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Home , Naphazoline

2016 State of New York eff 08/01/2016

Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits ANALGESICS NAPRELAN 3 GOUT NAPROSYN TABS 3 allopurinol tab 1 naproxen SUSP; TABS; 1 ALOPRIM 3 TBEC naproxen sodium colchicine w/ probenecid 1 TABS 1 275mg, 550mg COLCRYS 2 naproxen sodium TB24 3 probenecid 1 375mg ULORIC 2 NAPROXEN SODIUM TB24 3 ZYLOPRIM 3 500mg MISCELLANEOUS oxaprozin 1 ARTHROTEC 50 3 piroxicam CAPS 1 ARTHROTEC 75 3 PONSTEL 3 diclofenac w/ misoprostol 1 sulindac TABS 1 NSAIDS tolmetin sodium 1 ANAPROX DS 3 VIVLODEX 3 CELEBREX CAP 50MG 3 OPIOID ANALGESICS CELEBREX CAP 100MG 3 acetaminophen w/ codeine 1 QL SOLN CELEBREX CAP 200MG 3 QL (5000 mL / 30 days) CELEBREX CAP 400MG 3 acetaminophen w/ codeine 1 QL celecoxib CAPS 1 TABS DAYPRO 3 QL (400 tabs / 30 days) diclofenac potassium 1 acetaminophen-caff- 1 QL dihydrocod diclofenac sodium TB24; 1 QL (360 caps / 30 days) TBEC ASPIRIN-CAFFEINE- 1 diflunisal 1 DIHYDROCODEINE EC-NAPROSYN 3 BITARTRATE etodolac 1 BELBUCA 3 etodolac er 1 butorphanol nasal spray 1 FELDENE 3 butorphanol tartrate SOLN 1 FENOPROFEN CALCIUM 1 BUTRANS 5mcg/hr 2 QL CAPS 400mg QL (16 patches / 28 fenoprofen calcium TABS 1 days) flurbiprofen TABS 1 BUTRANS 7.5mcg/hr, 2 QL 10mcg/hr ibuprofen SUSP 1 QL (8 patches / 28 days) ibuprofen TABS 400mg, 1 BUTRANS 15mcg/hr, 2 QL 600mg, 800mg 20mcg/hr ketoprofen CAPS; CP24 1 QL (4 patches / 28 days) mefenamic acid CAPS 1 capital and codeine 3 QL QL (5000 mL / 30 days) MELOXICAM SUSP 1 nalbuphine hcl SOLN 1 meloxicam tabs 1 SYNALGOS-DC 3 MOBIC 3 TRAMADOL HCL CP24 1 nabumetone TABS 1 tramadol hcl er TB24 100mg, 1 NALFON 3 200mg

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy B/D - Covered under 1 Medicare B or D LA - Limited Access 2016 State of New York eff 08/01/2016

Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits TRAMADOL HCL ER TB24 1 fentanyl citrate LPOP 3 QL PA 300mg QL (120 lozenges / 30 tramadol hcl er (biphasic) 1 days) 100mg fentanyl patch 12 mcg/hr 1 QL tramadol hcl er (biphasic) 1 QL (10 patches / 30 200mg days) tramadol hcl er (biphasic) 1 fentanyl patch 25 mcg/hr 1 QL 300mg QL (10 patches / 30 days) tramadol hcl tab 50 mg 1 fentanyl patch 50 mcg/hr 1 QL tramadol-acetaminophen 1 QL QL (10 patches / 30 QL (240 tabs / 30 days) days) trezix 3 QL fentanyl patch 75 mcg/hr 1 QL QL (360 caps / 30 days) QL (10 patches / 30 tylenol with codeine 3 QL days) QL (400 tabs / 30 days) fentanyl patch 100 mcg/hr 1 QL ULTRACET 3 QL QL (10 patches / 30 QL (240 tabs / 30 days) days) ULTRAM 3 FENTORA 3 QL PA ULTRAM ER 3 QL (120 tabs / 30 days) ULTRAM ER TAB 100MG 3 hycet 3 QL QL (5400 mL / 30 days) ULTRAM ER TAB 200MG 3 hydrocodone-acetaminophen 1 QL OPIOID ANALGESICS, CII 2.5-325mg ABSTRAL 3 QL PA QL (360 tabs / 30 days) QL (120 tabs / 30 days) hydrocodone-acetaminophen 1 QL ACTIQ 3 QL PA 5-300mg QL (120 lozenges / 30 QL (400 tabs / 30 days) days) hydrocodone-acetaminophen 1 QL CODEINE SULFATE 1 5-325mg QL (360 tabs / 30 days) DILAUDID INJ 3 B/D hydrocodone-acetaminophen 1 QL DILAUDID TAB 3 7.5-300mg DILAUDID-5 ORAL LIQD 3 QL (400 tabs / 30 days) DILAUDID-HP INJ 10MG/ML 3 B/D hydrocodone-acetaminophen 1 QL DILAUDID-HP INJ 250MG 3 B/D 7.5-325 mg/15ml QL (5400 mL / 30 days) DOLOPHINE 3 QL QL (240 tabs / 30 days) hydrocodone-acetaminophen 1 QL 7.5-325mg DURAGESIC 3 QL QL (360 tabs / 30 days) QL (10 patches / 30 days) hydrocodone-acetaminophen 1 QL 10-300mg DURAMORPH 1 B/D QL (400 tabs / 30 days) EMBEDA 3 QL hydrocodone-acetaminophen 1 QL QL (60 caps / 30 days) tab 10-325mg endocet 1 QL QL (360 tabs / 30 days) QL (360 tabs / 30 days) hydrocodone-ibuprofen tab 1 EXALGO 3 QL 2.5-200mg QL (60 tabs / 30 days) hydrocodone-ibuprofen tab 5- 1 200mg

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy B/D - Covered under 2 Medicare B or D LA - Limited Access 2016 State of New York eff 08/01/2016

Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits hydrocodone-ibuprofen tab 1 methadone hcl SOLN 1 QL 7.5-200 mg QL (600 mL / 30 days) hydrocodone-ibuprofen tab 1 methadone hcl TABS 1 QL 10-200mg QL (240 tabs / 30 days) hydromorphone hcl LIQD 1 METHADONE INJ 10MG/ML 3 HYDROMORPHONE HCL 1 B/D METHADOSE CONC 3 QL SOLN 1mg/ml, 2mg/ml, QL (120 mL / 30 days) 4mg/ml MORPHINE SUL 20MG/ML 1 hydromorphone hcl SOLN 1 B/D ORAL SOL 500mg/50ml morphine sulfate CP24 1 QL hydromorphone hcl TABS 1 10mg, 20mg, 30mg, 50mg, hydromorphone tab 8mg er 1 QL 60mg QL (60 tabs / 30 days) QL (60 caps / 30 days) hydromorphone tab 12mg er 1 QL morphine sulfate CP24 3 QL QL (60 tabs / 30 days) 80mg, 100mg QL (60 caps / 30 days) hydromorphone tab 16mg er 3 QL QL (60 tabs / 30 days) MORPHINE SULFATE SOLN 1 B/D 1mg/ml, 10mg/ml, 15mg/ml HYDROMORPHONE TABS 3 QL 32MG MORPHINE SULFATE SOLN 3 B/D QL (60 tabs / 30 days) 2mg/ml, 4mg/ml, 8mg/ml HYSINGLA ER 20mg, 30mg, 2 QL MORPHINE SULFATE SOLN 1 40mg, 60mg 10mg/5ml, 20mg/5ml QL (60 tabs / 30 days) morphine sulfate SOLN 1 B/D HYSINGLA ER 80mg, 3 QL .5mg/ml, 1mg/ml, 4mg/ml, 100mg, 120mg 8mg/ml QL (30 tabs / 30 days) MORPHINE SULFATE TABS 1 ibudone tab 5-200mg 1 morphine sulfate beads 1 QL ibudone tab 10-200mg 1 QL (60 caps / 30 days) INFUMORPH 200 3 B/D morphine sulfate ext-rel tab 1 QL 15mg, 30mg, 60mg, 100mg INFUMORPH 500 3 B/D QL (90 tabs / 30 days) KADIAN 3 QL morphine sulfate ext-rel tab 1 QL QL (60 caps / 30 days) 200mg LAZANDA 3 QL PA QL (60 tabs / 30 days) QL (30 bottles / 30 days) MS CONTIN 15mg, 30mg, 3 QL levorphanol tartrate TABS 1 60mg, 100mg lorcet hd tab 10-325mg 1 QL QL (90 tabs / 30 days) QL (360 tabs / 30 days) MS CONTIN 200mg 3 QL lorcet plus tab 7.5-325 1 QL QL (60 tabs / 30 days) QL (360 tabs / 30 days) norco 3 QL lorcet tab 5-325mg 1 QL QL (360 tabs / 30 days) QL (360 tabs / 30 days) NUCYNTA 2 lortab tab 5-325mg 1 QL NUCYNTA ER 50mg, 100mg 2 QL QL (360 tabs / 30 days) QL (120 tabs / 30 days) lortab tab 7.5-325 1 QL NUCYNTA ER 150mg, 2 QL QL (360 tabs / 30 days) 200mg, 250mg lortab tab 10-325mg 1 QL QL (60 tabs / 30 days) QL (360 tabs / 30 days) OPANA TABS 3 methadone hcl CONC 1 QL QL (120 mL / 30 days) PA - Prior Authorization QL - Quantity Limits ST - Step Therapy B/D - Covered under 3 Medicare B or D LA - Limited Access 2016 State of New York eff 08/01/2016

Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits OPANA ER (CRUSH 2 QL vicodin hp 1 QL RESISTANT QL (400 tabs / 30 days) QL (120 tabs / 30 days) VICOPROFEN 3 oxycodone hcl CAPS; CONC; 1 XARTEMIS XR 3 QL TABS QL (120 tabs / 30 days) OXYCODONE HCL SOLN 1 xodol tab 5-300mg 3 QL oxycodone w/ acetaminophen 1 QL QL (400 tabs / 30 days) 2.5-325mg xodol tab 7.5-300 3 QL QL (360 tabs / 30 days) QL (400 tabs / 30 days) oxycodone w/ acetaminophen 1 QL xodol tab 10-300mg 3 QL 5-325mg QL (400 tabs / 30 days) QL (360 tabs / 30 days) xylon tab 10-200mg 1 oxycodone w/ acetaminophen 1 QL 7.5-325mg zamicet 1 QL QL (360 tabs / 30 days) QL (5400 mL / 30 days) oxycodone w/ acetaminophen 1 QL ZOHYDRO ER (ABUSE 3 QL 10-325mg DETERRENT) 10mg, 15mg, QL (360 tabs / 30 days) 20mg QL (120 caps / 30 days) oxycodone w/ acetaminophen 1 QL soln 5-325 mg/5ml ZOHYDRO ER (ABUSE 3 QL QL (1800 mL / 30 days) DETERRENT) 30mg, 40mg, 50mg oxycodone-aspirin 1 QL (60 caps / 30 days) oxycodone-ibuprofen 1 OXYCONTIN 2 QL QL (120 tabs / 30 days) LOCAL ANESTHETICS lidocaine hcl (local anesth.) 1 oxymorphone hcl TABS 1 4% percocet 2.5/325 3 QL lidocaine hcl (local anesth.) 1 B/D QL (360 tabs / 30 days) .5%, 1% percocet 7.5/325 3 QL lidocaine inj 0.5% 1 B/D QL (360 tabs / 30 days) lidocaine inj 1% 1 B/D percocet 10/325 3 QL QL (360 tabs / 30 days) lidocaine inj 1.5% 1 B/D percocet tab 5-325mg 3 QL lidocaine inj 2% 1 B/D QL (360 tabs / 30 days) XYLOCAINE .5%, 1%, 2% 3 B/D reprexain tab 2.5-200mg 3 XYLOCAINE-MPF 4% 3 reprexain tab 5-200mg 3 XYLOCAINE-MPF .5%, 1%, 3 B/D reprexain tab 10-200mg 1 1.5%, 2% roxicet soln 2 QL ANTI-INFECTIVES QL (1800 mL / 30 days) ANTI-BACTERIALS - MISCELLANEOUS roxicet tab 5-325mg 1 QL amikacin sulfate SOLN 1 QL (360 tabs / 30 days) BETHKIS 3 B/D ROXICODONE 3 gentamicin in 0.8 mg/ml 1 SUBSYS 3 QL PA QL (120 sprays / 30 gentamicin in saline 0.9mg/ml 3 days) gentamicin in saline 1 mg/ml 1 vicodin 1 QL gentamicin in saline 1.2 mg/ml 1 QL (400 tabs / 30 days) gentamicin in saline 1.4mg/ml 3 vicodin es 1 QL gentamicin in saline 1.6 mg/ml 1 QL (400 tabs / 30 days)

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy B/D - Covered under 4 Medicare B or D LA - Limited Access 2016 State of New York eff 08/01/2016

Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits gentamicin in saline 2 mg/ml 1 dapsone TABS 1 gentamicin sulfate SOLN 1 DARAPRIM 3 KITABIS PAK 3 B/D DORIBAX 3 sulfate TABS 1 FLAGYL 3 paromomycin sulfate CAPS 1 FURADANTIN 3 PA streptomycin sulfate SOLR 1 90 day limit per calendar year if 65 years and older sulfadiazine TABS 3 HIPREX 3 TOBI NEB 3 B/D imipenem-cilastatin 1 TOBI PODHALER 3 LA PA INVANZ 3 tobramycin NEBU 3 B/D ivermectin TABS 1 tobramycin sulfate SOLN; 1 SOLR linezolid SOLN 3 ANTI-INFECTIVES - MISCELLANEOUS LINEZOLID SUSR; TABS 3 ALBENZA 2 LINEZOLID IN SODIUM 3 CHLORIDE ALINIA 2 MACROBID 3 PA atovaquone SUSP 3 90 day limit per calendar AZACTAM 3 year if 65 years and older AZACTAM/DEX INJ 1GM 3 MACRODANTIN 3 PA 90 day limit per calendar AZACTAM/DEX INJ 2GM 3 year if 65 years and older aztreonam 1 MEPRON 3 BACTRIM 3 meropenem 1 BACTRIM DS 3 MEROPENEM/SODIUM 1 BILTRICIDE 2 CHLORIDE CAYSTON 2 LA PA MERREM 3 cleocin SOLR 3 methenamine hippurate 1 CLEOCIN CAP 75MG 3 METRO IV 3 CLEOCIN CAP 150MG 3 metronidazole CAPS; TABS 1 CLEOCIN CAP 300MG 3 metronidazole inj 1 CLEOCIN IN D5W 3 NEBUPENT 3 B/D CLEOCIN INJ 3 nitrofurantoin SUSP 1 PA CLEOCIN PHOSPHATE 3 90 day limit per calendar 9gm/60ml, 300mg/2ml, year if 65 years and older 600mg/4ml, 900mg/6ml nitrofurantoin macrocrystal 3 PA cleocin phosphate 3 25mg 600mg/4ml, 900mg/6ml PA applies if 65 years and older after a 90 day supply clindamycin hcl CAPS 1 in a calendar year clindamycin palmitate 1 nitrofurantoin macrocrystal 3 PA hydrochloride 50mg, 100mg clindamycin phosphate SOLN 1 90 day limit per calendar clindamycin phosphate in d5w 1 year if 65 years and older colistimethate sodium SOLR 1 nitrofurantoin monohyd macro 3 PA 100mg COLY-MYCIN M 3 90 day limit per calendar CUBICIN 3 year if 65 years and older DALVANCE 3

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy B/D - Covered under 5 Medicare B or D LA - Limited Access 2016 State of New York eff 08/01/2016

Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits nitrofurantoin monohyd macro 3 PA ketoconazole TABS 1 100mg LAMISIL PACK 3 PA PA applies if 65 years and older after a 90 day supply LAMISIL TABS 3 QL in a calendar year QL (90 tabs / 365 days) PENTAM 300 3 MYCAMINE 3 polymyxin b sulfate SOLR 1 NOXAFIL 3 PRIMAXIN 3 nystatin TABS 1 PRIMSOL 3 ONMEL 3 PA SIVEXTRO 3 SPORANOX 3 PA STROMECTOL 3 SPORANOX PULSEPAK 3 PA sulfamethoxazole-trimethop 1 SPORANOX SOL 10MG/ML 3 PA sulfamethoxazole- 1 terbinafine hcl TABS 1 QL trimethoprim inj QL (90 tabs / 365 days) SYNERCID 3 VFEND IV 3 trimethoprim TABS 1 VFEND SUS 40MG/ML 3 TYGACIL 3 VFEND TAB 3 VANCOCIN HCL 3 voriconazole SUSR; TABS 3 vancomycin hcl CAPS 3 voriconazole inj 200mg 1 vancomycin hcl inj 5gm 1 ANTIMALARIALS vancomycin hcl inj 10gm 1 atovaquone-proguanil hcl tab 1 62.5-25 mg vancomycin hcl inj 500mg 1 atovaquone-proguanil hcl tab 1 vancomycin hcl inj 750mg 3 250-100 mg vancomycin hcl inj 1000mg 1 chloroquine phosphate TABS 1 VANCOMYCIN IN NACL 3 COARTEM 2 XIFAXAN TAB 200MG 3 MALARONE 3 ZYVOX 3 mefloquine hcl 1 ANTIFUNGALS PRIMAQUINE PHOSPHATE 3 ABELCET 3 B/D QUALAQUIN 3 AMBISOME 3 B/D quinine sulfate CAPS 1 amphotericin b SOLR 1 B/D ANTIRETROVIRAL AGENTS ANCOBON 3 abacavir sulfate 1 CANCIDAS 3 APTIVUS 3 CRESEMBA 3 CRIXIVAN 3 DIFLUCAN 3 didanosine 1 ERAXIS 3 EDURANT 3 fluconazole SUSR; TABS 1 EMTRIVA 2 fluconazole in dextrose 1 EPIVIR SOL 10MG/ML 3 fluconazole in nacl 1 EPIVIR TABS 3 flucytosine CAPS 3 FUZEON 2 GRIS-PEG 3 INTELENCE 25mg 2 griseofulvin microsize 1 INTELENCE 100mg, 200mg 3 griseofulvin ultramicrosize 1 INVIRASE 3 itraconazole CAPS 1 PA

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy B/D - Covered under 6 Medicare B or D LA - Limited Access 2016 State of New York eff 08/01/2016

Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits ISENTRESS CHEW 25mg 2 COMPLERA 3 ISENTRESS CHEW 100mg 3 DESCOVY 3 ISENTRESS PACK 2 EPZICOM 3 ISENTRESS TABS 3 EVOTAZ 3 lamivudine 1 GENVOYA 3 LEXIVA 3 KALETRA SOL 3 NEVIRAPINE SUSP 1 KALETRA TAB 100-25MG 2 nevirapine TABS; TB24 1 KALETRA TAB 200-50MG 3 NORVIR 2 lamivudine-zidovudine 3 PREZISTA SUSP 3 ODEFSEY 3 PREZISTA TABS 75mg, 2 PREZCOBIX 3 150mg STRIBILD 3 PREZISTA TABS 600mg, 3 TRIUMEQ 3 800mg TRIZIVIR 3 RESCRIPTOR 2 TRUVADA 3 RETROVIR CAPS 3 TRUVADA TAB 100-150 3 RETROVIR IV INFUSION 3 TRUVADA TAB 133-200 3 RETROVIR SYRP 3 TRUVADA TAB 167-250 3 REYATAZ 3 ANTITUBERCULAR AGENTS SELZENTRY 3 CAPASTAT SULFATE 3 stavudine 1 cycloserine CAPS 3 SUSTIVA CAPS 2 ethambutol hcl TABS 1 SUSTIVA TABS 3 isoniazid SOLN; SYRP 1 TIVICAY 50mg 3 isoniazid tabs 1 TYBOST 2 MYAMBUTOL 3 VIDEX EC 3 MYCOBUTIN 3 VIDEX PEDIATRIC 3 paser d/r 3 VIRACEPT 3 PRIFTIN 3 VIRAMUNE 3 pyrazinamide TABS 1 VIRAMUNE XR 100mg 2 rifabutin 1 VIRAMUNE XR 400mg 3 rifadin CAPS 150mg 3 VIREAD 3 RIFADIN CAPS 300mg 3 VITEKTA 3 RIFADIN SOLR 3 ZERIT 3 rifamate 3 ZIAGEN SOLN 2 rifampin CAPS; SOLR 1 ZIAGEN TABS 3 RIFATER 3 zidovudine 1 SIRTURO 3 LA ANTIRETROVIRAL COMBINATION TRECATOR 3 AGENTS ANTIVIRALS abacavir sulfate-lamivudine- 3 zidovudine acyclovir CAPS; SUSP; 1 TABS ATRIPLA 3 acyclovir sodium SOLN 1 B/D COMBIVIR 3

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy B/D - Covered under 7 Medicare B or D LA - Limited Access 2016 State of New York eff 08/01/2016

Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits acyclovir sodium SOLR 1 B/D valacyclovir hcl TABS 1 500mg VALCYTE 3 adefovir dipivoxil 3 valganciclovir hcl 3 BARACLUDE SOLN 2 VALTREX 3 BARACLUDE TABS 3 ZOVIRAX CAPS; SUSP; 3 cidofovir 3 TABS COPEGUS 3 CEPHALOSPORINS CYTOVENE 3 B/D AVYCAZ 3 DAKLINZA 3 PA CEDAX 3 entecavir 3 cefaclor 1 EPIVIR HBV SOLN 2 cefaclor er tab 500mg 3 EPIVIR HBV TABS 3 cefadroxil 1 famciclovir TABS 1 CEFAZOLIN IN DEXTROSE 3 FAMVIR 3 2GM/100ML-4% FLUMADINE 3 cefazolin inj 1 ganciclovir inj 500mg 1 B/D cefazolin sodium 1gm, 20gm 1 HARVONI 3 PA cefazolin/dextrose 3 HEPSERA 3 cefdinir 1 lamivudine (hbv) 1 CEFEPIME 1GM SOLN 3 moderiba pak MISC 3 CEFEPIME 2GM SOLN 3 moderiba pak TABS 400mg 3 CEFEPIME HCL AND 3 DEXTROSE MODERIBA PAK TABS 3 600mg cefepime inj 1gm 1 moderiba tab 200mg 1 cefepime inj 2gm 1 PEG-INTRON REDIPEN 3 PA cefixime 1 PEGASYS 3 PA CEFOTAN 3 PEGASYS PROCLICK 3 PA cefotaxime sodium 1gm, 1 2gm, 500mg PEGINTRON 3 PA cefotetan disodium 1 REBETOL 3 cefoxitin sodium 1 RELENZA DISKHALER 2 CEFOXITIN SODIUM IN 3 ribapak mis 600/day 3 DEXTROSE ribasphere CAPS 1 cefpodoxime proxetil 1 ribasphere TABS 200mg, 1 cefprozil 1 400mg ceftazidime 1 ribasphere TABS 600mg 3 CEFTAZIDIME/DEXTROSE 3 ribasphere ribapak 800 3 CEFTIBUTEN 1 ribasphere ribapak 1000 3 CEFTIN 3 ribasphere ribapak 1200 3 ceftriaxone sodium SOLR 1 ribavirin 200mg 1 1gm, 2gm, 10gm, 250mg, rimantadine hydrochloride 1 500mg SOVALDI 3 PA cefuroxime axetil 1 TAMIFLU 2 cefuroxime sodium 1.5gm, 1 TYZEKA 3 7.5gm, 750mg cephalexin 1 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy B/D - Covered under 8 Medicare B or D LA - Limited Access 2016 State of New York eff 08/01/2016

Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits claforan 1gm, 2gm 3 CIPRO SUSP 3 CLAFORAN 1gm, 2gm, 3 CIPRO TABS 3 10gm, 500mg CIPRO XR 3 CLAFORAN/D5W 3 ciprofloxacin SOLN 1 FORTAZ 3 200mg/20ml MAXIPIME 3 ciprofloxacin SUSR 1 rocephin 3 ciprofloxacin er 1 SUPRAX CAPS 2 ciprofloxacin hcl TABS 1 suprax CHEW 2 ciprofloxacin in d5w 1 suprax SUSR 100mg/5ml, 2 ciprofloxacn inj 400mg/40ml 1 200mg/5ml LEVAQUIN 3 SUPRAX SUSR 500mg/5ml 2 levofloxacin 1 tazicef SOLR 1 levofloxacin in d5w 1 tazicef vial 1 MOXIFLOXACIN HCL SOLN 3 TEFLARO 3 moxifloxacin hcl TABS 1 ZERBAXA 3 PENICILLINS ZINACEF SOLR 3 amoxicillin 1 ERYTHROMYCINS/MACROLIDES amoxicillin & pot clavulanate 1 AZITHROMYCIN PACK 1 ampicillin & sulbactam sodium 1 azithromycin SOLR; SUSR; 1 ampicillin cap 250mg 1 TABS ampicillin cap 500 mg 1 BIAXIN 3 ampicillin inj 1 clarithromycin SUSR; TABS; 1 TB24 ampicillin sodium 1 DIFICID 3 ampicillin susp 1 e.e.s. 400 tab 400mg 1 AUGMENTIN 3 E.E.S. GRANULES 3 AUGMENTIN ES-600 3 ery-tab 1 AUGMENTIN XR 3 ERYPED 200 3 BACTOCILL INJ DEX 1GM 3 ERYPED 400 3 BACTOCILL INJ DEX 2GM 3 erythrocin lactobionate 3 BICILLIN C-R 3 erythrocin stearate 1 BICILLIN L-A 3 erythromycin base 1 dicloxacillin sodium 1 erythromycin cap 250mg ec 1 MOXATAG 3 erythromycin ethylsuccinate 1 NAFCILLIN 3 PCE 3 nafcillin sodium 1gm 1 ZITHROMAX 3 nafcillin sodium 2gm, 10gm 3 ZITHROMAX TRI-PAK 3 NALLPEN ISO-OSMOTIC IN 3 DE ZITHROMAX Z-PAK 3 oxacillin sodium 1gm, 2gm 1 ZMAX 3 oxacillin sodium 10gm 3 FLUOROQUINOLONES PENICILLIN G POT IN 3 AVELOX 3 DEXTROSE AVELOX ABC PACK 3

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy B/D - Covered under 9 Medicare B or D LA - Limited Access 2016 State of New York eff 08/01/2016

Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits PENICILLIN G POTASSIUM 3 EMCYT 2 IN GLEOSTINE 3 penicillin g procaine 3 HEXALEN 3 penicillin g sodium 1 IFEX INJ 1GM 3 B/D penicillin v potassium 1 IFEX INJ 3GM 3 B/D penicilln gk inj 5mu 1 ifosfamide inj 1 B/D penicilln gk inj 20mu 1 ifosfamide inj 1gm 1 B/D pfizerpen g inj 5mu 1 IFOSFAMIDE INJ 3GM 3 B/D pfizerpen-g inj 20mu 1 LEUKERAN 2 piperacillin sodium- 1 melphalan hcl 3 B/D tazobactam sodium MUSTARGEN 3 B/D UNASYN 3 thiotepa SOLR 3 B/D UNASYN BULK PACK 3 TREANDA 3 B/D ZOSYN 3 ZANOSAR 3 B/D TETRACYCLINES ANTHRACYCLINES demeclocycline hcl 1 daunorubicin hcl 1 B/D doxy 1 DOXIL 3 B/D doxycycline (monohydrate) 1 CAPS 50mg, 75mg, 100mg doxorubicin hcl 50mg 1 B/D doxycycline (monohydrate) 1 doxorubicin hcl liposomal inj 3 B/D SUSR (for iv infusion) 2 mg/ml doxycycline (monohydrate) 1 doxorubicin inj 50mg 1 B/D TABS ELLENCE 3 B/D doxycycline hyclate CAPS; 1 epirubicin inj 50mg/25ml 1 B/D SOLR; TABS epirubicin inj 200mg 1 B/D MINOCIN CAPS 3 IDAMYCIN PFS 3 B/D minocycline hcl CAPS; TABS; 1 idarubicin hcl 3 B/D TB24 SOLODYN 3 ANTIBIOTICS TETRACYCLINE HCL CAPS 1 bleomycin sulfate 1 B/D VIBRAMYCIN CAPS; SUSR 3 COSMEGEN 3 B/D VIBRAMYCIN SYRP 2 mitomycin SOLR 1 B/D ANTINEOPLASTIC AGENTS VALSTAR 3 ALKYLATING AGENTS ANTIMETABOLITES adrucil 1 B/D ALKERAN SOLR 3 B/D ALIMTA 3 B/D BENDEKA 3 B/D ARRANON 3 B/D BICNU 3 B/D azacitidine 3 B/D BUSULFEX 3 B/D cladribine 3 B/D CYCLOPHOSPHAMIDE 2 B/D CAPS CLOLAR 3 B/D cyclophosphamide SOLR 3 B/D cytarabine inj 1 B/D 1gm, 500mg DACOGEN 3 B/D cyclophosphamide SOLR 1 B/D decitabine 3 B/D 2gm fludarabine phosphate 1 B/D dacarbazine 1 B/D fluorouracil SOLN 1 B/D PA - Prior Authorization QL - Quantity Limits ST - Step Therapy B/D - Covered under 10 Medicare B or D LA - Limited Access 2016 State of New York eff 08/01/2016

Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits FOLOTYN 3 HERCEPTIN 3 B/D GEMCITABINE HCL SOLN 3 B/D IBRANCE 3 LA gemcitabine hcl SOLR 3 B/D ISTODAX 3 B/D GEMZAR 3 B/D KADCYLA 3 B/D mercaptopurine TABS 1 KEYTRUDA 3 METHOTREXATE SODIUM 1 B/D LYNPARZA 3 LA 50mg/2ml NINLARO 3 methotrexate sodium 1 B/D OPDIVO 3 50mg/2ml, 100mg/4ml, 200mg/8ml, 250mg/10ml PERJETA 3 methotrexate sodium inj 1 B/D PORTRAZZA 3 LA NIPENT 3 B/D PROLEUKIN 3 B/D PURIXAN 3 RITUXAN 2 LA TABLOID 2 TORISEL 3 B/D VIDAZA 3 B/D VECTIBIX 3 B/D ANTIMITOTIC, TAXOIDS VELCADE 3 B/D ABRAXANE 3 B/D VENCLEXTA 3 LA DOCETAXEL CONC 3 B/D VENCLEXTA STARTING 3 LA 20mg/ml, 80mg/4ml PACK docetaxel CONC 140mg/7ml 3 B/D YERVOY 3 DOCETAXEL SOLN 1 B/D ZALTRAP 3 20mg/2ml ZOLINZA 3 DOCETAXEL SOLN 3 B/D HORMONAL ANTINEOPLASTIC AGENTS 80mg/8ml, 160mg/16ml, anastrozole TABS 1 200mg/20ml ARIMIDEX 3 JEVTANA 3 AROMASIN 3 paclitaxel 1 B/D bicalutamide 1 TAXOTERE 3 B/D CASODEX 3 ANTIMITOTIC, VINCA ALKALOIDS DEPO-PROVERA INJ 400/ML 3 B/D vinblastine sulfate 1 B/D ELIGARD INJ 7.5MG 3 B/D vincasar 1 B/D ELIGARD INJ 22.5MG 3 B/D vincristine sulfate 1 B/D ELIGARD INJ 30MG 3 B/D vinorelbine tartrate 1 B/D ELIGARD INJ 45MG 3 B/D BIOLOGIC RESPONSE MODIFIERS exemestane 1 ARZERRA 3 B/D FARESTON 3 AVASTIN 3 B/D LA FASLODEX 3 B/D BELEODAQ 3 FEMARA 3 CYRAMZA 3 FIRMAGON 3 B/D DARZALEX 3 flutamide 1 EMPLICITI 3 LA letrozole TABS 1 ERBITUX 3 B/D leuprolide acetate KIT 1 PA ERIVEDGE 3 LA LUPRON DEP INJ 11.25MG 3 PA FARYDAK 3 LA LUPRON DEP-PED INJ 3 PA GAZYVA 3 7.5MG

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy B/D - Covered under 11 Medicare B or D LA - Limited Access 2016 State of New York eff 08/01/2016

Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits LUPRON DEP-PED INJ 3 PA IRESSA 3 LA 11.25MG JAKAFI 3 LA LUPRON DEP-PED INJ 3 PA LENVIMA 8MG DAILY DOSE 3 LA 15MG LENVIMA 10MG DAILY 3 LA LUPRON DEP-PED INJ 3 PA DOSE 30MG (3-MONTH) LENVIMA 14MG DAILY 3 LA LUPRON DEPOT 3 PA DOSE LUPRON DEPOT INJ 22.5MG 3 PA LENVIMA 18MG DAILY 3 LA (3-MONTH) DOSE LUPRON DEPOT INJ 30MG 3 PA LENVIMA 20MG DAILY 3 LA (3-MONTH) DOSE LYSODREN 2 LENVIMA 24MG DAILY 3 LA MEGACE ES 3 DOSE MEGACE ORAL 3 PA MEKINIST 3 LA PA if 65 years and older NEXAVAR 3 LA megestrol acetate SUSP; 3 PA SPRYCEL 3 TABS PA if 65 years and older STIVARGA 3 LA MEGESTROL SUS 3 SUTENT 3 625MG/5ML TAFINLAR 3 LA NILANDRON 3 TAGRISSO 3 LA SOLTAMOX 3 TARCEVA 3 LA tamoxifen citrate TABS 1 TASIGNA 3 TRELSTAR MIXJECT 3 PA TYKERB 3 LA VANTAS 3 PA VOTRIENT 3 LA XTANDI 3 LA XALKORI 3 LA ZOLADEX 3 PA ZELBORAF 3 LA ZYTIGA 3 LA ZYDELIG 3 LA KINASE INHIBITORS ZYKADIA 3 LA AFINITOR 3 MISCELLANEOUS AFINITOR DISPERZ 3 bexarotene 3 ALECENSA 3 LA DROXIA 3 BOSULIF 3 ERWINAZE 3 CABOMETYX 3 LA HALAVEN 3 B/D CAPRELSA 3 LA HYDREA 3 COMETRIQ 3 LA hydroxyurea CAPS 1 COTELLIC 3 LA IXEMPRA KIT 3 B/D GILOTRIF TAB 20MG 3 LA LONSURF 3 GILOTRIF TAB 30MG 3 LA MATULANE 3 LA GILOTRIF TAB 40MG 3 LA mitoxantrone hcl 1 B/D GLEEVEC 2 ODOMZO 3 LA ICLUSIG 3 LA ONCASPAR 3 imatinib mesylate 2 POMALYST 3 LA IMBRUVICA CAP 140MG 3 LA SYLATRON KIT 200MCG 3 INLYTA 3 LA SYLATRON KIT 300MCG 3

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy B/D - Covered under 12 Medicare B or D LA - Limited Access 2016 State of New York eff 08/01/2016

Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits SYLATRON KIT 600MCG 3 amlodipine besylate- 1 SYLVANT 3 benazepril hcl SYNRIBO 3 benazepril & 1 hydrochlorothiazide TARGRETIN CAPS 3 captopril & 1 tretinoin CAPS 2 hydrochlorothiazide TRISENOX 3 B/D enalapril maleate & 1 UVADEX 3 B/D hydrochlorothiazide PLATINUM-BASED AGENTS fosinopril sodium & 1 hydrochlorothiazide carboplatin 1 B/D lisinopril & 1 cisplatin 1 B/D hydrochlorothiazide ELOXATIN 3 B/D LOTREL 3 oxaliplatin 3 B/D moexipril-hydrochlorothiazide 1 PROTECTIVE AGENTS quinapril-hydrochlorothiazide 1 amifostine crystalline 3 B/D TARKA 3 dexrazoxane 250mg 3 B/D trandolapril-verapamil hcl 1 ELITEK 3 B/D VASERETIC 3 FUSILEV 3 B/D ZESTORETIC 3 KEPIVANCE 3 B/D ACE INHIBITORS leucovorin calcium TABS 1 ACCUPRIL 3 leucovorin calcium inj 50mg 1 B/D ALTACE 3 leucovorin calcium inj 100mg 1 B/D benazepril hcl TABS 1 leucovorin calcium inj 200mg 1 B/D captopril TABS 1 leucovorin calcium inj 350mg 1 B/D enalapril maleate TABS 1 leucovorin calcium inj 500mg 1 B/D fosinopril sodium 1 levoleucovorin calcium 3 B/D lisinopril TABS 1 mesna 1 B/D LOTENSIN 20mg, 40mg 3 MESNEX SOLN 3 B/D MAVIK 3 MESNEX TABS 3 moexipril hcl 1 ZINECARD 3 B/D perindopril erbumine 1 TOPOISOMERASE INHIBITORS PRINIVIL 3 CAMPTOSAR 3 B/D quinapril hcl 1 ETOPOPHOS 3 B/D ramipril 1 etoposide SOLN 500mg/25ml 1 B/D trandolapril 1 HYCAMTIN SOLR 3 B/D VASOTEC 3 irinotecan inj 40mg/2ml 1 B/D ZESTRIL 3 irinotecan inj 100/5ml 1 B/D ALDOSTERONE RECEPTOR irinotecan inj 500mg/25ml 1 B/D ANTAGONISTS toposar 1gm/50ml 1 B/D ALDACTONE 3 topotecan hcl SOLR 3 B/D eplerenone 1 CARDIOVASCULAR INSPRA 3 ACE INHIBITOR COMBINATIONS spironolactone TABS 1 ACCURETIC 3 ALPHA BLOCKERS

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy B/D - Covered under 13 Medicare B or D LA - Limited Access 2016 State of New York eff 08/01/2016

Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits CARDURA 3 valsartan-hydrochlorothiazide 1 mesylate 1 ANGIOTENSIN II RECEPTOR MINIPRESS 3 ANTAGONISTS hcl 1 ATACAND 3 hcl 1 AVAPRO 3 ANGIOTENSIN II RECEPTOR BENICAR 2 ANTAGONIST COMBINATIONS candesartan cilexetil 1 amlodipine besylate-valsartan 1 COZAAR 3 tab 5-160 mg DIOVAN 3 amlodipine besylate-valsartan 1 EDARBI 3 tab 5-320 mg eprosartan mesylate 1 amlodipine besylate-valsartan 1 tab 10-160 mg irbesartan 1 amlodipine besylate-valsartan 1 losartan potassium 1 tab 10-320 mg MICARDIS 3 amlodipine-valsartan- 1 telmisartan 1 hydrochlorothiazide 5-160- valsartan 1 12.5mg amlodipine-valsartan- 1 ANTIARRHYTHMICS hydrochlorothiazide 5-160- amiodarone hcl 1 25mg amiodarone inj 50mg/ml 1 amlodipine-valsartan- 1 BETAPACE 3 hydrochlorothiazide 10-160- 12.5mg BETAPACE AF 3 amlodipine-valsartan- 1 disopyramide phosphate 3 PA hydrochlorothiazide 10-160- PA if 65 years and older 25mg dofetilide 1 amlodipine-valsartan- 1 flecainide acetate 1 hydrochlorothiazide 10-320- mexiletine hcl 1 25mg MULTAQ 3 ATACAND HCT 3 NORPACE 3 PA AVALIDE 3 PA if 65 years and older AZOR 2 NORPACE CR 3 PA BENICAR HCT 2 PA if 65 years and older candesartan cilexetil- 1 pacerone 1 hydrochlorothiazide hcl 1 EDARBYCLOR 3 propafenone hcl 12hr 1 ENTRESTO 3 gluconate TBCR 1 HYZAAR 3 quinidine sulfate TABS 1 irbesartan-hydrochlorothiazide 1 RYTHMOL 3 losartan-hydrochlorothiazide 1 RYTHMOL SR 3 MICARDIS HCT 3 sorine 1 telmisartan-amlodipine 1 hcl 1 telmisartan- 1 sotalol hcl (afib/afl) 1 hydrochlorothiazide TIKOSYN 2 TWYNSTA 3

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy B/D - Covered under 14 Medicare B or D LA - Limited Access 2016 State of New York eff 08/01/2016

Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits ANTILIPEMICS, HMG-CoA REDUCTASE prevalite 1 INHIBITORS questran 3 atorvastatin calcium TABS 1 questran light 3 CRESTOR 2 TRICOR 3 fluvastatin sodium 1 TRILIPIX 3 fluvastatin sodium tab sr 24 hr 1 VASCEPA 3 80 mg VYTORIN 2 LESCOL 3 WELCHOL 2 LIVALO 3 ZETIA TAB 10MG 2 lovastatin 1 BETA-BLOCKER/DIURETIC PRAVACHOL 3 COMBINATIONS pravastatin sodium 1 & chlorthalidone 1 rosuvastatin calcium 1 & 1 simvastatin TABS 1 hydrochlorothiazide ZOCOR 3 CORZIDE 3 ANTILIPEMICS, MISCELLANEOUS DUTOPROL 3 ANTARA 3 LOPRESSOR HCT 3 cholestyramine 1 & hctz tab 50- 1 cholestyramine light 1 25mg choline fenofibrate 1 metoprolol & hctz tab 100- 1 25mg COLESTID 3 metoprolol & hctz tab 100- 1 colestipol hcl 1 50mg FENOFIBRATE CAPS 1 & bendroflumethiazide 1 FENOFIBRATE TABS 40mg, 1 & 1 120mg hydrochlorothiazide fenofibrate TABS 48mg, 1 TENORETIC 50 3 54mg, 145mg, 160mg TENORETIC 100 3 fenofibrate micronized 1 ZIAC 3 FENOFIBRIC ACID 1 BETA-BLOCKERS FENOGLIDE 3 hcl CAPS 1 FIBRICOR 3 atenolol TABS 1 gemfibrozil TABS 1 hcl 1 JUXTAPID 3 LA PA bisoprolol fumarate 1 KYNAMRO 3 PA BYSTOLIC 2 LIPOFEN 3 1 lofibra 3 COREG 3 LOPID 3 CORGARD 3 LOVAZA CAP 1GM 3 INDERAL LA 3 niacin er (antihyperlipidemic) 1 hcl SOLN; TABS 1 niacor 1 LOPRESSOR 3 NIASPAN 3 metoprolol succinate 1 omega-3-acid ethyl esters 1 metoprolol tartrate SOLN 1 PRALUENT 3 PA

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy B/D - Covered under 15 Medicare B or D LA - Limited Access 2016 State of New York eff 08/01/2016

Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits metoprolol tartrate TABS 1 nifedipine TB24 1 25mg, 50mg, 100mg nifedipine er 1 nadolol TABS 1 nimodipine CAPS 3 1 nisoldipine 1 propranolol hcl er 1 NORVASC 3 propranolol inj 1mg/ml 1 NYMALIZE 3 propranolol sol 1 PROCARDIA XL 3 propranolol tab 1 SULAR 3 SECTRAL 3 taztia xt 1 SOTYLIZE 3 TIAZAC 3 TENORMIN 3 verapamil hcl CP24 100mg, 1 maleate TABS 1 120mg, 180mg, 200mg, TOPROL XL 3 240mg, 300mg TRANDATE 3 VERAPAMIL HCL CP24 1 360mg ZEBETA 3 verapamil hcl SOLN 1 CALCIUM CHANNEL BLOCKERS verapamil hcl TABS 1 ADALAT CC 3 verapamil hcl TBCR 1 afeditab cr 1 VERELAN 3 amlodipine besylate TABS 1 VERELAN PM 3 CALAN 3 DIGITALIS GLYCOSIDES CALAN SR 3 digitek .25mg 1 PA CARDIZEM 60mg, 120mg 3 PA if 65 years and older CARDIZEM CD 3 digitek .125mg 1 CARDIZEM LA 3 digox 125mcg 1 cartia xt 1 digox 250mcg 1 PA dilt-xr cap 1 PA if 65 years and older diltiazem cap 120mg/24hr 1 digoxin TABS 125mcg 1 diltiazem cap 240mg/24hr 1 digoxin TABS 250mcg 1 PA diltiazem cap er/12hr 1 PA if 65 years and older diltiazem hcl TABS 1 digoxin inj 1 diltiazem hcl coated beads 1 DIGOXIN SOL 50MCG/ML 1 PA PA if 65 years and older diltiazem hcl er 1 LANOXIN 62.5mcg 3 diltiazem hcl extended release 1 beads LANOXIN 187.5mcg 3 PA PA if 65 years and older diltiazem inj 25mg/5ml 1 LANOXIN INJ 0.25MG/ML 3 diltiazem inj 50/10ml 1 LANOXIN PEDIATRIC 3 diltiazem inj 100mg 3 LANOXIN TAB 125mcg 3 diltiazem inj 125/25ml 1 LANOXIN TAB 250mcg 3 PA felodipine 1 PA if 65 years and older isradipine 1 DIRECT RENIN matzim la 1 INHIBITORS/COMBINATIONS nicardipine hcl CAPS 1 TEKTURNA 2 nifedical 1 TEKTURNA HCT 2 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy B/D - Covered under 16 Medicare B or D LA - Limited Access 2016 State of New York eff 08/01/2016

Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits DIURETICS BIDIL 2 acetazolamide CP12; TABS 1 CATAPRES TAB 3 acetazolamide sodium 1 CATAPRES-TTS DIS 3 ALDACTAZIDE 3 0.1/24HR ALDACTAZIDE TAB 50/50 3 CATAPRES-TTS DIS 3 0.2/24HR amiloride & 1 hydrochlorothiazide CATAPRES-TTS DIS 3 0.3/24HR amiloride hcl TABS 1 hcl PTWK; TABS 1 bumetanide 1 clorpres 1 chlorothiazide tabs 1 CORLANOR 3 chlorthalidone 25mg, 50mg 1 DEMSER 3 DEMADEX 3 DIBENZYLINE 3 DEMADEX TAB 20MG 3 hydralazine hcl SOLN; TABS 1 DIAMOX 3 KEVEYIS 3 PA DIURIL SUS 250/5ML 3 hcl 1 DYAZIDE 3 minoxidil TABS 1 DYRENIUM 3 hcl 3 EDECRIN 3 CAPS furosemide SOLN; TABS 1 RANEXA 2 furosemide inj 10mg/ml 1 NITRATES FUROSEMIDE INJ 10mg/ml 1 DILATRATE SR 3 furosemide oral soln 8 mg/ml 1 ISORDIL TITRADOSE 5mg 3 hydrochlorothiazide CAPS; 1 ISORDIL TITRADOSE 40mg 2 TABS isosorbide dinitrate 1 indapamide 1 isosorbide dinitrate er 1 LASIX 3 isosorbide mononitrate 1 MAXZIDE 3 isosorbide mononitrate er 1 MAXZIDE-25 3 minitran 1 methazolamide TABS 1 nitro-bid 3 methyclothiazide 1 NITRO-DUR .1mg/hr, 3 metolazone 1 .2mg/hr, .4mg/hr, .6mg/hr MICROZIDE 3 NITRO-DUR .3mg/hr, .8mg/hr 2 NEPTAZANE 3 nitroglycerin .4mg/spray 1 SODIUM DIURIL 3 NITROGLYCERIN LINGUAL 1 spironolactone & 1 nitroglycerin patches 1 hydrochlorothiazide NITROLINGUAL SPR 3 torsemide inj 50mg/5ml 3 PUMPSPRA torsemide tabs 1 NITROMIST 3 triamt/hctz cap 37.5-25 1 NITROSTAT 2 triamt/hctz cap 50-25mg 1 PULMONARY ARTERIAL HYPERTENSION triamt/hctz tab 37.5-25 1 ADCIRCA 3 PA triamt/hctz tab 75-50mg 1 ADEMPAS 3 LA PA MISCELLANEOUS epoprostenol sodium 3 B/D LA

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy B/D - Covered under 17 Medicare B or D LA - Limited Access 2016 State of New York eff 08/01/2016

Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits FLOLAN 3 B/D LA XANAX TAB 1MG 3 QL LETAIRIS 3 LA PA QL (120 tabs / 30 days) OPSUMIT 3 LA PA XANAX TAB 2MG 3 QL QL (150 tabs / 30 days) ORENITRAM TAB 0.25MG 3 LA PA ANTICONVULSANTS ORENITRAM TAB 0.125MG 3 LA PA APTIOM 3 ORENITRAM TAB 1MG 3 LA PA BANZEL SUS 40MG/ML 3 ORENITRAM TAB 2.5MG 3 LA PA BANZEL TAB 200MG 3 REMODULIN 3 B/D LA BANZEL TAB 400MG 3 REVATIO 3 PA BRIVIACT INJ 3 sildenafil citrate (pulmonary 3 PA hypertension) SOLN BRIVIACT SOLN 10MG/ML 3 sildenafil citrate (pulmonary 1 PA BRIVIACT TABS 3 hypertension) TABS carbamazepine CHEW; 1 TRACLEER 3 LA PA CP12; SUSP; TABS; TB12 TYVASO 3 B/D CARBATROL 3 UPTRAVI 3 LA PA CELONTIN 3 VELETRI 3 B/D LA clonazepam TABS 1mg 1 QL QL (120 tabs / 30 days) VENTAVIS 3 B/D clonazepam TABS 2mg 1 QL CENTRAL NERVOUS SYSTEM QL (300 tabs / 30 days) ANTIANXIETY clonazepam TABS .5mg 1 QL alprazolam CONC 3 QL QL (240 tabs / 30 days) QL (300 mL / 30 days) clonazepam TBDP 1mg 1 QL alprazolam TABS 1mg 1 QL QL (120 tabs / 30 days) QL (120 tabs / 30 days) clonazepam TBDP 2mg 1 QL alprazolam TABS 2mg 1 QL QL (300 tabs / 30 days) QL (150 tabs / 30 days) clonazepam TBDP .5mg 1 QL alprazolam TABS .5mg 1 QL QL (240 tabs / 30 days) QL (240 tabs / 30 days) clonazepam TBDP .25mg 1 QL alprazolam TABS .25mg 1 QL QL (480 tabs / 30 days) QL (480 tabs / 30 days) clonazepam TBDP .125mg 1 QL ATIVAN SOLN 3 QL (960 tabs / 30 days) ATIVAN TABS 3 QL clorazepate dipotassium 1 QL QL (150 tabs / 30 days) 3.75mg, 7.5mg QL (120 tabs / 30 days) hcl TABS 1 clorazepate dipotassium 1 QL fluvoxamine maleate 1 15mg fluvoxamine maleate er 1 QL (180 tabs / 30 days) lorazepam CONC 1 QL DEPACON 3 QL (150 mL / 30 days) DEPAKENE 3 lorazepam SOLN 1 DEPAKOTE 3 lorazepam TABS 1 QL DEPAKOTE ER 3 QL (150 tabs / 30 days) DEPAKOTE SPRINKLES 3 XANAX TAB 0.5MG 3 QL QL (240 tabs / 30 days) DIASTAT ACUDIAL 3 XANAX TAB 0.25MG 3 QL DIASTAT PEDIATRIC 3 QL (480 tabs / 30 days) diazepam CONC 1 QL QL (240 mL / 30 days)

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy B/D - Covered under 18 Medicare B or D LA - Limited Access 2016 State of New York eff 08/01/2016

Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits diazepam SOLN 1mg/ml 1 QL OXTELLAR XR 2 QL (1200 mL / 30 days) PEGANONE 3 diazepam SOLN 5mg/ml 1 phenobarbital ELIX; TABS 3 PA diazepam TABS 1 QL PA if 65 years and older QL (120 tabs / 30 days) PHENOBARBITAL SODIUM 3 PA DIAZEPAM GEL 1 SOLN 65mg/ml (ANTICONVULSANT) PA if 65 years and older dilantin 3 phenobarbital sodium SOLN 3 PA DILANTIN-125 3 130mg/ml PA if 65 years and older divalproex sodium 1 phenytek 3 epitol 1 phenytoin CHEW; SUSP 1 ethosuximide CAPS; SOLN 1 phenytoin inj 50mg/ml 1 felbamate SUSP 3 phenytoin sodium extended 1 felbamate TABS 1 POTIGA 3 FELBATOL 3 primidone TABS 1 FYCOMPA TABS 2 QUDEXY XR 2 gabapentin CAPS; SOLN; 1 TABS roweepra 1 GABITRIL 3 SABRIL 3 LA PA KEPPRA 3 SPRITAM 3 KEPPRA XR 3 TEGRETOL 3 KLONOPIN 1mg 3 QL TEGRETOL-XR 3 QL (120 tabs / 30 days) tiagabine hcl 1 KLONOPIN 2mg 3 QL TOPAMAX 3 QL (300 tabs / 30 days) TOPAMAX SPRINKLE 3 KLONOPIN .5mg 3 QL topiramate CPSP; TABS 1 QL (240 tabs / 30 days) TOPIRAMATE CS24 1 LAMICTAL TABS 3 TRANXENE T 3.75mg, 3 QL LAMICTAL CHEWABLE 3 7.5mg DISPERS QL (120 tabs / 30 days) LAMICTAL ODT 3 TRANXENE T 15mg 3 QL LAMICTAL STARTER 3 QL (180 tabs / 30 days) LAMICTAL XR 3 TRILEPTAL SUSP 3 lamotrigine CHEW; KIT; 1 TRILEPTAL TABS 3 TABS; TB24; TBDP TROKENDI XR 25mg, 50mg, 2 levetiracetam SOLN; TABS; 1 100mg TB24 TROKENDI XR 200mg 3 LEVETIRACETAM IV 3 VALIUM 3 QL levetiracetam oral soln 100 1 QL (120 tabs / 30 days) mg/ml valproate sodium SOLN; 1 LYRICA 2 SYRP MYSOLINE 3 valproic acid 1 NEURONTIN 3 VIMPAT SOLN 2 ONFI 3 VIMPAT TABS 50mg 2 oxcarbazepine 1 VIMPAT TABS 100mg, 3 150mg, 200mg

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy B/D - Covered under 19 Medicare B or D LA - Limited Access 2016 State of New York eff 08/01/2016

Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits ZARONTIN CAPS 3 hcl CAPS 3 PA zarontin SOLN 3 PA if 65 years and older ZONEGRAN 3 CYMBALTA 3 zonisamide CAPS 1 hcl TABS 1 ANTIDEMENTIA hcl CAPS; CONC 3 PA PA if 65 years and older ARICEPT 5mg, 10mg 3 duloxetine hcl CPEP 20mg, 1 donepezil odt 5mg 1 30mg, 60mg donepezil odt 10mg 1 EFFEXOR XR 3 donepezil tab hcl 23mg 1 EMSAM 3 donepezil tabs 5mg 1 escitalopram oxalate 1 donepezil tabs 10mg 1 FETZIMA 3 EXELON CAPS 3 FETZIMA TITRATION PACK 3 EXELON PATCHES 3 fluoxetine hcl CAPS 1 galantamine hydrobromide 1 fluoxetine hcl CPDR 1 memantine hcl 1 PA fluoxetine hcl SOLN 1 PA if < 30 yrs fluoxetine hcl TABS 10mg, 1 NAMENDA SOL 10MG/5ML 2 PA 20mg PA if < 30 yrs FLUOXETINE HCL TABS 2 NAMENDA TAB 3 PA 60mg PA if < 30 yrs FORFIVO XL 3 NAMENDA XR 3 PA PA if < 30 yrs imipramine hcl TABS 3 PA PA if 65 years and older NAMENDA XR TITRATION 3 PA PACK pamoate 3 PA PA if < 30 yrs PA if 65 years and older NAMZARIC 3 LEXAPRO 3 RAZADYNE 3 hcl 1 RAZADYNE ER 3 MARPLAN 3 rivastigmine tartrate 1 1 rivastigmine td patch 24hr 4.6 1 NARDIL 3 mg/24hr hcl 1 rivastigmine td patch 24hr 9.5 1 NORPRAMIN 3 mg/24hr hcl CAPS; SOLN 1 rivastigmine td patch 24hr 1 PAMELOR 3 13.3 mg/24hr PARNATE 3 paroxetine er tab 1 hcl TABS 3 PA PA if 65 years and older paroxetine hcl tabs 1 1 PAXIL 3 ANAFRANIL 3 PA PAXIL CR 3 PA if 65 years and older PEXEVA 3 BRINTELLIX 2 phenelzine sulfate TABS 1 bupropion hcl TABS; TB12; 1 PRISTIQ 3 TB24 hcl 1 CELEXA 3 PROZAC 3 citalopram hydrobromide 1 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy B/D - Covered under 20 Medicare B or D LA - Limited Access 2016 State of New York eff 08/01/2016

Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits PROZAC WEEKLY 3 ELDEPRYL 3 REMERON 3 ENTACAPONE 1 REMERON SOLTAB 3 LODOSYN 3 sertraline hcl CONC; TABS 1 MIRAPEX 3 SURMONTIL 3 PA MIRAPEX ER 2.25mg, 3mg, 2 PA if 65 years and older 3.75mg, 4.5mg TOFRANIL 3 PA MIRAPEX ER .375mg, 3 PA if 65 years and older .75mg, 1.5mg tranylcypromine sulfate 1 NEUPRO 2 hcl TABS 1 pramipexole dihydrochloride 1 maleate CAPS 3 PA REQUIP 3 PA if 65 years and older ropinirole hydrochloride 1 TRINTELLIX 2 TABS venlafaxine cap er 1 RYTARY 3 venlafaxine hcl 1 selegiline hcl CAPS; TABS 1 VENLAFAXINE HCL ER TAB 3 SINEMET 3 (VERT) SINEMET CR 3 venlafaxine tab 1 STALEVO 3 VENLAFAXINE TAB 225MG 1 ZELAPAR 3 ER ANTIPSYCHOTICS venlafaxine tab er 1 ABILIFY DISCMELT TAB 3 VIIBRYD 2 10MG VIIBRYD STARTER PACK 2 ABILIFY MAINTENA 3 WELLBUTRIN 3 ABILIFY TABS 3 WELLBUTRIN SR 3 odt 3 WELLBUTRIN XL 3 aripiprazole oral solution 1 3 ZOLOFT 3 mg/ml ANTIPARKINSONIAN AGENTS aripiprazole tabs 3 amantadine hcl CAPS; 1 ARISTADA 3 SYRP; TABS chlorpromaz inj 25mg/ml 3 APOKYN 3 LA PA hcl TABS 1 AZILECT 2 chlorpromazine inj 3 BENZTROPINE MESYLATE 1 1 SOLN CLOZAPINE ODT 12.5mg, 1 benztropine mesylate TABS 3 PA 25mg, 100mg PA if 65 years and older CLOZAPINE ODT 150mg, 3 mesylate 1 200mg CAPS; TABS CLOZARIL 3 carbidopa TABS 3 FANAPT 3 carbidopa-levodopa 1 FANAPT TITRATION PACK 3 CARBIDOPA/LEVODOPA/EN 1 TACAPONE FAZACLO 3 COGENTIN 3 decanoate 1 SOLN COMTAN 3 fluphenazine hcl 1 DUOPA 3 B/D GEODON 3 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy B/D - Covered under 21 Medicare B or D LA - Limited Access 2016 State of New York eff 08/01/2016

Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits GEODON INJ 3 hcl TABS 3 PA HALDOL 3 PA if 65 years and older HALDOL DECANOATE 50 3 thiothixene 1 HALDOL DECANOATE 100 3 hcl 1 TABS 1 VERSACLOZ 3 SOLN 1 VRAYLAR 3 haloperidol lactate 1 hcl 1 haloperidol lactate inj 5 mg/ml 1 ZYPREXA 3 INVEGA 3 ZYPREXA RELPREVV 3 INVEGA SUST INJ 39 3 ZYPREXA RELPREVV INJ 3 MG/0.25 ML 210MG INVEGA SUST INJ 78 MG/0.5 3 ZYPREXA ZYDI TAB 10MG 3 ML ZYPREXA ZYDIS 3 INVEGA SUST INJ 117 3 ATTENTION DEFICIT HYPERACTIVITY MG/0.75 ML DISORDER INVEGA SUST INJ 3 156MG/ML adderall tab 5mg 3 INVEGA SUST INJ 234 3 adderall tab 7.5mg 3 MG/1.5 ML ADDERALL TAB 10MG 3 INVEGA TRINZA 3 adderall tab 12.5mg 3 LATUDA 2 adderall tab 15mg 3 succinate 1 ADDERALL TAB 20MG 3 molindone hcl 1 ADDERALL TAB 30MG 3 NUPLAZID 3 QL LA PA ADDERALL XR CAP 5MG 3 QL (60 tabs / 30 days) ADDERALL XR CAP 10MG 3 1 ADDERALL XR CAP 15MG 3 olanzapine odt 1 ADDERALL XR CAP 20MG 3 ORAP 3 ADDERALL XR CAP 25MG 3 1 ADDERALL XR CAP 30MG 3 TABS 1 amphetamine cap 10mg er 1 pimozide 1 amphetamine cap 15mg er 1 fumarate 1 amphetamine cap 20mg er 1 REXULTI 3 amphetamine cap 25mg er 1 RISPERDAL 3 amphetamine cap 30mg er 1 RISPERDAL INJ 12.5MG 2 amphetamine- 1 RISPERDAL INJ 25MG 2 dextroamphetamine cap sr RISPERDAL INJ 37.5MG 3 24hr 5 mg RISPERDAL INJ 50MG 3 amphetamine- 1 dextroamphetamine tab 5 mg RISPERDAL M-TAB 3 amphetamine- 1 1 dextroamphetamine tab 7.5 risperidone odt 1 mg SAPHRIS 3 amphetamine- 1 SEROQUEL 3 dextroamphetamine tab 10 mg SEROQUEL XR 2

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy B/D - Covered under 22 Medicare B or D LA - Limited Access 2016 State of New York eff 08/01/2016

Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits amphetamine- 1 RESTORIL 7.5mg 3 QL PA dextroamphetamine tab 12.5 QL (30 caps / 30 days) mg 90 day limit per calendar amphetamine- 1 year if 65 years and older dextroamphetamine tab 15 RESTORIL 15mg 3 QL PA mg QL (60 caps / 30 days) amphetamine- 1 90 day limit per calendar dextroamphetamine tab 20 year if 65 years and older mg ROZEREM 3 QL amphetamine- 1 QL (30 tabs / 30 days) dextroamphetamine tab 30 SILENOR 2 mg temazepam 7.5mg 1 QL PA APTENSIO XR 3 QL (30 caps / 30 days) CONCERTA 3 90 day limit per calendar year if 65 years and older DAYTRANA 2 temazepam 15mg 1 QL PA hcl (adhd) 3 PA QL (60 caps / 30 days) PA if 65 years and older 90 day limit per calendar INTUNIV 3 PA year if 65 years and older PA if 65 years and older zolpidem tartrate TABS 3 QL PA METADATE CD 3 QL (30 tabs / 30 days) metadate er tab 20mg 1 90 day limit per calendar year if 65 years and older METHYLIN 3 MIGRAINE METHYLIN CHEW TAB 3 almotriptan malate 1 methylphenidate hcl CHEW 1 AMERGE 3 methylphenidate hcl CP24 1 20mg, 40mg AXERT 3 METHYLPHENIDATE HCL 1 cafergot tab 1-100mg 3 CP24 30mg D.H.E. 45 3 methylphenidate hcl CPCR 1 mesylate 1 methylphenidate hcl SOLN 1 1mg/ml methylphenidate hcl TABS 1 DIHYDROERGOTAMINE 3 MESYLATE 4mg/ml methylphenidate hcl TB24 1 ergomar 3 methylphenidate hcl TBCR 1 FROVA TAB 2.5MG 3 methylphenidate hcl er TB24 1 frovatriptan succinate 1 QUILLICHEW ER 3 IMITREX 3 QUILLIVANT XR 3 IMITREX STATDOSE REFILL 3 RITALIN 3 IMITREX STATDOSE 3 RITALIN LA 3 SYSTEM STRATTERA 2 MAXALT 3 VYVANSE 2 MAXALT-MLT 3 HYPNOTICS migergot 3 AMBIEN 3 QL PA MIGRANAL 3 QL (30 tabs / 30 days) 90 day limit per calendar naratriptan hcl 1 year if 65 years and older ONZETRA XSAIL 3 HETLIOZ 3 LA PA RELPAX 2

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy B/D - Covered under 23 Medicare B or D LA - Limited Access 2016 State of New York eff 08/01/2016

Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits rizatriptan benzoate 1 GILENYA CAP 0.5MG 3 PA SUMATRIPTAN INJ 1 glatopa 3 PA 4MG/0.5ML LEMTRADA 3 LA PA sumatriptan inj 6mg/0.5ml 1 PLEGRIDY 3 PA SUMATRIPTAN SUCCINATE 1 PLEGRIDY STARTER PACK 3 PA SOLN REBIF 3 PA sumatriptan succinate TABS 1 REBIF REBIDOSE 3 PA SUMAVEL DOSEPRO 3 REBIF REBIDOSE 3 PA ZEMBRACE SYMTOUCH 3 TITRATION zolmitriptan TABS 1 REBIF TITRATION PACK 3 PA zolmitriptan odt 1 TECFIDERA CAP 120MG 3 LA PA ZOMIG TABS 3 TECFIDERA CAP 240MG 3 LA PA ZOMIG ZMT 3 TECFIDERA MIS STARTER 3 LA PA MISCELLANEOUS TYSABRI 3 LA PA BRISDELLE 2 MUSCULOSKELETAL THERAPY AGENTS EQUETRO 3 baclofen TABS 1 GRALISE 2 BOTOX INJ 100UNIT 3 PA GRALISE STARTER 2 BOTOX INJ 200UNIT 3 PA HORIZANT 3 hcl TABS 3 PA lithium carbonate CAPS; 1 5mg, 10mg TABS; TBCR PA if 65 years and older LITHIUM SOLN 8MEQ/5ML 3 DANTRIUM 3 LITHOBID 3 dantrolene sodium CAPS 1 MESTINON 3 DYSPORT 3 PA MESTINON SYRUP 2 1 MESTINON TIMESPAN 2 XEOMIN 3 PA NUEDEXTA 2 XEOMIN 200UNIT 3 PA pyridostigmine bromide 1 ZANAFLEX 3 TABS; TBCR NARCOLEPSY/CATAPLEXY RILUTEK 3 armodafinil 50mg, 150mg, 1 PA riluzole 1 250mg SAVELLA 2 ARMODAFINIL 200mg 1 PA SAVELLA TITRATION PACK 2 modafinil 100mg 1 PA tetrabenazine 3 PA modafinil 200mg 3 PA XENAZINE 3 LA PA NUVIGIL 2 PA MULTIPLE SCLEROSIS AGENTS XYREM 3 QL LA PA AMPYRA 3 LA PA QL (540 mL / 30 days) AUBAGIO 3 LA PA PSYCHOTHERAPEUTIC-MISC AVONEX 3 PA acamprosate calcium 1 AVONEX PEN 3 PA antabuse 3 COPAXONE INJ 40MG/ML 3 PA buprenorphine hcl SUBL 1 COPAXONE KIT 20MG/ML 3 PA buprenorphine hcl-naloxone 1 hcl sl EXTAVIA 3 PA buproban 1

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy B/D - Covered under 24 Medicare B or D LA - Limited Access 2016 State of New York eff 08/01/2016

Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits bupropion hcl (smoking 1 LANTUS SOLOSTAR 2 deterrent) LEVEMIR 2 CHANTIX 2 LEVEMIR FLEXTOUCH 2 CHANTIX CONTINUING 2 NOVOLIN 70/30 2 MONTH NOVOLIN N 2 CHANTIX STARTER PACK 2 NOVOLIN R 2 disulfiram TABS 1 NOVOLOG 2 naloxone hcl SOLN 1 NOVOLOG FLEXPEN 2 naltrexone hcl TABS 1 NOVOLOG MIX 70/30 2 NICOTROL INHALER 3 NOVOLOG MIX 70/30 2 NICOTROL NS 3 PREFILL SARAFEM 3 NOVOLOG PENFILL 2 VIVITROL 3 PA SYMLINPEN 60 2 ZUBSOLV SUB 1.4-0.36MG 3 SYMLINPEN 120 3 ZUBSOLV SUB 2.9-0.71MG 3 TANZEUM 3 ZUBSOLV SUB 5.7-1.4MG 3 TOUJEO SOLOSTAR 2 ZUBSOLV SUB 8.6-2.1MG 3 TRESIBA FLEXTOUCH 2 ZUBSOLV SUB 11.4-2.9MG 3 TRULICITY 2 ZYBAN 3 VICTOZA 2 ENDOCRINE AND METABOLIC ANTIDIABETICS, ORAL ANDROGENS acarbose 1 ANDRODERM 2 PA ACTOPLUS MET TAB 15- 3 AVEED 3 PA 500MG AXIRON 2 PA ACTOPLUS MET TAB 15- 3 depo-testosterone 3 PA 850MG oxandrolone TABS 2.5mg 1 PA ACTOPLUS MET XR 15- 3 1000MG oxandrolone TABS 10mg 3 PA ACTOPLUS MET XR 30- 3 STRIANT 3 PA 1000MG testosterone cypionate SOLN 1 PA ACTOS 3 testosterone enanthate 1 PA AMARYL 3 SOLN DUETACT 3 ANTIDIABETICS, INJECTABLE FARXIGA 2 ALCOHOL SWABS 2 glimepiride 1 BYDUREON 3 glipizide TABS 1 BYETTA 3 glipizide er 1 GAUZE PADS 2X2 2 GLIPIZIDE XL TB24 2.5MG 1 HUMULIN R U-500 3 B/D (CONCENTRATE) GLIPIZIDE XL TB24 5MG 1 HUMULIN R U-500 KWIKPEN 3 glipizide-metformin 2.5-250 1 mg INSULIN PEN NEEDLES 2 glipizide-metformin 2.5-500 1 INSULIN SAFETY NEEDLES 2 mg INSULIN SYRINGES 2 glipizide-metformin 5-500mg 1 LANTUS 2 GLUCOPHAGE 3

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy B/D - Covered under 25 Medicare B or D LA - Limited Access 2016 State of New York eff 08/01/2016

Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits GLUCOPHAGE XR 3 repaglinide-metformin hcl 1 GLUCOTROL 3 RIOMET 3 GLUCOTROL XL 3 STARLIX 3 GLYSET 3 SYNJARDY TAB 5-500MG 3 GLYXAMBI 3 SYNJARDY TAB 5-1000MG 3 INVOKAMET TAB 50-500MG 3 SYNJARDY TAB 12.5-500 3 INVOKAMET TAB 50-1000 3 SYNJARDY TAB 12.5-1000 3 INVOKAMET TAB 150-500 3 TRADJENTA 2 INVOKAMET TAB 150-1000 3 XIGDUO XR TAB 5-500MG 2 INVOKANA TAB 100MG 3 XIGDUO XR TAB 5-1000MG 2 INVOKANA TAB 300MG 3 XIGDUO XR TAB 10-500MG 2 JANUMET 2 XIGDUO XR TAB 10-1000MG 2 JANUMET XR TAB 50- 2 BISPHOSPHONATES 500MG ACTONEL 3 JANUMET XR TAB 50-1000 2 alendronate sodium 1 JANUMET XR TAB 100-1000 2 BONIVA 3 B/D JANUVIA 2 FOSAMAX 3 JARDIANCE 2 ibandronate sodium 1 B/D JENTADUETO 2 ibandronate tab 150mg 1 B/D KAZANO 3 pamidronate disodium SOLN 3 B/D KOMBIGLYZE XR 2.5- 3 6mg/ml 1000MG pamidronate disodium SOLN 1 B/D KOMBIGLYZE XR 5-500MG 3 30mg/10ml, 90mg/10ml KOMBIGLYZE XR 5-1000MG 3 RECLAST 3 B/D metformin er 1 RISEDRONATE SODIUM 1 metformin hcl TABS; TB24 1 TABS 5mg, 30mg miglitol 1 risedronate sodium TABS 1 35mg, 150mg nateglinide 1 risedronate sodium TBEC 1 NESINA 3 zoledronic inj 4mg/5ml 1 B/D ONGLYZA 3 zoledronic inj 5/100ml 1 B/D OSENI TAB 12.5-15MG 3 ZOMETA 3 B/D OSENI TAB 12.5-30MG 3 CALCIUM RECEPTOR AGONISTS OSENI TAB 12.5-45MG 3 SENSIPAR 2 OSENI TAB 25-15MG 3 CHELATING AGENTS OSENI TAB 25-30MG 3 CHEMET 3 OSENI TAB 25-45MG 3 DEPEN TITRATABS 3 pioglitazone hcl 1 EXJADE 3 LA PA pioglitazone hcl-glimepiride 1 FERRIPROX 3 LA PA pioglitazone hcl-metformin hcl 1 JADENU 3 PA PRANDIMET 3 KAYEXALATE 3 PRANDIN 3 kionex 1 PRECOSE 3 sodium polystyrene sulfonate 1 repaglinide 1

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy B/D - Covered under 26 Medicare B or D LA - Limited Access 2016 State of New York eff 08/01/2016

Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits sps susp 15gm/60ml 1 falmina 28 day 1 SYPRINE 3 FEMCON FE 3 VELTASSA 3 LA GENERESS FE 3 CONTRACEPTIVES GIANVI TAB 3-0.02MG 1 altavera 1 gildagia 1 amethia 91 day 1 gildess 1.5/30 21 day 1 amethyst 28 day 1 gildess 24 fe 28 day 1 apri 28 day 1 heather 1 aranelle 28 1 introvale 91 day 1 ashlyna 91 day 1 JOLESSA TAB 0.15-0.03 MG 1 aubra 28 day 1 JOLIVETTE 1 aviane 28 1 juleber 28 day 1 balziva 28 day 1 junel 1.5/30 21 day 1 bekyree 28 day 1 junel 1/20 21 day 1 BEYAZ 2 junel fe 1.5/30 28 day 1 blisovi 21 fe 1.5/30 28 day 1 junel fe 1/20 28 day 1 pack junel fe 24 1/20 28 day 1 blisovi 21 fe 1/20 28 day pack 1 kaitlib fe 28 day 1 blisovi 24 fe 1/20 28 day 1 kariva 28 day 1 BREVICON-28 3 kelnor 1/35 28 day 1 briellyn 28 day 1 kimidess 28 day 1 camila 28 day 1 larin 1.5/30 1 CAMRESE LO TAB 1 larin 1/20 1 cryselle 28 1 larin fe 1.5/30 1 cyclafem 1/35 28 day 1 larin fe 1/20 1 cyclafem 7/7/7 28 day 1 LAYOLIS FE CHW 1 CYCLESSA 3 LEENA TAB 1 cyred tab 1 lessina 28 day 1 deblitane 28 day 1 levonest 28 day 1 delyla 28 day 1 levonor/ethi tab 1 DEPO-PROVERA 3 levonorgestrel & eth estradiol 1 CONTRACEPTIVE levonorgestrel (emergency 1 DEPO-SUBQ PROVERA 104 2 oc) DESOGEN 3 levonorgestrel-ethinyl 1 desogestrel-ethinyl estradiol 1 estradiol (91-day) (biphasic) levonorgestrel-ethinyl 1 drospirenone-ethinyl estradiol 1 estradiol (continuous) ELLA 3 levora 0.15/30 28 day 1 emoquette 1 LO LOESTRIN FE 2 enpresse 28 day 1 loestrin 1.5/30 21 day 3 errin 28 day 1 loestrin 1/20 21 day 3 estarylla tab 0.25-35 1 loestrin fe 1.5/30 28 day 3 ESTROSTEP FE 3 loestrin fe 1/20 28 day 3

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy B/D - Covered under 27 Medicare B or D LA - Limited Access 2016 State of New York eff 08/01/2016

Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits lomedia 24 fe 1 ogestrel 28 day 1 loryna 28 day 1 orsythia 28 day 1 LOSEASONIQUE 3 ORTHO MICRONOR 3 low-ogestrel 1 ORTHO TRI-CYCLEN LO 2 lutera 28 day 1 ORTHO-CYCLEN 3 lyza 1 ORTHO-NOVUM 1/35 3 marlissa 28 day 1 ORTHO-NOVUM 7/7/7 3 medroxyprogesterone acetate 1 ovcon 35 28 day 3 (contraceptive) philith 1 MICROGESTIN 1.5/30 1 pimtrea pack 1 MICROGESTIN 1/20 1 pirmella 1/35 28 day 1 MICROGESTIN FE 1.5/30 1 portia 28 day 1 MICROGESTIN FE 1/20 1 previfem 28 day 1 MINASTRIN 24 FE 2 QUARTETTE 3 mircette 3 quasense 91 day 1 MODICON 3 reclipsen 28 day 1 mono-linyah tab 0.25-35 1 SEASONIQUE 3 MONONESSA 1 setlakin tab 1 myzilra 1 sharobel 28 day 1 necon 0.5/35 28 day 1 sprintec 28 day 1 necon 1/35 28 day 1 sronyx 28 day 1 NECON 7/7/7 1 syeda 1 necon 10/11 28 day 3 tarina fe 1/20 28 day 1 NECON TAB 1/50-28 1 tri-legest 28 day 1 nikki 28 day 1 tri-lo- estarylla 28 day 1 NOR-QD 3 tri-lo- tab marzia 1 NORA-BE TAB 1 tri-lo-sprintec 28 day 1 norethin acet & estrad-fe 1 TRI-NORINYL 28 3 norethindrone & ethinyl 1 tri-previfem 28 day 1 estradiol-fe tri-sprintec 28 day 1 norethindrone (contraceptive) 1 TRINESSA 1 norgest/ethi tab 0.25/35 1 TRINESSA LO TAB 1 norgestimate-ethinyl estradiol 1 (triphasic) trivora 28 day 1 NORINYL 1+35 3 velivet 28 day 1 NORINYL 1+50 3 vestura 1 norlyroc 28 day 1 vienva 28 day 1 nortrel 0.5/35 28 day 1 viorele 1 nortrel 1/35 21 day 1 vyfemla 28 day 1 nortrel 1/35 28 day 1 wymzya fe 1 nortrel 7/7/7 28 day 1 xulane dis 150-35 1 NUVARING 2 YASMIN 28 3 OCELLA TAB 3-0.03MG 1 YAZ 3

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy B/D - Covered under 28 Medicare B or D LA - Limited Access 2016 State of New York eff 08/01/2016

Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits zarah 1 DELESTROGEN 3 zenchent fe 28 day 1 depo-estradiol 3 zenchent tab 1 estrace CREA 2 zovia 1/35e 28 day 1 estrace TABS 3 PA zovia 1/50e 28 day 1 PA if 65 years and older ENDOMETRIOSIS estradiol PTTW; PTWK; 3 PA TABS danazol CAPS 1 PA if 65 years and older LUPANETA PACK 3 PA estradiol valerate OIL 1 SYNAREL 3 ESTRING 3 ENZYME REPLACEMENTS FEMRING 3 ADAGEN 3 LA PA fyavolv tab 1 mg-5 mcg 3 PA ALDURAZYME 3 LA PA PA if 65 years and older BUPHENYL POWD 3 jinteli 3 PA PA if 65 years and older BUPHENYL TABS 3 LA PA MENOSTAR 3 PA CARBAGLU 3 LA PA PA if 65 years and older CARNITOR 3 B/D MINIVELLE 3 PA CERDELGA 3 PA PA if 65 years and older CEREZYME 3 LA PA norethindrone acetate-ethinyl 3 PA CYSTADANE 3 LA estradiol PA if 65 years and older CYSTAGON 3 LA PA PREMARIN CREAM 2 ELAPRASE 3 LA PA PREMARIN INJ 3 ELELYSO 3 PA VAGIFEM 2 FABRAZYME 3 LA PA VIVELLE-DOT 3 PA KANUMA 3 LA PA PA if 65 years and older KUVAN 3 LA PA GLUCOCORTICOIDS levocarnitine (metabolic 1 B/D a-hydrocort 1 modifiers) CORTEF 3 LUMIZYME 3 LA PA cortisone acetate TABS 1 MYOZYME 3 LA PA DEPO-MEDROL INJ 3 B/D NAGLAZYME 3 LA PA 20MG/ML ORFADIN CAPS 3 LA PA DEPO-MEDROL INJ 3 B/D PROCYSBI 3 LA PA 40MG/ML RAVICTI 3 PA DEPO-MEDROL INJ 3 B/D sodium phenylbutyrate 3 80MG/ML STRENSIQ 3 LA PA CONC 3 VIMIZIM 3 PA dexamethasone ELIX; SOLN; 1 TABS VPRIV 3 PA dexamethasone sodium 1 ZAVESCA 3 LA PA phosphate ESTROGENS dexpak 6 day 2 ALORA 3 PA dexpak 10 day 2 PA if 65 years and older dexpak taperpak 13 day 2 CLIMARA 3 PA PA if 65 years and older fludrocortisone acetate TABS 1

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy B/D - Covered under 29 Medicare B or D LA - Limited Access 2016 State of New York eff 08/01/2016

Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits hydrocortisone TABS 1 SOLU-CORTEF 250MG 3 MEDROL PAK 4MG 3 SOLU-CORTEF 500MG 3 MEDROL TAB 2MG 3 B/D SOLU-CORTEF 1000MG 3 MEDROL TAB 4MG 3 B/D SOLU-MEDROL INJ 1GM 3 B/D MEDROL TAB 8MG 3 B/D SOLU-MEDROL INJ 2GM 3 B/D MEDROL TAB 16MG 3 B/D SOLU-MEDROL INJ 40MG 3 B/D MEDROL TAB 32MG 3 B/D SOLU-MEDROL INJ 125MG 3 B/D methylpr ace inj 40mg/ml 1 B/D SOLU-MEDROL INJ 500MG 3 B/D methylpr ace inj 80mg/ml 1 B/D veripred 3 B/D methylpr ss inj 1gm 1 B/D GLUCOSE ELEVATING AGENTS methylpr ss inj 40mg 1 B/D GLUCAGEN HYPOKIT 2 methylpr ss inj 125mg 1 B/D GLUCAGON EMERGENCY 2 methylpred pak 4mg 1 KIT methylpred tab 4mg 1 B/D KORLYM 3 LA PA methylpred tab 8mg 1 B/D PROGLYCEM SUS 50MG/ML 3 methylpred tab 16mg 1 B/D HUMAN GROWTH HORMONES methylpred tab 32mg 1 B/D HUMATROPE 3 PA millipred 3 B/D HUMATROPE COMBO PACK 3 PA millipred dp 3 NORDITROPIN FLEXPRO 3 PA ORAPRED ODT TAB 10MG 3 B/D SEROSTIM 3 LA PA ORAPRED ODT TAB 15MG 3 B/D ZORBTIVE 3 PA ORAPRED ODT TAB 30MG 3 B/D MISCELLANEOUS pediapred sol 6.7/5ml 3 B/D 1 pred sod pho sol 5mg/5ml 1 B/D calcitonin (salmon) nasal 1 spray sodium 1 B/D phosphate CHORIONIC 1 GONADOTROPIN SOLR prednisolone sol 15mg/5ml 1 B/D EGRIFTA 1mg 3 LA PA prednisolone sol 25mg/5ml 1 B/D EVISTA 3 prednisolone syrup 15 mg/5ml 1 B/D FORTICAL SPR 200/ACT 3 prednisone con 5mg/ml 3 B/D H.P. ACTHAR 3 LA PA prednisone pak 5mg 1 INCRELEX 3 LA PA prednisone pak 10mg 1 methylergonovine maleate 1 prednisone sol 5mg/5ml 1 B/D TABS prednisone tab 1mg 1 B/D MIACALCIN INJ 200U/ML 3 B/D prednisone tab 2.5mg 1 B/D MIACALCIN SPR 200/ACT 3 prednisone tab 5mg 1 B/D MYALEPT 3 LA PA prednisone tab 10mg 1 B/D NOVAREL INJ 10000UNT 1 prednisone tab 20mg 1 B/D octreotide acetate 50mcg/ml, 1 PA prednisone tab 50mg 1 B/D 100mcg/ml RAYOS TAB 1MG 3 B/D octreotide acetate 3 PA RAYOS TAB 2MG 3 B/D 200mcg/ml, 500mcg/ml, 1000mcg/ml RAYOS TAB 5MG 3 B/D SOLU-CORTEF 100MG 3

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy B/D - Covered under 30 Medicare B or D LA - Limited Access 2016 State of New York eff 08/01/2016

Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits PREGNYL W/DILUENT 1 propylthiouracil TABS 1 BENZYL SYNTHROID 3 PROLIA 3 tapazole 3 raloxifene hcl 1 TIROSINT 3 SAMSCA 3 PA TRIOSTAT 3 SANDOSTATIN 3 PA UNITHROID 1 SANDOSTATIN LAR DEPOT 3 PA VASOPRESSINS SIGNIFOR 3 LA PA DDAVP 3 SIGNIFOR LAR 3 LA PA DESMOPRESSIN ACETATE 1 SOMATULINE DEPOT 3 PA SOLN SOMAVERT 3 LA PA desmopressin acetate TABS 1 XGEVA 3 B/D desmopressin acetate inj 1 PARATHYROID HORMONES desmopressin acetate spray 1 FORTEO 3 PA desmopressin acetate spray 1 NATPARA 3 PA refrigerated PHOSPHATE BINDER AGENTS STIMATE 3 AURYXIA 3 GASTROINTESTINAL calcium acetate (phosphate 1 ANTIEMETICS binder) AKYNZEO 3 B/D eliphos 3 ALOXI 3 FOSRENOL 3 CESAMET 3 B/D PHOSLO 3 compro supp 1 PHOSLYRA 2 dronabinol 2.5mg, 5mg 1 B/D RENAGEL 3 dronabinol 10mg 3 B/D RENVELA PAK 2 EMEND CAP 40MG 3 B/D RENVELA TAB 800MG 2 EMEND CAP 80MG 3 B/D VELPHORO 3 EMEND CAP 125MG 3 B/D PROGESTINS EMEND PAK 80 & 125 3 B/D aygestin 3 granisetron hcl SOLN 1 CRINONE 2 granisetron hcl TABS 1 B/D medroxyprogesterone acetate 1 MARINOL 3 B/D norethindrone acetate TABS 1 meclizine hcl TABS 1 progesterone micronized 1 metoclopramide hcl SOLN; 1 CAPS TABS; TBDP PROMETRIUM 3 metoclopramide hcl inj 5 1 PROVERA 3 mg/ml THYROID AGENTS metoclopramide odt 1 CYTOMEL 3 ondansetron hcl TABS 1 B/D levothyroxine sodium TABS 1 ondansetron hcl inj 1 LEVOXYL 1 ondansetron hcl oral soln 1 B/D liothyronine sodium SOLN; 1 ondansetron odt 1 B/D TABS phenadoz 3 PA methimazole TABS 1 PA if 65 years and older

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy B/D - Covered under 31 Medicare B or D LA - Limited Access 2016 State of New York eff 08/01/2016

Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits phenergan 3 PA ranitidine hcl CAPS 1 PA if 65 years and older ranitidine hcl SOLN 1 phenergan inj 3 PA ranitidine hcl SYRP 1 PA if 65 years and older ranitidine hcl TABS 150mg, 1 inj 5 mg/ml 1 300mg prochlorperazine maleate 1 ZANTAC 3 TABS INFLAMMATORY BOWEL DISEASE prochlorperazine supp 1 APRISO 2 hcl SOLN; 3 PA SUPP; SYRP; TABS AZULFIDINE 3 PA if 65 years and older AZULFIDINE EN-TABS 3 promethegan 3 PA balsalazide disodium 1 PA if 65 years and older CPEP 3 REGLAN 3 CANASA 3 SANCUSO 3 COLAZAL 3 TRANSDERM-SCOP 3 PA PA if 65 years and older colocort 1 VARUBI 2 B/D CORTENEMA 3 ZOFRAN SOLN 4mg/5ml 3 B/D DIPENTUM 3 ZOFRAN TABS 3 B/D ENTOCORT EC 3 ZOFRAN ODT 3 B/D ENTYVIO 3 PA ANTISPASMODICS GIAZO 3 HYDROCORTISONE 1 ATROPINE SULFATE SOLN 1 (INTRARECTAL) .05mg/ml, .1mg/ml LIALDA 2 BENTYL 3 mesalamine enema 1 CANTIL 3 PENTASA 2 CUVPOSA 3 ROWASA 3 dicyclomine hcl 1 SF-ROWASA 3 glycopyrrolate SOLN; TABS 1 sulfasalazine dr 1 methscopolamine bromide 1 TABS sulfasalazine ir 1 PAMINE 3 UCERIS 3 PAMINE FORTE 3 UCERIS AER 2MG/ACT 3 ROBINUL 3 LAXATIVES ROBINUL FORTE 3 COLYTE-FLAVOR PACKS 3 H2-RECEPTOR ANTAGONISTS constulose 1 cimetidine TABS 1 enulose 1 cimetidine sol 300/5ml 1 gaviltye-g 1 famotidine SUSR 1 gavilyte-c 1 famotidine TABS 20mg, 1 gavilyte-h 1 40mg gavilyte-n 1 famotidine inj 1 generlac 1 nizatidine 1 GOLYTELY 3 PEPCID SUSP 3 kristalose 3 pepcid tab 3 lactulose 1

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy B/D - Covered under 32 Medicare B or D LA - Limited Access 2016 State of New York eff 08/01/2016

Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits lactulose (encephalopathy) 1 VIBERZI 3 MOVIPREP 2 XIFAXAN TAB 550MG 3 NULYTELY/FLAVOR PACKS 3 PANCREATIC ENZYMES OSMOPREP 3 CREON 2 PEG 3350-KCL-SOD 1 PANCREAZE 3 BICARB-SOD CHLORIDE- PERTZYE 3 SOD SULFATE ULTRESA 2 peg 3350-potassium chloride- 1 sod bicarbonate-sod chloride VIOKACE 10 2 polyethylene glycol 3350 1 VIOKACE 20 3 PACK; POWD ZENPEP 2 PREPOPIK 3 PROTON PUMP INHIBITORS RELISTOR 3 ACIPHEX 3 SUCLEAR 2 ACIPHEX SPR CAP 5MG 3 SUPREP BOWEL PREP 2 ACIPHEX SPR CAP 10MG 3 trilyte 1 esomeprazole sodium inj 1 MISCELLANEOUS lansoprazole CPDR 1 ACTIGALL 3 NEXIUM I.V. 3 alosetron hcl 3 omeprazole CPDR 1 AMITIZA 2 pantoprazole sodium 1 amoxicillin-clarithromycin w/ 1 PREVACID 3 lansoprazole PRILOSEC 3 CARAFATE SUSP 2 PRILOSEC CAP 10MG 3 CARAFATE TABS 3 PRILOSEC CAP 20MG 3 cromolyn sodium 3 (mastocytosis) PRILOSEC CAP 40MG 3 CYTOTEC 3 PROTONIX INJ 3 diphenoxylate w/ atropine 1 rabeprazole sodium 1 GASTROCROM 3 GENITOURINARY GATTEX 3 LA PA BENIGN PROSTATIC HYPERPLASIA LINZESS 2 hcl 1 LOMOTIL 3 AVODART 2 loperamide hcl CAPS 1 CARDURA XL 3 LOTRONEX 3 dutasteride 1 misoprostol TABS 1 dutasteride- hcl 1 MOVANTIK 2 finasteride TABS 5mg 1 OMECLAMOX-PAK 3 FLOMAX 3 PREVPAC 3 PROSCAR 3 PYLERA 3 RAPAFLO 2 SUCRAID 3 LA tamsulosin hcl 1 sucralfate TABS 1 UROXATRAL 3 URSO 250 3 MISCELLANEOUS URSO FORTE 3 bethanechol chloride TABS 1 ursodiol CAPS; TABS 1 ELMIRON 3

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy B/D - Covered under 33 Medicare B or D LA - Limited Access 2016 State of New York eff 08/01/2016

Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits potassium citrate (alkalinizer) 1 ELIQUIS TAB 5MG 2 15meq enoxaparin sodium 1 POTASSIUM CITRATE 1 30mg/0.3ml, 40mg/0.4ml, (ALKALINIZER) 540mg, 60mg/0.6ml, 80mg/0.8ml, 1080mg 300mg/3ml urecholine 3 enoxaparin sodium 3 UROCIT-K 3 100mg/ml, 120mg/0.8ml, 150mg/ml URINARY ANTISPASMODICS fondaparinux sodium 1 DARIFENACIN 1 2.5mg/0.5ml HYDROBROMIDE fondaparinux sodium 3 DETROL 3 5mg/0.4ml, 7.5mg/0.6ml, DETROL LA 3 10mg/0.8ml DITROPAN XL 3 FRAGMIN 2500unit/0.2ml, 2 5000unit/0.2ml ENABLEX 3 FRAGMIN 7500unit/0.3ml, 3 GELNIQUE 2 10000unit/ml, MYRBETRIQ 2 12500unit/0.5ml, oxybutynin chloride 1 15000unit/0.6ml, 18000unt/0.72ml, tolterodine tartrate er 1 95000unit/3.8ml tolterodine tartrate tab 1 mg 1 HEP SOD/NACL INJ 25000 1 tolterodine tartrate tab 2 mg 1 HEPARIN (PORCINE) IN 1 trospium chloride 1 SODIUM CHLORIDE trospium chloride er 1 100U/ML VESICARE 2 heparin sod inj 1000u/ml 1 B/D VAGINAL ANTI-INFECTIVES HEPARIN SOD INJ 3 B/D 2000U/ML AVC 3 HEPARIN SOD INJ 3 B/D CLEOCIN CREA 3 2500U/ML CLEOCIN VAG SUPP 100MG 3 heparin sod inj 5000u/0.5ml 1 B/D clindamycin cre 2% vag 1 heparin sod inj 5000u/ml 1 B/D CLINDESSE 3 heparin sod inj 10000u/ml 1 B/D METROGEL-VAGINAL 3 heparin sod inj 20000u/ml 1 B/D metronidazole vaginal 1 HEPARIN SODIUM/D5W 1 miconazole 3 sup 200mg 1 HEPARIN SODIUM/NACL 3 NUVESSA 3 0.45% TERAZOL 3 3 jantoven 1 TERAZOL 7 3 LOVENOX 3 terconazole vaginal 1 PRADAXA 2 VANDAZOLE 1 SAVAYSA 3 ZAZOLE 1 warfarin sodium 1 HEMATOLOGIC XARELTO 2 ANTICOAGULANTS XARELTO STARTER PACK 2 ARIXTRA 3 HEMATOPOIETIC GROWTH FACTORS COUMADIN 3 ARANESP ALBUMIN FREE 2 PA ELIQUIS TAB 2.5MG 2 EPOGEN 3 PA

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy B/D - Covered under 34 Medicare B or D LA - Limited Access 2016 State of New York eff 08/01/2016

Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits GRANIX 3 PA HUMIRA 3 PA LEUKINE 3 PA HUMIRA PEDIATRIC 3 PA MIRCERA 3 PA CROHNS MOZOBIL 3 PA HUMIRA PEN 3 PA NEULASTA 3 PA HUMIRA PEN-CROHNS 3 PA STARTER KIT NEULASTA ONPRO KIT 3 PA HUMIRA PEN-PSORIASIS 3 PA NEUMEGA 3 PA STARTER KIT NEUPOGEN 3 PA hydroxychloroquine sulfate 1 NPLATE 3 PA KINERET 3 PA PROCRIT 2 PA leflunomide TABS 1 MISCELLANEOUS methotrexate sodium tabs 1 AGRYLIN 3 ORENCIA 3 PA anagrelide hcl 1 OTEZLA 3 PA BERINERT 3 PA OTREXUP 3 PA cilostazol 1 PLAQUENIL 3 CINRYZE 3 LA PA RASUVO 3 PA CYKLOKAPRON 3 REMICADE 3 PA FIRAZYR 2 PA RHEUMATREX 2 KALBITOR 3 PA SIMPONI 3 PA LYSTEDA 3 SIMPONI ARIA 3 PA pentoxifylline TBCR 1 trexall 2 B/D PLETAL 3 XELJANZ 3 PA PROMACTA 3 LA PA XELJANZ XR 3 PA RUCONEST 3 PA IMMUNOGLOBULINS SOLIRIS 3 PA BIVIGAM 3 PA tranexamic acid SOLN; TABS 1 CARIMUNE NANOFILTERED 3 PA PLATELET AGGREGATION INHIBITORS FLEBOGAMMA 3 PA AGGRENOX 3 FLEBOGAMMA DIF 3 PA ASPIRIN-DIPYRIDAMOLE 1 GAMASTAN S/D 2 B/D BRILINTA 2 GAMMAGARD LIQUID 3 PA clopidogrel bisulfate 1 GAMMAGARD S/D 3 PA DURLAZA 3 GAMMAGARD S/D IGA LESS 3 PA EFFIENT 2 TH ZONTIVITY 3 GAMMAKED 3 PA IMMUNOLOGIC AGENTS GAMMAPLEX 2.5gm/50ml, 3 PA 5gm/100ml, 10gm/200ml DISEASE-MODIFYING ANTI-RHEUMATIC GAMUNEX-C 3 PA DRUGS (DMARDS) HIZENTRA 3 PA ACTEMRA 3 PA HYQVIA 3 PA ARAVA 3 OCTAGAM 1gm/20ml, 3 PA CIMZIA 3 PA 2gm/20ml, 2.5gm/50ml, ENBREL 3 PA 5gm/100ml, 10gm/200ml, 25gm/500ml ENBREL SURECLICK 3 PA PRIVIGEN 3 PA PA - Prior Authorization QL - Quantity Limits ST - Step Therapy B/D - Covered under 35 Medicare B or D LA - Limited Access 2016 State of New York eff 08/01/2016

Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits IMMUNOMODULATORS SIMULECT 3 B/D ACTIMMUNE 3 LA PA SIROLIMUS TABS 2mg 3 B/D ARCALYST 3 PA sirolimus TABS .5mg, 1mg 1 B/D GRASTEK 2 tacrolimus CAPS 5mg 3 B/D ILARIS 3 PA tacrolimus CAPS .5mg, 1mg 1 B/D INTRON-A INJ 10MU 3 B/D THYMOGLOBULIN 3 B/D INTRON-A INJ 18MU 3 B/D ZORTRESS TAB 0.5MG 3 B/D INTRON-A INJ 25MU 3 B/D ZORTRESS TAB 0.25MG 3 B/D INTRON-A INJ 50MU 3 B/D ZORTRESS TAB 0.75MG 3 B/D RAGWITEK 2 VACCINES REVLIMID 3 LA ACTHIB 3 THALOMID 2 ADACEL 3 IMMUNOSUPPRESSANTS BCG VACCINE 3 ASTAGRAF XL 3 B/D BEXSERO 3 ATGAM 3 B/D BOOSTRIX 3 azasan 2 B/D CERVARIX 3 azathioprine SOLR; TABS 1 B/D COMVAX 3 BENLYSTA 3 PA DAPTACEL 3 CELLCEPT CAP 3 B/D DIPHTHERIA/TETANUS 3 B/D CELLCEPT INTRAVENOUS 3 B/D TOXOID CELLCEPT SUSP 3 B/D ENGERIX-B SUSP 3 B/D CELLCEPT TAB 3 B/D GARDASIL 3 cyclosporine CAPS; SOLN 1 B/D GARDASIL 9 3 cyclosporine modified (for 1 B/D HAVRIX 3 microemulsion) HIBERIX 3 ENVARSUS XR 3 B/D IMOVAX RABIES (H.D.C.V.) 3 gengraf 1 B/D INFANRIX 3 IMURAN 3 B/D IPOL INACTIVATED IPV 2 mycophenolate mofetil 1 B/D IXIARO 3 CAPS; TABS KINRIX 3 mycophenolate mofetil SUSR 3 B/D M-M-R II 3 mycophenolate sodium 1 B/D MENACTRA 3 180mg MENOMUNE-A/C/Y/W-135 3 mycophenolate sodium 3 B/D 360mg MENVEO 3 MYFORTIC 3 B/D PEDIARIX 3 NEORAL 3 B/D PEDVAX HIB 3 NULOJIX 3 B/D PENTACEL 3 PROGRAF 3 B/D PROQUAD 3 RAPAMUNE 3 B/D QUADRACEL 3 SANDIMMUNE CAPS 3 B/D RABAVERT 3 SANDIMMUNE INJ 3 B/D RECOMBIVAX HB 3 B/D SANDIMMUNE SOLN 2 B/D ROTARIX 2 ROTATEQ 3

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy B/D - Covered under 36 Medicare B or D LA - Limited Access 2016 State of New York eff 08/01/2016

Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits SYNAGIS 3 SODIUM CHLORIDE SOLN 1 TENIVAC 3 B/D 2.5meq/ml TETANUS/DIPHTHERIA 3 B/D SODIUM FLUORIDE CHEW; 1 TOXOID TAB; 1.1 (0.5 F) MG/ML SOLN TRUMENBA 3 TPN ELECTROLYTES 1 B/D TWINRIX INJ 3 IV NUTRITION TYPHIM VI 3 AMINOSYN 3 B/D VAQTA 3 AMINOSYN 3 B/D VARIVAX 3 7%/ELECTROLYTES YF-VAX 3 AMINOSYN II 3 B/D ZOSTAVAX 3 AMINOSYN II 1 B/D NUTRITIONAL/SUPPLEMENTS 8.5%/ELECTROL ELECTROLYTES AMINOSYN INJ 8.5/LYTE 1 B/D ammonium chloride SOLN 3 AMINOSYN M 3 B/D K-TAB 3 AMINOSYN-HBC 3 B/D KLOR-CON 8 1 AMINOSYN-PF 7% 3 B/D KLOR-CON 10 1 AMINOSYN-PF INJ 10% 3 B/D klor-con m10 1 AMINOSYN-RF 3 B/D klor-con m15 3 CLINIMIX 2.75%/DEXTROSE 3 B/D 5% klor-con m20 1 CLINIMIX 4.25%/DEXTROSE 3 B/D klor-con pow 20meq 1 5% klor-con spr cap 8meq 1 CLINIMIX 4.25%/DEXTROSE 3 B/D klor-con spr cap 10meq 1 10% MAGNESIUM SULFATE 3 CLINIMIX 4.25%/DEXTROSE 3 B/D SOLN 2gm/50ml, 4gm/100ml, 20% 4gm/50ml, 20gm/500ml, CLINIMIX 4.25%/DEXTROSE 3 B/D 40gm/1000ml 25% magnesium sulfate SOLN 1 CLINIMIX 5%/DEXTROSE 3 B/D 50% 15% MAGNESIUM SULFATE IN 3 CLINIMIX 5%/DEXTROSE 3 B/D D5W 20% MAGNESIUM SULFATE INJ 1 CLINIMIX 5%/DEXTROSE 3 B/D 50% 25% MICRO-K 3 CLINIMIX E 3 B/D POTASSIUM CHLORIDE 1 2.75%/DEXTROSE 5% SOLN 10%, 20% CLINIMIX E 3 B/D potassium chloride TBCR 1 2.75%/DEXTROSE 10% 8meq CLINIMIX E 4.25%/D10 3 B/D POTASSIUM CHLORIDE 1 CLINIMIX E 3 B/D TBCR 20meq 4.25%/DEXTROSE 5% potassium chloride caps er 1 CLINIMIX E 3 B/D potassium chloride 1 4.25%/DEXTROSE 25% microencapsulated crystals cr CLINIMIX E 5%/DEXTROSE 3 B/D POTASSIUM CHLORIDE 1 15% TAB CR 10 MEQ

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy B/D - Covered under 37 Medicare B or D LA - Limited Access 2016 State of New York eff 08/01/2016

Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits CLINIMIX E 5%/DEXTROSE 3 B/D DEXTROSE 10%/NACL 1 20% 0.45% CLINIMIX E 5%/DEXTROSE 3 B/D ELECTROLYTE-R IN 3 25% DEXTROSE clinisol 15 1 B/D IONOSOL-B/DEXTROSE 5% 3 FREAMINE HBC 6.9% 3 B/D IONOSOL-MB/DEXTROSE 3 FREAMINE III 3 B/D 5% HEPATAMINE 1 B/D ISOLYTE P 3 INTRALIPID INJ 20% 1 B/D ISOLYTE S 3 INTRALIPID INJ 30% 3 B/D KCL0.15%/D5W/NACL0.2% 1 LIPOSYN II 3 B/D KCL0.15%/D5W/NACL0.225 3 % LIPOSYN III 3 B/D KCL 0.3%/D5W/LR IV LAC RI 3 NEPHRAMINE 3 B/D KCL 0.3%/D5W/NACL 0.9% 3 NUTRILIPID INJ 20% 1 B/D KCL 0.3%/D5W/NACL 0.45% 1 plenamine 1 B/D KCL 0.15%/D5W/LR 3 premasol 6% 1 B/D KCL 0.15%/D5W/NACL 0.9% 1 premasol 10% 3 B/D KCL 0.075%/D5W/NACL 1 PROCALAMINE 3 B/D 0.45% PROSOL 3 B/D KCL IN NACL INJ .15-0.45 1 TRAVASOL 3 B/D KCL/D5W/NACL INJ 1 TROPHAMINE INJ 6% 3 B/D 0.22%/0.45% TROPHAMINE INJ 10% 3 B/D KCL/D5W/NACL INJ .15/.33% 1 IV REPLACEMENT SOLUTIONS KCL/D5W/NACL INJ .15/.45% 1 DEXTROSE SOLN 1 KCL/NACL INJ 0.15%-0.9% 1 DEXTROSE 2.5%/NACL 1 LACTATED RINGERS 1 0.45% VIAFLEX DEXTROSE 5% 1 NORMOSOL-M IN D5W 1 DEXTROSE 5% 3 NORMOSOL-R 3 /ELECTROLYTE PLASMA-LYTE A 3 DEXTROSE 5%/LACTATED 1 PLASMA-LYTE-56/D5W 3 RING PLASMA-LYTE-148 3 DEXTROSE 5%/NACL 0.2% 1 pot chloride inj 2meq/ml 1 DEXTROSE 5%/NACL 0.3% 3 POTASSIUM CHLORIDE 1 DEXTROSE 5%/NACL 0.9% 1 SOLN .4meq/ml, DEXTROSE 5%/NACL 0.33% 1 10meq/100ml, 10meq/50ml, 20meq/100ml, 40meq/100ml DEXTROSE 5%/NACL 0.45% 1 POTASSIUM CHLORIDE 1 DEXTROSE 5%/NACL 1 0.3%/D 0.225% potassium chloride in nacl 1 DEXTROSE 5%/POTASSIUM 1 CHL POTASSIUM CHLORIDE IN 1 NACL DEXTROSE 10% FLEX 1 CONTAIN RINGER'S 1 DEXTROSE 10% W/ 3 SODIUM CHLORIDE SOLN 1 SODIUM CHLORIDE 0.2% .9%, 3%, 5%

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy B/D - Covered under 38 Medicare B or D LA - Limited Access 2016 State of New York eff 08/01/2016

Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits SODIUM CHLORIDE 0.45% 1 gentamicin sulfate (ophth) 1 VIA ilotycin 1 VITAMINS levofloxacin (ophth) 1 calcitriol CAPS; SOLN 1 B/D MOXEZA 2 doxercalciferol CAPS 1mcg, 3 B/D NATACYN 3 2.5mcg neomycin-bacitracin zn- 1 doxercalciferol CAPS .5mcg 1 B/D polymyxin doxercalciferol SOLN 1 B/D neomycin-polymyxin- 1 HECTOROL 3 B/D gramicidin paricalcitol CAPS 1 B/D neosporin solution 3 PARICALCITOL SOLN 1 B/D OCUFLOX 3 PRENATAL VITAMIN/FOLIC 1 ofloxacin (ophth) 1 ACID > 0.8 MG (GENERIC) polymyxin b-trimethoprim 1 ROCALTROL 3 B/D POLYTRIM 3 ZEMPLAR 3 B/D sulfacet sod oin 10% op 1 OPHTHALMIC sulfacetamide sodium (ophth) 1 ANTI-INFECTIVE/ANTI-INFLAMMATORY tobramycin (ophth) 1 bacitracin-poly-neomycin-hc 1 TOBREX OINT 0.3% 3 blephamide OINT 3 TOBREX SOL 0.3% OP 3 BLEPHAMIDE SUSP 3 trifluridine SOLN 1 MAXITROL 3 VIGAMOX 2 neomycin-polymy-dexameth 1 VIROPTIC 3 neomycin-polymyxin-hc 1 ZIRGAN 3 (ophth) ZYMAXID 3 PRED-G 3 ANTI-INFLAMMATORIES PRED-G S.O.P. 3 ACULAR 3 sulfacetamide sod- 1 prednisolone ACULAR LS 3 TOBRADEX SUSP 3 ALREX 2 tobramycin-dexamethasone 1 bromfenac sodium (ophth) 1 ZYLET 2 BROMFENAC SODIUM 1 (OPHTH)(ONCE-DAILY) ANTI-INFECTIVES dexamethasone sodium 1 AZASITE 3 phosphate (ophth) bacitracin (ophthalmic) 1 diclofenac sodium (ophth) 1 bacitracin-polymyxin b (ophth) 1 DUREZOL 2 BESIVANCE 2 FLAREX 3 BLEPH-10 3 FLUOROMETHOLONE 1 CILOXAN OIN 0.3% OP 3 (OPHTH) CILOXAN SOL 0.3% OP 3 flurbiprofen sodium 1 ciprofloxacin hcl (ophth) 1 FML 3 erythromycin (ophth) 1 FML FORTE 3 garamycin 3 FML LIQUIFILM 3 gatifloxacin (ophth) 1 ILEVRO 3 gentak 1 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy B/D - Covered under 39 Medicare B or D LA - Limited Access 2016 State of New York eff 08/01/2016

Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits ketorolac tromethamine 1 ISOPTO CARPINE 3 (ophth) ISTALOL 3 LOTEMAX 2 latanoprost SOLN 1 MAXIDEX 3 hcl 1 OCUFEN 3 LUMIGAN 3 OMNIPRED 3 1 PRED FORTE 3 OPTIPRANOLOL 3 PRED MILD 3 PHOSPHOLINE IODIDE 3 PREDNISOLONE ACETATE 1 PILOCARPINE HCL SOLN 1 (OPHTH) SIMBRINZA SUS 1-0.2% 2 prednisolone sodium 3 phosphate (ophth) timolol maleate (ophth) 1 VEXOL 3 TIMOLOL MALEATE GEL 1 ANTIALLERGICS TIMOPTIC 3 ALOCRIL 3 TIMOPTIC OCUDOSE 3 ALOMIDE 3 TIMOPTIC-XE 3 drop 0.05% 1 TRAVATAN Z 2 BEPREVE 3 TRUSOPT 3 cromolyn sodium (ophth) 1 XALATAN 3 ELESTAT 3 ZIOPTAN 3 EMADINE 3 MISCELLANEOUS epinastine hcl (ophth) 1 alcaine 3 LASTACAFT 3 CYSTARAN 3 LA PA hcl 1 EYLEA 3 PATADAY 2 LACRISERT 3 PATANOL 2 LUCENTIS 3 PAZEO 3 naphazoline 0.1% 1 ANTIGLAUCOMA proparacaine hcl SOLN 1 ALPHAGAN P 0.1% 2 RESTASIS 2 ALPHAGAN P 0.15% 3 RESPIRATORY AZOPT 2 ANTICHOLINERGIC/BETA AGONIST BETAGAN 3 COMBINATIONS betaxolol hcl (ophth) 1 ANORO ELLIPT AER 62.5-25 2 BETIMOL 2 COMBIVENT RESPIMAT 2 BETOPTIC-S 2 ipratropium-albuterol 1 B/D sol 0.2% 1 STIOLTO RESPIMAT 3 BRIMONIDINE SOL 0.15% 1 UTIBRON NEOHALER 3 hcl (ophth) 1 ANTICHOLINERGICS COMBIGAN 2 ATROVENT 3 COSOPT 3 ATROVENT HFA 3 dorzolamide hcl 1 INCRUSE ELLIPTA 3 dorzolamide hcl-timolol 1 (nasal) 1 maleate ipratropium sol inhal 1 B/D

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy B/D - Covered under 40 Medicare B or D LA - Limited Access 2016 State of New York eff 08/01/2016

Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits SEEBRI NEOHALER 3 XOPENEX 3 B/D SPIRIVA HANDIHALER 2 XOPENEX CONCENTRATE 3 B/D SPIRIVA RESPIMAT 2 LEUKOTRIENE RECEPTOR TUDORZA PRESSAIR 3 ANTAGONISTS TUDORZA PRESSAIR 3 ACCOLATE 3 (INSTITUTIONAL PACK) montelukast sodium CHEW; 1 COMBINATIONS PACK; TABS CLARINEX-D TAB 2.5-120 3 SINGULAIR 3 SEMPREX-D 3 zafirlukast 1 ZYFLO CR 3 ASTEPRO 3 MAST CELL STABILIZERS azelastine spr 0.1% 1 cromolyn sodium NEBU 1 B/D azelastine spr 0.15% 1 MISCELLANEOUS cetirizine syrup 1 acetylcysteine SOLN 10%, 1 B/D CLARINEX 3 20% desloratadine 1 ARALAST NP 3 LA PA diphenhydram inj 50mg/ml 1 DALIRESP 2 hcl SOLN 3 PA EPINEPHRINE SOAJ 1 PA if 65 years and older .3mg/0.3ml levocetirizine soln 2.5mg/5ml 1 epinephrine SOAJ 1 levocetirizine tab 5 mg 1 .15mg/0.15ml olopatadine hcl (nasal) 1 EPIPEN 2-PAK 2 PATANASE 3 EPIPEN-JR 2-PAK 2 XYZAL 3 ESBRIET 3 PA BETA AGONISTS GLASSIA 3 LA PA albuterol sulfate NEBU 1 B/D KALYDECO 3 PA albuterol sulfate SYRP; TABS 1 NUCALA 3 LA PA albuterol sulfate er 1 OFEV 3 PA ARCAPTA NEOHALER 2 ORKAMBI 3 PA BROVANA 3 B/D PROLASTIN-C 3 LA PA FORADIL AEROLIZER 2 PULMOZYME 3 B/D levalbuterol conc 1 B/D tyzine .05% 3 1.25mg/0.5ml XOLAIR 3 LA PA LEVALBUTEROL HCL NEBU 1 B/D ZEMAIRA 3 LA PA 1.25mg/3ml NASAL STEROIDS levalbuterol hcl NEBU 1 B/D BECONASE AQ 3 .31mg/3ml, .63mg/3ml budesonide (nasal) 1 PERFOROMIST 2 B/D (nasal) 1 PROAIR HFA 2 propionate (nasal) 1 SEREVENT DISKUS 2 furoate (nasal) 1 STRIVERDI RESPIMAT 3 NASONEX 2 sulfate SOLN 3 OMNARIS 3 terbutaline sulfate TABS 1 QNASL 3 vospire 3

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy B/D - Covered under 41 Medicare B or D LA - Limited Access 2016 State of New York eff 08/01/2016

Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits QNASL CHILDRENS 3 AZELEX 3 RHINOCORT AQUA 3 BENZACLIN 2 1 BENZAMYCIN 3 ACETONIDE (NASAL) benzoyl peroxide- 1 ZETONNA 3 erythromycin STEROID INHALANTS claravis 1 AEROSPAN 3 CLEOCIN-T 3 ALVESCO 3 clindamax 1 ARNUITY ELLIPTA 3 clindamycin phosphate 1 ASMANEX 2 (topical) ASMANEX HFA 2 clindamycin phosphate- 1 benzoyl peroxide budesonide (inhalation) 1 B/D clindamycin phosphate- 1 FLOVENT DISKUS 2 benzoyl peroxide (refrigerate) FLOVENT HFA 2 DIFFERIN CREA; GEL 3 PULMICORT FLEXHALER 2 DIFFERIN LOTN 2 PULMICORT INH SUSP 3 B/D DUAC 3 0.5MG/2 ML ery pad 2% 1 PULMICORT INH SUSP 3 B/D 0.25MG/2 ML erygel 3 PULMICORT INH SUSP 3 B/D erythromycin (acne aid) 1 1MG/2ML EVOCLIN 3 QVAR 2 KLARON 3 STEROID/BETA-AGONIST myorisan 1 COMBINATIONS neuac gel 1.2-5% 1 ADVAIR DISKUS 2 RETIN-A 3 PA ADVAIR HFA 2 sulfacetamide sodium (acne) 1 BREO ELLIPTA 3 tretinoin CREA 1 PA DULERA 2 TRETINOIN GEL .01% 1 PA SYMBICORT 3 tretinoin GEL .025%, .05% 1 PA XANTHINES tretinoin microsphere .1% 1 PA aminophylline inj 1 TRETINOIN MICROSPHERE 1 PA .04% elixophyllin 3 zenatane 10mg, 20mg, 40mg 1 theo-24 3 ZENATANE 30mg 1 theophylline 1 DERMATOLOGY, ANTIBIOTICS TOPICAL ALTABAX 3 DERMATOLOGY, ACNE BACTROBAN CREA 3 ABSORICA 3 BACTROBAN OINT 2 ACANYA 2 BACTROBAN NASAL 2 ACZONE 3 CENTANY 3 adapalene CREA; GEL 1 CORTISPORIN 3 amnesteem 1 gentamicin sulfate (topical) 1 ATRALIN 2 PA OINT 1 AVITA 1 PA mupirocin calcium (topical) 1

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy B/D - Covered under 42 Medicare B or D LA - Limited Access 2016 State of New York eff 08/01/2016

Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits SILVADENE 3 calcipotriene CREA; OINT; 1 SILVER SULFADIAZINE 1 SOLN CREA calcitrene oin 0.005% 1 SSD 1 CALCITRIOL OINT 1 SULFAMYLON 3 COSENTYX 3 PA DERMATOLOGY, ANTIFUNGALS COSENTYX SENSOREADY 3 PA ciclopirox GEL 1 PEN ciclopirox cre 0.77% 1 DOVONEX CRE 0.005% 3 ciclopirox shampoo 1% 1 methoxsalen rapid 3 ciclopirox sus 0.77% 1 8-MOP 3 clotrimazole (topical) 1 OXSORALEN ULTRA 3 econazole nitrate CREA 1 SORIATANE 3 ERTACZO 3 SORILUX 2 EXELDERM 3 STELARA 3 PA EXTINA 3 TAZORAC 2 PA ketoconazole (topical) 1 VECTICAL 3 ketodan aer 2% 1 DERMATOLOGY, ANTISEBORRHEICS LOPROX SHAMPOO 3 ketoconazole shampoo 1 LUZU 2 NIZORAL 3 MENTAX 3 selenium sulfide LOTN 1 NAFTIFINE HCL 1% 1 DERMATOLOGY, naftifine hcl 2% 1 aclovate 3 NAFTIN 2 ala-cort 1 nyamyc 1 ala-scalp 3 nystatin (topical) 1 alclometasone dipropionate 1 nystatin pow 100000 1 amcinonide CREA; LOTN 1 nystop 1 amcinonide OINT 3 oxiconazole nitrate cream 1 dipropionate 1 (topical) OXISTAT 3 betamethasone dipropionate 1 DERMATOLOGY, ANTIPRURITIC augmented anusol hc 3 betamethasone valerate 1 CORTIFOAM 2 CREA; FOAM; LOTN; OINT DOXEPIN HCL 1 calcipotriene/betamethasone 3 (ANTIPRURITIC) CAPEX 2 procto-med 1 clobetasol e cream 0.05% 1 procto-pak 1 clobetasol propionate CREA; 1 proctosol hc 2.5 % 1 FOAM; GEL; LIQD; LOTN; proctozone hc 1 OINT; SOLN PRUDOXIN CRE 5% 1 clobetasol propionate 1 emulsion ZONALON 3 CLOBEX LIQD; LOTN 3 DERMATOLOGY, ANTIPSORIATICS clocortolone pivalate 1 acitretin 3 CLODERM PUMP 3 CORDRAN TAPE 3 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy B/D - Covered under 43 Medicare B or D LA - Limited Access 2016 State of New York eff 08/01/2016

Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits cormax 1 lokara 1 CUTIVATE 3 mometasone furoate CREA; 1 DERMA-SMOOTHE/FS 3 OINT; SOLN BODY OLUX 3 DERMA-SMOOTHE/FS 3 PANDEL 3 SCALP PREDNICARBATE CREA 1 DERMATOP 3 prednicarbate OINT 1 DERMATOP CREAM 0.1% 3 psorcon 3 DESONATE 3 SERNIVO 3 DESONIDE CREA 1 SYNALAR 3 desonide LOTN; OINT 1 TACLONEX 3 DESOWEN CREA 3 TEMOVATE CREAM 3 desowen LOTN 3 TEMOVATE E CREAM 3 desoximetasone CREA 1 TEMOVATE GEL 3 desoximetasone GEL 1 TEMOVATE OIN 3 DESOXIMETASONE OINT 1 TEMOVATE SOLN 3 .05% texacort 2 desoximetasone OINT .25% 1 topicort CREA 3 diflorasone diacetate 1 topicort GEL 3 DIPROLENE 3 TOPICORT OINT .05% 3 DIPROLENE AF 3 topicort OINT .25% 3 ELOCON 3 TOPICORT SPRAY 0.25% 3 ENSTILAR 3 1 fluocinolone acetonide 1 (topical) CREA; OIL; OINT; SOLN trianex 3 fluocinonide CREA .1% 3 triderm 1 fluocinonide CREA .05% 1 ULTRAVATE 3 fluocinonide GEL 1 VANOS 3 fluocinonide OINT 1 DERMATOLOGY, LOCAL ANESTHETICS fluocinonide SOLN 1 EMLA 3 B/D fluocinonide emulsified base 1 lidocaine OINT 1 flurandrenolide 1 lidocaine PTCH 1 PA CREA; 1 LOTN; OINT lidocaine hcl GEL 1 halobetasol propionate 1 lidocaine hcl SOLN 4% 1 HALOG 3 lidocaine-prilocaine 1 B/D hydrocortisone (topical) 1 LIDODERM 3 PA hydrocortisone butyrate 1 SYNERA 3 hydrocortisone butyrate 1 XYLOCAINE 4% 3 hydrophilic lipo base DERMATOLOGY, MISCELLANEOUS SKIN hydrocortisone valerate 1 AND MUCOUS MEMBRANE KENALOG 3 acyclovir topical 1 LOCOID 3 ALDARA 3 LOCOID LIPOCREAM 3

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy B/D - Covered under 44 Medicare B or D LA - Limited Access 2016 State of New York eff 08/01/2016

Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits ammonium lactate CREA; 1 ELIMITE 3 LOTN EURAX 3 CONDYLOX GEL 2 malathion 1 CONDYLOX SOLN 3 ovide 3 DENAVIR 3 permethrin 1 diclofenac sodium (actinic 3 SKLICE 3 keratoses) DERMATOLOGY, WOUND CARE AGENTS diclofenac sodium (topical) 1 acetic acid .25% 1 diclofenac sodium (topical) 1 1% gel neomycin/polymyxin b gu 1 DOXYCYCLINE (ROSACEA) 1 REGRANEX 3 EFUDEX 3 SANTYL 3 ELIDEL 2 SODIUM CHLORIDE 0.9% 1 FINACEA AER 15% 2 STERILE WATER 1 IRRIGATION FINACEA GEL 15% 2 fluorouracil (topical) CREA 1 MOUTH/THROAT/DENTAL AGENTS 5% cevimeline hcl 1 FLUOROURACIL (TOPICAL) 3 chlorhexidine gluconate 1 CREA .5% (mouth-throat) fluorouracil (topical) SOLN 1 clotrimazole TROC 1 imiquimod CREA 1 EVOXAC 3 LAC-HYDRIN 3 lidocaine hcl (mouth-throat) 1 METROCREAM 3 nystatin (mouth-throat) 1 METROGEL 3 ORAVIG 3 METROLOTION 3 paroex sol 0.12% 1 metronidazole (topical) 1 periogard soln 0.12% 1 ORACEA 3 PILOCARPINE HCL (ORAL) 1 5mg PANRETIN 3 pilocarpine hcl (oral) 7.5mg 1 PENNSAID 3 SALAGEN 3 PICATO 3 triamcinolone acetonide 1 podofilox SOLN 1 (mouth) PROTOPIC 3 OTIC RECTIV 3 acetasol hc 1 rosadan cre 0.75% 1 acetic acid (otic) 1 SOLARAZE 3 acetic acid sol/hc 1 SOOLANTRA 2 acetic acid-aluminum acetate 1 tacrolimus (topical) 1 CIPRO HC 3 TARGRETIN GEL 3 CIPRODEX 2 TOLAK 3 COLY-MYCIN S 3 VALCHLOR 3 LA CORTISPORIN-TC 3 VOLTAREN GEL 1% 2 DERMOTIC 3 ZOVIRAX CREA; OINT 3 fluocinolone acetonide (otic) 1 DERMATOLOGY, SCABICIDES AND neomycin-polymyxin-hc (otic) 1 PEDICULIDES PA - Prior Authorization QL - Quantity Limits ST - Step Therapy B/D - Covered under 45 Medicare B or D LA - Limited Access 2016 State of New York eff 08/01/2016

Drug Name Drug Requirements/ Tier Limits ofloxacin (otic) 1

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy B/D - Covered under 46 Medicare B or D LA - Limited Access 2016 State of New York eff 08/01/2016 acyclovir7 almotriptan malate23 Index acyclovir sodium7, 8 ALOCRIL40 acyclovir topical44 ALOMIDE40 8 ACZONE42 ALOPRIM1 8-MOP43 ADACEL36 ALORA29 ADAGEN29 alosetron hcl33 A ADALAT CC16 ALOXI31 a-hydrocort29 adapalene42 ALPHAGAN P 0.1%40 abacavir sulfate6 ADCIRCA17 ALPHAGAN P 0.15%40 abacavir sulfate-lamivudine- ADDERALL TAB 10MG22 alprazolam18 zidovudine7 adderall tab 12.5mg22 ALREX39 ABELCET6 adderall tab 15mg22 ALTABAX42 ABILIFY DISCMELT TAB ADDERALL TAB 20MG22 ALTACE13 10MG21 ADDERALL TAB 30MG22 altavera27 ABILIFY MAINTENA21 adderall tab 5mg22 ALVESCO42 ABILIFY TABS21 adderall tab 7.5mg22 amantadine hcl21 ABRAXANE11 ADDERALL XR CAP AMARYL25 ABSORICA42 10MG22 AMBIEN23 ABSTRAL2 ADDERALL XR CAP AMBISOME6 acamprosate calcium24 15MG22 amcinonide43 ACANYA42 ADDERALL XR CAP AMERGE23 acarbose25 20MG22 amethia 91 day27 ADDERALL XR CAP ACCOLATE41 amethyst 28 day27 25MG22 ACCUPRIL13 amifostine crystalline13 ADDERALL XR CAP amikacin sulfate4 ACCURETIC13 30MG22 acebutolol hcl15 amiloride & ADDERALL XR CAP 5MG22 hydrochlorothiazide17 acetaminophen w/ codeine1 adefovir dipivoxil8 acetaminophen-caff- amiloride hcl17 ADEMPAS17 dihydrocod1 aminophylline inj42 adrucil10 acetasol hc45 AMINOSYN37 ADVAIR DISKUS42 acetazolamide17 AMINOSYN ADVAIR HFA42 acetazolamide sodium17 7%/ELECTROLYTES37 AEROSPAN42 acetic acid45 AMINOSYN II37 afeditab cr16 acetic acid (otic)45 AMINOSYN II AFINITOR12 acetic acid sol/hc45 8.5%/ELECTROL37 acetic acid-aluminum AFINITOR DISPERZ12 AMINOSYN INJ 8.5/LYTE37 acetate45 AGGRENOX35 AMINOSYN M37 acetylcysteine41 AGRYLIN35 AMINOSYN-HBC37 ACIPHEX33 AKYNZEO31 AMINOSYN-PF 7%37 ACIPHEX SPR CAP 10MG33 ala-cort43 AMINOSYN-PF INJ 10%37 ACIPHEX SPR CAP 5MG33 ala-scalp43 AMINOSYN-RF37 acitretin43 ALBENZA5 amiodarone hcl14 aclovate43 albuterol sulfate41 amiodarone inj 50mg/ml14 ACTEMRA35 albuterol sulfate er41 AMITIZA33 ACTHIB36 alcaine40 amitriptyline hcl20 alclometasone ACTIGALL33 amlodipine besylate16 dipropionate43 ACTIMMUNE36 amlodipine besylate- ALCOHOL SWABS25 ACTIQ2 benazepril hcl13 ALDACTAZIDE17 ACTONEL26 amlodipine besylate-valsartan ACTOPLUS MET TAB 15- ALDACTAZIDE TAB 50/5017 tab 10-160 mg14 500MG25 ALDACTONE13 amlodipine besylate-valsartan ACTOPLUS MET TAB 15- ALDARA44 tab 10-320 mg14 850MG25 ALDURAZYME29 amlodipine besylate-valsartan ACTOPLUS MET XR 15- ALECENSA12 tab 5-160 mg14 1000MG25 alendronate sodium26 amlodipine besylate-valsartan ACTOPLUS MET XR 30- alfuzosin hcl33 tab 5-320 mg14 1000MG25 ALIMTA10 amlodipine-valsartan- hydrochlorothiazide 10- ACTOS25 ALINIA5 160-12.5mg14 ACULAR39 ALKERAN10 allopurinol tab1 amlodipine-valsartan- ACULAR LS39 hydrochlorothiazide 10- 47 2016 State of New York eff 08/01/2016 160-25mg14 ANORO ELLIPT AER 62.5- AUBAGIO24 amlodipine-valsartan- 2540 aubra 28 day27 hydrochlorothiazide 10- antabuse24 AUGMENTIN9 320-25mg14 ANTARA15 AUGMENTIN ES-6009 amlodipine-valsartan- anusol hc43 AUGMENTIN XR9 hydrochlorothiazide 5- APOKYN21 AURYXIA31 160-12.5mg14 apri 28 day27 AVALIDE14 amlodipine-valsartan- APRISO32 AVAPRO14 hydrochlorothiazide 5- APTENSIO XR23 AVASTIN11 160-25mg14 APTIOM18 AVC34 ammonium chloride37 APTIVUS6 AVEED25 ammonium lactate45 ARALAST NP41 AVELOX9 amnesteem42 aranelle 2827 AVELOX ABC PACK9 amoxapine20 ARANESP ALBUMIN aviane 2827 amoxicillin9 FREE34 AVITA42 amoxicillin & pot clavulanate9 ARAVA35 amoxicillin-clarithromycin w/ AVODART33 ARCALYST36 AVONEX24 lansoprazole33 ARCAPTA NEOHALER41 amphetamine cap 10mg er22 AVONEX PEN24 ARICEPT20 AVYCAZ8 amphetamine cap 15mg er22 ARIMIDEX11 amphetamine cap 20mg er22 AXERT23 aripiprazole odt21 AXIRON25 amphetamine cap 25mg er22 aripiprazole oral solution 1 amphetamine cap 30mg er22 aygestin31 mg/ml21 azacitidine10 amphetamine- aripiprazole tabs21 dextroamphetamine cap AZACTAM5 ARISTADA21 sr 24hr 5 mg22 AZACTAM/DEX INJ 1GM5 amphetamine- ARIXTRA34 AZACTAM/DEX INJ 2GM5 dextroamphetamine tab ARMODAFINIL24 azasan36 10 mg22 armodafinil24 AZASITE39 amphetamine- ARNUITY ELLIPTA42 azathioprine36 dextroamphetamine tab AROMASIN11 azelastine drop 0.05%40 12.5 mg23 ARRANON10 azelastine spr 0.1%41 amphetamine- ARTHROTEC 501 azelastine spr 0.15%41 dextroamphetamine tab ARTHROTEC 751 AZELEX42 15 mg23 ARZERRA11 AZILECT21 amphetamine- ashlyna 91 day27 AZITHROMYCIN9 dextroamphetamine tab ASMANEX42 azithromycin9 20 mg23 ASMANEX HFA42 AZOPT40 amphetamine- ASPIRIN-CAFFEINE- dextroamphetamine tab AZOR14 DIHYDROCODEINE aztreonam5 30 mg23 BITARTRATE1 amphetamine- AZULFIDINE32 ASPIRIN-DIPYRIDAMOLE35 AZULFIDINE EN-TABS32 dextroamphetamine tab 5 ASTAGRAF XL36 mg22 ASTEPRO41 amphetamine- ATACAND14 B dextroamphetamine tab ATACAND HCT14 bacitracin (ophthalmic)39 7.5 mg22 atenolol15 bacitracin-poly-neomycin- amphotericin b6 atenolol & chlorthalidone15 hc39 ampicillin & sulbactam bacitracin-polymyxin b ATGAM36 sodium9 (ophth) ATIVAN18 39 ampicillin cap 250mg9 baclofen atorvastatin calcium15 24 ampicillin cap 500 mg9 BACTOCILL INJ DEX 1GM9 ampicillin inj9 atovaquone5 atovaquone-proguanil hcl tab BACTOCILL INJ DEX 2GM9 ampicillin sodium9 250-100 mg6 BACTRIM5 ampicillin susp9 atovaquone-proguanil hcl tab BACTRIM DS5 AMPYRA24 62.5-25 mg6 BACTROBAN42 ANAFRANIL20 ATRALIN42 BACTROBAN NASAL42 anagrelide hcl35 ATRIPLA7 balsalazide disodium32 ANAPROX DS1 ATROPINE SULFATE32 balziva 28 day27 anastrozole11 ATROVENT40 BANZEL SUS 40MG/ML18 ANCOBON6 ATROVENT HFA40 BANZEL TAB 200MG18 ANDRODERM25 BANZEL TAB 400MG18 48 2016 State of New York eff 08/01/2016 BARACLUDE8 blisovi 24 fe 1/20 28 day27 binder)31 BCG VACCINE36 BONIVA26 camila 28 day27 BECONASE AQ41 BOOSTRIX36 CAMPTOSAR13 bekyree 28 day27 BOSULIF12 CAMRESE LO TAB27 BELBUCA1 BOTOX INJ 100UNIT24 CANASA32 BELEODAQ11 BOTOX INJ 200UNIT24 CANCIDAS6 benazepril & BREO ELLIPTA42 candesartan cilexetil14 hydrochlorothiazide13 BREVICON-2827 candesartan cilexetil- benazepril hcl13 briellyn 28 day27 hydrochlorothiazide14 BENDEKA10 BRILINTA35 CANTIL32 BENICAR14 BRIMONIDINE SOL 0.15%40 CAPASTAT SULFATE7 BENICAR HCT14 brimonidine sol 0.2%40 CAPEX43 BENLYSTA36 BRINTELLIX20 capital BENTYL32 BRISDELLE24 and codeine1 BENZACLIN42 BRIVIACT INJ18 CAPRELSA12 BENZAMYCIN42 BRIVIACT SOLN captopril13 benzoyl peroxide- 10MG/ML18 captopril & erythromycin42 BRIVIACT TABS18 hydrochlorothiazide13 BENZTROPINE bromfenac sodium (ophth)39 CARAFATE33 MESYLATE21 BROMFENAC SODIUM CARBAGLU29 benztropine mesylate21 (OPHTH)(ONCE- carbamazepine18 BEPREVE40 DAILY)39 CARBATROL18 BERINERT35 bromocriptine mesylate21 carbidopa21 BESIVANCE39 BROVANA41 carbidopa-levodopa21 BETAGAN40 budesonide32 CARBIDOPA/LEVODOPA/E betamethasone dipropionate budesonide (inhalation)42 NTACAPONE21 (topical)43 budesonide (nasal)41 carboplatin13 betamethasone dipropionate bumetanide17 CARDIZEM16 augmented43 BUPHENYL29 CARDIZEM CD16 betamethasone valerate43 buprenorphine hcl24 CARDIZEM LA16 BETAPACE14 buprenorphine hcl-naloxone CARDURA14 BETAPACE AF14 hcl sl24 CARDURA XL33 betaxolol hcl15 buproban24 CARIMUNE betaxolol hcl (ophth)40 bupropion hcl20 NANOFILTERED35 bethanechol chloride33 bupropion hcl (smoking CARNITOR29 BETHKIS4 deterrent)25 carteolol hcl (ophth)40 BETIMOL40 buspirone hcl18 cartia xt16 BETOPTIC-S40 BUSULFEX10 carvedilol15 bexarotene12 butorphanol nasal spray1 CASODEX11 BEXSERO36 butorphanol tartrate1 CATAPRES TAB17 BEYAZ27 BUTRANS1 CATAPRES-TTS DIS BIAXIN9 BYDUREON25 0.1/24HR17 bicalutamide11 BYETTA25 CATAPRES-TTS DIS BICILLIN C-R9 BYSTOLIC15 0.2/24HR17 BICILLIN L-A9 CATAPRES-TTS DIS BICNU10 0.3/24HR17 C CAYSTON5 BIDIL17 cabergoline30 BILTRICIDE5 CEDAX8 CABOMETYX12 cefaclor8 bisoprolol & cafergot tab 1-100mg 23 cefaclor er tab 500mg8 hydrochlorothiazide15 CALAN16 bisoprolol fumarate15 cefadroxil8 CALAN SR16 CEFAZOLIN IN DEXTROSE BIVIGAM35 calcipotriene43 bleomycin sulfate10 2GM/100ML-4%8 calcipotriene/betamethasone cefazolin inj8 BLEPH-1039 43 BLEPHAMIDE39 calcitonin (salmon) nasal cefazolin sodium8 cefazolin/dextrose blephamide39 spray30 8 cefdinir blisovi 21 fe 1.5/30 28 day calcitrene oin 0.005%43 8 pack27 CALCITRIOL43 CEFEPIME 1GM SOLN8 blisovi 21 fe 1/20 28 day calcitriol39 CEFEPIME 2GM SOLN8 pack27 calcium acetate (phosphate CEFEPIME HCL AND DEXTROSE8 49 2016 State of New York eff 08/01/2016 cefepime inj 1gm8 ciclopirox sus 0.77%43 5%37 cefepime inj 2gm8 cidofovir8 CLINIMIX 4.25%/DEXTROSE cefixime8 cilostazol35 10%37 CEFOTAN8 CILOXAN OIN 0.3% OP39 CLINIMIX 4.25%/DEXTROSE cefotaxime sodium8 CILOXAN SOL 0.3% OP39 20%37 cefotetan disodium8 cimetidine32 CLINIMIX 4.25%/DEXTROSE cefoxitin sodium8 cimetidine sol 300/5ml32 25%37 CEFOXITIN SODIUM IN CIMZIA35 CLINIMIX 4.25%/DEXTROSE DEXTROSE8 CINRYZE35 5%37 cefpodoxime proxetil8 CIPRO HC45 CLINIMIX 5%/DEXTROSE cefprozil8 CIPRO SUSP9 15%37 CLINIMIX 5%/DEXTROSE ceftazidime8 CIPRO TABS9 CEFTAZIDIME/DEXTROSE8 20%37 CIPRO XR9 CLINIMIX 5%/DEXTROSE CEFTIBUTEN8 CIPRODEX45 25%37 CEFTIN8 ciprofloxacin9 CLINIMIX E ceftriaxone sodium8 ciprofloxacin er9 2.75%/DEXTROSE cefuroxime axetil8 ciprofloxacin hcl9 10%37 cefuroxime sodium8 ciprofloxacin hcl (ophth)39 CLINIMIX E CELEBREX CAP 100MG1 ciprofloxacin in d5w9 2.75%/DEXTROSE 5%37 CELEBREX CAP 200MG1 ciprofloxacn inj 400mg/40ml9 CLINIMIX E 4.25%/D1037 CELEBREX CAP 400MG1 cisplatin13 CLINIMIX E CELEBREX CAP 50MG1 citalopram hydrobromide20 4.25%/DEXTROSE celecoxib1 cladribine10 25%37 CELEXA20 CLAFORAN9 CLINIMIX E CELLCEPT CAP36 claforan9 4.25%/DEXTROSE 5%37 CELLCEPT CLAFORAN/D5W9 CLINIMIX E 5%/DEXTROSE INTRAVENOUS36 claravis42 15%37 CELLCEPT SUSP36 CLARINEX41 CLINIMIX E 5%/DEXTROSE CELLCEPT TAB36 CLARINEX-D TAB 2.5-12041 20%38 CELONTIN18 clarithromycin9 CLINIMIX E 5%/DEXTROSE CENTANY42 CLEOCIN34 25%38 cephalexin8 cleocin5 clinisol 1538 CERDELGA29 CLEOCIN CAP 150MG5 clobetasol e cream 0.05%43 CEREZYME29 CLEOCIN CAP 300MG5 clobetasol propionate43 CERVARIX36 CLEOCIN CAP 75MG5 clobetasol propionate CESAMET31 CLEOCIN IN D5W5 emulsion43 cetirizine syrup41 CLEOCIN INJ5 CLOBEX43 cevimeline hcl45 CLEOCIN PHOSPHATE5 clocortolone pivalate43 CHANTIX25 cleocin phosphate5 CLODERM PUMP43 CHANTIX CONTINUING CLEOCIN VAG SUPP CLOLAR10 MONTH25 100MG34 clomipramine hcl20 CHANTIX STARTER CLEOCIN-T42 clonazepam18 PACK25 CLIMARA29 clonidine hcl17 CHEMET26 clindamax42 clopidogrel bisulfate35 chlorhexidine gluconate clindamycin cre 2% vag34 clorazepate dipotassium18 (mouth-throat)45 clindamycin hcl5 clorpres17 chloroquine phosphate6 clindamycin palmitate clotrimazole45 chlorothiazide tabs17 hydrochloride5 clotrimazole (topical)43 chlorpromaz inj 25mg/ml21 clindamycin phosphate5 clozapine21 chlorpromazine hcl21 clindamycin phosphate CLOZAPINE ODT21 chlorpromazine inj21 (topical)42 CLOZARIL21 chlorthalidone17 clindamycin phosphate in COARTEM6 cholestyramine15 d5w5 codeine cholestyramine light15 clindamycin phosphate- and capital1 choline fenofibrate15 benzoyl peroxide42 CODEINE SULFATE2 CHORIONIC clindamycin phosphate- COGENTIN21 GONADOTROPIN30 benzoyl peroxide COLAZAL32 ciclopirox43 (refrigerate)42 colchicine w/ probenecid1 ciclopirox cre 0.77%43 CLINDESSE34 COLCRYS1 ciclopirox shampoo 1%43 CLINIMIX 2.75%/DEXTROSE COLESTID15

50 2016 State of New York eff 08/01/2016 colestipol hcl15 cyclosporine36 400/ML11 colistimethate sodium5 cyclosporine modified (for DEPO-SUBQ PROVERA colocort32 microemulsion)36 10427 COLY-MYCIN M5 CYKLOKAPRON35 depo-testosterone25 COLY-MYCIN S45 CYMBALTA20 DERMA-SMOOTHE/FS COLYTE-FLAVOR PACKS32 CYRAMZA11 BODY44 COMBIGAN40 cyred tab27 DERMA-SMOOTHE/FS COMBIVENT RESPIMAT40 CYSTADANE29 SCALP44 COMBIVIR7 CYSTAGON29 DERMATOP44 COMETRIQ12 CYSTARAN40 DERMATOP CREAM 0.1%44 COMPLERA7 cytarabine inj10 DERMOTIC45 compro supp31 CYTOMEL31 DESCOVY7 COMTAN21 CYTOTEC33 desipramine hcl20 COMVAX36 CYTOVENE8 desloratadine41 CONCERTA23 DESMOPRESSIN CONDYLOX45 ACETATE31 D desmopressin acetate31 constulose32 D.H.E. 4523 COPAXONE INJ 40MG/ML24 desmopressin acetate inj31 dacarbazine10 desmopressin acetate COPAXONE KIT 20MG/ML24 DACOGEN10 COPEGUS8 spray31 DAKLINZA8 desmopressin acetate spray CORDRAN43 DALIRESP41 refrigerated31 COREG15 DALVANCE5 DESOGEN27 CORGARD15 danazol29 desogestrel-ethinyl estradiol CORLANOR17 DANTRIUM24 (biphasic)27 cormax44 dantrolene sodium24 DESONATE44 CORTEF29 dapsone5 DESONIDE44 CORTENEMA32 DAPTACEL36 desonide44 CORTIFOAM43 DARAPRIM5 DESOWEN44 cortisone acetate29 DARIFENACIN desowen44 CORTISPORIN42 HYDROBROMIDE34 DESOXIMETASONE44 CORTISPORIN-TC45 DARZALEX11 desoximetasone44 CORZIDE15 daunorubicin hcl10 DETROL34 COSENTYX43 DAYPRO1 DETROL LA34 COSENTYX SENSOREADY DAYTRANA23 dexamethasone29 PEN43 DDAVP31 dexamethasone sodium COSMEGEN10 deblitane 28 day27 phosphate29 COSOPT40 decitabine10 dexamethasone sodium COTELLIC12 DELESTROGEN29 phosphate (ophth)39 COUMADIN34 delyla 28 day27 dexpak 10 day29 COZAAR14 DEMADEX17 dexpak 6 day29 CREON33 DEMADEX TAB 20MG17 dexpak taperpak 13 day29 CRESEMBA6 demeclocycline hcl10 dexrazoxane13 CRESTOR15 DEMSER17 DEXTROSE38 CRINONE31 DENAVIR45 DEXTROSE 10% FLEX CRIXIVAN6 DEPACON18 CONTAIN38 cromolyn sodium41 DEPAKENE18 DEXTROSE 10% W/ cromolyn sodium DEPAKOTE18 SODIUM CHLORIDE (mastocytosis)33 DEPAKOTE ER18 0.2%38 cromolyn sodium (ophth)40 DEPAKOTE SPRINKLES18 DEXTROSE 10%/NACL cryselle 2827 DEPEN TITRATABS26 0.45%38 CUBICIN5 depo-estradiol29 DEXTROSE 2.5%/NACL CUTIVATE44 DEPO-MEDROL INJ 0.45%38 CUVPOSA32 20MG/ML29 DEXTROSE 5%38 cyclafem 1/35 28 day27 DEPO-MEDROL INJ DEXTROSE 5% cyclafem 7/7/7 28 day27 40MG/ML29 /ELECTROLYTE38 CYCLESSA27 DEPO-MEDROL INJ DEXTROSE 5%/LACTATED cyclobenzaprine hcl24 80MG/ML29 RING38 CYCLOPHOSPHAMIDE10 DEPO-PROVERA DEXTROSE 5%/NACL cyclophosphamide10 CONTRACEPTIVE27 0.2%38 cycloserine7 DEPO-PROVERA INJ DEXTROSE 5%/NACL 51 2016 State of New York eff 08/01/2016 0.225%38 release beads16 dutasteride33 DEXTROSE 5%/NACL diltiazem inj 100mg16 dutasteride-tamsulosin hcl33 0.3%38 diltiazem inj 125/25ml16 DUTOPROL15 DEXTROSE 5%/NACL diltiazem inj 25mg/5ml16 DYAZIDE17 0.33%38 diltiazem inj 50/10ml16 DYRENIUM17 DEXTROSE 5%/NACL DIOVAN14 DYSPORT24 0.45%38 DIPENTUM32 DEXTROSE 5%/NACL diphenhydram inj 50mg/ml41 0.9%38 E diphenoxylate w/ atropine33 e.e.s. 400 tab 400mg9 DEXTROSE DIPHTHERIA/TETANUS 5%/POTASSIUM CHL38 E.E.S. GRANULES9 TOXOID36 EC-NAPROSYN1 DIAMOX17 DIPROLENE44 DIASTAT ACUDIAL18 econazole nitrate43 DIPROLENE AF44 EDARBI14 DIASTAT PEDIATRIC18 disopyramide phosphate14 diazepam18, 19 EDARBYCLOR14 disulfiram25 EDECRIN17 DIAZEPAM GEL DITROPAN XL34 (ANTICONVULSANT)19 EDURANT6 DIURIL SUS 250/5ML17 EFFEXOR XR20 DIBENZYLINE17 divalproex sodium19 diclofenac potassium1 EFFIENT35 DOCETAXEL11 EFUDEX45 diclofenac sodium1 docetaxel11 diclofenac sodium (actinic EGRIFTA30 dofetilide14 keratoses)45 ELAPRASE29 DOLOPHINE2 diclofenac sodium (ophth)39 ELDEPRYL21 donepezil odt 10mg20 diclofenac sodium (topical)45 ELECTROLYTE-R IN diclofenac sodium (topical) donepezil odt 5mg20 DEXTROSE38 1% gel45 donepezil tab hcl 23mg20 ELELYSO29 diclofenac w/ misoprostol1 donepezil tabs 10mg20 ELESTAT40 dicloxacillin sodium9 donepezil tabs 5mg20 ELIDEL45 dicyclomine hcl32 DORIBAX5 ELIGARD INJ 22.5MG11 didanosine6 dorzolamide hcl40 ELIGARD INJ 30MG11 dorzolamide hcl-timolol DIFFERIN42 ELIGARD INJ 45MG11 maleate40 DIFICID9 ELIGARD INJ 7.5MG11 DOVONEX CRE 0.005%43 diflorasone diacetate44 ELIMITE45 doxazosin mesylate14 DIFLUCAN6 eliphos31 doxepin hcl20 ELIQUIS TAB 2.5MG34 diflunisal1 DOXEPIN HCL digitek16 ELIQUIS TAB 5MG34 (ANTIPRURITIC)43 ELITEK13 digox16 doxercalciferol39 digoxin16 elixophyllin42 DOXIL10 ELLA27 digoxin inj16 doxorubicin hcl10 DIGOXIN SOL 50MCG/ML16 doxorubicin hcl liposomal inj ELLENCE10 DIHYDROERGOTAMINE (for iv infusion) 2 mg/ml10 ELMIRON33 MESYLATE23 doxorubicin inj 50mg10 ELOCON44 dihydroergotamine doxy10 ELOXATIN13 mesylate23 doxycycline (monohydrate)10 EMADINE40 dilantin19 DOXYCYCLINE EMBEDA2 DILANTIN-12519 (ROSACEA)45 EMCYT10 DILATRATE SR17 doxycycline hyclate10 EMEND CAP 125MG31 DILAUDID INJ2 dronabinol31 EMEND CAP 40MG31 DILAUDID TAB2 drospirenone-ethinyl EMEND CAP 80MG31 DILAUDID-5 ORAL LIQD2 estradiol27 EMEND PAK 80 & 12531 DILAUDID-HP INJ DROXIA12 EMLA44 10MG/ML2 DUAC42 emoquette27 DILAUDID-HP INJ 250MG2 DUETACT25 EMPLICITI11 dilt-xr cap16 DULERA42 EMSAM20 diltiazem cap 120mg/24hr16 duloxetine hcl20 EMTRIVA6 diltiazem cap 240mg/24hr16 DUOPA21 ENABLEX34 diltiazem cap er/12hr16 DURAGESIC2 enalapril maleate13 diltiazem hcl16 DURAMORPH2 enalapril maleate & diltiazem hcl coated beads16 DUREZOL39 hydrochlorothiazide13 diltiazem hcl er16 DURLAZA35 ENBREL35 diltiazem hcl extended ENBREL SURECLICK35 52 2016 State of New York eff 08/01/2016 endocet2 etodolac er1 FINACEA GEL 15%45 ENGERIX-B36 ETOPOPHOS13 finasteride33 enoxaparin sodium34 etoposide13 FIRAZYR35 enpresse 28 day27 EURAX45 FIRMAGON11 ENSTILAR44 EVISTA30 FLAGYL5 ENTACAPONE21 EVOCLIN42 FLAREX39 entecavir8 EVOTAZ7 FLEBOGAMMA35 ENTOCORT EC32 EVOXAC45 FLEBOGAMMA DIF35 ENTRESTO14 EXALGO2 flecainide acetate14 ENTYVIO32 EXELDERM43 FLOLAN18 enulose32 EXELON CAPS20 FLOMAX33 ENVARSUS XR36 EXELON PATCHES20 FLOVENT DISKUS42 epinastine hcl (ophth)40 exemestane11 FLOVENT HFA42 EPINEPHRINE41 EXJADE26 fluconazole6 epinephrine41 EXTAVIA24 fluconazole in dextrose6 EPIPEN 2-PAK41 EXTINA43 fluconazole in nacl6 EPIPEN-JR 2-PAK41 EYLEA40 flucytosine6 epirubicin inj 200mg10 fludarabine phosphate10 epirubicin inj 50mg/25ml10 F fludrocortisone acetate29 epitol19 FABRAZYME29 FLUMADINE8 EPIVIR HBV8 falmina 28 day27 flunisolide (nasal)41 EPIVIR SOL 10MG/ML6 famciclovir8 fluocinolone acetonide44 EPIVIR TABS6 famotidine32 fluocinolone acetonide eplerenone13 famotidine inj32 (otic)45 EPOGEN34 FAMVIR8 fluocinonide44 fluocinonide emulsified epoprostenol sodium17 FANAPT21 eprosartan mesylate14 FANAPT TITRATION base44 EPZICOM7 PACK21 FLUOROMETHOLONE EQUETRO24 FARESTON11 (OPHTH)39 fluorouracil ERAXIS6 FARXIGA25 10 ERBITUX11 FLUOROURACIL FARYDAK11 (TOPICAL)45 ergomar23 FASLODEX11 ERIVEDGE11 fluorouracil (topical)45 FAZACLO21 FLUOXETINE HCL20 errin 28 day27 felbamate 19 fluoxetine hcl20 ERTACZO43 FELBATOL19 ERWINAZE12 fluphenazine decanoate21 FELDENE1 fluphenazine hcl21 ery pad 2%42 felodipine 16 flurandrenolide44 ery-tab9 FEMARA11 erygel42 flurbiprofen1 FEMCON FE27 flurbiprofen sodium39 ERYPED 2009 FEMRING29 ERYPED 4009 flutamide11 FENOFIBRATE15 fluticasone propionate44 erythrocin lactobionate9 fenofibrate15 erythrocin stearate9 fluticasone propionate fenofibrate micronized15 (nasal)41 erythromycin (acne aid)42 FENOFIBRIC ACID15 erythromycin (ophth)39 fluvastatin sodium15 FENOGLIDE15 fluvastatin sodium tab sr 24 erythromycin base9 FENOPROFEN CALCIUM1 hr 80 mg15 erythromycin cap 250mg ec9 fenoprofen calcium1 fluvoxamine maleate18 erythromycin ethylsuccinate9 fentanyl citrate2 fluvoxamine maleate er18 ESBRIET41 fentanyl patch 100 mcg/hr2 FML39 escitalopram oxalate20 fentanyl patch 12 mcg/hr2 FML FORTE39 esomeprazole sodium inj33 fentanyl patch 25 mcg/hr2 FML LIQUIFILM39 estarylla tab 0.25-3527 fentanyl patch 50 mcg/hr2 FOLOTYN11 estrace29 fentanyl patch 75 mcg/hr2 fondaparinux sodium34 estradiol29 FENTORA2 FORADIL AEROLIZER41 estradiol valerate29 FERRIPROX26 FORFIVO XL20 ESTRING29 FETZIMA20 FORTAZ9 ESTROSTEP FE27 FETZIMA TITRATION FORTEO31 ethambutol hcl7 PACK20 FORTICAL SPR 200/ACT30 ethosuximide19 FIBRICOR15 FOSAMAX26 etodolac1 FINACEA AER 15%45 53 2016 State of New York eff 08/01/2016 fosinopril sodium13 mg/ml4 HALAVEN12 fosinopril sodium & gentamicin in saline HALDOL22 hydrochlorothiazide13 1.4mg/ml4 HALDOL DECANOATE FOSRENOL31 gentamicin in saline 1.6 10022 FRAGMIN34 mg/ml4 HALDOL DECANOATE 5022 FREAMINE HBC 6.9%38 gentamicin in saline 2 mg/ml5 halobetasol propionate44 FREAMINE III38 gentamicin sulfate5 HALOG44 FROVA TAB 2.5MG23 gentamicin sulfate (ophth)39 haloperidol22 frovatriptan succinate23 gentamicin sulfate (topical)42 haloperidol decanoate22 FURADANTIN5 GENVOYA7 haloperidol lactate22 furosemide17 GEODON21 haloperidol lactate inj 5 FUROSEMIDE INJ17 GEODON INJ22 mg/ml22 furosemide inj17 GIANVI TAB 3-0.02MG27 HARVONI8 furosemide oral soln 8 GIAZO32 HAVRIX36 mg/ml17 gildagia27 heather27 FUSILEV13 gildess 1.5/30 21 day27 HECTOROL39 FUZEON6 gildess 24 fe 28 day27 HEP SOD/NACL INJ fyavolv tab 1 mg-5 mcg29 GILENYA CAP 0.5MG24 2500034 FYCOMPA19 GILOTRIF TAB 20MG12 HEPARIN (PORCINE) IN GILOTRIF TAB 30MG12 SODIUM CHLORIDE GILOTRIF TAB 40MG12 100U/ML34 G heparin sod inj 10000u/ml34 gabapentin GLASSIA41 19 heparin sod inj 1000u/ml34 GABITRIL19 glatopa24 GLEEVEC12 heparin sod inj 20000u/ml34 galantamine hydrobromide20 HEPARIN SOD INJ GAMASTAN S/D35 GLEOSTINE10 glimepiride25 2000U/ML34 GAMMAGARD LIQUID35 HEPARIN SOD INJ GAMMAGARD S/D35 glipizide25 glipizide er25 2500U/ML34 GAMMAGARD S/D IGA heparin sod inj LESS TH35 GLIPIZIDE XL TB24 2.5MG25 5000u/0.5ml34 GAMMAKED35 heparin sod inj 5000u/ml34 GAMMAPLEX35 GLIPIZIDE XL TB24 5MG25 glipizide-metformin 2.5-250 HEPARIN SODIUM/D5W34 GAMUNEX-C35 HEPARIN SODIUM/NACL ganciclovir inj 500mg8 mg25 glipizide-metformin 2.5-500 0.45%34 garamycin39 mg25 HEPATAMINE38 GARDASIL36 glipizide-metformin 5- HEPSERA8 GARDASIL 936 500mg25 HERCEPTIN11 GASTROCROM33 GLUCAGEN HYPOKIT30 HETLIOZ23 gatifloxacin (ophth)39 GLUCAGON EMERGENCY HEXALEN10 GATTEX33 KIT30 HIBERIX36 GAUZE PADS 2X225 GLUCOPHAGE25 HIPREX5 gaviltye-g32 GLUCOPHAGE XR26 HIZENTRA35 gavilyte-c32 GLUCOTROL26 HORIZANT24 gavilyte-h32 GLUCOTROL XL26 HUMATROPE30 gavilyte-n32 glycopyrrolate32 HUMATROPE COMBO GAZYVA11 GLYSET26 PACK30 GELNIQUE34 GLYXAMBI26 HUMIRA35 GEMCITABINE HCL11 GOLYTELY32 HUMIRA PEDIATRIC gemcitabine hcl11 GRALISE24 CROHNS35 gemfibrozil15 GRALISE STARTER24 HUMIRA PEN35 GEMZAR11 granisetron hcl31 HUMIRA PEN-CROHNS GENERESS FE27 GRANIX35 STARTER KIT35 HUMIRA PEN-PSORIASIS generlac32 GRASTEK36 gengraf36 STARTER KIT35 GRIS-PEG6 HUMULIN R U-500 gentak39 griseofulvin microsize6 gentamicin in saline 0.8 (CONCENTRATE)25 griseofulvin ultramicrosize6 mg/ml4 HUMULIN R U-500 gentamicin in saline guanfacine hcl (adhd)23 KWIKPEN25 0.9mg/ml4 HYCAMTIN13 gentamicin in saline 1 mg/ml4 H hycet2 gentamicin in saline 1.2 H.P. ACTHAR30 hydralazine hcl17 54 2016 State of New York eff 08/01/2016 HYDREA12 ifosfamide inj 1gm10 INVOKANA TAB 100MG26 hydrochlorothiazide17 IFOSFAMIDE INJ 3GM10 INVOKANA TAB 300MG26 hydrocodone-acetaminophen ILARIS36 IONOSOL-B/DEXTROSE 10-300mg2 ILEVRO39 5%38 hydrocodone-acetaminophen ilotycin39 IONOSOL-MB/DEXTROSE 2.5-325mg2 imatinib mesylate12 5%38 hydrocodone-acetaminophen IMBRUVICA CAP 140MG12 IPOL INACTIVATED IPV36 5-300mg2 imipenem-cilastatin5 ipratropium bromide hydrocodone-acetaminophen imipramine hcl20 (nasal)40 5-325mg2 imipramine pamoate20 ipratropium sol inhal40 hydrocodone-acetaminophen imiquimod45 ipratropium-albuterol40 7.5-300mg2 IMITREX23 irbesartan14 hydrocodone-acetaminophen IMITREX STATDOSE irbesartan- 7.5-325 mg/15ml2 REFILL23 hydrochlorothiazide14 hydrocodone-acetaminophen IMITREX STATDOSE IRESSA12 7.5-325mg2 SYSTEM23 irinotecan inj 100/5ml13 hydrocodone-acetaminophen IMOVAX RABIES irinotecan inj 40mg/2ml13 tab 10-325mg2 (H.D.C.V.)36 irinotecan inj 500mg/25ml13 hydrocodone-ibuprofen tab IMURAN36 ISENTRESS7 10-200mg3 ISOLYTE P38 hydrocodone-ibuprofen tab INCRELEX30 ISOLYTE S38 2.5-200mg2 INCRUSE ELLIPTA40 hydrocodone-ibuprofen tab 5- indapamide17 isoniazid7 200mg2 INDERAL LA15 isoniazid tabs7 hydrocodone-ibuprofen tab INFANRIX36 ISOPTO CARPINE40 7.5-200 mg3 INFUMORPH 2003 ISORDIL TITRADOSE17 hydrocortisone30 INFUMORPH 5003 isosorbide dinitrate17 HYDROCORTISONE INLYTA12 isosorbide dinitrate er17 (INTRARECTAL)32 INSPRA13 isosorbide mononitrate17 hydrocortisone (topical)44 INSULIN PEN NEEDLES25 isosorbide mononitrate er17 hydrocortisone butyrate44 INSULIN SAFETY isradipine16 hydrocortisone butyrate NEEDLES25 ISTALOL40 hydrophilic lipo base44 INSULIN SYRINGES25 ISTODAX11 hydrocortisone valerate44 INTELENCE6 itraconazole6 HYDROMORPHONE HCL3 INTRALIPID INJ 20%38 ivermectin5 hydromorphone hcl3 INTRALIPID INJ 30%38 IXEMPRA KIT12 hydromorphone tab 12mg er3 INTRON-A INJ 10MU36 IXIARO36 hydromorphone tab 16mg er3 INTRON-A INJ 18MU36 hydromorphone tab 8mg er3 INTRON-A INJ 25MU36 J HYDROMORPHONE TABS INTRON-A INJ 50MU36 JADENU26 32MG3 introvale 91 day27 JAKAFI12 hydroxychloroquine sulfate35 INTUNIV23 jantoven34 hydroxyurea12 INVANZ5 JANUMET26 hydroxyzine hcl41 INVEGA22 JANUMET XR TAB 100- HYQVIA35 INVEGA SUST INJ 117 100026 HYSINGLA ER3 MG/0.75 ML22 JANUMET XR TAB 50- HYZAAR14 INVEGA SUST INJ 100026 156MG/ML22 JANUMET XR TAB 50- INVEGA SUST INJ 234 I 500MG26 MG/1.5 ML22 JANUVIA26 ibandronate sodium26 INVEGA SUST INJ 39 ibandronate tab 150mg26 JARDIANCE26 MG/0.25 ML22 JENTADUETO26 IBRANCE11 INVEGA SUST INJ 78 ibudone tab 10-200mg3 JEVTANA11 MG/0.5 ML22 jinteli29 ibudone tab 5-200mg3 INVEGA TRINZA22 ibuprofen1 JOLESSA TAB 0.15-0.03 INVIRASE6 MG27 ICLUSIG12 INVOKAMET TAB 150- IDAMYCIN PFS10 JOLIVETTE27 100026 juleber 28 day27 idarubicin hcl10 INVOKAMET TAB 150-50026 IFEX INJ 1GM10 junel 1.5/30 21 day27 INVOKAMET TAB 50-100026 junel 1/20 21 day IFEX INJ 3GM10 INVOKAMET TAB 50- 27 junel fe 1.5/30 28 day ifosfamide inj10 500MG26 27 55 2016 State of New York eff 08/01/2016 junel fe 1/20 28 day27 KITABIS PAK5 LEMTRADA24 junel fe 24 1/20 28 day27 KLARON42 LENVIMA 10MG DAILY JUXTAPID15 KLONOPIN19 DOSE12 KLOR-CON 1037 LENVIMA 14MG DAILY KLOR-CON 837 DOSE12 K LENVIMA 18MG DAILY K-TAB37 klor-con m1037 klor-con m1537 DOSE12 KADCYLA11 LENVIMA 20MG DAILY KADIAN3 klor-con m2037 klor-con pow 20meq37 DOSE12 kaitlib fe 28 day27 LENVIMA 24MG DAILY KALBITOR35 klor-con spr cap 10meq37 klor-con spr cap 8meq37 DOSE12 KALETRA SOL7 LENVIMA 8MG DAILY KALETRA TAB 100-25MG7 KOMBIGLYZE XR 2.5- 1000MG26 DOSE12 KALETRA TAB 200-50MG7 LESCOL15 KALYDECO41 KOMBIGLYZE XR 5- 1000MG26 lessina 28 day27 KANUMA29 KOMBIGLYZE XR 5- LETAIRIS18 kariva 28 day 27 500MG26 letrozole11 KAYEXALATE26 KORLYM30 leucovorin calcium13 KAZANO26 kristalose32 leucovorin calcium inj KCL 0.075%/D5W/NACL 100mg13 0.45%38 KUVAN29 KYNAMRO15 leucovorin calcium inj KCL 0.15%/D5W/LR38 200mg13 KCL 0.15%/D5W/NACL leucovorin calcium inj 0.9%38 L 350mg13 KCL 0.3%/D5W/LR IV LAC labetalol hcl15 leucovorin calcium inj RI38 LAC-HYDRIN45 500mg13 KCL 0.3%/D5W/NACL LACRISERT40 leucovorin calcium inj 0.45%38 LACTATED RINGERS 50mg13 KCL 0.3%/D5W/NACL VIAFLEX38 LEUKERAN10 0.9%38 lactulose32 LEUKINE35 KCL IN NACL INJ .15-0.4538 lactulose (encephalopathy)33 leuprolide acetate11 KCL/D5W/NACL INJ LAMICTAL19 levalbuterol conc .15/.33%38 LAMICTAL CHEWABLE 1.25mg/0.5ml41 KCL/D5W/NACL INJ DISPERS19 LEVALBUTEROL HCL41 .15/.45%38 LAMICTAL ODT19 levalbuterol hcl41 KCL/D5W/NACL INJ LAMICTAL STARTER19 LEVAQUIN9 0.22%/0.45%38 LAMICTAL XR19 LEVEMIR25 KCL/NACL INJ 0.15%- LAMISIL6 LEVEMIR FLEXTOUCH25 0.9%38 lamivudine7 levetiracetam19 KCL0.15%/D5W/NACL0.2%3 lamivudine (hbv)8 LEVETIRACETAM IV19 8 lamivudine-zidovudine7 levetiracetam oral soln 100 KCL0.15%/D5W/NACL0.225 lamotrigine19 mg/ml %38 19 LANOXIN16 levobunolol hcl kelnor 1/35 28 day27 40 LANOXIN INJ 0.25MG/ML16 levocarnitine (metabolic KENALOG44 LANOXIN PEDIATRIC16 modifiers)29 KEPIVANCE13 LANOXIN TAB16 levocetirizine soln KEPPRA19 lansoprazole33 2.5mg/5ml41 KEPPRA XR19 LANTUS25 levocetirizine tab 5 mg41 ketoconazole6 LANTUS SOLOSTAR25 levofloxacin9 ketoconazole (topical)43 larin 1.5/3027 levofloxacin (ophth)39 ketoconazole shampoo43 larin 1/2027 levofloxacin in d5w9 ketodan aer 2%43 larin fe 1.5/3027 levoleucovorin calcium13 ketoprofen1 levonest 28 day27 ketorolac tromethamine larin fe 1/2027 LASIX17 levonor/ethi tab27 (ophth)40 levonorgestrel & eth KEVEYIS17 LASTACAFT40 latanoprost40 estradiol27 KEYTRUDA11 levonorgestrel (emergency kimidess 28 day27 LATUDA22 LAYOLIS FE CHW27 oc)27 KINERET35 levonorgestrel-ethinyl KINRIX36 LAZANDA3 LEENA TAB27 estradiol (91-day)27 kionex26 levonorgestrel-ethinyl leflunomide35 56 2016 State of New York eff 08/01/2016 estradiol (continuous)27 loryna 28 day28 MAXALT23 levora 0.15/30 28 day27 losartan potassium14 MAXALT-MLT23 levorphanol tartrate3 losartan- MAXIDEX40 levothyroxine sodium31 hydrochlorothiazide14 MAXIPIME9 LEVOXYL31 LOSEASONIQUE28 MAXITROL39 LEXAPRO20 LOTEMAX40 MAXZIDE17 LEXIVA7 LOTENSIN13 MAXZIDE-2517 LIALDA32 LOTREL13 meclizine hcl31 lidocaine44 LOTRONEX33 MEDROL PAK 4MG30 lidocaine hcl44 lovastatin15 MEDROL TAB 16MG30 lidocaine hcl (local anesth.)4 LOVAZA CAP 1GM15 MEDROL TAB 2MG30 lidocaine hcl (mouth-throat)45 LOVENOX34 MEDROL TAB 32MG30 lidocaine inj 0.5%4 low-ogestrel28 MEDROL TAB 4MG30 lidocaine inj 1%4 loxapine succinate22 MEDROL TAB 8MG30 lidocaine inj 1.5%4 LUCENTIS40 medroxyprogesterone lidocaine inj 2%4 LUMIGAN40 acetate31 lidocaine-prilocaine44 LUMIZYME29 medroxyprogesterone LIDODERM44 LUPANETA PACK29 acetate (contraceptive)28 LINEZOLID5 LUPRON DEP INJ mefenamic acid1 linezolid5 11.25MG11 mefloquine hcl6 LINEZOLID IN SODIUM LUPRON DEP-PED INJ MEGACE ES12 CHLORIDE5 11.25MG12 MEGACE ORAL12 LINZESS33 LUPRON DEP-PED INJ megestrol acetate12 liothyronine sodium31 15MG12 MEGESTROL SUS LIPOFEN15 LUPRON DEP-PED INJ 625MG/5ML12 LIPOSYN II38 30MG (3-MONTH)12 MEKINIST12 LIPOSYN III38 LUPRON DEP-PED INJ MELOXICAM1 lisinopril13 7.5MG11 meloxicam tabs1 lisinopril & LUPRON DEPOT12 melphalan hcl10 hydrochlorothiazide13 LUPRON DEPOT INJ memantine hcl20 lithium carbonate24 22.5MG (3-MONTH)12 MENACTRA36 LITHIUM SOLN LUPRON DEPOT INJ 30MG MENOMUNE-A/C/Y/W-13536 8MEQ/5ML24 (3-MONTH)12 MENOSTAR29 LITHOBID24 lutera 28 day28 MENTAX43 LIVALO15 LUZU43 MENVEO36 LO LOESTRIN FE27 LYNPARZA11 MEPRON5 LOCOID44 LYRICA19 mercaptopurine11 LOCOID LIPOCREAM44 LYSODREN12 meropenem5 LODOSYN21 LYSTEDA35 MEROPENEM/SODIUM loestrin 1.5/30 21 day27 lyza28 CHLORIDE5 loestrin 1/20 21 day27 MERREM5 loestrin fe 1.5/30 28 day27 M mesalamine enema32 loestrin fe 1/20 28 day27 M-M-R II36 mesna13 lofibra15 MACROBID5 MESNEX13 lokara44 MACRODANTIN5 MESTINON24 lomedia 24 fe28 MAGNESIUM SULFATE37 MESTINON SYRUP24 LOMOTIL33 magnesium sulfate37 MESTINON TIMESPAN24 LONSURF12 MAGNESIUM SULFATE IN METADATE CD23 loperamide hcl33 D5W37 metadate er tab 20mg23 LOPID15 MAGNESIUM SULFATE INJ metformin er26 LOPRESSOR15 50%37 metformin hcl26 LOPRESSOR HCT15 MALARONE6 methadone hcl3 LOPROX SHAMPOO43 malathion45 METHADONE INJ lorazepam18 maprotiline hcl20 10MG/ML3 lorcet hd tab 10-325mg3 MARINOL31 METHADOSE3 lorcet plus tab 7.5-3253 marlissa 28 day28 methazolamide17 lorcet tab 5-325mg3 MARPLAN20 methenamine hippurate5 lortab tab 10-325mg3 MATULANE12 methimazole31 lortab tab 5-325mg3 matzim la16 METHOTREXATE lortab tab 7.5-3253 MAVIK13 SODIUM11 57 2016 State of New York eff 08/01/2016 methotrexate sodium11 MIGRANAL23 MYOZYME29 methotrexate sodium inj11 millipred30 MYRBETRIQ34 methotrexate sodium tabs35 millipred dp30 MYSOLINE19 methoxsalen rapid43 MINASTRIN 24 FE28 myzilra28 methscopolamine bromide32 MINIPRESS14 methyclothiazide17 minitran17 N methylergonovine maleate30 MINIVELLE29 nabumetone1 METHYLIN23 MINOCIN10 nadolol16 METHYLIN CHEW TAB23 minocycline hcl10 nadolol & METHYLPHENIDATE HCL23 minoxidil17 bendroflumethiazide15 methylphenidate hcl23 MIRAPEX21 NAFCILLIN9 methylphenidate hcl er23 MIRAPEX ER21 nafcillin sodium9 methylpr ace inj 40mg/ml30 MIRCERA35 NAFTIFINE HCL43 methylpr ace inj 80mg/ml30 mircette28 naftifine hcl43 methylpr ss inj 125mg30 mirtazapine20 NAFTIN43 methylpr ss inj 1gm30 misoprostol33 NAGLAZYME29 methylpr ss inj 40mg30 mitomycin10 nalbuphine hcl1 methylpred pak 4mg30 mitoxantrone hcl12 NALFON1 methylpred tab 16mg30 MOBIC1 NALLPEN ISO-OSMOTIC IN methylpred tab 32mg30 modafinil24 DE9 methylpred tab 4mg30 MODERIBA PAK8 naloxone hcl25 methylpred tab 8mg30 moderiba pak8 naltrexone hcl25 metipranolol40 moderiba tab 200mg8 NAMENDA SOL metoclopramide hcl31 MODICON28 10MG/5ML20 metoclopramide hcl inj 5 moexipril hcl13 NAMENDA TAB20 mg/ml31 moexipril- NAMENDA XR20 metoclopramide odt31 hydrochlorothiazide13 NAMENDA XR TITRATION metolazone17 molindone hcl22 PACK20 metoprolol & hctz tab 100- mometasone furoate44 NAMZARIC20 25mg15 mometasone furoate naphazoline 0.1%40 metoprolol & hctz tab 100- (nasal)41 NAPRELAN1 50mg15 mono-linyah tab 0.25-3528 NAPROSYN TABS1 metoprolol & hctz tab 50- MONONESSA28 naproxen1 25mg15 montelukast sodium41 NAPROXEN SODIUM1 metoprolol succinate15 MORPHINE SUL 20MG/ML naproxen sodium1 metoprolol tartrate15, 16 ORAL SOL3 naratriptan hcl23 METRO IV5 MORPHINE SULFATE3 NARDIL20 METROCREAM45 morphine sulfate3 NASONEX41 METROGEL45 morphine sulfate beads3 NATACYN39 METROGEL-VAGINAL34 morphine sulfate ext-rel tab3 nateglinide26 METROLOTION45 MOVANTIK33 NATPARA31 metronidazole5 MOVIPREP33 NEBUPENT5 metronidazole (topical)45 MOXATAG9 necon 0.5/35 28 day28 metronidazole inj5 MOXEZA39 necon 1/35 28 day28 metronidazole vaginal34 MOXIFLOXACIN HCL9 necon 10/11 28 day28 mexiletine hcl14 moxifloxacin hcl9 NECON 7/7/728 MIACALCIN INJ 200U/ML30 MOZOBIL35 NECON TAB 1/50-2828 MIACALCIN SPR 200/ACT30 MS CONTIN3 nefazodone hcl20 MICARDIS14 MULTAQ14 neomycin sulfate5 MICARDIS HCT14 mupirocin42 neomycin-bacitracin zn- miconazole 3 sup 200mg34 mupirocin calcium (topical)42 polymyxin39 MICRO-K37 MUSTARGEN10 neomycin-polymy- MICROGESTIN 1.5/3028 MYALEPT30 dexameth39 MICROGESTIN 1/2028 MYAMBUTOL7 neomycin-polymyxin- MICROGESTIN FE 1.5/3028 MYCAMINE6 gramicidin39 MICROGESTIN FE 1/2028 MYCOBUTIN7 neomycin-polymyxin-hc MICROZIDE17 mycophenolate mofetil36 (ophth)39 midodrine hcl17 mycophenolate sodium36 neomycin-polymyxin-hc migergot23 MYFORTIC36 (otic)45 miglitol26 myorisan42 neomycin/polymyxin b gu45 58 2016 State of New York eff 08/01/2016 NEORAL36 norgest/ethi tab 0.25/3528 ofloxacin (otic)46 neosporin solution39 norgestimate-ethinyl estradiol ogestrel 28 day28 NEPHRAMINE38 (triphasic)28 olanzapine22 NEPTAZANE17 NORINYL 1+3528 olanzapine odt22 NESINA26 NORINYL 1+5028 olopatadine hcl40 neuac gel 1.2-5%42 norlyroc 28 day28 olopatadine hcl (nasal)41 NEULASTA35 NORMOSOL-M IN D5W38 OLUX44 NEULASTA ONPRO KIT35 NORMOSOL-R38 OMECLAMOX-PAK33 NEUMEGA35 NORPACE14 omega-3-acid ethyl esters15 NEUPOGEN35 NORPACE CR14 omeprazole33 NEUPRO21 NORPRAMIN20 OMNARIS41 NEURONTIN19 nortrel 0.5/35 28 day28 OMNIPRED40 NEVIRAPINE7 nortrel 1/35 21 day28 ONCASPAR12 nevirapine7 nortrel 1/35 28 day28 ondansetron hcl31 NEXAVAR12 nortrel 7/7/7 28 day28 ondansetron hcl inj31 NEXIUM I.V.33 nortriptyline hcl20 ondansetron hcl oral soln31 niacin er NORVASC16 ondansetron odt31 (antihyperlipidemic)15 NORVIR7 ONFI19 niacor15 NOVAREL INJ 10000UNT30 ONGLYZA26 NIASPAN15 NOVOLIN 70/3025 ONMEL6 nicardipine hcl16 NOVOLIN N25 ONZETRA XSAIL23 NICOTROL INHALER25 NOVOLIN R25 OPANA3 NICOTROL NS25 NOVOLOG25 OPANA ER (CRUSH nifedical16 NOVOLOG FLEXPEN25 RESISTANT4 nifedipine16 NOVOLOG MIX 70/3025 OPDIVO11 nifedipine er16 NOVOLOG MIX 70/30 OPSUMIT18 nikki 28 day28 PREFILL25 OPTIPRANOLOL40 NILANDRON12 NOVOLOG PENFILL25 ORACEA45 nimodipine16 NOXAFIL6 ORAP22 NINLARO11 NPLATE35 ORAPRED ODT TAB NIPENT11 NUCALA41 10MG30 nisoldipine16 NUCYNTA3 ORAPRED ODT TAB nitro-bid17 NUCYNTA ER3 15MG30 NITRO-DUR17 NUEDEXTA24 ORAPRED ODT TAB nitrofurantoin5 NULOJIX36 30MG30 nitrofurantoin macrocrystal5 NULYTELY/FLAVOR ORAVIG45 nitrofurantoin monohyd PACKS33 ORENCIA35 macro5, 6 NUPLAZID22 ORENITRAM TAB nitroglycerin17 NUTRILIPID INJ 20%38 0.125MG18 NITROGLYCERIN NUVARING28 ORENITRAM TAB 0.25MG18 LINGUAL17 NUVESSA34 ORENITRAM TAB 1MG18 nitroglycerin patches17 NUVIGIL24 ORENITRAM TAB 2.5MG18 NITROLINGUAL SPR nyamyc43 ORFADIN29 PUMPSPRA17 NYMALIZE16 ORKAMBI41 NITROMIST17 nystatin6 orsythia 28 day28 NITROSTAT17 nystatin (mouth-throat)45 ORTHO MICRONOR28 nizatidine32 nystatin (topical)43 ORTHO TRI-CYCLEN LO28 NIZORAL43 nystatin pow 10000043 ORTHO-CYCLEN28 NOR-QD28 nystop43 ORTHO-NOVUM 1/3528 NORA-BE TAB28 ORTHO-NOVUM 7/7/728 norco3 O OSENI TAB 12.5-15MG26 NORDITROPIN FLEXPRO30 OCELLA TAB 3-0.03MG28 OSENI TAB 12.5-30MG26 norethin acet & estrad-fe28 OCTAGAM35 OSENI TAB 12.5-45MG26 norethindrone & ethinyl octreotide acetate30 OSENI TAB 25-15MG26 estradiol-fe 28 OCUFEN40 OSENI TAB 25-30MG26 norethindrone OSENI TAB 25-45MG26 (contraceptive)28 OCUFLOX39 ODEFSEY7 OSMOPREP33 norethindrone acetate31 OTEZLA35 norethindrone acetate-ethinyl ODOMZO12 OFEV41 OTREXUP35 estradiol29 ovcon 35 28 day ofloxacin (ophth)39 28 59 2016 State of New York eff 08/01/2016 ovide45 CHLORIDE-SOD PILOCARPINE HCL oxacillin sodium9 SULFATE33 (ORAL)45 oxaliplatin13 peg 3350-potassium chloride- pilocarpine hcl (oral)45 oxandrolone25 sod bicarbonate-sod pimozide22 oxaprozin1 chloride33 pimtrea pack28 oxcarbazepine19 PEG-INTRON REDIPEN8 pindolol16 oxiconazole nitrate cream43 PEGANONE19 pioglitazone hcl26 OXISTAT43 PEGASYS8 pioglitazone hcl-glimepiride26 OXSORALEN ULTRA43 PEGASYS PROCLICK8 pioglitazone hcl-metformin OXTELLAR XR19 PEGINTRON8 hcl26 oxybutynin chloride34 PENICILLIN G POT IN piperacillin sodium- OXYCODONE HCL4 DEXTROSE9 tazobactam sodium10 oxycodone hcl4 PENICILLIN G POTASSIUM pirmella 1/35 28 day28 oxycodone w/ acetaminophen IN10 piroxicam1 10-325mg4 penicillin g procaine10 PLAQUENIL35 oxycodone w/ acetaminophen penicillin g sodium10 PLASMA-LYTE A38 2.5-325mg4 penicillin v potassium10 PLASMA-LYTE-14838 oxycodone w/ acetaminophen penicilln gk inj 20mu10 PLASMA-LYTE-56/D5W38 5-325mg4 penicilln gk inj 5mu10 PLEGRIDY24 oxycodone w/ acetaminophen PENNSAID45 PLEGRIDY STARTER 7.5-325mg4 PENTACEL36 PACK24 oxycodone w/ acetaminophen PENTAM 3006 plenamine38 soln 5-325 mg/5ml4 PENTASA32 PLETAL35 oxycodone-aspirin4 pentoxifylline35 podofilox45 oxycodone-ibuprofen4 PEPCID SUSP32 polyethylene glycol 335033 OXYCONTIN4 pepcid tab32 polymyxin b sulfate6 oxymorphone hcl4 percocet 10/3254 polymyxin b-trimethoprim39 percocet 2.5/3254 POLYTRIM39 P percocet 7.5/3254 POMALYST12 pacerone14 percocet tab 5-325mg4 PONSTEL1 paclitaxel11 PERFOROMIST41 portia 28 day28 paliperidone22 perindopril erbumine13 PORTRAZZA11 PAMELOR20 periogard soln 0.12%45 pot chloride inj 2meq/ml38 pamidronate disodium26 PERJETA11 POTASSIUM CHLORIDE37, PAMINE32 permethrin45 38 PAMINE FORTE32 perphenazine22 potassium chloride37 PANCREAZE33 PERTZYE33 POTASSIUM CHLORIDE PANDEL44 PEXEVA20 0.3%/D38 PANRETIN45 pfizerpen g inj 5mu10 potassium chloride caps er37 pantoprazole sodium33 pfizerpen-g inj 20mu10 POTASSIUM CHLORIDE IN PARICALCITOL39 phenadoz31 NACL38 potassium chloride in nacl paricalcitol39 phenelzine sulfate20 38 phenergan32 potassium chloride PARNATE20 microencapsulated paroex sol 0.12%45 phenergan inj32 phenobarbital19 crystals cr37 paromomycin sulfate5 POTASSIUM CHLORIDE paroxetine er tab20 PHENOBARBITAL SODIUM19 TAB CR 10 MEQ37 paroxetine hcl tabs20 POTASSIUM CITRATE paser d/r7 phenobarbital sodium19 phenoxybenzamine hcl17 (ALKALINIZER)34 PATADAY40 potassium citrate phenytek19 PATANASE41 (alkalinizer)34 phenytoin19 PATANOL40 POTIGA19 PAXIL20 phenytoin inj 50mg/ml19 phenytoin sodium PRADAXA34 PAXIL CR20 extended19 PRALUENT15 PAZEO40 pramipexole philith28 PCE9 dihydrochloride21 PHOSLO31 pediapred sol 6.7/5ml30 PRANDIMET26 PHOSLYRA31 PEDIARIX36 PRANDIN26 PHOSPHOLINE IODIDE40 PEDVAX HIB36 PRAVACHOL15 PICATO45 PEG 3350-KCL-SOD pravastatin sodium15 PILOCARPINE HCL40 BICARB-SOD prazosin hcl14 60 2016 State of New York eff 08/01/2016 PRECOSE26 PROCARDIA XL16 QUALAQUIN6 PRED FORTE40 prochlorperazine inj 5 QUARTETTE28 PRED MILD40 mg/ml32 quasense 91 day28 pred sod pho sol 5mg/5ml30 prochlorperazine maleate32 QUDEXY XR19 PRED-G39 prochlorperazine supp32 questran15 PRED-G S.O.P.39 PROCRIT35 questran light15 PREDNICARBATE44 procto-med43 quetiapine fumarate22 prednicarbate44 procto-pak43 QUILLICHEW ER23 PREDNISOLONE ACETATE proctosol hc 2.5 %43 QUILLIVANT XR23 (OPHTH)40 proctozone hc43 quinapril hcl13 prednisolone sodium PROCYSBI29 quinapril- phosphate30 progesterone micronized31 hydrochlorothiazide13 prednisolone sodium PROGLYCEM SUS quinidine gluconate14 phosphate (ophth)40 50MG/ML30 quinidine sulfate14 prednisolone sol 15mg/5ml30 PROGRAF36 quinine sulfate6 prednisolone sol 25mg/5ml30 PROLASTIN-C41 QVAR42 prednisolone syrup 15 PROLEUKIN11 mg/5ml30 PROLIA31 R prednisone con 5mg/ml30 PROMACTA35 prednisone pak 10mg30 RABAVERT36 promethazine hcl32 rabeprazole sodium33 prednisone pak 5mg30 promethegan32 prednisone sol 5mg/5ml30 RAGWITEK36 PROMETRIUM31 raloxifene hcl prednisone tab 10mg30 31 propafenone hcl14 ramipril13 prednisone tab 1mg30 propafenone hcl 12hr14 prednisone tab 2.5mg30 RANEXA17 proparacaine hcl40 ranitidine hcl32 prednisone tab 20mg30 propranolol & RAPAFLO33 prednisone tab 50mg30 hydrochlorothiazide 15 RAPAMUNE36 prednisone tab 5mg30 propranolol hcl er 16 RASUVO35 PREGNYL W/DILUENT propranolol inj 1mg/ml 16 RAVICTI29 BENZYL31 propranolol sol 16 RAYOS TAB 1MG30 PREMARIN CREAM29 propranolol tab 16 RAYOS TAB 2MG30 PREMARIN INJ29 propylthiouracil31 premasol 10%38 RAYOS TAB 5MG30 PROQUAD36 RAZADYNE20 premasol 6%38 PROSCAR33 PRENATAL VITAMIN/FOLIC RAZADYNE ER20 PROSOL38 REBETOL8 ACID > 0.8 MG PROTONIX INJ33 (GENERIC)39 REBIF24 PROTOPIC45 REBIF REBIDOSE24 PREPOPIK33 protriptyline hcl20 PREVACID33 REBIF REBIDOSE PROVERA31 TITRATION24 prevalite15 PROZAC20 previfem 28 day28 REBIF TITRATION PACK24 PROZAC WEEKLY21 RECLAST26 PREVPAC33 PRUDOXIN CRE 5%43 PREZCOBIX7 reclipsen 28 day28 psorcon44 RECOMBIVAX HB36 PREZISTA7 PULMICORT FLEXHALER42 PRIFTIN7 RECTIV45 PULMICORT INH SUSP REGLAN32 PRILOSEC33 0.25MG/2 ML42 PRILOSEC CAP 10MG33 PULMICORT INH SUSP REGRANEX45 PRILOSEC CAP 20MG33 0.5MG/2 ML42 RELENZA DISKHALER8 PRILOSEC CAP 40MG33 PULMICORT INH SUSP RELISTOR33 PRIMAQUINE 1MG/2ML42 RELPAX23 PHOSPHATE6 PULMOZYME41 REMERON21 PRIMAXIN6 PURIXAN11 REMERON SOLTAB21 primidone19 PYLERA33 REMICADE35 PRIMSOL6 pyrazinamide7 REMODULIN18 PRINIVIL13 pyridostigmine bromide24 RENAGEL31 PRISTIQ20 RENVELA PAK31 PRIVIGEN35 RENVELA TAB 800MG31 Q repaglinide26 PROAIR HFA41 QNASL41 probenecid repaglinide-metformin hcl26 1 QNASL CHILDRENS42 PROCALAMINE38 reprexain tab 10-200mg4 QUADRACEL36 reprexain tab 2.5-200mg4 61 2016 State of New York eff 08/01/2016 reprexain tab 5-200mg4 ROTARIX36 SINEMET21 REQUIP21 ROTATEQ36 SINEMET CR21 RESCRIPTOR7 ROWASA32 SINGULAIR41 RESTASIS40 roweepra19 SIROLIMUS36 RESTORIL23 roxicet soln4 sirolimus36 RETIN-A42 roxicet tab 5-325mg4 SIRTURO7 RETROVIR CAPS7 ROXICODONE4 SIVEXTRO6 RETROVIR IV INFUSION7 ROZEREM23 SKLICE45 RETROVIR SYRP7 RUCONEST35 SODIUM CHLORIDE37, 38 REVATIO18 RYTARY21 SODIUM CHLORIDE 0.45% REVLIMID36 RYTHMOL14 VIA39 REXULTI22 RYTHMOL SR14 SODIUM CHLORIDE 0.9%45 REYATAZ7 SODIUM DIURIL17 RHEUMATREX35 SODIUM FLUORIDE CHEW; S TAB; 1.1 (0.5 F) MG/ML RHINOCORT AQUA42 SABRIL19 ribapak mis 600/day8 SOLN37 SALAGEN45 sodium phenylbutyrate29 ribasphere8 SAMSCA31 ribasphere ribapak 10008 sodium polystyrene SANCUSO32 sulfonate26 ribasphere ribapak 12008 SANDIMMUNE CAPS36 ribasphere ribapak 8008 SOLARAZE45 SANDIMMUNE INJ36 SOLIRIS35 ribavirin 200mg8 SANDIMMUNE SOLN36 rifabutin7 SOLODYN10 SANDOSTATIN31 SOLTAMOX12 RIFADIN7 SANDOSTATIN LAR rifadin7 SOLU-CORTEF 1000MG30 DEPOT31 SOLU-CORTEF 100MG30 rifamate7 SANTYL45 rifampin7 SOLU-CORTEF 250MG30 SAPHRIS22 SOLU-CORTEF 500MG30 RIFATER7 SARAFEM25 RILUTEK24 SOLU-MEDROL INJ SAVAYSA34 125MG30 riluzole24 SAVELLA24 rimantadine hydrochloride8 SOLU-MEDROL INJ 1GM30 SAVELLA TITRATION SOLU-MEDROL INJ 2GM30 RINGER'S38 PACK24 RIOMET26 SOLU-MEDROL INJ 40MG30 SEASONIQUE28 SOLU-MEDROL INJ RISEDRONATE SODIUM26 SECTRAL16 500MG30 risedronate sodium26 SEEBRI NEOHALER41 SOMATULINE DEPOT31 RISPERDAL22 selegiline hcl21 SOMAVERT31 RISPERDAL INJ 12.5MG22 selenium sulfide43 SOOLANTRA45 RISPERDAL INJ 25MG22 SELZENTRY7 SORIATANE43 RISPERDAL INJ 37.5MG22 SEMPREX-D41 SORILUX43 RISPERDAL INJ 50MG22 SENSIPAR26 sorine14 RISPERDAL M-TAB22 SEREVENT DISKUS41 sotalol hcl14 risperidone22 SERNIVO44 sotalol hcl (afib/afl)14 risperidone odt22 SEROQUEL22 SOTYLIZE16 RITALIN23 SEROQUEL XR22 SOVALDI8 RITALIN LA23 SEROSTIM30 SPIRIVA HANDIHALER41 RITUXAN11 sertraline hcl21 SPIRIVA RESPIMAT41 rivastigmine tartrate20 setlakin tab28 rivastigmine td patch 24hr spironolactone13 SF-ROWASA32 spironolactone & 13.3 mg/24hr20 sharobel 28 day28 rivastigmine td patch 24hr 4.6 hydrochlorothiazide17 SIGNIFOR31 SPORANOX6 mg/24hr20 SIGNIFOR LAR31 rivastigmine td patch 24hr 9.5 SPORANOX PULSEPAK6 sildenafil citrate (pulmonary SPORANOX SOL 10MG/ML6 mg/24hr20 hypertension)18 rizatriptan benzoate24 sprintec 28 day28 SILENOR23 SPRITAM19 ROBINUL32 SILVADENE43 ROBINUL FORTE32 SPRYCEL12 SILVER SULFADIAZINE43 sps susp 15gm/60ml27 ROCALTROL39 SIMBRINZA SUS 1-0.2%40 rocephin9 sronyx 28 day28 SIMPONI35 SSD43 ropinirole hydrochloride21 SIMPONI ARIA35 rosadan cre 0.75%45 STALEVO21 SIMULECT36 STARLIX26 rosuvastatin calcium15 simvastatin15 62 2016 State of New York eff 08/01/2016 stavudine7 SYNERCID6 terbutaline sulfate41 STELARA43 SYNJARDY TAB 12.5- terconazole vaginal34 STERILE WATER 100026 testosterone cypionate25 IRRIGATION45 SYNJARDY TAB 12.5-50026 testosterone enanthate25 STIMATE31 SYNJARDY TAB 5- TETANUS/DIPHTHERIA STIOLTO RESPIMAT40 1000MG26 TOXOID37 STIVARGA12 SYNJARDY TAB 5-500MG26 tetrabenazine24 STRATTERA23 SYNRIBO13 TETRACYCLINE HCL10 STRENSIQ29 SYNTHROID31 texacort44 streptomycin sulfate5 SYPRINE27 THALOMID36 STRIANT25 theo-2442 STRIBILD7 T theophylline42 STRIVERDI RESPIMAT41 TABLOID11 thioridazine hcl22 STROMECTOL6 TACLONEX44 thiotepa10 SUBSYS4 tacrolimus36 thiothixene22 SUCLEAR33 tacrolimus (topical)45 THYMOGLOBULIN36 SUCRAID33 TAFINLAR12 tiagabine hcl19 sucralfate33 TAGRISSO12 TIAZAC16 SULAR16 TAMIFLU8 TIKOSYN14 sulfacet sod oin 10% op39 tamoxifen citrate12 timolol maleate16 sulfacetamide sod- tamsulosin hcl33 timolol maleate (ophth)40 prednisolone39 TANZEUM25 TIMOLOL MALEATE GEL40 sulfacetamide sodium tapazole31 TIMOPTIC40 (acne)42 TARCEVA12 TIMOPTIC OCUDOSE40 sulfacetamide sodium TARGRETIN13, 45 TIMOPTIC-XE40 (ophth) 39 tarina fe 1/20 28 day28 TIROSINT31 sulfadiazine 5 TARKA13 TIVICAY7 sulfamethoxazole-trimethop 6 TASIGNA12 tizanidine24 sulfamethoxazole- TOBI NEB5 trimethoprim inj6 TAXOTERE11 tazicef TOBI PODHALER5 SULFAMYLON43 9 tazicef vial9 TOBRADEX39 sulfasalazine dr32 tobramycin5 sulfasalazine ir32 TAZORAC43 taztia xt16 tobramycin (ophth)39 sulindac1 tobramycin sulfate5 SUMATRIPTAN INJ TECFIDERA CAP 120MG24 TECFIDERA CAP 240MG24 tobramycin- 4MG/0.5ML24 dexamethasone39 sumatriptan inj 6mg/0.5ml24 TECFIDERA MIS STARTER24 TOBREX OINT 0.3%39 SUMATRIPTAN TOBREX SOL 0.3% OP39 SUCCINATE24 TEFLARO9 TEGRETOL19 TOFRANIL21 sumatriptan succinate24 TOLAK45 SUMAVEL DOSEPRO24 TEGRETOL-XR19 TEKTURNA16 tolmetin sodium1 SUPRAX9 tolterodine tartrate er34 suprax9 TEKTURNA HCT16 telmisartan14 tolterodine tartrate tab 1 SUPREP BOWEL PREP33 mg34 SURMONTIL21 telmisartan-amlodipine14 telmisartan- tolterodine tartrate tab 2 SUSTIVA7 hydrochlorothiazide mg34 SUTENT12 14 temazepam23 TOPAMAX19 syeda28 TOPAMAX SPRINKLE19 SYLATRON KIT 200MCG12 TEMOVATE CREAM44 TEMOVATE E CREAM44 TOPICORT44 SYLATRON KIT 300MCG12 topicort44 SYLATRON KIT 600MCG13 TEMOVATE GEL44 TEMOVATE OIN44 TOPICORT SPRAY 0.25%44 SYLVANT13 TOPIRAMATE19 SYMBICORT42 TEMOVATE SOLN44 TENIVAC37 topiramate19 SYMLINPEN 12025 toposar13 SYMLINPEN 6025 TENORETIC 10015 TENORETIC 5015 topotecan hcl13 SYNAGIS37 TOPROL XL16 SYNALAR44 TENORMIN16 TERAZOL 334 TORISEL11 SYNALGOS-DC1 torsemide inj 50mg/5ml17 SYNAREL29 TERAZOL 734 terazosin hcl torsemide tabs17 SYNERA44 14 terbinafine hcl6 TOUJEO SOLOSTAR25 63 2016 State of New York eff 08/01/2016 TPN ELECTROLYTES37 trilyte33 UTIBRON NEOHALER40 TRACLEER18 trimethoprim6 UVADEX13 TRADJENTA26 trimipramine maleate21 TRAMADOL HCL1 TRINESSA28 V TRAMADOL HCL ER2 TRINESSA LO TAB28 VAGIFEM29 tramadol hcl er1 TRINTELLIX21 valacyclovir hcl8 tramadol hcl er (biphasic) TRIOSTAT31 VALCHLOR45 100mg2 TRISENOX13 VALCYTE8 tramadol hcl er (biphasic) TRIUMEQ7 valganciclovir hcl8 200mg2 trivora 28 day28 tramadol hcl er (biphasic) VALIUM19 TRIZIVIR7 valproate sodium 300mg2 19 TROKENDI XR19 valproic acid tramadol hcl tab 50 mg2 19 TROPHAMINE INJ 10%38 valsartan14 tramadol-acetaminophen2 TROPHAMINE INJ 6%38 valsartan- TRANDATE16 trospium chloride34 hydrochlorothiazide14 trandolapril 13 trospium chloride er34 VALSTAR10 trandolapril-verapamil hcl 13 TRULICITY25 VALTREX8 tranexamic acid 35 TRUMENBA37 VANCOCIN HCL6 TRANSDERM-SCOP32 TRUSOPT40 vancomycin hcl6 TRANXENE T19 TRUVADA7 vancomycin hcl inj 1000mg6 tranylcypromine sulfate 21 TRUVADA TAB 100-1507 vancomycin hcl inj 10gm6 TRAVASOL38 TRUVADA TAB 133-2007 vancomycin hcl inj 500mg6 TRAVATAN Z40 TRUVADA TAB 167-2507 vancomycin hcl inj 5gm6 trazodone hcl 21 TUDORZA PRESSAIR41 vancomycin hcl inj 750mg6 TREANDA10 TUDORZA PRESSAIR VANCOMYCIN IN NACL6 TRECATOR7 (INSTITUTIONAL VANDAZOLE34 TRELSTAR MIXJECT12 PACK)41 VANOS44 TRESIBA FLEXTOUCH25 TWINRIX INJ37 VANTAS12 TRETINOIN42 TWYNSTA14 VAQTA37 tretinoin13, 42 TYBOST7 TRETINOIN VARIVAX37 TYGACIL6 VARUBI32 MICROSPHERE42 TYKERB12 tretinoin microsphere42 VASCEPA15 tylenol with codeine2 VASERETIC13 trexall35 TYPHIM VI37 trezix2 VASOTEC13 TYSABRI24 VECTIBIX11 tri-legest 28 day28 TYVASO18 tri-lo- estarylla 28 day28 VECTICAL43 TYZEKA8 VELCADE11 tri-lo- tab marzia28 tyzine41 tri-lo-sprintec 28 day28 VELETRI18 velivet 28 day28 TRI-NORINYL 2828 U tri-previfem 28 day VELPHORO31 28 UCERIS32 tri-sprintec 28 day28 VELTASSA27 triamcinolone acetonide UCERIS AER 2MG/ACT32 VENCLEXTA11 (mouth)45 ULORIC1 VENCLEXTA STARTING TRIAMCINOLONE ULTRACET2 PACK11 ACETONIDE (NASAL)42 ULTRAM2 venlafaxine cap er21 triamcinolone acetonide ULTRAM ER2 venlafaxine hcl21 (topical)44 ULTRAM ER TAB 100MG2 VENLAFAXINE HCL ER TAB triamt/hctz cap 37.5-2517 ULTRAM ER TAB 200MG2 (VERT)21 triamt/hctz cap 50-25mg17 ULTRAVATE44 venlafaxine tab21 triamt/hctz tab 37.5-2517 ULTRESA33 VENLAFAXINE TAB 225MG triamt/hctz tab 75-50mg17 UNASYN10 ER21 venlafaxine tab er trianex44 UNASYN BULK PACK10 21 TRICOR15 UNITHROID31 VENTAVIS18 triderm44 UPTRAVI18 VERAPAMIL HCL16 verapamil hcl trifluoperazine hcl22 urecholine34 16 trifluridine39 UROCIT-K34 VERELAN16 TRILEPTAL SUSP19 UROXATRAL33 VERELAN PM16 veripred TRILEPTAL TABS19 URSO 25033 30 TRILIPIX15 URSO FORTE33 VERSACLOZ22 ursodiol33 VESICARE34 64 2016 State of New York eff 08/01/2016 vestura28 XANAX TAB 0.25MG18 ZEMAIRA41 VEXOL40 XANAX TAB 0.5MG18 ZEMBRACE SYMTOUCH24 VFEND IV6 XANAX TAB 1MG18 ZEMPLAR39 VFEND SUS 40MG/ML6 XANAX TAB 2MG18 ZENATANE42 VFEND TAB6 XARELTO34 zenatane42 VIBERZI33 XARELTO STARTER zenchent fe 28 day29 VIBRAMYCIN10 PACK34 zenchent tab29 vicodin4 XARTEMIS XR4 ZENPEP33 vicodin es4 XELJANZ35 ZERBAXA9 vicodin hp4 XELJANZ XR35 ZERIT7 VICOPROFEN4 XENAZINE24 ZESTORETIC13 VICTOZA25 XEOMIN24 ZESTRIL13 VIDAZA11 XEOMIN 200UNIT24 ZETIA TAB 10MG15 VIDEX EC7 XGEVA31 ZETONNA42 VIDEX PEDIATRIC7 XIFAXAN TAB 200MG6 ZIAC15 vienva 28 day28 XIFAXAN TAB 550MG33 ZIAGEN7 VIGAMOX39 XIGDUO XR TAB 10- zidovudine7 VIIBRYD21 1000MG26 ZINACEF9 VIIBRYD STARTER PACK21 XIGDUO XR TAB 10- ZINECARD13 VIMIZIM29 500MG26 ZIOPTAN40 VIMPAT19 XIGDUO XR TAB 5- ziprasidone hcl22 vinblastine sulfate11 1000MG26 ZIRGAN39 vincasar11 XIGDUO XR TAB 5- ZITHROMAX9 vincristine sulfate11 500MG26 ZITHROMAX TRI-PAK9 vinorelbine tartrate11 xodol tab 10-300mg4 ZITHROMAX Z-PAK9 VIOKACE 1033 xodol tab 5-300mg4 ZMAX9 VIOKACE 2033 xodol tab 7.5-3004 ZOCOR15 viorele28 XOLAIR41 ZOFRAN32 VIRACEPT7 XOPENEX41 ZOFRAN ODT32 XOPENEX VIRAMUNE7 ZOHYDRO ER (ABUSE CONCENTRATE41 VIRAMUNE XR7 DETERRENT)4 XTANDI12 VIREAD7 ZOLADEX12 xulane dis 150-3528 VIROPTIC39 zoledronic inj 4mg/5ml26 XYLOCAINE4, 44 VITEKTA7 zoledronic inj 5/100ml26 XYLOCAINE-MPF4 VIVELLE-DOT29 ZOLINZA11 xylon tab 10-200mg4 VIVITROL25 zolmitriptan24 XYREM24 VIVLODEX1 zolmitriptan odt24 XYZAL41 VOLTAREN GEL 1%45 ZOLOFT21 voriconazole6 zolpidem tartrate23 voriconazole inj 200mg6 Y ZOMETA26 vospire41 YASMIN 2828 ZOMIG24 VOTRIENT12 YAZ28 ZOMIG ZMT24 VPRIV29 YERVOY11 ZONALON43 VRAYLAR22 YF-VAX37 ZONEGRAN20 vyfemla 28 day28 zonisamide20 VYTORIN15 Z ZONTIVITY35 VYVANSE23 zafirlukast41 ZORBTIVE30 ZALTRAP11 ZORTRESS TAB 0.25MG36 W zamicet4 ZORTRESS TAB 0.5MG36 warfarin sodium34 ZANAFLEX24 ZORTRESS TAB 0.75MG36 WELCHOL15 ZANOSAR10 ZOSTAVAX37 WELLBUTRIN21 ZANTAC32 ZOSYN10 WELLBUTRIN SR21 zarah29 zovia 1/35e 28 day29 WELLBUTRIN XL21 ZARONTIN20 zovia 1/50e 28 day29 wymzya fe28 zarontin20 ZOVIRAX8, 45 ZAVESCA29 ZUBSOLV SUB 1.4- ZAZOLE34 0.36MG25 X ZEBETA16 ZUBSOLV SUB 11.4- XALATAN40 ZELAPAR21 2.9MG25 XALKORI12 ZELBORAF12 ZUBSOLV SUB 2.9- 65 2016 State of New York eff 08/01/2016 0.71MG25 ZUBSOLV SUB 5.7-1.4MG25 ZUBSOLV SUB 8.6-2.1MG25 ZYBAN25 ZYDELIG12 ZYFLO CR41 ZYKADIA12 ZYLET39 ZYLOPRIM1 ZYMAXID39 ZYPREXA22 ZYPREXA RELPREVV22 ZYPREXA RELPREVV INJ 210MG22 ZYPREXA ZYDI TAB 10MG22 ZYPREXA ZYDIS22 ZYTIGA12 ZYVOX6

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