5 MG TABLET 3 estrogens,esterified MENOSTAR 14 MCG/DAY PATCH 3 estradiol

microgestin 21 1-20 tablet 1

microgestin 21 1.5-30 tab 1

microgestin fe 1-20 tablet 1

microgestin fe 1.5-30 tab 1

mimvey 1-0.5 mg tablet 1

mimvey lo 0.5-0.1 mg tablet 1

MINASTRIN 24 FE CHEWABLE TAB 2 norethindrone acetate-ethinyl estradiol/ferrous fumarate MINIVELLE 0.0375 MG PATCH 2 QL 8 / 28 days estradiol MINIVELLE 0.05 MG PATCH 2 QL 8 / 28 days estradiol MINIVELLE 0.075 MG PATCH 2 QL 8 / 28 days estradiol MINIVELLE 0.1 MG PATCH 2 QL 8 / 28 days estradiol MIRCETTE 28 DAY TABLET 3 desogestrel-ethinyl estradiol/ethinyl estradiol MODICON 28 TABLET 3 norethindrone-ethinyl estradiol

mono-linyah 28 tablet 1

mononessa 28 tablet 1

myzilra-28 tablet 1

NATAZIA 28 TABLET 3 QL 30 / 30 days estradiol valerate/dienogest

necon 0.5-35-28 tablet 1

PAGE 412 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

necon 1-35-28 tablet

necon 1-50-28 tablet 1

necon 10-11-28 tablet 1

necon 7-7-7-28 tablet 1

nikki 3 mg-0.02 mg tablet 1

NORDETTE-28 TABLET 3 levonorgestrel-ethinyl estradiol

norethin-estrad-ferr 1-0.02 mg 1

norethin-ethinyl estrad ch tb 1

norethind-eth estrad 1-0.02 mg 1

norg-ethin estra 0.25-0.035 mg 1

norgestimate-eth estradiol tab 1

NORINYL 1+35-28 TABLET 3 norethindrone-ethinyl estradiol NORINYL 1+50-28 TABLET 3 norethindrone-mestranol

nortrel 0.5-35 tablet 1

nortrel 1-35 tablet 1

nortrel 7-7-7-28 tablet 1

NUVARING VAGINAL RING 3 QL 1 / 30 days etonogestrel/ethinyl estradiol

ocella 3 mg-0.03 mg tablet 1

OGEN 2.5 TABLET 3 estropipate

orsythia-28 tablet 1

ORTHO EVRA PATCH 3 QL 9 / 84 days norelgestromin/ethinyl estradiol ORTHO EVRA PATCH 3 QL 9 / 84 days norelgestromin/ethinyl estradiol ORTHO TRI-CYCLEN 28 TABLET 3 norgestimate-ethinyl estradiol ORTHO TRI-CYCLEN LO TABLET 2 norgestimate-ethinyl estradiol

PAGE 413 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ORTHO-CEPT 28 DAY TABLET 3 desogestrel-ethinyl estradiol ORTHO-CYCLEN 28 TABLET 1 norgestimate-ethinyl estradiol ORTHO-NOVUM 1-35-28 TABLET 3 norethindrone-ethinyl estradiol ORTHO-NOVUM 7-7-7-28 TABLET 3 norethindrone-ethinyl estradiol OVCON-35 28 TABLET 3 norethindrone-ethinyl estradiol

philith 0.4-0.035 mg tablet 1

pimtrea 28 day tablet 1

pirmella 1-35-28 tablet 1

pirmella 7-7-7-28 tablet 1

portia-28 tablet 1

PREFEST TABLET 2 estradiol/norgestimate PREMARIN 0.3 MG TABLET 2 estrogens, conjugated PREMARIN 0.45 MG TABLET 2 estrogens, conjugated PREMARIN 0.625 MG TABLET 2 estrogens, conjugated PREMARIN 0.9 MG TABLET 2 estrogens, conjugated PREMARIN 1.25 MG TABLET 2 estrogens, conjugated PREMARIN 25 MG VIAL 9 estrogens, conjugated PREMARIN VAGINAL CREAM-APPL 2 estrogens, conjugated PREMPHASE 0.625-5 MG TABLET 2 estrogens, conjugated/medroxyprogesterone acetate PREMPRO 0.3 MG-1.5 MG TABLET 2 estrogens, conjugated/medroxyprogesterone acetate PREMPRO 0.45-1.5 MG TABLET 2 estrogens, conjugated/medroxyprogesterone acetate

PREMPRO 0.625-2.5 MG TABLET 2

PAGE 414 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS estrogens, conjugated/medroxyprogesterone acetate PREMPRO 0.625-5 MG TABLET 2 estrogens, conjugated/medroxyprogesterone acetate

previfem tablet 1

QUARTETTE TABLET 2 levonorgestrel-eth estra/ethinyl estradiol

quasense 0.15-0.03 mg tablet 1

reclipsen 28 day tablet 1

SAFYRAL TABLET 3 drospirenone/ethinyl estradiol/levomefolate calcium SEASONIQUE 0.15-0.03-0.01 TAB 3 levonorgestrel-eth estra/ethinyl estradiol

sprintec 28 day tablet 1

sronyx 0.10-0.02 mg tablet 1

syeda 28 tablet 1

tarina fe 1-20 tablet 1

tilia fe 28 tablet 1

tri-estarylla tablet 1

tri-legest fe-28 day tablet 1

tri-linyah tablet 1

TRI-NORINYL 28 TABLET 3 norethindrone-ethinyl estradiol

tri-previfem tablet 3

tri-sprintec tablet 1

trinessa tablet 1

trivora-28 tablet 1

VAGIFEM 10 MCG VAGINAL TAB 3 estradiol

velivet 28 day tablet 1

vestura 3 mg-0.02 mg tablet 1

viorele 28 day tablet 1

PAGE 415 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS VIVELLE-DOT 0.025 MG PATCH 2 QL 8 / 28 days estradiol VIVELLE-DOT 0.0375 MG PATCH 2 QL 8 / 28 days estradiol VIVELLE-DOT 0.05 MG PATCH 2 QL 8 / 28 days estradiol VIVELLE-DOT 0.075 MG PATCH 2 QL 8 / 28 days estradiol VIVELLE-DOT 0.1 MG PATCH 2 QL 8 / 28 days estradiol

vyfemla 28 tablet 1

wera 0.5/0.035 mg 28 tablet 1

wymzya fe chewable tablet 1

WYMZYA FE CHEWABLE TABLET 1 norethindrone-ethinyl estradiol/ferrous fumarate

xulane patch 1 QL 9 / 84 days

YASMIN 28 TABLET 3 ethinyl estradiol/drospirenone YAZ 28 TABLET 3 ethinyl estradiol/drospirenone

zarah tablet 3

zenchent 0.4 mg-35 mcg tablet 1

zenchent fe tablet chewable 1

zeosa chewable tablet 1

zovia 1-35e tablet 1

Progestins

AYGESTIN 5 MG TABLET 3 norethindrone acetate

camila tablet 1

CRINONE 4% GEL 2 progesterone,micronized CRINONE 8% GEL 2 progesterone,micronized

PAGE 416 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

deblitane 0.35 mg tablet

DEPO-PROVERA 150 MG/ML SYRINGE 9 QL 1 / 90 days medroxyprogesterone acetate DEPO-PROVERA 150 MG/ML VIAL 9 QL 1 / 90 days medroxyprogesterone acetate DEPO-PROVERA 400 MG/ML VIAL 9 QL 1 / 90 days medroxyprogesterone acetate DEPO-SUBQ PROVERA 104 SYRINGE 9 medroxyprogesterone acetate ELLA 30 MG TABLET 3 ulipristal acetate ELLA 30 MG TABLET 3 ulipristal acetate ENDOMETRIN 100 MG SUPPOSITORY 3 progesterone,micronized ENDOMETRIN 100 MG SUPPOSITORY 3 progesterone,micronized

enskyce 28 tablet 1

errin 0.35 mg tablet 1

estarylla 0.25-0.035 mg tablet 1

FIRST-PROGESTERONE VGS 100 SUP 3 QL 90 / 30 days progesterone FIRST-PROGESTERONE VGS 200 SUP 3 QL 90 / 365 days progesterone FIRST-PROGESTERONE VGS 25 SUPP 3 QL 90 / 365 days progesterone FIRST-PROGESTERONE VGS 400 SUP 3 QL 90 / 365 days progesterone FIRST-PROGESTERONE VGS 50 SUPP 3 QL 90 / 365 days progesterone

gildagia 0.4 mg-0.035 mg tab 1

heather tablet 1

IMPLANON 68 MG IMPLANT 9 etonogestrel

jencycla 0.35 mg tablet 1

jolivette tablet 1

PAGE 417 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

larin fe 1-20 tablet

larin fe 1.5-30 tablet 1

levonorgestrel 0.75 mg tablet 1 QL 2 / 365 days

levonorgestrel 1.5 mg tablet 1 QL 1 / 365 days

lyza 0.35 mg tablet 1

medroxyprogesterone 10 mg tab 1

medroxyprogesterone 150 mg/ml 7 QL 1 / 90 days

medroxyprogesterone 2.5 mg tab 1

medroxyprogesterone 5 mg tab 1

MEGACE 40 MG/ML ORAL SUSP 3 megestrol acetate MEGACE ES 625 MG/5 ML SUSP 3 megestrol acetate

megestrol 20 mg tablet 1

megestrol 40 mg tablet 1

megestrol acet 40 mg/ml susp 1

megestrol acet 400 mg/10 ml 1

MINASTRIN 24 FE CHEWABLE TAB 2 norethindrone acetate-ethinyl estradiol/ferrous fumarate MIRENA SYSTEM 3 levonorgestrel MIRENA SYSTEM 3 levonorgestrel

mono-linyah 28 tablet 1

my way 1.5 mg tablet 1 QL 1 / 365 days

NEXPLANON 68 MG IMPLANT 9 etonogestrel NEXPLANON 68 MG IMPLANT 9 etonogestrel

next choice 0.75 mg tablet 1 QL 2 / 365 days

next choice one dose 1.5 mg tb 1 QL 1 / 365 days

PAGE 418 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS NOR-Q-D TABLET 3 norethindrone

nora-be tablet 1

norethindrone 0.35 mg tablet 1

norethindrone 5 mg tablet 1

norlyroc 0.35 mg tablet 1

ORTHO MICRONOR 0.35 MG TABLET 3 norethindrone

pimtrea 28 day tablet 1

pirmella 1-35-28 tablet 1

pirmella 7-7-7-28 tablet 1

PLAN B ONE-STEP 1.5 MG TABLET 3 QL 1 / 365 days levonorgestrel

progesterone 100 mg capsule 1

progesterone 200 mg capsule 1

progesterone oil 50 mg/ml vl 7

PROMETRIUM 100 MG CAPSULE 3 progesterone,micronized PROMETRIUM 200 MG CAPSULE 3 progesterone,micronized PROVERA 10 MG TABLET 3 medroxyprogesterone acetate PROVERA 2.5 MG TABLET 3 medroxyprogesterone acetate PROVERA 5 MG TABLET 3 medroxyprogesterone acetate

sharobel 0.35 mg tablet 1

SKYLA SYSTEM 3 levonorgestrel

tri-estarylla tablet 1

Selective Estrogen Receptor Modifying Agents

EVISTA 60 MG TABLET QL 30 / 30 days 2 raloxifene hcl ST

PAGE 419 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS OSPHENA 60 MG TABLET ospemifene

raloxifene hcl 60 mg tablet 1 QL 30 / 30 days

Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)

ARMOUR THYROID 120 MG TABLET 3 thyroid,pork ARMOUR THYROID 15 MG TABLET 3 thyroid,pork ARMOUR THYROID 180 MG TABLET 3 thyroid,pork ARMOUR THYROID 240 MG TABLET 3 thyroid,pork ARMOUR THYROID 30 MG TABLET 3 thyroid,pork ARMOUR THYROID 300 MG TABLET 3 thyroid,pork ARMOUR THYROID 60 MG TABLET 3 thyroid,pork ARMOUR THYROID 90 MG TABLET 3 thyroid,pork CYTOMEL 25 MCG TABLET 3 liothyronine sodium CYTOMEL 5 MCG TABLET 3 liothyronine sodium CYTOMEL 50 MCG TABLET 3 liothyronine sodium LEVOTHROID 100 MCG TABLET 1 levothyroxine sodium LEVOTHROID 112 MCG TABLET 1 levothyroxine sodium LEVOTHROID 125 MCG TABLET 1 levothyroxine sodium LEVOTHROID 137 MCG TABLET 1 levothyroxine sodium LEVOTHROID 150 MCG TABLET 1 levothyroxine sodium LEVOTHROID 175 MCG TABLET 1 levothyroxine sodium LEVOTHROID 200 MCG TABLET 1 levothyroxine sodium

PAGE 420 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS LEVOTHROID 25 MCG TABLET 1 levothyroxine sodium LEVOTHROID 300 MCG TABLET 1 levothyroxine sodium LEVOTHROID 50 MCG TABLET 1 levothyroxine sodium LEVOTHROID 75 MCG TABLET 1 levothyroxine sodium LEVOTHROID 88 MCG TABLET 1 levothyroxine sodium

levothyroxine 100 mcg tablet 1

levothyroxine 100 mcg vial 9

levothyroxine 112 mcg tablet 1

levothyroxine 125 mcg tablet 1

levothyroxine 137 mcg tablet 1

levothyroxine 150 mcg tablet 1

levothyroxine 175 mcg tablet 1

levothyroxine 200 mcg tablet 1

levothyroxine 200 mcg vial 1

levothyroxine 25 mcg tablet 1

levothyroxine 300 mcg tablet 1

levothyroxine 50 mcg tablet 1

levothyroxine 500 mcg vial 9

levothyroxine 75 mcg tablet 1

levothyroxine 88 mcg tablet 1

LEVOXYL 100 MCG TABLET 1 levothyroxine sodium LEVOXYL 112 MCG TABLET 1 levothyroxine sodium LEVOXYL 125 MCG TABLET 1 levothyroxine sodium

PAGE 421 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS LEVOXYL 137 MCG TABLET levothyroxine sodium LEVOXYL 150 MCG TABLET 1 levothyroxine sodium LEVOXYL 175 MCG TABLET 1 levothyroxine sodium LEVOXYL 200 MCG TABLET 1 levothyroxine sodium LEVOXYL 25 MCG TABLET 1 levothyroxine sodium LEVOXYL 50 MCG TABLET 1 levothyroxine sodium LEVOXYL 75 MCG TABLET 1 levothyroxine sodium LEVOXYL 88 MCG TABLET 1 levothyroxine sodium

liothyronine sod 10 mcg/ml vl 7

liothyronine sod 25 mcg tab 1

liothyronine sod 5 mcg tab 1

liothyronine sod 50 mcg tab 1

NATURE-THROID 113.75 MG TABLET 2 thyroid,pork NATURE-THROID 130 MG TABLET 2 thyroid,pork NATURE-THROID 146.25 MG TABLET 2 thyroid,pork NATURE-THROID 16.25 MG TABLET 2 thyroid,pork NATURE-THROID 162.5 MG TABLET 2 thyroid,pork NATURE-THROID 195 MG TABLET 2 thyroid,pork NATURE-THROID 260 MG TABLET 3 thyroid,pork NATURE-THROID 32.5 MG TABLET 2 thyroid,pork NATURE-THROID 325 MG TABLET 3 thyroid,pork

PAGE 422 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS NATURE-THROID 48.75 MG TABLET thyroid,pork NATURE-THROID 65 MG TABLET 2 thyroid,pork NATURE-THROID 81.25 MG TABLET 2 thyroid,pork NATURE-THROID 97.5 MG TABLET 3 thyroid,pork

np thyroid 30 mg tablet 1

np thyroid 60 mg tablet 1

np thyroid 90 mg tablet 1

SYNTHROID 100 MCG TABLET 2 levothyroxine sodium SYNTHROID 112 MCG TABLET 2 levothyroxine sodium SYNTHROID 125 MCG TABLET 2 levothyroxine sodium SYNTHROID 137 MCG TABLET 2 levothyroxine sodium SYNTHROID 150 MCG TABLET 2 levothyroxine sodium SYNTHROID 175 MCG TABLET 2 levothyroxine sodium SYNTHROID 200 MCG TABLET 2 levothyroxine sodium SYNTHROID 25 MCG TABLET 2 levothyroxine sodium SYNTHROID 300 MCG TABLET 2 levothyroxine sodium SYNTHROID 50 MCG TABLET 2 levothyroxine sodium SYNTHROID 75 MCG TABLET 2 levothyroxine sodium SYNTHROID 88 MCG TABLET 2 levothyroxine sodium THYROLAR-1 STRENGTH TABLET 3 liotrix THYROLAR-1/2 STRENGTH TAB 3 liotrix

PAGE 423 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS THYROLAR-1/4 STRENGTH TAB 3 liotrix THYROLAR-2 STRENGTH TABLET 3 liotrix THYROLAR-3 STRENGTH TABLET 3 liotrix TIROSINT 100 MCG CAPSULE 3 levothyroxine sodium TIROSINT 112 MCG CAPSULE 3 levothyroxine sodium TIROSINT 125 MCG CAPSULE 3 levothyroxine sodium TIROSINT 13 MCG CAPSULE 3 levothyroxine sodium TIROSINT 137 MCG CAPSULE 3 levothyroxine sodium TIROSINT 150 MCG CAPSULE 3 levothyroxine sodium TIROSINT 25 MCG CAPSULE 3 levothyroxine sodium TIROSINT 50 MCG CAPSULE 3 levothyroxine sodium TIROSINT 75 MCG CAPSULE 3 levothyroxine sodium TIROSINT 88 MCG CAPSULE 3 levothyroxine sodium TRIOSTAT 10 MCG/ML VIAL 9 liothyronine sodium UNITHROID 100 MCG TABLET 1 levothyroxine sodium UNITHROID 100 MCG TABLET 1 levothyroxine sodium UNITHROID 112 MCG TABLET 1 levothyroxine sodium UNITHROID 112 MCG TABLET 1 levothyroxine sodium UNITHROID 125 MCG TABLET 1 levothyroxine sodium UNITHROID 125 MCG TABLET 1 levothyroxine sodium

PAGE 424 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS UNITHROID 137 MCG TABLET levothyroxine sodium UNITHROID 150 MCG TABLET 1 levothyroxine sodium UNITHROID 150 MCG TABLET 1 levothyroxine sodium UNITHROID 175 MCG TABLET 1 levothyroxine sodium UNITHROID 175 MCG TABLET 1 levothyroxine sodium UNITHROID 200 MCG TABLET 1 levothyroxine sodium UNITHROID 200 MCG TABLET 1 levothyroxine sodium UNITHROID 25 MCG TABLET 1 levothyroxine sodium UNITHROID 25 MCG TABLET 1 levothyroxine sodium UNITHROID 300 MCG TABLET 1 levothyroxine sodium UNITHROID 300 MCG TABLET 1 levothyroxine sodium UNITHROID 50 MCG TABLET 1 levothyroxine sodium UNITHROID 50 MCG TABLET 1 levothyroxine sodium UNITHROID 75 MCG TABLET 1 levothyroxine sodium UNITHROID 75 MCG TABLET 1 levothyroxine sodium UNITHROID 88 MCG TABLET 1 levothyroxine sodium UNITHROID 88 MCG TABLET 1 levothyroxine sodium WESTHROID 113.75 MG TABLET 3 thyroid,pork WESTHROID 130 MG TABLET 2 thyroid,pork WESTHROID 146.25 MG TABLET 3 thyroid,pork

PAGE 425 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS WESTHROID 16.25 MG TABLET thyroid,pork WESTHROID 162.5 MG TABLET 2 thyroid,pork WESTHROID 195 MG TABLET 2 thyroid,pork WESTHROID 260 MG TABLET 3 thyroid,pork WESTHROID 32.5 MG TABLET 2 thyroid,pork WESTHROID 325 MG TABLET 3 thyroid,pork WESTHROID 48.75 MG TABLET 3 thyroid,pork WESTHROID 65 MG TABLET 2 thyroid,pork WESTHROID 81.25 MG TABLET 3 thyroid,pork WESTHROID 97.5 MG TABLET 3 thyroid,pork WESTHROID-P 130 MG TABLET 2 thyroid,pork WESTHROID-P 16.25 MG TABLET 2 thyroid,pork WESTHROID-P 32.5 MG TABLET 2 thyroid,pork WESTHROID-P 48.75 MG TABLET 3 thyroid,pork WESTHROID-P 65 MG TABLET 2 thyroid,pork WESTHROID-P 97.5 MG TABLET 3 thyroid,pork WP THYROID 113.75 MG TABLET 3 thyroid,pork WP THYROID 130 MG TABLET 2 thyroid,pork WP THYROID 16.25 MG TABLET 2 thyroid,pork WP THYROID 32.5 MG TABLET 2 thyroid,pork

PAGE 426 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS WP THYROID 48.75 MG TABLET thyroid,pork WP THYROID 65 MG TABLET 2 thyroid,pork WP THYROID 81.25 MG TABLET 3 thyroid,pork WP THYROID 97.5 MG TABLET 3 thyroid,pork Hormonal Agents, Suppressant (Adrenal)

LYSODREN 500 MG TABLET 2 mitotane SIGNIFOR 0.3 MG/ML AMPULE 5 PA pasireotide diaspartate SIGNIFOR 0.6 MG/ML AMPULE 5 PA pasireotide diaspartate SIGNIFOR 0.9 MG/ML AMPULE 5 PA pasireotide diaspartate Hormonal Agents, Suppressant (Parathyroid)

calcitriol 0.25 mcg capsule 1

calcitriol 0.5 mcg capsule 1

calcitriol 1 mcg/ml ampul 7

calcitriol 1 mcg/ml solution 1

paricalcitol 1 mcg capsule 1

paricalcitol 2 mcg capsule 1

paricalcitol 4 mcg capsule 1

ROCALTROL 0.25 MCG CAPSULE 3 calcitriol ROCALTROL 0.5 MCG CAPSULE 3 calcitriol

ROCALTROL 1 MCG/ML ORAL SOLN 3

PAGE 427 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS calcitriol SENSIPAR 30 MG TABLET 5 PA cinacalcet hcl SENSIPAR 60 MG TABLET 5 PA cinacalcet hcl SENSIPAR 90 MG TABLET 5 PA cinacalcet hcl ZEMPLAR 1 MCG CAPSULE 3 paricalcitol ZEMPLAR 10 MCG/2 ML VIAL 9 paricalcitol ZEMPLAR 2 MCG CAPSULE 3 paricalcitol ZEMPLAR 2 MCG/ML VIAL 9 paricalcitol ZEMPLAR 4 MCG CAPSULE 3 paricalcitol ZEMPLAR 5 MCG/ML VIAL 9 paricalcitol Hormonal Agents, Suppressant (Pituitary)

bromocriptine 2.5 mg tablet 1

bromocriptine 5 mg capsule 1

cabergoline 0.5 mg tablet 1

CETROTIDE 0.25 MG KIT 9 cetrorelix acetate CETROTIDE 3 MG KIT 9 cetrorelix acetate ELIGARD 22.5 MG SYRINGE B 5 leuprolide acetate ELIGARD 22.5 MG SYRINGE KIT 5 leuprolide acetate ELIGARD 22.5 MG SYRINGE KIT 5 leuprolide acetate ELIGARD 30 MG SYRINGE B 5 leuprolide acetate ELIGARD 30 MG SYRINGE KIT 5 leuprolide acetate

PAGE 428 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ELIGARD 30 MG SYRINGE KIT 5 leuprolide acetate ELIGARD 45 MG SYRINGE B 5 leuprolide acetate ELIGARD 45 MG SYRINGE KIT 5 leuprolide acetate ELIGARD 45 MG SYRINGE KIT 5 leuprolide acetate ELIGARD 7.5 MG SYRINGE B 5 leuprolide acetate ELIGARD 7.5 MG SYRINGE KIT 5 leuprolide acetate ELIGARD 7.5 MG SYRINGE KIT 5 leuprolide acetate FIRMAGON 2 X 120 MG KIT 9 QL 2 / 30 days degarelix acetate FIRMAGON 2 X 120 MG VIALS 9 QL 2 / 30 days degarelix acetate FIRMAGON 80 MG KIT 9 QL 1 / 30 days degarelix acetate FIRMAGON 80 MG VIAL 9 QL 1 / 30 days degarelix acetate GANIRELIX ACET 250 MCG/0.5 ML 9 ganirelix acetate

leuprolide 2wk 1 mg/0.2 ml kit 4

LUPANETA PK 11.25-5 MG 3MO KIT 3 leuprolide acetate/norethindrone acetate LUPANETA PK 3.75-5 MG 1MO KIT 3 leuprolide acetate/norethindrone acetate LUPRON DEPOT 11.25 MG 3MO KIT 5 leuprolide acetate LUPRON DEPOT 22.5 MG 3MO KIT 5 leuprolide acetate LUPRON DEPOT 3.75 MG KIT 5 leuprolide acetate LUPRON DEPOT 45 MG 6MO KIT 5 leuprolide acetate LUPRON DEPOT 7.5 MG KIT 5 leuprolide acetate

LUPRON DEPOT-4 MONTH KIT 5

PAGE 429 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS leuprolide acetate LUPRON DEPOT-PED 11.25 MG 3MO 5 leuprolide acetate LUPRON DEPOT-PED 11.25 MG KIT 5 leuprolide acetate LUPRON DEPOT-PED 15 MG KIT 5 leuprolide acetate LUPRON DEPOT-PED 30 MG 3MO KIT 5 leuprolide acetate LUPRON DEPOT-PED 7.5 MG KIT 5 leuprolide acetate

octreotide 1,000 mcg/5 ml vial 4 PA

octreotide 1,000 mcg/ml vial 4 PA

octreotide 5,000 mcg/5 ml vial 4 PA

octreotide acet 100 mcg/ml amp 4 PA

octreotide acet 100 mcg/ml syr 4 PA

octreotide acet 100 mcg/ml vl 4 PA

octreotide acet 200 mcg/ml vl 4 PA

octreotide acet 50 mcg/ml amp 4 PA

octreotide acet 50 mcg/ml syr 4 PA

octreotide acet 50 mcg/ml vial 4 PA

octreotide acet 500 mcg/ml amp 4 PA

octreotide acet 500 mcg/ml syr 4 PA

octreotide acet 500 mcg/ml vl 4 PA

PARLODEL 2.5 MG TABLET 3 bromocriptine mesylate PARLODEL 5 MG CAPSULE 3 bromocriptine mesylate

SANDOSTATIN 0.05 MG/ML AMPUL 5 PA

PAGE 430 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS octreotide acetate SANDOSTATIN 0.1 MG/ML AMPUL 5 PA octreotide acetate SANDOSTATIN 0.2 MG/ML VIAL 5 PA octreotide acetate SANDOSTATIN 0.5 MG/ML AMPUL 5 PA octreotide acetate SANDOSTATIN 1 MG/ML VIAL 5 PA octreotide acetate SANDOSTATIN LAR 10 MG KIT 5 PA octreotide acetate SANDOSTATIN LAR 20 MG KIT 5 PA octreotide acetate SANDOSTATIN LAR 30 MG KIT 5 PA octreotide acetate SOMATULINE 120 MG/0.5 ML SYRGE 9 lanreotide acetate SOMATULINE 60 MG/0.2 ML SYRING 9 lanreotide acetate SOMATULINE 90 MG/0.3 ML SYRING 9 lanreotide acetate SOMAVERT 10 MG VIAL 5 PA pegvisomant SOMAVERT 15 MG VIAL 5 PA pegvisomant SOMAVERT 20 MG VIAL 5 PA pegvisomant SOMAVERT 25 MG VIAL 5 PA pegvisomant SOMAVERT 30 MG VIAL 5 PA pegvisomant SUPPRELIN LA 50 MG KIT 3 histrelin acetate SYNAREL 2 MG/ML NASAL SPRAY 5 PA nafarelin acetate TRELSTAR 11.25 MG SYRINGE 3 triptorelin pamoate TRELSTAR 22.5 MG SYRINGE 3 triptorelin pamoate

TRELSTAR 22.5 MG VIAL 3

PAGE 431 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS triptorelin pamoate TRELSTAR 3.75 MG SYRINGE 3 triptorelin pamoate TRELSTAR DEPOT 3.75 MG VIAL 3 triptorelin pamoate TRELSTAR LA 11.25 MG VIAL 3 triptorelin pamoate VANTAS 50 MG KIT 9 histrelin acetate ZOLADEX 10.8 MG IMPLANT SYRN 3 goserelin acetate ZOLADEX 3.6 MG IMPLANT SYRN 3 goserelin acetate Hormonal Agents, Suppressant (Sex Hormones/Modifiers)

Antiandrogens

AVODART 0.5 MG SOFTGEL QL 30 / 30 days 2 dutasteride ST

bicalutamide 50 mg tablet 1 QL 30 / 30 days

CASODEX 50 MG TABLET 3 QL 30 / 30 days bicalutamide

finasteride 5 mg tablet 1 QL 30 / 30 days

flutamide 125 mg capsule 1

NILANDRON 150 MG TABLET 2 nilutamide NILANDRON 150 MG TABLET 2 nilutamide PROPECIA 1 MG TABLET 3 finasteride

PROSCAR 5 MG TABLET QL 30 / 30 days 3 finasteride ST

XTANDI 40 MG CAPSULE QL 120 / 30 days 9 enzalutamide PA

Hormonal Agents, Suppressant (Thyroid)

Antithyroid Agents

methimazole 10 mg tablet 1

PAGE 432 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

methimazole 5 mg tablet 1

propylthiouracil 50 mg tablet 1

TAPAZOLE 10 MG TABLET 3 methimazole TAPAZOLE 5 MG TABLET 3 methimazole Immunological Agents

Immune Suppressants

ASTAGRAF XL 0.5 MG CAPSULE 3 tacrolimus ASTAGRAF XL 1 MG CAPSULE 3 tacrolimus ASTAGRAF XL 5 MG CAPSULE 3 tacrolimus ATGAM 50 MG/ML AMPUL 9 lymphocyte immune globulin AZASAN 100 MG TABLET 3 azathioprine AZASAN 75 MG TABLET 3 azathioprine

azathioprine 50 mg tablet 1

BENLYSTA 120 MG VIAL 5 PA belimumab BENLYSTA 400 MG VIAL 5 PA belimumab CELLCEPT 200 MG/ML ORAL SUSP 2 mycophenolate mofetil CELLCEPT 250 MG CAPSULE 2 mycophenolate mofetil CELLCEPT 500 MG TABLET 2 mycophenolate mofetil CELLCEPT 500 MG VIAL 3 mycophenolate mofetil hcl CIMZIA 200 MG VIAL KIT 5 PA certolizumab pegol CIMZIA 200 MG/ML STARTER KIT 5 PA certolizumab pegol

PAGE 433 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS CIMZIA 200 MG/ML SYRINGE KIT 5 PA certolizumab pegol

COPAXONE 20 MG/ML SYRINGE QL 1 / 30 days 5 glatiramer acetate PA

CUPRIMINE 250 MG CAPSULE 3 penicillamine

cyclosporine 100 mg capsule 1

cyclosporine 100 mg/ml soln 1

cyclosporine 25 mg capsule 1

cyclosporine 50 mg/ml ampul 7

cyclosporine 50 mg/ml vial 7

cyclosporine modified 100 mg 1

cyclosporine modified 25 mg 1

cyclosporine modified 50 mg 1

DEPEN 250 MG TITRATAB 3 penicillamine ELIDEL 1% CREAM 3 pimecrolimus

ENBREL 25 MG KIT QL 4 / 30 days 5 etanercept PA

ENBREL 25 MG/0.5 ML SYRINGE QL 4 / 30 days 5 etanercept PA

ENBREL 50 MG/ML SURECLICK SYR QL 4 / 30 days 5 etanercept PA

ENBREL 50 MG/ML SYRINGE QL 4 / 30 days 5 etanercept PA

ENTYVIO 300 MG VIAL 5 vedolizumab

gengraf 100 mg capsule 1

gengraf 100 mg/ml solution 1

gengraf 25 mg capsule 1

PAGE 434 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

hecoria 0.5 mg capsule 1 ST

hecoria 1 mg capsule 1 ST

hecoria 5 mg capsule 1 ST

HUMIRA 10 MG/0.2 ML SYRINGE 5 adalimumab

HUMIRA 20 MG/0.4 ML SYRINGE QL 2 / 30 days 5 adalimumab PA

HUMIRA 40 MG/0.8 ML PEN QL 2 / 30 days 5 adalimumab PA

HUMIRA 40 MG/0.8 ML SYRINGE QL 2 / 30 days 5 adalimumab PA

HUMIRA CROHN'S STARTER PACK QL 6 / 30 days 5 adalimumab PA

HUMIRA PSORIASIS STARTER PACK QL 4 / 30 days 5 adalimumab PA

IMURAN 50 MG TABLET 3 azathioprine

KINERET 100 MG/0.67 ML SYRINGE QL 30 / 30 days 5 anakinra PA

methotrexate 1 gm vial 7

methotrexate 1 gm/40 ml vial 7

methotrexate 1 gram/40 ml vial 7

methotrexate 100 mg/4 ml vial 7

methotrexate 2.5 mg tablet 1

methotrexate 200 mg/8 ml vial 7

methotrexate 25 mg/ml vial 7

PAGE 435 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

methotrexate 25 mg/ml vial 7

methotrexate 250 mg/10 ml vial 7

methotrexate 50 mg/2 ml vial 7

mycophenolate 250 mg capsule 1

mycophenolate 500 mg tablet 1

mycophenolic acid dr 180 mg tb 1

mycophenolic acid dr 360 mg tb 1

MYFORTIC 180 MG TABLET 3 mycophenolate sodium MYFORTIC 360 MG TABLET 3 mycophenolate sodium NEORAL 100 MG GELATIN CAPSULE 2 cyclosporine, modified NEORAL 100 MG/ML SOLUTION 2 cyclosporine, modified NEORAL 25 MG GELATIN CAPSULE 2 cyclosporine, modified NULOJIX 250 MG VIAL 5 PA belatacept ORENCIA 125 MG/ML SYRINGE 5 PA abatacept ORENCIA 250 MG VIAL 5 PA abatacept/maltose OTREXUP 10 MG/0.4 ML AUTO-INJ 3 methotrexate/pf OTREXUP 15 MG/0.4 ML AUTO-INJ 3 methotrexate/pf OTREXUP 20 MG/0.4 ML AUTO-INJ 3 methotrexate/pf OTREXUP 25 MG/0.4 ML AUTO-INJ 3 methotrexate/pf

PAGE 436 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS PROGRAF 0.5 MG CAPSULE 3 ST tacrolimus PROGRAF 1 MG CAPSULE 3 ST tacrolimus PROGRAF 5 MG CAPSULE 3 ST tacrolimus PROGRAF 5 MG/ML AMPULE 3 tacrolimus RAPAMUNE 0.5 MG TABLET 3 sirolimus RAPAMUNE 1 MG TABLET 3 sirolimus RAPAMUNE 1 MG/ML ORAL SOLN 3 sirolimus RAPAMUNE 2 MG TABLET 3 sirolimus RASUVO 10 MG/0.2 ML AUTOINJ 3 methotrexate/pf RASUVO 12.5 MG/0.25 ML AUTOINJ 3 methotrexate/pf RASUVO 15 MG/0.3 ML AUTOINJ 3 methotrexate/pf RASUVO 17.5 MG/0.35 ML AUTOINJ 3 methotrexate/pf RASUVO 20 MG/0.4 ML AUTOINJ 3 methotrexate/pf RASUVO 22.5 MG/0.45 ML AUTOINJ 3 methotrexate/pf RASUVO 25 MG/0.5 ML AUTOINJ 3 methotrexate/pf RASUVO 27.5 MG/0.55 ML AUTOINJ 3 methotrexate/pf RASUVO 30 MG/0.6 ML AUTOINJ 3 methotrexate/pf RASUVO 7.5 MG/0.15 ML AUTOINJ 3 methotrexate/pf REMICADE 100 MG VIAL 5 PA infliximab RESTASIS 0.05% EYE EMULSION 3 cyclosporine

PAGE 437 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS RHEUMATREX 2.5 MG TABLET methotrexate sodium SANDIMMUNE 100 MG CAPSULE 2 cyclosporine SANDIMMUNE 100 MG/ML SOLN 2 cyclosporine SANDIMMUNE 25 MG CAPSULE 2 cyclosporine SANDIMMUNE 50 MG/ML AMPUL 8 cyclosporine SIMPONI 100 MG/ML PEN INJECTOR 5 PA golimumab SIMPONI 100 MG/ML SYRINGE 5 PA golimumab SIMPONI 50 MG/0.5 ML PEN INJEC 5 PA golimumab SIMPONI 50 MG/0.5 ML SYRINGE 5 PA golimumab SIMPONI ARIA 50 MG/4 ML VIAL 3 golimumab SIMULECT 10 MG VIAL 3 basiliximab SIMULECT 20 MG VIAL 3 basiliximab

sirolimus 0.5 mg tablet 1

SYLVANT 100 MG VIAL 3 siltuximab SYLVANT 400 MG VIAL 3 siltuximab

tacrolimus 0.5 mg capsule 1 ST

tacrolimus 1 mg capsule 1 ST

tacrolimus 5 mg capsule 1 ST

TORISEL 25 MG KIT 3 temsirolimus

PAGE 438 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS TREXALL 10 MG TABLET 3 methotrexate sodium TREXALL 15 MG TABLET 3 methotrexate sodium TREXALL 5 MG TABLET 3 methotrexate sodium TREXALL 7.5 MG TABLET 3 methotrexate sodium

ZORTRESS 0.25 MG TABLET QL 60 / 30 days 5 everolimus PA

ZORTRESS 0.5 MG TABLET QL 60 / 30 days 5 everolimus PA

ZORTRESS 0.75 MG TABLET QL 60 / 30 days 5 everolimus PA

Immunizing Agents, Passive

BIVIGAM LIQUID 10% VIAL 9 immune globulin,gamma(igg)

carimune nf 12 gm vial 8

carimune nf 3 gm vial 8

carimune nf 6 gm vial 8

FLEBOGAMMA DIF 10% VIAL 9 immune globulin,gamma(igg) FLEBOGAMMA DIF 10% VIAL 9 immune globulin,gamma(igg)

flebogamma dif 5% vial 8

FLEBOGAMMA DIF 5% VIAL 8 immune globulin,gamma(igg) GAMASTAN S-D VIAL 8 immune globulin,gamma(igg)

gammagard liquid 10% vial 7

GAMMAGARD LIQUID 10% VIAL 3 immune globulin,gamma(igg) GAMMAGARD S-D 10 G (IGA<1) SOL 3 immune globulin,gamma(igg) GAMMAGARD S-D 10 GM VL W/ST 3 immune globulin,gamma(igg)

PAGE 439 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS GAMMAGARD S-D 2.5 GM VL W/ST 3 immune globulin,gamma(igg) GAMMAGARD S-D 5 G (IGA<1) SOLN 3 immune globulin,gamma(igg) GAMMAGARD S-D 5 GM VL W/SET 3 immune globulin,gamma(igg) GAMMAKED 1 GRAM/10 ML VIAL 9 immune globulin,gamma caprylate (igg) GAMMAKED 10 GRAM/100 ML VIAL 9 immune globulin,gamma caprylate (igg) GAMMAKED 2.5 GRAM/25 ML VIAL 9 immune globulin,gamma caprylate (igg) GAMMAKED 20 GRAM/200 ML VIAL 9 immune globulin,gamma caprylate (igg) GAMMAKED 5 GRAM/50 ML VIAL 9 immune globulin,gamma caprylate (igg)

gammaplex 5% vial 8

GAMUNEX 10% VIAL 9 immune globulin,gamma caprylate (igg) GAMUNEX-C 1 GRAM/10 ML VIAL 9 immune globulin,gamma caprylate (igg) GAMUNEX-C 10 GRAM/100 ML VIAL 9 immune globulin,gamma caprylate (igg) GAMUNEX-C 2.5 GRAM/25 ML VIAL 9 immune globulin,gamma caprylate (igg) GAMUNEX-C 20 GRAM/200 ML VIAL 9 immune globulin,gamma caprylate (igg) GAMUNEX-C 5 GRAM/50 ML VIAL 9 immune globulin,gamma caprylate (igg) HIZENTRA 1 GRAM/5 ML VIAL 9 immune globulin,gamma(igg) HIZENTRA 10 GRAM/ 50 ML VIAL 9 immune globulin,gamma(igg) HIZENTRA 2 GRAM/10 ML VIAL 9 immune globulin,gamma(igg) HIZENTRA 4 GRAM/20 ML VIAL 9 immune globulin,gamma(igg) HYPERRAB S-D VIAL 8 rabies immune globulin/pf

PAGE 440 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

hyperrho s-d 250 units syringe 8

HYPERRHO S-D 250 UNITS SYRINGE 9 rho(d) immune globulin HYPERRHO S-D SYRINGE 9 rho(d) immune globulin HYPERTET S-D 250 UNITS SYRINGE 9 tetanus immune globulin/pf HYQVIA 10 GM/800 UNIT VIAL immune globulin,gamma(igg) human/hyaluronidase, 9 human recomb HYQVIA 2.5 GM/200 UNIT VIAL immune globulin,gamma(igg) human/hyaluronidase, 9 human recomb HYQVIA 20 GM/1,600 UNIT VIAL immune globulin,gamma(igg) human/hyaluronidase, 9 human recomb HYQVIA 30 GM/2,400 UNIT VIAL immune globulin,gamma(igg) human/hyaluronidase, 9 human recomb HYQVIA 5 GM/400 UNIT VIAL immune globulin,gamma(igg) human/hyaluronidase, 9 human recomb IMOGAM RABIES-HT 150 UNIT/ML 8 rabies immune globulin/pf MICRHOGAM ULTRA-FILTD PLUS SYR 8 rho(d) immune globulin MICRHOGAM ULTRA-FILTD PLUS SYR 8 rho(d) immune globulin OCTAGAM 10% VIAL 8 immune globulin,gamma (igg) human/maltose OCTAGAM 5% VIAL 8 immune globulin,gamma (igg) human/maltose

privigen 10% vial 9

RHOGAM ULTRA-FILTERED PLUS SYR 9 rho(d) immune globulin RHOGAM ULTRA-FILTERED PLUS SYR 9 rho(d) immune globulin RHOPHYLAC 300 MCG/2 ML SYR 9 rho(d) immune globulin THYMOGLOBULIN 25 MG VIAL 3 lymphocyte immune globulin,rabbit

PAGE 441 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS VARIZIG 125 UNIT VIAL 3 varicella-zoster immune globulin (human) VARIZIG 125 UNIT VIAL 3 varicella-zoster immune globulin (human) WINRHO SDF 1,500 UNITS VIAL 9 rho(d) immune globulin/maltose WINRHO SDF 15,000 UNITS VIAL 9 rho(d) immune globulin/maltose WINRHO SDF 2,500 UNITS VIAL 9 rho(d) immune globulin/maltose WINRHO SDF 5,000 UNITS VIAL 9 rho(d) immune globulin/maltose Immunomodulators

ACTEMRA 162 MG/0.9 ML SYRINGE 5 tocilizumab ACTEMRA 200 MG/10 ML VIAL 5 tocilizumab ACTEMRA 400 MG/20 ML VIAL 5 tocilizumab ACTEMRA 80 MG/4 ML VIAL 5 tocilizumab ACTIMMUNE 100 MCG/0.5 ML VIAL 5 PA interferon gamma-1b,recomb. ALDARA 5% CREAM 3 imiquimod ARAVA 10 MG TABLET 3 leflunomide ARAVA 20 MG TABLET 3 leflunomide ARCALYST 220 MG INJECTION 9 QL 4 / 28 days rilonacept

AVONEX ADMIN PACK 30 MCG VL QL 4 / 30 days 5 interferon beta-1a/albumin human PA

AVONEX PEN 30 MCG/0.5 ML 5 QL 2 / 30 days interferon beta-1a

AVONEX PEN 30 MCG/0.5 ML QL 1 / 30 days 5 interferon beta-1a PA

AVONEX PREFILLED SYR 30 MCG QL 2 / 30 days 5 interferon beta-1a PA

PAGE 442 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

AVONEX PREFILLED SYR 30 MCG KT QL 1 / 30 days 5 interferon beta-1a PA

AZULFIDINE 500 MG TABLET 3 sulfasalazine AZULFIDINE ENTAB 500 MG 3 sulfasalazine

BETASERON 0.3 MG KIT QL 15 / 30 days 5 interferon beta-1b PA

EXTAVIA 0.3 MG KIT QL 15 / 30 days 5 interferon beta-1b PA

EXTAVIA 0.3 MG VIAL QL 45 / 30 days 5 interferon beta-1b PA

FIRAZYR 30 MG/3 ML SYRINGE 5 QL 3 / 30 days icatibant acetate

GILENYA 0.5 MG CAPSULE QL 30 / 30 days 5 fingolimod hcl PA

ILARIS 180 MG VIAL QL 1 / 56 days 9 canakinumab/pf PA

imiquimod 5% cream packet 1

leflunomide 10 mg tablet 1

leflunomide 20 mg tablet 1

ORENCIA 250 MG VIAL 5 PA abatacept/maltose OTEZLA 30 MG TABLET 3 apremilast OTEZLA STARTER PACK 3 apremilast

POMALYST 1 MG CAPSULE QL 22 / 30 days 5 pomalidomide PA

POMALYST 2 MG CAPSULE QL 22 / 30 days 5 pomalidomide PA

PAGE 443 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

POMALYST 3 MG CAPSULE QL 22 / 30 days 5 pomalidomide PA

POMALYST 4 MG CAPSULE QL 22 / 30 days 5 pomalidomide PA

REBIF 22 MCG/0.5 ML SYRINGE QL 13 / 30 days 5 interferon beta-1a/albumin human PA

REBIF 44 MCG/0.5 ML SYRINGE QL 13 / 30 days 5 interferon beta-1a/albumin human PA

REBIF REBIDOSE 22 MCG/0.5 ML QL 13 / 30 days 5 interferon beta-1a/albumin human PA

REBIF REBIDOSE 44 MCG/0.5 ML QL 13 / 30 days 5 interferon beta-1a/albumin human PA

REBIF REBIDOSE TITRATION PACK QL 13 / 30 days 5 interferon beta-1a/albumin human PA

REBIF TITRATION PACK QL 13 / 30 days 5 interferon beta-1a/albumin human PA

REVLIMID 10 MG CAPSULE 5 PA lenalidomide REVLIMID 15 MG CAPSULE 5 PA lenalidomide REVLIMID 2.5 MG CAPSULE 5 PA lenalidomide REVLIMID 20 MG CAPSULE 5 PA lenalidomide REVLIMID 25 MG CAPSULE 5 PA lenalidomide REVLIMID 5 MG CAPSULE 5 PA lenalidomide RIDAURA 3 MG CAPSULE 3 auranofin STELARA 45 MG/0.5 ML SYRINGE 5 PA ustekinumab STELARA 90 MG/ML SYRINGE 5 PA ustekinumab

sulfasalazine 500 mg tablet 1

PAGE 444 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

sulfasalazine dr 500 mg tab 1

sulfazine 500 mg tablet 1

sulfazine ec 500 mg tab 1

SYNAGIS 100 MG/1 ML VIAL 5 palivizumab SYNAGIS 50 MG/0.5 ML VIAL 5 palivizumab THALOMID 100 MG CAPSULE 5 PA thalidomide THALOMID 150 MG CAPSULE 5 PA thalidomide THALOMID 200 MG CAPSULE 5 PA thalidomide THALOMID 50 MG CAPSULE 5 PA thalidomide TYSABRI 300 MG/15 ML VIAL 5 PA natalizumab

XELJANZ 5 MG TABLET QL 60 / 30 days 5 tofacitinib citrate PA

ZYCLARA 2.5% CREAM PUMP 3 imiquimod ZYCLARA 3.75% CREAM 3 imiquimod ZYCLARA 3.75% CREAM PUMP 3 imiquimod Vaccines

ACTHIB VACCINE VIAL haemophilus b conjugate vaccine(tetanus toxoid 9 conjugate)/pf ACTHIB VACCINE WITH DILUENT haemophilus b conjugate vaccine(tetanus toxoid 9 conjugate)/pf ADACEL TDAP SYRINGE 9 diphtheria,pertussis(acell),tetanus vaccine/pf ADACEL TDAP SYRINGE 9 diphtheria,pertussis(acell),tetanus vaccine/pf ADACEL TDAP VIAL 9 diphtheria,pertussis(acell),tetanus vaccine/pf

PAGE 445 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ADACEL TDAP VIAL diphtheria,pertussis(acell),tetanus vaccine/pf

adenovirus type 4 & 7 ec tabs 1

adenovirus type 4 ec tablet 1

adenovirus type 7 ec tablet 1

AFLURIA 2012-2013 SYRINGE 9 influenza virus vaccine tv split 2012-2013 (5 yr & older)/pf AFLURIA 2012-2013 VIAL 9 influenza virus vaccine tv split 2012-2013 (5 yr & older) AFLURIA 2013-2014 SYRINGE 9 QL 0 / 365 days influenza virus vaccine tv split 2013-2014 (5 yr & older)/pf AFLURIA 2013-2014 VIAL 9 QL 0 / 365 days influenza virus vaccine tv split 2013-2014 (5 yr & older) AFLURIA 2014-2015 SYRINGE 3 influenza virus vaccine trivalnt 2014-2015 (5 yr & older)/pf AFLURIA 2014-2015 VIAL 3 influenza virus vaccine trivalent 2014-2015 (5 yr & older) BCG VACCINE (TICE STRAIN) VIAL 9 bcg vaccine, live/pf BIOTHRAX VACCINE VIAL 9 anthrax vaccine BOOSTRIX TDAP VACCINE SYRINGE 9 diphtheria,pertussis(acellular),tetanus vaccine BOOSTRIX TDAP VACCINE VIAL 9 diphtheria,pertussis(acellular),tetanus vaccine

botulism antitoxin heptav vial 1

CERVARIX VACCINE SYRINGE 9 human papillomavirus vaccine, bivalent/pf COMVAX VACCINE VIAL hepatitis b virus vaccine/haemoph b polysac conj- 9 mening/pf CYTOGAM 2.5 GM/50 ML VIAL 9 cytomegalovirus immune globuln DAPTACEL DTAP VACCINE 9 diphtheria, pertussis(acell), tetanus ped vacc/pf

diphtheria-tetanus toxoids-ped 9

ENGERIX-B 10 MCG/0.5 ML PED VL 9

PAGE 446 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

hepatitis b virus vaccine recombinant/pf

ENGERIX-B 20 MCG/ML SYRN 9 hepatitis b virus vaccine recombinant/pf ENGERIX-B 20 MCG/ML VIAL 9 hepatitis b virus vaccine recombinant/pf ENGERIX-B PEDI 10 MCG/0.5 SYRN 9 hepatitis b virus vaccine recombinant/pf FLUARIX 2012-2013 SYRINGE 9 influenza virus vaccine tv split 2012-2013 (3 yr & older)/pf FLUARIX 2013-2014 SYRINGE influenza virus vaccine tvs 2013-2014 (36 mos and 9 QL 0 / 365 days older)/pf FLUARIX QUAD 2013-2014 SYRINGE influenza virus vaccine quad vs 2013-2014(36 mos & 9 QL 0 / 365 days older)/pf FLUBLOK 2012-2013 VIAL influenza virus vaccine tv 2012-2013 (18 to 49 3 yrs)recomb/pf FLUBLOK 2013-2014 VIAL influenza virus vaccine tv 2013-2014 (18 to 49 3 yrs)recomb/pf FLUCELVAX 2012-2013 SYRINGE 9 influenza vaccine tri-splt 2012-13(18 yr +)cell derived/pf FLUCELVAX 2013-2014 SYRINGE 9 influenza vaccine tv split 2013-14 (18 yr+) cell derived/pf FLULAVAL 2012-2013 VIAL 9 influenza virus vaccine tv split 2012-2013 (18 yr & older) FLULAVAL 2013-2014 VIAL 9 QL 0 / 365 days influenza virus vaccine tvs 2013-2014 (36 mos and older) FLULAVAL QUAD 2013-2014 VIAL influenza virus vaccine quad vs 2013-2014 (36 mos & 9 QL 0 / 365 days older) FLUMIST NASAL 2012-13 VACCINE 3 influenza virus vaccine tv live 2012-2013 (2 yrs-49 yrs) FLUMIST NASAL 2013-14 VACCINE 3 QL 0 / 365 days influenza virus vaccine qval live 2013-2014 (2 yrs-49 yrs) FLUVIRIN 2012-2013 SYRINGE 9 influenza virus vaccine tv split 2012-2013 (4 yr & older)/pf FLUVIRIN 2012-2013 VIAL 9 influenza virus vaccine tv split 2012-2013 (4 yr & older)

FLUVIRIN 2013-2014 SYRINGE 9 QL 0 / 365 days

PAGE 447 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS influenza virus vaccine tv split 2013-2014 (4 yr & older)/pf FLUVIRIN 2013-2014 VIAL 9 QL 0 / 365 days influenza virus vaccine tv split 2013-2014 (4 yr & older) FLUZONE 2012-2013 SYRINGE influenza virus vaccine tvs 2012-2013 (36 mos and 9 older)/pf FLUZONE 2012-2013 VIAL influenza virus vaccine tv split 2012-2013 (6 mos and 9 older) FLUZONE 2012-2013 VIAL influenza virus vaccine tvs 2012-2013 (36 mos and 9 older)/pf FLUZONE 2013-2014 SYRINGE influenza virus vaccine tvs 2013-2014 (36 mos and 9 QL 0 / 365 days older)/pf FLUZONE 2013-2014 VIAL 9 QL 0 / 365 days influenza virus vaccine tri-split 2013-14 (6 mos and older) FLUZONE 2013-2014 VIAL (PF) influenza virus vaccine tvs 2013-2014 (36 mos and 9 QL 0 / 365 days older)/pf FLUZONE HIGH-DOSE 2012-13 SYR 9 influenza virus vaccine trivalent-split 2012-2013 (65yr+)/pf FLUZONE HIGH-DOSE 2013-14 SYR 9 QL 0 / 365 days influenza virus vaccine tvs 2013-2014 (65 yr+)/pf FLUZONE INTRADER 2013-2014 SYR 9 QL 0 / 365 days influenza virus vaccine tvs 2013-2014 (18 yrs-64 yrs)/pf FLUZONE INTRADERM 2012-13 SYR 9 influenza virus vaccine tvs 2012-2013 (18 yrs-64 yrs)/pf FLUZONE PEDI 2012-2013 SYRINGE 9 influenza virus vaccine 2012-2013 (6 mos-35 mos)/pf FLUZONE PEDI 2013-2014 SYRINGE 9 QL 0 / 365 days influenza virus vaccine tvs 2013-2014 (6 mos-35 mos)/pf FLUZONE QUAD 2013-2014 SYRINGE influenza virus vaccine quad vs 2013-2014(36 mos & 9 QL 0 / 365 days older)/pf FLUZONE QUAD 2013-2014 VIAL influenza virus vaccine quad vs 2013-2014(36 mos & 9 QL 0 / 365 days older)/pf FLUZONE QUAD PEDI 2013-14 SYR influenza virus vaccine quad vs 2013-2014 (6 mos-35 9 QL 0 / 365 days mos)/pf

GARDASIL SYRINGE 9

PAGE 448 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS human papillomavirus vaccine, quadrivalent/pf GARDASIL SYRINGE 9 human papillomavirus vaccine, quadrivalent/pf GARDASIL VIAL 9 human papillomavirus vaccine, quadrivalent/pf HAVRIX 1,440 UNITS/ML SYRINGE 9 hepatitis a virus vaccine/pf HAVRIX 1,440 UNITS/ML VIAL 9 hepatitis a virus vaccine/pf HAVRIX 720 UNIT/0.5 ML SYRINGE 9 hepatitis a virus vaccine/pf HAVRIX 720 UNITS/0.5 ML VIAL 9 hepatitis a virus vaccine/pf HEPAGAM B VIAL 8 hepatitis b immune globulin/maltose HYPERHEP B S-D NEONATAL SYRIN. 8 hepatitis b immune globulin HYPERHEP B S-D SYRINGE 8 hepatitis b immune globulin HYPERHEP B S-D VIAL 8 hepatitis b immune globulin IMOVAX RABIES VACCINE 9 rabies vaccine, human diploid cell/pf INFANRIX DTAP SYRINGE 9 diphtheria, pertussis(acell), tetanus ped vacc/pf INFANRIX DTAP VIAL 9 diphtheria, pertussis(acell), tetanus ped vacc/pf IPOL SINGLE DOSE SYRINGE 9 poliomyelitis vaccine, killed IPOL VIAL 9 poliomyelitis vaccine, killed IXIARO 6 MCG/0.5 ML SYRINGE 9 japanese encephalitis vaccine/pf KINRIX TIP-LOK SYRINGE 3 diphtheria, pertussis(acell),tetanus,polio vaccine/pf KINRIX VIAL 3 diphtheria, pertussis(acell),tetanus,polio vaccine/pf M-M-R II VACCINE VIAL 3 measles,mumps&rubella vaccine live/pf

M-M-R II VACCINE WITH DILUENT 3

PAGE 449 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS measles,mumps&rubella vaccine live/pf MENACTRA VIAL meningococcal vaccine a,c,y,w-135,diphtheria toxoid 9 conj/pf MENHIBRIX VACCINE VIAL meningococcal vaccine c,y/haemophilus b conj-tetanus 9 tox/pf MENOMUNE-A-C-Y-W-135 VIAL 9 meningococcal vac a,c,y,w-135 MENOMUNE-A-C-Y-W-135 VIAL 9 meningococcal vaccine a,c,y,w-135/pf MENVEO A-C-Y-W-135-DIP VIAL meningococcal vaccine a,c,y,w-135,diphtheria toxoid 5 PA conj/pf NABI-HB VIAL 8 hepatitis b immune globulin PEDIARIX 0.5 ML SYRINGE 3 hep b virus,rcmb/dipth,pertus(acell),tet,polio vaccine/pf PEDVAXHIB VACCINE VIAL haemophilus b conjugate vaccine (meningococcal 8 prot.conj)/pf PEDVAXHIB VACCINE VIAL haemophilus b conjugate vaccine (meningococcal 8 prot.conj)/pf PENTACEL ACTHIB COMPONENT VIAL haemophilus b conjugate vaccine(tetanus toxoid 3 conjugate)/pf PENTACEL DTAP-IPV COMPONENT VL 3 diphtheria, pertussis(acell),tetanus,polio vaccine/pf PENTACEL VIAL KIT 3 diphtheria,pertuss(acell),tetanus,polio vacc/hib conj-tet/pf PHYSICIANS EZ USE FLU 2012-13 3 influenza virus vaccine tv split 2012-2013 (4 yr & older) PNEUMOVAX 23 SYRINGE 8 QL 0.5 / 365 days pneumococcal 23-valent polysaccharide vaccine PNEUMOVAX 23 VIAL 8 QL 0.5 / 365 days pneumococcal 23-valent polysaccharide vaccine PREVNAR 13 SYRINGE pneumococcal 13-valent conjugate vaccine (diphtheria 9 QL 0.5 / 365 days crm)/pf PROQUAD VIAL 9 measles, mumps, rubella, and varicella vaccine live/pf

PAGE 450 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS RABAVERT RABIES VACCINE VIAL 9 rabies vaccine, purified chicken embryo cell (pcec)/pf RABAVERT RABIES VACCINE VIAL 9 rabies vaccine, purified chicken embryo cell (pcec)/pf RECOMBIVAX HB 10 MCG/ML SYR 9 hepatitis b virus vaccine recombinant/pf RECOMBIVAX HB 10 MCG/ML SYR 9 hepatitis b virus vaccine recombinant/pf RECOMBIVAX HB 10 MCG/ML VIAL 9 hepatitis b virus vaccine recombinant/pf RECOMBIVAX HB 40 MCG/ML VIAL 9 hepatitis b virus vaccine recombinant/pf RECOMBIVAX HB 5 MCG/0.5 ML SYR 9 hepatitis b virus vaccine recombinant/pf RECOMBIVAX HB 5 MCG/0.5 ML SYR 9 hepatitis b virus vaccine recombinant/pf RECOMBIVAX HB 5 MCG/0.5 ML VL 9 hepatitis b virus vaccine recombinant/pf ROTARIX VACCINE SUSPENSION 3 rotavirus vacc, live oral attenuated, 89-12 strain, g1p(8) ROTATEQ VACCINE 3 rotavirus vaccine, live oral pentavalent SINGLE USE EZ FLU 2012-2013 KT 3 influenza virus vaccine tv split 2012-2013 (4 yr & older)/pf SINGLE USE EZ FLU 2013-2014 KT influenza virus vaccine quad vs 2013-2014(36 mos & 3 older)/pf SINGLE USE EZ FLU 2013-2014 KT 3 influenza virus vaccine tv split 2013-2014 (4 yr & older)/pf TENIVAC SYRINGE 8 tetanus and diphtheria toxoids, adsorbed, adult/pf TENIVAC VIAL 8 tetanus and diphtheria toxoids, adsorbed, adult/pf

tetanus diphtheria toxoids 9

tetanus toxoid adsorbed vial 9

TRIPEDIA PRESERVATIVE FREE 9 diphtheria, pertussis(acell), tetanus ped vacc/pf TWINRIX VACCINE SYRINGE 9 hepatitis a virus & hepatitis b virus vaccine/pf

TWINRIX VACCINE VIAL 9

PAGE 451 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

hepatitis a virus & hepatitis b virus vaccine/pf

TYPHIM VI 25 MCG/0.5 ML SYRNG 9 typhoid vaccine vi capsular polysaccharide TYPHIM VI 25 MCG/0.5 ML VIAL 9 typhoid vaccine vi capsular polysaccharide

vaqta 25 units/0.5 ml syringe 9

VAQTA 25 UNITS/0.5 ML SYRINGE 9 hepatitis a virus vaccine/pf VAQTA 25 UNITS/0.5 ML SYRINGE 9 hepatitis a virus vaccine/pf VAQTA 25 UNITS/0.5 ML VIAL 9 hepatitis a virus vaccine/pf VAQTA 50 UNITS/ML SYRINGE 9 hepatitis a virus vaccine/pf VAQTA 50 UNITS/ML SYRINGE 9 hepatitis a virus vaccine/pf VAQTA 50 UNITS/ML VIAL 9 hepatitis a virus vaccine/pf VAQTA 50 UNITS/ML VIAL 9 hepatitis a virus vaccine/pf VARIVAX VACCINE VIAL 9 varicella virus vaccine live/pf VARIVAX VACCINE WITH DILUENT 9 varicella virus vaccine live/pf VIVOTIF BERNA EC CAPSULE 3 typhoid vacc,live,attenuated YF-VAX 1 DOSE VIAL 9 yellow fever vaccine live/pf YF-VAX 1 DOSE VIAL 9 yellow fever vaccine live/pf YF-VAX 5 DOSE VIAL 9 yellow fever vaccine live/pf ZOSTAVAX VIAL 9 zoster vaccine live/pf Inflammatory Bowel Disease Agents

Aminosalicylates

APRISO ER 0.375 GRAM CAPSULE 3 QL 120 / 30 days mesalamine

ASACOL EC 400 MG TABLET 2

PAGE 452 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

mesalamine

ASACOL HD DR 800 MG TABLET 2 mesalamine

balsalazide disodium 750 mg cp 1

CANASA 1,000 MG SUPPOSITORY 2 mesalamine COLAZAL 750 MG CAPSULE 3 balsalazide disodium DELZICOL DR 400 MG CAPSULE 3 QL 180 / 30 days mesalamine DIPENTUM 250 MG CAPSULE 3 olsalazine sodium GIAZO 1.1 GM TABLET 3 balsalazide disodium LIALDA DR 1.2 GM TABLET 3 mesalamine

mesalamine 4 gm/60 ml enema 1

mesalamine 4 gm/60 ml kit 1

PENTASA 250 MG CAPSULE 3 mesalamine PENTASA 500 MG CAPSULE 3 mesalamine ROWASA 4 GM/60 ML ENEMA KIT 3 mesalamine with cleansing wipes SFROWASA 4 GM/60 ML ENEMA 3 mesalamine Glucocorticoids

a-hydrocort 100 mg vial 7

a-methapred 125 mg vial 7

a-methapred 40 mg univial 7

ANUSOL-HC 2.5% CREAM 3 hydrocortisone

budesonide ec 3 mg capsule 1

colocort 100 mg enema 1

PAGE 453 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS CORTEF 10 MG TABLET 3 hydrocortisone CORTEF 20 MG TABLET 3 hydrocortisone CORTEF 5 MG TABLET 3 hydrocortisone CORTENEMA 100 MG ENEMA 3 hydrocortisone CORTENEMA 100 MG/60 ML ENEMA 3 hydrocortisone DEPO-MEDROL 20 MG/ML VIAL 9 methylprednisolone acetate DEPO-MEDROL 40 MG/ML VIAL 9 methylprednisolone acetate DEPO-MEDROL 80 MG/ML VIAL 9 methylprednisolone acetate

dexamethasone 0.5 mg tablet 1

dexamethasone 0.5 mg/5 ml elx 1

dexamethasone 0.5 mg/5 ml liq 1

dexamethasone 0.75 mg tablet 1

dexamethasone 1 mg tablet 1

dexamethasone 1.5 mg tablet 1

dexamethasone 2 mg tablet 1

dexamethasone 4 mg tablet 1

dexamethasone 6 mg tablet 1

dexamethasone intensol 1mg/1ml 1

DEXPAK 10 DAY 1.5 MG TABLET 3 dexamethasone DEXPAK 13 DAY 1.5 MG TABLET 3 dexamethasone DEXPAK 6 DAY 1.5 MG TABLET 3 dexamethasone ENTOCORT EC 3 MG CAPSULE 3 budesonide

hydrocortisone 10 mg tablet 1

PAGE 454 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

hydrocortisone 100 mg enema 1

hydrocortisone 100 mg/60 ml 1

hydrocortisone 20 mg tablet 1

hydrocortisone 5 mg tablet 1

MEDROL 16 MG TABLET 3 methylprednisolone MEDROL 32 MG TABLET 3 methylprednisolone MEDROL 4 MG DOSEPAK 3 methylprednisolone MEDROL 4 MG TABLET 3 methylprednisolone MEDROL 8 MG TABLET 3 methylprednisolone

methylprednisolone 125 mg vial 7

methylprednisolone 16 mg tab 1

methylprednisolone 32 mg tab 1

methylprednisolone 4 mg dosepk 1

methylprednisolone 40 mg vial 7

methylprednisolone 40 mg/ml vl 7

methylprednisolone 8 mg tab 1

methylprednisolone 80 mg/ml vl 7

methylprednisolone ss 1 gm vl 7

prednisone 1 mg tablet 1

prednisone 10 mg tab dose pack 1

prednisone 10 mg tablet 1

prednisone 2.5 mg tablet 1

prednisone 20 mg tablet 1

prednisone 5 mg/5 ml solution 1

PAGE 455 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

prednisone 5 mg/ml solution

prednisone 50 mg tablet 1

procto-pak 1% cream 1

proctocream-hc 2.5% cream 1

proctosol-hc 2.5% cream 1

proctozone-hc 2.5% cream 1

SOLU-CORTEF 1,000 MG VIAL 9 hydrocortisone sodium succinate/pf SOLU-CORTEF 100 MG VIAL 9 hydrocortisone sod succinate SOLU-CORTEF 100 MG VIAL 9 hydrocortisone sodium succinate/pf SOLU-CORTEF 250 MG VIAL 9 hydrocortisone sodium succinate/pf SOLU-CORTEF 500 MG VIAL 9 hydrocortisone sodium succinate/pf SOLU-MEDROL 1 GM VIAL 9 methylprednisolone sodium succinate SOLU-MEDROL 1,000 MG VIAL 9 methylprednisolone sodium succinate/pf SOLU-MEDROL 125 MG VIAL 9 methylprednisolone sodium succinate SOLU-MEDROL 125 MG VIAL 9 methylprednisolone sodium succinate/pf SOLU-MEDROL 2,000 MG VIAL 9 methylprednisolone sodium succinate SOLU-MEDROL 40 MG VIAL 9 methylprednisolone sodium succinate/pf SOLU-MEDROL 500 MG VIAL 9 methylprednisolone sodium succinate SOLU-MEDROL 500 MG VIAL 9 methylprednisolone sodium succinate/pf UCERIS 9 MG ER TABLET 3 QL 30 / 30 days budesonide Sulfonamides

AZULFIDINE 500 MG TABLET 3 sulfasalazine

PAGE 456 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS AZULFIDINE ENTAB 500 MG 3 sulfasalazine

sulfasalazine 500 mg tablet 1

sulfasalazine dr 500 mg tab 1

sulfazine 500 mg tablet 1

sulfazine ec 500 mg tab 1

Metabolic Bone Disease Agents

ACTONEL 150 MG TABLET 2 ST risedronate sodium ACTONEL 30 MG TABLET 2 ST risedronate sodium ACTONEL 35 MG TABLET 2 ST risedronate sodium ACTONEL 5 MG TABLET 2 ST risedronate sodium

alendronate sod 70 mg/75 ml 3

alendronate sodium 10 mg tab 1

alendronate sodium 35 mg tab 1

alendronate sodium 40 mg tab 1

alendronate sodium 5 mg tablet 1

alendronate sodium 70 mg tab 1

ATELVIA DR 35 MG TABLET 3 risedronate sodium BINOSTO 70 MG TABLET EFF 3 alendronate sodium BONIVA 150 MG TABLET 3 ST ibandronate sodium

BONIVA 3 MG/3 ML SYRINGE PA 5 ibandronate sodium ST

calcitonin-salmon 200 units sp 1

calcitriol 0.25 mcg capsule 1

PAGE 457 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

calcitriol 0.25 mcg capsule 1

calcitriol 0.5 mcg capsule 1

calcitriol 1 mcg/ml ampul 7

calcitriol 1 mcg/ml solution 1

DIDRONEL 400 MG TABLET 3 etidronate disodium

doxercalciferol 0.5 mcg cap 1

doxercalciferol 1 mcg capsule 1

doxercalciferol 2.5 mcg cap 1

doxercalciferol 4 mcg/2 ml amp 7

doxercalciferol 4 mcg/2 ml vl 7

etidronate disodium 200 mg tab 1

etidronate disodium 400 mg tab 1

EVISTA 60 MG TABLET QL 30 / 30 days 2 raloxifene hcl ST

FORTEO 600 MCG/2.4 ML PEN INJ PA 5 teriparatide ST

FORTICAL 200 UNITS NASAL SPRAY 3 calcitonin,salmon,synthetic FOSAMAX 70 MG TABLET 3 ST alendronate sodium FOSAMAX PLUS D 70 MG-2,800 IU 3 alendronate sodium/cholecalciferol (vitamin d3) FOSAMAX PLUS D 70 MG-5,600 IU 3 alendronate sodium/cholecalciferol (vitamin d3) HECTOROL 0.5 MCG CAPSULE 3 doxercalciferol HECTOROL 1 MCG CAPSULE 3 doxercalciferol HECTOROL 2 MCG/ML VIAL 9 doxercalciferol HECTOROL 2.5 MCG CAPSULE 3 doxercalciferol

HECTOROL 4 MCG/2 ML VIAL 9

PAGE 458 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

doxercalciferol

HECTOROL 4 MCG/2 ML VIAL 9 doxercalciferol

PA ibandronate 3 mg/3 ml syringe 4 ST

ibandronate 3 mg/3 ml vial 4

ibandronate sodium 150 mg tab 1

MIACALCIN 200 UNIT NASAL SPRAY 3 calcitonin,salmon,synthetic MIACALCIN 200 UNIT/ML VIAL 9 PA calcitonin,salmon,synthetic OMONTYS 10 MG/ML VIAL 9 PA peginesatide OMONTYS 20 MG/2 ML VIAL 9 PA peginesatide

pamidronate 30 mg/10 ml vial 1

pamidronate 60 mg/10 ml vial 1

pamidronate 90 mg/10 ml vial 1

pamidronate disod 30 mg vial 1

pamidronate disod 90 mg vial 1

PROLIA 60 MG/ML SYRINGE 5 PA denosumab

RECLAST 5 MG/100 ML SOLUTION PA 5 zoledronic acid in mannitol & water for injection ST

risedronate sodium 150 mg tab 1 ST

ROCALTROL 0.25 MCG CAPSULE 3 calcitriol

PAGE 459 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ROCALTROL 0.5 MCG CAPSULE 3 calcitriol ROCALTROL 1 MCG/ML ORAL SOLN 3 calcitriol SKELID 200 MG TABLET 3 QL 60 / 30 days tiludronate disodium XGEVA 120 MG/1.7 ML VIAL 9 PA denosumab ZEMPLAR 1 MCG CAPSULE 3 paricalcitol ZEMPLAR 10 MCG/2 ML VIAL 9 paricalcitol ZEMPLAR 2 MCG CAPSULE 3 paricalcitol ZEMPLAR 2 MCG/ML VIAL 9 paricalcitol ZEMPLAR 4 MCG CAPSULE 3 paricalcitol ZEMPLAR 5 MCG/ML VIAL 9 paricalcitol

zoledronic acid 4 mg vial 1

zoledronic acid 4 mg/100 ml 1

zoledronic acid 4 mg/5 ml vial 1 PA

zoledronic acid 5 mg/100 ml 1 ST

ZOMETA 4 MG/100 ML INJECTION 3 PA zoledronic acid in mannitol & water for injection ZOMETA 4 MG/5 ML VIAL 3 PA zoledronic acid MISCELLANEOUS THERAPEUTIC AGENTS

ABLAVAR 2.5 MMOL/10 ML VIAL 9 gadofosveset trisodium ABLAVAR 3.75 MMOL/15 ML VIAL 9 gadofosveset trisodium ACETADOTE 200 MG/ML VIAL 9 acetylcysteine

acetylcysteine 6 gram/30 ml vl 7

ACTHREL 100 MCG VIAL 9 corticorelin ovine triflutate

PAGE 460 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ADENOSCAN 3 MG/ML VIAL 9 adenosine

adenosine 60 mg/20 ml vial 1

adenosine 90 mg/30 ml vial 1

ADREVIEW INJECTION VIAL 9 iobenguane sulfate i-123 AK-FLUOR 10% VIAL 7 fluorescein sodium AK-FLUOR 25% VIAL 9 fluorescein sodium

alcohol,dehydrated 98% ampule 7

alcohol,dehydrated 98% vial 7

ALPHANATE 2,000-800 UNIT VIAL 5 PA antihemophilic factor, human/von willebrand factor,human

aminohippurate 20% vial 9

AMYVID VIAL 9 florbetapir f 18 ANASCORP 120 MG VIAL 9 centruroides (scorpion) polyvalent antivenom

antivenin micrurus fulvius 9

antivenin(latrodectus) vial 9

APLIGRAF DISK 3 cult skin subst,human-bovine APLISOL 5T UNITS/0.1 ML VIAL 9 tuberculin, purified protein derivative APPTRIM CAPSULE 3 caffeine/choline bitartrate/aa comb.no7/hrb cb125 APPTRIM-D CAPSULE 3 choline bitartrate/amino acids combination no.7/hrb cb125 ARGINAID EXTRA LIQUID 3 whey protein isolate/arginine/c/e/zinc sulfate ARGINAID POWDER 3 arginine/ascorbate sodium/vitamin e acetate

ARIDOL BRONCHIAL CHALLENGE KIT 3

PAGE 461 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS mannitol ARTISS FROZEN 10 ML SYRINGE 3 thrombin(hum plas)/fibrinogen/aprotinin, syn/calcium cl ARTISS FROZEN 2 ML SYRINGE 3 thrombin(hum plas)/fibrinogen/aprotinin, syn/calcium cl ARTISS FROZEN 4 ML SYRINGE 3 thrombin(hum plas)/fibrinogen/aprotinin, syn/calcium cl ASCLERA 10 MG/2 ML (0.5%) AMP 9 polidocanol ASCLERA 20 MG/2 ML (1%) AMPULE 9 polidocanol ASTRINGYN SOLUTION 3 ferric subsulfate ATRYN 525 UNIT VIAL 5 antithrombin iii, human recombinant AVITENE FLOUR 3 microfibrillar collagen AVITENE SHEET 35MMX35MM 3 microfibrillar collagen AVITENE SHEET 70MMX35MM 3 microfibrillar collagen AVITENE SHEET 70MMX70MM 3 microfibrillar collagen

bacteriostatic water vial 7

bacteriostatic water vial 9

BAL IN OIL 100 MG/ML AMPULE 9 dimercaprol BETAQUIK EMULSION 3 nutritional tx, ketogenic/medium chain triglycerides BIONECT 0.2% FOAM 3 hyaluronate sodium BRAVELLE 75 UNIT VIAL 9 urofollitropin CA-DTPA 200 MG/ML AMPUL 3 pentetate ca trisodium CAMINO PRO 15 PE LIQUID PACKET 3 nutritional therapy for msud with iron CANDIN SKIN TEST 9 candida albicans skin test

PAGE 462 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS CANDIN SKIN TEST 9 candida albicans skin test CARBZERO EMULSION 3 nutritional tx, ketogenic/long chain triglycerides CARDIOLITE PREPARATION KIT 3 kit for prep tc 99m/sestamibi combination no.1 CARTICEL VIAL 9 autologous cult. chondrocytes CARTICEL VIAL 9 autologous cult. chondrocytes CERETEC INJECTION KIT 9 kit for prep tc-99m/exametazime CHIRHOSTIM 16 MCG VIAL 9 secretin acetate (human) CHOLEXTRA POWDER 3 cholesterol/soybean oil/ascorbic acid/vitamin e CHOLOGRAFIN MEGLUMINE 52% 9 iodipamide meglumine

clomiphene citrate 50 mg tab 1

comfort ez pen needles 5mm 31g 2

comfort ez pen needles 6mm 31g 2

comfort ez pen needles 8mm 31g 2

COMPLETE FORMULATION D3000 CAP 1 pediatric multivitamin no.61/cholecalciferol/phytonadione COMPLETE FORMULATION PEDIATRIC 3 pediatric multivitamin no.77/cholecalciferol/phytonadione CONRAY 60% VIAL 9 iothalamate meglumine CONRAY-30 INFUSION BOTTLE 9 iothalamate meglumine CONRAY-43 INFUSION BOTTLE 9 iothalamate meglumine CONTRAVE ER 8-90 MG TABLET 3 naltrexone hcl/bupropion hcl CORTROSYN 0.25 MG VIAL 9 cosyntropin

cosyntropin 0.25 mg vial 7

PAGE 463 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

cosyntropin 0.25 mg/ml 7

CROFAB VIAL 9 antivenin,crotalidae fab(ovin)

curity amd packing strips 3

cyanide antidote package 3

cyanocobal-levomef-pyridoxn tb 1

CYSTO-CONRAY 17.2% VIAL 9 iothalamate meglumine CYSTOGRAFIN 30% INFUS. BTL 9 diatrizoate meglumine CYSTOGRAFIN-DILUTE 18% BTL 9 diatrizoate meglumine CYSVIEW 100 MG KIT 9 hexaminolevulinate hcl DATSCAN VIAL 9 ioflupane i 123

deferoxamine 2 gram vial 7

deferoxamine 500 mg vial 7

DEFINITY 1.1 MG/ML VIAL 9 perflutren lipid microspheres DERMAGRAFT 2"X3" SHEET 3 cult skin subst,human-bovine DESFERAL 2 GRAM VIAL 9 deferoxamine mesylate DESFERAL MESYLATE 500 MG VL 9 deferoxamine mesylate

dexcom g4 receiver kit 3

dexcom g4 sensor 3

dexcom g4 sensor kit 3

dexcom g4 transmitter kit 3

DIGIBAR 190 SUSPENSION 3 barium sulfate

diluent for epoprostenol vial 1

PAGE 464 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS DILUENT FOR FLOLAN VIAL glycine/sodium/water for injection,sterile/sodium hydroxide DMSA INJECTION KIT 9 kit for prep tc-99m/succimer DOTAREM 10 MMOL/20 ML SYRINGE 3 gadoterate meglumine DOTAREM 10 MMOL/20 ML VIAL 3 gadoterate meglumine DOTAREM 5 MMOL/10 ML SYRINGE 3 gadoterate meglumine DOTAREM 5 MMOL/10 ML VIAL 3 gadoterate meglumine DOTAREM 50 MMOL/100 ML VIAL 3 gadoterate meglumine DOTAREM 7.5 MMOL/15 ML SYRINGE 3 gadoterate meglumine DOTAREM 7.5 MMOL/15 ML VIAL 3 gadoterate meglumine DRAXIMAGE DTPA PREPARATION KIT 9 kit for prep tc-99m/pentetic acid DRAXIMAGE MAA PREPARATION KIT 3 kit for prep of tc-99m/albumin human,aggregated DRAXIMAGE MDP-25 PREP KIT 3 kit for prep tc-99m/medronate sodium DUODOTE 2.1 MG-600 MG SYRINGE 9 pralidoxime chloride/atropine sulfate E-Z DISK 700 MG TABLET 3 barium sulfate E-Z-CAT CONCENTRATE SUSP 3 barium sulfate E-Z-CAT DRY SUSPENSION 3 barium sulfate E-Z-DOSE 105% ENEMA 3 barium sulfate E-Z-HD SUSPENSION 3 barium sulfate E-Z-PAQUE BARIUM SULFATE SUSP 3 barium sulfate E-Z-PASTE 60% CREAM 3 barium sulfate

PAGE 465 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ELLIOTTS B SOLUTION AMPULE 9 chemo diluent,e-lytes, & dextrose, buffered no.1/pf ELOCTATE 1,000 UNIT NOMINAL 5 factor viii recombinant, fc fusion protein ELOCTATE 1,500 UNIT NOMINAL 5 factor viii recombinant, fc fusion protein ELOCTATE 2,000 UNIT NOMINAL 5 factor viii recombinant, fc fusion protein ELOCTATE 250 UNIT NOMINAL 5 factor viii recombinant, fc fusion protein ELOCTATE 3,000 UNIT NOMINAL 5 factor viii recombinant, fc fusion protein ELOCTATE 500 UNIT NOMINAL 5 factor viii recombinant, fc fusion protein ELOCTATE 750 UNIT NOMINAL 5 factor viii recombinant, fc fusion protein ENDO-AVITENE 10MM SHEET 3 microfibrillar collagen ENDO-AVITENE 5MM SHEET 3 microfibrillar collagen ENTERO VU 13% LIQUID 3 barium sulfate/methylcellulose ENTERO VU 13% PACKET 3 barium sulfate/methylcellulose ENTERO VU 24% LIQUID 3 barium sulfate/methylcellulose EOVIST 2.5 MMOL/10 ML VIAL 9 gadoxetate disodium EOVIST 3.75 MMOL/15 ML VIAL 9 gadoxetate disodium ESCAVITE D TABLET CHEWABLE 3 pediatric multivitamin no.78 with iron & sodium fluoride ESOPHO-CAT 3% CREAM 3 barium sulfate ETHAMOLIN 5% AMPUL 9 ethanolamine oleate

ethanol 98% ampul 7

euflexxa 20 mg/2 ml syringe 1

FERIDEX I.V. 11.2 MG/ML VIAL 3 ferumoxides

PAGE 466 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS FERRLECIT 62.5 MG/5 ML VIAL 9 sodium ferric gluconate complex in sucrose

fludeoxyglucose f 18 vial 1

flumazenil 0.1 mg/ml vial 7

flumazenil 0.5 mg/5 ml vial 7

flumazenil 1 mg/10 ml vial 7

FLUOR-I-STRIP AT 1 fluorescein sodium FLUORESCITE 10% VIAL 9 fluorescein sodium

fluorets 1 mg opth strips 1

FOLLISTIM AQ 150 UNIT VIAL 9 follitropin beta,recomb FOLLISTIM AQ 300 UNIT CARTRIDG 9 follitropin beta,recomb FOLLISTIM AQ 600 UNIT CARTRIDG 9 follitropin beta,recomb FOLLISTIM AQ 75 UNIT VIAL 9 follitropin beta,recomb FOLLISTIM AQ 900 UNIT CARTRIDG 9 follitropin beta,recomb

freestyle navigator sensor kit 2

ful-glo 1 mg opth strips 1

FUL-GLO EYE STRIPS 3 fluorescein sodium GADAVIST 1 MMOL/ML BULK VIAL 9 gadobutrol GADAVIST 10 MMOL/10 ML SYRINGE 9 gadobutrol GADAVIST 10 MMOL/10 ML VIAL 9 gadobutrol GADAVIST 15 MMOL/15 ML SYRINGE 9 gadobutrol

GADAVIST 15 MMOL/15 ML VIAL 9

PAGE 467 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS gadobutrol GADAVIST 2 MMOL/2 ML VIAL 9 gadobutrol GADAVIST 7.5 MMOL/7.5 ML SYR 9 gadobutrol GADAVIST 7.5 MMOL/7.5 ML VIAL 9 gadobutrol GASTROGRAFIN 66-10 SOLUTION 3 diatrizoate meglumine/diatrizoate sodium GASTROMARK 175 MCG/ML SUSP 3 ferumoxsil GELFOAM 12-7MM SPONGE 3 gelatin sponge,absorbable GELFOAM COMPRESSED SPONGE 3 gelatin sponge,absorbable GELFOAM DENTAL SPONGE SZ 4 3 gelatin sponge,absorbable GELFOAM POWDER 3 gelatin sponge,absorbable GELFOAM SIZE 100 SPONGE 3 gelatin sponge,absorbable GELFOAM SIZE 200 SPONGE 3 gelatin sponge,absorbable GELFOAM SIZE 50 SPONGE 3 gelatin sponge,absorbable GONAL-F 1,050 UNITS VIAL 9 follitropin alfa, recomb GONAL-F 450 UNITS VIAL 9 follitropin alfa, recomb GONAL-F RFF 300 UNITS PEN 9 follitropin alfa, recomb GONAL-F RFF 450 UNITS PEN 9 follitropin alfa, recomb GONAL-F RFF 75 UNITS VIAL 9 follitropin alfa, recomb GONAL-F RFF 900 UNITS PEN 9 follitropin alfa, recomb GONAL-F RFF REDI-JECT 300 UNIT 3 follitropin alfa, recomb

GONAL-F RFF REDI-JECT 450 UNIT 3

PAGE 468 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS follitropin alfa, recomb GONAL-F RFF REDI-JECT 900 UNIT 3 follitropin alfa, recomb GRAFIX CORE 1.5CM X 2CM MATRIX 3 human regenerative tissue matrix GRAFIX CORE 3CM X 4CM MATRIX 3 human regenerative tissue matrix GRAFIX PRIME 1.5CM X 2CM MATRX 3 human regenerative tissue matrix GRAFIX PRIME 3CM X 4CM MATRIX 3 human regenerative tissue matrix

guardian real-time glu monitor 3

humapen luxura hd 2

HYALGAN 20 MG/2 ML SYRINGE 3 hyaluronate sodium HYALGAN 20 MG/2 ML VIAL 3 hyaluronate sodium HYLENEX 150 UNITS/ML VIAL 9 hyaluronidase, human recomb. HYLENEX 150 UNITS/ML VIAL 9 hyaluronidase, human recomb. IC GREEN 25 MG VIAL 9 indocyanine green INDICLOR SOLUTION 9 indium-111 chloride INDIGO CARMINE 0.8% AMPUL 7 indigotindisulfonate sodium INDIUM IN-111 DTPA SOLUTION 9 pentetate indium disodium in-111

indium in-111 oxyquinoline sol 9

isosulfan blue 1% vial 7

ISOVUE MULTIPK-250 51% BTLE 9 iopamidol ISOVUE MULTIPK-370 76% BTLE 9 iopamidol ISOVUE-200 41% INFUS BOTTLE 9 iopamidol

ISOVUE-200 41% VIAL 9

PAGE 469 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS iopamidol ISOVUE-250 51% INFUS BOTTLE 9 iopamidol ISOVUE-250 51% VIAL 9 iopamidol ISOVUE-300 61% INFUS BOTTLE 9 iopamidol ISOVUE-300 61% MULTIPACK 9 iopamidol ISOVUE-300 61% VIAL 9 iopamidol ISOVUE-370 76% INFUS BOTTLE 9 iopamidol ISOVUE-M 200 41% VIAL 9 iopamidol ISOVUE-M 300 61% VIAL 9 iopamidol KALBITOR 10 MG/ML VIAL 5 ecallantide KCENTRA 1,000 UNIT VIAL 3 human prothrombin complex concentrate (pcc) KORLYM 300 MG TABLET 5 mifepristone

levomef-pyridoxal-mec-algal cp 1

levomefolate-algal 15 mg cap 1

levomefolate-algal 7.5 mg cap 1

LEXISCAN INJECTION 9 regadenoson LIPIODOL 4.8 GM/10 ML AMPUL 9 ethiodized oil

liquid e-z paque 60% susp 3

LIQUID POLIBAR PLUS SUSP 3 barium sulfate LIQUID POLIBAR SUSPENSION 3 barium sulfate LYMPHAZURIN 1% VIAL 9 isosulfan blue

magellan insul syringe 0.3 ml 2

PAGE 470 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

magellan insul syringe 0.5 ml 2

magellan insulin syr 0.3 ml 3

magellan insulin syr 0.5 ml 2

magellan insulin syringe 1 ml 2

MAGNEVIST BULK VIAL 9 gadopentetate dimeglumine MAGNEVIST SYRINGE 9 gadopentetate dimeglumine MAGNEVIST VIAL 9 gadopentetate dimeglumine MATRISTEM 10CM X 15CM WD SHEET 3 extracellular matrix (ecm),porcine derived,fenestrated MATRISTEM 3CM X 3.5CM WD SHEET 3 extracellular matrix (ecm),porcine derived,fenestrated MATRISTEM 3CM X 7CM WND SHEET 3 extracellular matrix (ecm),porcine derived,fenestrated MATRISTEM 7CM X 10CM WND SHEET 3 extracellular matrix (ecm),porcine derived,fenestrated MATRISTEM MICROMATRIC 30 MG PD 3 extracellular matrix (ecm), porcine derived MATRISTEM MICROMATRIX 20 MG PD 3 extracellular matrix (ecm), porcine derived MATRISTEM MICROMATRIX 60 MG PD 3 extracellular matrix (ecm), porcine derived MATRISTEM MICROMTRX 100 MG PD 3 extracellular matrix (ecm), porcine derived MATRISTEM MICROMTRX 200 MG PD 3 extracellular matrix (ecm), porcine derived

maxibar 210% susp 3

MD-76 R 66-10 INFUSION BOTTLE 9 diatrizoate meglumine/diatrizoate sodium MD-76 R 66-10 VIAL 9 diatrizoate meglumine/diatrizoate sodium

md-gastroview 66%-10% soln 1

MENOPUR 75 UNIT VIAL 9 menotropins METASTRON VIAL 9 strontium-89 chloride

PAGE 471 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

methylene blue 1% ampul 7

methylene blue 1% vial 7

METOPIRONE 250 MG CAPSULE 3 metyrapone METOPIRONE 250 MG CAPSULE 3 metyrapone MIFEPREX 200 MG TABLET 3 mifepristone

minilink real-time transmitter 3

monoject 0.5 ml syrn 28gx1/2" 2

monoject 1 ml syrn 28gx1/2" 2

monoject insulin syr 0.3 ml 2

monoject insulin syr 0.5 ml 2

monoject insulin syr 1 ml 2

monoject insulin syr u-100 2

monoject syringe 1 ml 2

MONOVISC 88 MG/4 ML SYRINGE 9 hyaluronate sodium, stabilized MONSEL'S FERRIC SUBSULFATE SOL 3 ferric subsulfate

morrhuate sodium 50 mg/ml 7

multi-vit w-fluor 0.25 mg/ml 1

multi-vit w-fluor 0.5 mg/ml 1

MULTIHANCE 529 MG/ML VIAL 9 gadobenate dimeglumine MULTIHANCE 529 MG/ML VIAL 9 gadobenate dimeglumine

multivit-fluor-iron 0.25 mg/ml 1

mv-iron fum-asp-asc-b12-fa-suc 1

mv-iron-asc-b12-thre-suc-stom 1

MYALEPT 11.3 MG (5 MG/ML) VIAL 9 metreleptin

PAGE 472 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS MYOVIEW KIT kit for prep tc-99m/tetrofosmin NASCOBAL 500 MCG NASAL SPRAY 3 cyanocobalamin (vitamin b-12) NEXAVIR VIAL 9 liver extract (beef-pork)

niacin-aze ac-turmer-fa-b6-zn 1

NITHIODOTE 300 MG-12.5 GRAM 9 sodium nitrite/sodium thiosulfate

novopen echo insulin device 2

nutren 1.5 liquid 1

nutren 2.0 liquid 1

NUTRIHEP 1.5 CAL LIQUID 3 nutritional therapy, impaired hepatic function OCTREOSCAN KIT 9 indium-111 chloride/pentetreotide OFIRMEV 1,000 MG/100 ML VIAL 9 acetaminophen OMNIPAQUE 140 MG/ML BOTTLE 9 iohexol OMNIPAQUE 180 MG/ML VIAL 9 iohexol OMNIPAQUE 240 MG/ML BOTTLE 9 iohexol OMNIPAQUE 240 MG/ML INFU BTL 9 iohexol OMNIPAQUE 240 MG/ML VIAL 9 iohexol OMNIPAQUE 300 MG/ML BOTTLE 9 iohexol OMNIPAQUE 300 MG/ML CARTRIDGE 9 iohexol OMNIPAQUE 300 MG/ML INFU BTL 9 iohexol OMNIPAQUE 300 MG/ML PLUSPAK BT 9 iohexol OMNIPAQUE 300 MG/ML SYRINGE 9 iohexol

PAGE 473 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS OMNIPAQUE 300 MG/ML VIAL iohexol OMNIPAQUE 350 MG/ML CARTRIDGE 9 iohexol OMNIPAQUE 350 MG/ML INFU BTL 9 iohexol OMNISCAN 287 MG/ML BOTTLE 9 gadodiamide OMNISCAN 287 MG/ML SYRINGE 9 gadodiamide OMNISCAN 287 MG/ML VIAL 9 gadodiamide OMNISCAN PREFILL PLUS SYRINGE 3 gadodiamide in 0.9 % sodium chloride OPTIMARK 10 MMOL/20 ML SYRINGE 9 gadoversetamide OPTIMARK 15 MMOL/30 ML SYRINGE 9 gadoversetamide OPTIMARK 330.9 MG/ML VIAL 9 gadoversetamide OPTIMARK 5 MMOL/10 ML SYRINGE 9 gadoversetamide OPTIMARK 7.5 MMOL/15 ML SYRING 9 gadoversetamide OPTIRAY 300 (300 MG/ML) SYRN 9 ioversol OPTIRAY 300 (300 MG/ML) VIAL 9 ioversol OPTIRAY 320 (320 MG/ML) SYRN 9 ioversol OPTIRAY 320 (320 MG/ML) VIAL 9 ioversol OPTIRAY 350 (350 MG/ML) SYRN 9 ioversol OPTIRAY 350 (350 MG/ML) VIAL 9 ioversol OPTISON VIAL 9 perflutren protein-a microsphr ORTHOVISC 15 MG/ML SYRINGE 3 hyaluronate sodium

PAGE 474 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS OVIDREL 250 MCG/0.5 ML SYRG choriogonadotropin alfa OXILAN-350 350 MG/ML BOTTLE 9 ioxilan OXYCEL COTTON-TYPE PLEDGET 3 cellulose,oxidized PANHEMATIN 313 MG VIAL 5 PA hemin PANHEMATIN 313 MG VIAL 5 PA hemin

paradigm real-time system 3

PARAGARD T 380-A IUD 3 copper

pen needle 30g x 5/16" 2

pen needle 31g x 3/16" 2

pen needle 31g x 5/16" 2

PEPTAMEN JUNIOR 1 CAL LIQUID 3 nutritional supplement PEPTAMEN JUNIOR-PREBIO1 LIQUID 3 nutritional supplement/inulin/fructooligosaccharides POLIBAR ACB 96% ENEMA BAG 3 barium sulfate

pralidoxime chloride 300 mg/ml 9

PRE-PEN AMPUL 9 benzylpenicilloyl polylysine PROHANCE 279.3 MG/ML SYRINGE 9 gadoteridol PROHANCE 279.3 MG/ML VIAL 9 gadoteridol PROHANCE 279.3 MG/ML VIAL 9 gadoteridol PROSTASCINT KIT 9 capromab pendetide PROTOPAM CHLORIDE 1 GM VIAL 9 pralidoxime chloride PROVOCHOLINE 100 MG VIAL 3 methacholine chloride

PROVOCHOLINE 100 MG VIAL 3

PAGE 475 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS methacholine chloride QUADRAMET VIAL 7 samarium sm 153 lexidronam QUFLORA PED 0.25 MG/ML DROP 3 pediatric multivitamin no.83 with sodium fluoride QUFLORA PED 0.5 MG/ML DROP 3 pediatric multivitamin no.84 with sodium fluoride R-GENE 10 VIAL 9 arginine hcl RADIOGARDASE 0.5 GM CAPSULE 3 prussian blue (insoluble) READI-CAT 1.2% SUSPENSION 3 barium sulfate READI-CAT 2 2% SUSPENSION 3 barium sulfate RECOTHROM 20,000 UNITS KIT 3 thrombin (recombinant) RECOTHROM 20,000 UNITS VIAL 3 thrombin (recombinant) RECOTHROM 5,000 UNITS VIAL 3 thrombin (recombinant) RELAGESIC 650-50 MG TABLET 3 acetaminophen/phenyltoloxamine citrate RELAMINE TABLET glucosamine sulfate/chondroitin sulfate a/antioxid 3 multvit#5 REMESENSE 3% DESENSITIZER STRP 3 potassium oxalate REPRONEX 75 UNIT VIAL 9 menotropins RESTORA RX CAPSULE 3 lactobacillus casei/folic acid

rhinoflex-650 tablet 3

ROMAZICON 0.1 MG/ML VIAL 9 flumazenil RUCONEST 2,100 UNIT VIAL 5 c1 esterase inhibitor, recombinant SCLEROSOL INTRAPLEURAL AERO 3 talc

SCULPTRA AESTHETIC VIAL 9

PAGE 476 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS poly-l-lactic acid/carboxymethylcellulose sodium/mannitol SCULPTRA VIAL 9 poly-l-lactic acid/carboxymethylcellulose sodium/mannitol SEROPHENE 50 MG TABLET 3 clomiphene citrate

seven plus replacemnt receiver 3

seven plus replacmnt trnsmtter 3

seven plus system starter kit 3

seven system sensor 3

SINOGRAFIN VIAL 9 iodipamide meglumine/diatrizoate meglumine SITZMARKS CAPSULE 3 radiopaque pvc markers/barium sulfate SITZMARKS CAPSULE 3 radiopaque pvc markers/barium sulfate

sodium iodide i-123 3.7 mbq cp 1

sodium thiosulfat 12.5 g/50 ml 7

sodium thiosulfate 1 g/10 ml 8

sof-sensor 3

SOLESTA INJECTABLE GEL dextranomer microspheres/hyaluronate sodium in 0.9 % 3 nacl SOTRADECOL 1% VIAL 3 sodium tetradecyl sulfate SOTRADECOL 3% VIAL 3 sodium tetradecyl sulfate SPHERUSOL VIAL 9 spherule-derived coccidioides antigen skin test

sterile talc powder 3

sterile water for injection 7

sterile water for irrigation 7

supartz 10 mg/ml syringe 1

supartz 25 mg/2.5 ml syringe 1

PAGE 477 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS SYNAPRYN ORAL SUSPENSION 3 tramadol hcl/glucosamine sulfate SYNVISC SYRINGE 3 hylan g-f 20 SYNVISC-ONE SYRINGE 3 hylan g-f 20 SYRINGE AVITENE FLOUR 3 microfibrillar collagen TACHOSIL 4.8 CM X 4.8 CM PATCH 3 fibrinogen/thrombin (human plasma derived) TACHOSIL 9.5 CM X 4.8 CM PATCH 3 fibrinogen/thrombin (human plasma derived) TAGITOL V 40% SUSPENSION 3 barium sulfate

tc99m mebrofenin prep kit 1

tc99m medronate prep kit 1

tc99m pyrophosphate prep kit 1

tc99m sestamibi prep kit 1

tc99m sulfur colloid prep kit 1

thallous cl tl 201 inj vial 9

THERAMINE PLUS POWDER PACKET choline bitartrate/aa no.10/gaba/herb #129/protein/soy 3 lecit THROMBI-GEL SIZE 10 thrombin (bov)/calcium cl/cmc/gel,pork/dressing, 3 hemostatic THROMBI-GEL SIZE 100 thrombin (bov)/calcium cl/cmc/gel,pork/dressing, 3 hemostatic THROMBI-GEL SIZE 40 thrombin (bov)/calcium cl/cmc/gel,pork/dressing, 3 hemostatic THROMBI-PAD 3"X3" thrombin (bov)/calcium cl/cme-cell sod/dressing, 3 hemostatic THROMBIN-JMI 20,000 UNITS PUMP 3 thrombin (bovine)

PAGE 478 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS THROMBIN-JMI 20,000 UNITS SYR 3 thrombin (bovine) THROMBIN-JMI 20,000 UNITS VIAL 3 thrombin (bovine) THROMBIN-JMI 5,000 UNITS EPIST 3 thrombin (bovine) THROMBIN-JMI 5,000 UNITS SYR 3 thrombin (bovine) THROMBIN-JMI 5,000 UNITS VIAL 3 thrombin (bovine) THYROGEN 1.1 MG VIAL 9 thyrotropin alfa TISSEEL VHSD 10 ML KIT 3 thrombin(human plasma der)/fibrinogen/aprotinin/calcium TISSEEL VHSD 10 ML KIT 3 thrombin(human plasma der)/fibrinogen/aprotinin/calcium TISSEEL VHSD 2 ML KIT 3 thrombin(human plasma der)/fibrinogen/aprotinin/calcium TISSEEL VHSD 2 ML KIT 3 thrombin(human plasma der)/fibrinogen/aprotinin/calcium TISSEEL VHSD 4 ML KIT 3 thrombin(human plasma der)/fibrinogen/aprotinin/calcium TISSEEL VHSD 4 ML KIT 3 thrombin(human plasma der)/fibrinogen/aprotinin/calcium TISSEEL VHSD FROZEN 10 ML SYR 3 thrombin(human plasma der)/fibrinogen/aprotinin/calcium TISSEEL VHSD FROZEN 2 ML SYR 3 thrombin(human plasma der)/fibrinogen/aprotinin/calcium TISSEEL VHSD FROZEN 4 ML SYR 3 thrombin(human plasma der)/fibrinogen/aprotinin/calcium TOLEREX POWDER PACKET 3 nut.tx.impaired digest fxn TRANSCYTE 5"X7.5" SHEET 3 cult skin subst,human-porcine TREPADONE CAPSULE glucosamine sulfate/chondroitin sulfate/dietary supp 3 comb.25

triple-vit w-fluor 0.25 mg/ml 1

TUBERSOL 5T UNITS/0.1 ML VIAL 9 tuberculin, purified protein derivative

PAGE 479 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS TUBERSOL 5T UNITS/0.1 ML VIAL 9 tuberculin, purified protein derivative TYR ANAMIX NEXT POWDER 3 nutritional therapy for tyrosinemia with iron

ulticare ins safety 1ml 29x1/2 2

ulticare safety 0.5 ml 29gx1/2 2

ULTRAFOAM 2X6.25X7CM SPONGE 3 microfibrillar collagen ULTRAFOAM 8X12.5X1CM SPONGE 3 microfibrillar collagen ULTRAFOAM 8X12.5X3CM SPONGE 3 microfibrillar collagen ULTRAFOAM 8X6.25X1CM SPONGE 3 microfibrillar collagen ULTRAVIST 150 MG/ML VIAL 9 iopromide ULTRAVIST 240 MG/ML VIAL 9 iopromide ULTRAVIST 300 MG/ML VIAL 9 iopromide ULTRAVIST 370 MG/ML VIAL 9 iopromide VARIBAR HONEY SUSPENSION 3 barium sulfate VARIBAR NECTAR 40% SUSPENSION 3 barium sulfate VARIBAR PUDDING 40% PASTE 3 barium sulfate VARIBAR THIN HONEY SUSPENSION 3 barium sulfate VARIBAR THIN LIQUID 40% SUSP 3 barium sulfate VARITHENA INJECTABLE FOAM 9 polidocanol

vaseline white petroleum jelly 3

VEHICLE-N MILD SOLUTION 3 alcohol/isopropyl alcohol/propylene glycol/water VEHICLE-N SOLUTION 3 alcohol/isopropyl alcohol/propylene glycol/water

PAGE 480 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS VISIPAQUE 270 MG/ML BOTTLE 9 iodixanol VISIPAQUE 270 MG/ML INFU BTL 9 iodixanol VISIPAQUE 270 MG/ML VIAL 9 iodixanol VISIPAQUE 320 MG/ML BOTTLE 9 iodixanol VISIPAQUE 320 MG/ML CARTRIDGE 9 iodixanol VISIPAQUE 320 MG/ML INFU BTL 9 iodixanol VISIPAQUE 320 MG/ML INFUS BTL 9 iodixanol VISIPAQUE 320 MG/ML VIAL 9 iodixanol VITRASE 200 UNITS/ML VIAL 9 hyaluronidase,ovine VIVONEX PEDIATRIC POWD PACKET 3 nut.tx.impaired digest fxn VIVONEX PLUS POWDER PACKET 3 nut.tx.impaired digest fxn VIVONEX T.E.N POWDER PACKET 3 nut.tx.impaired digest fxn VOLUMEN 0.1% SUSPENSION 3 barium sulfate

water for injection ampul 7

water for injection vial 7

XIAFLEX 0.9 MG VIAL 9 collagenase clostridium histolyticum

zflex tablet 1

zgesic tablet 1

ZN-DTPA 200 MG/ML AMPUL 3 pentetate zinc trisodium Ophthalmic Agents

Ophthalmic Prostaglandin and Prostamide Analogs

latanoprost 0.005% eye drops 1 QL 15 / 90 days

PAGE 481 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS LUMIGAN 0.01% EYE DROPS 3 QL 15 / 90 days bimatoprost LUMIGAN 0.03% EYE DROPS 3 QL 15 / 90 days bimatoprost TRAVATAN Z 0.004% EYE DROP 3 QL 15 / 90 days travoprost

travoprost 0.004% eye drop 1

XALATAN 0.005% EYE DROPS 3 QL 15 / 90 days latanoprost Ophthalmic Agents, Other

ak-poly-bac eye ointment 1

akorn balanced salt soln 1

AKTEN 3.5% GEL DROPS 3 lidocaine hcl/pf AKTEN 3.5% GEL DROPS 3 lidocaine hcl/pf ALCAINE 0.5% EYE DROPS 3 proparacaine hcl

altafluor eye drops 1

altafrin 10% eye drops 1

altafrin 2.5% eye drops 3

AMVISC 12 MG/ML SYRINGE 9 hyaluronate sodium AMVISC PLUS 16 MG/ML SYRINGE 9 hyaluronate sodium

atropine 1% eye drops 1

atropine 1% eye ointment 1

atropine care 1% eye drops 1

AZASITE 1% EYE DROPS 3 azithromycin AZASITE 1% EYE DROPS 3 azithromycin

bacitracin 500 unit/gm ophth 1

PAGE 482 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

bacitracin-polymyxin eye oint

balanced salt solution 1

BESIVANCE 0.6% SUSP 3 besifloxacin hcl BETADINE 5% EYE SOLUTION 3 povidone-iodine BLEPH-10 10% EYE DROPS 3 sulfacetamide sodium BLEPHAMIDE EYE DROPS 3 sulfacetamide sodium/prednisolone acetate BLEPHAMIDE EYE OINTMENT 3 sulfacetamide sodium/prednisolone acetate BSS EYE SOLUTION 7 balanced salt irrig soln no.2 BSS PLUS EYE SOLUTION 9 balanced salt irrigation solution combination no.1 CELLUGEL 3 hypromellose CILOXAN 0.3% EYE DROPS 3 ciprofloxacin hcl CILOXAN 0.3% OINTMENT 3 ciprofloxacin hcl

ciprofloxacin 0.3% eye drop 1

CYCLOGYL 0.5% EYE DROPS 3 cyclopentolate hcl CYCLOGYL 1% EYE DROPS 3 cyclopentolate hcl CYCLOGYL 2% EYE DROPS 3 cyclopentolate hcl CYCLOMYDRIL EYE DROPS 3 cyclopentolate hcl/phenylephrine hcl

cyclopentolate 1% eye drops 1

cyclopentolate hcl 2% drops 1

CYSTARAN 0.44% EYE DROPS 5 PA cysteamine hcl DISCOVISC DISP SYRINGE 3 chondroitin sulfate a sodium/hyaluronate sodium

DUOVISC VISCOELASTIC SYSTEM 3

PAGE 483 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS chondroitin sulfate a sodium/hyaluronate sodium

erythromycin 0.5% eye ointment 1

erythromycin eye ointment 1

EYLEA 2 MG/0.05 ML VIAL 3 aflibercept FLUCAINE EYE DROPS 1 proparacaine hcl/fluorescein sodium

fluorescein-benoxinate eye drp 1

fluorescein-proparacaine drops 1

FLURESS EYE DROPS 3 benoxinate hcl/fluorescein sodium

flurox eye drops 1

GARAMYCIN 3 MG/GM EYE OINTMENT 1 gentamicin sulfate GARAMYCIN 3 MG/ML EYE DROPS 3 gentamicin sulfate GELFILM OPHTHALMIC 25X50MM 3 gelatin

gentak 0.3 % eye ointment 1

gentak 3 mg/ml eye drops 1

gentamicin 0.3% eye drops 1

gentamicin 0.3% eye ointment 1

gentamicin 3 mg/gm eye oint 1

gentamicin 3 mg/ml eye drops 1

goniovisc 2.5% opht soln 1

homatropaire 5% eye drops 1

homatropine 5% eye drops 1

ILOTYCIN 0.5% EYE OINTMENT 3 erythromycin base

ISOPTO ATROPINE 1% EYE DROPS 3

PAGE 484 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS atropine sulfate ISOPTO HOMATROPINE 2% DROPS 3 homatropine hbr ISOPTO HOMATROPINE 5% DROPS 3 homatropine hbr ISOPTO HYOSCINE 0.25% DROPS 2 scopolamine hydrobromide JETREA 2.5 MG/ML VIAL 5 ocriplasmin/pf LACRISERT 5 MG EYE INSERT 2 hydroxypropyl cellulose

levofloxacin 0.5% eye drops 1

LUCENTIS 0.3 MG VIAL 3 ranibizumab LUCENTIS 0.5 MG VIAL 3 ranibizumab MACUGEN 0.3 MG/90 MICROLITERS 9 pegaptanib sodium MAXITROL EYE DROPS 3 neomycin/polymyxin b sulfate/dexamethasone MAXITROL EYE OINTMENT 3 neomycin/polymyxin b sulfate/dexamethasone MEMBRANEBLUE 0.15% OPHTH SOLN 3 trypan blue MIOCHOL-E KIT 9 acetylcholine chloride MITOSOL 0.2 MG KIT 3 mitomycin MOXEZA 0.5% EYE DROPS 3 QL 9 / 90 days moxifloxacin hcl

mydfrin 2.5% eye drops 3

MYDRIACYL 1% EYE DROPS 3 tropicamide

naphazoline 0.1% eye drops 1

NATACYN EYE DROPS 3 natamycin

neo-bacit-poly-hc eye ointment 1

neo-polycin eye ointment 1

PAGE 485 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

neo-polycin hc eye ointment 1

neofrin 10% eye drops 1

neofrin 2.5% eye drops 1

neomyc-bacit-polymix eye oint 1

neomyc-polym-dexamet eye ointm 1

neomyc-polym-dexameth eye drop 1

neomyc-polym-gramicid eye drop 1

neomycin-poly-hc eye drops 1

neosporin eye drops 3

ocucoat viscoadherent syringe 1

OCUFLOX 0.3% EYE DROPS 3 ofloxacin

ofloxacin 0.3% eye drops 1

parcaine 0.5% eye drops 1

PAREMYD EYE DROPS 3 hydroxyamphetamine hbr/tropicamide

phenylephrine 10% eye drops 1

phenylephrine 2.5% eye drop 1

polycin eye ointment 1

polymyxin b-tmp eye drops 1

POLYTRIM EYE DROPS 3 polymyxin b sulfate/trimethoprim PRED-G 1% EYE DROPS 3 gentamicin sulfate/prednisolone acetate PRED-G S.O.P. EYE OINTMENT 3 gentamicin sulfate/prednisolone acetate

proparacaine 0.5% eye drops 1

provisc 10 mg/ml disp syrng 9

RESTASIS 0.05% EYE EMULSION 3 cyclosporine

PAGE 486 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

sulf-pred 10-0.23% eye drops 1

sulf-pred 10-0.25% eye drops 1

sulfacetamide 10% eye drops 1

sulfacetamide 10% eye ointment 1

sulfamide 10% eye drops 1

tetcaine 0.5% eye drops 1

tetracaine 0.5% eye drops 1

TETRAVISC 0.5% EYE DROPS 1 tetracaine hcl TETRAVISC FORTE 0.5% EYE DROPS 1 tetracaine hcl TOBRADEX EYE DROPS 3 tobramycin/dexamethasone TOBRADEX EYE OINTMENT 2 tobramycin/dexamethasone TOBRADEX ST EYE DROPS 3 QL 5 / 30 days tobramycin/dexamethasone

tobramycin 0.3% eye drops 1

tobramycin-dexameth ophth susp 1

TOBREX 0.3% EYE DROPS 3 tobramycin TOBREX 0.3% EYE OINTMENT 2 tobramycin

trifluridine 1% eye drops 1

tropicamide 0.5% eye drops 1

tropicamide 1% eye drops 1

VIGAMOX 0.5% EYE DROPS 3 moxifloxacin hcl VIROPTIC 1% EYE DROPS 3 trifluridine VISCOAT SYRINGE 3 chondroitin sulfate a sodium/hyaluronate sodium

PAGE 487 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS VISIONBLUE 0.06% SYRINGE 3 trypan blue VISUDYNE 15 MG VIAL 9 verteporfin VITRASERT 4.5 MG IMPLANT 9 ganciclovir ZIRGAN 0.15% OPHTHALMIC GEL 3 ganciclovir ZYLET EYE DROPS 3 tobramycin/loteprednol etabonate ZYMAXID 0.5% EYE DROPS 3 QL 2 / 30 days gatifloxacin Ophthalmic Anti-allergy Agents

ALOCRIL 2% EYE DROPS 2 nedocromil sodium ALOMIDE 0.1% EYE DROPS 2 lodoxamide tromethamine

azelastine hcl 0.05% drops 1

BEPREVE 1.5% EYE DROPS 3 QL 10 / 30 days bepotastine besilate

cromolyn 4% eye drops 1

ELESTAT 0.05% EYE DROPS 3 epinastine hcl EMADINE 0.05% EYE DROPS 3 emedastine difumarate

epinastine hcl 0.05% eye drops 1

LASTACAFT 0.25% EYE DROPS 3 alcaftadine OPTIVAR 0.05% DROPS 3 azelastine hcl PATADAY 0.2% EYE DROPS 3 olopatadine hcl PATANOL 0.1% EYE DROPS 3 olopatadine hcl Ophthalmic Anti-inflammatories

ACULAR 0.5% EYE DROPS 3 ketorolac tromethamine

ACULAR LS 0.4% OPHTH SOL 3

PAGE 488 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ketorolac tromethamine ACUVAIL 0.45% OPHTH SOLUTION 3 QL 30 / 60 days ketorolac tromethamine/pf ALREX 0.2% EYE DROPS 2 loteprednol etabonate BROMDAY 0.09% EYE DROP TWINPAK 3 bromfenac sodium BROMDAY 0.09% EYE DROPS 3 bromfenac sodium

bromfenac sodium 0.09% eye drp 1

dexamethasone 0.1% eye drop 1

diclofenac 0.1% eye drops 1

DUREZOL 0.05% EYE DROPS 3 QL 10 / 30 days difluprednate FLAREX 0.1% EYE DROPS 2 fluorometholone acetate

fluorometholone 0.1% drops 1

flurbiprofen 0.03% eye drop 1

FML FORTE 0.25% EYE DROPS 2 fluorometholone FML LIQUIFILM 0.1% EYE DROP 3 fluorometholone FML S.O.P. 0.1% OINTMENT 2 fluorometholone ILEVRO 0.3% OPHTH DROPS 3 nepafenac ILEVRO 0.3% OPHTH DROPS 3 nepafenac

ketorolac 0.4% ophth solution 1

ketorolac 0.5% ophth solution 1

LOTEMAX 0.5% EYE DROPS 2 loteprednol etabonate LOTEMAX 0.5% EYE OINTMENT 2 loteprednol etabonate

LOTEMAX 0.5% OPHTHALMIC GEL 2

PAGE 489 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS loteprednol etabonate MAXIDEX 0.1% EYE DROPS 3 dexamethasone NEVANAC 0.1% DROPTAINER 3 nepafenac OCUFEN 0.03% EYE DROPS 3 flurbiprofen sodium OMNIPRED 1% EYE DROPS 3 prednisolone acetate OZURDEX 0.7 MG IMPLANT 9 dexamethasone PRED FORTE 1% EYE DROPS 3 prednisolone acetate PRED MILD 0.12% EYE DROPS 3 prednisolone acetate

prednisolone ac 1% eye drop 1

prednisolone sod 1% eye drop 1

PROLENSA 0.07% EYE DROPS 3 bromfenac sodium RETISERT IMPLANT 9 fluocinolone acetonide TRIESENCE 40 MG/ML VIAL 9 triamcinolone acetonide/pf VEXOL 1% EYE DROPS 3 rimexolone Ophthalmic Antiglaucoma Agents

ALPHAGAN P 0.1% DROPS 2 brimonidine tartrate ALPHAGAN P 0.15% EYE DROPS 3 brimonidine tartrate

apraclonidine hcl 0.5% drops 1

AZOPT 1% EYE DROPS 2 brinzolamide BETAGAN 0.5% EYE DROPS 3 levobunolol hcl

betaxolol hcl 0.5% eye drop 1

BETIMOL 0.25% EYE DROPS 3 timolol

PAGE 490 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS BETIMOL 0.25% EYE DROPS 3 timolol BETIMOL 0.5% EYE DROPS 3 timolol BETIMOL 0.5% EYE DROPS 3 timolol BETOPTIC S 0.25% EYE DROPS 2 ST betaxolol hcl

brimonidine 0.2% eye drop 1

brimonidine tartrate 0.15% drp 1

carteolol hcl 1% eye drops 1

COMBIGAN EYE DROPS 3 brimonidine tartrate/timolol maleate COSOPT EYE DROPS 3 dorzolamide hcl/timolol maleate COSOPT EYE DROPS 3 dorzolamide hcl/timolol maleate COSOPT PF EYE DROPS 3 dorzolamide hcl/timolol maleate/pf COSOPT PF EYE DROPS 3 dorzolamide hcl/timolol maleate/pf

dorzolamide hcl 2% eye drops 1

dorzolamide-timolol eye drops 1

IOPIDINE 0.5% EYE DROPS 3 apraclonidine hcl IOPIDINE 1% EYE DROPS 3 apraclonidine hcl ISOPTO CARBACHOL 1.5% DROPS 3 carbachol ISOPTO CARBACHOL 3% DROPS 3 carbachol ISOPTO CARPINE 1% EYE DROPS 3 pilocarpine hcl ISOPTO CARPINE 2% EYE DROPS 3 pilocarpine hcl ISOPTO CARPINE 4% EYE DROPS 3 pilocarpine hcl

ISTALOL 0.5% EYE DROPS 3 ST

PAGE 491 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS timolol maleate

latanoprost 0.005% eye drops 1 QL 15 / 90 days

levobunolol 0.25% eye drops 1

levobunolol 0.5% eye drops 1

LUMIGAN 0.01% EYE DROPS 3 QL 15 / 90 days bimatoprost

methazolamide 25 mg tablet 1

methazolamide 50 mg tablet 1

metipranolol 0.3% eye drops 1

MIOSTAT VIAL 9 carbachol NEPTAZANE 25 MG TABLET 3 methazolamide NEPTAZANE 50 MG TABLET 3 methazolamide PHOSPHOLINE IODIDE 0.125% 3 echothiophate iodide

pilocarpine 1% eye drops 1

pilocarpine 2% eye drops 1

pilocarpine 4% eye drops 1

PILOPINE HS 4% EYE GEL 3 pilocarpine hcl RESCULA 0.15% EYE DROPS 2 unoprostone isopropyl SIMBRINZA 1%-0.2% EYE DROPS 3 brinzolamide/brimonidine tartrate

timolol 0.25% eye drops 1

timolol 0.25% gel-solution 1

timolol 0.25% gfs gel-solution 1

timolol 0.5% eye drops 1

timolol 0.5% gel-solution 1

timolol 0.5% gfs gel-solution 1

TIMOPTIC 0.25% EYE DROPS 3 ST

PAGE 492 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

timolol maleate

TIMOPTIC 0.25% OCUDOSE DROP 3 timolol maleate/pf TIMOPTIC 0.5% EYE DROPS 3 ST timolol maleate TIMOPTIC 0.5% OCUDOSE DROP 3 timolol maleate/pf TIMOPTIC-XE 0.25% EYE SOLN 3 ST timolol maleate TIMOPTIC-XE 0.5% EYE SOLN 3 ST timolol maleate TRUSOPT 2% EYE DROPS 3 dorzolamide hcl XALATAN 0.005% EYE DROPS 3 QL 15 / 90 days latanoprost ZIOPTAN 0.0015% EYE DROPS 3 tafluprost/pf Otic Agents

acetasol hc ear drops 1

acetic acid 2% ear solution 1

acetic acid-aluminum drops 1

aero otic hc ear drops 1

antipyrine-benzocaine ear drop 1

antipyrine-benzocaine otic sol 1

aurax otic solution 1

aurodex otic solution 1

auroguard otic solution 1

CETRAXAL 0.2% EAR SOLUTION 3 QL 14 / 7 days ciprofloxacin hcl CIPRO HC OTIC SUSPENSION 2 ciprofloxacin hcl/hydrocortisone CIPRODEX OTIC SUSPENSION 2 ciprofloxacin hcl/dexamethasone

3 QL

PAGE 493 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

ciprofloxacin 0.2% otic soln 14 / 7 days

COLY-MYCIN S EAR DROPS neomycin sulfate/colistin 2 sulfate/hydrocortisone/thonzonium

cortane-b otic drops 3

CORTANE-B OTIC DROPS 3 hydrocortisone/pramoxine hcl/chloroxylenol/water CORTISPORIN EAR SOLUTION 3 neomycin sulfate/polymyxin b sulfate/hydrocortisone CORTISPORIN-TC EAR SUSP neomycin sulfate/colistin 2 sulfate/hydrocortisone/thonzonium CRESYLATE EAR DROPS 2 cresyl acetate DERMOTIC OIL 0.01% EAR DROPS 3 fluocinolone acetonide oil

exotic-hc ear drop 1

fluocinolone oil 0.01% ear drp 1

hydrocortison-acetic acid soln 1

myoxin otic suspension 1

neomycin-polymyxin-hc ear soln 1

neomycin-polymyxin-hc ear susp 1

otic care otic solution 1

oticin drops 1

oticin hc drops 3

oto-end 10 ear drops 1

otomax-hc ear drops 1

otozin ear drops 1

pinnacaine 20% otic drops 2

pramoxine-hc otic drops 1

treagan otic drops 3

TRIOXIN OTIC SUSPENSION 3 chloroxylenol/benzocaine/hydrocortisone acetate

PAGE 494 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS VOSOL HC EAR DROPS 3 acetic acid/hydrocortisone Respiratory Tract Agents

Anti-inflammatories, Inhaled Corticosteroids

AEROSPAN 80 MCG INHALER 3 flunisolide AEROSPAN 80 MCG INHALER 3 flunisolide ALVESCO 160 MCG INHALER 3 QL 12 / 30 days ciclesonide ALVESCO 80 MCG INHALER 3 QL 12 / 30 days ciclesonide

ASMANEX TWISTHALER 110 MCG #30 QL 3 / 90 days 3 mometasone furoate ST

ASMANEX TWISTHALER 110 MCG #7 3 ST mometasone furoate ASMANEX TWISTHALER 220 MCG #14 3 ST mometasone furoate

ASMANEX TWISTHALER 220 MCG #30 QL 3 / 90 days 3 mometasone furoate ST

ASMANEX TWISTHALER 220 MCG #60 QL 3 / 90 days 3 mometasone furoate ST

ASMANEX TWISTHALR 220 MCG #120 QL 3 / 90 days 3 mometasone furoate ST

BECONASE AQ 0.042% SPRAY 3 beclomethasone dipropionate BREO ELLIPTA 100-25 MCG INH 3 fluticasone furoate/vilanterol trifenatate

budesonide 0.25 mg/2 ml susp 1 QL 140 / 30 days

budesonide 0.5 mg/2 ml susp 1 QL 140 / 30 days

budesonide 32 mcg nasal spray 1

FLONASE 0.05% NASAL SPRAY 3 ST fluticasone propionate FLOVENT 100 MCG DISKUS 2 fluticasone propionate

FLOVENT 250 MCG DISKUS 2

PAGE 495 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

fluticasone propionate

FLOVENT 50 MCG DISKUS 2 fluticasone propionate FLOVENT HFA 110 MCG INHALER 2 fluticasone propionate FLOVENT HFA 220 MCG INHALER 2 fluticasone propionate FLOVENT HFA 44 MCG INHALER 2 fluticasone propionate

flunisolide 0.025% spray 1

flunisolide 29 mcg-0.025% spr 1

fluticasone prop 50 mcg spray 1

NASACORT AQ NASAL SPRAY 3 ST triamcinolone acetonide NASONEX 50 MCG NASAL SPRAY 3 ST mometasone furoate

OMNARIS 50 MCG NASAL SPRAY QL 12 / 30 days 3 ciclesonide ST

PULMICORT 0.25 MG/2 ML RESPUL 3 QL 140 / 30 days budesonide PULMICORT 0.5 MG/2 ML RESPULE 3 QL 140 / 30 days budesonide PULMICORT 1 MG/2 ML RESPULE 3 QL 140 / 30 days budesonide PULMICORT 180 MCG FLEXHALER 2 budesonide PULMICORT 90 MCG FLEXHALER 2 budesonide

QNASL 80 MCG NASAL SPRAY QL 9 / 30 days 3 beclomethasone dipropionate ST

QVAR 40 MCG ORAL INHALER 2 beclomethasone dipropionate QVAR 40 MCG ORAL INHALER 2 beclomethasone dipropionate QVAR 80 MCG ORAL INHALER 2 beclomethasone dipropionate

QVAR 80 MCG ORAL INHALER 2

PAGE 496 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS beclomethasone dipropionate RHINOCORT AQUA NASAL SPRAY 2 budesonide

triamcinolone 55 mcg nasal spr 1

VERAMYST 27.5 MCG NASAL SPRAY 2 ST fluticasone furoate

ZETONNA 37 MCG NASAL SPRAY QL 6 / 30 days 3 ciclesonide ST

Antihistamines

ALLEGRA ODT 30 MG TABLET 3 fexofenadine hcl

arbinoxa 4 mg tablet 1

arbinoxa 4 mg/5 ml liquid 1

ASTELIN 137 MCG NASAL SPRAY 3 azelastine hcl ASTEPRO 0.15% NASAL SPRAY 3 QL 30 / 30 days azelastine hcl

azelastine 0.15% nasal spray 1 QL 30 / 30 days

azelastine 137 mcg nasal spray 1

azelastine hcl 0.1% nasal spry 1

carbinoxamine 4 mg/5 ml liquid 1

carbinoxamine maleate 4 mg tab 1

cetirizine hcl 1 mg/ml soln 1

cetirizine hcl 1 mg/ml syrup 1

CLARINEX 0.5 MG/ML (2.5 MG/5) 3 desloratadine CLARINEX 2.5 MG REDITABS 3 QL 90 / 30 days desloratadine CLARINEX 5 MG REDITABS 3 QL 60 / 30 days desloratadine CLARINEX 5 MG TABLET 3 QL 30 / 30 days desloratadine

clemastine 0.5 mg/5 ml syrup 1

PAGE 497 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

clemastine fum 2.68 mg tab 1

cyproheptadine 2 mg/5 ml syrup 1

cyproheptadine 4 mg tablet 1

cyproheptadine 4 mg/10 ml syrp 1

desloratadine 2.5 mg odt 1 QL 90 / 30 days

desloratadine 5 mg odt 1 QL 60 / 30 days

desloratadine 5 mg tablet 1 QL 30 / 30 days

dexchlorphen 2 mg/5 ml syrup 1

dexchlorpheniramine 6 mg tab 1

DICOPANOL ORAL SUSPENSION 3 diphenhydramine hcl

diphenhydramine 12.5 mg/5 ml 1

diphenhydramine 50 mg capsule 1

doxytex 2.5 mg/2.5 ml liquid 3

fexofenadine hcl 180 mg tablet 1 QL 30 / 30 days

fexofenadine hcl 30 mg tablet 1 QL 60 / 30 days

fexofenadine hcl 60 mg tablet 1 QL 60 / 30 days

hydroxyzine 10 mg/5 ml syrup 1

hydroxyzine hcl 10 mg tablet 1

hydroxyzine hcl 25 mg tablet 1

hydroxyzine hcl 50 mg tablet 1

hydroxyzine pam 100 mg cap 1

hydroxyzine pam 25 mg cap 1

hydroxyzine pam 50 mg cap 1

KARBINAL ER 4 MG/ 5 ML SUSP 3

PAGE 498 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS carbinoxamine maleate

levocetirizine 2.5 mg/5 ml sol 1

levocetirizine 5 mg tablet 1 QL 30 / 30 days

palgic 4 mg tablet 3

PATANASE 665 MCG NASAL SPRAY 3 QL 30 / 30 days olopatadine hcl

phenergan 25 mg/ml ampul 9

PHENERGAN 25 MG/ML AMPUL 9 promethazine hcl

phenergan 25 mg/ml vial 9

PHENERGAN 25 MG/ML VIAL 9 promethazine hcl

phenergan 50 mg/ml ampul 7

PHENERGAN 50 MG/ML AMPUL 9 promethazine hcl

phenergan 50 mg/ml vial 7

PHENERGAN 50 MG/ML VIAL 9 promethazine hcl

promethazine 12.5 mg tablet 1

promethazine 25 mg tablet 1

promethazine 25 mg/ml ampul 7

promethazine 25 mg/ml syringe 7

promethazine 25 mg/ml vial 7

promethazine 50 mg tablet 1

promethazine 50 mg/ml ampul 7

promethazine 50 mg/ml vial 7

promethazine 6.25 mg/5 ml syrp 1

VISTARIL 25 MG CAPSULE 3 hydroxyzine pamoate

PAGE 499 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS VISTARIL 50 MG CAPSULE 3 hydroxyzine pamoate VITUZ SOLUTION 3 hydrocodone bitartrate/chlorpheniramine maleate XYZAL 2.5 MG/5 ML SOLUTION 3 levocetirizine dihydrochloride XYZAL 5 MG TABLET 3 QL 30 / 30 days levocetirizine dihydrochloride Antileukotrienes

ACCOLATE 10 MG TABLET 3 QL 60 / 30 days zafirlukast ACCOLATE 20 MG TABLET 3 QL 60 / 30 days zafirlukast

montelukast sod 10 mg tablet 1 QL 30 / 30 days

montelukast sod 4 mg granules 1 QL 30 / 30 days

montelukast sod 4 mg tab chew 1 QL 30 / 30 days

montelukast sod 5 mg tab chew 1 QL 30 / 30 days

SINGULAIR 10 MG TABLET 3 QL 30 / 30 days montelukast sodium SINGULAIR 4 MG GRANULES 3 QL 30 / 30 days montelukast sodium SINGULAIR 4 MG TABLET CHEW 3 QL 30 / 30 days montelukast sodium SINGULAIR 5 MG TABLET CHEW 3 QL 30 / 30 days montelukast sodium

zafirlukast 10 mg tablet 1 QL 60 / 30 days

zafirlukast 20 mg tablet 1 QL 60 / 30 days

ZYFLO 600 MG FILMTAB 3 zileuton ZYFLO CR 600 MG TABLET 3 QL 120 / 30 days zileuton Bronchodilators, Anticholinergic

ATROVENT 0.03% SPRAY 3 ipratropium bromide

ATROVENT 0.06% SPRAY 3

PAGE 500 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ipratropium bromide ATROVENT HFA INHALER 2 ipratropium bromide

ipratropium 0.03% spray 1

ipratropium 0.06% spray 1

ipratropium br 0.02% soln 1

SPIRIVA 18 MCG CP-HANDIHALER 2 QL 90 / 90 days tiotropium bromide TUDORZA PRESSAIR 400 MCG INH 3 QL 1 / 30 days aclidinium bromide TUDORZA PRESSAIR 400 MCG INH 3 QL 1 / 30 days aclidinium bromide Bronchodilators, Phosphodiesterase Inhibitors (Xanthines)

aminophylline 250 mg/10 ml vl 7

aminophylline 500 mg/20 ml vl 7

ELIXOPHYLLIN 80 MG/15 ML ELIX 3 theophylline anhydrous LUFYLLIN 200 MG TABLET 3 dyphylline LUFYLLIN-400 TABLET 3 dyphylline THEO-24 ER 100 MG CAPSULE 3 theophylline anhydrous THEO-24 ER 200 MG CAPSULE 3 theophylline anhydrous THEO-24 ER 300 MG CAPSULE 3 theophylline anhydrous THEO-24 ER 400 MG CAPSULE 3 theophylline anhydrous

theochron er 100 mg tablet 1

theochron er 200 mg tablet 1

theochron er 300 mg tablet 1

theophylline 200 mg/100 ml d5w 1

theophylline 200 mg/50 ml d5w 1

theophylline 400 mg/250 ml d5w 7

PAGE 501 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

theophylline 400 mg/500 ml d5w 7

theophylline 80 mg/15 ml soln 1

theophylline 800 mg/250 ml d5w 1

theophylline 800 mg/500 ml d5w 7

theophylline er 100 mg tablet 1

theophylline er 200 mg tablet 1

theophylline er 300 mg tab 1

theophylline er 400 mg tablet 1

theophylline er 450 mg tab 1

theophylline er 600 mg tablet 1

Bronchodilators, Sympathomimetic

ACCUNEB 0.63 MG/3 ML INH SOLN 3 QL 360 / 30 days albuterol sulfate ACCUNEB 1.25 MG/3 ML INH SOLN 3 albuterol sulfate ADRENACLICK 0.15 MG AUTO-INJCT 9 epinephrine ADRENACLICK 0.3 MG AUTO-INJECT 9 QL 6 / 90 days epinephrine ADRENALIN 1 MG/ML VIAL 9 epinephrine ADRENALIN 1 MG/ML VIAL 9 epinephrine ADRENALIN 1:1,000 NASAL SOLN 3 epinephrine hcl ADRENALIN CL 1 MG/ML VIAL 9 epinephrine

ADVAIR 100-50 DISKUS QL 60 / 30 days 2 fluticasone propionate/salmeterol xinafoate ST

ADVAIR 250-50 DISKUS QL 60 / 30 days 2 fluticasone propionate/salmeterol xinafoate ST

PAGE 502 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

ADVAIR 500-50 DISKUS QL 60 / 30 days 2 fluticasone propionate/salmeterol xinafoate ST

ADVAIR HFA 115-21 MCG INHALER QL 12 / 30 days 2 fluticasone propionate/salmeterol xinafoate ST

ADVAIR HFA 230-21 MCG INHALER QL 12 / 30 days 2 fluticasone propionate/salmeterol xinafoate ST

ADVAIR HFA 45-21 MCG INHALER QL 12 / 30 days 2 fluticasone propionate/salmeterol xinafoate ST

albuterol 0.083% inhal soln 1

albuterol 2.5 mg/0.5 ml sol 1

albuterol 5 mg/ml solution 1

albuterol sul 0.63 mg/3 ml sol 1 QL 360 / 30 days

albuterol sul 1.25 mg/3 ml sol 1

albuterol sulf 2 mg/5 ml syrup 1

albuterol sulfate 2 mg tab 1

albuterol sulfate 4 mg tab 1

albuterol sulfate er 4 mg tab 1

albuterol sulfate er 8 mg tab 1

ANORO ELLIPTA 62.5-25 MCG INH 3 umeclidinium bromide/vilanterol trifenatate ARCAPTA NEOHALER 75 MCG CAP 3 indacaterol maleate AUVI-Q 0.15 MG AUTO-INJECTOR 9 epinephrine AUVI-Q 0.3 MG AUTO-INJECTOR 8 QL 6 / 90 days epinephrine BREO ELLIPTA 100-25 MCG INH 3 fluticasone furoate/vilanterol trifenatate BROVANA 15 MCG/2 ML SOLUTION 3 arformoterol tartrate COMBIVENT INHALER 2 ipratropium bromide/albuterol sulfate

PAGE 503 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS COMBIVENT RESPIMAT INHAL SPRAY 3 QL 6 / 30 days ipratropium bromide/albuterol sulfate

DULERA 100 MCG/5 MCG INHALER QL 13 / 30 days 3 mometasone furoate/formoterol fumarate ST

DULERA 200 MCG/5 MCG INHALER QL 13 / 30 days 3 mometasone furoate/formoterol fumarate ST

DUONEB 0.5 MG-3 MG/3 ML SOLN 3 ipratropium bromide/albuterol sulfate

epinephrine 0.1 mg/ml syringe 7

epinephrine 0.15 mg auto-injct 9

epinephrine 0.3 mg auto-inject 9 QL 6 / 90 days

epinephrine 1 mg/ml ampul 7

epinephrine 1 mg/ml vial 7

EPIPEN 2-PAK 0.3 MG AUTO-INJCT 8 QL 6 / 90 days epinephrine EPIPEN JR 2-PAK 0.15 MG INJCTR 8 QL 6 / 90 days epinephrine FORADIL AEROLIZER 12 MCG CAP 3 QL 60 / 30 days formoterol fumarate

iprat-albut 0.5-3(2.5) mg/3 ml 1

levalbuterol 0.31 mg/3 ml sol 1

levalbuterol 0.63 mg/3 ml sol 1

levalbuterol 1.25 mg/3 ml sol 1

levalbuterol conc 1.25 mg/0.5 1

PAGE 504 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS MAXAIR AUTOHALER 0.2 MG AERO 3 pirbuterol acetate

metaproterenol 10 mg tablet 1

metaproterenol 10 mg/5 ml syr 1

metaproterenol 20 mg tablet 1

PERFOROMIST 20 MCG/2 ML SOLN 3 formoterol fumarate PROAIR HFA 90 MCG INHALER 2 QL 51 / 90 days albuterol sulfate PROVENTIL HFA 90 MCG INHALER 2 QL 40 / 90 days albuterol sulfate SEREVENT DISKUS 50 MCG 2 QL 60 / 30 days salmeterol xinafoate STRIVERDI RESPIMAT INHAL SPRAY 3 olodaterol hcl

SYMBICORT 160-4.5 MCG INHALER QL 10 / 30 days 2 budesonide/formoterol fumarate ST

SYMBICORT 80-4.5 MCG INHALER QL 10 / 30 days 2 budesonide/formoterol fumarate ST

terbutaline sulf 1 mg/ml vial 7

terbutaline sulfate 2.5 mg tab 1

terbutaline sulfate 5 mg tab 1

VENTOLIN HFA 90 MCG INHALER 2 QL 108 / 90 days albuterol sulfate VOSPIRE ER 4 MG TABLET 3 albuterol sulfate VOSPIRE ER 8 MG TABLET 3 albuterol sulfate XOPENEX 0.31 MG/3 ML SOLUTION 3 levalbuterol hcl XOPENEX 0.63 MG/3 ML SOLUTION 3 levalbuterol hcl XOPENEX 1.25 MG/3 ML SOLUTION 3 levalbuterol hcl XOPENEX CONC 1.25 MG/0.5 ML 3 levalbuterol hcl

PAGE 505 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS XOPENEX HFA 45 MCG INHALER 3 levalbuterol tartrate Mast Cell Stabilizers

cromolyn 20 mg/2 ml neb soln 1

cromolyn sodium 100 mg/5 ml 1

GASTROCROM 100 MG/5 ML CONC 3 cromolyn sodium Pulmonary Antihypertensives

ADCIRCA 20 MG TABLET QL 60 / 30 days 5 tadalafil PA

ADEMPAS 0.5 MG TABLET 3 riociguat ADEMPAS 1 MG TABLET 3 riociguat ADEMPAS 1.5 MG TABLET 3 riociguat ADEMPAS 2 MG TABLET 3 riociguat ADEMPAS 2.5 MG TABLET 3 riociguat

epoprostenol sodium 0.5 mg vl 7

epoprostenol sodium 1.5 mg vl 7

FLOLAN 0.5 MG VIAL 9 epoprostenol sodium (glycine) FLOLAN 1.5 MG VIAL 9 epoprostenol sodium (glycine) LETAIRIS 10 MG TABLET 5 PA ambrisentan LETAIRIS 5 MG TABLET 5 PA ambrisentan OPSUMIT 10 MG TABLET 3 macitentan OPSUMIT 10 MG TABLET 3 macitentan ORENITRAM ER 0.125 MG TABLET 3 treprostinil diolamine

ORENITRAM ER 0.25 MG TABLET 3

PAGE 506 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS treprostinil diolamine ORENITRAM ER 1 MG TABLET 3 treprostinil diolamine ORENITRAM ER 2.5 MG TABLET 3 treprostinil diolamine REMODULIN 1 MG/ML VIAL 5 treprostinil sodium REMODULIN 10 MG/ML VIAL 5 treprostinil sodium REMODULIN 2.5 MG/ML VIAL 5 treprostinil sodium REMODULIN 5 MG/ML VIAL 5 treprostinil sodium REVATIO 10 MG/12.5 ML VIAL 5 PA sildenafil citrate REVATIO 10 MG/ML ORAL SUSP 5 PA sildenafil citrate

REVATIO 20 MG TABLET QL 90 / 30 days 5 sildenafil citrate PA

QL 90 / 30 days sildenafil 20 mg tablet 1 PA

TRACLEER 125 MG TABLET 5 bosentan TRACLEER 62.5 MG TABLET 5 bosentan TYVASO 1.74 MG/2.9 ML SOLUTION 5 treprostinil TYVASO INHALATION REFILL KIT 5 treprostinil/nebulizer accessories TYVASO INHALATION STARTER KIT 5 treprostinil/nebulizer/nebulizer accessories VELETRI 0.5 MG VIAL 8 epoprostenol sodium (arginine) VELETRI 1.5 MG VIAL 8 epoprostenol sodium (arginine)

VENTAVIS 10 MCG/1 ML SOLUTION 9

PAGE 507 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS iloprost tromethamine VENTAVIS 20 MCG/1 ML SOLUTION 9 iloprost tromethamine Respiratory Tract Agents, Other

acetylcysteine 10% vial 1

acetylcysteine 20% vial 1

ALA-HIST AC LIQUID 3 phenylephrine hcl/codeine phosphate ALAHIST DHC LIQUID 3 phenylephrine hcl/dihydrocodeine bitartrate ALLEGRA-D 24 HOUR TABLET 3 fexofenadine hcl/pseudoephedrine hcl ALLFEN CD TABLET 3 guaifenesin/codeine phosphate ALLFEN CDX LIQUID 3 guaifenesin/codeine phosphate ALLFEN CDX TABLET 3 guaifenesin/codeine phosphate AMBIFED DM TABLET 3 guaifenesin/dextromethorphan hbr/pseudoephedrine hcl AMBIFED TABLET 3 guaifenesin/pseudoephedrine hcl ARALAST NP 1,000 MG VIAL 9 alpha-1-proteinase inhibitor ARALAST NP 1,000 MG VIAL 9 alpha-1-proteinase inhibitor ARALAST NP 500 MG VIAL 9 alpha-1-proteinase inhibitor ARALAST NP 500 MG VIAL 9 alpha-1-proteinase inhibitor

benzonatate 100 mg capsule 1

benzonatate 200 mg capsule 1

bromfed dm cough syrup 1

bromphenir-pseudoephed-dm syr 1

BRONCOMAR-1 ELIXIR 3

PAGE 508 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS guaifenesin/theophylline anhydrous/pseudoephedrine CAYSTON 75 MG INHAL SOLUTION 5 QL 84 / 56 days aztreonam lysine

centergy dm pediatric drops 1

centergy pediatric drops 1

chloramphen na succ 1 gm vl 1

CLARINEX-D 12 HOUR TABLET 3 QL 120 / 30 days desloratadine/pseudoephedrine sulfate CLARINEX-D 24 HOUR TABLET 3 QL 150 / 30 days desloratadine/pseudoephedrine sulfate CODAR AR LIQUID 3 chlorpheniramine maleate/codeine phosphate CODAR D LIQUID 3 pseudoephedrine hcl/codeine phosphate CODAR GF LIQUID 3 guaifenesin/codeine phosphate COTABFLU TABLET chlorpheniramine maleate/codeine 3 phosphate/acetaminophen CUROSURF 120 MG/1.5 ML VIAL 3 poractant alfa CUROSURF 240 MG/3 ML VIAL 3 poractant alfa DALIRESP 500 MCG TABLET 3 QL 30 / 30 days roflumilast DESPEC-PDC LIQUID phenylephrine hcl/dihydrocodeine 3 bitartrate/chlorpheniramine DONATUSS DC SYRUP 3 phenylephrine hcl/dihydrocodeine bitartrate/guaifenesin DOPRAM 400 MG/20 ML VIAL 9 doxapram hcl

doxapram hcl 20 mg/ml vial 7

DYMISTA NASAL SPRAY 3 azelastine hcl/fluticasone propionate

endacof-c liquid 1

ephedrine 50 mg/ml ampul 7

ephedrine su 50 mg/ml vial 7

PAGE 509 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

fexofenadine-pse er 180-240 tb 1

GLASSIA 1 GM/50 ML VIAL 9 alpha-1-proteinase inhibitor

glycopyrrolate 0.2 mg/ml vial 7

glycopyrrolate 0.4 mg/2 ml vl 7

glycopyrrolate 1 mg/5 ml vial 7

glycopyrrolate 4 mg/20 ml vial 7

GRASTEK 2,800 BAU SL TABLET 3 grass pollen-timothy, std

hydrocod-cpm-pseudoep 5-4-60/5 1

hydrocodone-chlorpheniram susp 1

hydrocodone-homatropine syrup 1

hydrocodone-homatropine tablet 1

hydromet syrup 1

HYPER-SAL 3.5% VIAL 3 sodium chloride for inhalation HYPER-SAL 7% VIAL 3 sodium chloride for inhalation INFASURF 35 MG/ML VIAL 3 calfactant J-COF DHC LIQUID 3 brompheniramine/pseudoephedrine hcl/dihydrocodeine

KALYDECO 150 MG TABLET QL 60 / 30 days 5 ivacaftor PA

lusair liquid 1

m-clear capsule 1

MAXIFED CD TABLET 3 pseudoephedrine hcl/codeine phosphate/guaifenesin MAXIFED CDX TABLET 3 pseudoephedrine hcl/codeine phosphate/guaifenesin

MAXIFLU CD TABLET 3

PAGE 510 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS pseudoephedrine hcl/codeine phosphate/acetaminophen/guaifen MAXIFLU CDX TABLET pseudoephedrine hcl/codeine 3 phosphate/acetaminophen/guaifen MAXIPHEN CD TABLET 3 phenylephrine hcl/codeine phosphate/guaifenesin MAXIPHEN CDX TABLET 3 phenylephrine hcl/codeine phosphate/guaifenesin

mesehist wc liquid 1

NEBUSAL 6% VIAL 3 sodium chloride for inhalation NOTUSS-NX LIQUID 3 chlorcyclizine hcl/codeine phosphate NOTUSS-NXD LIQUID chlorcyclizine hcl/pseudoephedrine hcl/codeine 3 phosphate ORALAIR 300 IR SUBLINGUAL TAB grass pollen-orchard/sweet vernal/rye/kentucky/timothy, 3 std. PHENFLU CD TABLET phenylephrine hcl/codeine 3 phosphate/acetaminophen/guaifen PHENFLU CDX TABLET phenylephrine hcl/codeine 3 phosphate/acetaminophen/guaifen POLY HIST DHC LIQUID 3 pyrilamine maleate/phenylephrine hcl/dihydrocodeine bt POLY HIST NC LIQUID 3 pseudoephedrine hcl/codeine phosphate/triprolidine POLY-TUSSIN DHC LIQUID brompheniramine maleate/phenylephrine 3 hcl/dihydrocodeine bt POLY-TUSSIN EX LIQUID 3 phenylephrine hcl/dihydrocodeine bitartrate/guaifenesin PROLASTIN 1,000 MG VIAL 9 alpha-1-proteinase inhibitor PROLASTIN 500 MG VIAL 9 alpha-1-proteinase inhibitor PROLASTIN C 1,000 MG VIAL 9 alpha-1-proteinase inhibitor

PAGE 511 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

promethazine vc syrup

promethazine vc-codeine syrup 1

promethazine-codeine syrup 1

promethazine-dm syrup 1

pulmosal 7% vial 3

PULMOZYME 1 MG/ML AMPUL QL 75 / 30 days 5 dornase alfa PA

pyril d suspension 1

RAGWITEK SUBLINGUAL TABLET 3 weed pollen-short ragweed RESPA A.R. TABLET SA 3 pseudoephedrine hcl/chlorpheniramine maleate/bellad alk REZIRA SOLUTION 2 pseudoephedrine hcl/hydrocodone bitartrate ROBINUL 0.2 MG/ML VIAL 9 glycopyrrolate ROBINUL 0.4 MG/2 ML VIAL 9 glycopyrrolate ROBINUL 1 MG/5 ML VIAL 9 glycopyrrolate ROBINUL 4 MG/20 ML VIAL 9 glycopyrrolate SEMPREX-D 8 MG-60 MG CAPSULE 3 pseudoephedrine hcl/acrivastine

sodium chloride 0.9% inhal vl 1

sodium chloride 10% vial 1

sodium chloride 3% vial 1

sodium chloride 7% vial 1

SURFAXIN 34 MG/ML VIAL 3 lucinactant SURVANTA 25 MG/ML VIAL 3 beractant TESSALON 200 MG CAPSULE 3 benzonatate

TESSALON PERLE 100 MG CAP 3

PAGE 512 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

benzonatate

TRICODE AR LIQUID 3 chlorpheniramine maleate/pseudoephedrine hcl/codeine TRICODE GF LIQUID 3 pseudoephedrine hcl/codeine phosphate/guaifenesin TUSNEL PEDIATRIC LIQUID 3 guaifenesin/dextromethorphan hbr/pseudoephedrine hcl TUSSICAPS 10 MG-8 MG CAPSULE 3 hydrocodone polistirex/chlorpheniramine polistirex TUSSICAPS 10 MG-8 MG CAPSULE 3 hydrocodone polistirex/chlorpheniramine polistirex TUSSICAPS 5 MG-4 MG CAPSULE 3 hydrocodone polistirex/chlorpheniramine polistirex TUSSICAPS 5 MG-4 MG CAPSULE 3 hydrocodone polistirex/chlorpheniramine polistirex

tussigon tablet 1

TUSSIONEX PENNKINETIC SUSP 3 hydrocodone polistirex/chlorpheniramine polistirex TYZINE 0.1% NOSE DROPS 3 tetrahydrozoline hcl TYZINE 0.1% NOSE SPRAY 3 tetrahydrozoline hcl TYZINE PEDIATRIC 0.05% DROP 3 tetrahydrozoline hcl V-HIST SUSPENSION 1 phenylephrine hcl/brompheniramine maleate VANACOF CD LIQUID 3 dexchlorpheniramine maleate/phenylephrine hcl/codeine XOLAIR 150 MG VIAL 5 omalizumab ZEMAIRA 1,000 MG VIAL 9 alpha-1-proteinase inhibitor ZONATUSS 150 MG CAPSULE 3 benzonatate ZOTEX-C SYRUP 3 pyrilamine maleate/phenylephrine hcl/codeine phosphate ZUTRIPRO SOLUTION pseudoephedrine hcl/hydrocodone 3 bitartrate/chlorpheniramine

PAGE 513 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS Skeletal Muscle Relaxants

AMRIX ER 15 MG CAPSULE 3 QL 30 / 30 days cyclobenzaprine hcl AMRIX ER 30 MG CAPSULE 3 QL 30 / 30 days cyclobenzaprine hcl

carisoprodl-aspirin 200-325 mg 1 QL 150 / 30 days

carisoprodol 250 mg tablet 1

carisoprodol 350 mg tablet 1 QL 120 / 30 days

carisoprodol compound tab 1 QL 150 / 30 days

chlorzoxazone 500 mg tablet 1

COMFORT PAC-CYCLOBENZAPRINE KT 3 cyclobenzaprine hcl/irritants counter-irritants combo #2

cyclobenzaprine 10 mg tablet 1

cyclobenzaprine 5 mg tablet 1

cyclobenzaprine 7.5 mg tablet 1

cyclobenzaprine er 15 mg cap 1 QL 30 / 30 days

cyclobenzaprine er 30 mg cap 1 QL 30 / 30 days

FEXMID 7.5 MG TABLET 3 cyclobenzaprine hcl FLEXERIL 10 MG TABLET 3 cyclobenzaprine hcl FLEXERIL 5 MG TABLET 3 cyclobenzaprine hcl LORZONE 375 MG TABLET 3 chlorzoxazone LORZONE 750 MG TABLET 3 chlorzoxazone

metaxalone 800 mg tablet 1

PAGE 514 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

metaxalone 800 mg tablet

methocarbamol 500 mg tablet 1

methocarbamol 750 mg tablet 1

orphenadrine 30 mg/ml ampule 7

orphenadrine 30 mg/ml vial 7

orphenadrine 60 mg/2 ml vial 7

orphenadrine comp forte tab 1

orphenadrine comp tablet 1

orphenadrine er 100 mg tablet 1

PARAFON FORTE DSC 500 MG CAPLT 3 chlorzoxazone ROBAXIN 1,000 MG/10 ML VIAL 9 methocarbamol ROBAXIN 500 MG TABLET 3 methocarbamol ROBAXIN-750 TABLET 3 methocarbamol RYANODEX 250 MG VIAL 9 dantrolene sodium SKELAXIN 800 MG TABLET 3 metaxalone SOMA 250 MG TABLET 3 carisoprodol SOMA 350 MG TABLET 3 QL 120 / 30 days carisoprodol TABRADOL ORAL SUSPENSION 3 cyclobenzaprine with methylsulfonylmethane (msm) Sleep Disorder Agents

GABA Receptor Modulators

PAGE 515 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

AMBIEN 10 MG TABLET QL 30 / 30 days 3 zolpidem tartrate ST

AMBIEN 5 MG TABLET QL 30 / 30 days 3 zolpidem tartrate ST

AMBIEN CR 12.5 MG TABLET QL 30 / 30 days 3 zolpidem tartrate ST

AMBIEN CR 6.25 MG TABLET QL 30 / 30 days 3 zolpidem tartrate ST

AMYTAL SODIUM 0.5 GRAM VIAL 9 PA amobarbital sodium DORAL 15 MG TABLET 3 quazepam EDLUAR 10 MG SL TABLET 3 zolpidem tartrate EDLUAR 5 MG SL TABLET 3 zolpidem tartrate

estazolam 1 mg tablet 1

estazolam 2 mg tablet 1

eszopiclone 1 mg tablet 1 QL 30 / 30 days

eszopiclone 2 mg tablet 1 QL 30 / 30 days

eszopiclone 3 mg tablet 1 QL 30 / 30 days

flurazepam 15 mg capsule 1

flurazepam 30 mg capsule 1

HALCION 0.25 MG TABLET 3 triazolam INTERMEZZO 1.75 MG TAB SUBLING 3 zolpidem tartrate INTERMEZZO 3.5 MG TAB SUBLING 3 zolpidem tartrate

LUNESTA 1 MG TABLET QL 30 / 30 days 3 eszopiclone ST

LUNESTA 2 MG TABLET QL 30 / 30 days 3 eszopiclone ST

PAGE 516 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

LUNESTA 3 MG TABLET QL 30 / 30 days 3 eszopiclone ST

NEMBUTAL SODIUM 50 MG/ML VIAL 9 pentobarbital sodium

quazepam 15 mg tablet 3

RESTORIL 15 MG CAPSULE 3 temazepam RESTORIL 22.5 MG CAPSULE 3 temazepam RESTORIL 30 MG CAPSULE 3 temazepam RESTORIL 7.5 MG CAPSULE 3 temazepam SECONAL SODIUM 100 MG CAPSULE 3 secobarbital sodium

SONATA 10 MG CAPSULE QL 30 / 30 days 3 zaleplon ST

SONATA 5 MG CAPSULE QL 30 / 30 days 3 zaleplon ST

temazepam 15 mg capsule 1

temazepam 22.5 mg capsule 1

temazepam 30 mg capsule 1

temazepam 7.5 mg capsule 1

triazolam 0.125 mg tablet 1

triazolam 0.25 mg tablet 1

zaleplon 10 mg capsule 1 QL 30 / 30 days

zaleplon 5 mg capsule 1 QL 30 / 30 days

zolpidem tart er 12.5 mg tab 1 QL 30 / 30 days

zolpidem tart er 6.25 mg tab 1 QL 30 / 30 days

zolpidem tartrate 10 mg tablet 1 QL 30 / 30 days

PAGE 517 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

zolpidem tartrate 10 mg tablet 1 QL 30 / 30 days

zolpidem tartrate 5 mg tablet 1 QL 30 / 30 days

ZOLPIMIST 5 MG ORAL SPRAY 3 zolpidem tartrate Sleep Disorders, Other

dexmedetomidine 200 mcg/2 ml 7

doxepin 10 mg capsule 1

doxepin 10 mg/ml oral conc 1

doxepin 100 mg capsule 1

doxepin 150 mg capsule 1

doxepin 25 mg capsule 1

doxepin 50 mg capsule 1

doxepin 75 mg capsule 1

HETLIOZ 20 MG CAPSULE 3 tasimelteon

modafinil 100 mg tablet 1 QL 120 / 30 days

modafinil 200 mg tablet 1 QL 60 / 30 days

NUVIGIL 150 MG TABLET 3 QL 30 / 30 days armodafinil NUVIGIL 200 MG TABLET 3 QL 30 / 30 days armodafinil NUVIGIL 250 MG TABLET 3 QL 30 / 30 days armodafinil NUVIGIL 50 MG TABLET 3 QL 30 / 30 days armodafinil PRECEDEX 200 MCG/2 ML VIAL 9 dexmedetomidine hcl PRECEDEX 200 MCG/50 ML INJECT 3 dexmedetomidine hcl in 0.9 % sodium chloride

PAGE 518 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS PRECEDEX 400 MCG/100 ML INJECT dexmedetomidine hcl in 0.9 % sodium chloride PROVIGIL 100 MG TABLET 3 QL 120 / 30 days modafinil PROVIGIL 200 MG TABLET 3 QL 60 / 30 days modafinil

ROZEREM 8 MG TABLET QL 30 / 30 days 3 ramelteon ST

SILENOR 3 MG TABLET 3 doxepin hcl SILENOR 6 MG TABLET 3 doxepin hcl

XYREM 500 MG/ML ORAL SOLUTION QL 540 / 30 days 9 sodium oxybate PA

Therapeutic Nutrients/ Minerals/ Electrolytes

Electrolyte/Mineral Modifiers

CARNITOR 1 GM/5 ML VIAL 9 levocarnitine CARNITOR 100 MG/ML ORAL SOLN 3 levocarnitine (with sugar) CARNITOR 330 MG TABLET 3 levocarnitine CARNITOR SF 100 MG/ML ORAL SOL 3 levocarnitine CHEMET 100 MG CAPSULE 3 succimer CUPRIMINE 250 MG CAPSULE 3 penicillamine DEPEN 250 MG TITRATAB 3 penicillamine EXJADE 125 MG TABLET 5 deferasirox EXJADE 250 MG TABLET 5 deferasirox EXJADE 500 MG TABLET 5 deferasirox FERRIPROX 500 MG TABLET 5 PA deferiprone

PAGE 519 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS KAYEXALATE POWDER sodium polystyrene sulfonate KAYEXALATE POWDER 3 sodium polystyrene sulfonate

kionex 15 gm/60 ml suspension 1

kionex powder 1

levocarnitine 100 mg/ml soln 1

levocarnitine 200 mg/ml vial 7

levocarnitine 330 mg tablet 1

marlexate powder 1

SAMSCA 15 MG TABLET QL 60 / 30 days 5 tolvaptan PA

SAMSCA 30 MG TABLET QL 60 / 30 days 5 tolvaptan PA

sod polystyren sulf 15 g/60 ml 1

sodium polystyrene sulf powder 1

sps 15 gm/60 ml suspension 1

SPS 15 GM/60 ML SUSPENSION 3 sodium polystyrene sulfonate

sps 30 gm/120 ml enema 1

SPS 30 GM/120 ML ENEMA 3 sodium polystyrene sulfonate

sps 50 gm/200 ml enema 1

SYPRINE 250 MG CAPSULE 3 trientine hcl VAPRISOL 20 MG/100 ML BAG 9 conivaptan hcl/dextrose 5 % in water Electrolyte/Mineral Replacement

ACTIVE FE TABLET 3 iron,carbonyl/folic acid/multivitamin w-minerals

PAGE 520 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ACTIVE OB SOFTGEL prenatal vitamins combo no.66/iron,carbonyl/folic acid/dha ADDAMEL N AMPULE 3 trace elements comb no.1

advanced am/pm combo pack 3

alanine 1000 powder packet 1

alz-nac tablet 3

amino acids 15% solution 7

AMINOSYN 10% IV SOLUTION 9 parenteral amino acid 10% combination no.2 AMINOSYN 3.5% IV SOLUTION 5 parenteral amino acid 3.5% combination no.1 AMINOSYN 7% IV SOLUTION 9 parenteral amino acid 7% combination no.1 AMINOSYN 7%-ELECTROLYTE SOL 9 amino acids 7 %/electrolyte-tpn soln AMINOSYN 8.5% IV SOLUTION 7 parenteral amino acid 8.5% combination no.2 AMINOSYN 8.5%-ELECTROLYTES SOL 7 amino acids 8.5 %/electrolyte-tpn soln AMINOSYN II 10% IV SOLUTION 9 parenteral amino acid 10 % combination no.1 AMINOSYN II 15% IV SOLUTION 9 parenteral amino acid 15 % combination no.2 AMINOSYN II 7% IV SOLUTION 9 parenteral amino acid 7 % combination no.2 AMINOSYN II 8.5% IV SOLUTION 7 parenteral amino acid 8.5 % combination no.3 AMINOSYN II 8.5%-ELECTROLYTES 7 amino acids 8.5 %/electrolyte-tpn soln AMINOSYN M 3.5% IV SOLUTION 5 amino acids 3.5 %/electrolyte-m solution AMINOSYN-HBC 7% IV SOLUTION 9 amino acids 7 % AMINOSYN-PF 10% IV SOLUTION 9 parenteral amino acid 10 % combination no.5 (pediatric) AMINOSYN-PF 7% IV SOLUTION 9 parenteral amino acid 7 % combination no.1 (pediatric)

PAGE 521 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS AMINOSYN-RF 5.2% IV SOLUTION parenteral amino acid 5.2 % combination no.1 (renal)

ammonium chloride 5 meq/ml 1

ammonium molybdate 25 mcg/ml 8

ANIMI-3 CAPSULE omega-3/dha/epa/b12/folic acid/pyridoxine 3 hcl/phytosterols ANIMI-3 CAPSULE 3 omega-3/dha/epa/d3/b12/folic acid/pyridox hcl/phytosterol ANIMI-3 WITH VITAMIN D CAPSULE 3 omega-3/dha/epa/d3/b12/folic acid/pyridox hcl/phytosterol

ap-zel tablet 1

AQUASOL A 50,000 UNITS/ML VIAL 9 vitamin a palmitate

ascorbic acid 500 mg/ml vial 7

ATABEX EC CAPLET prenatal vitamins comb no.43/iron,carbonyl/fa/docusate 3 sod AVAILNEX 750 MG TABLET CHEW 3 carbocysteine AXONA POWDER PACKET 3 nutritional therapy, metabolic disorder, multivit & min #2

b-complex 100 injection 7

B-NEXA TABLET 3 prenatal vit/folic acid/b6/calcium phos di & tribasic/ginger

b-plex plus tablet 1

b-plex tablet 1

BACMIN CAPLET 1 multivitamins w-minerals combination no.20/iron/folic acid

bal-care dha combo pack 1

BAL-CARE DHA ESSENTIAL PACK prenatal vitamin#100/iron sod edta&polysac 3 complx/fa/omega-3

bd normal saline flush syringe 7

BIFERA RX TABLET 3 iron ps complex/iron heme polypeptide/folic acid/vit b12

bp folinatal plus b tablet 2

PAGE 522 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

bp vit 3 capsule 1

c-nate dha softgel 3

calcium chloride 10% abbjct 7

calcium chloride 10% ampul 1

calcium chloride 10% syringe 7

calcium chloride 10% syrng 7

calcium chloride 10% vial 7

calcium gluconate 10% ampul 1

calcium gluconate 10% vial 7

calcium-folic acid plus d wfer 3

calcium-pnv 28-1-250 mg sftgl 1

CARDIOTEK-RX TABLET folic acid/arginine hcl/cyanocobalamin/pyridoxine/pepper 3 ext CARDIOVID PLUS SOFTGEL 3 fish oil/omega-3 fatty acids/dl-vit e/folic acid/b6-b12

cavan-alpha kit combo pack 3

cavan-ec sod dha vitamins 2

centratex capsule 2

CEREFOLIN CAPLET cyanocobalamin/levomefolate 3 calcium/pyridoxine/riboflavin CEREFOLIN NAC CAPLET 3 acetylcysteine/mecobalamin/levomefolate calcium CEREFOLIN NAC CAPLET levomefolate ca/acetylcysteine/mecobalamin/schiz. algal 3 oil

choice-ob + dha combo pack 3

choice-tabs tablet 1

chromium cl 40 mcg/10 ml vial 7

CITRANATAL 90 DHA COMBO PACK 2

PAGE 523 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS prenatal vitamins no.72/iron carbonyl & gluconate/fa/dss/dha CITRANATAL 90 DHA PACK 2 prenatal vit with ca no.64/iron carb&gluc/folic acid/dss/dha CITRANATAL ASSURE COMBO PACK 2 prenatal vitamins no.38/iron cbn&glucon/folic acid/dss/dha CITRANATAL ASSURE COMBO PACK prenatal vitamins no.73/iron carbonyl & 2 gluconate/fa/dss/dha CITRANATAL B-CALM COMBO PACK 3 prenatal vit comb no.48/iron, carbonyl & gluconate/fa/b6 CITRANATAL DHA PACK 2 prenatal vitamins no.22/iron cbn&glucon/folic acid/dss/dha CITRANATAL DHA PACK prenatal vitamins no.76/iron carbonyl & 2 gluconate/fa/dss/dha CITRANATAL HARMONY CAPSULE 1 prenatal vitamins combo no.34/iron,carb/folic acid/dss/dha CITRANATAL HARMONY CAPSULE 1 prenatal vitamins combo no.59/iron,carb/folic acid/dss/dha CITRANATAL HARMONY CAPSULE prenatal vitamins no.59/iron carbonyl & 1 fumarate/fa/dss/dha CITRANATAL RX TABLET 2 prenatal vitamins no.22/iron cbn & gluc/folic acid/dss CLINIMIX 2.75%-5% SOLUTION 9 amino acids 2.75 %/dextrose 5 % in water CLINIMIX 4.25%-10% SOLUTION 8 amino acids 4.25 %/dextrose 10 % in water CLINIMIX 4.25%-20% SOLUTION 8 amino acids 4.25 %/dextrose 20 % in water CLINIMIX 4.25%-25% SOLUTION 8 amino acids 4.25 %/dextrose 25 % in water CLINIMIX 4.25%-5% SOLUTION 9 amino acids 4.25 % in dextrose 5 % in water CLINIMIX 5%-15% SOLUTION 9 amino acids 5 %/dextrose 15 % in water CLINIMIX 5%-20% SOLUTION 9 amino acids 5 %/dextrose 20 % in water CLINIMIX 5%-25% SOLUTION 9 amino acids 5 %/dextrose 25 % in water

PAGE 524 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS CLINIMIX E 2.75%-10% SOLUTION 9 amino acids 2.75 %/calcium/electrolyte-tpn soln/d10w CLINIMIX E 2.75%-5% SOLUTION 9 amino acids 2.75 %/calcium/electrolyte-tpn soln/d5w CLINIMIX E 4.25%-10% SOLUTION amino acids 4.25 %/calcium/electrolyte-tpn soln/dextrose 9 10% CLINIMIX E 4.25%-25% SOLUTION 8 amino acids 4.25 %/calcium/electrolyte-tpn soln/d25w CLINIMIX E 4.25%-5% SOLUTION 9 amino acids 4.25 %/calcium/electrolyte-tpn soln/d5w CLINIMIX E 5%-15% SOLUTION amino acids 5 %/calcium/electrolyte-tpn soln/dextrose 15 9 % CLINIMIX E 5%-20% SOLUTION amino acids 5 %/calcium/electrolyte-tpn soln/dextrose 20 9 % CLINIMIX E 5%-25% SOLUTION amino acids 5 %/calcium/electrolyte-tpn soln/dextrose 25 9 %

clinisol 15% solution 7

complete natal dha 2

complete-rf prenatal tablet 3

completenate tablet chew 2

CONCEPT DHA CAPSULE 3 prenatal vit #16/iron fum & ps complex/folic acid/omega-3 CONCEPT OB CAPSULE 3 prenatal vitamins no.15/iron fumarate & polysac comp/fa

copper chloride 4 mg/10 ml vl 9

corvita 150 tablet 1

corvita tablet 1

CORVITE 150 TABLET 3 iron,carbonyl/folic acid/vit c/pyridoxine hcl/vit b12/zinc CORVITE 150 TABLET 3 iron,carbonyl/methyltetrahydrofolate gluc,fa/mv, min no.41 CORVITE FE TABLET 3 iron,carbonyl/ferrous asparto glycinate/fa/mv, min cmb#27

CORVITE FE TABLET 3

PAGE 525 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS iron,carbonyl/methyltetrahydrofolate gluc,fa/mv, min no.40 CORVITE FREE TABLET 1 multivitamins with min no.6/folic acid/lutein/lycop/ubidecar CORVITE TABLET 3 folic acid/multivitamins,ther w-minerals/lycopene/lutein

cupric sulfate 4 mg/10 ml vl 9

cyanocobalamin 1,000 mcg/ml 7

CYTOSE POWDER 3 ribose

d5%-1/2ns-kcl 10 meq/l iv sol 7

d5%-1/2ns-kcl 30 meq/l iv sol 7

d5%-1/2ns-kcl 40 meq/l iv sol 7

d5%-1/4ns-kcl 10 meq/l iv sol 1

d5%-1/4ns-kcl 30 meq/l iv sol 1

d5%-1/4ns-kcl 40 meq/l iv sol 1

d5w-kcl 30 meq/l iv solution 1

DELFLEX WITH 1.5% DEXTROSE 9 peritoneal dialysis no.19 with dextrose 1.5% DELFLEX WITH 1.5% DEXTROSE 9 peritoneal dialysis no.6 with dextrose 1.5 % DELFLEX WITH 2.5% DEXTROSE 5 peritoneal dialysis no.7 with dextrose 2.5 % DELFLEX WITH 4.25% DEXTROSE 7 peritoneal dialysis no.8 with dextrose 4.25 % DEPLIN 15 MG TABLET 3 levomefolate calcium DEPLIN 7.5 MG TABLET 3 levomefolate calcium DEPLIN-ALGAL OIL 15 MG CAPSULE 3 levomefolate calcium/schizochytrium algal oil DEPLIN-ALGAL OIL 7.5 MG CAP 3 levomefolate calcium/schizochytrium algal oil DERMANIC TABLET niacin no.1/fa/b12/iron/a-cyst zn/chrom poly/inos niac/a- 3 cys

DEXFERRUM 100 MG/2 ML VIAL 7

PAGE 526 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS iron dextran complex DEXFERRUM 50 MG/ML VIAL 7 iron dextran complex

dextrose 10% ampul 7

dextrose 10%-0.2% nacl iv soln 7

dextrose 10%-0.45% nacl iv sol 9

dextrose 10%-0.9% nacl iv soln 1

dextrose 10%-1/4ns iv soln 8

dextrose 10%-water iv solution 7

dextrose 2.5%-0.45% nacl iv 7

dextrose 2.5%-water iv soln 7

dextrose 20%-water iv soln 7

dextrose 25%-water syringe 7

dextrose 30%-water iv soln 7

dextrose 40%-water iv soln 7

dextrose 5%-0.2% nacl iv soln 7

dextrose 5%-0.225% nacl iv sol 8

dextrose 5%-0.3% nacl iv soln 8

dextrose 5%-0.33% nacl iv soln 7

dextrose 5%-0.45% nacl iv soln 7

dextrose 5%-0.9% nacl iv soln 7

dextrose 5%-electrolyte 48 8

dextrose 5%-lr iv solution 7

dextrose 5%-ringers iv soln 7

dextrose 5%-water iv soln 7

dextrose 5%-water vial 7

dextrose 50%-water abboject 7

dextrose 50%-water iv soln 7

PAGE 527 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

dextrose 50%-water syringe 7

dextrose 50%-water vial 7

dextrose 70%-water iv soln 7

DIALYVITE 3,000 TABLET 3 folic acid/vitamin b comp w-c/selenium/min aa chel/zinc DIALYVITE 5000 TABLET 3 multivitamins with minerals no.11/folic acid DIALYVITE 800 WITH IRON TAB 3 ferrous fumarate/folic acid/vitamin b comp w-c DIALYVITE SUPREME D TABLET 3 multivitamins with min no.25/folic acid/vitamin d3 DIALYVITE TABLET 1 folic acid/vitamin b comp w-c DIALYVITE WITH ZINC TABLET vitamin b complex#11/folic acid/ascorbic acid/biotin/zn 2 oxid DIANEAL PD-2 WITH 1.5% DEXT 8 peritoneal dialysis no.4 with dextrose 1.5 % DIANEAL PD-2 WITH 2.5% DEXT 8 peritoneal dialysis no.13 with dextrose 2.5 % DIANEAL PD-2 WITH 4.25% DEXT 8 peritoneal dialysis no.3 with dextrose 4.25 % DIANEAL WITH 1.5% DEXTROSE 7 peritoneal dialysis no.6 with dextrose 1.5 % DIANEAL WITH 2.5% DEXTROSE 9 peritoneal dialysis no.7 with dextrose 2.5 % DIANEAL WITH 4.25% DEXTROSE 5 peritoneal dialysis no.8 with dextrose 4.25 % DRISDOL 50,000 UNITS CAPSULE 3 ergocalciferol (vitamin d2) DUET DHA 400 COMBO PACK prenatal vitamin no.106/sod ferede-iron 3 poly/fa/om3/dha/epa DUET DHA 400 EC COMBO PACK prenatal vitamin no.107/sod ferede-iron 3 poly/fa/om3/dha/epa DUET DHA 400 MG COMBO PACK prenatal vitamin no.106/sod ferede-iron 3 poly/fa/om3/dha/epa

DUET DHA 430 EC COMBO PACK 3

PAGE 528 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS prenatal vitamin no.107/sod ferede-iron poly/fa/om3/dha/epa DUET DHA 430 MG COMBO PACK prenatal vitamin no.106/sod ferede-iron 3 poly/fa/om3/dha/epa DUET DHA BALANCED (24 MG IRON) prenatal vitamin no.113/iron edta 3 &polysaccha/fa/om3/dha/epa DUET DHA BALANCED (25 MG IRON) prenatal vitamin no.117/sod ferede-iron 3 poly/fa/om3/dha/epa DUET DHA BALANCED (26 MG IRON) prenatal vitamin no.110/iron edta 3 &polysaccha/fa/om3/dha/epa DUET DHA BALANCED COMBO PACK prenatal vitamin no.105/iron edta 3 &polysaccha/fa/om3/dha/epa DUET DHA EC 400 MG COMBO PACK prenatal vitamin no.107/sod ferede-iron 3 poly/fa/om3/dha/epa DUET DHA EC 430 MG COMBO PACK prenatal vitamin no.107/sod ferede-iron 3 poly/fa/om3/dha/epa EFFER-K 10 MEQ TABLET EFF 3 potassium bicarbonate/citric acid EFFER-K 20 MEQ TABLET EFF 3 potassium bicarbonate/citric acid

effer-k 25 meq tablet eff 1

ELDERCAPS CAPSULE 3 multivitamins with min no.5/folic acid

elite ob dha softgel 3

elite-ob 400 capsule 3

elite-ob caplet 2

ENLYTE SOFTGEL folate #5/iron/c/calcium-threonate/phosphat-dha/b cmp 3 no.14 ENTERAGAM POWDER PACKET 3 immune globulin,bovine/plasma protein fraction, bovine

ergocalciferol 1.25 mg capsule 1

ESCAVITE LQ DROPS 1

PAGE 529 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS pediatric multivitamin combo no.57/fluoride/ferrous sulfate ESCAVITE TABLET CHEWABLE 3 pediatric multivitamin no.47 with iron & sodium fluoride

extra-virt plus dha softgel 1

EXTRANEAL ICODEXTRIN DIAL SOLN 5 peritoneal dialysis no.28 with icodextrin 7.5 %

fabb tablet 1

fe 90 plus tablet 3

fe c plus tablet 1

FERAHEME 510 MG/17 ML VIAL 9 ferumoxytol FERIVA MULTIPHASE CAPSULE 3 iron bisgly&carbonyl/folic acid/vit c/cyanocobalamin/biotin FERIVAFA CAPSULE 3 iron bisgly&carbonyl/fa#6/vit c/b12/biotin/cupric/docusate

ferocon capsule 1

FEROTRINSIC CAPSULE 1 ferrous fumarate/ascorbic acid/b12-if/folic acid FERRALET 90 TABLET iron, carbonyl & gluconate/fa/vit b12/vit c/docusate 3 sodium

ferraplus 90 tablet 3

ferrex 150 forte capsule 1

ferrex 150 forte plus capsule 1

ferrex 28 tablet 1

FERRLECIT 62.5 MG/5 ML VIAL 9 sodium ferric gluconate complex in sucrose

ferrocite plus tablet 1

ferrogels forte softgel 1

FLUOR-A-DAY 2.5 MG/ML DROPS 1 sodium fluoride FLUORABON 0.25 MG/0.6 ML DROPS 3 sodium fluoride

fluoride 0.25 mg tablet chew 1

PAGE 530 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

fluoride 0.5 mg tablet chew

fluoride 1 mg tablet chewable 1

fluoritab 0.125 mg/drp drops 1

fluoritab 0.5 mg tablet chew 1

FLUORITAB 1 MG TABLET CHEW 1 sodium fluoride

flura-drops 0.25 mg/drop 1

FLURA-DROPS 0.25 MG/DROP 2 sodium fluoride

focalgin-b tablet 1

folastin tablet 1

folbecal tablet 2

folbee plus cz tablet 1

folbee plus tablet 2

folbee tablet 1

folbic rf tablet 1

folbic tablet 1

folcal dha capsule 3

folcaps omega-3 capsule 1

folcaps tablet 1

FOLET ONE SOFTGEL prenatal no.80/iron carb & bisgly/methylfolate 3 gluc/dss/dha FOLGARD OS TABLET 3 ca carbonate/mag oxide/vitamin d3/vit b12/fa/vit b6/boron FOLGARD RX TABLET 3 cyanocobalamin/folic acid/pyridoxine

folic acid 1 mg tablet 1

folic acid 2.5 mg tablet 1

folic acid 5 mg/ml vial 1

folic acid-vit b6-vit b12 tab 1

PAGE 531 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

folivane-f capsule 1

folivane-ob capsule 3

folivane-plus capsule 3

folivane-prx dha nf capsule 3

folplex 2.2 tablet 1

foltanx rf capsule 1

foltanx tablet 3

FOLTRATE TABLET 3 cyanocobalamin/folic acid FOLTX TABLET 3 cyanocobalamin/folic acid/pyridoxine FOLTX TABLET 3 cyanocobalamin/levomefolate calcium/pyridoxine hcl FORTAVIT SOFTGEL multivits w-fe,other min/dietary 4/deoxyribonucleic 3 acid/rna FOSTEUM CAPSULE 3 genistein/citrated zinc bisglycinate/vitamin d3 FOSTEUM PLUS CAPSULE calcium comb no.19/phosphate/genistein/d3/citrated 3 zinc/k2 FOVEX CAPSULE omega-3 fatty acids/docosahexanoic 3 acid/epa/lutein/zeaxanth FREAMINE HBC 6.9% IV SOLN 9 amino acids 6.9 % FREAMINE III 10% IV SOLN. 9 parenteral amino acid 10% combination no. 4 FREAMINE III 8.5% IV SOLN. 9 parenteral amino acid 8.5 % combination no.1 FREAMINE III-ELECTROLYTES 3 amino acids 3 %/electrolyte-tpn soln FUSION PLUS CAPSULE iron fumarate & polysac comp/fa/vit b comp & c #18/l. 3 casei GABADONE CAPSULE 3 aa comb.no8/acetylcarnitine hcl/grape/cocoa/hrb cb126

GALZIN 25 MG CAPSULE 3

PAGE 532 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS zinc acetate GALZIN 50 MG CAPSULE 3 zinc acetate GESTICARE DHA COMBO PACK 3 prenatal vit with calcium #60/iron/folic acid/dha GLUTARADE GA-1 POWDER 3 nutritional therapy, glutaric aciduria 1/flaxseed/fiber GLUTASOLVE GLUTAMINE POWD PCKT 3 glutamine GLYCOPHOS VIAL 3 sodium glycerophosphate GLYTACTIN 10 PE BETTERMILK 3 nutritional therapy for pku with iron no.41 GLYTACTIN 15 PE BETTERMILK 3 nutritional therapy for pku with iron no.41 GLYTACTIN 15 PE BETTERMILK PKT 3 nutritional therapy for pku with iron no.41 GLYTACTIN RTD 10 PE LIQUID 3 nutritional therapy for pku with iron no.41 GLYTACTIN RTD 15 PE LIQUID 3 nutritional therapy for pku with iron no.41

hematinic-folic acid tablet 1

hematinic-vitamin-mineral tab 1

hematogen fa softgel 2

hematogen forte softgel 1

HEMATOGEN SOFTGEL ferrous fumarate/ascorbic acid/cyanocobalamin/stomach 1 conc HEMATRON LIQUID 3 ferric ammonium citrate/lysine/vitamin b complex/folic acid HEMATRON-AF SR CAPLET 3 iron,carbonyl/docusate sodium/b12-if/fa/multivits-min

hemax caplet 1

hemenatal ob + dha combo pack 3

hemenatal ob tablet 3

hemetab iron supplement tablet 1

PAGE 533 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS HEMOCYTE PLUS CAPSULE ferrous fumarate/folic acid/multivitamins with min no. 15 HEMOCYTE-F TABLET 1 ferrous fumarate/folic acid HEPATAMINE 8% IV SOLUTION 7 amino acids 8 % HEPATASOL 8% IV SOLUTION 7 amino acids 8 %

hydroxocobalamin 1,000 mcg/ml 1

HYPERLYTE CR VIAL 7 sodium/potassium/magnesium/calcium/chloride/acetate HYPERTENSA CAPSULE caffeine/choline bitartrate/aa comb11/herbal complex no. 3 130 ICAR-C PLUS TABLET 3 iron,carbonyl/ascorbic acid/cyanocobalamin/folic acid

iferex 150 forte capsule 1

inatal advance tablet 1

inatal ultra tablet 2

INFANATE BALANCE SOFTGEL 3 prenatal vitamins combo no.34/iron,carb/folic acid/dss/dha

infanate plus softgel 1

INFED 100 MG/2 ML VIAL 7 iron dextran complex INFUVITE ADULT BULK VIAL 7 mvi, adult no.4 with vit k INFUVITE ADULT VIAL 7 mvi, adult no.4 with vit k INFUVITE PEDIATRIC VIAL 7 mvi, pedi no.1 with vit k INJECTAFER 750 MG/15 ML VIAL 3 ferric carboxymaltose INTEGRA F CAPSULE 3 iron fumarate & polysac comp/folic acid/vitamin c/niacin INTEGRA PLUS CAPSULE iron fumarate & polysac comp/folic acid/vit b comp & c 3 no.9 INTRALIPID 20% IV FAT EMUL 7 fat emulsions

PAGE 534 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS INTRALIPID 30% IV FAT EMUL 9 fat emulsions IODOPEN 100 MCG/ML VIAL 9 sodium iodide IONOSOL B-D5W IV SOLUTION 9 electrolyte-b solution/dextrose 5 % in water IONOSOL MB-D5W IV SOLUTION 9 electrolyte-mb solution/dextrose 5 % in water

iron ag-ps-asc-b12-fa-thre-suc 1

iron tablet 3

IROSPAN 24/6 TABLET 3 iron bisgl & ps cmplx/folic acid/vit b&c#12/succinic acid ISOLYTE H-DEXTROSE 5% SOLN 8 electrolyte-h solution/dextrose 5 % in water ISOLYTE M-DEXTROSE 5% SOLN 7 electrolyte-m solution/dextrose 5 % in water ISOLYTE P-DEXTROSE 5% SOLN 9 electrolyte-p solution/dextrose 5 % in water ISOLYTE S IV SOLN PH7.4 9 electrolyte-s (ph 7.4) ISOLYTE S IV SOLUTION-EXCEL 9 electrolyte-s solution

k effervescent 25 meq tablet 1

K-TAB ER 10 MEQ TABLET 3 potassium chloride K-TAB ER 20 MEQ TABLET 3 potassium chloride KABIVEN IV EMULSION amino acid 3.31 % no.1/d9.8w/fat emulsions/electrolyte 9 no.10 KAOCHLOR-EFF 20 MEQ TABLET 3 potassium chloride/potassium bicarbonate

kcl 10 meq in d5w-0.2% nacl 7

kcl 10 meq in d5w-0.225% nacl 8

kcl 10 meq in d5w-0.3% nacl 7

kcl 10 meq in d5w-0.45% nacl 7

kcl 10 meq in d5w-1/3 ns 7

PAGE 535 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

kcl 20 meq in d5w solution 7

kcl 20 meq in d5w-0.2% nacl 7

kcl 20 meq in d5w-0.225% nacl 8

kcl 20 meq in d5w-0.3% nacl 7

kcl 20 meq in d5w-0.33% nacl 7

kcl 20 meq in d5w-0.45% nacl 7

kcl 20 meq in d5w-lact ringer 1

kcl 20 meq in d5w-ns 7

kcl 20 meq-ns 1,000 ml iv soln 7

kcl 40 meq in d5w solution 7

kcl 40 meq in d5w-lact ringer 1

kcl 40 meq in d5w-nacl 0.9% 1

kcl 40 meq-ns 1,000 ml iv soln 7

kcl 5 meq in d5w-0.2% nacl 7

KLOR-CON 10 MEQ TABLET 1 potassium chloride KLOR-CON 10 MEQ TABLET 1 potassium chloride

klor-con 20 meq packet 1

KLOR-CON 25 MEQ PACKET 3 potassium chloride KLOR-CON 8 MEQ TABLET 1 potassium chloride KLOR-CON 8 MEQ TABLET 1 potassium chloride

klor-con m10 tablet 1

klor-con m15 tablet 1

KLOR-CON M15 TABLET 1 potassium chloride

klor-con m20 tablet 1

PAGE 536 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

klor-con m20 tablet 1

klor-con-ef 25 meq tab eff 1

l-cysteine 50 mg/ml vial 7

l-mefolate-pyridox-mecobalamin 3

l-methyl-b6-b12 tablet 3

l-methyl-mc nac tablet 3

l-methyl-mc tablet 1

l-methylfolate 15 mg caplet 1

l-methylfolate 7.5 mg tablet 3

l-methylfolate ca p-5-p me-cbl 1

l-methylfolate calcium 15 mg 1

l-methylfolate calcium 7.5 mg 3

L-METHYLFOLATE FORMULA 15 MG 3 levomefolate calcium/schizochytrium algal oil L-METHYLFOLATE FORMULA 7.5 MG 3 levomefolate calcium/schizochytrium algal oil L-METHYLFOLATE FORTE 15 MG CAP 3 levomefolate calcium/schizochytrium algal oil L-METHYLFOLATE FORTE 7.5 MG CP 3 levomefolate calcium/schizochytrium algal oil

l-methylfolate pnv dha softgel 3

l-methylfolate-mecobalamin-nac 1

lactated ringers injection 7

lactated ringers irrigation 7

levomefol-nac-mecobal-algal tb 1

levomefola-nac-mecobalm-algal 1

levomefolate dha capsule 3

levomefolatepnv combo pack 3

PAGE 537 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS LIMBREL 250 MG CAPSULE 3 baicalin/catechin LIMBREL 500 MG CAPSULE 3 baicalin/catechin LIMBREL250 CAPSULE 3 baicalin/catechin/citrated zinc bisglycinate LIMBREL500 CAPSULE 3 baicalin/catechin/citrated zinc bisglycinate LIPICHOL 540 CAPSULE omega-3/dha/epa/marine phospholipids/astaxanthin/krill 3 oil LIPOSYN II 20% IV FAT EMULSION 9 fat emulsions LIPOSYN III 10% IV FAT EMULSN 9 fat emulsions LIPOSYN III 20% IV FAT EMULSN 9 fat emulsions LIPOSYN III 30% IV FAT EMULSN 7 fat emulsions

lmthf-pyridoxine-cyanocoba tb 1

ludent fluoride 0.25 mg tb chw 1

ludent fluoride 0.5 mg tb chew 1

ludent fluoride 1 mg tab chew 1

lugol's solution 3

lukaid gla for asthma emulsion 1

LUNGLAID FOR ASTHMA EMULSION 3 borage oil/fish oil (anchovy,sardine)/fructose/soy lecithin LYSIPLEX PLUS TABLET 1 lysine/vitamin e/folic acid/vitamin b comp w-c/zinc M-VIT CAPLET 2 prenatal vitamin w-o calcium/ferrous fumarate/folic acid M.V.I. ADULT VIAL 8 mvi, adult no.1 with vit k M.V.I. PEDIATRIC VIAL 8 mvi, pedi no.2 with vit k M.V.I.-12 VIAL 8 mvi, adult no.2 without vit k

macnatal cn dha softgel 1

PAGE 538 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

MACUTEK SMOOTH DISSOLVE TABLET beta-carotene/vit c/vite ac/znox/cupric 3 oxide/lut/zeaxanthin MAGNEBIND 400 RX TABLET 3 calcium carbonate/magnesium carbonate/folic acid

magnesium chl 200 mg/ml vial 7

magnesium sulf 4% iv soln 9

magnesium sulf 8% iv soln 9

magnesium sulfate 50% syringe 7

magnesium sulfate 50% vial 7

magnesium-d5w 1 gm/100 ml soln 9

manganese 1 mg/10 ml vial 9

manganese 1 mg/10 ml vial 8

MARNATAL-F CAPSULE prenatal vit with calcium comb no.65/iron polysacch 3 cmplx/fa MARTINIC CAPSULE 1 vitamin b12-intrinsic factor

maternity vitamin 1

MAXARON FORTE TABLET iron glycin.sul&fumurat/c/b12/methyltetrahydrofolate 3 calcium MAXFE CAPLET iron carb & 3 bisgly/methylfolate/b12/ascorbat/biotin/zinc/dss MAXINATE TABLET prenatal vitamin comb#3/iron fumarate & gluconate/folic 3 acid MEPHYTON 5 MG TABLET 3 phytonadione

metafolbic plus caplet 3

metafolbic plus rf caplet 1

metafolbic tablet 1

PAGE 539 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS METANX CAPSULE levomefolate ca/pyridoxal phos/mecobalamin/schiz. algal 3 oil METANX CAPSULE levomefolate ca/pyridoxal phos/mecobalamin/schiz. algal 3 oil METANX TABLET 3 mecobalamin/levomefolate calcium/pyridoxal phosphate

mi-omega nf capsule 1

monoject 0.9% sodium cl syring 7

monoject prefill 0.9% flush 7

monoject prefill 0.9% na syr 7

mult-vit-fluor 0.5 mg tab chw 1

multi-vit w-fluor 0.25 mg/ml 1

multi-vit w-fluor 0.5 mg/ml 1

MULTICHEW CHEWABLE TABLET 3 multivits, iron, minerals combo no #4, folic acid

multigen caplet 1

multigen folic caplet 2

multigen plus caplet 1

multitrace-4 conc vial 7

multitrace-4 vial 8

MULTITRACE-4 VIAL zinc sulfate/cupric sulfate/manganese sulf/chromic 9 chloride

multitrace-5 conc vial 7

multitrace-5 vial 8

multivit & fluor 0.5 mg/ml drp 1

multivit-fluor 0.25 mg tab chw 1

PAGE 540 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

multivit-fluor 0.25 mg/ml drop 1

multivit-fluor 0.5 mg tab chew 1

multivit-fluor 0.5 mg tab chw 1

multivit-fluor 0.5 mg/ml drop 1

multivit-fluor-iron 0.25 mg/ml 1

multivit-fluoride 1 mg tab chw 1

multivit-iron-fl 0.25 mg/ml 1

MULTIVITAMINS PEDIATRIC DROPS 3 pediatric multivitamin no.65/cholecalciferol/phytonadione

multivitamins softgels 3

MVC-FLUORIDE 0.25 MG TAB CHEW 1 pediatric multivitamins combination no.12/sodium fluoride MVC-FLUORIDE 0.5 MG TAB CHEW 1 pediatric multivitamins combination no.12/sodium fluoride MVC-FLUORIDE 1 MG TAB CHEW 1 pediatric multivitamins combination no.12/sodium fluoride

myferon-150 forte capsule 1

MYKIDZ IRON FL SUSPENSION 3 ferrous sulfate/sodium fluoride/vit a palm/vit c/vitamin d3

mynatal advance tablet 1

MYNATAL CAPSULE 2 prenatal vitamins with calcium/ferrous fumarate/folic acid

mynatal plus captab 2

mynatal ultracaplet 2

mynatal-z captab 2

mynate 90 plus caplet sa 2

mynephrocaps softgel 1

PAGE 541 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS NASCOBAL 500 MCG NASAL SPRAY 3 cyanocobalamin (vitamin b-12) NATA KOMPLETE PRENATAL TABLET prenatal vitamin #50/iron fumarate & bisglycinate/folic 3 acid NATACHEW TABLET prenatal vitamin #55/iron fumarate & bisglycinate/folic 3 acid NATAFORT TABLET 3 prenatal vitamins no.27/iron carbonyl & fumarate/folic acid

natal-v rx tablet 1

natalvirt 90 dha combo pack 2

natalvirt ca combo pack 2

natalvirt flt tablet 3

NATALVIT TABLET 3 prenatal vitamins with calcium/ferrous fumarate/folic acid NATELLE ONE CAPSULE 3 prenatal vits with calcium #70/ferrous fumarate/fa/dha NEEVO COMBO PACK prenatal vitamin no.88/iron ps complex/fa/l-mefolate 3 ca/dha NEEVO DHA GELCAP prenatal vitamin comb no.79/iron fumarat/fa/lmefolate 3 ca/dha NEEVODHA CAPSULE 3 prenatal no.64/iron fum/l-mefolate ca/algal oil/soy lecithin NEOCATE JR WITH PREBIOTICS PWD 3 nut.tx.impaired digest fxn/fiber NEOCATE SPLASH LIQUID 3 nut.tx.impaired digest fxn NEPHPLEX RX TABLET 2 vitamin b complx no.3/folic acid/ascorbic acid/biotin/znox NEPHRAMINE 5.4% IV SOLUTION 9 amino acids 5.4 % NEPHRO-VITE RX TABLET 3 vitamin b complx no.3/folic acid/ascorbic acid/biotin NEPHROCAPS QT TABLET 3 vitamin b complex & vitamin c no.13/folic acid/vitamin d3 NEPHROCAPS SOFTGEL 3 vitamin b complex & vitamin c no.20/folic acid

PAGE 542 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS NEPHRON FA TABLET 2 ferrous fumarate/docusate/folic acid/vitamin b comp w-c NESTABS ABC PRENATAL COMBO PK prenatal vitamin comb no.86/iron ps cmplx/folic 3 acid/dha/epa NESTABS DHA COMBO PACK 3 prenatal vitamins comb no.87/iron bisgly/folic acid/dha NESTABS TABLET 3 prenatal vitamin no.86/iron bis-glycinate/folic acid NEURIN-SL TABLET SL 3 cyanocobalamin/mecobalamin NEUT 4% VIAL 9 sodium bicarbonate NEUT 4% VIAL 9 sodium bicarbonate

newgen tablet 1

NEXA PLUS SOFTGEL 3 prenatal vitamin no.53/iron fum/folic acid/docusate ca/dha NEXA PLUS SOFTGEL 3 prenatal vitamin no.53/iron fum/folic acid/docusate ca/dha NEXA SELECT CAPSULE 3 prenatal vit with calcium no.80/iron fum/folic acid/dss/dha NEXA SELECT SOFTGEL 3 prenatal vitamin no.58/iron fumarate/folic acid/dss/dha NICADAN TABLET 3 niacinamide/vit b6/vit c/fa/copper/mg cit/zn gluc/alip acid NICAZEL FORTE TABLET niacinamide/azelaic ac/quercet/turmer/fa/b6/zinc 1 ox/copper NICAZEL TABLET 1 niacinamide/azelaic acid/zinc oxide/vit b6/copper/fa NICOMIDE TABLET methyltetrahydrofolate glucosamine/niacinamide/cupric 3 &zn ox

nicotinamide tablet 1

NIRON KOMPLETE IRON TABLET 3 ferrous fumarate/iron bisgly/folic acid/vit c/vit e/vit b12

normal saline flush syringe 7

NORMOSOL-M AND DEXTROSE 5% 7 electrolyte-m solution/dextrose 5 % in water

PAGE 543 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS NORMOSOL-R IV SOLUTION 9 electrolyte-r solution NORMOSOL-R PH 7.4 IV SOLUTION 9 electrolyte-r (ph 7.4) NORMOSOL-R-DEXTROSE 5% IV SOLN 9 electrolyte-r solution/dextrose 5 % in water NOVAFERRUM SOLUTION 3 iron polysaccharide complex/folic acid/ascorbic acid

nulecit 62.5 mg/5 ml vial 7

NUTREN JUNIOR 1 CAL LIQUID 3 nutritional supplement NUTREN JUNIOR FIBER 1 CAL LIQ 3 nutritional supplement/inulin/fructooligosaccharides/fiber NUTRESTORE POWDER PACKET 3 glutamine

nutri-tab ob + dha combo pack 3

nutri-tab ob tablet 1

NUTRICAP CAPLET 1 folic acid/multivits w-fe,other min

nutrilyte ii vial 7

NUTRILYTE VIAL sodium/potassium/magnes/calcium/chloride/acetate/gluco 7 nate O-CAL FA TABLET 2 prenatal vitamins with calcium/ferrous fumarate/folic acid O-CAL PRENATAL TABLET 3 prenatal vitamins with calcium/ferrous fumarate/folic acid OB COMPLETE 400 CAPSULE 3 prenatal no.29/iron carb & asp.glycinate/fa/dha/fish oil OB COMPLETE CAPLET 2 iron,carbonyl/folic acid/multivitamin w-minerals OB COMPLETE CHEWABLE TABLET 3 prenatal vits with calcium #84/iron,carbonyl/folic acid/dha OB COMPLETE ONE SOFTGEL 3 pnv#85/iron carb./iron asp.glycinate/folic acid/dha/fish oil OB COMPLETE PETITE SOFTGEL 3 prenatal no.56/iron carbonyl & asparto glycinate/fa/dha

OB COMPLETE PREMIER TABLET 3 prenatal vitamins comb #83/iron,carbonyl/iron asparto

PAGE 544 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS gly/fa OB COMPLETE WITH DHA SOFTGEL prenatal no.30/iron carbonly & asparto 3 glycinate/fa/omega3

ob-natal one prenatal capsule 1

obstetrix dha combo pak 3

OBSTETRIX EC CAPLET 2 prenatal vitamin w-o calcium/iron,carbonyl/docusate/fa OBTREX DHA PRENATAL VITAMIN prenatal vitamins no.12/iron,carbonyl/fa/docusate 3 na/omega-3 OBTREX PRENATAL CAPLET 2 prenatal vitamin w-o calcium/iron,carbonyl/docusate/fa OPTISOURCE LIQUID 3 nutritional therapy, milk protein, special formula OSMOPREP TABLET sodium phosphate,m-basic m-hyd/sodium 3 phosphate,dibasic

paire ob plus dha combo pack 3

PEDITRACE VIAL zinc,copper,manganese chl/sod selen/sod fluoride/pot 3 iodide PEPTAMEN JUNIOR FIBER 1 CAL LQ 3 nutritional supplement/inulin/fructooligosaccharides/fiber PERCURA CAPSULE choline/amino acid 3 #21/gaba/inositol/griffonia/glucose/creat PERIKABIVEN IV EMULSION amino acid 2.36 % no.1/d6.8w/fat emulsions/electrolytes 9 no.9 PHYSICIANS EZ USE B-12 KIT 9 cyanocobalamin (vitamin b-12) PHYSIOLYTE IRRIGATION SOLN 3 physiological irrigating solution combo #1 PHYSIOSOL IRRIGATION SOLN 7 physiological irrigating solution combo #1

phytonadione 1 mg disp syrn 7

phytonadione 1 mg/0.5 ml syr 7

PLASMA-LYTE 148 IV SOLUTION 8

PAGE 545 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS electrolyte-148 solution PLASMA-LYTE 56-DEXTROSE 5% 8 electrolyte-56 solution/dextrose 5 % in water PLASMA-LYTE A PH 7.4 SOLN. 9 electrolyte-a solution

pnv 29-1 tablet 1

pnv folic acid + iron tablet 2

pnv ob+dha combo pack 2

pnv prenatal plus multivit tab 2

pnv-dha + docusate softgel 3

PNV-DHA PLUS SOFTGEL prenatal vit with calcium no42/iron fum/fa/l-mefolate 3 ca/dha

pnv-dha softgel 3

pnv-ferrous fumarate-docu-fa 1

pnv-first softgel 3

PNV-IRON TABLET prenatal vit with calcium no8-iron ps cmplx,fa,l-mefolate 3 ca

pnv-ob with dha combo pack 3

pnv-omega softgel 3

pnv-select tablet 3

pnv-total softgel 3

PODIAPN CAPSULE pyridoxal phos/methyltetrahydrofolate 3 gluc/mecobalamin/ala

poly-iron 150 forte capsule 1

POLY-VI-FLOR 0.25 MG DROPS 3 pediatric multivitamin no.37 with sodium fluoride POLY-VI-FLOR 0.25 MG TAB CHEW 3 pediatric multivitamin no.33 with sodium fluoride POLY-VI-FLOR 0.5 MG TAB CHEW 3 pediatric multivitamin no.33 with sodium fluoride POLY-VI-FLOR 1 MG TAB CHEW 3 pediatric multivitamin no.33 with sodium fluoride

PAGE 546 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS POLY-VI-FLOR WITH IRON 0.25 MG 3 pediatric multivit #37/sodium fluoride/iron bisglycinate hcl POLY-VI-FLOR WITH IRON 0.5 MG 3 pediatric multivitamin no.33/sodium fluoride/iron carbonyl

polysaccharide iron forte 1

pot citrate-citric acid packet 1

POTABA 500 MG CAPSULE 3 potassium aminobenzoate POTABA 500 MG TABLET 3 potassium aminobenzoate

potassium 25 meq tablet eff 1

potassium acet 100 meq/50 ml 7

potassium acet 2 meq/ml vial 7

potassium acet 4 meq/ml vial 7

potassium acet 40 meq/20 ml vl 7

potassium citrate er 10 meq tb 1

potassium citrate er 15 meq tb 1

potassium citrate er 5 meq tab 1

potassium cl 10 meq/100 ml sol 9

potassium cl 10 meq/50 ml sol 9

potassium cl 10% (20 meq/15 ml 1

potassium cl 10% (40 meq/30 ml 1

potassium cl 2 meq/ml iv sol 7

potassium cl 2 meq/ml vial 7

potassium cl 20 meq packet 1

PAGE 547 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

potassium cl 20 meq-0.45% nacl 9

potassium cl 20 meq/100 ml sol 9

potassium cl 20 meq/50 ml sol 9

potassium cl 20% (40 meq/15 ml 7

potassium cl 25 meq tab eff 1

potassium cl 30 meq/100 ml sol 9

potassium cl 40 meq/100 ml sol 9

potassium cl er 10 meq capsule 1

potassium cl er 10 meq tablet 1

potassium cl er 20 meq tablet 1

potassium cl er 8 meq capsule 1

potassium cl er 8 meq tablet 1

potassium phosp 150 mmol/50 ml 7

potassium phosp 45 mmol/15 ml 7

potassium phosph 15 mmol/5 ml 7

pr natal 400 combo pack 2

pr natal 400 ec combo pack 2

pr natal 430 combo pack 2

pr natal 430 ec combo pack 2

PREFERA OB TABLET 3 prenatal vitamins comb. no.21 with iron & folic acid

PREFERA-OB ONE SOFTGEL 3

PAGE 548 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS prenatal vitamin combination no.19/iron/folic acid/dha PREFERA-OB PLUS DHA COMBO PACK 3 prenatal vitamin combo no.22/iron/folic acid/omega-3/dha PREFLIN 113 MG CAPSULE 3 stevioside/rebaudioside a & b/steviol/steviolbioside/vit d3

prefol-dha capsule 1

PREMASOL 10% IV SOLUTION 9 parenteral amino acid 10% combination no.7 PREMASOL 6% IV SOLUTION 9 parenteral amino acid 6% combination no.1

prena1 chew tablet 1

PRENA1 CHEW TABLET 3 prenatal vitamins combination no.42/folic acid

prena1 plus combo pack 1

prena1 softgel 1

prenaissance 90 dha combo pack 2

prenaissance capsule 3

prenaissance dha combo pack 2

prenaissance dha harmony cmbpk 3

prenaissance harmony dha cmbpk 3

prenaissance next tablet 1

PRENAISSANCE NEXT-B TABLET 3 prenatal vit/folic acid/b6/calcium carb/ginger

prenaissance plus softgel 1

prenaissance promise combo pck 2

prenaplus tablet 2

PRENATA CHEWABLE TABLET 3 prenatal vitamins combo no.37/ferrous fumarate/folic acid PRENATABS FA TABLET 2 prenatal vits with calcium #78/ferrous fumarate/folic acid PRENATABS RX TABLET 1 prenatal vits with calcium #76/iron,carbonyl/folic acid

prenatal 19 chewable tablet 2

PAGE 549 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

prenatal 19 tablet 1

prenatal ad tablet 1

prenatal low iron tablet 2

prenatal mv & min capsule 1

prenatal plus iron tablet 1

prenatal plus multivitamin tab 1

prenatal plus tablet 2

prenatal vitamin with low iron 2

prenatal-u capsule 2

PRENATE AM TABLET prenatal vitamins no.114/methyltetrahydfolate 3 gluc,fa/ginger PRENATE CHEWABLE TABLET prenatal vitamins no.112/methyltetrahydrofolate 3 glucosami,fa PRENATE DHA SOFTGEL prenatal vitamins no.38/iron fumarate/folate comb 3 no.6/dha PRENATE DHA SOFTGEL 3 prenatal vitamins no.78/iron asparto glycin/folate no.1/dha PRENATE ELITE TABLET prenatal vitamins combo #36/ferrous fumarate/folate 3 combo #6 PRENATE ELITE TABLET prenatal vitamins no.79/ferrous aspart glycinate/folate 3 no.1 PRENATE ENHANCE SOFTGEL prenatal vitamin combo no.68/iron fumarate/fa combo 3 no.6/dha PRENATE ESSENTIAL SOFTGEL 3 pnv no.35/iron fumarate/folate comb. #6/dha PRENATE MINI SOFTGEL 3 prenatal vitamins #44/iron,carbonyl/folic acid/dha

PRENATE RESTORE SOFTGEL 3 prenatal vitamins combo no.69/iron fumarate/fa comb

PAGE 550 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS no.6/dha PRENATE STAR TABLET 3 prenatal vitamins no.77/ferrous asparto glycinate/folic acid PRENEXA CAPSULE 3 prenatal vit with calcium no.66/iron fum/folic acid/dss/dha

preplus ca-fe 27 mg-fa 1 mg tb 1

PREQUE 10 TABLET pnv no18/iron,carbonyl/folic acid/docusate 3 na/ubidecar/dha

pretab 29 mg-1 mg tablet 1

PRISMASOL B22GK 2/0 DIALYSIS 9 bicarbonate dialysis solution no.14 without calcium PRISMASOL B22GK 4/0 DIALYSIS 9 bicarbonate dialysis solution no.16 without calcium PRISMASOL B22GK 4/0 DIALYSIS 9 bicarbonate dialysis solution no.16 without calcium PRISMASOL BGK 0/2.5 DIALYSIS 9 bicarbonate dialysis solution no.11 without potassium PRISMASOL BGK 2/0 DIALYSIS 9 bicarbonate dialysis solution no.8 without calcium PRISMASOL BGK 2/0 DIALYSIS 9 bicarbonate dialysis solution no.8 without calcium PRISMASOL BGK 2/3.5 DIALYSIS 9 bicarbonate dialysis solution no.2 PRISMASOL BGK 4/0/1.2 DIALYSIS 9 bicarbonate dialysis solution no.15 without calcium PRISMASOL BGK 4/0/1.2 DIALYSIS 9 bicarbonate dialysis solution no.15 without calcium PRISMASOL BGK 4/2.5 DIALYSIS 9 bicarbonate dialysis soln no.9 PRISMASOL BK 0/0/1.2 DIALYSIS 9 bicarbonate dialysis solution no.13 without ca, k, dextrose PROBARIMIN QT TABLET 3 multivitamins with min no. 17/iron/fa/min aa chelate PROCALAMINE IV SOLUTION 3 amino acids 3 %/electrolyte-tpn soln/glycerin PROFERRIN-FORTE TABLET 3 fe heme polypeptide/folic acid

promar capsule 3

PAGE 551 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS PROSOL 20% INJECTION 3 parenteral amino acid 20 % combination no.1 PROSOURCE TF LIQUID PACKET 3 amino acids/protein hydrolysate/whey protein isolate PROTECT BONE WAFERS 3 multivitamins with min no.23/folic acid PROTECT CARDIO SOFTGEL multivitamins with min no.8/folic 3 acid/ubidecarenone/omega-3 PROTECT IRON TABLET multivitamins with min no.24/iron polysaccharide 3 complex/fa PROTECT NATAL TABLET pnv cmb#82/iron ps cmplx/folic acid/omega 3/dha/epa/fish 3 oil PROTECT PLUS LIQUID 3 amino acids/multivits,th w-fe,other min PROTECT PLUS NR SOFTGEL 3 amino acids/folic acid/multivitamin w-minerals/dietary 2 PROVIDA OB CAPSULE prenatal vits #65/iron fumarate & polysac complex/folic 3 acid PUREFE OB PLUS CAPSULE prenatal vits #4/iron fumarate & polysacc complex/folic 2 acid PUREFE PLUS CAPSULE 2 prenatal vitamins no.4/ferrous fumarate/folic acid

purevit dualfe plus capsule 1

pyridoxine 100 mg/ml vial 7

Q-TABS 1 MG TABLET 3 methyltetrahydrofolate glucosamine QUFLORA PED 0.25 MG CHEW TAB 3 pediatric multivitamin no.63 with sodium fluoride QUFLORA PED 0.5 MG CHEW TAB 3 pediatric multivitamin no.63 with sodium fluoride QUFLORA PED 1 MG CHEW TAB 3 pediatric multivitamin no.63 with sodium fluoride

r-natal ob softgel 1

REAPHIRM CAPSULE 3 prenatal vitamins no.26/iron polysaccharides/fa/dha

PAGE 552 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

relnate dha prenatal softgel 3

rena-vite rx tablet 1

renal caps softgel 1

RENAX CAPLET vitamin e acid succinate/folic acid/vitamin b comp w- 3 c/zn/se

reno caps softgel 1

REQ49+ TABLET 1 multivitamins with min no. 16/folic acid/lutein/lycopene RHEUMATE CAPSULE 3 methyltetrahydrofolate gluc/mecobalamin/herbal no.236

ringer's iv solution 7

ringers irrigation solution 7

saline 0.45% soln-excel con 7

saline 0.9% soln-excel cont 7

se-natal 19 chewable tablet 2

se-natal 19 tablet 2

se-tan dha capsule 2

se-tan plus capsule 1

SELECT-OB + DHA PACK prenatal vitamins combo no.33/iron ps cmplx/folic 3 acid/dha SELECT-OB CHEWABLE CAPLET prenatal vitamin w-o calcium/iron polysaccharide 2 complex/fa SELECT-OB CHEWABLE CAPLET 2 prenatal vitamins no.13/iron polysaccharides/fa cmb no.1

selenium 40 mcg/ml vial 9

SENTRA AM CAPSULE aa comb.no9/acetylcarnitine hcl/dextrose/cocoa/hrb 3 cb127 SENTRA PM CAPSULE aa comb.no9/acetylcarnitine hcl/dextrose/cocoa/hrb 3 cb128

setonet prenatal vitamin 2

PAGE 553 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS SETONET-EC PRENATAL VITAMINS prenatal vitamins comb no.55/iron bg hcl&succ- 2 p2/fa/omega-3 SIDEROL LIQUID 1 iron/folic acid/vitamin b comp w-c/minerals SIDEROL TABLET 1 iron/liver extract/vitamin b comp w-c/minerals

sod fer gluc cplx 62.5 mg/5 ml 7

sodium acetate 100 meq/50 ml 7

sodium acetate 200 meq/100 ml 7

sodium acetate 4 meq/ml vial 7

sodium acetate 40 meq/20 ml vl 7

sodium bicarb 4.2% abbjct 7

sodium bicarb 4.2% vial 7

sodium bicarb 7.5% abboject 7

sodium bicarb 8.4% abboject 7

sodium bicarb 8.4% syringe 7

sodium bicarb 8.4% vial 7

sodium chloride 0.45% soln 7

sodium chloride 0.45% solution 7

sodium chloride 0.9% 100 ml 7

sodium chloride 0.9% 1000 ml 7

sodium chloride 0.9% 50 ml 7

sodium chloride 0.9% 500 ml 7

sodium chloride 0.9% irrig. 7

PAGE 554 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

sodium chloride 0.9% soln 7

sodium chloride 0.9% soln. 7

sodium chloride 0.9% solution 7

sodium chloride 0.9% syringe 7

sodium chloride 0.9% vial 7

sodium chloride 0.9% zr syr 7

sodium chloride 3% iv soln 7

sodium chloride 4 meq/ml vl 7

sodium chloride 5% iv soln 7

sodium cl 2.5 meq/ml vial 7

sodium fluoride 0.25 (0.55) mg 1

sodium fluoride 0.5 mg(1.1 mg) 1

sodium fluoride 0.5 mg/ml drop 1

sodium fluoride 1 mg (2.2 mg) 1

sodium lactate 1/6molar inj 8

sodium lactate 5 meq/ml vial 7

sodium phosphate 3mm/ml vial 7

sski 1 gm/ml solution 3

strong iodine solution 1

STROVITE FORTE CAPLET 3 multivits, iron, minerals combo no #5, folic acid STROVITE ONE CAPLET 1 multivit with min#10/folic acid//vit d3/a lipoic acid/lutein STROVITE PLUS CAPLET 1 multivits, iron, minerals combo no #6, folic acid STROVITE TABLET 3 vitamin b comp and vit c no.6

SUPERVITE EC CAPLET 3

PAGE 555 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS multivitamins with min no.21/folic acid SUPERVITE LIQUID 3 lysine hcl/vitamin b complex/folic acid/zinc SUPPORT-500 CAPSULE 3 b complex with vitamin c SWABFLUSH 0.9% NACL SYRINGE 7 0.9 % sodium chloride SYNAGEX CAPSULE 3 multivit w-min no.26/folic acid/alpha lipoic acid/lutein

syrex sodium chl 0.9% syr 7

TANDEM PLUS CAPSULE 3 iron fumarate-iron polysacchar/folic acid/mv comb18

taron-bc tablet 3

taron-c dha capsule 1

TARON-DUO EC COMB PACK prenatal vitamins comb no.19/iron bg hcl&succ- 2 p2/fa/omega-3

taron-prex prenatal dha cap 2

THAM IV SOLUTION 9 tromethamine THERAMINE CAPSULE 3 choline bitartrate/aa comb10/g-aminobuty acid/hrb cb129 THERAMINE CAPSULE 3 choline bitartrate/aa comb10/g-aminobuty acid/hrb cb129

therapeutic hematinic tab 1

therapeutic vit-mineral cap 1

thiamine 200 mg/2 ml vial 7

tl g-fol os tablet 3

tl gard rx tablet 1

tl icon capsule 1

tl-care dha softgel 3

tl-fluorivite chewable tablet 3

tl-fol 500 caplet 1

PAGE 556 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

tl-hem 150 caplet 1

TL-ICARE SOFTGEL 3 multivitamins with min no.43/lutein/omega-3/dha/epa

tl-select capsule 3

TL-SELECT DHA SOFTGEL 3 prenatal vitamin no.57/iron fum/folic acid/dss/dha TOZAL SOFTGEL 3 multivitamins with min no.22/lutein/omega-3/dha/epa TPN ELECTROLYTES II IV SOLN 7 sodium/potassium/magnesium/calcium/chloride/acetate TPN ELECTROLYTES VIAL 7 sodium/potassium/magnesium/calcium/chloride/acetate TRACE ELEMENTS-4 VIAL zinc sulfate/cupric sulfate/manganese sulf/chromic 9 chloride TRAVASOL 10% SOLN VIAFLEX 9 parenteral amino acid 10% combination no. 6

tri rx tablet 2

tri-tabs dha combo pack 1

TRI-VI-FLOR 0.25 MG DROPS 3 pediatric multivitamins a,c,& d3 no.38 with sodium fluoride TRI-VI-FLOR 0.5 MG DROPS 3 pediatric multivitamins a,c,& d3 no.38 with sodium fluoride

tri-vi-floro 0.25 mg/ml drop 1

tri-vi-floro 0.5 mg/ml drop 1

tri-vit-fluor 0.25 mg/ml drop 1

tri-vit-fluor 0.5 mg/ml drop 1

tri-vit-fluor-iron 0.25 mg/ml 1

tri-zel tablet 1

triadvance tablet 1

TRICARE PRENATAL COMPLEAT PACK prenatal vitamin no.103/iron fum/fa/dha/epa/other omega- 3 3s TRICARE PRENATAL DHA ONE SFTGL pnv no.20/iron fumarate/fa/docusate na/fish oil 3 conc/dha/epa

PAGE 557 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS TRICARE PRENATAL TABLET 2 prenatal vits with calcium#103/ferrous fumarate/folic acid

tricon capsule 1

trigels-f forte softgel 1

trimesis rx tablet 2

trinatal gt tablet 1

trinatal rx 1 tablet 2

trinatal ultra tablet 2

TRINATE TABLET 2 prenatal vits with calcium #73/ferrous fumarate/folic acid

triphrocaps softgel 1

triple-vit w-fluor 0.25 mg/ml 1

triveen-duo dha combo pack 2

triveen-one capsule 3

triveen-prx rnf capsule 1

triveen-ten tablets 3

triveen-u capsule 2

TROPHAMINE 10% IV SOLUTION 9 amino acids 10 % TROPHAMINE 6% IV SOLUTION 9 amino acids 6 %

trust natal dha 2

UDAMIN CAPLET 3 multivitamins with min no.28/folic acid/lycopene UDAMIN SP CAPLET 3 multivitamins with min no.9/folic acid/saw palmetto extract

ultimate ob dha combo pack 3

ultimatecare one capsule 1

ultimatecare one nf capsule 2

UROCIT-K ER 15 MEQ TABLET 3 potassium citrate

PAGE 558 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS UROCIT-K SR 10 MEQ TABLET 3 potassium citrate UROCIT-K SR 5 MEQ TABLET 3 potassium citrate

v-c forte capsule 1

v-natal dha combo pack 3

v-natal tablet 1

VASCAZEN CAPSULE 3 omega-3 fatty acids/dha/epa/other omega-3s/fish oil VASCULERA 630 MG TABLET 3 diosmin complex no.1 VAYACOG CAPSULES 3 phosphatidyl serine/omega-3 fatty acids/dha/epa VAYARIN CAPSULE 3 phosphatidyl serine/omega-3 fatty acids/dha/epa

vemavite-prx 2 capsule 3

vena-bal dha combo pack 1

venatal complete dha combo 3

venatal-fa tablet 1

VENOFER 100 MG/5 ML VIAL 9 iron sucrose complex VENOFER 100 MG/5 ML VIAL 9 iron sucrose complex VENOFER 200 MG/10 ML VIAL 9 iron sucrose complex VENOFER 50 MG/2.5 ML VIAL 9 iron sucrose complex

vic-forte capsule 1

vinacal prenatal tablet 2

vinate az tablet 3

vinate calcium prenatal tablet 2

VINATE CARE CHEWABLE TABLET 2 prenatal vits with calcium#109/ferrous fumarate/folic acid

vinate dha gelcap 3

PAGE 559 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS VINATE DHA RF GELCAP prenatal no.64/iron fum/l-mefolate ca/algal oil/soy lecithin

vinate gt tablet 1

vinate ic capsule 2

vinate ii tablet 2

vinate one tablet 2

vinate pn care tablet 2

vinate ultra tablet 2

vinate-m tablet 2

virt nate tablet 1

virt-advance tablet 1

VIRT-BAL DHA COMBO PACK prenatal vitamin no.94/sodium feredetate-iron 3 poly/fa/omega3 VIRT-BAL DHA PLUS COMBO PACK prenatal vitamin no.94/sodium feredetate-iron 3 poly/fa/omega3

virt-c dha softgel 1

virt-caps (1 mg fa b comp w-c) 3

virt-care one capsule 1

virt-pn dha softgel 3

virt-pn plus softgel 3

virt-pn tablet 3

virt-select capsule 3

virt-vite forte tablet 1

virt-vite gt tablet 1

VIRT-VITE PLUS TABLET 2 folic acid/vitamin b complex with vitamin c no.17

virt-vite tablet 1

virtprex capsule 1

vit d2 1.25 mg (50,000 unit) 1

PAGE 560 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

vit d2 1.25 mg (50,000 unit) 1

VITA-RESPA TABLET 3 cyanocobalamin/folic acid/pyridoxine

vitacirc-b tablet 3

VITAFOL CAPLET 3 ferrous fumarate/calcium/vitamin e/folic acid/multivitamin VITAFOL NANO TABLET prenatal vitamins comb no.75/ferrous fumarate/folate 3 comb #1 VITAFOL ULTRA SOFTGEL prenatal vitamins no.67/iron polysaccharides/fa cmb 3 no.1/dha VITAFOL-OB CAPLET 2 prenatal vitamins comb 10/ferrous fumarate/folic acid VITAFOL-OB+DHA COMBO PACK 3 prenatal vitamins comb 10/ferrous fumarate/folic acid/dha VITAFOL-ONE CAPSULE 3 prenatal vitamins no.26/iron polysaccharides/fa/dha VITAFOL-PLUS CAPSULE prenatal vitamins combo no.43/iron ps cmplx/folic 3 acid/dha VITAFOL-PN CAPLET prenatal vit with calcium cmb 11/ferrous fumarate/folic 2 acid VITAL-D RX TABLET 3 vit b complx no.4/cholecalciferol/ascorbic acid/fa/zinc ox VITAMEDMD ONE RX SOFTGEL prenatal vitamins combo no.25/iron fumarate/fa 3 combo#6/dha VITAMEDMD PLUS RX COMBO PACK prenatal vitamins #39/iron amino acid chelate/fa 3 combo#6/dha VITAMEDMD REDICHEW RX TAB CHEW 3 prenatal vitamins comb no.42/folic acid comb no.6 VITAMEDMD REDICHEW RX TAB CHEW 3 prenatal vitamins combination no.42/folic acid

vitamin k-1 1 mg/0.5 ml ampul 7

vitamin k-1 10 mg/ml ampul 7

PAGE 561 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

vitamins a,c,d & fluoride drop

VITAPEARL SOFTGEL prenatal vit no.71/iron fum-sodium feredetate/folic 3 acid/dha

vitaspire tablet 2

VIVA CT PRENATAL CHEWABLE TAB 3 prenatal vitamins combo no.45/ferrous fumarate/folic acid VIVA DHA PRENATAL SOFTGEL prenatal vitamins no.11/ferrous fumarate/folic 3 acid/omega-3

vol-care rx tablet 1

vol-nate tablet 1

vol-plus tablet 2

vol-tab rx tablet 1

VP CH ULTRA SOFTGEL prenatal vitamins no.34/iron carbonyl & 3 fumarate/fa/dss/dha

vp-era ob plus tablet 3

vp-ggr-b6 tablet 1

vp-gstn capsule 3

vp-heme ob + dha combo pack 1

vp-heme ob tablet 1

vp-heme one softgel 3

VP-PNV-DHA CAPSULE 3 prenatal vitamins combo no.52/ferrous fumarate/fa/dha

vp-zel tablet 1

vynatal-fa tablet 1

zatean-ch capsule 3

zatean-pn dha capsule 3

zatean-pn plus softgel 3

zatean-pn tablet 3

PAGE 562 LAST UPDATED 10/2014 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

zinc chloride 10 mg/10 ml vial 8

zinc sulfate 10 mg/10 ml vial 9

zinc sulfate 220 mg capsule 1

zinc sulfate 25 mg/5 ml vial 9

zingiber tablet 1

ZYTAZE CAPSULE 3 zinc citrate/phytase Uncategorized

Unclassified

CITRANATAL RX TABLET 2 prenatal vitamins no.81/iron carbonyl & gluconate/fa/dss PRENATE ESSENTIAL SOFTGEL 3 prenatal vitamins no.84/iron asparto glycin/folate no.1/dha TL FOLATE TABLET prenatal vitamins comb no.82/ferrous fumarate/folate 3 comb #2

PAGE 563 LAST UPDATED 10/2014 Index of covered drugs ACD226 0 ACD-A227 0.9 % SODIUM ACEBUTOLOL HCL259,263 CHLORIDE522,540,543,553,554,555,556 ACEMANNAN/ALLANTOIN347 ACEON250 8 ACETADOTE460 8-MOP325 ACETAMINOPHEN473 ACETAMINOPHEN WITH CODEINE A PHOSPHATE20,21,34 AA COMB.NO8/ACETYLCARNITINE ACETAMINOPHEN/PHENYLTOLOXAMINE HCL/GRAPE/COCOA/HRB CB126532 CITRATE476,481 AA COMB.NO9/ACETYLCARNITINE ACETAZOLAMIDE94,289 HCL/DEXTROSE/COCOA/HRB CB127553 ACETAZOLAMIDE SODIUM94,289 AA COMB.NO9/ACETYLCARNITINE ACETIC ACID62,380,493 HCL/DEXTROSE/COCOA/HRB CB128553 ACETIC ACID/ALUMINUM ACETATE62,493 ABACAVIR SULFATE188,191 ACETIC ABACAVIR SULFATE/DOLUTEGRAVIR ACID/ANTIPYRINE/BENZOCAINE/POLICOSANOL SODIUM/LAMIVUDINE191 NO.1/AL ACETAT494 ABACAVIR SULFATE/LAMIVUDINE189 ACETIC ACID/HYDROCORTISONE62,66,71,493,494 ABACAVIR ACETIC ACID/OXYQUINOLINE SULFATE65,68 SULFATE/LAMIVUDINE/ZIDOVUDINE189,190 ACETOHYDROXAMIC ACID382 ABATACEPT436 ACETYLCHOLINE CHLORIDE485 ABATACEPT/MALTOSE436,443 ACETYLCYSTEINE460,508 ABCIXIMAB245 ACETYLCYSTEINE/MECOBALAMIN/LEVOMEFOLAT ABELCET132 E CALCIUM521,523,537,539 ABILIFY111,178,208 ACIPHEX373 ABILIFY DISCMELT111,178,208 ACIPHEX SPRINKLE373 ABILIFY MAINTENA112 ACITRETIN325,350,351 ABIRATERONE ACETATE163 ACLARO325 ABLAVAR460 ACLARO PD325 ABOBOTULINUMTOXINA312 ACLIDINIUM BROMIDE501 ABRAXANE154 ACTEMRA442 ABSORICA325 ACTHIB445 ABSTRAL20 ACTHREL460 ACAMPROSATE CALCIUM45 ACTICLATE91 ACANYA325 ACTIGALL364 ACARBOSE216,224 ACTIMMUNE442 ACCOLATE500 ACTIQ11,20,21 ACCUNEB502 ACTIVASE227 ACCUPRIL250 ACTIVE FE520 ACCURETIC273 ACTIVE OB520

PAGE 564 LAST UPDATED 10/2014 ACTIVELLA404 ADRIAMYCIN154 ACTONEL457 ADVAIR DISKUS502 ACTOPLUS MET216 ADVAIR HFA503 ACTOPLUS MET XR216 ADVATE237,238 ACTOS216 ADVATE H238 ACULAR488 ADVATE L238 ACULAR LS488 ADVATE M238 ACUVAIL489 ADVATE SH237 ACYCLOVIR197,198,199,325,358 ADVATE UH237 ACYCLOVIR SODIUM197 ADVICOR297 ACYCLOVIR/HYDROCORTISONE198 AEROSPAN495 ACYCLOVIR/LIDOCAINE HCL198 AFATINIB DIMALEATE162 ACZONE326 AFINITOR163 ADACEL TDAP445 AFINITOR DISPERZ163,164 ADAGEN358 AFLIBERCEPT484 ADALAT CC264 AFLURIA 2012-2013446 ADALIMUMAB435 AFLURIA 2013-2014446 ADAPALENE326,334,335 AFLURIA 2014-2015446 ADAPALENE/BENZOYL PEROXIDE336 AGALSIDASE BETA359 ADASUVE175 AGGRASTAT243 ADCETRIS166 AGGRENOX243 ADCIRCA506 AGRYLIN233,243 ADDAMEL N521 AK-FLUOR461 ADDERALL302,303 AKNE-MYCIN84,326 ADDERALL XR303,304 AKTEN482 ADEFOVIR DIPIVOXIL193,194 AKYNZEO130 ADEMPAS506 ALA-CORT47,326,385 ADENOCARD254 ALA-HIST AC508 ADENOSCAN460 ALA-QUIN326 ADENOSINE254,460,461 ALA-SCALP48,326,385 ADENOVIRUS VAC LIVE TYPE-4 & ADENOVIRUS ALAHIST DHC508 VAC LIVE TYPE-7446 ALANINE521 ADENOVIRUS VACCINE LIVE TYPE-4446 ALBENDAZOLE168 ADENOVIRUS VACCINE LIVE TYPE-7446 ALBENZA168 ADIPEX-P310 ALBIGLUTIDE225 ADO-TRASTUZUMAB EMTANSINE164 ALBUKED-25233 ADOXA91,320 ALBUKED-5233 ADRENACLICK502 ALBUMEN (ALBUMIN)/TANNIC ACID365 ADRENALIN502 ALBUMIN HUMAN233,234,235,236 ADRENALIN CHLORIDE502 ALBUMINAR-25233 ADREVIEW461 ALBUMINAR-5233

PAGE 565 LAST UPDATED 10/2014 ALBURX233 ALMOTRIPTAN MALATE141 ALBUTEIN233 ALOCRIL488 ALBUTEROL SULFATE502,503,505 ALODOX91,320 ALCAFTADINE488 ALOGLIPTIN BENZOATE223 ALCAINE35,482 ALOGLIPTIN BENZOATE/METFORMIN HCL222 ALCLOMETASONE DIPROPIONATE48,326,385 ALOGLIPTIN BENZOATE/PIOGLITAZONE HCL223 ALCOHOL/ISOPROPYL ALCOHOL/PROPYLENE ALOMIDE488 GLYCOL/WATER480 ALOPRIM138 ALCORTIN A326 ALOQUIN326 ALDACTAZIDE273,274 ALORA404,405 ALDACTONE290 ALOSETRON HCL371 ALDARA154,326,442 ALOXI126,130 ALDESLEUKIN159 ALPHA-1-PROTEINASE INHIBITOR508,510,511,513 ALDURAZYME358 ALPHAGAN P490 ALEMTUZUMAB167 ALPHANATE238,461 ALENDRONATE SODIUM457,458 ALPHANINE SD238,239 ALENDRONATE SODIUM/CHOLECALCIFEROL ALPHAQUIN HP326 (VITAMIN D3)458 ALPRAZOLAM199,200,204,205 ALFENTA21 ALPROLIX239 ALFENTANIL HCL21 ALPROSTADIL274,285,380,381,382 ALFERON N154 ALREX489 ALFUZOSIN HCL378,380 ALSUMA141 ALGLUCOSIDASE ALFA359 ALTABAX62 ALIMTA151 ALTACE250,251 ALINIA168 ALTEPLASE227 ALISKIREN HEMIFUMARATE286 ALTOPREV294 ALISKIREN HEMIFUMARATE/AMLODIPINE ALTRETAMINE156 BESYLATE286 ALUMINUM ACETATE326 ALISKIREN ALUMINUM CHLORIDE335,340,357 HEMIFUMARATE/AMLODIPINE/HYDROCHLOROTHI ALUVEA326 AZIDE276 ALVESCO495 ALISKIREN ALVIMOPAN366 HEMIFUMARATE/HYDROCHLOROTHIAZIDE286 AMANTADINE HCL170,193 ALITRETINOIN167,345 AMARYL216,217 ALKERAN146 AMBIEN515,516 ALLEGRA ODT497 AMBIEN CR516 ALLEGRA-D 24 HOUR508 AMBIFED508 ALLFEN CD508 AMBIFED DM508 ALLFEN CDX508 AMBISOME132 ALLOPURINOL138,139 AMBRISENTAN506 ALLOPURINOL SODIUM138 AMCINONIDE48,326,385

PAGE 566 LAST UPDATED 10/2014 AMERGE141 AMINO ACIDS 5 %/CALCIUM/ELECTROLYTE-TPN AMIDATE35 SOLN/DEXTROSE 25 %525 AMIFOSTINE CRYSTALLINE154,156 AMINO ACIDS 5 %/DEXTROSE 15 % IN WATER524 AMIKACIN SULFATE60 AMINO ACIDS 5 %/DEXTROSE 20 % IN WATER524 AMILORIDE HCL291 AMINO ACIDS 5 %/DEXTROSE 25 % IN WATER524 AMILORIDE HCL/HYDROCHLOROTHIAZIDE274 AMINO ACIDS 5.4 %542 AMINO ACID 2.36 % NO.1/D6.8W/FAT AMINO ACIDS 6 %558 EMULSIONS/ELECTROLYTES NO.9545 AMINO ACIDS 6.9 %532 AMINO ACID 3.31 % NO.1/D9.8W/FAT AMINO ACIDS 7 %521 EMULSIONS/ELECTROLYTE NO.10535 AMINO ACIDS 7 %/ELECTROLYTE-TPN SOLN521 AMINO ACIDS 10 %558 AMINO ACIDS 8 %534 AMINO ACIDS 2.75 %/CALCIUM/ELECTROLYTE- AMINO ACIDS 8.5 %/ELECTROLYTE-TPN SOLN521 TPN SOLN/D10W524 AMINO ACIDS/FOLIC ACID/MULTIVITAMIN W- AMINO ACIDS 2.75 %/CALCIUM/ELECTROLYTE- MINERALS/DIETARY 2552 TPN SOLN/D5W525 AMINO ACIDS/MULTIVITS,TH W-FE,OTHER MIN552 AMINO ACIDS 2.75 %/DEXTROSE 5 % IN AMINO ACIDS/PROTEIN HYDROLYSATE/WHEY WATER524 PROTEIN ISOLATE552 AMINO ACIDS 3 %/ELECTROLYTE-TPN SOLN532 AMINOACETIC ACID62 AMINO ACIDS 3 %/ELECTROLYTE-TPN AMINOCAPROIC ACID239 SOLN/GLYCERIN551 AMINOHIPPURATE SODIUM461 AMINO ACIDS 3.5 %/ELECTROLYTE-M AMINOLEVULINIC ACID HCL341 SOLUTION521 AMINOPHYLLINE501 AMINO ACIDS 4.25 % IN DEXTROSE 5 % IN AMINOSALICYLIC ACID145 WATER524 AMINOSYN521 AMINO ACIDS 4.25 %/CALCIUM/ELECTROLYTE- AMINOSYN II521 TPN SOLN/D25W525 AMINOSYN II WITH ELECTROLYTES521 AMINO ACIDS 4.25 %/CALCIUM/ELECTROLYTE- AMINOSYN M521 TPN SOLN/D5W525 AMINOSYN WITH ELECTROLYTES521 AMINO ACIDS 4.25 %/CALCIUM/ELECTROLYTE- AMINOSYN-HBC521 TPN SOLN/DEXTROSE 10%525 AMINOSYN-PF521 AMINO ACIDS 4.25 %/DEXTROSE 10 % IN AMINOSYN-RF521 WATER524 AMIODARONE HCL254,255,257 AMINO ACIDS 4.25 %/DEXTROSE 20 % IN AMIODARONE IN DEXTROSE, ISO- WATER524 OSMOTIC256,257 AMINO ACIDS 4.25 %/DEXTROSE 25 % IN AMITIZA371 WATER524 AMITRIPTYLINE HCL122,123 AMINO ACIDS 5 %/CALCIUM/ELECTROLYTE-TPN AMITRIPTYLINE HCL/CHLORDIAZEPOXIDE201 SOLN/DEXTROSE 15 %525 AMLODIPINE BESYLATE264,265,270,271 AMINO ACIDS 5 %/CALCIUM/ELECTROLYTE-TPN AMLODIPINE BESYLATE/ATORVASTATIN SOLN/DEXTROSE 20 %525 CALCIUM274,275,277,278

PAGE 567 LAST UPDATED 10/2014 AMLODIPINE BESYLATE/BENAZEPRIL ANDRODERM402 HCL275,276,283 ANDROGEL402,403 AMLODIPINE BESYLATE/OLMESARTAN ANDROID403 MEDOXOMIL276,277 ANECTINE310 AMLODIPINE BESYLATE/VALSARTAN276,280 ANGELIQ405 AMLODIPINE ANGIOMAX227 BESYLATE/VALSARTAN/HYDROCHLOROTHIAZIDE ANIDULAFUNGIN133 280,281 ANIMI-3522 AMMONIUM CHLORIDE522 ANIMI-3 WITH VITAMIN D522 AMMONIUM LACTATE326,327,341 ANORO ELLIPTA503 AMMONUL358 ANSAID5,56 AMOBARBITAL SODIUM516 ANTABUSE45 AMOXAPINE123 ANTARA292 AMOXICILLIN80,82 ANTHRALIN335,358 AMOXICILLIN/POTASSIUM CLAVULANATE79,80,81 ANTHRALIN MICRONIZED358 AMPHOTERICIN B LIPID COMPLEX132 ANTHRAX VACCINE446 AMPHOTERICIN B LIPOSOME132 ANTI-INHIBITOR COAGULANT COMPLEX239,240 AMPICILLIN SODIUM80,81 ANTIHEMOPHILIC FACTOR VIII (PLASMA/ALBUMIN- AMPICILLIN SODIUM/SULBACTAM SODIUM81,83 FREE)237,238,243 AMPICILLIN TRIHYDRATE80,81 ANTIHEMOPHILIC FACTOR VIII, HUMAN AMPYRA318 RECOMBINANT240,241,242 AMRIX513,514 ANTIHEMOPHILIC FACTOR, HUMAN240,241 AMTURNIDE276 ANTIHEMOPHILIC FACTOR, HUMAN/VON AMVISC482 WILLEBRAND FACTOR,HUMAN238,240,243,461 AMVISC PLUS482 ANTIPYRINE/BENZOCAINE493,494 AMYTAL SODIUM516 ANTIPYRINE/BENZOCAINE/GLYCERIN/ZINC AMYVID461 ACETATE494 ANACAINE35 ANTITHROMBIN III (HUMAN PLASMA DERIVED)237 ANADROL-50402 ANTITHROMBIN III, HUMAN RECOMBINANT234,462 ANAFRANIL123 ANTIVENIN,CROTALIDAE FAB(OVIN)464 ANAGRELIDE HCL233,243,244 ANTIVENIN,LATRODECTUS MACTANS461 ANAKINRA435 ANTIVENIN,MICRURUS FULVIUS461 ANALPRAM ADVANCED364 ANTIVERT126 ANALPRAM E364 ANUSOL-HC48,385,453 ANALPRAM HC364 ANZEMET130 ANAPROX5,56 APIDRA225 ANAPROX DS5,56 APIDRA SOLOSTAR225 ANASCORP461 APIXABAN228 ANASPAZ361 APLENZIN112 ANASTROZOLE161 APLIGRAF461 ANCOBON132 APLISOL461

PAGE 568 LAST UPDATED 10/2014 APOKYN171 ARSENIC TRIOXIDE160 APOMORPHINE HCL171 ARTEMETHER/LUMEFANTRINE168 APOP325 ARTHROTEC 505 APPTRIM461 ARTHROTEC 755 APPTRIM-D461 ARTICADENT DENTAL35 APRACLONIDINE HCL490,491 ARTICAINE HCL/EPINEPHRINE BITARTRATE35 APREMILAST443 ARTISS462 APREPITANT130 ARZERRA166 APRISO364,452 ASACOL365,452 APTIOM105 ASACOL HD365,453 APTIVUS192 ASCLERA462 AQUA GLYCOLIC HC385 ASCORBIC ACID522 AQUASOL A522 ASENAPINE MALEATE183,210 AQUORAL320 ASMANEX495 ARALAST NP508 ASPARAGINASE156 ARANESP233,234 ASPARAGINASE (ERWINIA CHRYSANTHEMI)156 ARAVA442 ASPIRIN5 ARCALYST442 ASPIRIN/DIPYRIDAMOLE243 ARCAPTA NEOHALER503 ASPIRIN/SALICYLAMIDE/ACETAMINOPHEN/CAFFEI ARESTIN320 NE8 ARFORMOTEROL TARTRATE503 ASTAGRAF XL433 ARGATROBAN227 ASTELIN497 ARGATROBAN IN 0.9 % SODIUM CHLORIDE227 ASTEPRO497 ARGATROBAN IN SODIUM CHLORIDE, ISO- ASTRAMORPH-PF21 OSMOTIC227 ASTRINGYN462 ARGINAID461 ATABEX EC522 ARGINAID EXTRA461 ATACAND247,248 ARGININE HCL476 ATACAND HCT276 ARGININE/ASCORBATE SODIUM/VITAMIN E ATAZANAVIR SULFATE193 ACETATE461 ATELVIA457 ARICEPT109 ATENOLOL259,263,264 ARICEPT ODT109 ATENOLOL/CHLORTHALIDONE276,287 ARIDOL461 ATGAM433 ARIMIDEX161 ATIVAN200 ARIPIPRAZOLE111,112,178,208 ATOMOXETINE HCL310 ARISTOSPAN385 ATOPICLAIR327 ARIXTRA227 ATORVASTATIN CALCIUM294,295 ARMODAFINIL518 ATOVAQUONE168,169 ARMOUR THYROID420 ATOVAQUONE/PROGUANIL HCL168,169 AROMASIN161 ATRACURIUM BESYLATE311 ARRANON151 ATRALIN327

PAGE 569 LAST UPDATED 10/2014 ATRAPRO CP327 AVONEX ADMINISTRATION PACK318,442 ATRAPRO DERMAL SPRAY327 AVONEX PEN318,442 ATRAPRO HYDROGEL327 AXERT141 ATRIPLA191 AXID369 ATROPEN255,361 AXIRON403 ATROPINE SULFATE255,361,482,484 AXITINIB162 ATROPINE SULFATE/PF482 AXONA522 ATROVENT500 AYGESTIN416 ATROVENT HFA501 AZACITIDINE151,154 ATRYN234,462 AZACTAM78 AUBAGIO318 AZACTAM-ISO-OSMOTIC DEXTROSE78 AUGMENTIN81 AZASAN433 AUGMENTIN ES-60081 AZASITE84,482 AUGMENTIN XR81 AZATHIOPRINE433,435 AURANOFIN444 AZELAIC ACID328,337 AURSTAT327 AZELAIC ACID/CERAMIDES (1,3,6-11)337 AUTOLOGOUS CULT. CHONDROCYTES463 AZELASTINE HCL488,497 AUVI-Q503 AZELASTINE HCL/FLUTICASONE PROPIONATE509 AVAGE327 AZELEX328 AVAILNEX522 AZILECT175 AVALIDE276 AZILSARTAN MEDOXOMIL249 AVANAFIL383 AZILSARTAN MEDOXOMIL/CHLORTHALIDONE280 AVANDAMET217 AZITHROMYCIN84,85,86,87,482 AVANDARYL217 AZOPT490 AVANDIA217 AZOR276,277 AVAPRO248 AZTREONAM78 AVAR327 AZTREONAM LYSINE78,509 AVAR LS327 AZTREONAM/DEXTROSE-WATER78 AVAR-E LS327 AZULFIDINE365,443,456 AVASTIN166 AVC90 B AVEED403 B COMPLEX WITH VITAMIN C556 AVELOX87 B-NEXA522 AVELOX ABC PACK87 BACITRACIN62,63,482 AVELOX IV87 BACITRACIN/POLYMYXIN B SULFATE482,486 AVIDOXY DK91 BACLOFEN185,186 AVINZA11 BACMIN522 AVITA328 BACTRIM90 AVITENE462 BACTRIM DS90 AVODART378,432 BACTROBAN63,328 AVONEX318,442,443 BACTROBAN NASAL63,328

PAGE 570 LAST UPDATED 10/2014 BAICALIN/CATECHIN537,538 BENTYL361 BAICALIN/CATECHIN/CITRATED ZINC BENZAC AC328 BISGLYCINATE538 BENZACLIN328 BAL IN OIL462 BENZALKONIUM CHLORIDE328 BAL-CARE DHA ESSENTIAL522 BENZAMYCIN328 BALANCED SALT IRRIG SOLN NO.2482,483 BENZAMYCINPAK328 BALANCED SALT IRRIGATION SOLUTION BENZEFOAM328 COMBINATION NO.1483 BENZEFOAM ULTRA328 BALSALAZIDE DISODIUM453 BENZOCAINE35,494 BALSAM PERU/CASTOR OIL357 BENZOCAINE/TANNIC BANZEL105 ACID/MENTHOL/CETYLPYRIDINIUM CHLORIDE42 BARACLUDE193,194 BENZOCAINE/ZINC CHLORIDE/PINE BARIUM TAR/CETYLPYRIDINIUM CHLORIDE36 SULFATE464,465,466,470,471,475,476,478,480,481 BENZOIC ACID/SALICYLIC ACID328 BARIUM SULFATE/METHYLCELLULOSE466 BENZONATATE508,512,513 BASILIXIMAB438 BENZOYL BCG LIVE154,159 PEROXIDE328,329,330,333,334,345,346,348 BCG VACCINE (TICE STRAIN)154,446 BENZOYL PEROXIDE MICROSPHERES343,349 BCG VACCINE, LIVE/PF446 BENZOYL PEROXIDE/HYDROCORTISONE357 BEBULIN239 BENZOYL PEROXIDE/SULFUR343 BEBULIN VH IMMUNO239 BENZOYL PEROXIDE/VITAMIN E MIXED340 BECAPLERMIN347 BENZPHETAMINE HCL311,312,316 BECLOMETHASONE DIPROPIONATE495,496 BENZTROPINE MESYLATE170 BECONASE AQ495 BENZYL ALCOHOL168,170,355 BEDAQUILINE FUMARATE146 BENZYLPENICILLOYL POLYLYSINE475 BELATACEPT436 BEPOTASTINE BESILATE488 BELEODAQ154 BEPREVE488 BELIMUMAB433 BERACTANT512 BELINOSTAT154 BERINERT234 BELVIQ311 BESIFLOXACIN HCL87,483 BENAZEPRIL HCL251,252 BESIVANCE87,483 BENAZEPRIL BETA-CAROTENE/VIT C/VITE AC/ZNOX/CUPRIC HCL/HYDROCHLOROTHIAZIDE277,282,283 OXIDE/LUT/ZEAXANTHIN539 BENDAMUSTINE HCL149 BETADINE483 BENEFIX239 BETAGAN490 BENICAR248 BETAINE359 BENICAR HCT277 BETAMETHASONE386 BENLYSTA433 BETAMETHASONE ACETATE/BETAMETHASONE BENOXINATE HCL/FLUORESCEIN SODIUM482,484 SODIUM PHOSPHATE385,386 BENOXYLDOXY 3091 BETAMETHASONE DIPROPIONATE48,329,385 BENOXYLDOXY 6091

PAGE 571 LAST UPDATED 10/2014 BETAMETHASONE DIPROPIONATE/PROPYLENE BIMATOPROST341,481,482,492 GLYCOL48,51,329,335,385,389 BINOSTO457 BETAMETHASONE BIONECT329,462 VALERATE48,52,329,342,386,392 BIOTHRAX446 BETAPACE255 BIOTIN/CARBITOL/EQUISETUM BETAPACE AF255 XT/ETHANOL/HYDROXYPROPYL CHITO/MSM338 BETAQUIK462 BISACODYL/SODIUM CHLOR/SODIUM BETASERON318,443 BICARB/POTASSIUM CHL/PEG 3350372 BETAXOLOL HCL259,261,490,491 BISMUTH BETHANECHOL CHLORIDE380,383 SUBSALICYLATE/METRONIDAZOLE/TETRACYCLIN BETHKIS60 E HCL366 BETIMOL490,491 BISOPROLOL FUMARATE259,264 BETOPTIC S491 BISOPROLOL BEVACIZUMAB166 FUMARATE/HYDROCHLOROTHIAZIDE277,288 BEXAROTENE167,352 BIVALIRUDIN227 BEXXAR166 BIVIGAM439 BEYAZ405 BLEOMYCIN SULFATE154 BIAFINE329 BLEPH-1090,483 BIAXIN85,365 BLEPHAMIDE483 BIAXIN XL85 BLEPHAMIDE S.O.P.483 BICALUTAMIDE432 BLOOD-GLUCOSE METER,CONTINUOUS464,477 BICARBONATE DIALYSIS SOLN NO.9551 BLOOD-GLUCOSE METER,CONTINUOUS/BLOOD- BICARBONATE DIALYSIS SOLUTION NO.11 GLUCOSE TRANSMITTER469,477 WITHOUT POTASSIUM551 BLOOD-GLUCOSE SENSOR464,467,477 BICARBONATE DIALYSIS SOLUTION NO.13 BLOOD-GLUCOSE TRANSMITTER464,472,477 WITHOUT CA, K, DEXTROSE551 BLOOD-GLUCOSE TRANSMITTER/BLOOD- BICARBONATE DIALYSIS SOLUTION NO.14 GLUCOSE SENSOR475 WITHOUT CALCIUM551 BLOXIVERZ144 BICARBONATE DIALYSIS SOLUTION NO.15 BOCEPREVIR196 WITHOUT CALCIUM551 BONIVA457 BICARBONATE DIALYSIS SOLUTION NO.16 BONTRIL PDM311 WITHOUT CALCIUM551 BOOSTRIX TDAP446 BICARBONATE DIALYSIS SOLUTION NO.2551 BORAGE OIL/FISH OIL BICARBONATE DIALYSIS SOLUTION NO.8 (ANCHOVY,SARDINE)/FRUCTOSE/SOY WITHOUT CALCIUM551 LECITHIN538 BICILLIN C-R81 BORTEZOMIB166 BICILLIN L-A81 BOSENTAN507 BICNU146 BOSULIF161 BIDIL277 BOSUTINIB161 BIFERA RX522 BOTOX139,185 BILTRICIDE168 BOTOX COSMETIC139,185

PAGE 572 LAST UPDATED 10/2014 BOTULISM ANTITOXIN HEPTAVALENT BUPIVACAINE HCL/PF36,40,43,44 A,B,C,D,E,F,G(EQUINE)/MALTOSE446 BUPIVACAINE LIPOSOME/PF38 BRAVELLE462 BUPRENEX21,46 BRENTUXIMAB VEDOTIN166 BUPRENORPHINE11,12 BREO ELLIPTA495,503 BUPRENORPHINE HCL21,46 BREVIBLOC259 BUPRENORPHINE HCL/NALOXONE HCL46,47 BREVICON405 BUPROPION HBR112 BREVITAL SODIUM35 BUPROPION HCL47,112,115,116 BRILINTA244 BUSPIRONE HCL200 BRIMONIDINE TARTRATE342,490,491 BUSULFAN146,148 BRIMONIDINE TARTRATE/TIMOLOL MALEATE491 BUSULFEX146 BRINTELLIX116 BUTABARBITAL SODIUM200,201 BRINZOLAMIDE490 BUTALBITAL/ACETAMINOPHEN310,311,314,315,316 BRINZOLAMIDE/BRIMONIDINE TARTRATE492 BUTALBITAL/ACETAMINOPHEN/CAFFEINE311,312, BRISDELLE116,205 313,315,316,317 BROMDAY489 BUTALBITAL/ACETAMINOPHEN/CAFFEINE/CODEIN BROMFENAC SODIUM489,490 E PHOSPHATE21,24,311,313 BROMOCRIPTINE BUTALBITAL/ASPIRIN/CAFFEINE311,313 MESYLATE171,172,173,218,428,430 BUTENAFINE HCL135,342 BROMPHENIRAMINE MALEATE/PHENYLEPHRINE BUTISOL SODIUM200,201 HCL/DIHYDROCODEINE BT511 BUTOCONAZOLE NITRATE134,339 BROMPHENIRAMINE BUTORPHANOL TARTRATE21 MALEATE/PSEUDOEPHEDRINE HCL/CODEINE511 BUTRANS11,12 BROMPHENIRAMINE/PSEUDOEPHEDRINE BYDUREON218 HCL/DIHYDROCODEINE510 BYDUREON PEN217 BRONCOMAR-1508 BYETTA218 BROVANA503 BYSTOLIC259,260 BSS483 BSS PLUS483 C BUCALSEP36 C-CLARIFYING SERUM344 BUDESONIDE386,389,453,454,456,495,496,497 C-THERAPY NIGHT CREAM344 BUDESONIDE/FORMOTEROL FUMARATE505 C1 ESTERASE INHIBITOR234 BUMETANIDE289 C1 ESTERASE INHIBITOR, RECOMBINANT476 BUMINATE234 CA CARBONATE/MAG OXIDE/VITAMIN D3/VIT BUNAVAIL46 B12/FA/VIT B6/BORON523,531,556 BUPHENYL358 CA-DTPA462 BUPIVACAINE HCL36,40,43 CABAZITAXEL157 BUPIVACAINE HCL/DEXTROSE-WATER/PF36,40,43 CABERGOLINE428 BUPIVACAINE HCL/EPINEPHRINE36,40,43 CABOZANTINIB S-MALATE164 BUPIVACAINE HCL/EPINEPHRINE BITARTRATE36 CADEXOMER IODINE340 BUPIVACAINE HCL/EPINEPHRINE/PF36,40,43 CADUET277,278

PAGE 573 LAST UPDATED 10/2014 CAFCIT311 CANTIL362 CAFERGOT139 CAPASTAT SULFATE145 CAFFEINE CITRATED311 CAPECITABINE151,154 CAFFEINE/CHOLINE BITARTRATE/AA CAPEX SHAMPOO48,330,386 COMB.NO7/HRB CB125461 CAPHOSOL320 CAFFEINE/CHOLINE BITARTRATE/AA CAPITAL W-CODEINE21 COMB11/HERBAL COMPLEX NO. 130534 CAPRELSA164 CAFFEINE/SODIUM BENZOATE311 CAPREOMYCIN SULFATE145 CALAN255,265 CAPROMAB PENDETIDE475 CALAN SR265 CAPSAICIN/SKIN CLEANSER347 CALCIPOTRIENE330,335,351 CAPTOPRIL251 CALCIPOTRIENE/BETAMETHASONE CAPTOPRIL/HYDROCHLOROTHIAZIDE278 DIPROPIONATE330,352 CARAC330 CALCITONIN,SALMON,SYNTHETIC457,458,459 CARAFATE373 CALCITRIOL330,357,427,457,458,459,460 CARBACHOL491,492 CALCIUM ACETATE384 CARBAGLU358 CALCIUM CARBONATE/MAGNESIUM CARBAMAZEPINE105,106,107,108,212,213,215,216 CARBONATE/FOLIC ACID539 CARBATROL106,212 CALCIUM CHLORIDE523 CARBIDOPA174 CALCIUM COMB CARBIDOPA/LEVODOPA174,175 NO.19/PHOSPHATE/GENISTEIN/D3/CITRATED CARBIDOPA/LEVODOPA/ENTACAPONE170,171 ZINC/K2532 CARBINOXAMINE MALEATE497,498,499 CALCIUM GLUCONATE523 CARBITOL/EQUISETUM CALDOLOR5 EXT/ETHANOL/HYDROXYPROPYL CALFACTANT510 CHITOSAN/MSM338 CAMBIA5 CARBOCAINE36,37 CAMINO PRO 15 PE462 CARBOCYSTEINE522 CAMPATH167 CARBOPLATIN146,147 CAMPRAL45 CARBOPROST TROMETHAMINE402 CAMPTOSAR161 CARBZERO463 CAMRESE LO405 CARDENE I.V.265 CANAGLIFLOZIN221 CARDENE SR265 CANAGLIFLOZIN/METFORMIN HCL220,221 CARDIOLITE463 CANAKINUMAB/PF443 CARDIOPLEGIC SOLUTION NO.1278,285 CANASA365,453 CARDIOTEK-RX523 CANCIDAS132 CARDIOVID PLUS523 CANDESARTAN CILEXETIL247,248,249 CARDIZEM266 CANDESARTAN CARDIZEM CD266 CILEXETIL/HYDROCHLOROTHIAZIDE276,278 CARDIZEM LA266 CANDIDA ALBICANS SKIN TEST462 CARDURA246,378 CANDIN462 CARDURA XL247,378

PAGE 574 LAST UPDATED 10/2014 CARFILZOMIB164 CEFOXITIN SODIUM/DEXTROSE, ISO-OSMOTIC73 CARGLUMIC ACID358 CEFPODOXIME PROXETIL73 CARISOPRODOL514,515 CEFPROZIL73,74 CARISOPRODOL/ASPIRIN514 CEFTAROLINE FOSAMIL ACETATE77 CARMOL HC48,330,386 CEFTAZIDIME PENTAHYDRATE74,76,77 CARMUSTINE146 CEFTAZIDIME PENTAHYDRATE IN DEXTROSE 5%- CARMUSTINE IN POLIFEPROSAN 20147 WATER74 CARNITOR519 CEFTAZIDIME SODIUM/DEXTROSE, ISO- CARNITOR SF519 OSMOTIC76 CARTEOLOL HCL491 CEFTIBUTEN DIHYDRATE71,74 CARTICEL463 CEFTIN74 CARVEDILOL260 CEFTRIAXONE SODIUM74,75,77 CARVEDILOL PHOSPHATE260 CEFTRIAXONE SODIUM/DEXTROSE, ISO- CASODEX432 OSMOTIC74,75 CASPOFUNGIN ACETATE132 CEFUROXIME AXETIL74,75 CATAFLAM5,57 CEFUROXIME SODIUM75,78 CATAPRES245 CEFUROXIME SODIUM/DEXTROSE, ISO- CATAPRES-TTS 1245 OSMOTIC75,78 CATAPRES-TTS 2245 CEFUROXIME SODIUM/WATER FOR CATAPRES-TTS 3245 INJECTION,STERILE78 CATHFLO ACTIVASE227 CELEBREX5,57 CAVERJECT380 CELECOXIB5,57 CAYSTON78,509 CELESTONE386 CEDAX71 CELEXA116 CEENU147 CELLCEPT433 CEFACLOR72 CELLUGEL483 CEFADROXIL72 CELLULOSE,OXIDIZED475 CEFAZOLIN SODIUM72 CELONTIN96 CEFAZOLIN SODIUM/DEXTROSE, ISO-OSMOTIC72 CENESTIN405,406 CEFDINIR72 CENTANY63,330 CEFDITOREN PIVOXIL72,73,77 CENTANY AT63,330 CEFEPIME HCL73,76,77 CENTRUROIDES (SCORPION) POLYVALENT CEFEPIME HCL/DEXTROSE 5 % IN WATER73 ANTIVENOM461 CEFEPIME HCL/DEXTROSE, ISO-OSMOTIC73 CEPHALEXIN75,76 CEFIXIME77 CEPROTIN227 CEFOTAXIME SODIUM73,75,76 CERDELGA358 CEFOTETAN DISODIUM73 CEREBYX106 CEFOTETAN DISODIUM/DEXTROSE, ISO- CEREFOLIN523 OSMOTIC73 CEREFOLIN NAC523 CEFOXITIN SODIUM73 CERETEC463 CEFOXITIN SODIUM/DEXTROSE 5 % IN WATER77 CEREZYME359

PAGE 575 LAST UPDATED 10/2014 CERITINIB166 CHLORPHENIRAMINE MALEATE/CODEINE CERTOLIZUMAB PEGOL433 PHOSPHATE/ACETAMINOPHEN509 CERUBIDINE154 CHLORPHENIRAMINE CERVARIX446 MALEATE/PSEUDOEPHEDRINE HCL/CODEINE513 CERVIDIL380 CHLORPROMAZINE HCL126,175,176,208 CESAMET130 CHLORPROPAMIDE218 CESINEX365 CHLORTHALIDONE291 CETACAINE37 CHLORZOXAZONE514,515 CETACAINE ANESTHETIC37 CHOLESTEROL/SOYBEAN OIL/ASCORBIC CETACAINE MEDICAL KIT E37 ACID/VITAMIN E463 CETIRIZINE HCL497 CHOLESTYRAMINE (WITH SUGAR)297 CETRAXAL493 CHOLESTYRAMINE/ASPARTAME297,298 CETRORELIX ACETATE428 CHOLEXTRA463 CETROTIDE428 CHOLINE BITARTRATE/AA COMB10/G-AMINOBUTY CETUXIMAB167 ACID/HRB CB129556 CEVIMELINE HCL312,320,321 CHOLINE BITARTRATE/AA NO.10/GABA/HERB CHANTIX47 #129/PROTEIN/SOY LECIT478 CHEMET519 CHOLINE BITARTRATE/AMINO ACIDS CHEMO DILUENT,E-LYTES, & DEXTROSE, COMBINATION NO.7/HRB CB125461 BUFFERED NO.1/PF465 CHOLINE SALICYLATE/MAGNESIUM SALICYLATE5 CHENODAL365 CHOLINE/AMINO ACID CHENODIOL365 #21/GABA/INOSITOL/GRIFFONIA/GLUCOSE/CREAT CHIRHOSTIM463 545 CHLORAMBUCIL148 CHOLOGRAFIN MEGLUMINE463 CHLORAMPHENICOL SOD SUCC63,509 CHONDROITIN SULFATE A CHLORCYCLIZINE HCL/CODEINE PHOSPHATE511 SODIUM/HYALURONATE SODIUM483,487 CHLORCYCLIZINE HCL/PSEUDOEPHEDRINE CHORIOGONADOTROPIN ALFA474 HCL/CODEINE PHOSPHATE511 CHORIONIC GONADOTROPIN, HUMAN398,400,401 CHLORDIAZEPOXIDE HCL201 CHROMIC CHLORIDE523 CHLORDIAZEPOXIDE/CLIDINIUM BROMIDE362,363 CIALIS378,380 CHLORHEXIDINE GLUCONATE63,68,320,323 CICLESONIDE495,496,497 CHLOROPROCAINE HCL41 CICLODAN132,330 CHLOROPROCAINE HCL/PF37,42 CICLOPIROX132,135,137,330,331,341,345 CHLOROQUINE PHOSPHATE168 CICLOPIROX & NAIL LACQUER REMOVER, NON- CHLOROTHIAZIDE291 ACETONE133,333 CHLOROTHIAZIDE SODIUM291,292 CICLOPIROX OLAMINE132,330 CHLOROXYLENOL/BENZOCAINE/HYDROCORTISO CICLOPIROX OLAMINE/SKIN CLEANSER NE ACETATE494 COMBINATION NO.28132,330 CHLOROXYLENOL/PRAMOXINE HCL494 CICLOPIROX/NAIL LACQUER REMOVER, NON- CHLORPHENIRAMINE MALEATE/CODEINE ACET/FOOT DEODORANT#4137,345 PHOSPHATE509

PAGE 576 LAST UPDATED 10/2014 CICLOPIROX/UREA/CAMPHOR/MENTHOL/EUCALY CITRIC/CITRONELLYL/HYDROXYPROPYL/METHYL PTOL132,330,331 SALICYLATE342 CICLOPIROX/VITAMIN E MIXED/NAIL LACQUER CLADRIBINE151 REMOVER, NON-ACET132,331 CLAFORAN75,76 CIDOFOVIR187,188 CLARIFOAM EF331 CILOSTAZOL244,245 CLARINEX497 CILOXAN87,483 CLARINEX-D 12 HOUR509 CIMETIDINE369 CLARINEX-D 24 HOUR509 CIMETIDINE HCL369 CLARITHROMYCIN85,365 CIMZIA433 CLEMASTINE FUMARATE497,498 CINACALCET HCL428 CLENIA331 CINRYZE234 CLEOCIN63,331 CIPRO87 CLEOCIN HCL63,168 CIPRO HC493 CLEOCIN PALMITATE63 CIPRO I.V.87,88 CLEOCIN PHOSPHATE63,64 CIPRO XR88 CLEOCIN PHOSPHATE IN D5W63 CIPRODEX493 CLEOCIN T64,331 CIPROFLOXACIN87,88 CLEVIDIPINE BUTYRATE267 CIPROFLOXACIN HCL87,88,483,493 CLEVIPREX267 CIPROFLOXACIN HCL/DEXAMETHASONE493 CLIMARA406 CIPROFLOXACIN HCL/HYDROCORTISONE493 CLIMARA PRO406 CIPROFLOXACIN LACTATE88 CLINDACIN ETZ64,331 CIPROFLOXACIN LACTATE/DEXTROSE 5 % IN CLINDACIN PAC64,331 WATER87,88 CLINDAGEL331,332 CIPROFLOXACIN/CIPROFLOXACIN HCL88 CLINDAMYCIN HCL63,64,168 CISATRACURIUM BESYLATE312,314 CLINDAMYCIN PALMITATE HCL63,64 CISPLATIN147 CLINDAMYCIN PHOSPHATE63,64,65,331,332,337 CITALOPRAM HYDROBROMIDE116,117 CLINDAMYCIN PHOSPHATE/BENZOYL CITANEST PLAIN DENTAL37 PEROXIDE325,328,331,332,335,343 CITRANATAL 90 DHA523,524 CLINDAMYCIN PHOSPHATE/BENZOYL CITRANATAL ASSURE524 PEROXIDE/EMOLLIENT COMB NO.94343 CITRANATAL B-CALM524 CLINDAMYCIN PHOSPHATE/DEXTROSE 5 % IN CITRANATAL DHA524 WATER63,65 CITRANATAL HARMONY524 CLINDAMYCIN PHOSPHATE/SKIN CLEANSER CITRANATAL RX524,563 COMB NO.1964,331 CITRATE DEXTROSE SOLUTION227 CLINDAMYCIN PHOSPHATE/TRETINOIN357,358 CITRATE PHOSPHATE DEXTROS SOLN227 CLINDESSE65,332 CITRIC ACID/GLUCONOLACTONE/MAGNESIUM CLINIMIX524 CARBONATE383 CLINIMIX E524,525 CITRIC ACID/SODIUM CITRATE381,382,383 CLINPRO 5000320 CLIOQUINOL/HYDROCORTISONE326

PAGE 577 LAST UPDATED 10/2014 CLIOQUINOL/HYDROCORTISONE/EMOLLIENT CODEINE COMBINATION NO.88334 PHOSPHATE/CARISOPRODOL/ASPIRIN21 CLOBAZAM100 CODEINE SULFATE21,22 CLOBETASOL COGENTIN170 PROPIONATE48,49,53,55,332,333,344,352,386,387,3 COLAZAL453 94,397 COLCHICINE138 CLOBETASOL PROPIONATE/EMOLLIENT COLCHICINE/PROBENECID138 BASE49,53,55,332,344,352,386,394,397 COLCRYS138 CLOBETASOL PROPIONATE/SKIN CLEANSER COLESEVELAM HCL225,299 COMB NO.28386 COLESTID297 CLOBEX49,332,386 COLESTIPOL HCL297 CLOCORTOLONE PIVALATE49,332,386,387 COLISTIN (AS COLISTIMETHATE SODIUM)65 CLODAN386 COLLAGENASE CLOSTRIDIUM CLODERM49,332,386,387 HISTOLYTICUM349,481 CLOFARABINE151 COLLOIDAL BISMUTH CLOLAR151 SUBCITRATE/METRONIDAZOLE/TETRACYCLINE CLOMIPHENE CITRATE463,477 HCL368 CLOMIPRAMINE HCL123 COLY-MYCIN M PARENTERAL65 CLONAZEPAM201,202 COLY-MYCIN S494 CLONIDINE245 COLYTE WITH FLAVOR PACKETS371 CLONIDINE HCL245,246,306,308 COLYTE WITH FLAVOR PACKS372 CLONIDINE HCL/PF245,246 COMBIGAN491 CLOPIDOGREL BISULFATE244,245 COMBIPATCH406 CLORAZEPATE DIPOTASSIUM201,204 COMBIVENT503 CLOTRIMAZOLE132,133,320 COMBIVENT RESPIMAT503 CLOTRIMAZOLE/BETAMETHASONE COMBIVIR189 DIPROPIONATE333,341 COMETRIQ164 CLOZAPINE184,185 COMFORT PAC-CYCLOBENZAPRINE514 CLOZARIL185 COMFORT PAC-MELOXICAM5,57 CNL 8133,333 COMFORT PAC-NAPROXEN5,57 COAGULATION FACTOR VIIA (RECOMBINANT)241 COMFORT PAC-TIZANIDINE185 COAL TAR333 COMPAZINE126 COARTEM168 COMPLERA189 COBICISTAT191 COMPLETE FORMULATION D3000463 COCAINE HCL37 COMPLETE FORMULATION PEDIATRIC463 CODAR AR509 COMTAN171 CODAR D509 COMVAX446 CODAR GF509 CONCEPT DHA525 CODEINE CONCEPT OB525 PHOSPHATE/BUTALBITAL/ASPIRIN/CAFFEINE310,3 CONCERTA306 11,313 CONDYLOX333

PAGE 578 LAST UPDATED 10/2014 CONIVAPTAN HCL/DEXTROSE 5 % IN WATER520 CRESYL ACETATE494 CONRAY463 CRESYLATE494 CONRAY-30463 CRINONE416 CONRAY-43463 CRIXIVAN192 CONTRAVE ER463 CRIZOTINIB166 CONZIP12 CROFAB464 COPAXONE318,434 CROFELEMER366 COPEGUS194 CROMOLYN SODIUM488,506 COPPER475 CROTAMITON169,336 CORDARONE255 CUBICIN65 CORDRAN49,333,387 CULT SKIN SUBST,HUMAN-BOVINE461,464 COREG260 CULT SKIN SUBST,HUMAN-PORCINE479 COREG CR260 CUPRIC CHLORIDE525 CORGARD260,261 CUPRIC SULFATE526 CORIFACT239 CUPRIMINE380,434,519 CORLOPAM299 CUROSURF509 CORTANE-B387,494 CUTIVATE50,333,387 CORTEF387,453,454 CUVPOSA362 CORTENEMA454 CYANOCOBALAMIN (VITAMIN B-12)473,526,541,545 CORTICORELIN OVINE TRIFLUTATE460 CYANOCOBALAMIN/FOLIC ACID532 CORTICOTROPIN400 CYANOCOBALAMIN/FOLIC CORTIFOAM365 ACID/PYRIDOXINE530,531,532,556,560,561 CORTISONE ACETATE49,387 CYANOCOBALAMIN/LEVOMEFOLATE CORTISPORIN49,333,387,494 CALCIUM/PYRIDOXINE HCL464,531,532,538 CORTISPORIN-TC494 CYANOCOBALAMIN/LEVOMEFOLATE CORTROSYN463 CALCIUM/PYRIDOXINE/RIBOFLAVIN523,537,539 CORVERT256 CYANOCOBALAMIN/MECOBALAMIN543 CORVITE526 CYANOKIT278 CORVITE 150525 CYCLESSA406 CORVITE FE525 CYCLOBENZAPRINE HCL513,514 CORVITE FREE526 CYCLOBENZAPRINE HCL/IRRITANTS COUNTER- CORZIDE278 IRRITANTS COMBO #2514 COSMEGEN155 CYCLOBENZAPRINE WITH COSOPT491 METHYLSULFONYLMETHANE (MSM)515 COSOPT PF491 CYCLOGYL483 COSYNTROPIN463 CYCLOMYDRIL483 COTABFLU509 CYCLOPENTOLATE HCL483 COUMADIN227,228 CYCLOPENTOLATE HCL/PHENYLEPHRINE HCL483 COZAAR249 CYCLOPHOSPHAMIDE147 CREON359 CYCLOSERINE65,69,145,146 CRESTOR295 CYCLOSET218

PAGE 579 LAST UPDATED 10/2014 CYCLOSPORINE434,437,438,486 DAPAGLIFLOZIN PROPANEDIOL218 CYCLOSPORINE, MODIFIED333,338,343,434,436 DAPSONE144,145,326,333 CYKLOKAPRON239 DAPTACEL DTAP446 CYMBALTA117,205,317 DAPTOMYCIN65 CYPROHEPTADINE HCL498 DARAPRIM168 CYRAMZA167 DARBEPOETIN ALFA IN POLYSORBATE 80233,234 CYSTADANE359 DARIFENACIN HYDROBROMIDE376 CYSTAGON381 DARUNAVIR ETHANOLATE192,193 CYSTARAN483 DASATINIB165 CYSTEAMINE BITARTRATE381,382 DATSCAN464 CYSTEAMINE HCL483 DAUNORUBICIN CITRATE LIPOSOMAL155 CYSTEINE HCL537 DAUNORUBICIN HCL154,155 CYSTO-CONRAY II464 DAUNOXOME155 CYSTOGRAFIN464 DAYPRO5,57 CYSTOGRAFIN-DILUTE464 DAYTRANA306 CYSVIEW464 DDAVP398,399 CYTARABINE151 DEBACTEROL320 CYTARABINE LIPOSOME/PF152 DECITABINE151,152 CYTARABINE/PF151 DEFERASIROX519 CYTOGAM446 DEFERIPRONE519 CYTOMEGALOVIRUS IMMUNE GLOBULN446 DEFEROXAMINE MESYLATE464 CYTOMEL420 DEFINITY464 CYTOSE526 DEGARELIX ACETATE429 CYTOTEC373,402 DELATESTRYL403 CYTOVENE187 DELAVIRDINE MESYLATE188 DELESTROGEN407 D DELFLEX WITH 1.5% DEXTROSE526 D.H.E.45139 DELFLEX WITH 2.5% DEXTROSE526 DABIGATRAN ETEXILATE MESYLATE232 DELFLEX WITH 4.25% DEXTROSE526 DABRAFENIB MESYLATE163 DELOS333 DACARBAZINE147 DELZICOL365,453 DACOGEN151 DEMADEX289 DACTINOMYCIN155 DEMECLOCYCLINE HCL91,399 DALBAVANCIN HCL65 DEMEROL22 DALFAMPRIDINE318 DEMSER278 DALIRESP509 DENAVIR197 DALTEPARIN SODIUM,PORCINE228,229 DENILEUKIN DIFTITOX158 DALVANCE65 DENOSUMAB167,459,460 DANAZOL403 DEPACON97 DANTRIUM186 DEPAKENE97,139,212 DANTROLENE SODIUM186,187,515 DEPAKOTE98,139,213

PAGE 580 LAST UPDATED 10/2014 DEPAKOTE ER98,140,213 DESOXIMETASONE50,55,56,334,353,388,397 DEPAKOTE SPRINKLE97,139,213 DESOXYN304 DEPEN381,434,519 DESPEC-PDC509 DEPLIN526 DESVENLAFAXINE117,119 DEPLIN-ALGAL OIL526 DESVENLAFAXINE FUMARATE117 DEPO-ESTRADIOL407 DESVENLAFAXINE SUCCINATE121 DEPO-MEDROL50,387,454 DETROL376 DEPO-PROVERA417 DETROL LA376 DEPO-SUBQ PROVERA 104417 DEXAMETHASONE388,389,393,454,490 DEPO-TESTOSTERONE403 DEXAMETHASONE SOD DEPOCYT152 PHOSPHATE50,51,388,389,489 DEPODUR22 DEXAMETHASONE SODIUM PHOSPHATE/PF50,388 DEPRIZINE369 DEXCHLORPHENIRAMINE MALEATE498 DERMA-SMOOTHE-FS50,334,387,388 DEXCHLORPHENIRAMINE DERMAGRAFT464 MALEATE/PHENYLEPHRINE HCL/CODEINE513 DERMANIC526 DEXEDRINE304,305 DERMASORB AF334 DEXFERRUM526,527 DERMASORB HC388 DEXILANT373 DERMASORB TA388 DEXLANSOPRAZOLE373 DERMASORB XM334 DEXMEDETOMIDINE HCL518 DERMATOP334 DEXMEDETOMIDINE HCL IN 0.9 % SODIUM DERMOTIC388,494 CHLORIDE518 DESFERAL464 DEXMETHYLPHENIDATE HCL306,307 DESFERAL MESYLATE464 DEXPAK389,454 DESFLURANE44 DEXPANTHENOL365 DESIPRAMINE HCL123,124 DEXRAZOXANE155,159,160 DESIRUDIN231 DEXTRANOMER MICROSPHERES/HYALURONATE DESLORATADINE497,498 SODIUM IN 0.9 % NACL477 DESLORATADINE/PSEUDOEPHEDRINE DEXTROAMPHETAMINE SULF- SULFATE509 SACCHARATE/AMPHETAMINE SULF- DESMOPRESSIN ACETATE398,399,401 ASPARTATE302,303,304,305 DESMOPRESSIN ACETATE (NON- DEXTROAMPHETAMINE SULFATE304,305,306 REFRIGERATED)398,399 DEXTROMETHORPHAN HBR/PHENYLEPHRINE DESOGEN407 HCL/CHLORPHENIRAMINE509 DESOGESTREL-ETHINYL DEXTROMETHORPHAN HBR/PROMETHAZINE ESTRADIOL405,406,407,408,413,415,417 HCL512 DESOGESTREL-ETHINYL ESTRADIOL/ETHINYL DEXTROMETHORPHAN HBR/PSEUDOEPHEDRINE ESTRADIOL405,407,410,412,414,415,419 HCL/BROMPHENIRAMINE508 DESONATE50,334,388 DEXTROMETHORPHAN HBR/QUINIDINE DESONIDE50,52,56,334,341,357,388,392,398 SULFATE315 DESOWEN50,334,388

PAGE 581 LAST UPDATED 10/2014 DEXTROSE 10 % AND 0.2 % SODIUM DIASTAT ACUDIAL98 CHLORIDE527 DIATRIZOATE MEGLUMINE464 DEXTROSE 10 % AND 0.45 % SODIUM DIATRIZOATE MEGLUMINE/DIATRIZOATE CHLORIDE527 SODIUM468,471 DEXTROSE 10 % AND 0.9 % SODIUM DIAZEPAM98,201,202,204 CHLORIDE527 DIAZOXIDE225 DEXTROSE 10 % IN WATER527 DIBENZYLINE247 DEXTROSE 2.5 % AND 0.45 % SODIUM DICLEGIS126 CHLORIDE527 DICLOFENAC EPOLAMINE7,58 DEXTROSE 2.5 % IN WATER527 DICLOFENAC POTASSIUM5,6,11,57,60 DEXTROSE 20 % IN WATER527 DICLOFENAC DEXTROSE 25 % IN WATER527 SODIUM6,11,57,60,334,345,350,357,389,396,398,489 DEXTROSE 30 % IN WATER527 DICLOFENAC SODIUM/MISOPROSTOL5,6 DEXTROSE 40 % IN WATER527 DICLOFENAC SUBMICRONIZED11 DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE527 DICLOXACILLIN SODIUM82 DEXTROSE 5 % AND 0.3 % SODIUM CHLORIDE527 DICOPANOL498 DEXTROSE 5 % AND 0.45 % SODIUM DICYCLOMINE HCL361,362 CHLORIDE527 DIDANOSINE189,190 DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE527 DIDREX312 DEXTROSE 5 % IN LACTATED RINGERS527 DIDRONEL458 DEXTROSE 5 % IN WATER527 DIETHYLPROPION HCL312 DEXTROSE 5% IN RINGERS527 DIFENOXIN HCL/ATROPINE SULFATE367 DEXTROSE 50 % IN WATER527,528 DIFFERIN334,335 DEXTROSE 70 % IN WATER528 DIFICID85 DEXTROSE-WATER/SODIUM CITRATE/CITRIC DIFLORASONE DIACETATE51,335,389 ACID226 DIFLUCAN133 DIABETA218 DIFLUNISAL6,57 DIALYVITE528 DIFLUPREDNATE389,489 DIALYVITE 3000528 DIGEX NF362 DIALYVITE 5000528 DIGIBAR464 DIALYVITE 800 WITH IRON528 DIGIFAB278 DIALYVITE SUPREME D528 DIGOXIN278,279,281,282 DIALYVITE ZINC528 DIGOXIN IMMUNE FAB278 DIAMOX SEQUELS289 DIHYDROCODEINE DIANEAL PD-2 W-1.5% DEXTROSE528 BITARTRATE/ACETAMINOPHEN/CAFFEINE20,34 DIANEAL PD-2 W-2.5% DEXTROSE528 DIHYDROCODEINE DIANEAL PD-2 W-4.25% DEXTROSE528 BITARTRATE/ASPIRIN/CAFFEINE21,33 DIANEAL WITH 1.5% DEXTROSE528 DIHYDROCODEINE BITARTRATE/GUAIFENESIN27 DIANEAL WITH 2.5% DEXTROSE528 DIHYDROERGOTAMINE MESYLATE139 DIANEAL WITH 4.25% DEXTROSE528 DILACOR XR267 DIASTAT98 DILANTIN106

PAGE 582 LAST UPDATED 10/2014 DILANTIN-125106 DNA MEDICATED COLLECTION37 DILATRATE-SR300 DOBUTAMINE HCL279 DILAUDID22,23 DOBUTAMINE HCL/DEXTROSE 5 % IN WATER279 DILAUDID-HP23 DOCEFREZ155 DILTIAZEM HCL256,266,267,268,269,270,271,272 DOCETAXEL155,159 DILUENT464 DOFETILIDE258,259 DIMERCAPROL462 DOLASETRON MESYLATE130 DIMETHYL FUMARATE320 DOLGIC PLUS312 DIMETHYL SULFOXIDE383 DOLOPHINE HCL12,23 DINOPROSTONE380,382 DOLUTEGRAVIR SODIUM191 DIOSMIN COMPLEX NO.1559 DONATUSS DC509 DIOVAN249 DONEPEZIL HCL109 DIOVAN HCT279 DONNATAL365,366 DIOXYBENZONE/PADIMATE DOPAMINE HCL279 O/HYDROQUINONE343,344 DOPAMINE HCL/DEXTROSE 5 % IN WATER279,280 DIPENTUM453 DOPRAM509 DIPHENHYDRAMINE HCL126,498 DORAL516 DIPHENOXYLATE HCL/ATROPINE SULFATE365,367 DORIBAX78,79 DIPHTHERIA, PERTUSSIS(ACELL), TETANUS PED DORIPENEM78,79 VACC/PF446,449,451 DORNASE ALFA512 DIPHTHERIA, PERTUSSIS(ACELL),TETANUS,POLIO DORYX91,320 VACCINE/PF449,450 DORZOLAMIDE HCL491,493 DIPHTHERIA,PERTUSS(ACELL),TETANUS,POLIO DORZOLAMIDE HCL/TIMOLOL MALEATE491 VACC/HIB CONJ-TET/PF450 DORZOLAMIDE HCL/TIMOLOL MALEATE/PF491 DIPHTHERIA,PERTUSSIS(ACELL),TETANUS DOTAREM465 VACCINE/PF445 DOVONEX335 DIPHTHERIA,PERTUSSIS(ACELLULAR),TETANUS DOXAPRAM HCL509 VACCINE446 DOXAZOSIN MESYLATE246,247,378 DIPRIVAN37 DOXEPIN HCL124,202,346,358,518,519 DIPROLENE51,335,389 DOXERCALCIFEROL458,459 DIPROLENE AF51,335,389 DOXIL155 DIPYRIDAMOLE244 DOXORUBICIN HCL154,155,156 DISCOVISC483 DOXORUBICIN HCL PEGYLATED DISKETS12,23 LIPOSOMAL155,156,158 DISOPYRAMIDE PHOSPHATE256,257 DOXYCYCLINE CALCIUM94,325 DISULFIRAM45 DOXYCYCLINE DITROPAN XL376 HYCLATE91,92,93,94,320,321,323,325 DIURIL291 DOXYCYCLINE HYCLATE/EYELID CLNS DIVALPROEX SODIUM97,98,139,140,213 NO.3/EYELID EMOLLIENT NO.194,323 DIVIGEL407 DOXYCYCLINE HYCLATE/EYELID CLNS DMSA465 NO2/EYELID CLNS NO391,320

PAGE 583 LAST UPDATED 10/2014 DOXYCYCLINE HYCLATE/SKIN CLEANSER COMB DUREZOL389,489 NO.1993,323 DUTASTERIDE378,432 DOXYCYCLINE DUTASTERIDE/TAMSULOSIN HCL379 MONOHYDRATE91,92,93,94,320,321,322,323,325 DUTOPROL280 DOXYCYCLINE MONOHYDRATE/BENZOYL DYAZIDE280 PEROXIDE91 DYMISTA509 DOXYCYCLINE MONOHYDRATE/SALICYLIC DYNACIN93,321 ACID/OCTINOXATE/ZINC OXIDE91 DYNACIRC CR269 DOXYLAMINE SUCCINATE498 DYPHYLLINE501 DOXYLAMINE SUCCINATE/PYRIDOXINE HCL126 DYRENIUM291 DRAXIMAGE DTPA465 DYSPORT312 DRAXIMAGE MAA465 DRAXIMAGE MDP-25465 E DRISDOL528 E-Z DISK465 DRITHOCREME HP335 E-Z-CAT465 DRONABINOL130,131,312,313 E-Z-DOSE465 DRONEDARONE HCL256 E-Z-HD465 DROPERIDOL126 E-Z-PAQUE465 DROSPIRENONE/ESTRADIOL405 E-Z-PASTE465 DROSPIRENONE/ETHINYL E.E.S. 20085 ESTRADIOL/LEVOMEFOLATE CALCIUM405,415 E.E.S. 40085 DROXIA152 EC-NAPROSYN6,9,57,59 DROXIDOPA284 ECALLANTIDE470 DRYSOL335 ECHOTHIOPHATE IODIDE492 DUAC335 ECONAZOLE NITRATE133,335 DUAVEE407 ECOZA133 DUET DHA528,529 ECULIZUMAB237 DUET DHA 400528 EDARBI249 DUET DHA BALANCED529 EDARBYCLOR280 DUET DHA EC528,529 EDECRIN289 DUETACT218 EDEX381 DUEXIS6 EDLUAR516 DULAGLUTIDE225 EDROPHONIUM CHLORIDE/ATROPINE DULERA504 SULFATE144 DULOXETINE HCL117,205,317 EDURANT188 DUODOTE465 EFAVIRENZ188 DUONEB504 EFAVIRENZ/EMTRICITABINE/TENOFOVIR DUOVISC483 DISOPROXIL FUMARATE191 DURACLON246 EFFER-K529 DURAGESIC12,23 EFFEXOR XR117,205 DURAMORPH23 EFFIENT244

PAGE 584 LAST UPDATED 10/2014 EFINACONAZOLE134 ELITEK359 EFLORNITHINE HCL356 ELIXOPHYLLIN501 EFUDEX335 ELLA417 EGRIFTA399 ELLENCE156 ELAPRASE359 ELLIOTTS B465 ELDEPRYL175 ELMIRON381 ELDERCAPS529 ELOCON335,336,389 ELDOPAQUE FORTE335 ELOCTATE466 ELECTROLYTE-148 SOLUTION545 ELOSULFASE ALFA360 ELECTROLYTE-48 SOLUTION/DEXTROSE 5 % IN ELOXATIN147 WATER527 ELSPAR156 ELECTROLYTE-56 SOLUTION/DEXTROSE 5 % IN ELTROMBOPAG OLAMINE237 WATER546 ELVITEGRAVIR/COBICISTAT/EMTRICITABINE/TEN ELECTROLYTE-A SOLUTION546 OFOVIR191 ELECTROLYTE-B SOLUTION/DEXTROSE 5 % IN EMADINE488 WATER535 EMCYT150 ELECTROLYTE-H SOLUTION/DEXTROSE 5 % IN EMEDASTINE DIFUMARATE488 WATER535 EMEND130 ELECTROLYTE-M SOLUTION/DEXTROSE 5 % IN EMLA37,336 WATER535,543 EMOL#53/NA MG ELECTROLYTE-MB SOLUTION/DEXTROSE 5 % IN FLUOROSILICATE/CYCLOMETH/PHOSPH WATER535 AC/NAHCO3/NACL327 ELECTROLYTE-P SOLUTION/DEXTROSE 5 % IN EMOL53/E.WATER/NAMGFS/NAPHOS/NACL/HYPO WATER535 CHLOROUS ACID/NAHYPOCL327,339,342 ELECTROLYTE-R (PH 7.4)544 EMOLLIENT COMBINATION NO. 25335 ELECTROLYTE-R SOLUTION543 EMOLLIENT COMBINATION NO.10328,329,347,350 ELECTROLYTE-R SOLUTION/DEXTROSE 5 % IN EMOLLIENT COMBINATION NO.32336 WATER544 EMOLLIENT COMBINATION NO.35342,347 ELECTROLYTE-S (PH 7.4)535 EMOLLIENT COMBINATION NO.38343 ELECTROLYTE-S SOLUTION535 EMOLLIENT COMBINATION NO.43346,353 ELECTROLYZED WATER/SOD CHLOR/SOD EMOLLIENT COMBINATION NO.43/SKIN CLEANSER HYPOCHLORITE/HYPOCHLORUS AC327 COMBINATION #27346 ELELYSO359 EMOLLIENT COMBINATION NO.44339,340 ELESTAT488 EMOLLIENT COMBINATION NO.47343 ELESTRIN407 EMOLLIENT COMBINATION NO.47/EMOLLIENT ELETONE335 COMBINATION NO.60327 ELETRIPTAN HBR142 EMOLLIENT COMBINATION NO.48355 ELIDEL335,434 EMOLLIENT COMBINATION NO.53339,340,343 ELIGARD428,429 EMOLLIENT COMBINATION NO.57355 ELIGLUSTAT TARTRATE358 EMOLLIENT COMBINATION NO.60327 ELIQUIS228 EMOLLIENT COMBINATION NO.80346

PAGE 585 LAST UPDATED 10/2014 EMOLLIENT COMBINATION NO.85341 EPINEPHRINE502,503,504 EMPAGLIFLOZIN221 EPINEPHRINE HCL502 EMSAM116 EPINEPHRINE/PF504 EMTRICITABINE189 EPIPEN 2-PAK504 EMTRICITABINE/RILPIVIRINE HCL/TENOFOVIR EPIPEN JR 2-PAK504 DISOPROXIL FUMARATE189 EPIQUIN MICRO336 EMTRICITABINE/TENOFOVIR DISOPROXIL EPIRUBICIN HCL156 FUMARATE190 EPISIL321 EMTRIVA189 EPIVIR189 ENABLEX376 EPIVIR HBV194 ENALAPRIL MALEATE251,254 EPLERENONE291 ENALAPRIL EPOETIN ALFA235,236,237 MALEATE/HYDROCHLOROTHIAZIDE280,288 EPOGEN235 ENALAPRILAT DIHYDRATE251 EPOPROSTENOL SODIUM (ARGININE)507 ENBREL434 EPOPROSTENOL SODIUM (GLYCINE)506 ENDO-AVITENE466 EPROSARTAN MESYLATE249,250 ENDOMETRIN417 EPROSARTAN ENFLURANE37 MESYLATE/HYDROCHLOROTHIAZIDE287 ENFUVIRTIDE191 EPTIFIBATIDE244 ENGERIX-B ADULT447 EPZICOM189 ENGERIX-B PEDIATRIC-ADOLESCENT446,447 EQUETRO106,213 ENJUVIA407,408 ERAXIS (WATER DILUENT)133 ENLON-PLUS144 ERBITUX167 ENLYTE529 ERGOCALCIFEROL (VITAMIN D2)528,529,560 ENOXAPARIN SODIUM228,231,232 ERGOLOID MESYLATES108 ENTACAPONE171 ERGOMAR139 ENTECAVIR193,194 ERGOTAMINE TARTRATE139 ENTERAGAM529 ERGOTAMINE TARTRATE/CAFFEINE139 ENTEREG366 ERIBULIN MESYLATE156 ENTERO VU466 ERIVEDGE164 ENTOCORT EC389,454 ERLOTINIB HCL165 ENTYVIO434 ERTACZO133,336 ENZALUTAMIDE432 ERTAPENEM SODIUM79 EOVIST466 ERWINAZE156 EPANED251 ERY-TAB85 EPHEDRINE SULFATE509 ERYPED 20085 EPICERAM336 ERYPED 40085 EPIDUO336 ERYTHROCIN LACTOBIONATE85,86 EPIFIX AMNIOTIC MEMBRANE336 ERYTHROCIN STEARATE86 EPIFOAM390 ERYTHROMYCIN BASE84,85,86,326,484 EPINASTINE HCL488

PAGE 586 LAST UPDATED 10/2014 ERYTHROMYCIN BASE/BENZOYL ESTROGENS, PEROXIDE328,336 CONJUGATED/MEDROXYPROGESTERONE ERYTHROMYCIN BASE/ETHYL ALCOHOL85,86,336 ACETATE414,415 ERYTHROMYCIN ETHYLSUCCINATE85,86 ESTROGENS,CONJ.,SYNTHETIC A405,406 ERYTHROMYCIN ESTROGENS,CONJ.,SYNTHETIC B407,408 ETHYLSUCCINATE/SULFISOXAZOLE ACETYL65 ESTROGENS,ESTERIFIED411,412 ERYTHROMYCIN LACTOBIONATE85,86 ESTROGENS,ESTERIFIED/METHYLTESTOSTERON ERYTHROMYCIN STEARATE86 E406,407,409 ESCAVITE530 ESTROPIPATE409,413 ESCAVITE D466 ESTROSTEP FE409 ESCAVITE LQ529 ESZOPICLONE516 ESCITALOPRAM OXALATE118,119,205,206 ETANERCEPT434 ESGIC312 ETHACRYNATE SODIUM290 ESGIC-PLUS312 ETHACRYNIC ACID289 ESLICARBAZEPINE ACETATE105 ETHAMBUTOL HCL145 ESMOLOL HCL259,261 ETHAMOLIN466 ESMOLOL HCL IN SODIUM CHLORIDE, ISO- ETHANOLAMINE OLEATE466 OSMOTIC259 ETHINYL ESOMEPRAZOLE MAGNESIUM374 ESTRADIOL/DROSPIRENONE407,410,411,413,415,4 ESOMEPRAZOLE SODIUM374 16 ESOMEPRAZOLE STRONTIUM373,374 ETHIODIZED OIL470 ESOPHO-CAT466 ETHIONAMIDE146 ESTAZOLAM516 ETHOSUXIMIDE96,97 ESTRACE408 ETHOTOIN107 ESTRADIOL404,405,406,407,408,409,412,415,416 ETHRANE37 ESTRADIOL ACETATE409,410 ETHYL ALCOHOL461,466 ESTRADIOL CYPIONATE407 ETHYL CHLORIDE38 ESTRADIOL VALERATE407,408,409 ETHYNODIOL DIACETATE-ETHINYL ESTRADIOL VALERATE/DIENOGEST412 ESTRADIOL410,416 ESTRADIOL/LEVONORGESTREL406 ETHYOL156 ESTRADIOL/NORETHINDRONE ETIDRONATE DISODIUM458 ACETATE404,406,409,412 ETODOLAC6,7,57 ESTRADIOL/NORGESTIMATE414 ETOMIDATE35,38 ESTRAMUSTINE PHOSPHATE SODIUM150 ETONOGESTREL417,418 ESTRASORB409 ETONOGESTREL/ETHINYL ESTRADIOL413 ESTRING409 ETOPOPHOS161 ESTROGEL409 ETOPOSIDE161,162,163 ESTROGENS, CONJUGATED414 ETOPOSIDE PHOSPHATE161 ESTROGENS, CONJUGATED/BAZEDOXIFENE ETRAVIRINE188 ACETATE407 EURAX169,336 EVAMIST409

PAGE 587 LAST UPDATED 10/2014 EVEROLIMUS163,164,439 FACTOR XIII239 EVISTA419,458 FACTOR XIII A-SUBUNIT, RECOMBINANT243 EVOCLIN65,337 FAMCICLOVIR197,198 EVOXAC312,321 FAMOTIDINE369,370 EVZIO45 FAMOTIDINE IN SODIUM CHLORIDE, ISO- EXACTACAIN38 OSMOTIC/PF370 EXALGO12 FAMOTIDINE/PF370 EXELDERM133 FAMVIR198 EXELON109,110 FANAPT178,179 EXEMESTANE161 FANATREX98 EXENATIDE218 FARESTON150 EXENATIDE MICROSPHERES217,218 FARXIGA218 EXFORGE280 FASLODEX150 EXFORGE HCT280,281 FAT EMULSIONS534,538 EXJADE519 FAZACLO185 EXPAREL38 FE HEME POLYPEPTIDE/FOLIC ACID551 EXTAVIA319,443 FEBUXOSTAT138 EXTINA133,337 FEIBA NF239,240 EXTRACELLULAR MATRIX (ECM), PORCINE FEIBA VH IMMUNO240 DERIVED471 FELBAMATE101 EXTRACELLULAR MATRIX (ECM),PORCINE FELBATOL101 DERIVED,FENESTRATED471 FELDENE7,57 EXTRANEAL ICODEXTRIN DIALYSIS530 FELODIPINE269 EYLEA484 FEM PH65 EZ USE JOINT-TUNNEL-TRIGGER390 FEMARA161 EZETIMIBE299 FEMCON FE409 EZETIMIBE/ATORVASTATIN CALCIUM298 FEMHRT409 EZETIMIBE/SIMVASTATIN299 FEMRING409,410 EZOGABINE96 FEMTRACE410 FENOFIBRATE292,293,294 F FENOFIBRATE NANOCRYSTALLIZED292,293,294 FABIOR337 FENOFIBRATE,MICRONIZED292,293,294 FABRAZYME359 FENOFIBRIC ACID293 FACTIVE88 FENOFIBRIC ACID (CHOLINE)293,294 FACTOR IX238,239,241 FENOGLIDE293 FACTOR IX COMPLEX HUMAN239,241,242 FENOLDOPAM MESYLATE299 FACTOR IX HUMAN RECOMBINANT239,242 FENOPROFEN CALCIUM7,9,58 FACTOR IX RECOMBINANT, FC FUSION FENTANYL12,13,19,23,24,33 PROTEIN239 FENTANYL CITRATE11,13,14,15,17,20,21,24,27,30 FACTOR VIII RECOMBINANT, FC FUSION FENTANYL CITRATE/PF13,19,33 PROTEIN466 FENTORA13,14,24

PAGE 588 LAST UPDATED 10/2014 FERAHEME530 FEXOFENADINE HCL/PSEUDOEPHEDRINE FERIDEX I.V.466 HCL508,510 FERIVA530 FIBRICOR293 FERIVAFA530 FIBRINOGEN242 FEROTRINSIC530 FIBRINOGEN/THROMBIN (HUMAN PLASMA FERRALET 90530 DERIVED)478 FERRIC AMMONIUM CITRATE/LYSINE/VITAMIN B FIDAXOMICIN85 COMPLEX/FOLIC ACID533 FILGRASTIM236 FERRIC CARBOXYMALTOSE534 FINACEA337 FERRIC CITRATE384 FINACEA PLUS337 FERRIC SUBSULFATE462,472 FINASTERIDE379,432 FERRIPROX519 FINGOLIMOD HCL319,443 FERRLECIT466,530 FIORICET WITH CODEINE24,313 FERROUS FUMARATE/ASCORBIC ACID/B12- FIORINAL313 IF/FOLIC ACID530,556,558 FIORINAL WITH CODEINE #3313 FERROUS FUMARATE/ASCORBIC FIRAZYR443 ACID/CYANOCOBALAMIN/FOLIC ACID530,533,558 FIRMAGON429 FERROUS FUMARATE/ASCORBIC FIRST-BXN321 ACID/CYANOCOBALAMIN/STOMACH CONC533 FIRST-DUKE'S321 FERROUS FUMARATE/CALCIUM/VITAMIN E/FOLIC FIRST-HYDROCORTISONE390 ACID/MULTIVITAMIN561 FIRST-LANSOPRAZOLE374 FERROUS FUMARATE/DOCUSATE/FOLIC FIRST-MARY'S321 ACID/VITAMIN B COMP W-C542 FIRST-MOUTHWASH BLM321 FERROUS FUMARATE/FOLIC ACID533,534 FIRST-OMEPRAZOLE374 FERROUS FUMARATE/FOLIC FIRST-PROGESTERONE VGS 100417 ACID/MULTIVITAMINS WITH MIN NO. 15523,533 FIRST-PROGESTERONE VGS 200417 FERROUS FUMARATE/FOLIC ACID/VITAMIN B FIRST-PROGESTERONE VGS 25417 COMP W-C528 FIRST-PROGESTERONE VGS 400417 FERROUS FUMARATE/IRON BISGLY/FOLIC FIRST-PROGESTERONE VGS 50417 ACID/VIT C/VIT E/VIT B12543 FIRST-TESTOSTERONE403 FERROUS SULFATE/ASCORBIC ACID/FOLIC FIRST-TESTOSTERONE MC403 ACID556 FISH OIL/OMEGA-3 FATTY ACIDS/DL-VIT E/FOLIC FERROUS SULFATE/SODIUM FLUORIDE/VIT A ACID/B6-B12523 PALM/VIT C/VITAMIN D3541 FLAGYL65,66 FERUMOXIDES466 FLAGYL ER66 FERUMOXSIL468 FLAREX390,489 FERUMOXYTOL530 FLAVOXATE HCL377 FESOTERODINE FUMARATE377 FLAXSEED323 FETZIMA118 FLEBOGAMMA DIF439 FEXMID514 FLECAINIDE ACETATE256,258 FEXOFENADINE HCL497,498 FLECTOR7,58

PAGE 589 LAST UPDATED 10/2014 FLEXBUMIN235 FLUOCINOLONE ACETONIDE/SKIN CLEANSER FLEXERIL514 COMB NO.2855,352,397 FLO-PRED51 FLUOCINOLONE FLOLAN506 ACETONIDE/TRETINOIN/HYDROQUINONE354 FLOMAX379 FLUOCINONIDE51,56,337,357,390,391,398 FLONASE390,495 FLUOCINONIDE/EMOLLIENT BASE51,337,391 FLORBETAPIR F 18461 FLUOR-A-DAY322,530 FLOVENT DISKUS390,495,496 FLUOR-I-STRIP AT467 FLOVENT HFA390,496 FLUORABON530 FLOXURIDINE152 FLUORESCEIN SODIUM461,467 FLUARIX 2012-2013447 FLUORESCITE467 FLUARIX 2013-2014447 FLUORIDE/IRON/VITAMINS A,C,AND D557 FLUARIX QUAD 2013-2014447 FLUORITAB531 FLUBLOK 2012-2013447 FLUOROMETHOLONE391,489 FLUBLOK 2013-2014447 FLUOROMETHOLONE ACETATE390,489 FLUCAINE484 FLUOROPLEX337 FLUCELVAX447 FLUOROURACIL151,152,330,335,337 FLUCONAZOLE133,134 FLUOXETINE HCL118,121 FLUCONAZOLE IN DEXTROSE, ISO-OSMOTIC134 FLUOXYMESTERONE403 FLUCONAZOLE IN SODIUM CHLORIDE, ISO- FLUPHENAZINE HCL176 OSMOTIC134 FLURA-DROPS531 FLUCYTOSINE132,134 FLURANDRENOLIDE49,333,387 FLUDARA152 FLURAZEPAM HCL516 FLUDARABINE PHOSPHATE152 FLURBIPROFEN5,7,56,58 FLUDEOXYGLUCOSE F 18467 FLURBIPROFEN SODIUM489,490 FLUDROCORTISONE ACETATE51,390 FLURESS484 FLULAVAL 2012-2013447 FLUTAMIDE156,432 FLULAVAL 2013-2014447 FLUTICASONE FUROATE398,497 FLULAVAL QUAD 2013-2014447 FLUTICASONE FUROATE/VILANTEROL FLUMADINE193 TRIFENATATE495,503 FLUMAZENIL467,476 FLUTICASONE FLUMIST447 PROPIONATE50,51,52,333,337,387,390,391,495,496 FLUNISOLIDE495,496 FLUTICASONE PROPIONATE/SALMETEROL FLUOCINOLONE XINAFOATE502,503 ACETONIDE48,50,51,55,330,334,337,352,386,387,39 FLUVASTATIN SODIUM295 0,396,397,490 FLUVIRIN 2012-2013447 FLUOCINOLONE ACETONIDE OIL388,390,494 FLUVIRIN 2013-2014447,448 FLUOCINOLONE ACETONIDE/EMOLLIENT FLUVOXAMINE MALEATE118,119 COMBINATION NO.6555,352,396,397 FLUZONE 2012-2013448 FLUOCINOLONE ACETONIDE/SHOWER FLUZONE 2013-2014448 CAP50,51,334,337,388,390 FLUZONE HIGH-DOSE 2012-13448

PAGE 590 LAST UPDATED 10/2014 FLUZONE HIGH-DOSE 2013-2014448 FORADIL504 FLUZONE INTRADERMAL 2012-2013448 FORANE38 FLUZONE INTRADERMAL 2013-2014448 FORFIVO XL112 FLUZONE PEDI 2012-2013448 FORMA-RAY338 FLUZONE PEDI 2013-2014448 FORMADON338 FLUZONE QUAD 2013-2014448 FORMALDEHYDE338 FLUZONE QUAD PEDI 2013-2014448 FORMOTEROL FUMARATE504,505 FML391,489 FORTAMET218 FML FORTE391,489 FORTAVIT532 FML S.O.P.391,489 FORTAZ76 FOCALIN307 FORTAZ IN ISO-OSMOTIC DEXTROSE76 FOCALIN XR307 FORTEO458 FOLATE #5/IRON/C/CALCIUM- FORTESTA403 THREONATE/PHOSPHAT-DHA/B CMP NO.14529 FORTICAL458 FOLET ONE531 FOSAMAX458 FOLGARD OS531 FOSAMAX PLUS D458 FOLGARD RX531 FOSAMPRENAVIR CALCIUM192 FOLIC ACID531 FOSAPREPITANT DIMEGLUMINE130 FOLIC ACID/ARGININE FOSCARNET SODIUM187,198 HCL/CYANOCOBALAMIN/PYRIDOXINE/PEPPER FOSCAVIR187,198 EXT523 FOSFOMYCIN TROMETHAMINE67 FOLIC ACID/MULTIVITAMINS,THER W- FOSINOPRIL SODIUM251,252 MINERALS/LYCOPENE/LUTEIN525,526 FOSINOPRIL FOLIC ACID/MULTIVITS W-FE,OTHER MIN544 SODIUM/HYDROCHLOROTHIAZIDE281 FOLIC ACID/NIACINAMIDE/CUPRIC OXIDE/ZINC FOSPHENYTOIN SODIUM106 OXIDE543 FOSRENOL384 FOLIC ACID/VITAMIN B COMP W-C522,528,531 FOSTEUM532 FOLIC ACID/VITAMIN B COMP W-C/COPPER/ZINC FOSTEUM PLUS532 OXIDE531 FOVEX532 FOLIC ACID/VITAMIN B COMP W-C/SELENIUM/MIN FRAGMIN228,229 AA CHEL/ZINC528 FREAMINE HBC532 FOLIC ACID/VITAMIN B COMPLEX WITH VITAMIN C FREAMINE III532 NO.17560 FREAMINE III WITH ELECTROLYTES532 FOLLISTIM AQ467 FROVA141 FOLLITROPIN ALFA, RECOMB468,469 FROVATRIPTAN SUCCINATE141 FOLLITROPIN BETA,RECOMB467 FUL-GLO467 FOLOTYN152 FULVESTRANT150 FOLTRATE532 FULYZAQ366 FOLTX532 FURADANTIN66 FOMEPIZOLE281 FUROSEMIDE289,290 FONDAPARINUX SODIUM227,228 FUSILEV156

PAGE 591 LAST UPDATED 10/2014 FUSION PLUS532 GAZYVA167 FUZEON191 GELATIN484 FYCOMPA94,95 GELATIN SPONGE,ABSORBABLE468 GELCLAIR322 G GELFILM484 GABADONE532 GELFOAM468 GABAPENTIN98,99,100,313,314 GELFOAM COMPRESSED468 GABAPENTIN ENACARBIL99,313 GELNIQUE377 GABITRIL99 GELX322 GABLOFEN186 GEMCITABINE HCL152,153 GADAVIST467,468 GEMFIBROZIL293,294 GADOBENATE DIMEGLUMINE472 GEMIFLOXACIN MESYLATE88 GADOBUTROL467,468 GEMZAR153 GADODIAMIDE474 GENADUR338 GADODIAMIDE IN 0.9 % SODIUM CHLORIDE474 GENERESS FE410 GADOFOSVESET TRISODIUM460 GENISTEIN/CITRATED ZINC GADOPENTETATE DIMEGLUMINE471 BISGLYCINATE/VITAMIN D3532,562 GADOTERATE MEGLUMINE465 GENOTROPIN399,400 GADOTERIDOL475 GENTAMICIN SULFATE60,61,338,484 GADOVERSETAMIDE474 GENTAMICIN SULFATE IN SODIUM CHLORIDE, GADOXETATE DISODIUM466 ISO-OSMOTIC61 GALANTAMINE HBR110 GENTAMICIN SULFATE/PF61 GALSULFASE359 GENTAMICIN SULFATE/PREDNISOLONE GALZIN532,533 ACETATE486 GAMASTAN S-D439 GENTIAN VIOLET/BRILLIANT GAMMAGARD LIQUID439 GREEN/PROFLAVINE355 GAMMAGARD S-D439,440 GEODON179,208,209 GAMMAKED440 GESTICARE DHA533 GAMUNEX440 GIAZO453 GAMUNEX-C440 GILENYA319,443 GANCICLOVIR188,488 GILOTRIF162 GANCICLOVIR SODIUM187 GLASSIA510 GANIRELIX ACETATE429 GLATIRAMER ACETATE318,434 GARAMYCIN60,484 GLEEVEC164 GARDASIL448,449 GLIADEL147 GASTROCROM506 GLIMEPIRIDE216,217,218 GASTROGRAFIN468 GLIPIZIDE218,219 GASTROMARK468 GLIPIZIDE/METFORMIN HCL219 GATIFLOXACIN88,90,488 GLUCAGEN225 GATTEX366 GLUCAGON EMERGENCY KIT225 GAUZE BANDAGE464 GLUCAGON,HUMAN RECOMBINANT225

PAGE 592 LAST UPDATED 10/2014 GLUCARPIDASE160 GRAFIX CORE338,469 GLUCOPHAGE219 GRAFIX PRIME338,469 GLUCOPHAGE XR219 GRALISE99,313 GLUCOSAMINE SULFATE/CHONDROITIN SULFATE GRANISETRON131 A/ANTIOXID MULTVIT#5476 GRANISETRON HCL130 GLUCOSAMINE SULFATE/CHONDROITIN GRANISETRON HCL/PF130 SULFATE/DIETARY SUPP COMB.25479 GRANIX235 GLUCOTROL219 GRANULEX339 GLUCOTROL XL219 GRASS POLLEN-ORCHARD/SWEET GLUCOVANCE219 VERNAL/RYE/KENTUCKY/TIMOTHY, STD.511 GLUMETZA219 GRASS POLLEN-TIMOTHY, STD510 GLUTAMINE533,544 GRASTEK510 GLUTARADE GA-1533 GRIFULVIN V134 GLUTARALDEHYDE66 GRIS-PEG134 GLUTASOLVE533 GRISEOFULVIN ULTRAMICROSIZE134 GLYBURIDE218,220 GRISEOFULVIN, MICROSIZE134 GLYBURIDE,MICRONIZED220 GUAIFENESIN/CODEINE PHOSPHATE508,509,510 GLYBURIDE/METFORMIN HCL219,220 GUAIFENESIN/DEXTROMETHORPHAN GLYCATE362 HBR/PSEUDOEPHEDRINE HCL508,513 GLYCERIN/CARBOMER HOMOPOLYMER TYPE GUAIFENESIN/PHENYLEPHRINE HCL510 A/POTASSIUM HYDROXIDE323 GUAIFENESIN/PSEUDOEPHEDRINE HCL508 GLYCEROL PHENYLBUTYRATE360 GUAIFENESIN/THEOPHYLLINE GLYCINE UROLOGIC SOLUTION62,66 ANHYDROUS/PSEUDOEPHEDRINE508 GLYCINE/SODIUM/WATER FOR GUANFACINE HCL246,307,308 INJECTION,STERILE/SODIUM HYDROXIDE464 GUANIDINE HCL144 GLYCOPHOS533 GYNAZOLE-1134,339 GLYCOPYRROLATE256,257,258,362,363,364,510,51 2 H GLYNASE220 H.P. ACTHAR400 GLYSET220 HAEMOPHILUS B CONJUGATE VACCINE GLYTACTIN 10 PE BETTERMILK533 (MENINGOCOCCAL PROT.CONJ)/PF450 GLYTACTIN 15 PE BETTERMILK533 HAEMOPHILUS B CONJUGATE VACCINE(TETANUS GLYTACTIN RTD 10 PE533 TOXOID CONJUGATE)/PF445,450 GLYTACTIN RTD 15 PE533 HALAVEN156 GOLIMUMAB438 HALCINONIDE52,339,391 GOLYTELY372 HALCION516 GONAL-F468 HALDOL176 GONAL-F RFF468 HALDOL DECANOATE 100176 GONAL-F RFF REDI-JECT468,469 HALDOL DECANOATE 50176 GORDO-UREA338 HALFLYTELY-BISACODYL372 GOSERELIN ACETATE432 HALOBETASOL PROPIONATE52,56,339,355,391,398

PAGE 593 LAST UPDATED 10/2014 HALOBETASOL PROPIONATE/AMMONIUM HEPATITIS A VIRUS VACCINE/PF449,452 LACTATE391,398 HEPATITIS B IMMUNE GLOBULIN449,450 HALOBETASOL PROPIONATE/LACTIC ACID398 HEPATITIS B IMMUNE GLOBULIN/MALTOSE449 HALOG52,339,391 HEPATITIS B VIRUS VACCINE HALOPERIDOL176 RECOMBINANT/PF446,447,451 HALOPERIDOL DECANOATE176,177 HEPATITIS B VIRUS VACCINE/HAEMOPH B HALOPERIDOL LACTATE176,177 POLYSAC CONJ-MENING/PF446 HARVONI194 HEPSERA194 HAVRIX449 HERCEPTIN164 HC ACETATE/PRAMOXINE HCL/DIOSMIN#1/ALOE HESPAN235 POLYSACCH#1/POLICOS364 HETASTARCH IN 0.9 % SODIUM CHLORIDE235 HECTOROL458,459 HETASTARCH/ELECTROLYTE HELIDAC366 SOLUTION,LACTATED235 HELIXATE FS240 HETLIOZ518 HEMABATE402 HEXACHLOROPHENE345 HEMANGEOL261 HEXALEN156 HEMATOGEN533 HEXAMINOLEVULINATE HCL464 HEMATRON533 HEXTEND LACTATED ELECTROLYTE235 HEMATRON-AF533 HIPREX66 HEMIN475 HISTRELIN ACETATE431,432 HEMOCYTE PLUS533 HIZENTRA440 HEMOCYTE-F534 HOMATROPINE HBR484,485 HEMOFIL M240 HONEY342 HEP B HORIZANT99,313 VIRUS,RCMB/DIPTH,PERTUS(ACELL),TET,POLIO HUMALOG226 VACCINE/PF450 HUMALOG MIX 50-50226 HEPAGAM B449 HUMALOG MIX 75-25226 HEPARIN SODIUM,PORCINE229,230,231 HUMAN PAPILLOMAVIRUS VACCINE, HEPARIN SODIUM,PORCINE IN 0.45 % SODIUM BIVALENT/PF446 CHLORIDE231 HUMAN PAPILLOMAVIRUS VACCINE, HEPARIN SODIUM,PORCINE IN 0.9 % SODIUM QUADRIVALENT/PF448,449 CHLORIDE229 HUMAN PROTHROMBIN COMPLEX HEPARIN SODIUM,PORCINE IN 0.9 % SODIUM CONCENTRATE (PCC)240,470 CHLORIDE/PF231 HUMAN REGENERATIVE TISSUE HEPARIN SODIUM,PORCINE/DEXTROSE 5 % IN MATRIX336,338,469 WATER231 HUMATE-P240 HEPARIN SODIUM,PORCINE/PF229,230,231 HUMATROPE400 HEPATAMINE534 HUMIRA435 HEPATASOL534 HUMULIN R226 HEPATITIS A VIRUS & HEPATITIS B VIRUS HYALGAN469 VACCINE/PF451

PAGE 594 LAST UPDATED 10/2014 HYALURONATE HYDROCORTISONE ACETATE/LIDOCAINE SODIUM329,462,466,469,474,477,482,486 HCL366,367 HYALURONATE SODIUM, STABILIZED472 HYDROCORTISONE ACETATE/LIDOCAINE HYALURONATE SODIUM/ALLANTOIN/ALOE VERA HCL/ALOE VERA366,367 EXTRACT347 HYDROCORTISONE ACETATE/PRAMOXINE HYALURONATE HCL364,366,367,368,390,392,394,395 SODIUM/HYDROXYETHYLCELLULOSE/POLYETHY HYDROCORTISONE ACETATE/PRAMOXINE LENE GLYCOL339 HCL/ALOE POLYSACCHARIDE394 HYALURONATE SODIUM/VITE AC/EMOL HYDROCORTISONE ACETATE/PRAMOXINE CMB12/ALLANTOIN/SHEA TREE357 HCL/EMOLLIENT BASE395 HYALURONIDASE, HUMAN RECOMB.469 HYDROCORTISONE ACETATE/PRAMOXINE HYALURONIDASE,OVINE481 HCL/SKIN CLEANSER NO.16369 HYCAMTIN162 HYDROCORTISONE HYCET24 ACETATE/PRAMOXINE/EMOLLIENT/PRAMOXINE HYDRALAZINE HCL299,300 COMB#1364,366 HYDREA153 HYDROCORTISONE ACETATE/UREA48,330,386,398 HYDRO 35339 HYDROCORTISONE BUTYRATE52,339,391,392 HYDRO 40339 HYDROCORTISONE BUTYRATE/EMOLLIENT HYDROCHLOROTHIAZIDE291,292 BASE52,339,391,392 HYDROCODONE BIT/ACETAMINOPHEN25 HYDROCORTISONE PROBUTATE394 HYDROCODONE BITARTRATE20 HYDROCORTISONE SOD HYDROCODONE SUCCINATE385,396,453,456 BITARTRATE/ACETAMINOPHEN21,24,25,27,30,33,3 HYDROCORTISONE SODIUM 4,35 SUCCINATE/PF396,456 HYDROCODONE HYDROCORTISONE VALERATE392,398 BITARTRATE/CHLORPHENIRAMINE HYDROCORTISONE/EMOLLIENT COMBINATION MALEATE34,500 NO.4554,345,394 HYDROCODONE BITARTRATE/HOMATROPINE HYDROCORTISONE/IODOQUINOL334,339 METHYLBROMIDE510,513 HYDROCORTISONE/MINERAL HYDROCODONE OIL/PETROLATUM,WHITE391 POLISTIREX/CHLORPHENIRAMINE HYDROCORTISONE/PRAMOXINE POLISTIREX510,513 HCL/CHLOROXYLENOL387,493,494 HYDROCODONE/IBUPROFEN25,26,32,34,35 HYDROCORTISONE/PRAMOXINE HYDROCORTISONE47,48,52,54,55,326,339,349,353, HCL/CHLOROXYLENOL/WATER494 385,387,390,391,392,395,396,397,453,454,455,456 HYDROCORTISONE/SALICYLIC HYDROCORTISONE ACETATE364,365,366,368 ACID/SULFUR/SHAMPOO CMB 1396 HYDROCORTISONE ACETATE/ALOE VERA392,394 HYDROCORTISONE/SKIN CLEANSER HYDROCORTISONE ACETATE/IODOQUINOL/ALOE COMBINATION NO.25385 POLYSACCHARIDES #2326 HYDROCORTISONE/SKIN CLEANSER HYDROCORTISONE ACETATE/IODOQUINOL/ALOE COMBINATION NO.35388 VERA357 HYDROGEN PEROXIDE339

PAGE 595 LAST UPDATED 10/2014 HYDROMORPHONE HCL12,14,22,23,26 IBUDONE26 HYDROMORPHONE HCL/PF22,23,26 IBUPROFEN5,7 HYDROQUINONE335,339,341,342,344,353 IBUPROFEN LYSINE/PF284 HYDROQUINONE MICROSPHERES336,339 IBUPROFEN/FAMOTIDINE6 HYDROQUINONE/ASCORBIC ACID344 IBUPROFEN/OXYCODONE HCL10,32,59 HYDROQUINONE/ASCORBIC ACID/VITAMIN E IBUTILIDE FUMARATE256 ACETATE344 IC GREEN469 HYDROQUINONE/AVOBENZONE/OCTINOXATE325 ICAR-C PLUS534 HYDROQUINONE/FERRIC OXIDE335,342 ICATIBANT ACETATE443 HYDROXOCOBALAMIN278,534 ICLUSIG164 HYDROXYAMPHETAMINE HBR/TROPICAMIDE486 ICOSAPENT ETHYL299 HYDROXYCHLOROQUINE SULFATE169 IDAMYCIN PFS157 HYDROXYETHYL STARCH 130/0.4 IN 0.9 % IDARUBICIN HCL157 SODIUM CHLORIDE237 IDELALISIB166 HYDROXYPROGESTERONE CAPROATE411 IDURSULFASE359 HYDROXYPROPYL CELLULOSE485 IFEX147,148 HYDROXYUREA152,153 IFOSFAMIDE147,148 HYDROXYZINE HCL127,202,498 IFOSFAMIDE/MESNA148 HYDROXYZINE PAMOATE127,130,202,204,498,499 ILARIS443 HYLAN G-F 20478 ILEVRO489 HYLASE339 ILOPERIDONE178,179 HYLATOPIC340 ILOPROST TROMETHAMINE507,508 HYLATOPIC PLUS340 ILOTYCIN86,484 HYLENEX469 IMATINIB MESYLATE164 HYOSCYAMINE SULFATE361,362,363,364 IMBRUVICA162 HYOSCYAMINE SULFATE/PHENYLTOLOXAMINE IMDUR300 CITRATE362 IMIGLUCERASE359 HYPER-SAL510 IMIPENEM/CILASTATIN SODIUM79 HYPERHEP B S-D449 IMIPRAMINE HCL124,125 HYPERLYTE CR534 IMIPRAMINE PAMOATE124,125 HYPERRAB S-D440 IMIQUIMOD154,157,161,326,340,358,442,443,445 HYPERRHO S-D441 IMITREX141,142 HYPERTENSA534 IMMUNE GLOBULIN,BOVINE/PLASMA PROTEIN HYPERTET S-D441 FRACTION, BOVINE529 HYPROMELLOSE483,484,486 IMMUNE GLOBULIN,GAMMA (IGG) HYQVIA441 HUMAN/MALTOSE441 HYZAAR281 IMMUNE GLOBULIN,GAMMA CAPRYLATE (IGG)440 IMMUNE GLOBULIN,GAMMA(IGG)439,440,441 I IMMUNE GLOBULIN,GAMMA(IGG) IBANDRONATE SODIUM457,459 HUMAN/HYALURONIDASE, HUMAN RECOMB441 IBRUTINIB162 IMOGAM RABIES-HT441

PAGE 596 LAST UPDATED 10/2014 IMOVAX RABIES VACCINE449 INFLUENZA VIRUS VACCINE QVAL LIVE 2013-2014 IMPLANON417 (2 YRS-49 YRS)447 IMURAN435 INFLUENZA VIRUS VACCINE TRI-SPLIT 2013-14 (6 INCIVEK194 MOS AND OLDER)448 INCOBOTULINUMTOXINA187 INFLUENZA VIRUS VACCINE TRIVALENT 2014-2015 INCRELEX400 (5 YR & OLDER)446 INDACATEROL MALEATE503 INFLUENZA VIRUS VACCINE TRIVALENT-SPLIT INDAPAMIDE292 2012-2013 (65YR+)/PF448 INDERAL LA261 INFLUENZA VIRUS VACCINE TRIVALNT 2014-2015 INDERAL XL261 (5 YR & OLDER)/PF446 INDICLOR469 INFLUENZA VIRUS VACCINE TV 2012-2013 (18 TO INDIGO CARMINE469 49 YRS)RECOMB/PF447 INDIGOTINDISULFONATE SODIUM469 INFLUENZA VIRUS VACCINE TV 2013-2014 (18 TO INDINAVIR SULFATE192 49 YRS)RECOMB/PF447 INDIUM IN-111 DTPA469 INFLUENZA VIRUS VACCINE TV LIVE 2012-2013 (2 INDIUM IN-111 OXYQUINOLINE469 YRS-49 YRS)447 INDIUM-111 CHLORIDE469 INFLUENZA VIRUS VACCINE TV SPLIT 2012-2013 INDIUM-111 CHLORIDE/PENTETREOTIDE473 (18 YR & OLDER)447 INDOCIN7,58 INFLUENZA VIRUS VACCINE TV SPLIT 2012-2013 (3 INDOCIN I.V.7 YR & OLDER)/PF447 INDOCYANINE GREEN469 INFLUENZA VIRUS VACCINE TV SPLIT 2012-2013 (4 INDOMETHACIN7,8,58 YR & OLDER)447,450 INDOMETHACIN SODIUM7 INFLUENZA VIRUS VACCINE TV SPLIT 2012-2013 (4 INFANATE BALANCE534 YR & OLDER)/PF447,451 INFANRIX DTAP449 INFLUENZA VIRUS VACCINE TV SPLIT 2012-2013 (5 INFASURF510 YR & OLDER)446 INFED534 INFLUENZA VIRUS VACCINE TV SPLIT 2012-2013 (5 INFERGEN194 YR & OLDER)/PF446 INFLIXIMAB437 INFLUENZA VIRUS VACCINE TV SPLIT 2012-2013 (6 INFLUENZA VACCINE TRI-SPLT 2012-13(18 YR MOS AND OLDER)448 +)CELL DERIVED/PF447 INFLUENZA VIRUS VACCINE TV SPLIT 2013-2014 (4 INFLUENZA VACCINE TV SPLIT 2013-14 (18 YR+) YR & OLDER)448 CELL DERIVED/PF447 INFLUENZA VIRUS VACCINE TV SPLIT 2013-2014 (4 INFLUENZA VIRUS VACCINE 2012-2013 (6 MOS-35 YR & OLDER)/PF447,451 MOS)/PF448 INFLUENZA VIRUS VACCINE TV SPLIT 2013-2014 (5 INFLUENZA VIRUS VACCINE QUAD VS 2013-2014 YR & OLDER)446 (36 MOS & OLDER)447 INFLUENZA VIRUS VACCINE TV SPLIT 2013-2014 (5 INFLUENZA VIRUS VACCINE QUAD VS 2013-2014 YR & OLDER)/PF446 (6 MOS-35 MOS)/PF448 INFLUENZA VIRUS VACCINE TVS 2012-2013 (18 INFLUENZA VIRUS VACCINE QUAD VS 2013- YRS-64 YRS)/PF448 2014(36 MOS & OLDER)/PF447,448,451

PAGE 597 LAST UPDATED 10/2014 INFLUENZA VIRUS VACCINE TVS 2012-2013 (36 INTERFERON ALFACON-1194 MOS AND OLDER)/PF448 INTERFERON BETA-1A318,442,443 INFLUENZA VIRUS VACCINE TVS 2013-2014 (18 INTERFERON BETA-1A/ALBUMIN YRS-64 YRS)/PF448 HUMAN318,319,442,444 INFLUENZA VIRUS VACCINE TVS 2013-2014 (36 INTERFERON BETA-1B318,319,443 MOS AND OLDER)447 INTERFERON GAMMA-1B,RECOMB.442 INFLUENZA VIRUS VACCINE TVS 2013-2014 (36 INTERMEZZO516 MOS AND OLDER)/PF447,448 INTRALIPID534 INFLUENZA VIRUS VACCINE TVS 2013-2014 (6 INTRON A157,194 MOS-35 MOS)/PF448 INTUNIV307,308 INFLUENZA VIRUS VACCINE TVS 2013-2014 (65 INVANZ79 YR+)/PF448 INVEGA179 INFUMORPH26,27 INVEGA SUSTENNA179,180 INFUVITE534 INVIRASE192 INFUVITE ADULT534 INVOKAMET220,221 INGENOL MEBUTATE346 INVOKANA221 INJECTAFER534 IOBENGUANE SULFATE I-123461 INLYTA162 IODINE/POTASSIUM IODIDE341 INNOPRAN XL261 IODIPAMIDE MEGLUMINE463 INOVA340 IODIPAMIDE MEGLUMINE/DIATRIZOATE INOVA 4-1340 MEGLUMINE477 INOVA 8-2340 IODIXANOL480,481 INSPRA291 IODOFLEX340 INSULIN ADMIN. SUPPLIES469,473 IODOPEN535 INSULIN ASPART226 IODOQUINOL169 INSULIN ASPART PROTAMINE HUMAN/INSULIN IODOQUINOL/ALOE POLYSACCHARIDES #1326 ASPART226 IODOSORB340 INSULIN DETEMIR226 IOFLUPANE I 123464 INSULIN GLARGINE, HUMAN RECOMBINANT IOHEXOL473,474 ANALOG226 IONOSOL B WITH DEXTROSE 5%535 INSULIN GLULISINE225 IONOSOL MB-DEXTROSE 5%535 INSULIN LISPRO226 IOPAMIDOL469,470 INSULIN LISPRO PROTAMINE & INSULIN IOPIDINE491 LISPRO226 IOPROMIDE480 INSULIN REGULAR, HUMAN226 IOTHALAMATE MEGLUMINE463,464 INTEGRA F534 IOVERSOL474 INTEGRA PLUS534 IOXILAN475 INTEGRILIN244 IPECAC366 INTELENCE188 IPILIMUMAB167 INTERFERON ALFA-2B,RECOMB.157,194 IPOL449 INTERFERON ALFA-N3154 IPRATROPIUM BROMIDE500,501

PAGE 598 LAST UPDATED 10/2014 IPRATROPIUM BROMIDE/ALBUTEROL IRON POLYSACCHARIDE COMPLEX/FOLIC SULFATE503,504 ACID/ASCORBIC ACID544 IPRIVASK231 IRON PS COMPLEX/IRON HEME IRBESARTAN248,249 POLYPEPTIDE/FOLIC ACID/VIT B12522,533 IRBESARTAN/HYDROCHLOROTHIAZIDE276,281 IRON SUCROSE COMPLEX559 IRINOTECAN HCL161,162 IRON, CARBONYL & GLUCONATE/FA/VIT B12/VIT IRON ASP GLY&PS CMPLX/ASCORB.CAL/VIT C/DOCUSATE SODIUM530,542 B12/FA/CA-THR/SUCC.ACID530,535 IRON,CARBONYL/ASCORBIC IRON ASP GLY/ASCORB.CAL/VIT B12/FA/CA- ACID/CYANOCOBALAMIN/FOLIC ACID530,534 THREONTE/SUCCINIC ACID540 IRON,CARBONYL/DOCUSATE SODIUM/B12- IRON ASP.GLYCIN & FUMARATE /VIT C/FA/MV IF/FA/MULTIVITS-MIN533,556 COMB 11/CA-THREONATE530 IRON,CARBONYL/FERROUS ASPARTO IRON ASPGLY/ASCORB.CAL/VIT B12/CALCIUM GLYCINATE/FA/MV, MIN CMB#27525 THR/SUCC.ACID/STOMACH472,540 IRON,CARBONYL/FERROUS ASPARTO IRON BISGL & PS CMPLX/FOLIC ACID/VIT GLYCINATE/FA/MV, MIN CMB#38535 B&C#12/SUCCINIC ACID535 IRON,CARBONYL/FOLIC ACID/MULTIVITAMIN W- IRON BISGLY&CARBONYL/FA#6/VIT MINERALS520,529,544 C/B12/BIOTIN/CUPRIC/DOCUSATE530 IRON,CARBONYL/FOLIC ACID/VIT C/PYRIDOXINE IRON BISGLY&CARBONYL/FOLIC ACID/VIT HCL/VIT B12/ZINC525 C/CYANOCOBALAMIN/BIOTIN530 IRON,CARBONYL/FOLIC ACID/VITAMIN IRON CARB & B12/VITAMIN C/DOCUSATE NA530 BISGLY/METHYLFOLATE/B12/ASCORBAT/BIOTIN/ZI IRON,CARBONYL/METHYLTETRAHYDROFOLATE NC/DSS539 GLUC,FA/MV, MIN NO.40525 IRON DEXTRAN COMPLEX526,527,534 IRON,CARBONYL/METHYLTETRAHYDROFOLATE IRON FUMARATE & POLYSAC COMP/FA/VIT B GLUC,FA/MV, MIN NO.41525 COMP & C #18/L. CASEI532 IRON/FOLIC ACID/VITAMIN B COMP W- IRON FUMARATE & POLYSAC COMP/FOLIC C/MINERALS530,533,554 ACID/VIT B COMP & C NO.9532,534 IRON/LIVER EXTRACT/VITAMIN B COMP W- IRON FUMARATE & POLYSAC COMP/FOLIC C/MINERALS554 ACID/VITAMIN C/NIACIN531,534 IROSPAN535 IRON FUMARATE-IRON POLYSACCHAR/FOLIC ISENTRESS191 ACID/MV COMB18552,553,556 ISOCARBOXAZID116 IRON FUMARTE &ASP GLY/ASCORB.CAL/VIT ISOFLURANE38,44 B12/FA/CA-THR/SUCC.ACID472,540 ISOLYTE H WITH DEXTROSE535 IRON ISOLYTE M WITH DEXTROSE535 GLYCIN.SUL&FUMURAT/C/B12/METHYLTETRAHYD ISOLYTE P WITH DEXTROSE535 ROFOLATE CALCIUM539 ISOLYTE S535 IRON POLYSACCHARIDE ISOMETHEPTENE COMPLEX/CYANOCOBALAMIN/FOLIC MUCATE/CAFFEINE/ACETAMINOPHEN313,315 ACID530,534,541,546,547

PAGE 599 LAST UPDATED 10/2014 ISOMETHEPTENE JANUMET XR221 MUCATE/DICHLORALPHENAZONE/ACETAMINOPH JANUVIA221 EN313,314 JAPANESE ENCEPHALITIS VACCINE/PF449 ISONIAZID145 JARDIANCE221 ISOPROTERENOL HCL281 JENTADUETO221 ISOPTO ATROPINE484 JETREA485 ISOPTO CARBACHOL491 JEVTANA157 ISOPTO CARPINE491 JUBLIA134 ISOPTO HOMATROPINE485 JUVISYNC221,222 ISOPTO HYOSCINE485 JUXTAPID297,298 ISORDIL300 ISORDIL TITRADOSE300 K ISOSORBIDE DINITRATE300 K-PHOS NEUTRAL381 ISOSORBIDE DINITRATE/HYDRALAZINE HCL277 K-PHOS NO.2381 ISOSORBIDE MONONITRATE300,301 K-PHOS ORIGINAL381 ISOSULFAN BLUE469,470 K-TAB ER535 ISOTRETINOIN325,327,331,342,343,357,358 KABIVEN535 ISOVUE-200469 KADCYLA164 ISOVUE-250469,470 KADIAN14,15 ISOVUE-300470 KALBITOR470 ISOVUE-370469,470 KALETRA192 ISOVUE-M 200470 KALYDECO510 ISOVUE-M 300470 KAOCHLOR-EFF535 ISOXSUPRINE HCL281 KAPVAY308 ISRADIPINE269 KARBINAL ER498 ISTALOL491 KAYEXALATE519,520 ISTODAX164 KAZANO222 ISUPREL281 KCENTRA240,470 ITRACONAZOLE134,136,137 KEDBUMIN235 IVACAFTOR510 KEFLEX76 IVERMECTIN168,170 KENALOG52,340,392 IXABEPILONE157 KENALOG-10392 IXEMPRA157 KENALOG-40392 IXIARO449 KEPIVANCE322 KEPPRA95 J KEPPRA XR95 J-COF DHC510 KERAFOAM340 J-MAX DHC27 KERALAC340 JAKAFI162 KERALYT340 JALYN379 KERALYT SCALP340 JANUMET221 KERLONE261

PAGE 600 LAST UPDATED 10/2014 KEROL340 KOMBIGLYZE XR222 KERYDIN135 KORLYM470 KETALAR38 KRISTALOSE372 KETAMINE HCL38 KRYSTEXXA138 KETEK86 KUVAN359 KETOCONAZOLE133,135,136,138,337,340,341 KYNAMRO298 KETOCONAZOLE/SKIN CLEANSER COMBINATION KYPROLIS164 NO.28135,341 KETODAN135,341 L KETOPROFEN8,58 L-METHYLFOLATE FORMULA537 KETOROLAC TROMETHAMINE8,58,60,488,489 L-METHYLFOLATE FORTE537 KETOROLAC TROMETHAMINE/PF489 LABETALOL HCL261,262,264 KEYTRUDA167 LAC-HYDRIN341 KHEDEZLA119 LACOSAMIDE108 KINERET435 LACRISERT485 KINEVAC366 LACTIC ACID341 KINRIX449 LACTOBACILLUS ACIDOPHILUS/BIFIDOBACT KIT FOR PREP OF TC-99M/ALBUMIN BIFIDUM/BIFIDO LONGUM368 HUMAN,AGGREGATED465 LACTOBACILLUS CASEI/FOLIC ACID476 KIT FOR PREP TC 99M/SESTAMIBI COMBINATION LACTOBACILLUS COMBINATION NO.1463,478 NO.2/S.THERMOPHL/BIF CMB NO.1369 KIT FOR PREP TC 99M/SODIUM THIOSULFATE478 LACTULOSE372 KIT FOR PREP TC-99M/EXAMETAZIME463 LAMICTAL101,102,213 KIT FOR PREP TC-99M/MEBROFENIN478 LAMICTAL (BLUE)102,214 KIT FOR PREP TC-99M/MEDRONATE LAMICTAL (GREEN)102,214 SODIUM465,478 LAMICTAL (ORANGE)102,214 KIT FOR PREP TC-99M/PENTETIC ACID465 LAMICTAL ODT102,213,214 KIT FOR PREP TC-99M/SODIUM LAMICTAL ODT (BLUE)102,214 PYROPHOSPHATE478 LAMICTAL ODT (GREEN)102,214 KIT FOR PREP TC-99M/SUCCIMER465 LAMICTAL ODT (ORANGE)102,214 KIT FOR PREP TC-99M/TETROFOSMIN472 LAMICTAL XR102,103,214 KIT FOR PREP YTTRIUM-90/IBRITUMOMAB LAMICTAL XR (BLUE)103,214 TIUXETAN/ALBUMIN HUMAN167 LAMICTAL XR (GREEN)103,214 KLARON90,341 LAMICTAL XR (ORANGE)103,214 KLONOPIN202 LAMISIL135 KLOR-CON536 LAMIVUDINE189,194 KLOR-CON 10536 LAMIVUDINE/ZIDOVUDINE189 KLOR-CON 8536 LAMOTRIGINE101,102,103,213,214,215 KLOR-CON M15536 LANOXIN281,282 KOATE-DVI240,241 LANOXIN PEDIATRIC282 KOGENATE FS241 LANREOTIDE ACETATE431

PAGE 601 LAST UPDATED 10/2014 LANSOPRAZOLE374,375 LEVOBUNOLOL HCL490,492 LANSOPRAZOLE/AMOXICILLIN LEVOCARNITINE519,520 TRIHYDRATE/CLARITHROMYCIN366,368 LEVOCARNITINE (WITH SUGAR)519,520 LANTHANUM CARBONATE384 LEVOCETIRIZINE DIHYDROCHLORIDE499,500 LANTUS226 LEVOFLOXACIN88,89,485 LANTUS SOLOSTAR226 LEVOFLOXACIN/DEXTROSE 5 % IN WATER89 LAPATINIB DITOSYLATE165 LEVOLEUCOVORIN CALCIUM156 LARONIDASE358 LEVOMEFOLATE LASIX290 CA/ACETYLCYSTEINE/MECOBALAMIN/SCHIZ. LASTACAFT488 ALGAL OIL523,537,539 LATANOPROST481,482,492,493 LEVOMEFOLATE CA/PYRIDOXAL LATISSE341 PHOS/MECOBALAMIN/SCHIZ. ALGAL LATUDA180 OIL470,532,537,539,540 LAZANDA15,27 LEVOMEFOLATE CALCIUM526,537 LEDIPASVIR/SOFOSBUVIR194 LEVOMEFOLATE CALCIUM/SCHIZOCHYTRIUM LEFLUNOMIDE442,443 ALGAL OIL470,526,537 LENALIDOMIDE150,444 LEVOMILNACIPRAN HYDROCHLORIDE118 LEPIRUDIN,RECOMBINANT232 LEVONORGESTREL418,419 LESCOL295 LEVONORGESTREL-ETH ESTRA/ETHINYL LESCOL XL295 ESTRADIOL405,407,411,415 LETAIRIS506 LEVONORGESTREL-ETHINYL LETROZOLE161 ESTRADIOL405,406,407,408,409,410,411,412,413,41 LEUCOVORIN CALCIUM154,157,158 4,415 LEUKERAN148 LEVOPHED BITARTRATE282 LEUKINE235 LEVORPHANOL TARTRATE15 LEUPROLIDE ACETATE428,429,430 LEVOTHROID420,421 LEUPROLIDE ACETATE/NORETHINDRONE LEVOTHYROXINE SODIUM420,421,422,423,424,425 ACETATE429 LEVOXYL421,422 LEVACET8 LEVSIN363 LEVALBUTEROL HCL504,505 LEVSIN-SL363 LEVALBUTEROL TARTRATE505 LEVULAN341 LEVAQUIN88,89 LEXAPRO119,206 LEVATOL262 LEXISCAN470 LEVBID363 LEXIVA192 LEVEMIR226 LIALDA366,453 LEVEMIR FLEXPEN226 LIBRAX363 LEVEMIR FLEXTOUCH226 LIDOCAINE39,40,341 LEVETIRACETAM95,96 LIDOCAINE HCL38,39,40,42,44,45 LEVETIRACETAM IN SODIUM CHLORIDE, ISO- LIDOCAINE HCL/COLLAGEN43 OSMOTIC96 LIDOCAINE HCL/DEXTROSE 5%-WATER/PF38 LEVITRA381 LIDOCAINE HCL/DEXTROSE 7.5%-WATER/PF39

PAGE 602 LAST UPDATED 10/2014 LIDOCAINE HCL/EPINEPHRINE38,39,44 LITHIUM CITRATE215 LIDOCAINE HCL/EPINEPHRINE BITARTRATE38 LITHOBID215 LIDOCAINE HCL/EPINEPHRINE/PF38,39,44,45 LITHOSTAT382 LIDOCAINE HCL/GLYCERIN37 LIVALO295 LIDOCAINE HCL/PF39,40,44,45,256,482 LIVER EXTRACT (BEEF-PORK)473 LIDOCAINE/ALLANTOIN/PETROLATUM,WHITE44 LO LOESTRIN FE411 LIDOCAINE/PRILOCAINE37,40,336,341 LO MINASTRIN FE411 LIDOCAINE/TETRACAINE42,44 LOCOID392 LIDODERM40 LOCOID LIPOCREAM392 LIDORX40 LODOSYN174 LIDOVIR198 LODOXAMIDE TROMETHAMINE488 LIMBREL537,538 LOESTRIN411 LIMBREL250538 LOESTRIN 24 FE411 LIMBREL500538 LOESTRIN FE411 LINACLOTIDE371 LOMITAPIDE MESYLATE297,298 LINAGLIPTIN225 LOMOTIL367 LINAGLIPTIN/METFORMIN HCL221 LOMUSTINE147,148 LINCOCIN66 LOPERAMIDE HCL367 LINCOMYCIN HCL66 LOPID294 LINDANE169 LOPINAVIR/RITONAVIR192 LINEZOLID71 LOPRESSOR262 LINZESS371 LOPRESSOR HCT282 LIORESAL INTRATHECAL186 LOPROX135,341 LIOTHYRONINE SODIUM420,422,424 LORAZEPAM200,202,203 LIOTRIX423,424 LORCASERIN HCL311 LIPASE/PROTEASE/AMYLASE359,360,361 LORCET 10-65027 LIPICHOL 540538 LORCET PLUS27 LIPIODOL470 LORTAB27 LIPITOR295 LORZONE514 LIPOCHOL PLUS298 LOSARTAN POTASSIUM249,250 LIPOFEN293,294 LOSARTAN LIPOSYN II538 POTASSIUM/HYDROCHLOROTHIAZIDE281,282 LIPOSYN III538 LOSEASONIQUE411 LIPTRUZET298 LOTEMAX489 LIQUID POLIBAR470 LOTENSIN252 LIQUID POLIBAR PLUS470 LOTENSIN HCT282,283 LIRAGLUTIDE225 LOTEPREDNOL ETABONATE489 LISDEXAMFETAMINE DIMESYLATE305,306 LOTREL283 LISINOPRIL252,253,254 LOTRISONE341 LISINOPRIL/HYDROCHLOROTHIAZIDE282,285,288 LOTRONEX371 LITHIUM CARBONATE215 LOUTREX341

PAGE 603 LAST UPDATED 10/2014 LOVASTATIN294,295,296 M.V.I. PEDIATRIC538 LOVAZA298 M.V.I.-12538 LOVENOX231,232 MACITENTAN506 LOXAPINE175 MACROBID66 LOXAPINE SUCCINATE177 MACRODANTIN66 LOXITANE177 MACUGEN485 LUBIPROSTONE371 MACUTEK539 LUCENTIS485 MAFENIDE ACETATE66,69 LUCINACTANT512 MAG HYDROXIDE/AL LUFYLLIN501 HYDROXIDE/SIMETH/DIPHENHYDRAMINE/LIDOCAI LULICONAZOLE135 NE321 LUMIGAN481,482,492 MAGNACET27 LUMIZYME359 MAGNEBIND 400 RX539 LUNESTA516 MAGNESIUM CHLORIDE539 LUNGLAID538 MAGNESIUM SULFATE539 LUPANETA PACK429 MAGNESIUM SULFATE IN STERILE WATER539 LUPRON DEPOT429 MAGNESIUM SULFATE/DEXTROSE 5 % IN LUPRON DEPOT-PED430 WATER539 LURASIDONE HCL180 MAGNEVIST471 LUSTRA-AF342 MAKENA411 LUSTRA-ULTRA342 MALARONE169 LUVOX CR119 MALATHION169,170,342 LUXIQ52,342,392 MANGANESE CHLORIDE539 LUZU135 MANGANESE SULFATE539 LYCELLE342 MANNITOL283,285,383,461 LYMPHAZURIN470 MANNITOL/SORBITOL SOLUTION383 LYMPHOCYTE IMMUNE GLOBULIN433 MAPROTILINE HCL112,113 LYMPHOCYTE IMMUNE GLOBULIN,RABBIT441 MARAVIROC191 LYRICA96,97,317 MARCAINE40 LYSINE HCL/VITAMIN B COMPLEX/FOLIC MARCAINE SPINAL40 ACID/ZINC556 MARCAINE WITH EPINEPHRINE40 LYSINE/VITAMIN E/FOLIC ACID/VITAMIN B COMP MARCAINE-EPINEPHRINE40 W-C/ZINC538 MARGESIC313 LYSIPLEX PLUS538 MARINOL131,313 LYSODREN427 MARNATAL-F539 LYSTEDA241 MARPLAN116 MARQIBO158 M MARTEN-TAB314 M-M-R II VACCINE449 MARTINIC539 M-VIT538 MATRISTEM471 M.V.I. ADULT538 MATRISTEM MICROMATRIX471

PAGE 604 LAST UPDATED 10/2014 MATULANE148 MELOXICAM/IRRITANTS COUNTER-IRRITANTS MAVIK252 COMBINATION NO.25,57 MAXAIR AUTOHALER504 MELPHALAN146 MAXALT142 MELPHALAN HCL146,148 MAXALT MLT142 MEMANTINE HCL110,111 MAXARON FORTE539 MEMBRANEBLUE485 MAXFE539 MENACTRA450 MAXIDEX393,490 MENEST411,412 MAXIDONE27 MENHIBRIX450 MAXIFED CD510 MENINGOCOCCAL VAC A,C,Y,W-135450 MAXIFED CDX510 MENINGOCOCCAL VACCINE A,C,Y,W- MAXIFLU CD510 135,DIPHTHERIA TOXOID CONJ/PF450 MAXIFLU CDX511 MENINGOCOCCAL VACCINE A,C,Y,W-135/PF450 MAXINATE539 MENINGOCOCCAL VACCINE C,Y/HAEMOPHILUS B MAXIPHEN CD511 CONJ-TETANUS TOX/PF450 MAXIPHEN CDX511 MENOMUNE-A-C-Y-W-135450 MAXIPIME76,77 MENOPUR471 MAXITROL485 MENOSTAR412 MAXZIDE283 MENOTROPINS471,476 MAXZIDE-25 MG283 MENTAX135,342 MD-76 R471 MENVEO A-C-Y-W-135-DIP450 MEASLES, MUMPS, RUBELLA, AND VARICELLA MEPENZOLATE BROMIDE362 VACCINE LIVE/PF450 MEPERIDINE HCL22,27,28 MEASLES,MUMPS&RUBELLA VACCINE LIVE/PF449 MEPERIDINE HCL/PF22,28 MECASERMIN400 MEPHYTON539 MECHLORETHAMINE HCL148,149 MEPIVACAINE HCL36,42 MECLIZINE HCL126,127 MEPIVACAINE HCL/PF36,37,42 MECLOFENAMATE SODIUM8,58 MEPROBAMATE203 MECOBALAMIN/LEVOMEFOLATE MEPRON169 CALCIUM/PYRIDOXAL PHOSPHATE532,537,540,561 MERCAPTOPURINE153 MEDIHONEY342 MEROPENEM79 MEDROL52,393,455 MERREM79 MEDROXYPROGESTERONE ACETATE417,418,419 MESALAMINE364,365,366,367,368,452,453 MEFENAMIC ACID8,10,58,59 MESALAMINE WITH CLEANSING MEFLOQUINE HCL169 WIPES367,368,453 MEFOXIN77 MESNA158 MEGACE418 MESNEX158 MEGACE ES418 MESTINON144 MEGESTROL ACETATE418 METADATE CD308 MEKINIST163 METANX539,540 MELOXICAM8,9,58 METAPROTERENOL SULFATE505

PAGE 605 LAST UPDATED 10/2014 METASTRON471 METHYLDOPA/HYDROCHLOROTHIAZIDE283 METAXALONE514,515 METHYLDOPATE HCL246 METFORMIN HCL218,219,222,224 METHYLENE BLUE471,472 METHACHOLINE CHLORIDE475 METHYLERGONOVINE MALEATE382 METHADONE HCL12,15,16,23,28 METHYLIN308 METHADOSE15,28 METHYLNALTREXONE BROMIDE368 METHAMPHETAMINE HCL304,305 METHYLPHENIDATE306 METHAZOLAMIDE289,492 METHYLPHENIDATE HCL306,308,309,310 METHENAMINE HIPPURATE66 METHYLPREDNISOLONE52,53,393,455 METHENAMINE MANDELATE66 METHYLPREDNISOLONE METHENAMINE MANDELATE/SODIUM ACETATE50,387,393,454,455 PHOSPHATE,M-BASIC M-HYD70 METHYLPREDNISOLONE ACETATE/BUPIVACAINE METHENAMINE/METHYLENE BLUE/BENZOIC HCL394 ACID/SALICYLATE/HYOSCY66,68 METHYLPREDNISOLONE SODIUM METHENAMINE/METHYLENE SUCCINATE47,52,53,55,385,393,396,453,455,456 BLUE/SALICYLATE/SODIUM PHOS/HYOSCY69,70 METHYLPREDNISOLONE SODIUM METHENAMINE/METHYLENE BLUE/SODIUM SUCCINATE/PF55,396,456 PHOS/PNYL SAL/HYOSC SUL68,69,70 METHYLTESTOSTERONE403,404 METHENAMINE/SODIUM METHYLTETRAHYDROFOLATE PHOSPHATE,MONOBASIC/METH BLUE/HYOSC GLUC/MECOBALAMIN/HERBAL NO.236553 SUL70 METHYLTETRAHYDROFOLATE METHIMAZOLE432,433 GLUCOSAMINE366,552 METHIONINE/INOSITOL/CHOLINE/FOLIC ACID298 METHYLTETRAHYDROFOLATE METHITEST403 GLUCOSAMINE/NIACINAMIDE/CUPRIC &ZN OX543 METHOCARBAMOL515 METIPRANOLOL492 METHOHEXITAL SODIUM35 METOCLOPRAMIDE HCL127,128,129,367,368 METHOTREXATE METOLAZONE292 SODIUM153,154,342,354,435,437,438,439 METOPIRONE472 METHOTREXATE SODIUM/PF153,342,435,436 METOPROLOL SUCCINATE262,264 METHOTREXATE/PF436,437 METOPROLOL METHOXSALEN325,345,356 SUCCINATE/HYDROCHLOROTHIAZIDE280 METHOXSALEN, RAPID342,345 METOPROLOL TARTRATE262,263 METHSCOPOLAMINE BROMIDE363 METOPROLOL METHSCOPOLM TARTRATE/HYDROCHLOROTHIAZIDE282,283,284 BR/L.ACIDOPHILUS/S.THERMOPHL/L.PARACASEI/ METOZOLV ODT127,128,367 BIFIDO363 METRELEPTIN472 METHSUXIMIDE96 METRO IV66 METHYCLOTHIAZIDE292 METROCREAM66 METHYL AMINOLEVULINATE HCL342 METROGEL66 METHYL SALICYLATE342 METROGEL-VAGINAL67 METHYLDOPA246 METROLOTION67

PAGE 606 LAST UPDATED 10/2014 METRONIDAZOLE65,66,67,68,71 MINOCYCLINE HCL/SKIN CLEANSER METRONIDAZOLE IN SODIUM CHLORIDE66,67 COMBINATION NO.493,322 METRONIDAZOLE/SKIN CLEANSER COMBINATION MINOXIDIL300 NO.2368 MIOCHOL-E485 METVIXIA342 MIOSTAT492 METYRAPONE472 MIPOMERSEN SODIUM298 METYROSINE278 MIRABEGRON186 MEVACOR296 MIRAPEX172 MEXILETINE HCL256 MIRAPEX ER172 MIACALCIN459 MIRCETTE412 MICAFUNGIN SODIUM135 MIRENA418 MICARDIS250 MIRTAZAPINE113,114 MICARDIS HCT284 MIRVASO342 MICONAZOLE136 MISOPROSTOL373,402 MICONAZOLE NITRATE135 MITIGARE138 MICONAZOLE NITRATE/ZINC MITOMYCIN158,485 OXIDE/PETROLATUM,WHITE357 MITOSOL485 MICRHOGAM ULTRA-FILTERED PLUS441 MITOTANE427 MICROFIBRILLAR COLLAGEN462,466,478,480 MITOXANTRONE HCL158,319 MICROZIDE292 MOBIC8,9,58 MIDAZOLAM HCL203,204 MODAFINIL518,519 MIDAZOLAM HCL/PF203,204 MODICON412 MIDODRINE HCL246 MOEXIPRIL HCL252,253 MIFEPREX472 MOEXIPRIL HCL/HYDROCHLOROTHIAZIDE284,288 MIFEPRISTONE470,472 MOLYBDENUM (AMMONIUM MOLYBDATE)522 MIGLITOL220 MOMETASONE MIGLUSTAT361 FUROATE335,336,342,389,393,495,496 MIGRANAL139 MOMETASONE FUROATE/AMMONIUM MILLIPRED53,393 LACTATE393 MILNACIPRAN HCL317,318 MOMETASONE FUROATE/FORMOTEROL MILRINONE LACTATE284 FUMARATE504 MILRINONE LACTATE/DEXTROSE 5 % IN MOMEXIN393 WATER284 MONOCLATE-P241 MIMYX342 MONODOX93,322,323 MINASTRIN 24 FE412,418 MONOKET301 MINIPRESS247,379 MONONINE241 MINIVELLE412 MONOVISC472 MINOCIN93,322 MONSEL'S472 MINOCYCLINE HCL92,93,94,321,322,324 MONTELUKAST SODIUM500 MINOCYCLINE HCL MICROSPHERES320 MONUROL67 MORGIDOX93,323

PAGE 607 LAST UPDATED 10/2014 MORPHINE SULFATE11,14,15,16,17,28,29,30 MULTIVITAMINS WITH MIN NO.43/LUTEIN/OMEGA- MORPHINE SULFATE LIPOSOMAL/PF22 3/DHA/EPA557 MORPHINE SULFATE/DEXTROSE 5%-WATER/PF28 MULTIVITAMINS WITH MIN MORPHINE SULFATE/PF21,23,26,27,28,29,30 NO.44/CHOLECALCIFEROL (VIT D3)/VIT K541 MOTOFEN367 MULTIVITAMINS WITH MIN NO.5/FOLIC ACID529 MOVIPREP372 MULTIVITAMINS WITH MIN NO.6/FOLIC MOXATAG82 ACID/LUTEIN/LYCOP/UBIDECAR526 MOXEZA89,485 MULTIVITAMINS WITH MIN NO.7/FOLIC MOXIFLOXACIN HCL87,89,90,485,487 ACID556,559 MOXIFLOXACIN HCL/SODIUM CHLORIDE, ISO- MULTIVITAMINS WITH MIN NO.8/FOLIC OSMOTIC87 ACID/UBIDECARENONE/OMEGA-3552 MOZOBIL235 MULTIVITAMINS WITH MIN NO.9/FOLIC ACID/SAW MS CONTIN16,17 PALMETTO EXTRACT558 MUCOSITIS & STOMATITIS COMBO 1323 MULTIVITAMINS WITH MINERALS NO.11/FOLIC MUCOTROL323 ACID528 MUGARD323 MULTIVITAMINS-A,B,D,E,K,ZN541 MULTAQ256 MULTIVITS W-FE,OTHER MIN/DIETARY MULTICHEW540 4/DEOXYRIBONUCLEIC ACID/RNA532 MULTIHANCE472 MULTIVITS W-IRON,HEMATINIC551 MULTIHANCE MULTIPACK472 MULTIVITS, IRON, MINERALS COMBO NO #4, MULTITRACE-4540 FOLIC ACID540 MULTIVIT W-MIN NO.26/FOLIC ACID/ALPHA LIPOIC MULTIVITS, IRON, MINERALS COMBO NO #5, ACID/LUTEIN556 FOLIC ACID555 MULTIVIT WITH MIN#10/FOLIC ACID//VIT D3/A MULTIVITS, IRON, MINERALS COMBO NO #6, LIPOIC ACID/LUTEIN523,555 FOLIC ACID555 MULTIVITAMINS W-MINERALS COMBINATION MULTIVITS,THERAP W-FE,HEMATIN522,556 NO.20/IRON/FOLIC ACID522 MUPIROCIN63,67,328,330,342 MULTIVITAMINS WITH MIN NO. 16/FOLIC MUPIROCIN CALCIUM63,67,328 ACID/LUTEIN/LYCOPENE553 MUSE382 MULTIVITAMINS WITH MIN NO. 17/IRON/FA/MIN AA MUSTARGEN148 CHELATE551 MVC-FLUORIDE541 MULTIVITAMINS WITH MIN NO.21/FOLIC ACID555 MVI, ADULT NO.1 WITH VIT K538 MULTIVITAMINS WITH MIN NO.22/LUTEIN/OMEGA- MVI, ADULT NO.2 WITHOUT VIT K538 3/DHA/EPA557 MVI, ADULT NO.4 WITH VIT K534 MULTIVITAMINS WITH MIN NO.23/FOLIC ACID552 MVI, PEDI NO.1 WITH VIT K534 MULTIVITAMINS WITH MIN NO.24/IRON MVI, PEDI NO.2 WITH VIT K538 POLYSACCHARIDE COMPLEX/FA552 MYALEPT472 MULTIVITAMINS WITH MIN NO.25/FOLIC MYAMBUTOL145 ACID/VITAMIN D3528 MYCAMINE135 MULTIVITAMINS WITH MIN NO.28/FOLIC MYCOBUTIN145 ACID/LYCOPENE558 MYCOPHENOLATE MOFETIL433,436

PAGE 608 LAST UPDATED 10/2014 MYCOPHENOLATE MOFETIL HCL433 NAPROXEN/IRRITANTS COUNTER-IRRITANTS MYCOPHENOLATE SODIUM436 COMBINATION #25,57 MYDRIACYL485 NARATRIPTAN HCL141,142 MYFORTIC436 NARDIL116 MYKIDZ IRON FL541 NAROPIN40,41 MYLERAN148 NASACORT AQ394,496 MYNATAL541 NASCOBAL473,541 MYOBLOC314 NASONEX496 MYOVIEW472 NATA KOMPLETE542 MYOZYME359 NATACHEW542 MYRBETRIQ186 NATACYN136,485 MYSOLINE96 NATAFORT542 NATALIZUMAB320,445 N NATALVIT542 NABI-HB450 NATAMYCIN136,485 NABILONE130 NATAZIA412 NABUMETONE9,58 NATEGLINIDE223,224 NADOLOL260,261,263 NATELLE ONE542 NADOLOL/BENDROFLUMETHIAZIDE278,284 NATRECOR284 NAFARELIN ACETATE431 NATROBA343 NAFCILLIN IN DEXTROSE, ISO-OSMOTIC82 NATURE-THROID422,423 NAFCILLIN SODIUM82 NAVELBINE158 NAFRINSE DAILY-NEUTRAL323 NEBIVOLOL HCL259,260 NAFTIFINE HCL135,136,343 NEBUPENT169 NAFTIN135,136,343 NEBUSAL511 NAGLAZYME359 NEDOCROMIL SODIUM488 NALBUPHINE HCL30 NEEDLES, INSULIN DISPOSABLE463,475 NALFON9,58 NEEVO542 NALOXONE HCL45,46 NEEVO DHA542 NALTREXONE HCL45,46 NEEVODHA542 NALTREXONE HCL/BUPROPION HCL463 NEFAZODONE HCL113,119 NALTREXONE MICROSPHERES46,47 NELARABINE151 NAMENDA110,111 NELFINAVIR MESYLATE193 NAMENDA XR111 NEMBUTAL SODIUM517 NAPHAZOLINE HCL485 NEO-SYNALAR343 NAPRELAN9,58,59 NEO-SYNEPHRINE284 NAPROSYN9,59 NEOBENZ MICRO343 NAPROXEN6,9,10,57,59 NEOCATE JUNIOR WITH PREBIOTICS542 NAPROXEN SODIUM5,9,10,56,58,59 NEOCATE SPLASH542 NAPROXEN/ESOMEPRAZOLE MAGNESIUM10 NEOMYCIN SULFATE61

PAGE 609 LAST UPDATED 10/2014 NEOMYCIN SULFATE/BACITRACIN NESTABS DHA543 ZINC/POLYMYXIN B/HYDROCORTISONE485 NETUPITANT/PALONOSETRON HCL130 NEOMYCIN SULFATE/BACITRACIN/POLYMYXIN NEUAC343 B485,486 NEULASTA236 NEOMYCIN SULFATE/COLISTIN NEUMEGA236 SULFATE/HYDROCORTISONE/THONZONIUM494 NEUPOGEN236 NEOMYCIN SULFATE/FLUOCINOLONE NEUPRO172 ACETONIDE343 NEURIN-SL543 NEOMYCIN SULFATE/FLUOCINOLONE NEURONTIN99,100,314 ACETONIDE/EMOLLIENT COMB NO.65343 NEUT543 NEOMYCIN SULFATE/POLYMYXIN B SULFATE67 NEUTRASAL323 NEOMYCIN SULFATE/POLYMYXIN B NEVANAC490 SULFATE/GRAMICIDIN D486 NEVIRAPINE188 NEOMYCIN SULFATE/POLYMYXIN B NEXA PLUS543 SULFATE/HYDROCORTISONE49,53,333,387,394,48 NEXA SELECT543 6,494 NEXAVAR165 NEOMYCIN/BACITRACIN/POLYMYXIN NEXAVIR473 B/HYDROCORTISONE333 NEXIUM374 NEOMYCIN/POLYMYXIN B NEXIUM I.V.374 SULFATE/DEXAMETHASONE485,486 NEXPLANON418 NEOPROFEN284 NEXTERONE256,257 NEORAL343,436 NIACIN298 NEOSALUS343 NIACIN NO.1/FA/B12/IRON/A-CYST ZN/CHROM NEOSALUS CP343 POLY/INOS NIAC/A-CYS526 NEOSPORIN G.U. IRRIGANT67 NIACIN/LOVASTATIN297 NEOSTIGMINE BROMIDE144 NIACIN/SIMVASTATIN299 NEOSTIGMINE METHYLSULFATE144 NIACINAMIDE/AZELAIC NEPAFENAC489,490 AC/QUERCET/TURMER/FA/B6/ZINC NEPHPLEX RX542 OX/COPPER473,543 NEPHRAMINE542 NIACINAMIDE/AZELAIC ACID/ZINC OXIDE/VIT NEPHRO-VITE RX542 B6/COPPER/FA522,543,557,562 NEPHROCAPS542 NIACINAMIDE/VIT B6/VIT C/FA/COPPER/MG CIT/ZN NEPHROCAPS QT542 GLUC/ALIP ACID543 NEPHRON FA542 NIASPAN298 NEPTAZANE289,492 NICADAN543 NESACAINE41 NICARDIPINE HCL265,270 NESACAINE-MPF42 NICARDIPINE IN DEXTROSE, ISO-OSMOTIC265 NESINA223 NICARDIPINE IN SODIUM CHLORIDE, ISO- NESIRITIDE284 OSMOTIC265 NESTABS543 NICAZEL543 NESTABS ABC543 NICAZEL FORTE543

PAGE 610 LAST UPDATED 10/2014 NICOMIDE543 NORETHINDRONE ACETATE416,419 NICOTINE47 NORETHINDRONE ACETATE-ETHINYL NICOTROL47 ESTRADIOL409,410,411,412,413 NICOTROL NS47 NORETHINDRONE ACETATE-ETHINYL NIFEDIPINE264,270,271 ESTRADIOL/FERROUS NILANDRON432 FUMARATE409,410,411,412,413,415,417,418 NILOTINIB HCL165 NORETHINDRONE-ETHINYL NILUTAMIDE432 ESTRADIOL405,406,407,410,412,413,414,415,416,41 NIMBEX314 7,419 NIMODIPINE270,271 NORETHINDRONE-ETHINYL NIPENT153 ESTRADIOL/FERROUS FUMARATE409,410,413,416 NIRAVAM204 NORETHINDRONE-MESTRANOL413 NIRON KOMPLETE543 NORFLOXACIN89 NISOLDIPINE270,271 NORFLURANE/HFC 245FA42,44 NITAZOXANIDE168 NORGESTIMATE-ETHINYL NITHIODOTE473 ESTRADIOL408,412,413,414,415,417,418,419 NITISINONE360 NORGESTREL-ETHINYL ESTRADIOL406,407,411 NITRO-BID301 NORINYL 1+35413 NITRO-DUR301 NORINYL 1+50413 NITROFURANTOIN66,68 NORITATE68 NITROFURANTOIN MACROCRYSTAL66,68 NORMOSOL-M AND DEXTROSE543 NITROFURANTOIN NORMOSOL-R543 MONOHYDRATE/MACROCRYSTALS66,68 NORMOSOL-R AND DEXTROSE544 NITROGLYCERIN300,301,302,383 NORMOSOL-R PH 7.4544 NITROGLYCERIN/DEXTROSE 5 % IN WATER302 NOROXIN89 NITROLINGUAL302 NORPACE257 NITROMIST302 NORPACE CR257 NITRONAL302 NORPRAMIN124 NITROPRESS300 NORTHERA284 NITROPRUSSIDE SODIUM300 NORTRIPTYLINE HCL124,125 NITROSTAT302 NORVASC270,271 NIZATIDINE369,370 NORVIR192 NIZORAL136 NOTUSS-NX511 NOR-Q-D418 NOTUSS-NXD511 NORCO30 NOVACORT394 NORDETTE-28413 NOVAFERRUM544 NORDITROPIN FLEXPRO400 NOVAREL400 NORDITROPIN NORDIFLEX400 NOVOLOG226 NORELGESTROMIN/ETHINYL ESTRADIOL413,416 NOVOLOG FLEXPEN226 NOREPINEPHRINE BITARTRATE282,284 NOVOLOG MIX 70-30226 NORETHINDRONE416,417,418,419 NOVOLOG MIX 70-30 FLEXPEN226

PAGE 611 LAST UPDATED 10/2014 NOVOSEVEN RT241 NUTRITIONAL TX, KETOGENIC/LONG CHAIN NOXAFIL136 TRIGLYCERIDES463 NPLATE236 NUTRITIONAL TX, KETOGENIC/MEDIUM CHAIN NU-DERM SUNFADER344 TRIGLYCERIDES462 NUCORT394 NUTROPIN400 NUCYNTA30,314 NUTROPIN AQ401 NUCYNTA ER17,314,315 NUTROPIN AQ NUSPIN401 NUEDEXTA315 NUVAIL344 NULOJIX436 NUVARING413 NULYTELY WITH FLAVOR PACKS372 NUVIGIL518 NUMOISYN323 NYMALIZE271 NUOX343 NYSTATIN136,137,344,345 NUT.TX.IMPAIRED DIGEST FXN479,481,542 NYSTATIN/EMOLLIENT COMBINATION NO.54137 NUT.TX.IMPAIRED DIGEST FXN/FIBER542 NYSTATIN/HYDROCORTISONE/DIPHENHYDRAMIN NUTREN JUNIOR544 E HCL321 NUTREN JUNIOR FIBER544 NYSTATIN/LIDOCAINE HCL/DIPHENHYDRAMINE NUTRESTORE544 HCL321 NUTRICAP544 NYSTATIN/TETRACYCLINE NUTRIHEP473 HCL/HYDROCORTISONE/DIPHENHYDRAMINE NUTRILYTE544 HCL321 NUTRITIONAL SUPPLEMENT473,475,544 NYSTATIN/TRIAMCINOLONE ACETONIDE53,344 NUTRITIONAL SUPPLEMENT/INULIN/FRUCTOOLIGOSACCHARID O ES475 O-CAL FA544 NUTRITIONAL O-CAL PRENATAL544 SUPPLEMENT/INULIN/FRUCTOOLIGOSACCHARID OB COMPLETE544 ES/FIBER544,545 OB COMPLETE 400544 NUTRITIONAL THERAPY FOR MSUD WITH OB COMPLETE ONE544 IRON462 OB COMPLETE PETITE544 NUTRITIONAL THERAPY FOR PKU WITH IRON OB COMPLETE PREMIER544 NO.41533 OB COMPLETE WITH DHA545 NUTRITIONAL THERAPY FOR TYROSINEMIA WITH OBINUTUZUMAB167 IRON480 OBSTETRIX EC545 NUTRITIONAL THERAPY, GLUTARIC ACIDURIA OBTREX545 1/FLAXSEED/FIBER533 OBTREX DHA545 NUTRITIONAL THERAPY, IMPAIRED HEPATIC OCRIPLASMIN/PF485 FUNCTION473 OCTAGAM441 NUTRITIONAL THERAPY, METABOLIC DISORDER, OCTAPLAS236 MULTIVIT & MIN #2522 OCTREOSCAN473 NUTRITIONAL THERAPY, MILK PROTEIN, SPECIAL OCTREOTIDE ACETATE430,431 FORMULA545 OCUDOX94,323

PAGE 612 LAST UPDATED 10/2014 OCUFEN490 OMEPRAZOLE/SODIUM BICARBONATE375,376 OCUFLOX90,486 OMNARIS496 OFATUMUMAB166 OMNIPAQUE473,474 OFIRMEV473 OMNIPAQUE REDIFLO473,474 OFLOXACIN90,486 OMNIPRED490 OGEN413 OMNISCAN474 OLANZAPINE180,181,184,209,211,212 OMNISCAN PREFILL PLUS474 OLANZAPINE PAMOATE184 OMNITROPE401 OLANZAPINE/FLUOXETINE HCL113,114,115 OMONTYS459 OLEPTRO ER113,114 ONABOTULINUMTOXINA139,185 OLMESARTAN MEDOXOMIL248 ONCASPAR158 OLMESARTAN MEDOXOMIL/AMLODIPINE ONDANSETRON131,132 BESYLATE/HYDROCHLOROTHIAZIDE287 ONDANSETRON HCL131 OLMESARTAN ONDANSETRON HCL/DEXTROSE 5%- MEDOXOMIL/HYDROCHLOROTHIAZIDE277 WATER/PF131 OLODATEROL HCL505 ONDANSETRON HCL/PF131 OLOPATADINE HCL488,499 ONFI100 OLSALAZINE SODIUM453 ONGLYZA223 OLUX53,344,394 ONMEL136 OLUX-E53,344,394 ONSOLIS17,30 OLYSIO195 ONTAK158 OMACETAXINE MEPESUCCINATE159 OPANA31 OMALIZUMAB513 OPANA ER17 OMECLAMOX-PAK367 OPIUM TINCTURE367 OMEGA-3 ACID ETHYL ESTERS298 OPIUM/BELLADONNA ALKALOIDS365 OMEGA-3 FATTY ACIDS/CA CARBONATE/VITAMIN OPRELVEKIN236 D3/FA/MV CMB 13521 OPSUMIT506 OMEGA-3 FATTY ACIDS/DHA/EPA/OTHER OMEGA- OPTIMARK474 3S/FISH OIL559 OPTIRAY 300474 OMEGA-3 FATTY ACIDS/DOCOSAHEXANOIC OPTIRAY 320474 ACID/EPA/LUTEIN/ZEAXANTH532 OPTIRAY 350474 OMEGA-3/DHA/EPA/B12/FOLIC ACID/PYRIDOXINE OPTISON474 HCL/PHYTOSTEROLS522,523,540 OPTISOURCE545 OMEGA-3/DHA/EPA/D3/B12/FOLIC ACID/PYRIDOX OPTIVAR488 HCL/PHYTOSTEROL522 ORACEA94,323 OMEGA-3/DHA/EPA/MARINE ORACIT382 PHOSPHOLIPIDS/ASTAXANTHIN/KRILL OIL538 ORAL MUCOSITIS & STOMATITIS ANTI- OMEPRAZOLE374,375 INFLAMMATORY AGENT COMB 2321 OMEPRAZOLE MAGNESIUM375 ORALAIR511 OMEPRAZOLE/CLARITHROMYCIN/AMOXICILLIN ORAMAGICRX323 TRIHYDRATE367 ORAP177

PAGE 613 LAST UPDATED 10/2014 ORAPRED53,394 OXANDRIN402 ORAPRED ODT53,54,394 OXANDROLONE402 ORASEP42 OXAPROZIN5,10,57,59 ORAVIG136 OXAZEPAM204 ORBACTIV68 OXCARBAZEPINE106,107,108 ORBIVAN315 OXECTA31 ORBIVAN CF315 OXICONAZOLE NITRATE136,137,345 ORENCIA436,443 OXILAN-350475 ORENITRAM ER506,507 OXISTAT136,137,345 ORFADIN360 OXSORALEN345 ORITAVANCIN DIPHOSPHATE68 OXSORALEN-ULTRA345 ORLISTAT369 OXTELLAR XR107 ORPHENADRINE CITRATE515 OXYBENZONE/OCTINOXATE/HYDROQUINONE326, ORPHENADRINE CITRATE/ASPIRIN/CAFFEINE515 344 ORTHO EVRA413 OXYBUTYNIN377 ORTHO MICRONOR419 OXYBUTYNIN CHLORIDE376,377 ORTHO TRI-CYCLEN413 OXYCEL475 ORTHO TRI-CYCLEN LO413 OXYCODONE HCL17,18,31,32,33 ORTHO-CEPT413 OXYCODONE ORTHO-CYCLEN414 HCL/ACETAMINOPHEN19,23,27,31,32,34 ORTHO-NOVUM414 OXYCODONE HCL/ASPIRIN23,32 ORTHOVISC474 OXYCONTIN18 OSELTAMIVIR PHOSPHATE193 OXYMETHOLONE402 OSENI223 OXYMORPHONE HCL17,18,31,32 OSMITROL285 OXYTOCIN382 OSMOPREP545 OXYTROL377 OSPEMIFENE419 OZURDEX490 OSPHENA419 OTEZLA443 P OTREXUP436 PACERONE257 OVACE344 PACLITAXEL158,159 OVACE PLUS90,344 PACLITAXEL PROTEIN-BOUND154 OVACE PLUS WASH344 PACNEX345 OVCON-35414 PACNEX HP345 OVIDE170 PACNEX LP345 OVIDREL474 PACNEX MX345 OXACILLIN SODIUM82 PAIN EASE42 OXACILLIN SODIUM/DEXTROSE, ISO-OSMOTIC82 PALIFERMIN322 OXALIC ACID345 PALIPERIDONE179 OXALIPLATIN147,148 PALIPERIDONE PALMITATE179,180 OXALIS345 PALIVIZUMAB445

PAGE 614 LAST UPDATED 10/2014 PALONOSETRON HCL126,130 PARENTERAL AMINO ACID 6% COMBINATION PAMELOR125 NO.1549 PAMIDRONATE DISODIUM459 PARENTERAL AMINO ACID 7 % COMBINATION PAMINE363 NO.1 (PEDIATRIC)521 PAMINE FORTE363 PARENTERAL AMINO ACID 7 % COMBINATION PAMINE FQ363 NO.2521 PANCREAZE360 PARENTERAL AMINO ACID 7% COMBINATION PANCURONIUM BROMIDE315 NO.1521 PANDEL394 PARENTERAL AMINO ACID 8.5 % COMBINATION PANHEMATIN475 NO.1532 PANITUMUMAB165,166 PARENTERAL AMINO ACID 8.5 % COMBINATION PANRETIN167,345 NO.3521 PANTOPRAZOLE SODIUM375,376 PARENTERAL AMINO ACID 8.5% COMBINATION PAPAVERINE HCL285 NO.2521 PARAFON FORTE DSC515 PARICALCITOL427,428,460 PARAGARD T 380-A475 PARLODEL172,173,430 PARCOPA175 PARNATE116 PAREGORIC367 PAROMOMYCIN SULFATE61 PAREMYD486 PAROXETINE HCL119,120,206 PARENTERAL AMINO ACID 10 % COMBINATION PAROXETINE MESYLATE116,120,121,205,207 NO.1521 PASER145 PARENTERAL AMINO ACID 10 % COMBINATION PASIREOTIDE DIASPARTATE427 NO.5 (PEDIATRIC)521 PATADAY488 PARENTERAL AMINO ACID 10% COMBINATION PATANASE499 NO. 4532 PATANOL488 PARENTERAL AMINO ACID 10% COMBINATION PAXIL120,206 NO. 6557 PAXIL CR120,206 PARENTERAL AMINO ACID 10% COMBINATION PAZOPANIB HCL163 NO.2521 PCE86 PARENTERAL AMINO ACID 10% COMBINATION PEDIADERM AF137 NO.7549 PEDIADERM HC54,345,394 PARENTERAL AMINO ACID 15 % COMBINATION PEDIADERM TA345,394 NO.2521 PEDIAPRED54,394 PARENTERAL AMINO ACID 15% COMBINATION PEDIARIX450 NO.1521,525 PEDIATRIC MULTIVIT #37/SODIUM PARENTERAL AMINO ACID 20 % COMBINATION FLUORIDE/IRON BISGLYCINATE HCL546 NO.1551 PEDIATRIC MULTIVITAMIN COMBINATION PARENTERAL AMINO ACID 3.5% COMBINATION NO.2/SODIUM FLUORIDE472,540 NO.1521 PEDIATRIC MULTIVITAMIN COMBO PARENTERAL AMINO ACID 5.2 % COMBINATION NO.45/FLUORIDE/FERROUS SULFATE472,541 NO.1 (RENAL)521

PAGE 615 LAST UPDATED 10/2014 PEDIATRIC MULTIVITAMIN COMBO PEG 3350/SOD SULF/SOD BICARBONATE/SOD NO.57/FLUORIDE/FERROUS SULFATE529 CHLORIDE/POTASSIUM CHL371,372 PEDIATRIC MULTIVITAMIN COMBO PEG 3350/SODIUM SULFATE/SOD NO.75/FLUORIDE/FERROUS SULFATE541 CHLORIDE/KCL/ASCORBATE SOD/VIT C372 PEDIATRIC MULTIVITAMIN NO.33 WITH SODIUM PEGADEMASE BOVINE358 FLUORIDE546 PEGANONE107 PEDIATRIC MULTIVITAMIN NO.33/SODIUM PEGAPTANIB SODIUM485 FLUORIDE/IRON CARBONYL547 PEGASPARGASE158 PEDIATRIC MULTIVITAMIN NO.37 WITH SODIUM PEGASYS195 FLUORIDE546 PEGASYS PROCLICK195 PEDIATRIC MULTIVITAMIN NO.47 WITH IRON & PEGFILGRASTIM236 SODIUM FLUORIDE530,556 PEGINESATIDE459 PEDIATRIC MULTIVITAMIN PEGINTERFERON ALFA-2A195 NO.61/CHOLECALCIFEROL/PHYTONADIONE463 PEGINTERFERON ALFA-2B159,195,196 PEDIATRIC MULTIVITAMIN NO.63 WITH SODIUM PEGINTERFERON BETA-1A319 FLUORIDE552 PEGINTRON195 PEDIATRIC MULTIVITAMIN PEGINTRON REDIPEN195,196 NO.65/CHOLECALCIFEROL/PHYTONADIONE541 PEGLOTICASE138 PEDIATRIC MULTIVITAMIN PEGVISOMANT431 NO.77/CHOLECALCIFEROL/PHYTONADIONE463 PEMBROLIZUMAB167 PEDIATRIC MULTIVITAMIN NO.78 WITH IRON & PEMETREXED DISODIUM151 SODIUM FLUORIDE466 PENBUTOLOL SULFATE262 PEDIATRIC MULTIVITAMIN NO.83 WITH SODIUM PENCICLOVIR197 FLUORIDE476 PENICILLAMINE380,381,434,519 PEDIATRIC MULTIVITAMIN NO.84 WITH SODIUM PENICILLIN G BENZATHINE81 FLUORIDE476 PENICILLIN G BENZATHINE/PENICILLIN G PEDIATRIC MULTIVITAMINS A,C,& D3 NO.21 WITH PROCAINE81 SODIUM FLUORIDE479,557,558,561 PENICILLIN G POTASSIUM83 PEDIATRIC MULTIVITAMINS A,C,& D3 NO.38 WITH PENICILLIN G POTASSIUM/DEXTROSE-WATER82 SODIUM FLUORIDE557 PENICILLIN G PROCAINE82,83 PEDIATRIC MULTIVITAMINS COMBINATION PENICILLIN V POTASSIUM83 NO.12/SODIUM FLUORIDE541 PENLAC137,345 PEDIATRIC MULTIVITAMINS NO.16 WITH SODIUM PENNSAID345 FLUORIDE540,541 PENTACEL450 PEDIATRIC MULTIVITAMINS NO.17 WITH SODIUM PENTACEL ACTHIB COMPONENT450 FLUORIDE540,541 PENTACEL DTAP-IPV COMPONENT450 PEDIATRIC MULTIVITAMINS NO.82 WITH SODIUM PENTAM 300169 FLUORIDE541 PENTAMIDINE ISETHIONATE169 PEDIPIROX-4137,345 PENTASA367,453 PEDITRACE545 PENTAZOCINE HCL/ACETAMINOPHEN32 PEDVAXHIB450 PENTAZOCINE HCL/NALOXONE HCL32

PAGE 616 LAST UPDATED 10/2014 PENTAZOCINE LACTATE34 PERPHENAZINE/AMITRIPTYLINE HCL114 PENTETATE CA TRISODIUM462 PERSANTINE244 PENTETATE INDIUM DISODIUM IN-111469 PERTUZUMAB167 PENTETATE ZINC TRISODIUM481 PERTZYE360 PENTOBARBITAL SODIUM517 PETROLATUM,WHITE480 PENTOSAN POLYSULFATE SODIUM381 PEXEVA120,121,207 PENTOSTATIN153 PHENAZOPYRIDINE HCL382,383 PENTOXIFYLLINE285,287 PHENAZOPYRIDINE PEPCID370 HCL/HYOSCYAMINE/BUTABARBITAL382 PEPTAMEN JUNIOR475 PHENDIMETRAZINE TARTRATE311,315 PEPTAMEN JUNIOR FIBER545 PHENELZINE SULFATE116 PEPTAMEN JUNIOR WITH PREBIO1475 PHENERGAN128,499 PERAMPANEL94,95 PHENFLU CD511 PERCOCET32 PHENFLU CDX511 PERCODAN32 PHENOBARBITAL100 PERCURA545 PHENOBARBITAL SODIUM99,100 PERFLUTREN LIPID MICROSPHERES464 PHENOBARBITAL/HYOSCYAMINE SULF/ATROPINE PERFLUTREN PROTEIN-A MICROSPHR474 SULF/SCOPOLAMINE HB365,366,367,368 PERFOROMIST505 PHENOL345 PERIDEX68,323 PHENOXYBENZAMINE HCL247 PERIKABIVEN545 PHENTERMINE HCL310,315,316 PERINDOPRIL ERBUMINE250,252,253 PHENTERMINE HCL/TOPIRAMATE315 PERITONEAL DIALYSIS NO.13 WITH DEXTROSE PHENTOLAMINE MESYLATE247 2.5 %528 PHENYLEPHRINE HCL284,285,288,482,485,486 PERITONEAL DIALYSIS NO.19 WITH DEXTROSE PHENYLEPHRINE HCL/BROMPHENIRAMINE 1.5%526 MALEATE513 PERITONEAL DIALYSIS NO.28 WITH ICODEXTRIN PHENYLEPHRINE HCL/CHLORPHENIRAMINE 7.5 %530 MALEATE509 PERITONEAL DIALYSIS NO.3 WITH DEXTROSE PHENYLEPHRINE HCL/CODEINE PHOSPHATE508 4.25 %528 PHENYLEPHRINE HCL/CODEINE PERITONEAL DIALYSIS NO.4 WITH DEXTROSE 1.5 PHOSPHATE/ACETAMINOPHEN/GUAIFEN511 %528 PHENYLEPHRINE HCL/CODEINE PERITONEAL DIALYSIS NO.6 WITH DEXTROSE 1.5 PHOSPHATE/GUAIFENESIN511 %526,528 PHENYLEPHRINE HCL/DIHYDROCODEINE PERITONEAL DIALYSIS NO.7 WITH DEXTROSE 2.5 BITARTRATE508 %526,528 PHENYLEPHRINE HCL/DIHYDROCODEINE PERITONEAL DIALYSIS NO.8 WITH DEXTROSE BITARTRATE/CHLORPHENIRAMINE509 4.25 %526,528 PHENYLEPHRINE HCL/DIHYDROCODEINE PERJETA167 BITARTRATE/GUAIFENESIN509,511 PERMETHRIN170 PHENYLEPHRINE HCL/PROMETHAZINE HCL511 PERPHENAZINE128,177 PHENYLEPHRINE HCL/PYRILAMINE MALEATE512

PAGE 617 LAST UPDATED 10/2014 PHENYTEK107 PITRESSIN401 PHENYTOIN106,107 PLAN B ONE-STEP419 PHENYTOIN SODIUM107 PLAQUENIL169 PHENYTOIN SODIUM EXTENDED106,107 PLASBUMIN-25236 PHISOHEX345 PLASBUMIN-5236 PHOSLO384 PLASMA HUMAN, BLOOD GROUP A236 PHOSLYRA384 PLASMA HUMAN, BLOOD GROUP AB236 PHOSPHATIDYL SERINE/OMEGA-3 FATTY PLASMA HUMAN, BLOOD GROUP B236 ACIDS/DHA/EPA559 PLASMA HUMAN, BLOOD GROUP O236 PHOSPHOLINE IODIDE492 PLASMA PROTEIN FRACTION236 PHOSPHORUS #1381,382,384 PLASMA-LYTE 148545 PHOTOFRIN159 PLASMA-LYTE 56 IN DEXTROSE546 PHRENILIN FORTE315 PLASMA-LYTE A PH 7.4546 PHYSICIANS EZ USE B-12545 PLASMANATE236 PHYSICIANS EZ USE FLU 2012-13450 PLAVIX244,245 PHYSICIANS EZ USE M-PRED394 PLEGISOL285 PHYSIOLOGICAL IRRIGATING SOLUTION COMBO PLEGRIDY319 #1545 PLERIXAFOR235 PHYSIOLYTE545 PLETAL245 PHYSIOSOL545 PLEXION346 PHYSOSTIGMINE SALICYLATE144 PLIAGLIS42 PHYTONADIONE539,545,561 PNEUMOCOCCAL 13-VALENT CONJUGATE PHYTOSTEROL/OMEGA-3 FATTY VACCINE (DIPHTHERIA CRM)/PF450 ACIDS/DHA/EPA/FISH OIL299 PNEUMOCOCCAL 23-VALENT POLYSACCHARIDE PICATO346 VACCINE450 PILOCARPINE HCL323,324,491,492 PNEUMOVAX 23450 PILOPINE HS492 PNV CMB#82/IRON PS CMPLX/FOLIC ACID/OMEGA PIMECROLIMUS335,434 3/DHA/EPA/FISH OIL552 PIMOZIDE177 PNV NO.20/IRON FUMARATE/FA/DOCUSATE PINDOLOL263 NA/FISH OIL CONC/DHA/EPA556,557 PIOGLITAZONE HCL216,223 PNV NO.35/IRON FUMARATE/FOLATE COMB. PIOGLITAZONE HCL/GLIMEPIRIDE218,223 #6/DHA550 PIOGLITAZONE HCL/METFORMIN HCL216,224 PNV NO17/IRON,CARB/IRON BISGLY/FA/FISH PIPERACILLIN AND TAZOBACTAM IN DEXTROSE, OIL/DHA/OMEGA 3,6 #1529,546 ISO-OSMOTIC83,84 PNV NO18/IRON,CARBONYL/FOLIC PIPERACILLIN SODIUM/TAZOBACTAM ACID/DOCUSATE NA/UBIDECAR/DHA551 SODIUM83,84 PNV WITH CA NO.37/IRON CARB & ASP PIRBUTEROL ACETATE504 GLY/FA/OMEGA-3 FATTY ACIDS531,545,558,560 PIROXICAM7,10,57,59 PNV#85/IRON CARB./IRON ASP.GLYCINATE/FOLIC PITAVASTATIN CALCIUM295 ACID/DHA/FISH OIL544 PITOCIN382

PAGE 618 LAST UPDATED 10/2014 PNV,CA,NO.35/IRON,CARBONYL & ASP POTASSIUM CHLORIDE535,536,547,548 GLY/FA/DSS/OMEGA-3558 POTASSIUM CHLORIDE IN 0.45 % SODIUM PNV-DHA PLUS546 CHLORIDE547 PNV-IRON546 POTASSIUM CHLORIDE IN 0.9 % SODIUM PODIAPN546 CHLORIDE536 PODOFILOX333,346 POTASSIUM CHLORIDE IN 5 % DEXTROSE IN PODOPHYLLUM RESIN346 WATER526,535,536 POLIBAR ACB475 POTASSIUM CHLORIDE IN DEXTROSE 5 % AND 0.9 POLIDOCANOL462,480 % SODIUM CHLORIDE536 POLIOMYELITIS VACCINE, KILLED449 POTASSIUM CHLORIDE IN DEXTROSE 5 %-0.2 % POLY HIST DHC511 SODIUM CHLORIDE526,535,536 POLY HIST NC511 POTASSIUM CHLORIDE IN DEXTROSE 5 %-0.45 % POLY-L-LACTIC SODIUM CHLORIDE526,535,536 ACID/CARBOXYMETHYLCELLULOSE POTASSIUM CHLORIDE IN DEXTROSE 5% AND 0.3 SODIUM/MANNITOL476,477 % SODIUM CHLORIDE535,536 POLY-TUSSIN DHC511 POTASSIUM CHLORIDE IN LACTATED RINGERS POLY-TUSSIN EX511 AND 5 % DEXTROSE536 POLY-UREAURETHANE344 POTASSIUM CHLORIDE/POTASSIUM POLY-VI-FLOR546 BICARBONATE535 POLY-VI-FLOR WITH IRON546,547 POTASSIUM CHLORIDE/POTASSIUM POLYETHYLENE GLYCOL 3350373 BICARBONATE/CITRIC ACID548 POLYETHYLENE GLYCOL 3350/BOWEL PREP POTASSIUM CITRATE547,558,559 #2,TWO PART PREP373 POTASSIUM CITRATE/CITRIC ACID381,383,547 POLYHEXAMETHYLENE BIGUANIDE/GAUZE POTASSIUM HYDROXIDE346 BANDAGE464 POTASSIUM IODIDE555 POLYMYXIN B SULFATE68 POTASSIUM IODIDE/IODINE538,555 POLYMYXIN B SULFATE/TRIMETHOPRIM486 POTASSIUM OXALATE476 POLYTRIM486 POTASSIUM PHOS,M-BASIC-D-BASIC548 POMALIDOMIDE149,150,443,444 POTASSIUM PHOSPHATE,MONOBASIC381 POMALYST149,150,443,444 POTASSIUM PONATINIB HCL164 SORBATE/HYDROXYETHYLCELLULOSE/POVIDON PONSTEL10,59 E/HYALUR AC322 PONTOCAINE42 POTASSIUM SORBATE/MALTODEXTRIN/ALOE PORACTANT ALFA509 VERA/MANN PS323 PORFIMER SODIUM159 POTIGA96 POSACONAZOLE136 POVIDONE-IODINE483 POTABA547 POVIDONE/TAURINE/ZINC GLUCONATE/PEG-40 POTASSIUM ACETATE547 CASTOR OIL322 POTASSIUM AMINOBENZOATE547 PRADAXA232 POTASSIUM BICARBONATE/CITRIC PRALATREXATE152 ACID529,535,537,547 PRALIDOXIME CHLORIDE475

PAGE 619 LAST UPDATED 10/2014 PRALIDOXIME CHLORIDE/ATROPINE SULFATE465 PRENATABS RX549 PRAMIPEXOLE DI-HCL172,173 PRENATAL NO.29/IRON CARB & PRAMLINTIDE ACETATE224 ASP.GLYCINATE/FA/DHA/FISH OIL544 PRAMOSONE394,395 PRENATAL NO.30/IRON CARBONLY & ASPARTO PRAMOSONE E395 GLYCINATE/FA/OMEGA3545 PRANDIMET224 PRENATAL NO.56/IRON CARBONYL & ASPARTO PRANDIN224 GLYCINATE/FA/DHA544 PRASUGREL HCL244 PRENATAL NO.64/IRON FUM/L-MEFOLATE PRAVACHOL296 CA/ALGAL OIL/SOY LECITHIN542,559 PRAVASTATIN SODIUM296 PRENATAL NO.80/IRON CARB & PRAZIQUANTEL168 BISGLY/METHYLFOLATE GLUC/DSS/DHA531 PRAZOSIN HCL247,379 PRENATAL VIT #16/IRON FUM & PS PRE-ATTACHED LTA KIT42 COMPLEX/FOLIC ACID/OMEGA-3525,556,560 PRE-PEN475 PRENATAL VIT COMB NO.4/IRON CARBONYL-IRON PRECEDEX518 GLUCONATE/FA/DOSS559 PRECOSE224 PRENATAL VIT COMB NO.48/IRON, CARBONYL & PRED FORTE490 GLUCONATE/FA/B6524 PRED MILD490 PRENATAL VIT NO.71/IRON FUM-SODIUM PRED-G486 FEREDETATE/FOLIC ACID/DHA562 PREDNICARBATE334,346 PRENATAL VIT W/O CALC NO.10/IRON PREDNISOLONE53,54,393,395 FUM&POLYSAC COMP/FA/OMEGA-3553 PREDNISOLONE ACETATE51,490 PRENATAL VIT WITH CA NO.64/IRON PREDNISOLONE SOD CARB&GLUC/FOLIC ACID/DSS/DHA524,542,549 PHOSPHATE53,54,56,393,394,395,398,490 PRENATAL VIT WITH CA NO.68/IRON PREDNISONE54,55,395,396,455,456 FUMARATE/FOLIC ACID #1/DHA546,560,562 PREFERA OB548 PRENATAL VIT WITH CALCIUM #60/IRON/FOLIC PREFERA-OB ONE548 ACID/DHA533 PREFERA-OB PLUS DHA549 PRENATAL VIT WITH CALCIUM PREFEST414 #69/IRON,CARBON/FOLIC PREFLIN549 ACID/DSS/DHA538,549,562 PREGABALIN96,97,317 PRENATAL VIT WITH CALCIUM CMB 11/FERROUS PREGNYL401 FUMARATE/FOLIC ACID561 PRELONE54,395 PRENATAL VIT WITH CALCIUM COMB PREMARIN414 NO.63/IRON,CARBONYL/FA/B6556 PREMASOL549 PRENATAL VIT WITH CALCIUM COMB NO.65/IRON PREMPHASE414 POLYSACCH CMPLX/FA539 PREMPRO414,415 PRENATAL VIT WITH CALCIUM NO. 40/IRON PRENA1 CHEW549 FUMARATE/FA CMB NO.1546,560,562 PRENAISSANCE NEXT-B549 PRENATAL VIT WITH CALCIUM NO.39/IRON PRENATA549 FUM/FOLIC ACID/DSS/DHA532,556 PRENATABS FA549

PAGE 620 LAST UPDATED 10/2014 PRENATAL VIT WITH CALCIUM NO.66/IRON PRENATAL VITAMIN NO.110/IRON EDTA FUM/FOLIC &POLYSACCHA/FA/OM3/DHA/EPA529 ACID/DSS/DHA531,546,549,551,558,559,560 PRENATAL VITAMIN NO.113/IRON EDTA PRENATAL VIT WITH CALCIUM NO.80/IRON &POLYSACCHA/FA/OM3/DHA/EPA529 FUM/FOLIC ACID/DSS/DHA543,549,557,560 PRENATAL VITAMIN NO.117/SOD FEREDE-IRON PRENATAL VIT WITH CALCIUM NO42/IRON POLY/FA/OM3/DHA/EPA529 FUM/FA/L-MEFOLATE CA/DHA537,546 PRENATAL VITAMIN PRENATAL VIT WITH CALCIUM NO8-IRON PS NO.15/IRON,CARBONYL/FOLIC ACID/DOCUSATE CMPLX,FA,L-MEFOLATE CA546 SOD534,541,550,557,560 PRENATAL VIT/FOLIC ACID/B6/CALCIUM PRENATAL VITAMIN CARB/GINGER549 NO.16/IRON,CARBONYL/FOLIC ACID/DOCUSATE PRENATAL VIT/FOLIC ACID/B6/CALCIUM PHOS DI SOD558,560 & TRIBASIC/GINGER522,531,549,562,563 PRENATAL VITAMIN PRENATAL VITAMIN #50/IRON FUMARATE & NO.17/IRON,CARBONYL/FOLIC ACID/DOCUSATE BISGLYCINATE/FOLIC ACID542 SOD525 PRENATAL VITAMIN #55/IRON FUMARATE & PRENATAL VITAMIN BISGLYCINATE/FOLIC ACID542 NO.18/IRON,CARBONYL/FOLIC ACID/DOCUSATE PRENATAL VITAMIN 27 WITH CALCIUM/FERROUS SOD534,558,560 FUMARATE/FOLIC ACID558,560 PRENATAL VITAMIN NO.53/IRON FUM/FOLIC PRENATAL VITAMIN COMB NO.79/IRON ACID/DOCUSATE CA/DHA543 FUMARAT/FA/LMEFOLATE CA/DHA537,542,559 PRENATAL VITAMIN NO.57/IRON FUM/FOLIC PRENATAL VITAMIN COMB NO.86/IRON PS ACID/DSS/DHA530,557 CMPLX/FOLIC ACID/DHA/EPA543 PRENATAL VITAMIN NO.58/IRON PRENATAL VITAMIN COMB#3/IRON FUMARATE & FUMARATE/FOLIC ACID/DSS/DHA543 GLUCONATE/FOLIC ACID539 PRENATAL VITAMIN NO.67/SODIUM FEREDETATE- PRENATAL VITAMIN COMBINATION IRON POLY/FA/OMEGA3523 NO.19/IRON/FOLIC ACID/DHA548,550,562 PRENATAL VITAMIN NO.77/SODIUM FEREDETATE- PRENATAL VITAMIN COMBO NO.22/IRON/FOLIC IRON POLY/FA/OMEGA3559 ACID/OMEGA-3/DHA533,549,562 PRENATAL VITAMIN NO.81/SODIUM FEREDETATE- PRENATAL VITAMIN COMBO NO.68/IRON IRON POLY/FA/OMEGA3522,559 FUMARATE/FA COMBO NO.6/DHA550 PRENATAL VITAMIN NO.86/IRON BIS- PRENATAL VITAMIN COMBO NO.8/IRON PS CMPLX GLYCINATE/FOLIC ACID543,544,559 & ASPGL/FA/DHA545,558 PRENATAL VITAMIN NO.88/IRON PS PRENATAL VITAMIN NO.103/IRON COMPLEX/FA/L-MEFOLATE CA/DHA537,542 FUM/FA/DHA/EPA/OTHER OMEGA-3S557 PRENATAL VITAMIN NO.94/SODIUM FEREDETATE- PRENATAL VITAMIN NO.105/IRON EDTA IRON POLY/FA/OMEGA3549,560 &POLYSACCHA/FA/OM3/DHA/EPA529,549 PRENATAL VITAMIN W-O CALCIUM/FERROUS PRENATAL VITAMIN NO.106/SOD FEREDE-IRON FUMARATE/FOLIC ACID538 POLY/FA/OM3/DHA/EPA528,529 PRENATAL VITAMIN W-O CALCIUM/IRON PRENATAL VITAMIN NO.107/SOD FEREDE-IRON POLYSACCHARIDE COMPLEX/FA553 POLY/FA/OM3/DHA/EPA528,529

PAGE 621 LAST UPDATED 10/2014 PRENATAL VITAMIN W-O PRENATAL VITAMINS COMB NO.82/FERROUS CALCIUM/IRON,CARBONYL/DOCUSATE/FA545 FUMARATE/FOLATE COMB #2563 PRENATAL VITAMIN#100/IRON SOD PRENATAL VITAMINS COMB NO.87/IRON EDTA&POLYSAC COMPLX/FA/OMEGA-3522 BISGLY/FOLIC ACID/DHA543,544,557,559 PRENATAL VITAMINS #39/IRON AMINO ACID PRENATAL VITAMINS COMB. NO.21 WITH IRON & CHELATE/FA COMBO#6/DHA549,561 FOLIC ACID533,548,562 PRENATAL VITAMINS #44/IRON,CARBONYL/FOLIC PRENATAL VITAMINS COMBINATION NO.42/FOLIC ACID/DHA550 ACID549,561 PRENATAL VITAMINS COMB PRENATAL VITAMINS COMBO #36/FERROUS #83/IRON,CARBONYL/IRON ASPARTO GLY/FA544 FUMARATE/FOLATE COMBO #6550 PRENATAL VITAMINS COMB 10/FERROUS PRENATAL VITAMINS COMBO NO.14/FERROUS FUMARATE/FOLIC ACID561 FUMARATE/FOLIC ACID525 PRENATAL VITAMINS COMB 10/FERROUS PRENATAL VITAMINS COMBO NO.25/IRON FUMARATE/FOLIC ACID/DHA546,561 FUMARATE/FA COMBO#6/DHA549,561 PRENATAL VITAMINS COMB NO.115/IRON PRENATAL VITAMINS COMBO NO.33/IRON PS FUMARATE/FOLIC ACID549 CMPLX/FOLIC ACID/DHA523,553 PRENATAL VITAMINS COMB NO.115/IRON PRENATAL VITAMINS COMBO FUMARATE/FOLIC ACID/DSS546,549 NO.34/IRON,CARB/FOLIC ACID/DSS/DHA524,534 PRENATAL VITAMINS COMB NO.119/IRON PRENATAL VITAMINS COMBO NO.37/FERROUS FUMARATE/FOLIC ACID/DSS553 FUMARATE/FOLIC ACID549 PRENATAL VITAMINS COMB NO.19/IRON BG PRENATAL VITAMINS COMBO NO.43/IRON PS HCL&SUC-PROT/FA/OMEGA-3548 CMPLX/FOLIC ACID/DHA561 PRENATAL VITAMINS COMB NO.19/IRON BG PRENATAL VITAMINS COMBO NO.45/FERROUS HCL&SUCC-P2/FA/OMEGA-3556 FUMARATE/FOLIC ACID562 PRENATAL VITAMINS COMB NO.42/FOLIC ACID PRENATAL VITAMINS COMBO NO.52/FERROUS COMB NO.6549,561 FUMARATE/FA/DHA562 PRENATAL VITAMINS COMB PRENATAL VITAMINS COMBO NO.43/IRON,CARBONYL/FA/DOCUSATE SOD522 NO.59/IRON,CARB/FOLIC ACID/DSS/DHA524 PRENATAL VITAMINS COMB NO.48/IRON NA PRENATAL VITAMINS COMBO NO.60/FERROUS FEREDETATE/FA/OMEGA-3523 FUMARATE/FOLIC ACID546 PRENATAL VITAMINS COMB NO.53/IRON B-G HCL PRENATAL VITAMINS COMBO SUC-P/FA/OMEGA-3548,558 NO.66/IRON,CARBONYL/FOLIC ACID/DHA520,552 PRENATAL VITAMINS COMB NO.54/IRON B-G HCL PRENATAL VITAMINS COMBO NO.69/IRON SUC-P/FA/OMEGA-3548,553 FUMARATE/FA COMB NO.6/DHA550 PRENATAL VITAMINS COMB NO.55/IRON BG PRENATAL VITAMINS NO.11/FERROUS HCL&SUC-PROT/FA/OMEGA-3548 FUMARATE/FOLIC ACID/OMEGA-3523,552,562 PRENATAL VITAMINS COMB NO.55/IRON BG PRENATAL VITAMINS HCL&SUCC-P2/FA/OMEGA-3553 NO.112/METHYLTETRAHYDROFOLATE PRENATAL VITAMINS COMB NO.75/FERROUS GLUCOSAMI,FA550 FUMARATE/FOLATE COMB #1561

PAGE 622 LAST UPDATED 10/2014 PRENATAL VITAMINS PRENATAL VITAMINS NO.78/IRON ASPARTO NO.114/METHYLTETRAHYDFOLATE GLYCIN/FOLATE NO.1/DHA550 GLUC,FA/GINGER550 PRENATAL VITAMINS NO.79/FERROUS ASPART PRENATAL VITAMINS GLYCINATE/FOLATE NO.1550 NO.12/IRON,CARBONYL/FA/DOCUSATE PRENATAL VITAMINS NO.81/IRON CARBONYL & NA/OMEGA-3545 GLUCONATE/FA/DSS563 PRENATAL VITAMINS NO.13/IRON PRENATAL VITAMINS NO.84/IRON ASPARTO POLYSACCHARIDES/FA CMB NO.1553 GLYCIN/FOLATE NO.1/DHA563 PRENATAL VITAMINS NO.15/IRON FUMARATE & PRENATAL VITAMINS W-O CA COMB. NO. 8 WITH POLYSAC COMP/FA525,532 IRON & FOLIC ACID562 PRENATAL VITAMINS PRENATAL VITAMINS WITH CALCIUM/FE NO.18/IRON,CARBONYL/FA/UBIDECARENONE/DHA BISGLY/FOLIC ACID559,560 558 PRENATAL VITAMINS WITH CALCIUM/FERROUS PRENATAL VITAMINS NO.22/IRON CBN & FUMARATE/DOCUSATE/FA541 GLUC/FOLIC ACID/DSS524,557,559 PRENATAL VITAMINS WITH CALCIUM/FERROUS PRENATAL VITAMINS NO.22/IRON FUMARATE/FA/SELENIUM539,560 CBN&GLUCON/FOLIC ACID/DSS/DHA524,546,549 PRENATAL VITAMINS WITH CALCIUM/FERROUS PRENATAL VITAMINS NO.26/IRON FUMARATE/FOLIC ACID541,542,544,562 POLYSACCHARIDES/FA/DHA546,552,561 PRENATAL VITAMINS WITH PRENATAL VITAMINS NO.27/IRON CARBONYL & CALCIUM/IRON,CARBONYL/DOCUSATE/FA541 FUMARATE/FOLIC ACID542 PRENATAL VITS #4/IRON FUMARATE & POLYSACC PRENATAL VITAMINS NO.34/IRON CARBONYL & COMPLEX/FOLIC ACID552 FUMARATE/FA/DSS/DHA562 PRENATAL VITS #65/IRON FUMARATE & POLYSAC PRENATAL VITAMINS NO.38/IRON COMPLEX/FOLIC ACID552 CBN&GLUCON/FOLIC ACID/DSS/DHA524,542,549 PRENATAL VITS CMB W-O CA NO.2560 PRENATAL VITAMINS NO.38/IRON PRENATAL VITS W-O CA COMB. NO. 7 W/ IRON & FUMARATE/FOLATE COMB NO.6/DHA550 FOLIC ACID & DHA529 PRENATAL VITAMINS NO.4/FERROUS PRENATAL VITS WITH CALCIUM #2/IRON B-G SUC- FUMARATE/FOLIC ACID552 P/FA/OMEGA-3525,558 PRENATAL VITAMINS NO.59/IRON CARBONYL & PRENATAL VITS WITH CALCIUM FUMARATE/FA/DSS/DHA524,534 #44/IRON,CARBONYL/FOLIC ACID562 PRENATAL VITAMINS NO.67/IRON PRENATAL VITS WITH CALCIUM #47/FE POLYSACCHARIDES/FA CMB NO.1/DHA561 FUMARATE/FA CMB #1/DHA546,560,562 PRENATAL VITAMINS NO.72/IRON CARBONYL & PRENATAL VITS WITH CALCIUM #62/FERROUS GLUCONATE/FA/DSS/DHA523 FUMARATE/FA/DHA558 PRENATAL VITAMINS NO.73/IRON CARBONYL & PRENATAL VITS WITH CALCIUM #7/FE ASP GLUCONATE/FA/DSS/DHA524 GLY/DOCUSATE/FOLIC ACID560 PRENATAL VITAMINS NO.76/IRON CARBONYL & PRENATAL VITS WITH CALCIUM #70/FERROUS GLUCONATE/FA/DSS/DHA524 FUMARATE/FA/DHA523,542 PRENATAL VITAMINS NO.77/FERROUS ASPARTO PRENATAL VITS WITH CALCIUM #71/FERROUS GLYCINATE/FOLIC ACID551 FUMARATE/FOLIC ACID549,562

PAGE 623 LAST UPDATED 10/2014 PRENATAL VITS WITH CALCIUM #72/FERROUS PREVIDENT 5000 ENAMEL PROTECT324 FUMARATE/FOLIC ACID546,550,551 PREVIDENT 5000 PLUS324 PRENATAL VITS WITH CALCIUM PREVIDENT 5000 SENSITIVE324 #72/IRON,CARBONYL/FOLIC ACID550 PREVNAR 13450 PRENATAL VITS WITH CALCIUM #73/FERROUS PREVPAC368 FUMARATE/FOLIC ACID558,560,562 PREZISTA192,193 PRENATAL VITS WITH CALCIUM #74/FERROUS PRIALT315 FUMARATE/FOLIC ACID550 PRIFTIN145 PRENATAL VITS WITH CALCIUM PRILOCAINE HCL37 #76/IRON,CARBONYL/FOLIC ACID542,546,549,562 PRILOSEC375 PRENATAL VITS WITH CALCIUM #78/FERROUS PRIMAQUINE PHOSPHATE169 FUMARATE/FOLIC ACID549,551,559 PRIMAXIN79 PRENATAL VITS WITH CALCIUM PRIMIDONE96 #84/IRON,CARBONYL/FOLIC ACID/DHA544 PRIMSOL68 PRENATAL VITS WITH CALCIUM#103/FERROUS PRINIVIL253 FUMARATE/FOLIC ACID557 PRINZIDE285 PRENATAL VITS WITH CALCIUM#109/FERROUS PRISMASOL551 FUMARATE/FOLIC ACID559 PRISTIQ ER121 PRENATAL VITS WITH CALCIUM#118/FERROUS PROAIR HFA505 FUMARATE/FOLIC ACID553 PROBARIMIN QT551 PRENATAL VITS WITHOUT CALC NO5/FERROUS PROBENECID138 FUMARATE/FOLIC ACID550,558 PROCAINAMIDE HCL257 PRENATAL WITHOUT IRON/FOLIC ACID/CALCIUM PROCALAMINE551 CARB/PYRIDOXINE/B12522,531,558 PROCARBAZINE HCL148 PRENATE AM550 PROCARDIA271 PRENATE CHEWABLE550 PROCARDIA XL271 PRENATE DHA550 PROCHLORPERAZINE MALEATE126,128,177 PRENATE ELITE550 PROCORT368 PRENATE ENHANCE550 PROCRIT236,237 PRENATE ESSENTIAL550,563 PROCTOCORT54,368 PRENATE MINI550 PROCTOFOAM-HC368 PRENATE RESTORE550 PROCYSBI382 PRENATE STAR551 PRODRIN315 PRENEXA551 PROFERRIN-FORTE551 PREPIDIL382 PROFILNINE241,242 PREPOPIK373 PROGESTERONE417,419 PREQUE 10551 PROGESTERONE,MICRONIZED416,417,419 PRESERA346 PROGLYCEM225 PREVACID375 PROGRAF436,437 PREVIDENT324 PROHANCE475 PREVIDENT 5000324 PROHANCE MULTIPACK475

PAGE 624 LAST UPDATED 10/2014 PROLASTIN511 PROTECTIVES COMBINATION NO.2/CERAMIDES PROLASTIN C511 1,3,6-11346,352 PROLENSA490 PROTEIN C CONCENTRATE, HUMAN227 PROLEUKIN159 PROTONIX375 PROLIA167,459 PROTONIX IV376 PROMACTA237 PROTOPAM CHLORIDE475 PROMETHAZINE HCL128,129,499 PROTOPIC346 PROMETHAZINE HCL/CODEINE512 PROTRIPTYLINE HCL125,126 PROMETHAZINE/PHENYLEPHRINE PROVENGE159 HCL/CODEINE512 PROVENTIL HFA505 PROMETRIUM419 PROVERA419 PROMISEB346 PROVIDA OB552 PROMISEB COMPLETE346 PROVIGIL519 PROPAFENONE HCL257,258 PROVOCHOLINE475 PROPANTHELINE BROMIDE368 PROZAC121 PROPARACAINE HCL35,42,482,486 PROZAC WEEKLY121 PROPARACAINE HCL/FLUORESCEIN SODIUM484 PRUDOXIN346 PROPECIA379,432 PRUSSIAN BLUE (INSOLUBLE)476 PROPOFOL37,42 PSEUDOEPHEDRINE HCL/ACRIVASTINE512 PROPOFOL/PF42,43 PSEUDOEPHEDRINE HCL/CHLORPHENIRAMINE PROPOVEN42,43 MALEATE/BELLAD ALK512 PROPRANOLOL HCL261,263 PSEUDOEPHEDRINE HCL/CODEINE PROPRANOLOL HCL/HYDROCHLOROTHIAZIDE285 PHOSPHATE509 PROPYLTHIOURACIL433 PSEUDOEPHEDRINE HCL/CODEINE PROQUAD450 PHOSPHATE/ACETAMINOPHEN/GUAIFEN510,511 PROSCAR379,432 PSEUDOEPHEDRINE HCL/CODEINE PROSED-DS68 PHOSPHATE/GUAIFENESIN510,513 PROSOL551 PSEUDOEPHEDRINE HCL/CODEINE PROSOURCE TF552 PHOSPHATE/TRIPROLIDINE511 PROSTASCINT475 PSEUDOEPHEDRINE HCL/HYDROCODONE PROSTIGMIN144 BITARTRATE512 PROSTIN E2 VAGINAL SUPPOSITORY382 PSEUDOEPHEDRINE HCL/HYDROCODONE PROSTIN VR PEDIATRIC285 BITARTRATE/CHLORPHENIRAMINE510,513 PROTAMINE SULFATE242 PULMICORT496 PROTECT BONE552 PULMICORT FLEXHALER496 PROTECT CARDIO552 PULMOZYME512 PROTECT IRON552 PUREFE OB PLUS552 PROTECT NATAL552 PUREFE PLUS552 PROTECT PLUS552 PURINETHOL153 PROTECT PLUS NR552 PURIXAN153 PYLERA368

PAGE 625 LAST UPDATED 10/2014 PYRAZINAMIDE145 RABIES IMMUNE GLOBULIN/PF440,441 PYRIDIUM383 RABIES VACCINE, HUMAN DIPLOID CELL/PF449 PYRIDOSTIGMINE BROMIDE144 RABIES VACCINE, PURIFIED CHICKEN EMBRYO PYRIDOXAL PHOS/METHYLTETRAHYDROFOLATE CELL (PCEC)/PF450,451 GLUC/MECOBALAMIN/ALA546 RADIAPLEXRX347 PYRIDOXINE HCL552 RADIGEL347 PYRILAMINE MALEATE/PHENYLEPHRINE RADIOGARDASE476 HCL/CODEINE PHOSPHATE513 RADIOPAQUE PVC MARKERS/BARIUM PYRILAMINE MALEATE/PHENYLEPHRINE SULFATE477 HCL/DIHYDROCODEINE BT511 RADIUM-223 DICHLORIDE160 PYRIMETHAMINE168 RAGWITEK512 PYROGALLIC ACID347 RALOXIFENE HCL419,420,458 PYROGALLOL347 RALTEGRAVIR POTASSIUM191 RAMELTEON519 Q RAMIPRIL250,251,253 Q-TABS552 RAMUCIRUMAB167 QNASL496 RANEXA285 QSYMIA315 RANIBIZUMAB485 QUADRAMET476 RANITIDINE HCL369,370,371 QUALAQUIN169 RANITIDINE HCL IN 0.45 % SODIUM CHLORIDE371 QUARTETTE415 RANOLAZINE285 QUAZEPAM516,517 RAPAFLO379 QUDEXY XR103,104 RAPAMUNE437 QUELICIN316 RASAGILINE MESYLATE175 QUESTRAN LIGHT298 RASBURICASE359 QUETIAPINE FUMARATE114,181,183,211 RASUVO437 QUFLORA476,552 RAVICTI360 QUILLIVANT XR309 RAYOS54,55,395,396 QUINAPRIL HCL250,253 RAZADYNE110 QUINAPRIL HCL/HYDROCHLOROTHIAZIDE273,285 RAZADYNE ER110 QUINIDINE GLUCONATE257 READI-CAT476 QUINIDINE SULFATE257 READI-CAT 2476 QUININE SULFATE169 REAPHIRM552 QUINUPRISTIN/DALFOPRISTIN69 REBETOL196 QUTENZA347 REBIF319,444 QVAR496 REBIF REBIDOSE319,444 RECLAST459 R RECOMBINATE242 R-GENE 10476 RECOMBIVAX HB451 RABAVERT450,451 RECOTHROM476 RABEPRAZOLE SODIUM373,376 RECTIV300,383

PAGE 626 LAST UPDATED 10/2014 REFLUDAN232 RETAPAMULIN62 REGADENOSON470 RETAVASE232 REGENECARE43 RETEPLASE232 REGIMEX316 RETIN-A347,348 REGLAN129,368 RETIN-A MICRO348 REGONOL144 RETIN-A MICRO PUMP348 REGORAFENIB165 RETISERT490 REGRANEX347 RETROVIR189 RELAGESIC476 REVATIO507 RELAMINE476 REVLIMID150,444 RELENZA193 REYATAZ193 RELISTOR368 REZIRA512 RELPAX142 REZYST368 REMERON114 REZYST IM368 REMESENSE476 RHEUMATE553 REMICADE437 RHEUMATREX437 REMIFENTANIL HCL34 RHINOCORT AQUA497 REMODULIN507 RHO(D) IMMUNE GLOBULIN440,441 RENACIDIN383 RHO(D) IMMUNE GLOBULIN/MALTOSE442 RENAGEL384 RHOGAM ULTRA-FILTERED PLUS441 RENAX553 RHOPHYLAC441 RENOVA347 RIASTAP242 RENOVA PUMP347 RIAX348 RENVELA384 RIBAPAK196 REOPRO245 RIBATAB196 REPAGLINIDE224 RIBAVIRIN194,195,196 REPAGLINIDE/METFORMIN HCL224 RIBOSE526 REPAN316 RIDAURA444 REPREXAIN32 RIFABUTIN145 REPRONEX476 RIFADIN145 REQ49+553 RIFAMATE145 REQUIP173 RIFAMPIN145,146 REQUIP XL173 RIFAMPIN/ISONIAZID145 RESCRIPTOR188 RIFAMPIN/ISONIAZID/PYRAZINAMIDE146 RESCULA492 RIFAPENTINE145 RESECTISOL383 RIFATER146 RESERPINE247 RIFAXIMIN71,369 RESPA A.R.512 RILONACEPT442 RESTASIS437,486 RILPIVIRINE HCL188 RESTORA RX476 RILUTEK316 RESTORIL517 RILUZOLE316

PAGE 627 LAST UPDATED 10/2014 RIMABOTULINUMTOXINB314 ROSIGLITAZONE MALEATE/METFORMIN HCL217 RIMANTADINE HCL193 ROSUVASTATIN CALCIUM295 RIMEXOLONE490 ROTARIX451 RIMSO-50383 ROTATEQ451 RINGERS SOLUTION553 ROTAVIRUS VACC, LIVE ORAL ATTENUATED, 89- RINGERS SOLUTION,LACTATED537 12 STRAIN, G1P(8)451 RIOCIGUAT506 ROTAVIRUS VACCINE, LIVE ORAL RIOMET224 PENTAVALENT451 RISEDRONATE SODIUM457,459 ROTIGOTINE172 RISPERDAL181,209 ROWASA368,453 RISPERDAL CONSTA181,182,210 ROXICET32 RISPERDAL M-TAB182,210 ROXICODONE32,33 RISPERIDONE181,182,183,209,210 ROZEREM519 RISPERIDONE MICROSPHERES181,182,210 RUCONEST476 RITALIN310 RUFINAMIDE105 RITALIN LA310 RUXOLITINIB PHOSPHATE162 RITALIN-SR310 RYANODEX515 RITONAVIR192 RYBIX ODT33 RITUXAN167 RYTHMOL258 RITUXIMAB167 RYTHMOL SR258 RIVAROXABAN233 RYZOLT18,19 RIVASTIGMINE109,110 RIVASTIGMINE TARTRATE109,110 S RIXUBIS242 SABRIL100 RIZATRIPTAN BENZOATE142,143 SACCHAROMYCES BOULARDII368 ROBAXIN515 SACROSIDASE360 ROBAXIN-750515 SAFYRAL415 ROBINUL257,258,363,364,512 SAIZEN401 ROBINUL FORTE364 SALAGEN324 ROCALTROL427,459,460 SALEX348 ROCEPHIN77 SALICYLIC ACID328,340,348,349,355,357 ROCURONIUM BROMIDE316,317 SALICYLIC ACID/AMMONIUM LACTATE/ALOE ROFLUMILAST509 VERA349 ROMAZICON476 SALICYLIC ACID/BENZOYL PEROXIDE/VITAMIN E ROMIDEPSIN164 MIXED340 ROMIPLOSTIM236 SALICYLIC ACID/CERAMIDES 1,3,6-11348,349 ROPINIROLE HCL173,174 SALICYLIC ACID/UREA349 ROPIVACAINE HCL/PF40,41,43 SALIVA SUBSTITUTION COMBO NO.2320 ROSADAN68 SALIVA SUBSTITUTION COMBO NO.3320 ROSIGLITAZONE MALEATE217 SALIVA SUBSTITUTION COMBO NO.5323 ROSIGLITAZONE MALEATE/GLIMEPIRIDE217 SALKERA349

PAGE 628 LAST UPDATED 10/2014 SALMETEROL XINAFOATE505 SENSORCAINE43 SALSALATE10 SENSORCAINE-MPF43 SALVAX349 SENSORCAINE-MPF EPINEPHRINE43 SALVAX DUO PLUS349 SENTRA AM553 SAMARIUM SM 153 LEXIDRONAM476 SENTRA PM553 SAMSCA520 SEREVENT DISKUS505 SANCTURA377 SEROMYCIN69,146 SANCTURA XR377 SEROPHENE477 SANCUSO131 SEROQUEL183,211 SANDIMMUNE438 SEROQUEL XR114,183,211 SANDOSTATIN430,431 SEROSTIM401 SANDOSTATIN LAR431 SERTACONAZOLE NITRATE133,336 SANTYL349 SERTRALINE HCL121,122,207,208 SAPHRIS183,210 SETONET-EC553 SAPROPTERIN DIHYDROCHLORIDE359 SEVELAMER CARBONATE384 SAQUINAVIR MESYLATE192 SEVELAMER HCL384 SARAFEM121 SEVOFLURANE44 SARGRAMOSTIM235 SFROWASA368,453 SAVELLA317,318 SIDEROL554 SAXAGLIPTIN HCL223 SIGNIFOR427 SAXAGLIPTIN HCL/METFORMIN HCL222 SILDENAFIL CITRATE384,507 SCALACORT DK396 SILENOR519 SCLEROSOL476 SILODOSIN379 SCOPOLAMINE129 SILTUXIMAB438 SCOPOLAMINE HYDROBROMIDE364,485 SILVADENE90,349 SCULPTRA476,477 SILVER350 SEASONIQUE415 SILVER NITRATE349 SECOBARBITAL SODIUM517 SILVER NITRATE/POTASSIUM NITRATE338 SECONAL SODIUM517 SILVER SULFADIAZINE90,91,349,351,353 SECRETIN ACETATE (HUMAN)463 SILVRSTAT350 SECTRAL263 SIMBRINZA492 SELECT-OB553 SIMCOR299 SELECT-OB + DHA553 SIMEPREVIR SODIUM195 SELEGILINE116 SIMPONI438 SELEGILINE HCL175 SIMPONI ARIA438 SELENIUM553 SIMULECT438 SELENIUM SULFIDE349,352 SIMVASTATIN296,297 SELRX349 SINCALIDE366 SELZENTRY191 SINECATECHINS357 SEMPREX-D512 SINEMET 10-100175 SENSIPAR428 SINEMET 25-100175

PAGE 629 LAST UPDATED 10/2014 SINEMET 25-250175 SODIUM SINEMET CR175 FLUORIDE320,322,323,324,530,531,538,555 SINGLE USE EZ FLU 2012-2013451 SODIUM FLUORIDE/POTASSIUM NITRATE324 SINGLE USE EZ FLU 2013-2014451 SODIUM FLUORIDE/XYLITOL322 SINGULAIR500 SODIUM GLYCEROPHOSPHATE533 SINOGRAFIN477 SODIUM IODIDE535 SIPULEUCEL-T/LACTATED RINGERS SODIUM IODIDE-123477 SOLUTION159 SODIUM LACTATE555 SIROLIMUS437,438 SODIUM MORRHUATE472 SIRTURO146 SODIUM NITRITE286 SITAGLIPTIN PHOSPHATE221 SODIUM NITRITE/SODIUM THIOSULFATE473 SITAGLIPTIN PHOSPHATE/METFORMIN HCL221 SODIUM NITRITE/SODIUM THIOSULFATE/AMYL SITAGLIPTIN PHOSPHATE/SIMVASTATIN221,222 NITRITE464 SITAVIG198 SODIUM OXYBATE519 SITZMARKS477 SODIUM PHENYLBUTYRATE358,360 SIVEXTRO69 SODIUM PHOS,M-BASIC-D-BASIC555 SKELAXIN515 SODIUM PHOSPHATE,M-BASIC M-HYD/SODIUM SKELID460 PHOSPHATE,DIBASIC545 SKLICE170 SODIUM PHOSPHATE,MONOBASIC/POTASSIUM SKYLA419 PHOSPHATE,MONOBASIC381 SOD MAG FLUOROSILIC/CYCLOMETH/PHOSPH SODIUM PICOSULFATE/MAGNESIUM AC/SOD BICARB/SOD CHLOR327 OXIDE/CITRIC ACID373 SODIUM ACETATE554 SODIUM POLYSTYRENE SULFONATE519,520 SODIUM BENZOATE/SODIUM SODIUM SULFATE/POTASSIUM PHENYLACETATE358 SULFATE/MAGNESIUM SULFATE373 SODIUM BICARBONATE543,554 SODIUM TETRADECYL SULFATE477 SODIUM CHLORIDE555 SODIUM THIOSULFATE477 SODIUM CHLORIDE 0.45 %553,554 SODIUM THIOSULFATE/SALICYLIC ACID337 SODIUM CHLORIDE 3 %555 SODIUM/POTASSIUM/MAGNES/CALCIUM/CHLORID SODIUM CHLORIDE 5 %555 E/ACETATE/GLUCONATE544 SODIUM CHLORIDE FOR INHALATION510,511,512 SODIUM/POTASSIUM/MAGNESIUM/CALCIUM/CHLO SODIUM CHLORIDE IRRIGATING SOLUTION554 RIDE/ACETATE534,544,557 SODIUM CHLORIDE/SODIUM SODIUM/POTASSIUM/POTASSIUM BICARBONATE/POTASSIUM CITRATE/SODIUM CITRATE/CIT AC381,383 CHLORIDE/PEG372,373 SOFOSBUVIR196 SODIUM CITRATE DIHYDRATE232 SOLARAZE350,396 SODIUM DIURIL292 SOLESTA477 SODIUM EDECRIN290 SOLIFENACIN SUCCINATE378 SODIUM FERRIC GLUCONATE COMPLEX IN SOLIRIS237 SUCROSE466,530,544,554 SOLODYN94,324 SOLTAMOX150

PAGE 630 LAST UPDATED 10/2014 SOLU-CORTEF396,456 STAXYN383 SOLU-MEDROL55,396,456 STELARA351,444 SOMA515 STENDRA383 SOMATROPIN399,400,401,402 STEVIOSIDE/REBAUDIOSIDE A & SOMATULINE DEPOT431 B/STEVIOL/STEVIOLBIOSIDE/VIT D3549 SOMAVERT431 STIMATE401 SONATA517 STIVARGA165 SORAFENIB TOSYLATE165 STRATTERA310 SORBITOL SOLUTION383 STREPTOMYCIN SULFATE61,146 SORBITOL/SALIVA STIMULANT COMB NO. 1/MALIC STREPTOZOCIN149 ACID/CAL PHOS323 STRIANT403 SORIATANE350,351 STRIBILD191 SORILUX351 STRIVERDI RESPIMAT505 SOTALOL HCL255,258 STROMECTOL168 SOTRADECOL477 STRONTIUM-89 CHLORIDE471 SOVALDI196 STROVITE555 SPECTRACEF77 STROVITE FORTE555 SPHERULE-DERIVED COCCIDIOIDES ANTIGEN STROVITE ONE555 SKIN TEST477 STROVITE PLUS555 SPHERUSOL477 SUBLIMAZE19,33 SPINOSAD168,343,351 SUBOXONE46,47 SPIRIVA501 SUBSYS19,33 SPIRONOLACTONE290,291 SUCCIMER519 SPIRONOLACTONE/HYDROCHLOROTHIAZIDE273, SUCCINYLCHOLINE CHLORIDE310,316 274,286 SUCLEAR373 SPORANOX137 SUCRAID360 SPRAY AND STRETCH44 SUCRALFATE373 SPRIX60 SUCROFERRIC OXYHYDROXIDE385 SPRYCEL165 SUFENTA33 SPS520 SUFENTANIL CITRATE33 SSD90,351 SULAR271 STALEVO 100171 SULCONAZOLE NITRATE133 STALEVO 125171 SULFACETAMIDE STALEVO 150171 SODIUM90,91,341,344,349,350,351,483,487 STALEVO 200171 SULFACETAMIDE STALEVO 50171 SODIUM/AVOBENZONE/SULFUR346 STALEVO 75171 SULFACETAMIDE SODIUM/BAKUCHIOL325 STANNOUS FLUORIDE325 SULFACETAMIDE SODIUM/PREDNISOLONE STARLIX224 ACETATE483 STAVUDINE190,191 SULFACETAMIDE SODIUM/PREDNISOLONE STAVZOR100,101,140,215 SODIUM PHOSPHATE486,487

PAGE 631 LAST UPDATED 10/2014 SULFACETAMIDE SURMONTIL125 SODIUM/SULFUR327,329,330,331,346,348,350,351,3 SURVANTA512 52,357,358 SUSTIVA188 SULFACETAMIDE SUTENT165 SODIUM/SULFUR/AVOBENZONE/OCTINOXATE/OC SWABFLUSH556 TYL SAL350,351 SYLATRON159 SULFACETAMIDE SODIUM/SULFUR/SKIN SYLATRON 4-PACK159 CLEANSER COMB NO.23350,351 SYLVANT438 SULFACETAMIDE SYMAX DUOTAB364 SODIUM/SULFUR/UREA329,331,350 SYMBICORT505 SULFACETAMIDE SODIUM/SULFUR/WITCH SYMBYAX114,115 HAZEL349 SYMLINPEN 120224 SULFACETAMIDE SODIUM/UREA350 SYMLINPEN 60224 SULFADIAZINE91 SYNAGEX556 SULFAMETHOXAZOLE/TRIMETHOPRIM90,91 SYNAGIS445 SULFAMYLON69 SYNALAR55,352,396,397 SULFANILAMIDE90 SYNALAR TS55,352,397 SULFASALAZINE365,368,369,443,444,445,456,457 SYNALGOS-DC33 SULFATRIM91 SYNAPRYN477 SULFURIC ACID/SULFONATED PHENOL320 SYNAREL431 SULINDAC10,60,138 SYNERA44 SUMADAN351 SYNERCID69 SUMADAN XLT351 SYNRIBO159 SUMATRIPTAN141,142,143 SYNTHROID423 SUMATRIPTAN SUCCINATE141,142,143 SYNVISC478 SUMATRIPTAN SUCCINATE/NAPROXEN SYNVISC-ONE478 SODIUM143 SYPRINE520 SUMAVEL DOSEPRO143 SYRINGE AVITENE478 SUMAXIN351,352 SYRINGE WITH NEEDLE, INSULIN, SAFETY, 0.3 SUMAXIN CP351 ML470,471 SUMAXIN TS352 SYRINGE WITH NEEDLE, INSULIN, SAFETY, 0.5 SUNITINIB MALATE165 ML470,471 SUPERVITE556 SYRINGE WITH NEEDLE, INSULIN, SAFETY, 1 SUPERVITE EC555 ML471 SUPPORT-500556 SYRINGE WITH NEEDLE,DISPOSABLE,INSULIN 1 SUPPRELIN LA431 ML472,480 SUPRANE44 SYRINGE WITH NEEDLE,INSULIN DISPOSABLE,0.3 SUPRAX77 ML472 SUPRENZA ODT316 SYRINGE WITH NEEDLE,INSULIN DISPOSABLE,0.5 SUPREP373 ML472,480 SURFAXIN512

PAGE 632 LAST UPDATED 10/2014 TEKTURNA286 T TEKTURNA HCT286 TABLOID153 TELAPREVIR194 TABRADOL515 TELAVANCIN HCL71 TACHOSIL478 TELBIVUDINE196 TACLONEX352 TELITHROMYCIN86 TACROLIMUS346,433,435,436,437,438 TELMISARTAN250 TADALAFIL378,380,506 TELMISARTAN/AMLODIPINE BESYLATE286,287 TAFINLAR163 TELMISARTAN/HYDROCHLOROTHIAZIDE284,286,2 TAFLUPROST/PF493 87 TAGITOL478 TEMAZEPAM517 TALC476,477 TEMODAR148,149 TALIGLUCERASE ALFA359 TEMOVATE55,352,397 TALWIN34 TEMOVATE EMOLLIENT55,352,397 TAMBOCOR258 TEMOZOLOMIDE148,149 TAMIFLU193 TEMSIROLIMUS165,438 TAMOXIFEN CITRATE150,151 TENECTEPLASE232 TAMSULOSIN HCL379 TENEX246 TANDEM PLUS556 TENIPOSIDE159,160 TANZEUM225 TENIVAC451 TAPAZOLE433 TENOFOVIR DISOPROXIL FUMARATE190,197 TAPENTADOL HCL17,30,314,315 TENORETIC 100287 TARCEVA165 TENORETIC 50287 TARGRETIN167,352 TENORMIN263,264 TARKA286 TERAZOL 3137 TARON-DUO EC556 TERAZOL 7137 TASIGNA165 TERAZOSIN HCL247,379,380 TASIMELTEON518 TERBINAFINE HCL135,137 TASMAR171 TERBINAFINE HCL/HYDROXYPROPYL TAVABOROLE135 CHITOSAN137 TAXOTERE159 TERBINEX137 TAZAROTENE327,337,352 TERBUTALINE SULFATE505 TAZORAC352 TERCONAZOLE137,138 TBO-FILGRASTIM235 TERIFLUNOMIDE318 TECFIDERA320 TERIPARATIDE458 TEDIZOLID PHOSPHATE69 TERSI FOAM352 TEDUGLUTIDE366 TESAMORELIN ACETATE399 TEFLARO77 TESSALON512 TEGRETOL107,215 TESSALON PERLE512 TEGRETOL XR108,215,216 TESTIM403 TEKAMLO286 TESTOPEL403,404

PAGE 633 LAST UPDATED 10/2014 TESTOSTERONE402,403,404 THIOLA383 TESTOSTERONE CYPIONATE403,404 THIORIDAZINE HCL177,178 TESTOSTERONE ENANTHATE403,404 THIOTHIXENE178 TESTOSTERONE PROPIONATE403 THROMBATE III237 TESTOSTERONE UNDECANOATE403 THROMBI-GEL478 TESTRED404 THROMBI-PAD478 TETANUS AND DIPHTHERIA TOXOIDS, THROMBIN (BOV)/CALCIUM ADSORBED, ADULT/PF451 CL/CMC/GEL,PORK/DRESSING, HEMOSTATIC478 TETANUS AND DIPHTHERIA TOXOIDS, ADULT451 THROMBIN (BOV)/CALCIUM CL/CME-CELL TETANUS IMMUNE GLOBULIN/PF441 SOD/DRESSING, HEMOSTATIC478 TETANUS TOXOID, ADSORBED/PF451 THROMBIN (BOVINE)478,479 TETANUS,DIPHTHERIA TOXOID PED/PF446 THROMBIN (RECOMBINANT)476 TETRABENAZINE316 THROMBIN(HUM PLAS)/FIBRINOGEN/APROTININ, TETRACAINE HCL42,487 SYN/CALCIUM CL462 TETRACAINE HCL/PF42,44,487 THROMBIN(HUMAN PLASMA TETRACAINE/BENZOCAINE/BUTAMBEN37,38 DER)/FIBRINOGEN/APROTININ/CALCIUM479 TETRACYCLINE HCL94 THROMBIN-JMI478,479 TETRAHYDROZOLINE HCL513 THYMOGLOBULIN441 TETRAVISC487 THYROGEN479 TETRAVISC FORTE487 THYROID,PORK420,422,423,425,426,427 TETRIX352 THYROLAR-1423 TEV-TROPIN401 THYROLAR-1/2423 TEVETEN250 THYROLAR-1/4423 TEVETEN HCT287 THYROLAR-2424 TEXACORT55,353,397 THYROLAR-3424 THALIDOMIDE150,445 THYROTROPIN ALFA479 THALLOUS CHLORIDE TL-201478 TIAGABINE HCL99,101 THALOMID150,445 TIAZAC271,272 THAM556 TICAGRELOR244 THEO-24501 TICARCILLIN DISODIUM/POTASSIUM THEOPHYLLINE ANHYDROUS501,502 CLAVULANATE83 THEOPHYLLINE/DEXTROSE 5 % IN WATER501,502 TICLOPIDINE HCL245 THERACYS159 TIGAN129 THERAMINE556 TIGECYCLINE69 THERAMINE PLUS478 TIKOSYN258,259 THERMAZENE91,353 TILUDRONATE DISODIUM460 THIAMINE HCL556 TIMENTIN83 THIAMINE TIMOLOL490,491 HCL/RIBOFLAVIN/NIACINAMIDE/DEXPANTHENOL/P TIMOLOL MALEATE140,264,491,492,493 YRIDOXINE522 TIMOLOL MALEATE/PF493 THIOGUANINE153 TIMOPTIC492,493

PAGE 634 LAST UPDATED 10/2014 TIMOPTIC OCUDOSE493 TOLVAPTAN520 TIMOPTIC-XE493 TOPAMAX104,140 TINDAMAX69 TOPICORT55,56,353,397 TINIDAZOLE69 TOPIRAMATE101,103,104,105,140,141 TIOPRONIN383 TOPOTECAN HCL162,163 TIOTROPIUM BROMIDE501 TOPROL XL264 TIPRANAVIR192 TOREMIFENE CITRATE150 TIPRANAVIR/VITAMIN E TPGS192 TORISEL165,438 TIROFIBAN HCL MONOHYDRATE IN 0.9 % SODIUM TORSEMIDE289,290 CHLORIDE243 TOSITUMOMAB (WITH MALTOSE)166 TIROSINT424 TOSITUMOMAB IODINE-131 (WITH MALTOSE)166 TISSEEL VHSD479 TOTECT159 TIVICAY191 TOVIAZ377 TIZANIDINE HCL187 TOZAL557 TIZANIDINE HCL/IRRITANTS COUNTER-IRRITANTS TPN ELECTROLYTES557 COMBINATION NO.2185 TPN ELECTROLYTES II557 TL FOLATE563 TRACE ELEMENTS COMB NO.1521 TL-ICARE557 TRACE ELEMENTS-4557 TL-SELECT DHA557 TRACLEER507 TNKASE232 TRADJENTA225 TOBI61 TRAMADOL HCL12,18,19,33,34 TOBI PODHALER61 TRAMADOL HCL/ACETAMINOPHEN34 TOBRADEX61,487 TRAMADOL HCL/GLUCOSAMINE SULFATE477 TOBRADEX ST487 TRAMETINIB DIMETHYL SULFOXIDE163 TOBRAMYCIN60,61,62,487 TRANDATE264 TOBRAMYCIN IN 0.225 % SODIUM CHLORIDE61,62 TRANDOLAPRIL252,253 TOBRAMYCIN SULFATE62 TRANDOLAPRIL/VERAPAMIL HCL286 TOBRAMYCIN SULFATE/SODIUM CHLORIDE62 TRANEXAMIC ACID239,241,242,243 TOBRAMYCIN/DEXAMETHASONE61,487 TRANSCYTE479 TOBRAMYCIN/LOTEPREDNOL ETABONATE488 TRANSDERM-SCOP129 TOBREX62,487 TRANXENE T-TAB204 TOCILIZUMAB442 TRANYLCYPROMINE SULFATE116 TOFACITINIB CITRATE445 TRASTUZUMAB164 TOFRANIL125 TRAVASOL557 TOFRANIL-PM125 TRAVATAN Z482 TOLAZAMIDE225 TRAVOPROST482 TOLBUTAMIDE225 TRAVOPROST (BENZALKONIUM)482 TOLCAPONE171 TRAZODONE HCL113,114,115 TOLEREX479 TREANDA149 TOLMETIN SODIUM10,60 TRECATOR146 TOLTERODINE TARTRATE376,377 TRELSTAR159,160,431,432

PAGE 635 LAST UPDATED 10/2014 TRELSTAR DEPOT160,432 TRICARE557 TRELSTAR LA160,432 TRICARE PRENATAL COMPLEAT557 TRENTAL287 TRICARE PRENATAL DHA ONE557 TREPADONE479 TRICHLOROACETIC ACID354,355 TREPROSTINIL507 TRICITRASOL232 TREPROSTINIL DIOLAMINE506,507 TRICODE AR513 TREPROSTINIL SODIUM507 TRICODE GF513 TREPROSTINIL/NEBULIZER ACCESSORIES507 TRICOR294 TREPROSTINIL/NEBULIZER/NEBULIZER TRIENTINE HCL520 ACCESSORIES507 TRIESENCE490 TRETIN-X167,353 TRIFLUOPERAZINE HCL178 TRETINOIN167,168,327,328,347,348,353,354 TRIFLURIDINE198,487 TRETINOIN MICROSPHERES348,354 TRIGLIDE294 TRETINOIN/EMOLLIENT BASE347,354 TRIHEXYPHENIDYL HCL170 TRETINOIN/EMOLLIENT COMBINATION NO. 9/SKIN TRILEPTAL108 CLN1353 TRILIPIX294 TRETINOIN/EMOLLIENT COMBINATION NO. 9/SKIN TRIMETHOBENZAMIDE HCL129,130 CLN1/GEL353 TRIMETHOPRIM68,69 TRETTEN243 TRIMIPRAMINE MALEATE125 TREXALL153,154,354,438,439 TRINATE558 TREXIMET143 TRIOSTAT424 TRI-CHLOR354 TRIOXIN494 TRI-LUMA354 TRIPEDIA451 TRI-NORINYL415 TRIPLE DYE355 TRI-VI-FLOR557 TRIPTORELIN PAMOATE159,160,431,432 TRIACETIN137 TRISENOX160 TRIAMCINOLONE TRIUMEQ191 ACETONIDE52,53,56,323,325,340,354,355,392,394,3 TRIZIVIR190 97,398,496,497 TROKENDI XR101,105,141 TRIAMCINOLONE ACETONIDE/EMOLLIENT TROMETHAMINE556 COMBINATION NO.45345,394 TROPAZONE355 TRIAMCINOLONE ACETONIDE/EMOLLIENT TROPHAMINE558 COMBINATION NO.86388 TROPICAMIDE485,487 TRIAMCINOLONE ACETONIDE/LIDOCAINE HCL390 TROSPIUM CHLORIDE377 TRIAMCINOLONE ACETONIDE/PF490 TRULICITY225 TRIAMCINOLONE HEXACETONIDE385 TRUSOPT493 TRIAMTERENE291 TRUVADA190 TRIAMTERENE/HYDROCHLOROTHIAZIDE280,283,2 TRYPAN BLUE485,487 87 TRYPSIN/BALSAM PERU/CASTOR OIL339,357 TRIAZOLAM516,517 TUBERCULIN, PURIFIED PROTEIN TRIBENZOR287 DERIVATIVE461,479

PAGE 636 LAST UPDATED 10/2014 TUBERSOL479 ULTRESA360 TUDORZA PRESSAIR501 UMECLIDINIUM BROMIDE/VILANTEROL TUSNEL PEDIATRIC513 TRIFENATATE503 TUSSICAPS513 UMECTA355 TUSSIONEX513 UMECTA PD355 TWINRIX451 UNASYN83 TWYNSTA287 UNIRETIC288 TYBOST191 UNITHROID424,425 TYGACIL69 UNIVASC253 TYKERB165 UNOPROSTONE ISOPROPYL492 TYLENOL-CODEINE NO.334 URAMAXIN355,356 TYLENOL-CODEINE NO.434 URAMAXIN GT356 TYLOX34 UREA326,330,338,339,340,347,353,355,356,357 TYPHIM VI452 UREA/EMOLLIENT COMBINATION NO. 18334 TYPHOID VACC,LIVE,ATTENUATED452 UREA/EMOLLIENT COMBINATION NO.65356 TYPHOID VACCINE VI CAPSULAR UREA/HYALURONATE SODIUM356 POLYSACCHARIDE452 UREA/LACTIC ACID/SALICYLIC ACID340,341,356 TYR ANAMIX NEXT480 UREA/LACTIC ACID/ZINC TYSABRI320,445 UNDECYLENATE329,341,356 TYVASO507 URECHOLINE383 TYZEKA196 URELLE69 TYZINE513 URETRON D-S69 URIBEL69 U UROCIT-K558,559 UCERIS456 UROFOLLITROPIN462 UDAMIN558 UROGESIC-BLUE70 UDAMIN SP558 UROQID-ACID NO.270 ULESFIA168,170,355 UROXATRAL380 ULIPRISTAL ACETATE417 URSO369 ULORIC138 URSO FORTE369 ULTANE44 URSODIOL364,369 ULTIVA34 USTEKINUMAB351,444 ULTRACET34 UTA70 ULTRAFOAM480 UTOPIC356 ULTRAM34 UVADEX356 ULTRAM ER19 ULTRASAL-ER355 V ULTRAVATE56,355,398 V-HIST513 ULTRAVATE PAC398 VAGIFEM415 ULTRAVATE X398 VALACYCLOVIR HCL198 ULTRAVIST480 VALCHLOR149

PAGE 637 LAST UPDATED 10/2014 VALCYTE187 VASERETIC288 VALGANCICLOVIR HCL187 VASOPRESSIN401,402 VALIUM204 VASOTEC254 VALPROIC ACID97,100,101,139,140,141,212,215,216 VAYACOG559 VALPROIC ACID (AS SODIUM SALT) (VALPROATE VAYARIN559 SODIUM)97,101,139,141,212,216 VAYAROL299 VALRUBICIN160 VAZCULEP288 VALSARTAN249,250 VECTIBIX165,166 VALSARTAN/HYDROCHLOROTHIAZIDE279,288 VECTICAL357 VALSTAR160 VECURONIUM BROMIDE316 VALTREX198 VEDOLIZUMAB434 VANACOF CD513 VEHICLE-N480 VANCOCIN HCL70 VEHICLE-N MILD480 VANCOMYCIN HCL70,71 VELAGLUCERASE ALFA361 VANCOMYCIN HCL/DEXTROSE 5 % IN VELCADE166 WATER70,71 VELETRI507 VANCOMYCIN IN DEXTROSE, ISO-OSMOTIC70 VELPHORO385 VANDAZOLE71 VELTIN357 VANDETANIB164 VEMURAFENIB163 VANIQA356 VENELEX357 VANOS56,357,398 VENLAFAXINE HCL117,121,122,205,207 VANOXIDE-HC357 VENLAFAXINE HCL ER122,207 VANTAS432 VENOFER559 VAPRISOL520 VENTAVIS507,508 VAQTA452 VENTOLIN HFA505 VARDENAFIL HCL381,383 VERAMYST398,497 VARENICLINE TARTRATE47 VERAPAMIL HCL255,259,265,272,273 VARIBAR HONEY480 VERDESO56,357,398 VARIBAR NECTAR480 VEREGEN357 VARIBAR PUDDING480 VERELAN273 VARIBAR THIN HONEY480 VERELAN PM273 VARIBAR THIN LIQUID480 VERIPRED 2056,398 VARICELLA VIRUS VACCINE LIVE/PF452 VERSACLOZ185 VARICELLA-ZOSTER IMMUNE GLOBULIN VERTEPORFIN488 (HUMAN)441,442 VESICARE378 VARITHENA480 VEXA44 VARIVAX VACCINE452 VEXOL490 VARIZIG441,442 VFEND137 VASCAZEN559 VFEND IV137 VASCEPA299 VIAGRA384 VASCULERA559 VIBATIV71

PAGE 638 LAST UPDATED 10/2014 VIBRAMYCIN94,325 VIT B COMPLX VICOPROFEN34 NO.4/CHOLECALCIFEROL/ASCORBIC VICTOZA 2-PAK225 ACID/FA/ZINC OX561 VICTOZA 3-PAK225 VITA-RESPA561 VICTRELIS196 VITAFOL561 VIDAZA154 VITAFOL NANO561 VIDEX190 VITAFOL ULTRA561 VIDEX EC190 VITAFOL-OB561 VIGABATRIN100 VITAFOL-OB+DHA561 VIGAMOX90,487 VITAFOL-ONE561 VIIBRYD115 VITAFOL-PLUS561 VILAZODONE HYDROCHLORIDE115 VITAFOL-PN561 VIMIZIM360 VITAL-D RX561 VIMOVO10 VITAMEDMD ONE RX561 VIMPAT108 VITAMEDMD PLUS RX561 VINATE CARE559 VITAMEDMD REDICHEW RX561 VINATE DHA RF559 VITAMIN A PALMITATE522 VINBLASTINE SULFATE160 VITAMIN A/VITAMIN VINCRISTINE SULFATE160 E/AVOBENZONE/OCTINOXATE/HYDROQUINONE34 VINCRISTINE SULFATE LIPOSOMAL158 2 VINORELBINE TARTRATE158,160 VITAMIN B COMP AND VIT C NO.6555 VIOKACE360,361 VITAMIN B COMPLEX & VITAMIN C NO.13/FOLIC VIRACEPT193 ACID/VITAMIN D3542 VIRAMUNE188 VITAMIN B COMPLEX & VITAMIN C NO.20/FOLIC VIRAMUNE XR188 ACID541,542,553,558,560 VIRASAL357 VITAMIN B COMPLEX#11/FOLIC ACID/ASCORBIC VIRAZOLE196 ACID/BIOTIN/ZN OXID528 VIREAD190,197 VITAMIN B COMPLX NO.3/FOLIC ACID/ASCORBIC VIROPTIC198,487 ACID/BIOTIN542,553,562 VIRT-BAL DHA560 VITAMIN B COMPLX NO.3/FOLIC ACID/ASCORBIC VIRT-BAL DHA PLUS560 ACID/BIOTIN/ZNOX542 VIRT-VITE PLUS560 VITAMIN B12-INTRINSIC FACTOR539 VISCOAT487 VITAMIN E ACET VISIONBLUE487 (DL,TOCOPHERYL)/GRAPE/HYALURONIC VISIPAQUE480,481 ACID327,346 VISMODEGIB164 VITAMIN E VISTARIL130,204,499 ACETATE/AVOBENZONE/OCTINOXATE/HYDROQUI VISTIDE188 NONE342 VISUDYNE488 VITAMIN E ACID SUCCINATE/FOLIC ACID/VITAMIN B COMP W-C/ZN/SE553 VITAMIN E/LIDOCAINE/ALOE VERA/COLLAGEN43

PAGE 639 LAST UPDATED 10/2014 VITAPEARL562 WATER FOR VITRASE481 INJ.,BACTERIOSTATIC/METHYLPARABEN/PROPYL VITRASERT488 PARABEN462 VITUZ34,500 WATER FOR INJECTION,STERILE477,481 VIVA CT562 WATER FOR IRRIGATION,STERILE477 VIVA DHA562 WEED POLLEN-SHORT RAGWEED512 VIVACTIL126 WELCHOL225,299 VIVELLE-DOT415,416 WELLBUTRIN115 VIVITROL46,47 WELLBUTRIN SR115 VIVONEX481 WELLBUTRIN XL115,116 VIVONEX PLUS481 WESTCORT398 VIVONEX T.E.N481 WESTHROID425,426 VIVOTIF BERNA452 WESTHROID-P426 VOGELXO404 WHEY PROTEIN ISOLATE/ARGININE/C/E/ZINC VOLTAREN357,398 SULFATE461 VOLTAREN-XR11,60 WILATE243 VOLUMEN481 WINRHO SDF442 VOLUVEN237 WP THYROID426,427 VORAPAXAR SULFATE245 WYMZYA FE416 VORAXAZE160 VORICONAZOLE137,138 X VORINOSTAT166 XALATAN482,493 VORTIOXETINE HYDROBROMIDE116 XALKORI166 VOSOL HC71,494 XANAX204,205 VOSPIRE ER505 XANAX XR205 VOTRIENT163 XARELTO233 VP CH ULTRA562 XARTEMIS XR19 VP-PNV-DHA562 XCLAIR357 VPRIV361 XELJANZ445 VSL#3 DS369 XELODA154 VUMON160 XENADERM357 VUSION357 XENAZINE316 VYTONE357 XENICAL369 VYTORIN299 XEOMIN187 VYVANSE305,306 XERAC AC357 XERESE198 W XGEVA167,460 WARFARIN SODIUM227,228,231,232 XIAFLEX481 WATER FOR INJ.,BACTERIOSTATIC462 XIFAXAN71,369 XODOL 10-30034 XODOL 5-30035

PAGE 640 LAST UPDATED 10/2014 XODOL 7.5-30035 ZEBUTAL316 XOFIGO160 ZEGERID376 XOLAIR513 ZELAPAR175 XOLEGEL138 ZELBORAF163 XOPENEX505 ZEMAIRA513 XOPENEX CONCENTRATE505 ZEMPLAR428,460 XOPENEX HFA505 ZEMURON317 XTANDI432 ZENPEP361 XYLOCAINE44 ZENZEDI306 XYLOCAINE IV44 ZERIT190,191 XYLOCAINE WITH EPINEPHRINE44 ZESTORETIC288 XYLOCAINE-MPF45 ZESTRIL254 XYLOCAINE-MPF WITH EPINEPHRINE44,45 ZETIA299 XYNTHA243 ZETONNA497 XYNTHA SOLOFUSE243 ZEVALIN167 XYREM519 ZIAC288 XYZAL500 ZIAGEN191 ZIANA358 Y ZICONOTIDE ACETATE315 YASMIN 28416 ZIDOVUDINE189,191 YAZ416 ZILEUTON500 YELLOW FEVER VACCINE LIVE/PF452 ZINACEF78 YERVOY167 ZINACEF ISO-OSMOTIC DEXTROSE78 YF-VAX452 ZINC ACETATE532,533 YODOXIN169 ZINC CHLORIDE562 YOHIMBINE HCL384 ZINC CITRATE/PHYTASE563 ZINC SULFATE563 Z ZINC SULFATE HEPTAHYDRATE/CUSO4 P- ZAFIRLUKAST500 HYD/MANGANESE/CHROMIUM/SE540 ZALEPLON517 ZINC SULFATE/CUPRIC SULFATE/MANGANESE ZALTRAP166 SULF/CHROMIC CHLORIDE540,557 ZAMICET35 ZINC,COPPER,MANGANESE CHL/SOD SELEN/SOD ZANAFLEX187 FLUORIDE/POT IODIDE545 ZANAMIVIR193 ZINECARD160 ZANOSAR149 ZIOPTAN493 ZANTAC371 ZIPRASIDONE HCL108,179,183,184,208,209,211 ZANTAC 25371 ZIPRASIDONE MESYLATE179,209 ZARONTIN97 ZIPSOR11,60 ZAROXOLYN292 ZIRGAN188,488 ZAVESCA361 ZITHRANOL358 ZEBETA264 ZITHRANOL-RR358

PAGE 641 LAST UPDATED 10/2014 ZITHROMAX86,87 ZYDONE35 ZITHROMAX TRI-PAK87 ZYFLO500 ZIV-AFLIBERCEPT166 ZYFLO CR500 ZMAX87 ZYKADIA166 ZN-DTPA481 ZYLET488 ZOCOR296,297 ZYLOPRIM138,139 ZOFRAN131 ZYMAXID90,488 ZOFRAN ODT131,132 ZYPRAM369 ZOHYDRO ER20 ZYPREXA184,211,212 ZOLADEX432 ZYPREXA RELPREVV184 ZOLEDRONIC ACID460 ZYPREXA ZYDIS184,212 ZOLEDRONIC ACID IN MANNITOL & WATER FOR ZYTAZE563 INJECTION459,460 ZYTIGA163 ZOLINZA166 ZYVOX71 ZOLMITRIPTAN143,144 ZOLOFT122,207,208 ZOLPIDEM TARTRATE515,516,517,518 ZOLPIMIST518 ZOLVIT35 ZOMETA460 ZOMIG144 ZOMIG ZMT144 ZONALON358 ZONATUSS513 ZONEGRAN97,108 ZONISAMIDE97,108 ZONTIVITY245 ZORBTIVE402 ZORTRESS439 ZORVOLEX11 ZOSTAVAX452 ZOSTER VACCINE LIVE/PF452 ZOSYN83,84 ZOTEX-C513 ZOVIRAX198,199,358 ZUBSOLV47 ZUPLENZ132 ZUTRIPRO513 ZYBAN47 ZYCLARA161,358,445 ZYDELIG166

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