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CDPHP Medicaid Select/HARP Clinical Formulary 2021

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

CDPHP provides the following: • Free aids and services to people with disabilities to help you communicate with us, such as: ○ Qualified sign language interpreters ○ Written information in other formats (large print, audio, accessible electronic formats, other formats) • Free language services to people whose first language is not English, such as: ○ Qualified interpreters ○ Information written in other languages

If you need these services, call CDPHP at 1-800-388-2994. For TTY/TDD services, call 711.

If you believe that CDPHP has not given you these services or treated you differently because of race, color, national origin, age, disability, or sex, you can file a grievance with CDPHP by: • Mail: CDPHP Civil Rights Coordinator, 500 Patroon Creek Blvd., Albany, New York 12206 • Phone: 1-844-391-4803 (for TTY/TDD services, call 711) • Fax: (518) 641-3401 • In person: 500 Patroon Creek Blvd., Albany, New York 12206 • Email: https://www.cdphp.com/customer-support/email-cdphp

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights by: • Web: Office for Civil Rights Complaint Portal at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf • Mail: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building Washington, DC 20211 • Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html • Phone: 1-800-368-1019 (TTY/TDD 1-800-537-7697)

Multi-language Interpreter Services ATTENTION: If you speak a non-, language assistance services, free of charge, are available to you. Call (518) 641-3800 or 1-800-388-2994 (TTY: 711).

ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (518) 641-3800 o 1-800-388-2994 (TTY: 711).

注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 (518) 641-3800 或 1-800-388-2994（TTY：711）。

ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (518) 641-3800 или 1-800-388-2994 (телетайп: 711).

ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele (518) 641-3800 oswa 1-800-388-2994 (TTY: 711).

주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. (518) 641-3800 또는 1-800- 388-2994 (TTY: 711) 번으로 전화해 주십시오.

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ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero (518) 641-3800 o 1-800-388-2994 (TTY: 711).

אויפמערקזאם : אויב איר רעדט אידיש, זענען פארהאן פאר אייך שפראך הילף סערוויסעס פריי פון אפצאל . רופט 641-3800 (518)או TTY: 711) 1-800-388-2994).

লক্ষ্য ক쇁নঃ যদি আপদন বাাংলা, কথা বলতে পাতেন, োহতল দনঃখেচায় ভাষা সহায়ো পদেতষবা উপলব্ধ আতে। ফ ান ক쇁ন (518) 641-3800 বা 1-800-388-2994 (TTY: 711)।

UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer (518) 641-3800 lub 1-800-388-2994 (TTY: 711).

تنبيه: إذا كنت تتحدث لغة غير اإلنجليزية، تتوفر إليك خدمات مساعدة اللغة مجا ًنا. اتصل بالرقم 3800-641 (518)أو TTY: 711) 1-800-388-2994).

ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le (518) 641-3800 ou 1-800-388-2994 (ATS : 711).

توجہ دیں: اگر آپ غیر انگر ی زی زبان بولتے ہیں تو، آپ کے لیے زبان سے متعلق اعانت کی خدمات، مفت دستیاب ہیں۔ 3800-641 (518) يا TTY: 711) 1-800-388-2994) پر کال کر یں۔

PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa (518) 641-3800 o 1-800-388-2994 (TTY: 711).

ΠΡΟΣΟΧΗ: Αν μιλάτε ελληνικά, στη διάθεσή σας βρίσκονται υπηρεσίες γλωσσικής υποστήριξης, οι οποίες παρέχονται δωρεάν. Καλέστε (518) 641-3800 ή 1-800-388-2994 (TTY: 711).

KUJDES: Nëse flitni shqip, për ju ka në dispozicion shërbime të asistencës gjuhësore, pa pagesë. Telefononi në (518) 641-3800 ose 1-800-388-2994 (TTY: 711)

INTRODUCTION Capital District Physicians' Health Plan, Inc. (CDPHP) is pleased to provide the CDPHP Medicaid Select/HARP Clinical Formulary 2021 as a useful reference and informational tool to assist practitioners in selecting clinically appropriate and cost-effective therapies.

The information contained in this CDPHP Medicaid Select/HARP Clinical Formulary and its appendices is provided by CDPHP, solely for the convenience of medical practitioners. CDPHP does not warrant or assure accuracy of such information nor is it intended to be comprehensive in nature. This CDPHP Medicaid Select/HARP Clinical Formulary is not intended to be a substitute for the knowledge, expertise, skill, and judgment of the medical practitioner in his/her choice of prescription . All the information in the CDPHP Medicaid Select/HARP Clinical Formulary is provided as a reference for drug therapy selection. Specific drug selection for an individual patient rests solely with the prescriber. The document is subject to state-specific regulations and rules, including, but not limited to, those regarding generic substitution, controlled substance schedules, preference for brands and mandatory generics whenever applicable.

CDPHP assumes no responsibility for the actions or omissions of any medical practitioner based upon reliance, in whole or in part, on the information contained herein. The medical practitioner should consult the drug manufacturer's product literature or standard references for more detailed information.

National guidelines can be found on the National Guideline Clearinghouse site at www.guideline.gov.

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PREFACE The document is organized by sections. Each section is divided by therapeutic primarily defined by mechanism of action. Products are listed by generic name with brand name for reference only. Unless the cited drug is available as an injectable or an exception is specifically noted, generally, all applicable dosage forms and strengths of the drug cited are included in the document.

Coverage of any agent listed in the formulary may be subject to quantity limits and/or prior authorization requirements. Injectables are generally covered under the medical benefit. Pharmacy benefits may impose additional coverage restrictions or may not cover selected drug products.

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

The actions of the CDPHP P&T Committee are communicated after each committee meeting by posting final decisions on the CDPHP web page Formulary Updates section of Rx Corner on the providers tab of www.cdphp.com. PRODUCT SELECTION CRITERIA When a new drug is considered for formulary inclusion, it will be reviewed relative to similar drugs currently on formulary. In addition, the entire CDPHP formulary is reviewed on an annual basis.

Quantity limitations and/or prior authorizations may also apply to formulary drugs. Excluded drugs are not covered unless medical exception procedures have been followed and a medical exception is approved. GENERIC SUBSTITUTION Generic substitution is a pharmacy action whereby a generic version is dispensed rather than a prescribed brand-name product. The document is subject to state specific regulations and rules regarding generic substitution and mandatory generic rules apply where appropriate.

Generic drugs are usually priced lower than their brand-name equivalents. Prescription generic drugs are:

• Approved by the U.S. Food and Drug Administration for safety and effectiveness, and are manufactured under the same strict standards that apply to brand-name drugs. • Tested in humans to assure the generic is absorbed into the bloodstream in a similar rate and extent compared to the brand-name drug (). Generics may be different from the brand in size, color and inactive ingredients, but this does not alter their effectiveness or ability to be absorbed just like the brand-name drug. • Manufactured in the same strength and dosage form as the brand-name drugs.

When a is substituted for a brand-name drug, you can expect the generic to produce the same clinical effect and safety profile as the brand-name drug (therapeutic equivalence). SPECIALTY DRUGS (SP) Specialty pharmaceuticals are used in the management of complex chronic or genetic conditions and certain catastrophic diseases. They are often injectable , but they may also include oral agents. CDPHP has chosen CVS Specialty™ Pharmacy as the preferred vendor to dispense high-cost injectables and biotech drugs for its members. Eligible members will need to register and will receive a 30-day supply of medications and additional

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supplies needed to administer the medications. Specialty medications are available through CVS Specialty Pharmacy, toll-free at 1-800-237-2767.

Managed Medicaid members, or providers on behalf of members, may contact CDPHP and request to obtain specialty drugs at a retail pharmacy, rather than CVS Specialty Pharmacy. CDPHP will facilitate the process by sending the appropriate paperwork to the network pharmacy. The network retail pharmacy must accept the price comparable to that of the specialty pharmacy, as well as sign a member/drug-specific contract amendment. Contract amendments refer only to price, not terms and conditions, and are not required for each refill. For further information, please call the CDPHP Pharmacy Department at (518) 641-3784.

Drugs that are considered specialty medications are noted within this booklet by the "SP" symbol. PRIOR AUTHORIZATION (PA) CDPHP requires prior authorization for certain drugs before they will be approved for coverage. Coverage will be approved when specific approval criteria for that drug is met, according to CDPHP policies.

The list of drugs that require prior authorization is subject to change from time to time and may not be all-inclusive. If a drug requires prior authorization, the prescribing practitioner should initiate a prior authorization request with CDPHP. Prior authorization can be requested through the CDPHP Pharmacy Department by faxing the request to (518) 641- 3208. Drugs that require prior authorization are noted within this booklet by the "PA" symbol. PRESCRIPTION QUANTITY MANAGEMENT CDPHP, working closely with the P&T Committee members, has chosen to limit the quantity of certain drugs that CDPHP may cover for a member. Quantity limits are in place for quality and/or clinical considerations. The list of drugs that have quantity limits is subject to change from time to time and may not be all-inclusive. Drugs that have quantity limits are noted within this booklet by the "QL" symbol. MEDICAL EXCEPTION The CDPHP P&T Committee developed the Medical Exception policy so that practitioners may request an excluded drug for a specific patient when medically necessary. The Medical Exception process is coordinated through CDPHP's Pharmacy Department. Requests are processed in the order received. Medical exceptions can be requested through the CDPHP Pharmacy Department by faxing the request to (518) 641-3208. In addition, a member may initiate a medical exception request by calling the telephone number to CVS Caremark® printed on their CDPHP identification card or by utilizing the "Medical Exception Request" option found under Prescription Forms & Lists on the Forms and Tools section on the members tab of CDPHP's website, www.cdphp.com. A response will be sent to both the medical practitioner and member as soon as possible. PLAN DESIGN The document represents a closed formulary plan design. The medications listed on the document are covered by the plan as represented. Certain medications on the list are covered if utilization management criteria are met (i.e. Prior Authorization, Quantity Limits, etc); requests for use of such medications outside of their listed criteria will be reviewed for medical necessity. If a is not listed on the document, a formulary exception may be requested for coverage. Medical necessity or formulary exception requests will be reviewed based on drug-specific prior authorization criteria or standard non-formulary prescription request criteria. EDITOR Your comments and suggestions regarding the CDPHP Medicaid Select/HARP Clinical Formulary 2021 are encouraged. Your input is vital to this formulary's continued success. All responses will be reviewed and considered. Please send your comments to:

CDPHP, Pharmacy Department 500 Patroon Creek Boulevard Albany, NY 12206-1057 E-mail: [email protected] Internet: www.cdphp.com

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LEGEND OTC Over the counter PA Prior Authorization; refer to Prior Authorization section QL Quantity Limitations; refer to Prescription Quantity Management section SP Specialty Drug RxC/M Pharmacy Care Management Program

delayed-rel Delayed-release (also known as enteric-coated) ext-rel Extended-release (also known as sustained-release)

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

The drug names listed here are the registered and/or unregistered trademarks of third-party pharmaceutical companies unrelated to and unaffiliated with CDPHP. These trademarked brand names are included here for informational purposes only and are not intended to imply or suggest any affiliation between CDPHP and such third-party pharmaceutical companies.

CDPHP and CVS Caremark do not operate the websites/organizations listed here, nor are they responsible for the availability or reliability of the websites' content. These listings do not imply or constitute an endorsement, sponsorship or recommendation by CDPHP or CVS Caremark.

Please be advised that this document is updated periodically and changes may appear prior to their effective date to allow for client notification.

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CDPHP Medicaid eff 07/01/2021 Drug Name Requirements/Limits ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS - cap er 24hr 5 QL (60 caps / 30 days) mg amphetamine-dextroamphetamine cap er 24hr 10 QL (60 caps / 30 days) mg amphetamine-dextroamphetamine cap er 24hr 15 QL (60 caps / 30 days) mg amphetamine-dextroamphetamine cap er 24hr 20 QL (60 caps / 30 days) mg amphetamine-dextroamphetamine cap er 24hr 25 QL (60 caps / 30 days) mg amphetamine-dextroamphetamine cap er 24hr 30 QL (60 caps / 30 days) mg amphetamine-dextroamphetamine tab 5 mg QL (90 tabs / 30 days) amphetamine-dextroamphetamine tab 7.5 mg QL (90 tabs / 30 days) amphetamine-dextroamphetamine tab 10 mg QL (90 tabs / 30 days) amphetamine-dextroamphetamine tab 12.5 mg QL (90 tabs / 30 days) amphetamine-dextroamphetamine tab 15 mg QL (90 tabs / 30 days) amphetamine-dextroamphetamine tab 20 mg QL (90 tabs / 30 days) amphetamine-dextroamphetamine tab 30 mg QL (90 tabs / 30 days) dextroamphetamine sulfate cap er 24hr 5 mg QL (120 caps / 30 days) dextroamphetamine sulfate cap er 24hr 10 mg QL (120 caps / 30 days) dextroamphetamine sulfate cap er 24hr 15 mg QL (120 caps / 30 days) dextroamphetamine sulfate tab 5 mg QL (120 tabs / 30 days) dextroamphetamine sulfate tab 10 mg QL (120 tabs / 30 days) VYVANSE CAP 10MG QL (30 caps / 30 days) VYVANSE CAP 20MG QL (30 caps / 30 days) VYVANSE CAP 30MG QL (30 caps / 30 days) VYVANSE CAP 40MG QL (30 caps / 30 days) VYVANSE CAP 50MG QL (30 caps / 30 days) VYVANSE CAP 60MG QL (30 caps / 30 days) VYVANSE CAP 70MG QL (30 caps / 30 days) ATTENTION-DEFICIT/HYPERACTIVITY DISORDER (ADHD) AGENTS hcl cap 10 mg (base equiv) QL (30 caps / 30 days) atomoxetine hcl cap 18 mg (base equiv) QL (30 caps / 30 days) atomoxetine hcl cap 25 mg (base equiv) QL (30 caps / 30 days) atomoxetine hcl cap 40 mg (base equiv) QL (30 caps / 30 days) atomoxetine hcl cap 60 mg (base equiv) QL (30 caps / 30 days) atomoxetine hcl cap 80 mg (base equiv) QL (30 caps / 30 days) atomoxetine hcl cap 100 mg (base equiv) QL (30 caps / 30 days) hcl tab er 12hr 0.1 mg QL (120 tabs / 30 days) hcl tab er 24hr 1 mg (base equiv) QL (60 tabs / 30 days)

OTC - Over the counter PA - Prior Authorization; refer to Prior Authorization section QL 6 - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program

Drug Name Requirements/Limits guanfacine hcl tab er 24hr 2 mg (base equiv) QL (60 tabs / 30 days) guanfacine hcl tab er 24hr 3 mg (base equiv) QL (60 tabs / 30 days) guanfacine hcl tab er 24hr 4 mg (base equiv) QL (60 tabs / 30 days) - MISC. tab 50 mg QL (30 tabs / 30 days) armodafinil tab 150 mg QL (30 tabs / 30 days) armodafinil tab 200 mg QL (30 tabs / 30 days) armodafinil tab 250 mg QL (30 tabs / 30 days) hcl cap er 24 hr 5 mg QL (60 caps / 30 days) dexmethylphenidate hcl cap er 24 hr 10 mg QL (60 caps / 30 days) dexmethylphenidate hcl cap er 24 hr 15 mg QL (60 caps / 30 days) dexmethylphenidate hcl cap er 24 hr 20 mg QL (60 caps / 30 days) dexmethylphenidate hcl cap er 24 hr 25 mg QL (60 caps / 30 days) dexmethylphenidate hcl cap er 24 hr 30 mg QL (60 caps / 30 days) dexmethylphenidate hcl cap er 24 hr 35 mg QL (60 caps / 30 days) dexmethylphenidate hcl cap er 24 hr 40 mg QL (60 caps / 30 days) dexmethylphenidate hcl tab 2.5 mg QL (90 tabs / 30 days) dexmethylphenidate hcl tab 5 mg QL (90 tabs / 30 days) dexmethylphenidate hcl tab 10 mg QL (90 tabs / 30 days) hcl cap er 10 mg (cd) QL (60 ea / 30 days) methylphenidate hcl cap er 20 mg (cd) QL (60 caps / 30 days) methylphenidate hcl cap er 24hr 20 mg (la) QL (60 caps / 30 days) methylphenidate hcl cap er 24hr 30 mg (la) QL (60 caps / 30 days) methylphenidate hcl cap er 24hr 40 mg (la) QL (60 caps / 30 days) methylphenidate hcl cap er 30 mg (cd) QL (60 ea / 30 days) methylphenidate hcl cap er 40 mg (cd) QL (60 caps / 30 days) methylphenidate hcl cap er 50 mg (cd) QL (60 caps / 30 days) methylphenidate hcl cap er 60 mg (cd) QL (60 caps / 30 days) methylphenidate hcl chew tab 2.5 mg QL (60 tabs / 30 days) methylphenidate hcl chew tab 5 mg QL (60 tabs / 30 days) methylphenidate hcl chew tab 10 mg QL (60 tabs / 30 days) methylphenidate hcl soln 5 mg/5ml QL (1800 mL / 30 days) methylphenidate hcl soln 10 mg/5ml QL (360 mL / 30 days) methylphenidate hcl tab 5 mg QL (90 tabs / 30 days) methylphenidate hcl tab 10 mg QL (90 tabs / 30 days) methylphenidate hcl tab 20 mg QL (90 tabs / 30 days) methylphenidate hcl tab er 10 mg QL (60 tabs / 30 days) methylphenidate hcl tab er 20 mg QL (60 tabs / 30 days) methylphenidate hcl tab er 24hr 18 mg QL (60 tabs / 30 days) methylphenidate hcl tab er 24hr 27 mg QL (60 tabs / 30 days) methylphenidate hcl tab er 24hr 36 mg QL (60 tabs / 30 days) methylphenidate hcl tab er 24hr 54 mg QL (60 tabs / 30 days) methylphenidate hcl tab er osmotic release (osm) QL (60 ea / 30 days) 18 mg

OTC - Over the counter PA - Prior Authorization; refer to Prior Authorization section QL 7 - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program

Drug Name Requirements/Limits methylphenidate hcl tab er osmotic release (osm) QL (60 ea / 30 days) 27 mg methylphenidate hcl tab er osmotic release (osm) QL (60 ea / 30 days) 36 mg methylphenidate hcl tab er osmotic release (osm) QL (60 ea / 30 days) 54 mg ALLERGENIC EXTRACTS/BIOLOGICALS MISC ALLERGENIC EXTRACTS PALFORZIA CAP ESCALAT PA PALFORZIA CAP LEVEL 1 PA PALFORZIA CAP LEVEL 2 PA PALFORZIA CAP LEVEL 3 PA PALFORZIA CAP LEVEL 4 PA PALFORZIA CAP LEVEL 5 PA PALFORZIA CAP LEVEL 6 PA PALFORZIA CAP LEVEL 7 PA PALFORZIA CAP LEVEL 8 PA PALFORZIA CAP LEVEL 9 PA PALFORZIA CAP LEVEL 10 PA PALFORZIA POW LEVEL 11 PA AMINOGLYCOSIDES sulfate tab 500 mg tobramycin nebu soln 300 mg/5ml PA; SP - ANTI-INFLAMMATORY ANTI-TNF-ALPHA - MONOCLONAL ANTIBODIES HUMIRA INJ 10/0.1ML PA, QL ; SP HUMIRA INJ 10MG/0.2 PA, QL ; SP HUMIRA INJ 20/0.2ML PA, QL ; SP HUMIRA INJ 40/0.4ML PA, QL ; SP HUMIRA KIT 20MG/0.4 PA, QL ; SP HUMIRA KIT 40MG/0.8 PA, QL ; SP HUMIRA PEDIA INJ CROHNS PA, QL ; SP HUMIRA PEN INJ 40/0.4ML PA, QL ; SP HUMIRA PEN INJ 40MG/0.8 PA, QL ; SP HUMIRA PEN KIT CD/UC/HS PA, QL ; SP HUMIRA PEN KIT PS/UV PA, QL ; SP ANTIRHEUMATIC - INHIBITORS RINVOQ TAB 15MG ER PA, QL ; SP XELJANZ SOL 1MG/ML PA, QL (60 mL / 30 days); SP XELJANZ TAB 5MG PA, QL ; SP XELJANZ TAB 10MG PA, QL ; SP

OTC - Over the counter PA - Prior Authorization; refer to Prior Authorization section QL 8 - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program

Drug Name Requirements/Limits XELJANZ XR TAB 11MG PA, QL ; SP XELJANZ XR TAB 22MG PA, QL ; SP INTERLEUKIN-1BETA BLOCKERS ILARIS INJ 150MG PA; SP ILARIS INJ 150MG/ML PA; SP INTERLEUKIN-6 INHIBITORS ACTEMRA INJ 162/0.9 PA, QL ; SP ACTEMRA INJ ACTPEN PA, QL ; SP KEVZARA INJ 150/1.14 PA, QL ; SP KEVZARA INJ 200/1.14 PA, QL ; SP ANTI-INFLAMMATORY AGENTS (NSAIDS) cap 50 mg QL (60 caps / 30 days) celecoxib cap 100 mg QL (60 caps / 30 days) celecoxib cap 200 mg QL (60 caps / 30 days) celecoxib cap 400 mg QL (60 caps / 30 days) diclofenac tab 50 mg diclofenac tab delayed release 25 mg diclofenac sodium tab delayed release 50 mg Rx4L diclofenac sodium tab delayed release 75 mg Rx4L diclofenac sodium tab er 24hr 100 mg etodolac cap 200 mg etodolac cap 300 mg etodolac tab 400 mg etodolac tab 500 mg flurbiprofen tab 50 mg flurbiprofen tab 100 mg susp 100 mg/5ml QL ibuprofen tab 400 mg Rx4L ibuprofen tab 600 mg Rx4L ibuprofen tab 800 mg Rx4L indomethacin cap 25 mg Rx4L indomethacin cap 50 mg indomethacin cap er 75 mg ketoprofen cap 50 mg ketoprofen cap 75 mg ketorolac tromethamine tab 10 mg QL (20 tabs / 30 days) meloxicam tab 7.5 mg Rx4L meloxicam tab 15 mg Rx4L nabumetone tab 500 mg nabumetone tab 750 mg naproxen dr tab 375mg naproxen dr tab 500mg naproxen sodium tab 275 mg naproxen sodium tab 550 mg OTC - Over the counter PA - Prior Authorization; refer to Prior Authorization section QL 9 - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program

Drug Name Requirements/Limits naproxen susp 125 mg/5ml naproxen tab 250 mg naproxen tab 375 mg Rx4L naproxen tab 500 mg Rx4L sulindac tab 150 mg sulindac tab 200 mg PHOSPHODIESTERASE 4 (PDE4) INHIBITORS OTEZLA TAB 10/20/30 PA, QL (55 tabs / 28 days); SP OTEZLA TAB 30MG PA, QL (60 tabs / 30 days); SP PYRIMIDINE SYNTHESIS INHIBITORS leflunomide tab 10 mg SP leflunomide tab 20 mg SP SOLUBLE TUMOR NECROSIS FACTOR RECEPTOR AGENTS ENBREL INJ 25/0.5ML PA, QL ; SP ENBREL INJ 25MG PA, QL ; SP ENBREL INJ 25MG PA, QL ; SP ENBREL INJ 50MG/ML PA, QL ; SP ENBREL MINI INJ 50MG/ML PA, QL ; SP ENBREL SRCLK INJ 50MG/ML PA, QL ; SP ANALGESICS - NONNARCOTIC COMBINATIONS bac tab QL (60 tabs / 30 days) -acetaminophen- cap 50-325-40 QL (60 caps / 30 days) mg butalbital--caffeine cap 50-325-40 mg QL (60 caps / 30 days) butalbital-acetaminophen-caffeine cap 50-300-40 QL (60 caps / 30 days) mg SALICYLATES diflunisal tab 500 mg ANALGESICS – The quantity of opioid products covered (including those that are combined with acetaminophen, aspirin or ibuprofen) will be limited to up to 90 milligram equivalents (MME) per day. For members who are opioid-naïve, first fill will be limited to seven days OPIOID citrate lozenge on a handle 200 mcg PA, QL fentanyl citrate lozenge on a handle 400 mcg PA, QL fentanyl citrate lozenge on a handle 600 mcg PA, QL fentanyl citrate lozenge on a handle 800 mcg PA, QL fentanyl citrate lozenge on a handle 1200 mcg PA, QL fentanyl citrate lozenge on a handle 1600 mcg PA, QL fentanyl td patch 72hr 12 mcg/hr PA, QL

OTC - Over the counter PA - Prior Authorization; refer to Prior Authorization section QL 10 - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program

Drug Name Requirements/Limits fentanyl td patch 72hr 25 mcg/hr PA, QL fentanyl td patch 72hr 50 mcg/hr PA, QL fentanyl td patch 72hr 75 mcg/hr PA, QL fentanyl td patch 72hr 100 mcg/hr PA, QL hcl liqd 1 mg/ml QL hydromorphone hcl tab 2 mg QL hydromorphone hcl tab 4 mg QL hydromorphone hcl tab 8 mg PA, QL hydromorphone hcl tab er 24hr 8 mg PA, QL hydromorphone hcl tab er 24hr 12 mg PA, QL hydromorphone hcl tab er 24hr 16 mg PA, QL hydromorphone hcl tab er 24hr 32 mg PA, QL hcl tab 5 mg PA, QL methadone hcl tab 10 mg PA, QL morphine sulfate oral soln 10 mg/5ml QL morphine sulfate oral soln 20 mg/5ml QL morphine sulfate oral soln 100 mg/5ml (20 mg/ml) QL morphine sulfate suppos 5 mg QL morphine sulfate suppos 10 mg QL morphine sulfate suppos 20 mg QL MORPHINE SULFATE SUPPOS 30 MG QL morphine sulfate tab 15 mg QL morphine sulfate tab 30 mg PA, QL morphine sulfate tab er 15 mg PA, QL morphine sulfate tab er 30 mg PA, QL morphine sulfate tab er 60 mg PA, QL NUCYNTA ER TAB 50MG PA, QL NUCYNTA ER TAB 100MG PA, QL NUCYNTA ER TAB 150MG PA, QL NUCYNTA ER TAB 200MG PA, QL NUCYNTA ER TAB 250MG PA, QL NUCYNTA TAB 50MG PA NUCYNTA TAB 75MG PA NUCYNTA TAB 100MG PA hcl cap 5 mg QL oxycodone hcl soln 5 mg/5ml QL oxycodone hcl tab 5 mg QL oxycodone hcl tab 10 mg QL oxycodone hcl tab 15 mg PA, QL oxycodone hcl tab 20 mg PA, QL oxycodone hcl tab 30 mg PA, QL oxycodone hcl tab er 12hr deter 10 mg PA, QL oxycodone hcl tab er 12hr deter 20 mg PA, QL oxycodone hcl tab er 12hr deter 40 mg PA, QL

OTC - Over the counter PA - Prior Authorization; refer to Prior Authorization section QL 11 - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program

Drug Name Requirements/Limits oxycodone hcl tab er 12hr deter 80 mg PA, QL hcl tab 5 mg PA, QL oxymorphone hcl tab 10 mg PA, QL oxymorphone hcl tab er 12hr 5 mg PA, QL oxymorphone hcl tab er 12hr 7.5 mg PA, QL oxymorphone hcl tab er 12hr 10 mg PA, QL oxymorphone hcl tab er 12hr 15 mg PA, QL oxymorphone hcl tab er 12hr 20 mg PA, QL oxymorphone hcl tab er 12hr 30 mg PA, QL oxymorphone hcl tab er 12hr 40 mg PA, QL hcl tab 50 mg QL tramadol hcl tab er 24hr 100 mg QL tramadol hcl tab er 24hr 200 mg QL tramadol hcl tab er 24hr 300 mg QL OPIOID COMBINATIONS acetaminophen w/ soln 120-12 mg/5ml QL acetaminophen w/ codeine tab 300-15 mg QL acetaminophen w/ codeine tab 300-30 mg QL acetaminophen w/ codeine tab 300-60 mg QL butalbital-acetaminophen-caff w/ cod cap 50-325- QL 40-30 mg -acetaminophen soln 7.5-325 QL mg/15ml hydrocodone-acetaminophen tab 5-325 mg QL hydrocodone-acetaminophen tab 7.5-325 mg QL hydrocodone-acetaminophen tab 10-325 mg QL hydrocodone-ibuprofen tab 7.5-200 mg QL oxycodone w/ acetaminophen tab 2.5-325 mg QL oxycodone w/ acetaminophen tab 5-325 mg QL oxycodone w/ acetaminophen tab 7.5-325 mg QL oxycodone w/ acetaminophen tab 10-325 mg QL oxycodone-aspirin tab 4.8355-325 mg QL oxycodone-ibuprofen tab 5-400 mg QL tramadol-acetaminophen tab 37.5-325 mg QL OPIOID PARTIAL AGONISTS hcl sl tab 2 mg (base equiv) QL (90 tabs / 30 days) buprenorphine hcl sl tab 8 mg (base equiv) QL (90 tabs / 30 days) buprenorphine hcl- hcl sl film 2-0.5 mg QL (90 films / 30 days) (base equiv) buprenorphine hcl-naloxone hcl sl film 4-1 mg QL (90 films / 30 days) (base equiv) buprenorphine hcl-naloxone hcl sl film 8-2 mg QL (90 films / 30 days) (base equiv)

OTC - Over the counter PA - Prior Authorization; refer to Prior Authorization section QL 12 - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program

Drug Name Requirements/Limits buprenorphine hcl-naloxone hcl sl film 12-3 mg QL (60 films / 30 days) (base equiv) buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg QL (90 tabs / 30 days) (base equiv) buprenorphine hcl-naloxone hcl sl tab 8-2 mg QL (90 tabs / 30 days) (base equiv) buprenorphine td patch weekly 5 mcg/hr QL buprenorphine td patch weekly 10 mcg/hr QL buprenorphine td patch weekly 15 mcg/hr QL buprenorphine td patch weekly 20 mcg/hr QL ZUBSOLV SUB 0.7-0.18 QL (90 tabs / 30 days) ZUBSOLV SUB 1.4-0.36 QL (90 tabs / 30 days) ZUBSOLV SUB 2.9-0.71 QL (90 tabs / 30 days) ZUBSOLV SUB 5.7-1.4 QL (90 tabs / 30 days) ZUBSOLV SUB 8.6-2.1 QL (60 tabs / 30 days) ZUBSOLV SUB 11.4-2.9 QL (30 tabs / 30 days) -ANABOLIC ANDROGENS ANDRODERM DIS 2MG/24HR PA, QL (30 patches / 30 days) ANDRODERM DIS 4MG/24HR PA, QL (30 patches / 30 days) cap 50 mg danazol cap 100 mg danazol cap 200 mg cypionate im inj in oil 100 mg/ml im inj in oil 200 mg/ml im inj in oil 200 mg/ml testosterone td gel 12.5 mg/act (1%) PA, QL (300 gm / 30 days) testosterone td gel 20.25 mg/1.25gm (1.62%) PA, QL (300 gm / 30 days) testosterone td gel 20.25 mg/act (1.62%) PA, QL (150 gm / 30 days) testosterone td gel 25 mg/2.5gm (1%) PA, QL (300 gm / 30 days) testosterone td gel 40.5 mg/2.5gm (1.62%) PA, QL (300 gm / 30 days) testosterone td gel 50 mg/5gm (1%) PA, QL (300 gm / 30 days) ANORECTAL AGENTS INTRARECTAL CORTIFOAM AER 90MG enema 100 mg/60ml RECTAL STEROIDS hydrocortisone perianal cream 1% hydrocortisone perianal cream 2.5% ANTHELMINTICS albendazole tab 200 mg QL (4 tabs / 30 days)

OTC - Over the counter PA - Prior Authorization; refer to Prior Authorization section QL 13 - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program

Drug Name Requirements/Limits tab 3 mg QL (20 tabs / 30 days) ANTI-INFECTIVE AGENTS - MISC. ANTI-INFECTIVE AGENTS - MISC. AEMCOLO TAB 194MG PA cap 375 mg metronidazole tab 250 mg metronidazole tab 500 mg tab 100 mg XIFAXAN TAB 200MG PA XIFAXAN TAB 550MG PA ANTI-INFECTIVE MISC. - COMBINATIONS -trimethoprim susp 200-40 mg/5ml sulfamethoxazole-trimethoprim tab 400-80 mg sulfamethoxazole-trimethoprim tab 800-160 mg AGENTS susp 750 mg/5ml QL (100 mL / 30 days) GLYCOPEPTIDES vancomycin hcl cap 125 mg (base equivalent) QL (56 caps / 30 days) vancomycin hcl cap 250 mg (base equivalent) QL (56 caps / 30 days) LEPROSTATICS tab 25 mg dapsone tab 100 mg LINCOSAMIDES hcl cap 150 mg clindamycin hcl cap 300 mg clindamycin palmitate hcl for soln 75 mg/5ml (base equiv) OXAZOLIDINONES for susp 100 mg/5ml QL (840 mL / year) linezolid tab 600 mg QL (56 ea / year) AGENTS -OTHER tab er 12hr 500 mg ranolazine tab er 12hr 1000 mg tab 5 mg isosorbide dinitrate tab 10 mg isosorbide dinitrate tab 20 mg isosorbide dinitrate tab 30 mg isosorbide dinitrate tab er 40 mg tab 10 mg isosorbide mononitrate tab 20 mg

OTC - Over the counter PA - Prior Authorization; refer to Prior Authorization section QL 14 - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program

Drug Name Requirements/Limits isosorbide mononitrate tab er 24hr 30 mg isosorbide mononitrate tab er 24hr 60 mg isosorbide mononitrate tab er 24hr 120 mg NITRO-BID OIN 2% nitroglycerin cap er 6.5 mg nitroglycerin cap er 9 mg nitroglycerin sl tab 0.3 mg nitroglycerin sl tab 0.4 mg nitroglycerin sl tab 0.6 mg nitroglycerin td patch 24hr 0.1 mg/hr nitroglycerin td patch 24hr 0.2 mg/hr nitroglycerin td patch 24hr 0.4 mg/hr nitroglycerin td patch 24hr 0.6 mg/hr ANTIANXIETY AGENTS ANTIANXIETY AGENTS - MISC. hcl tab 5 mg Rx4L buspirone hcl tab 7.5 mg buspirone hcl tab 10 mg Rx4L buspirone hcl tab 15 mg buspirone hcl tab 30 mg hcl syrup 10 mg/5ml hydroxyzine hcl tab 10 mg hydroxyzine hcl tab 25 mg hydroxyzine hcl tab 50 mg hydroxyzine pamoate cap 25 mg hydroxyzine pamoate cap 50 mg hydroxyzine pamoate cap 100 mg orally disintegrating tab 0.5 mg QL (150 ea / 30 days); PA if < 18 yoa alprazolam orally disintegrating tab 0.25 mg QL (150 ea / 30 days); PA if < 18 yoa alprazolam orally disintegrating tab 1 mg QL (150 ea / 30 days); PA if < 18 yoa alprazolam orally disintegrating tab 2 mg QL (150 ea / 30 days); PA if < 18 yoa alprazolam tab 0.5 mg QL (150 tabs / 30 days); PA if < 18 yoa alprazolam tab 0.5mg xr QL (60 tabs / 30 days); PA if < 18 yoa alprazolam tab 0.25 mg QL (150 tabs / 30 days); PA if < 18 yoa alprazolam tab 1 mg QL (150 tabs / 30 days); PA if < 18 yoa

OTC - Over the counter PA - Prior Authorization; refer to Prior Authorization section QL 15 - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program

Drug Name Requirements/Limits alprazolam tab 1mg xr QL (60 tabs / 30 days); PA if < 18 yoa alprazolam tab 2 mg QL (150 tabs / 30 days); PA if < 18 yoa alprazolam tab 2mg xr QL (60 tabs / 30 days); PA if < 18 yoa alprazolam tab 3mg xr QL (60 tabs / 30 days); PA if < 18 yoa chlordiazepoxide hcl cap 5 mg chlordiazepoxide hcl cap 10 mg chlordiazepoxide hcl cap 25 mg oral soln 1 mg/ml QL (1200 mL / 30 days) diazepam tab 2 mg QL (120 ea / 30 days) diazepam tab 5 mg QL (120 ea / 30 days) diazepam tab 10 mg QL (120 ea / 30 days) conc 2 mg/ml QL (150 mL / 30 days) lorazepam tab 0.5 mg QL (150 ea / 30 days) lorazepam tab 1 mg QL (150 ea / 30 days) lorazepam tab 2 mg QL (150 ea / 30 days) cap 10 mg QL (120 caps / 30 days) oxazepam cap 15 mg QL (120 caps / 30 days) oxazepam cap 30 mg QL (120 caps / 30 days) ANTIARRHYTHMICS ANTIARRHYTHMICS TYPE I-A phosphate cap 100 mg disopyramide phosphate cap 150 mg NORPACE CAP 100MG CR ANTIARRHYTHMICS TYPE I-C tab 50 mg flecainide acetate tab 100 mg flecainide acetate tab 150 mg hcl cap er 12hr 225 mg propafenone hcl cap er 12hr 325 mg propafenone hcl cap er 12hr 425 mg propafenone hcl tab 150 mg propafenone hcl tab 225 mg propafenone hcl tab 300 mg ANTIARRHYTHMICS TYPE III hcl tab 200 mg amiodarone hcl tab 400 mg cap 125 mcg (0.125 mg) SP dofetilide cap 250 mcg (0.25 mg) SP dofetilide cap 500 mcg (0.5 mg) SP

OTC - Over the counter PA - Prior Authorization; refer to Prior Authorization section QL 16 - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program

Drug Name Requirements/Limits ANTIASTHMATIC AND AGENTS ANTI-INFLAMMATORY AGENTS cromolyn sodium soln nebu 20 mg/2ml QL (240 mL / 30 days) ANTIASTHMATIC - MONOCLONAL ANTIBODIES XOLAIR INJ 75/0.5 PA; SP XOLAIR INJ 150MG/ML PA; SP XOLAIR SOL 150MG PA; SP - ATROVENT HFA AER 17MCG QL (2 / 30 days) INCRUSE ELPT INH 62.5MCG ipratropium inhal soln 0.02% Rx4L SPIRIVA AER 1.25MCG QL (1 / 30 days) SPIRIVA SPR 2.5MCG QL (1 inhaler / 30 days) MODULATORS sodium chew tab 4 mg (base equiv) montelukast sodium chew tab 5 mg (base equiv) montelukast sodium oral granules packet 4 mg (base equiv) montelukast sodium tab 10 mg (base equiv) Rx4L ALVESCO AER 80MCG QL (1 inhaler / 30 days) ALVESCO AER 160MCG QL (1 inhaler / 30 days) ARNUITY ELPT INH 50MCG QL (1 inhaler / 30 days) ARNUITY ELPT INH 100MCG QL (1 inhaler / 30 days) ARNUITY ELPT INH 200MCG QL (1 inhaler / 30 days) ASMANEX 30 AER 110MCG QL (1 inhaler / 30 days) ASMANEX 120 AER 220MCG QL (1 inhaler / 30 days) ASMANEX HFA AER 50MCG QL (1 inhaler / 30 days) ASMANEX HFA AER 100 MCG QL (1 inhaler / 30 days) ASMANEX HFA AER 200 MCG QL (1 inhaler / 30 days) inhalation susp 0.5 mg/2ml QL (120 mL / 30 days) budesonide inhalation susp 0.25 mg/2ml QL (120 mL / 30 days) budesonide inhalation susp 1 mg/2ml QL (120 mL / 30 days) FLOVENT DISK AER 50MCG QL (1 Diskus / 30 days) FLOVENT DISK AER 100MCG QL (1 Diskus / 30 days) FLOVENT DISK AER 250MCG QL (1 Diskus / 30 days) FLOVENT HFA AER 44MCG QL (1 inhaler / 30 days) FLOVENT HFA AER 110MCG QL (1 inhaler / 30 days) FLOVENT HFA AER 220MCG QL (1 inhaler / 30 days) PULMICORT INH 90MCG QL (1 inhaler / 30 days) PULMICORT INH 180MCG QL (1 inhaler / 30 days) QVAR AER 40MCG QL (1 inhaler / 30 days) QVAR AER 80MCG QL (1 inhaler / 30 days)

OTC - Over the counter PA - Prior Authorization; refer to Prior Authorization section QL 17 - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program

Drug Name Requirements/Limits QVAR REDIHA AER 80MCG QL (1 inhaler / 30 days) QVAR REDIHAL AER 40MCG QL (1 inhaler / 30 days) SYMPATHOMIMETICS albuterol sulfate inhal aero 108 mcg/act (90mcg QL (2 inhalers / 30 days) base equiv) albuterol sulfate soln nebu 0.5% (5 mg/ml) QL (60 mL / 30 days) albuterol sulfate soln nebu 0.63 mg/3ml (base QL (375 mL / 30 days) equiv) albuterol sulfate soln nebu 0.083% (2.5 mg/3ml) QL (375 mL / 30 days); Rx4L albuterol sulfate soln nebu 1.25 mg/3ml (base QL (375 mL / 30 days) equiv) albuterol sulfate syrup 2 mg/5ml albuterol sulfate tab 2 mg albuterol sulfate tab 4 mg albuterol sulfate tab er 12hr 4 mg albuterol sulfate tab er 12hr 8 mg ANORO ELLIPT AER 62.5-25 QL (1 inhaler / 30 days) budesonide- fumarate dihyd aerosol 80- QL (1 inhaler / 30 days) 4.5 mcg/act budesonide-formoterol fumarate dihyd aerosol QL (1 inhaler / 30 days) 160-4.5 mcg/act COMBIVENT AER 20-100 QL (1 inhaler / 30 days) - aer powder ba 55-14 QL (1 inhaler / 30 days) mcg/act fluticasone-salmeterol aer powder ba 100-50 QL (1 inhaler / 30 days) mcg/dose fluticasone-salmeterol aer powder ba 113-14 QL (1 inhaler / 30 days) mcg/act fluticasone-salmeterol aer powder ba 232-14 QL (1 inhaler / 30 days) mcg/act fluticasone-salmeterol aer powder ba 250-50 QL (1 inhaler / 30 days) mcg/dose fluticasone-salmeterol aer powder ba 500-50 QL (1 inhaler / 30 days) mcg/dose ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml QL (540 mL / 30 days) levalbuterol tartrate inhal aerosol 45 mcg/act QL (2 inhalers / 30 days) (base equiv) SEREVENT DIS AER 50MCG QL (1 Diskus / 30 days); PA under 40 years old STIOLTO AER 2.5-2.5 QL (1 inhaler / 30 days) sulfate tab 2.5 mg terbutaline sulfate tab 5 mg TRELEGY AER ELLIPTA QL (1 inhaler / 30 days) VENTOLIN HFA AER QL (2 inhalers / 30 days)

OTC - Over the counter PA - Prior Authorization; refer to Prior Authorization section QL 18 - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program

Drug Name Requirements/Limits wixela inhub aer 100/50 QL (1 inhaler / 30 days) wixela inhub aer 250/50 QL (1 inhaler / 30 days) wixela inhub aer 500/50 QL (1 inhaler / 30 days) ELIXOPHYLLIN ELX 80/15ML THEO-24 CAP 100MG CR THEO-24 CAP 200MG CR THEO-24 CAP 300MG CR THEO-24 CAP 400MG ER soln 80 mg/15ml theophylline tab er 12hr 100 mg theophylline tab er 12hr 200 mg theophylline tab er 12hr 300 mg theophylline tab er 12hr 450 mg theophylline tab er 24hr 400 mg theophylline tab er 24hr 600 mg ANTICOAGULANTS sodium tab 1 mg Rx4L warfarin sodium tab 2 mg Rx4L warfarin sodium tab 2.5 mg Rx4L warfarin sodium tab 3 mg Rx4L warfarin sodium tab 4 mg Rx4L warfarin sodium tab 5 mg Rx4L warfarin sodium tab 6 mg Rx4L warfarin sodium tab 7.5 mg Rx4L warfarin sodium tab 10 mg Rx4L DIRECT FACTOR XA INHIBITORS ELIQUIS TAB 2.5MG ELIQUIS TAB 5MG XARELTO STAR TAB 15/20MG XARELTO TAB 2.5MG XARELTO TAB 10MG XARELTO TAB 15MG XARELTO TAB 20MG AND -LIKE AGENTS inj 30 mg/0.3ml QL (60 syringes / 30 days) enoxaparin sodium inj 40 mg/0.4ml QL (60 syringes / 30 days) enoxaparin sodium inj 60 mg/0.6ml QL (60 syringes / 30 days) enoxaparin sodium inj 80 mg/0.8ml QL (60 syringes / 30 days) enoxaparin sodium inj 100 mg/ml QL (60 syringes / 30 days) enoxaparin sodium inj 120 mg/0.8ml QL (60 syringes / 30 days) enoxaparin sodium inj 150 mg/ml QL (60 syringes / 30 days)

OTC - Over the counter PA - Prior Authorization; refer to Prior Authorization section QL 19 - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program

Drug Name Requirements/Limits enoxaparin sodium inj 300 mg/3ml sodium subcutaneous inj 2.5 QL (15 mL / 180 days) mg/0.5ml fondaparinux sodium subcutaneous inj 5 mg/0.4ml QL (12 mL / 180 days) fondaparinux sodium subcutaneous inj 7.5 QL (18 mL / 180 days) mg/0.6ml fondaparinux sodium subcutaneous inj 10 QL (24 mL / 180 days) mg/0.8ml sodium (porcine) inj 5000 unit/ml ANTICONVULSANTS - BENZODIAZEPINES suspension 2.5 mg/ml clobazam tab 10 mg clobazam tab 20 mg orally disintegrating tab 0.5 mg QL (300 tabs / 30 days) clonazepam orally disintegrating tab 0.25 mg QL (300 tabs / 30 days) clonazepam orally disintegrating tab 0.125 mg QL (300 tabs / 30 days) clonazepam orally disintegrating tab 1 mg QL (300 tabs / 30 days) clonazepam orally disintegrating tab 2 mg QL (300 tabs / 30 days) clonazepam tab 0.5 mg QL (300 ea / 30 days) clonazepam tab 1 mg QL (300 ea / 30 days) clonazepam tab 2 mg QL (300 ea / 30 days) diazepam rectal gel delivery system 2.5 mg diazepam rectal gel delivery system 10 mg diazepam rectal gel delivery system 20 mg NAYZILAM SPR 5MG QL (4 bottles / 30 days); PA if > 12 yoa VALTOCO LIQ 15MG QL (2 doses (1 carton) / 30 days); PA if > 6 yoa VALTOCO LIQ 20MG QL (2 doses (1 carton) / 30 days); PA if > 6 yoa VALTOCO SPR 5MG QL (2 doses (1 carton) / 30 days); PA if > 6 yoa VALTOCO SPR 10MG QL (2 doses (1 carton) / 30 days); PA if > 6 yoa ANTICONVULSANTS - MISC. BANZEL TAB 200MG PA BANZEL TAB 400MG PA cap er 12hr 100 mg carbamazepine cap er 12hr 200 mg carbamazepine cap er 12hr 300 mg carbamazepine chew tab 100 mg carbamazepine susp 100 mg/5ml carbamazepine tab 200 mg

OTC - Over the counter PA - Prior Authorization; refer to Prior Authorization section QL 20 - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program

Drug Name Requirements/Limits carbamazepine tab er 12hr 100 mg carbamazepine tab er 12hr 200 mg carbamazepine tab er 12hr 400 mg FINTEPLA SOL 2.2MG/ML PA; SP cap 100 mg QL (480 caps / 30 days) gabapentin cap 300 mg QL (480 caps / 30 days) gabapentin cap 400 mg QL (480 caps / 30 days) gabapentin oral soln 250 mg/5ml gabapentin tab 600 mg QL (480 ea / 30 days) gabapentin tab 800 mg QL (480 ea / 30 days) orally disintegrating tab 25 mg lamotrigine orally disintegrating tab 50 mg lamotrigine orally disintegrating tab 100 mg lamotrigine orally disintegrating tab 200 mg lamotrigine tab 25 mg lamotrigine tab 100 mg lamotrigine tab 150 mg lamotrigine tab 200 mg lamotrigine tab chewable dispersible 5 mg lamotrigine tab chewable dispersible 25 mg oral soln 100 mg/ml levetiracetam tab 250 mg levetiracetam tab 500 mg levetiracetam tab 750 mg levetiracetam tab 1000 mg levetiracetam tab er 24hr 500 mg levetiracetam tab er 24hr 750 mg susp 300 mg/5ml (60 mg/ml) oxcarbazepine tab 150 mg oxcarbazepine tab 300 mg oxcarbazepine tab 600 mg cap 25 mg QL (90 caps / 30 days) pregabalin cap 50 mg QL (90 caps / 30 days) pregabalin cap 75 mg QL (90 caps / 30 days) pregabalin cap 100 mg QL (90 caps / 30 days) pregabalin cap 150 mg QL (90 caps / 30 days) pregabalin cap 200 mg QL (90 caps / 30 days) pregabalin cap 225 mg QL (60 caps / 30 days) pregabalin cap 300 mg QL (60 caps / 30 days) pregabalin soln 20 mg/ml PA, QL (900 mL / 30 days) tab 50 mg primidone tab 250 mg susp 40 mg/ml PA sprinkle cap 15 mg

OTC - Over the counter PA - Prior Authorization; refer to Prior Authorization section QL 21 - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program

Drug Name Requirements/Limits topiramate sprinkle cap 25 mg topiramate tab 25 mg topiramate tab 50 mg topiramate tab 100 mg topiramate tab 200 mg VIMPAT SOL 10MG/ML PA VIMPAT TAB 50MG PA VIMPAT TAB 100MG PA VIMPAT TAB 150MG PA VIMPAT TAB 200MG PA cap 25 mg zonisamide cap 50 mg zonisamide cap 100 mg GABA MODULATORS hcl tab 2 mg tiagabine hcl tab 4 mg tiagabine hcl tab 12 mg tiagabine hcl tab 16 mg powd pack 500 mg PA; SP vigabatrin tab 500 mg PA; SP DILANTIN CAP 30MG chew tab 50 mg phenytoin sodium extended cap 100 mg phenytoin sodium extended cap 200 mg phenytoin sodium extended cap 300 mg phenytoin susp 125 mg/5ml cap 250 mg ethosuximide soln 250 mg/5ml VALPROIC divalproex sodium cap delayed release sprinkle 125 mg divalproex sodium tab delayed release 125 mg divalproex sodium tab delayed release 250 mg divalproex sodium tab delayed release 500 mg divalproex sodium tab er 24 hr 250 mg divalproex sodium tab er 24 hr 500 mg sodium oral soln 250 mg/5ml (base equiv) valproic acid cap 250 mg

OTC - Over the counter PA - Prior Authorization; refer to Prior Authorization section QL 22 - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program

Drug Name Requirements/Limits ALPHA-2 RECEPTOR ANTAGONISTS () orally disintegrating tab 15 mg mirtazapine orally disintegrating tab 30 mg mirtazapine orally disintegrating tab 45 mg mirtazapine tab 7.5 mg mirtazapine tab 15 mg mirtazapine tab 30 mg mirtazapine tab 45 mg ANTIDEPRESSANTS - MISC. hcl tab 75 mg bupropion hcl tab 100 mg bupropion hcl tab er 12hr 100 mg bupropion hcl tab er 12hr 150 mg bupropion hcl tab er 12hr 200 mg bupropion hcl tab er 24hr 150 mg bupropion hcl tab er 24hr 300 mg INHIBITORS (MAOIS) MARPLAN TAB 10MG sulfate tab 15 mg sulfate tab 10 mg SELECTIVE INHIBITORS (SSRIS) hydrobromide oral soln 10 mg/5ml citalopram hydrobromide tab 10 mg (base equiv) citalopram hydrobromide tab 20 mg (base equiv) Rx4L citalopram hydrobromide tab 40 mg (base equiv) Rx4L soln 5 mg/5ml (base equiv) escitalopram oxalate tab 5 mg (base equiv) escitalopram oxalate tab 10 mg (base equiv) Rx4L escitalopram oxalate tab 20 mg (base equiv) Rx4L hcl cap 10 mg Rx4L fluoxetine hcl cap 20 mg Rx4L fluoxetine hcl cap 40 mg fluoxetine hcl solution 20 mg/5ml maleate tab 25 mg fluvoxamine maleate tab 50 mg fluvoxamine maleate tab 100 mg hcl tab 10 mg Rx4L paroxetine hcl tab 20 mg Rx4L paroxetine hcl tab 30 mg paroxetine hcl tab 40 mg paroxetine hcl tab er 24hr 12.5 mg paroxetine hcl tab er 24hr 25 mg

OTC - Over the counter PA - Prior Authorization; refer to Prior Authorization section QL 23 - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program

Drug Name Requirements/Limits paroxetine hcl tab er 24hr 37.5 mg PAXIL SUS 10MG/5ML hcl oral concentrate for solution 20 mg/ml sertraline hcl tab 25 mg Rx4L sertraline hcl tab 50 mg Rx4L sertraline hcl tab 100 mg Rx4L SEROTONIN MODULATORS hcl tab 50 mg Rx4L trazodone hcl tab 100 mg Rx4L trazodone hcl tab 150 mg Rx4L trazodone hcl tab 300 mg SEROTONIN- REUPTAKE INHIBITORS (SNRIS) succinate tab er 24hr 25 mg (base QL (30 tabs / 30 days) equiv) desvenlafaxine succinate tab er 24hr 50 mg (base QL (30 tabs / 30 days) equiv) desvenlafaxine succinate tab er 24hr 100 mg QL (30 tabs / 30 days) (base equiv) hcl enteric coated pellets cap 20 mg QL (60 caps / 30 days) (base eq) duloxetine hcl enteric coated pellets cap 30 mg QL (60 caps / 30 days) (base eq) duloxetine hcl enteric coated pellets cap 60 mg QL (60 caps / 30 days) (base eq) hcl cap er 24hr 37.5 mg (base Rx4L equivalent) venlafaxine hcl cap er 24hr 75 mg (base Rx4L equivalent) venlafaxine hcl cap er 24hr 150 mg (base Rx4L equivalent) venlafaxine hcl tab 25 mg (base equivalent) venlafaxine hcl tab 37.5 mg (base equivalent) venlafaxine hcl tab 50 mg (base equivalent) venlafaxine hcl tab 75 mg (base equivalent) venlafaxine hcl tab 100 mg (base equivalent) AGENTS hcl tab 10 mg amitriptyline hcl tab 25 mg amitriptyline hcl tab 50 mg amitriptyline hcl tab 75 mg amitriptyline hcl tab 100 mg amitriptyline hcl tab 150 mg tab 25 mg amoxapine tab 50 mg

OTC - Over the counter PA - Prior Authorization; refer to Prior Authorization section QL 24 - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program

Drug Name Requirements/Limits amoxapine tab 100 mg amoxapine tab 150 mg hcl cap 25 mg clomipramine hcl cap 50 mg clomipramine hcl cap 75 mg hcl tab 10 mg desipramine hcl tab 25 mg desipramine hcl tab 50 mg desipramine hcl tab 75 mg desipramine hcl tab 100 mg desipramine hcl tab 150 mg hcl cap 10 mg doxepin hcl cap 25 mg doxepin hcl cap 50 mg doxepin hcl cap 75 mg doxepin hcl cap 100 mg doxepin hcl cap 150 mg doxepin hcl conc 10 mg/ml hcl tab 10 mg imipramine hcl tab 25 mg imipramine hcl tab 50 mg hcl cap 10 mg Rx4L nortriptyline hcl cap 25 mg Rx4L nortriptyline hcl cap 50 mg nortriptyline hcl cap 75 mg nortriptyline hcl soln 10 mg/5ml hcl tab 5 mg protriptyline hcl tab 10 mg ANTIDIABETICS ALPHA-GLUCOSIDASE INHIBITORS acarbose tab 25 mg acarbose tab 50 mg acarbose tab 100 mg ANTIDIABETIC - ANALOGS SYMLINPEN 60 INJ 1000MCG PA SYMLNPEN 120 INJ 1000MCG PA ANTIDIABETIC COMBINATIONS alogliptin- hcl tab 12.5-500 mg QL (60 tabs / 30 days) alogliptin-metformin hcl tab 12.5-1000 mg QL (60 tabs / 30 days) -metformin hcl tab 2.5-250 mg glipizide-metformin hcl tab 2.5-500 mg glipizide-metformin hcl tab 5-500 mg glyburide-metformin tab 1.25-250 mg

OTC - Over the counter PA - Prior Authorization; refer to Prior Authorization section QL 25 - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program

Drug Name Requirements/Limits glyburide-metformin tab 2.5-500 mg glyburide-metformin tab 5-500 mg GLYXAMBI TAB 10-5 MG QL (30 tabs / 30 days) GLYXAMBI TAB 25-5 MG QL (30 tabs / 30 days) INVOKAMET TAB 50-500MG QL (60 tabs / 30 days) INVOKAMET TAB 50-1000 QL (60 tabs / 30 days) INVOKAMET TAB 150-500 QL (60 tabs / 30 days) INVOKAMET TAB 150-1000 QL (60 tabs / 30 days) JANUMET TAB 50-500MG JANUMET TAB 50-1000 JENTADUETO TAB 2.5-500 JENTADUETO TAB 2.5-850 JENTADUETO TAB 2.5-1000 JENTADUETO TAB XR pioglitazone hcl- tab 30-2 mg pioglitazone hcl-glimepiride tab 30-4 mg pioglitazone hcl-metformin hcl tab 15-500 mg pioglitazone hcl-metformin hcl tab 15-850 mg SYNJARDY TAB SYNJARDY TAB 5-500MG SYNJARDY TAB 5-1000MG SYNJARDY TAB 12.5-500 BIGUANIDES metformin hcl tab 500 mg Rx4L metformin hcl tab 850 mg Rx4L metformin hcl tab 1000 mg Rx4L metformin hcl tab er 24hr 500 mg Rx4L metformin hcl tab er 24hr 750 mg Rx4L DIABETIC OTHER BAQSIMI ONE POW 3MG/DOSE QL (2 ea / 30 days) GLUCAGEN INJ HYPOKIT QL (2 syringes / 30 days) KIT 1MG QL (2 kits / 30 days) KORLYM TAB 300MG PA DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS alogliptin benzoate tab 6.25 mg (base equiv) QL (30 tabs / 30 days) alogliptin benzoate tab 12.5 mg (base equiv) QL (30 tabs / 30 days) alogliptin benzoate tab 25 mg (base equiv) QL (30 tabs / 30 days) JANUVIA TAB 25MG JANUVIA TAB 50MG JANUVIA TAB 100MG TRADJENTA TAB 5MG MIMETIC AGENTS (GLP-1 RECEPTOR AGONISTS) OZEMPIC INJ 2/1.5ML

OTC - Over the counter PA - Prior Authorization; refer to Prior Authorization section QL 26 - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program

Drug Name Requirements/Limits RYBELSUS TAB 3MG RYBELSUS TAB 7MG RYBELSUS TAB 14MG TRULICITY INJ 0.75/0.5 TRULICITY INJ 1.5/0.5 TRULICITY INJ 3/0.5 TRULICITY INJ 4.5/0.5 VICTOZA INJ 18MG/3ML ADMELOG INJ 100U/ML ADMELOG SOLO INJ 100U/ML BASAGLAR INJ 100UNIT HUMALOG MIX INJ 50/50 HUMALOG MIX INJ 50/50KWP HUMALOG MIX INJ 75/25KWP HUMALOG MIX SUS 75/25 HUMULIN INJ 70/30 OTC HUMULIN INJ 70/30KWP OTC HUMULIN N INJ U-100 OTC HUMULIN N INJ U-100KWP OTC HUMULIN R INJ U-100 OTC HUMULIN R INJ U-500 HUMULIN R INJ U-500 QL (6 pens / 30 days); Kwikpen Formulation NOVOLIN INJ 70/30 OTC NOVOLIN INJ 70/30 FP OTC NOVOLIN N INJ U-100 OTC NOVOLIN R INJ U-100 OTC NOVOLOG MIX INJ 70/30 NOVOLOG MIX INJ FLEXPEN INSULIN SENSITIZING AGENTS pioglitazone hcl tab 15 mg (base equiv) pioglitazone hcl tab 30 mg (base equiv) pioglitazone hcl tab 45 mg (base equiv) MEGLITINIDE ANALOGUES tab 60 mg nateglinide tab 120 mg tab 0.5 mg repaglinide tab 1 mg repaglinide tab 2 mg SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITORS INVOKANA TAB 100MG QL (30 tabs / 30 days) INVOKANA TAB 300MG QL (30 tabs / 30 days)

OTC - Over the counter PA - Prior Authorization; refer to Prior Authorization section QL 27 - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program

Drug Name Requirements/Limits JARDIANCE TAB 10MG QL (30 tabs / 30 days) JARDIANCE TAB 25MG QL (30 tabs / 30 days) SULFONYLUREAS glimepiride tab 1 mg Rx4L glimepiride tab 2 mg Rx4L glimepiride tab 4 mg Rx4L glipizide tab 5 mg Rx4L glipizide tab 10 mg Rx4L glipizide tab er 24hr 5 mg Rx4L glipizide tab er 24hr 10 mg Rx4L glipizide xl tab 2.5mg Rx4L glyburide micronized tab 1.5 mg glyburide micronized tab 3 mg glyburide micronized tab 6 mg glyburide tab 1.25 mg glyburide tab 2.5 mg glyburide tab 5 mg ANTIDIARRHEALS ANTIPERISTALTIC AGENTS w/ liq 2.5-0.025 mg/5ml diphenoxylate w/ atropine tab 2.5-0.025 mg hcl cap 2 mg QL AND SPECIFIC ANTAGONISTS ANTIDOTES - CHELATING AGENTS FERPRX 2-DAY TAB 1000MG PA OPIOID ANTAGONISTS naloxone hcl soln prefilled syringe 2 mg/2ml hcl tab 50 mg NARCAN SPR VIVITROL INJ 380MG 5-HT3 RECEPTOR ANTAGONISTS hcl tab 1 mg QL (6 ea / 15 days) hcl oral soln 4 mg/5ml QL (100 mL / 15 days) ondansetron hcl tab 4 mg ondansetron hcl tab 8 mg ondansetron hcl tab 24 mg QL (1 ea / 15 days) ondansetron orally disintegrating tab 4 mg ondansetron orally disintegrating tab 8 mg ANTIEMETICS - hcl tab 12.5 mg meclizine hcl tab 25 mg td patch 72hr 1 mg/3days QL (10 patches / 30 days)

OTC - Over the counter PA - Prior Authorization; refer to Prior Authorization section QL 28 - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program

Drug Name Requirements/Limits hcl cap 300 mg ANTIEMETICS - MISCELLANEOUS BONJESTA TAB 20-20MG QL (60 tabs / year) - tab delayed release 10-10 mg cap 2.5 mg PA dronabinol cap 5 mg PA dronabinol cap 10 mg PA SUBSTANCE P/NEUROKININ 1 (NK1) RECEPTOR ANTAGONISTS 40 mg QL (3 caps / 180 days) aprepitant capsule 80 mg QL (2 caps / 15 days) aprepitant capsule 125 mg QL (1 cap / 15 days) aprepitant capsule therapy pack 80 & 125 mg QL (3 caps / 15 days) EMEND SUS 125MG PA, QL (3 kits / 15 days) VARUBI TAB 90MG PA, QL (4 tabs / 30 days) ANTIFUNGALS microsize susp 125 mg/5ml griseofulvin ultramicrosize tab 125 mg griseofulvin ultramicrosize tab 250 mg oral powder nystatin tab 500000 unit hcl tab 250 mg QL (90 tabs / year) -RELATED ANTIFUNGALS for susp 10 mg/ml fluconazole for susp 40 mg/ml fluconazole tab 50 mg fluconazole tab 100 mg fluconazole tab 150 mg fluconazole tab 200 mg cap 100 mg QL (120 caps / 30 days) tab 200 mg SPORANOX SOL 10MG/ML PA for susp 40 mg/ml voriconazole tab 50 mg voriconazole tab 200 mg ANTIHISTAMINES - ETHANOLAMINES fumarate tab 2.68 mg hcl elixir 12.5 mg/5ml QL ANTIHISTAMINES - NON-SEDATING hcl oral soln 1 mg/ml (5 mg/5ml) QL (300 mL / 30 days); QL

OTC - Over the counter PA - Prior Authorization; refer to Prior Authorization section QL 29 - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program

Drug Name Requirements/Limits dihydrochloride soln 2.5 mg/5ml (0.5 mg/ml) levocetirizine dihydrochloride tab 5 mg ANTIHISTAMINES - phenergan sup 12.5mg phenergan sup 25mg phenergan sup 50mg hcl syrup 6.25 mg/5ml promethazine hcl tab 12.5 mg promethazine hcl tab 25 mg promethazine hcl tab 50 mg ANTIHISTAMINES - PIPERIDINES hcl syrup 2 mg/5ml cyproheptadine hcl tab 4 mg ANTIHYPERLIPIDEMICS ANTIHYPERLIPIDEMICS - MISC. icosapent ethyl cap 1 gm omega-3-acid ethyl cap 1 gm SEQUESTRANTS cholestyramine light powder 4 gm/dose cholestyramine light powder packets 4 gm cholestyramine powder 4 gm/dose cholestyramine powder packets 4 gm hcl granule packets 5 gm colestipol hcl granules 5 gm colestipol hcl tab 1 gm FIBRIC ACID DERIVATIVES fenofibrate micronized cap 67 mg fenofibrate micronized cap 134 mg fenofibrate micronized cap 200 mg fenofibrate tab 48 mg fenofibrate tab 54 mg fenofibrate tab 145 mg fenofibrate tab 160 mg gemfibrozil tab 600 mg HMG COA REDUCTASE INHIBITORS atorvastatin tab 10 mg (base equivalent) QL (45 tabs / 30 days); Rx4L atorvastatin calcium tab 20 mg (base equivalent) QL (45 tabs / 30 days); Rx4L atorvastatin calcium tab 40 mg (base equivalent) QL (45 tabs / 30 days); Rx4L

OTC - Over the counter PA - Prior Authorization; refer to Prior Authorization section QL 30 - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program

Drug Name Requirements/Limits atorvastatin calcium tab 80 mg (base equivalent) QL (45 tabs / 30 days); Rx4L tab 10 mg QL (45 tabs / 30 days); Rx4L lovastatin tab 20 mg QL (45 tabs / 30 days); Rx4L lovastatin tab 40 mg QL (45 tabs / 30 days); Rx4L pravastatin sodium tab 10 mg QL (45 tabs / 30 days); Rx4L pravastatin sodium tab 20 mg QL (45 tabs / 30 days); Rx4L pravastatin sodium tab 40 mg QL (45 tabs / 30 days); Rx4L pravastatin sodium tab 80 mg QL (45 tabs / 30 days) calcium tab 5 mg QL (30 tabs / 30 days) rosuvastatin calcium tab 10 mg QL (30 tabs / 30 days) rosuvastatin calcium tab 20 mg QL (30 tabs / 30 days) rosuvastatin calcium tab 40 mg QL (30 tabs / 30 days) tab 5 mg QL (45 tabs / 30 days) simvastatin tab 10 mg QL (45 tabs / 30 days); Rx4L simvastatin tab 20 mg QL (45 tabs / 30 days); Rx4L simvastatin tab 40 mg QL (45 tabs / 30 days); Rx4L simvastatin tab 80 mg QL (45 tabs / 30 days); Rx4L INTESTINAL ABSORPTION INHIBITORS tab 10 mg QL (30 tabs / 30 days) NICOTINIC ACID DERIVATIVES tab er 500 mg (antihyperlipidemic) niacin tab er 750 mg (antihyperlipidemic) niacin tab er 1000 mg (antihyperlipidemic) PROPROTEIN CONVERTASE SUBTILISIN/KEXIN TYPE 9 INHIBITORS REPATHA PUSH INJ 420/3.5 PA REPATHA SURE INJ 140MG/ML PA ANTIHYPERTENSIVES ACE INHIBITORS hcl tab 5 mg Rx4L benazepril hcl tab 10 mg Rx4L benazepril hcl tab 20 mg Rx4L benazepril hcl tab 40 mg Rx4L tab 12.5 mg

OTC - Over the counter PA - Prior Authorization; refer to Prior Authorization section QL 31 - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program

Drug Name Requirements/Limits captopril tab 25 mg captopril tab 50 mg captopril tab 100 mg maleate tab 2.5 mg Rx4L enalapril maleate tab 5 mg Rx4L enalapril maleate tab 10 mg Rx4L enalapril maleate tab 20 mg Rx4L sodium tab 10 mg Rx4L fosinopril sodium tab 20 mg Rx4L fosinopril sodium tab 40 mg Rx4L tab 2.5 mg Rx4L lisinopril tab 5 mg Rx4L lisinopril tab 10 mg Rx4L lisinopril tab 20 mg Rx4L lisinopril tab 30 mg Rx4L lisinopril tab 40 mg Rx4L hcl tab 5 mg Rx4L quinapril hcl tab 10 mg Rx4L quinapril hcl tab 20 mg Rx4L quinapril hcl tab 40 mg Rx4L ramipril cap 1.25 mg Rx4L ramipril cap 2.5 mg Rx4L ramipril cap 5 mg Rx4L ramipril cap 10 mg Rx4L tab 1 mg trandolapril tab 2 mg trandolapril tab 4 mg ANGIOTENSIN II RECEPTOR ANTAGONISTS cilexetil tab 4 mg candesartan cilexetil tab 8 mg candesartan cilexetil tab 16 mg candesartan cilexetil tab 32 mg tab 75 mg Rx4L irbesartan tab 150 mg Rx4L irbesartan tab 300 mg Rx4L potassium tab 25 mg Rx4L losartan potassium tab 50 mg Rx4L losartan potassium tab 100 mg Rx4L medoxomil tab 5 mg olmesartan medoxomil tab 20 mg olmesartan medoxomil tab 40 mg tab 40 mg valsartan tab 80 mg valsartan tab 160 mg

OTC - Over the counter PA - Prior Authorization; refer to Prior Authorization section QL 32 - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program

Drug Name Requirements/Limits valsartan tab 320 mg ANTIADRENERGIC ANTIHYPERTENSIVES clonidine hcl tab 0.1 mg Rx4L clonidine hcl tab 0.2 mg Rx4L clonidine hcl tab 0.3 mg Rx4L clonidine td patch weekly 0.1 mg/24hr clonidine td patch weekly 0.2 mg/24hr clonidine td patch weekly 0.3 mg/24hr mesylate tab 1 mg doxazosin mesylate tab 2 mg doxazosin mesylate tab 4 mg doxazosin mesylate tab 8 mg guanfacine hcl tab 1 mg Rx4L guanfacine hcl tab 2 mg Rx4L tab 250 mg methyldopa tab 500 mg hcl cap 1 mg prazosin hcl cap 2 mg prazosin hcl cap 5 mg hcl cap 1 mg (base equivalent) Rx4L terazosin hcl cap 2 mg (base equivalent) Rx4L terazosin hcl cap 5 mg (base equivalent) Rx4L terazosin hcl cap 10 mg (base equivalent) Rx4L ANTIHYPERTENSIVE COMBINATIONS besylate-benazepril hcl cap 2.5-10 mg amlodipine besylate-benazepril hcl cap 5-10 mg amlodipine besylate-benazepril hcl cap 5-20 mg amlodipine besylate-benazepril hcl cap 5-40 mg amlodipine besylate-benazepril hcl cap 10-20 mg amlodipine besylate-benazepril hcl cap 10-40 mg & chlorthalidone tab 50-25 mg Rx4L atenolol & chlorthalidone tab 100-25 mg Rx4L benazepril & tab 5-6.25 mg benazepril & hydrochlorothiazide tab 10-12.5 mg benazepril & hydrochlorothiazide tab 20-12.5 mg benazepril & hydrochlorothiazide tab 20-25 mg & hydrochlorothiazide tab 2.5-6.25 mg Rx4L bisoprolol & hydrochlorothiazide tab 5-6.25 mg Rx4L bisoprolol & hydrochlorothiazide tab 10-6.25 mg Rx4L enalapril maleate & hydrochlorothiazide tab 5-12.5 Rx4L mg enalapril maleate & hydrochlorothiazide tab 10-25 Rx4L mg

OTC - Over the counter PA - Prior Authorization; refer to Prior Authorization section QL 33 - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program

Drug Name Requirements/Limits fosinopril sodium & hydrochlorothiazide tab 10- 12.5 mg fosinopril sodium & hydrochlorothiazide tab 20- 12.5 mg irbesartan-hydrochlorothiazide tab 150-12.5 mg irbesartan-hydrochlorothiazide tab 300-12.5 mg lisinopril & hydrochlorothiazide tab 10-12.5 mg Rx4L lisinopril & hydrochlorothiazide tab 20-12.5 mg Rx4L lisinopril & hydrochlorothiazide tab 20-25 mg Rx4L losartan potassium & hydrochlorothiazide tab 50- 12.5 mg losartan potassium & hydrochlorothiazide tab 100- 12.5 mg losartan potassium & hydrochlorothiazide tab 100- 25 mg & hydrochlorothiazide tab 50-25 mg metoprolol & hydrochlorothiazide tab 100-25 mg metoprolol & hydrochlorothiazide tab 100-50 mg olmesartan medoxomil-hydrochlorothiazide tab 20- 12.5 mg olmesartan medoxomil-hydrochlorothiazide tab 40- 12.5 mg olmesartan medoxomil-hydrochlorothiazide tab 40- 25 mg olmesartan-amlodipine-hydrochlorothiazide tab 20-5-12.5 mg olmesartan-amlodipine-hydrochlorothiazide tab 40-5-12.5 mg olmesartan-amlodipine-hydrochlorothiazide tab 40-5-25 mg olmesartan-amlodipine-hydrochlorothiazide tab 40-10-12.5 mg olmesartan-amlodipine-hydrochlorothiazide tab 40-10-25 mg quinapril-hydrochlorothiazide tab 10-12.5 mg Rx4L quinapril-hydrochlorothiazide tab 20-12.5 mg Rx4L quinapril-hydrochlorothiazide tab 20-25 mg valsartan-hydrochlorothiazide tab 80-12.5 mg valsartan-hydrochlorothiazide tab 160-12.5 mg valsartan-hydrochlorothiazide tab 160-25 mg valsartan-hydrochlorothiazide tab 320-12.5 mg SELECTIVE RECEPTOR ANTAGONISTS (SARAS) tab 25 mg eplerenone tab 50 mg

OTC - Over the counter PA - Prior Authorization; refer to Prior Authorization section QL 34 - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program

Drug Name Requirements/Limits VASODILATORS hcl tab 10 mg hydralazine hcl tab 25 mg hydralazine hcl tab 50 mg hydralazine hcl tab 100 mg tab 2.5 mg minoxidil tab 10 mg ANTIMALARIALS ANTIMALARIAL COMBINATIONS atovaquone-proguanil hcl tab 62.5-25 mg QL (12 tabs / 180 days) atovaquone-proguanil hcl tab 250-100 mg QL (12 tabs / 180 days) COARTEM TAB 20-120MG QL (24 tabs / 180 days) ANTIMALARIALS chloroquine phosphate tab 250 mg QL (10 tabs / 180 days) chloroquine phosphate tab 500 mg QL (10 tabs / 180 days) hydroxychloroquine sulfate tab 200 mg hcl tab 250 mg QL (6 tabs / 180 days) ANTIMYASTHENIC/ AGENTS ANTIMYASTHENIC/CHOLINERGIC AGENTS pyridostigmine bromide tab 60 mg pyridostigmine bromide tab er 180 mg AGENTS ANTIMYCOBACTERIAL AGENTS ethambutol hcl tab 100 mg ethambutol hcl tab 400 mg syrup 50 mg/5ml isoniazid tab 100 mg isoniazid tab 300 mg PRETOMANID TAB 200MG PA pyrazinamide tab 500 mg cap 150 mg rifampin cap 150 mg rifampin cap 300 mg SIRTURO TAB 20MG PA; SP SIRTURO TAB 100MG PA ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES ALKYLATING AGENTS cap 25 mg cyclophosphamide cap 50 mg HEXALEN CAP 50MG LEUKERAN TAB 2MG lomustine cap 10 mg lomustine cap 40 mg

OTC - Over the counter PA - Prior Authorization; refer to Prior Authorization section QL 35 - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program

Drug Name Requirements/Limits lomustine cap 100 mg melphalan tab 2 mg MYLERAN TAB 2MG cap 5 mg PA; SP temozolomide cap 20 mg PA; SP temozolomide cap 100 mg PA; SP temozolomide cap 140 mg PA; SP temozolomide cap 180 mg PA; SP temozolomide cap 250 mg PA; SP capecitabine tab 150 mg PA; SP capecitabine tab 500 mg PA; SP mercaptopurine tab 50 mg methotrexate sodium inj 50 mg/2ml (25 mg/ml) methotrexate sodium inj 250 mg/10ml (25 mg/ml) methotrexate sodium inj pf 50 mg/2ml (25 mg/ml) methotrexate sodium inj pf 100 mg/4ml (25 mg/ml) methotrexate sodium inj pf 200 mg/8ml (25 mg/ml) methotrexate sodium inj pf 250 mg/10ml (25 mg/ml) methotrexate sodium inj pf 1000 mg/40ml (25 mg/ml) methotrexate sodium tab 2.5 mg (base equiv) PURIXAN SUS 20MG/ML SP TREXALL TAB 5MG TREXALL TAB 7.5MG TREXALL TAB 10MG TREXALL TAB 15MG ANTINEOPLASTIC - BCL-2 INHIBITORS VENCLEXTA TAB 10MG PA; SP VENCLEXTA TAB 50MG PA; SP VENCLEXTA TAB 100MG PA; SP VENCLEXTA TAB START PK PA; SP ANTINEOPLASTIC - HEDGEHOG PATHWAY INHIBITORS ERIVEDGE CAP 150MG PA; SP ODOMZO CAP 200MG PA; SP ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS tab 1 mg tab 50 mg tab 25 mg FIRMAGON INJ 80MG PA; SP FIRMAGON INJ 120MG PA; SP

OTC - Over the counter PA - Prior Authorization; refer to Prior Authorization section QL 36 - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program

Drug Name Requirements/Limits cap 125 mg inj 250 mg/5ml tab 2.5 mg leuprolide acetate inj kit 5 mg/ml PA; SP LUPRON DEPOT INJ 3.75MG PA; SP LUPRON DEPOT INJ 7.5MG PA; SP LUPRON DEPOT INJ 11.25MG PA; SP LUPRON DEPOT INJ 22.5MG PA; SP LUPRON DEPOT INJ 30MG PA; SP LUPRON DEPOT INJ 45MG PA; SP LYSODREN TAB 500MG acetate susp 40 mg/ml tab 20 mg megestrol acetate tab 40 mg NUBEQA TAB 300MG PA; SP citrate tab 10 mg (base equivalent) tamoxifen citrate tab 20 mg (base equivalent) citrate tab 60 mg (base equivalent) TRELSTAR INJ 3.75MG PA; SP TRELSTAR INJ 11.25MG PA; SP TRELSTAR MIX INJ 22.5MG PA; SP XTANDI CAP 40MG PA; SP XTANDI TAB 40MG PA; SP XTANDI TAB 80MG PA; SP ZOLADEX IMP 3.6MG PA; SP ZOLADEX IMP 10.8MG PA; SP ANTINEOPLASTIC - XPO1 INHIBITORS XPOVIO PAK 40MG PA; SP XPOVIO PAK 50MG PA; SP XPOVIO PAK 60MG PA XPOVIO PAK 60MG PA; SP XPOVIO PAK 80MG PA XPOVIO PAK 100MG PA ANTINEOPLASTIC COMBINATIONS LONSURF TAB 15-6.14 PA; SP LONSURF TAB 20-8.19 PA; SP ANTINEOPLASTIC ENZYME INHIBITORS AFINITOR TAB 10MG PA; SP AYVAKIT TAB 100MG PA, QL (30 tabs / 30 days); SP AYVAKIT TAB 200MG PA, QL (30 tabs / 30 days); SP AYVAKIT TAB 300MG PA, QL (30 tabs / 30 days); SP

OTC - Over the counter PA - Prior Authorization; refer to Prior Authorization section QL 37 - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program

Drug Name Requirements/Limits BALVERSA TAB 3MG PA BALVERSA TAB 4MG PA BALVERSA TAB 5MG PA BOSULIF TAB 100MG PA; SP BOSULIF TAB 400MG PA; SP BOSULIF TAB 500MG PA; SP BRUKINSA CAP 80MG PA; SP CABOMETYX TAB 20MG PA; SP CABOMETYX TAB 40MG PA; SP CABOMETYX TAB 60MG PA; SP CAPRELSA TAB 100MG PA; SP CAPRELSA TAB 300MG PA; SP COMETRIQ KIT 60MG PA; SP COMETRIQ KIT 100MG PA; SP COMETRIQ KIT 140MG PA; SP COTELLIC TAB 20MG PA; SP erlotinib hcl tab 25 mg (base equivalent) PA; SP erlotinib hcl tab 100 mg (base equivalent) PA; SP erlotinib hcl tab 150 mg (base equivalent) PA; SP everolimus tab 2.5 mg PA; SP everolimus tab 5 mg PA; SP everolimus tab 7.5 mg PA; SP GAVRETO CAP 100MG PA; SP GILOTRIF TAB 20MG PA; SP GILOTRIF TAB 30MG PA; SP GILOTRIF TAB 40MG PA; SP IBRANCE CAP 75MG PA; SP IBRANCE CAP 100MG PA; SP IBRANCE CAP 125MG PA; SP IBRANCE TAB 75MG PA; SP IBRANCE TAB 100MG PA; SP IBRANCE TAB 125MG PA; SP ICLUSIG TAB 10MG PA; SP ICLUSIG TAB 15MG PA; SP ICLUSIG TAB 30MG PA; SP ICLUSIG TAB 45MG PA; SP mesylate tab 100 mg (base equivalent) PA; SP imatinib mesylate tab 400 mg (base equivalent) PA; SP IMBRUVICA CAP 70MG PA; SP IMBRUVICA CAP 140MG PA; SP IMBRUVICA TAB 140MG PA; SP IMBRUVICA TAB 280MG PA; SP IMBRUVICA TAB 420MG PA; SP IMBRUVICA TAB 560MG PA; SP

OTC - Over the counter PA - Prior Authorization; refer to Prior Authorization section QL 38 - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program

Drug Name Requirements/Limits ISTODAX INJ 10MG PA; SP JAKAFI TAB 5MG PA, QL (60 tabs / 30 days); SP JAKAFI TAB 10MG PA, QL (60 tabs / 30 days); SP JAKAFI TAB 15MG PA, QL (60 tabs / 30 days); SP JAKAFI TAB 20MG PA, QL (60 tabs / 30 days); SP JAKAFI TAB 25MG PA, QL (60 tabs / 30 days); SP lapatinib ditosylate tab 250 mg (base equiv) PA; SP LENVIMA CAP 4MG PA; SP LENVIMA CAP 8 MG PA; SP LENVIMA CAP 10 MG PA; SP LENVIMA CAP 12MG PA; SP LENVIMA CAP 14 MG PA; SP LENVIMA CAP 18 MG PA; SP LENVIMA CAP 20 MG PA; SP LENVIMA CAP 24 MG PA; SP NEXAVAR TAB 200MG PA; SP NINLARO CAP 2.3MG PA; SP NINLARO CAP 3MG PA; SP NINLARO CAP 4MG PA; SP PIQRAY 200MG TAB DOSE PA; SP PIQRAY 250MG TAB DOSE PA; SP PIQRAY 300MG TAB DOSE PA; SP RETEVMO CAP 40MG PA; SP RETEVMO CAP 80MG PA; SP ROZLYTREK CAP 100MG PA; SP ROZLYTREK CAP 200MG PA; SP RUBRACA TAB 200MG PA; SP RUBRACA TAB 250MG PA; SP RUBRACA TAB 300MG PA; SP RYDAPT CAP 25MG PA; SP SPRYCEL TAB 20MG PA; SP SPRYCEL TAB 50MG PA; SP SPRYCEL TAB 70MG PA; SP SPRYCEL TAB 80MG PA; SP SPRYCEL TAB 100MG PA; SP SPRYCEL TAB 140MG PA; SP STIVARGA TAB 40MG PA; SP SUTENT CAP 12.5MG PA; SP SUTENT CAP 25MG PA; SP SUTENT CAP 37.5MG PA; SP OTC - Over the counter PA - Prior Authorization; refer to Prior Authorization section QL 39 - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program

Drug Name Requirements/Limits SUTENT CAP 50MG PA; SP TABRECTA TAB 150MG PA; SP TABRECTA TAB 200MG PA; SP TAFINLAR CAP 50MG PA; SP TAFINLAR CAP 75MG PA; SP TAGRISSO TAB 40MG PA; SP TAGRISSO TAB 80MG PA; SP TALZENNA CAP 0.25MG PA TALZENNA CAP 1MG PA TASIGNA CAP 50MG PA; SP TASIGNA CAP 150MG PA; SP TASIGNA CAP 200MG PA; SP TAZVERIK TAB 200MG PA; SP TURALIO CAP 200MG PA VERZENIO TAB 50MG PA; SP VERZENIO TAB 100MG PA; SP VERZENIO TAB 150MG PA; SP VERZENIO TAB 200MG PA; SP VIZIMPRO TAB 15MG PA; SP VIZIMPRO TAB 30MG PA; SP VIZIMPRO TAB 45MG PA; SP VOTRIENT TAB 200MG PA; SP XALKORI CAP 200MG PA; SP XALKORI CAP 250MG PA; SP XOSPATA TAB 40MG PA ZEJULA CAP 100MG PA; SP ZELBORAF TAB 240MG PA; SP ZOLINZA CAP 100MG PA; SP ZYDELIG TAB 100MG PA; SP ZYDELIG TAB 150MG PA; SP ZYKADIA CAP 150MG PA; SP ZYKADIA TAB 150MG PA; SP ANTINEOPLASTICS MISC. bexarotene cap 75 mg PA; SP hydroxyurea cap 500 mg INTRON A INJ 10MU PA; SP INTRON A INJ 18MU PA; SP INTRON A INJ 25MU PA; SP INTRON A INJ 50MU PA; SP MATULANE CAP 50MG cap 10 mg RESCUE/ AGENTS leucovorin calcium tab 5 mg leucovorin calcium tab 10 mg

OTC - Over the counter PA - Prior Authorization; refer to Prior Authorization section QL 40 - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program

Drug Name Requirements/Limits leucovorin calcium tab 15 mg leucovorin calcium tab 25 mg MITOTIC INHIBITORS etoposide cap 50 mg ANTIPARKINSON AGENTS ANTIPARKINSON ANTICHOLINERGICS benztropine mesylate tab 0.5 mg benztropine mesylate tab 1 mg benztropine mesylate tab 2 mg hcl oral soln 0.4 mg/ml trihexyphenidyl hcl tab 2 mg trihexyphenidyl hcl tab 5 mg ANTIPARKINSON COMT INHIBITORS tab 200 mg ANTIPARKINSON hcl cap 100 mg amantadine hcl syrup 50 mg/5ml amantadine hcl tab 100 mg APOKYN INJ 10MG/ML PA; SP mesylate cap 5 mg (base equivalent) bromocriptine mesylate tab 2.5 mg (base equivalent) & levodopa orally disintegrating tab 10- 100 mg carbidopa & levodopa orally disintegrating tab 25- 100 mg carbidopa & levodopa orally disintegrating tab 25- 250 mg carbidopa & levodopa tab 10-100 mg carbidopa & levodopa tab 25-100 mg carbidopa & levodopa tab 25-250 mg carbidopa & levodopa tab er 25-100 mg carbidopa & levodopa tab er 50-200 mg carbidopa-levodopa-entacapone tabs 12.5-50-200 mg carbidopa-levodopa-entacapone tabs 18.75-75- 200 mg carbidopa-levodopa-entacapone tabs 25-100-200 mg carbidopa-levodopa-entacapone tabs 31.25-125- 200 mg carbidopa-levodopa-entacapone tabs 37.5-150- 200 mg

OTC - Over the counter PA - Prior Authorization; refer to Prior Authorization section QL 41 - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program

Drug Name Requirements/Limits carbidopa-levodopa-entacapone tabs 50-200-200 mg INBRIJA CAP 42MG PA; SP; RxC/M dihydrochloride tab 0.5 mg pramipexole dihydrochloride tab 0.25 mg pramipexole dihydrochloride tab 0.75 mg pramipexole dihydrochloride tab 0.125 mg pramipexole dihydrochloride tab 1 mg pramipexole dihydrochloride tab 1.5 mg hydrochloride tab 0.5 mg ropinirole hydrochloride tab 0.25 mg ropinirole hydrochloride tab 1 mg ropinirole hydrochloride tab 2 mg ropinirole hydrochloride tab 3 mg ropinirole hydrochloride tab 4 mg ropinirole hydrochloride tab 5 mg ANTIPARKINSON MONOAMINE OXIDASE INHIBITORS mesylate tab 0.5 mg (base equiv) Excluded for new starts rasagiline mesylate tab 1 mg (base equiv) Excluded for new starts hcl cap 5 mg selegiline hcl tab 5 mg /ANTIMANIC AGENTS ANTIMANIC AGENTS cap 150 mg Rx4L cap 300 mg Rx4L lithium carbonate cap 600 mg lithium carbonate tab 300 mg lithium carbonate tab er 300 mg lithium carbonate tab er 450 mg LITHIUM SOL 8MEQ/5ML ANTIPSYCHOTICS - MISC. CAPLYTA CAP 42MG PA LATUDA TAB 20MG PA, QL (30 tabs / 30 days) LATUDA TAB 40MG PA, QL (30 ea / 30 days) LATUDA TAB 60MG PA, QL (30 ea / 30 days) LATUDA TAB 80MG PA, QL (30 ea / 30 days) LATUDA TAB 120MG PA, QL (30 tabs / 30 days) VRAYLAR CAP 1.5-3MG PA, QL (30 caps / 30 days) VRAYLAR CAP 1.5MG PA, QL (30 caps / 30 days) VRAYLAR CAP 3MG PA, QL (30 caps / 30 days) VRAYLAR CAP 4.5MG PA, QL (30 caps / 30 days) VRAYLAR CAP 6MG PA, QL (30 caps / 30 days) hcl cap 20 mg PA, QL (90 ea / 30 days); PA if < 16 yoa

OTC - Over the counter PA - Prior Authorization; refer to Prior Authorization section QL 42 - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program

Drug Name Requirements/Limits ziprasidone hcl cap 40 mg PA, QL (90 ea / 30 days); PA if < 16 yoa ziprasidone hcl cap 60 mg PA, QL (90 ea / 30 days); PA if < 16 yoa ziprasidone hcl cap 80 mg PA, QL (90 ea / 30 days); PA if < 16 yoa BENZISOXAZOLES FANAPT PAK PA, QL (60 tabs / 30 days) FANAPT TAB 1MG PA, QL (60 tabs / 30 days) FANAPT TAB 2MG PA, QL (60 tabs / 30 days) FANAPT TAB 4MG PA, QL (60 tabs / 30 days) FANAPT TAB 6MG PA, QL (60 tabs / 30 days) FANAPT TAB 8MG PA, QL (60 tabs / 30 days) FANAPT TAB 10MG PA, QL (60 tabs / 30 days) FANAPT TAB 12MG PA, QL (60 tabs / 30 days) INVEGA SUST INJ 39/0.25 INVEGA SUST INJ 78/0.5ML INVEGA SUST INJ 117/0.75 INVEGA SUST INJ 156MG/ML INVEGA SUST INJ 234/1.5 INVEGA TRINZ INJ 273MG INVEGA TRINZ INJ 410MG INVEGA TRINZ INJ 546MG INVEGA TRINZ INJ 819MG tab er 24hr 1.5 mg PA, QL (30 tabs / 30 days) paliperidone tab er 24hr 3 mg PA, QL (30 tabs / 30 days) paliperidone tab er 24hr 6 mg PA, QL (30 tabs / 30 days) paliperidone tab er 24hr 9 mg PA, QL (30 tabs / 30 days) RISPERDAL INJ 12.5MG RISPERDAL INJ 25MG RISPERDAL INJ 37.5MG RISPERDAL INJ 50MG orally disintegrating tab 0.5 mg QL (90 ea / 30 days) risperidone orally disintegrating tab 0.25 mg QL (90 ea / 30 days) risperidone orally disintegrating tab 1 mg QL (90 tabs / 30 days) risperidone orally disintegrating tab 2 mg QL (90 ea / 30 days) risperidone orally disintegrating tab 3 mg QL (90 ea / 30 days) risperidone orally disintegrating tab 4 mg QL (90 ea / 30 days) risperidone soln 1 mg/ml QL (90 mL / 30 days) risperidone tab 0.5 mg QL (90 tabs / 30 days); Rx4L risperidone tab 0.25 mg QL (90 tabs / 30 days); Rx4L

OTC - Over the counter PA - Prior Authorization; refer to Prior Authorization section QL 43 - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program

Drug Name Requirements/Limits risperidone tab 1 mg QL (90 tabs / 30 days); Rx4L risperidone tab 2 mg QL (90 tabs / 30 days); Rx4L risperidone tab 3 mg QL (90 tabs / 30 days) risperidone tab 4 mg QL (90 tabs / 30 days) BUTYROPHENONES HALDOL DECAN INJ 50MG/ML HALDOL DECAN INJ 100MG/ML decanoate im soln 50 mg/ml im soln 100 mg/ml haloperidol lactate inj 5 mg/ml haloperidol lactate oral conc 2 mg/ml haloperidol tab 0.5 mg haloperidol tab 1 mg haloperidol tab 2 mg haloperidol tab 5 mg haloperidol tab 10 mg haloperidol tab 20 mg DIBENZAPINES orally disintegrating tab 12.5 mg clozapine orally disintegrating tab 25 mg clozapine orally disintegrating tab 100 mg clozapine orally disintegrating tab 150 mg clozapine orally disintegrating tab 200 mg clozapine tab 25 mg clozapine tab 50 mg clozapine tab 100 mg clozapine tab 200 mg succinate cap 5 mg loxapine succinate cap 10 mg loxapine succinate cap 25 mg loxapine succinate cap 50 mg orally disintegrating tab 5 mg PA, QL (90 ea / 30 days); PA if < 13 yoa olanzapine orally disintegrating tab 10 mg PA, QL (90 ea / 30 days); PA if < 13 yoa olanzapine orally disintegrating tab 15 mg PA, QL (90 ea / 30 days); PA if < 13 yoa olanzapine orally disintegrating tab 20 mg PA, QL (90 ea / 30 days); PA if < 13 yoa olanzapine tab 2.5 mg PA, QL (90 ea / 30 days); PA if < 13 yoa olanzapine tab 5 mg PA, QL (90 ea / 30 days); PA if < 13 yoa OTC - Over the counter PA - Prior Authorization; refer to Prior Authorization section QL 44 - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program

Drug Name Requirements/Limits olanzapine tab 7.5 mg PA, QL (90 tabs / 30 days); PA if < 13 yoa olanzapine tab 10 mg PA, QL (90 ea / 30 days); PA if < 13 yoa olanzapine tab 15 mg PA, QL (90 ea / 30 days); PA if < 13 yoa olanzapine tab 20 mg PA, QL (90 ea / 30 days); PA if < 13 yoa quetiapine fumarate tab 25 mg PA, QL (90 tabs / 30 days); PA if < 10 yoa quetiapine fumarate tab 50 mg PA, QL (90 tabs / 30 days); PA if < 10 yoa; Rx4L quetiapine fumarate tab 100 mg PA, QL (90 tabs / 30 days); PA if < 10 yoa; Rx4L quetiapine fumarate tab 200 mg PA, QL (90 tabs / 30 days); PA if < 10 yoa; Rx4L quetiapine fumarate tab 300 mg PA, QL (90 tabs / 30 days); PA if < 10 yoa; Rx4L quetiapine fumarate tab 400 mg PA, QL (90 tabs / 30 days); PA if < 10 yoa quetiapine fumarate tab er 24hr 50 mg PA, QL (60 tabs / 30 days); PA if < 10 yoa quetiapine fumarate tab er 24hr 150 mg PA, QL (60 tabs / 30 days); PA if < 10 yoa quetiapine fumarate tab er 24hr 200 mg PA, QL (60 tabs / 30 days); PA if < 10 yoa quetiapine fumarate tab er 24hr 300 mg PA, QL (60 tabs / 30 days); PA if < 10 yoa quetiapine fumarate tab er 24hr 400 mg PA, QL (60 tabs / 30 days); PA if < 10 yoa SAPHRIS SUB 2.5MG PA, QL (90 ea / 30 days) SAPHRIS SUB 5MG PA, QL (90 ea / 30 days) SAPHRIS SUB 10MG PA, QL (90 tabs / 30 days) SECUADO DIS 3.8MG PA SECUADO DIS 5.7MG PA SECUADO DIS 7.6MG PA VERSACLOZ SUS 50MG/ML PA ZYPREXA RELP INJ 210MG ZYPREXA RELP INJ 300MG ZYPREXA RELP INJ 405MG PHENOTHIAZINES hcl tab 10 mg chlorpromazine hcl tab 25 mg chlorpromazine hcl tab 50 mg chlorpromazine hcl tab 100 mg

OTC - Over the counter PA - Prior Authorization; refer to Prior Authorization section QL 45 - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program

Drug Name Requirements/Limits chlorpromazine hcl tab 200 mg compro sup 25mg decanoate inj 25 mg/ml fluphenazine hcl elixir 2.5 mg/5ml fluphenazine hcl inj 2.5 mg/ml fluphenazine hcl oral conc 5 mg/ml fluphenazine hcl tab 1 mg fluphenazine hcl tab 2.5 mg fluphenazine hcl tab 5 mg fluphenazine hcl tab 10 mg tab 2 mg perphenazine tab 4 mg perphenazine tab 8 mg perphenazine tab 16 mg maleate tab 5 mg (base equivalent) prochlorperazine maleate tab 10 mg (base equivalent) hcl tab 10 mg thioridazine hcl tab 25 mg thioridazine hcl tab 50 mg thioridazine hcl tab 100 mg hcl tab 1 mg (base equivalent) trifluoperazine hcl tab 2 mg (base equivalent) trifluoperazine hcl tab 5 mg (base equivalent) trifluoperazine hcl tab 10 mg (base equivalent) QUINOLINONE DERIVATIVES ABILIFY MAIN INJ 300MG ABILIFY MAIN INJ 400MG oral solution 1 mg/ml PA, QL (600 mL / 30 days) aripiprazole orally disintegrating tab 10 mg PA, QL (30 tabs / 30 days) aripiprazole orally disintegrating tab 15 mg PA, QL (30 tabs / 30 days) aripiprazole tab 2 mg QL (60 tabs / 30 days) aripiprazole tab 5 mg QL (60 tabs / 30 days) aripiprazole tab 10 mg QL (30 tabs / 30 days) aripiprazole tab 15 mg QL (30 tabs / 30 days) aripiprazole tab 20 mg QL (30 tabs / 30 days) aripiprazole tab 30 mg QL (30 tabs / 30 days) ARISTADA INJ 441MG/1. ARISTADA INJ 662MG/2 ARISTADA INJ 882MG/3 ARISTADA INJ 1064MG ARISTADA INJ INITIO REXULTI TAB 0.5MG PA, QL (30 tabs / 30 days)

OTC - Over the counter PA - Prior Authorization; refer to Prior Authorization section QL 46 - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program

Drug Name Requirements/Limits REXULTI TAB 0.25MG PA, QL (30 tabs / 30 days) REXULTI TAB 1MG PA, QL (30 tabs / 30 days) REXULTI TAB 2MG PA, QL (30 tabs / 30 days) REXULTI TAB 3MG PA, QL (30 tabs / 30 days) REXULTI TAB 4MG PA, QL (30 tabs / 30 days) thiothixene cap 1 mg thiothixene cap 2 mg thiothixene cap 5 mg thiothixene cap 10 mg ANTIVIRALS ANTIRETROVIRALS abacavir sulfate soln 20 mg/ml (base equiv) abacavir sulfate tab 300 mg (base equiv) abacavir sulfate-lamivudine tab 600-300 mg abacavir sulfate-lamivudine-zidovudine tab 300- 150-300 mg APTIVUS CAP 250MG APTIVUS SOL atazanavir sulfate cap 150 mg (base equiv) atazanavir sulfate cap 200 mg (base equiv) atazanavir sulfate cap 300 mg (base equiv) BIKTARVY TAB CIMDUO TAB 300-300 COMPLERA TAB CRIXIVAN CAP 200MG CRIXIVAN CAP 400MG DESCOVY TAB 200/25MG didanosine delayed release capsule 125 mg didanosine delayed release capsule 200 mg didanosine delayed release capsule 250 mg didanosine delayed release capsule 400 mg DOVATO TAB 50-300MG EDURANT TAB 25MG cap 50 mg efavirenz cap 200 mg efavirenz tab 600 mg efavirenz-emtricitabine-tenofovir df tab 600-200- 300 mg efavirenz-lamivudine-tenofovir df tab 400-300-300 mg efavirenz-lamivudine-tenofovir df tab 600-300-300 mg emtricitabine caps 200 mg

OTC - Over the counter PA - Prior Authorization; refer to Prior Authorization section QL 47 - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program

Drug Name Requirements/Limits emtricitabine-tenofovir disoproxil fumarate tab 100-150 mg emtricitabine-tenofovir disoproxil fumarate tab 133-200 mg emtricitabine-tenofovir disoproxil fumarate tab 167-250 mg emtricitabine-tenofovir disoproxil fumarate tab 200-300 mg EMTRIVA SOL 10MG/ML EVOTAZ TAB 300-150 fosamprenavir calcium tab 700 mg (base equiv) FUZEON INJ 90MG PA GENVOYA TAB QL (30 tabs / 30 days) INTELENCE TAB 25MG INTELENCE TAB 100MG INTELENCE TAB 200MG INVIRASE CAP 200MG INVIRASE TAB 500MG ISENTRESS CHW 25MG ISENTRESS CHW 100MG ISENTRESS HD TAB 600MG ISENTRESS POW 100MG ISENTRESS TAB 400MG JULUCA TAB 50-25MG KALETRA TAB 100-25MG KALETRA TAB 200-50MG lamivudine oral soln 10 mg/ml lamivudine tab 150 mg lamivudine tab 300 mg lamivudine-zidovudine tab 150-300 mg LEXIVA SUS 50MG/ML lopinavir- soln 400-100 mg/5ml (80-20 mg/ml) susp 50 mg/5ml nevirapine tab 200 mg nevirapine tab er 24hr 100 mg nevirapine tab er 24hr 400 mg NORVIR CAP 100MG NORVIR SOL 80MG/ML ODEFSEY TAB PREZCOBIX TAB 800-150 PREZISTA SUS 100MG/ML PREZISTA TAB 75MG PREZISTA TAB 150MG PREZISTA TAB 600MG OTC - Over the counter PA - Prior Authorization; refer to Prior Authorization section QL 48 - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program

Drug Name Requirements/Limits PREZISTA TAB 800MG RESCRIPTOR TAB 100 MG RESCRIPTOR TAB 200MG REYATAZ POW 50MG ritonavir tab 100 mg RUKOBIA TAB 600MG ER SELZENTRY SOL 20MG/ML SELZENTRY TAB 25MG SELZENTRY TAB 75MG SELZENTRY TAB 150MG SELZENTRY TAB 300MG stavudine cap 15 mg stavudine cap 20 mg stavudine cap 30 mg stavudine cap 40 mg stavudine for oral soln 1 mg/ml STRIBILD TAB SYMTUZA TAB tenofovir disoproxil fumarate tab 300 mg TIVICAY PD TAB 5MG TIVICAY TAB 10MG TIVICAY TAB 25MG TIVICAY TAB 50MG TRIUMEQ TAB TRIZIVIR TAB TRUVADA TAB 100-150 TRUVADA TAB 133-200 TRUVADA TAB 167-250 TRUVADA TAB 200-300 TYBOST TAB 150MG VIDEX EC CAP 400MG VIDEX SOL 2GM VIDEX SOL 4GM VIRACEPT TAB 250MG VIRACEPT TAB 625MG VIRAMUNE XR TAB 100MG VIREAD TAB 150MG VIREAD TAB 200MG VIREAD TAB 250MG VITEKTA TAB 85MG QL (30 tabs / 30 days) VITEKTA TAB 150MG QL (30 tabs / 30 days) zidovudine cap 100 mg zidovudine syrup 10 mg/ml zidovudine tab 300 mg

OTC - Over the counter PA - Prior Authorization; refer to Prior Authorization section QL 49 - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program

Drug Name Requirements/Limits CMV AGENTS PREVYMIS TAB 240MG PA PREVYMIS TAB 480MG PA valganciclovir hcl for soln 50 mg/ml (base equiv) valganciclovir hcl tab 450 mg (base equivalent) HEPATITIS AGENTS adefovir dipivoxil tab 10 mg SP BARACLUDE SOL SP entecavir tab 0.5 mg SP entecavir tab 1 mg SP EPIVIR HBV SOL 5MG/ML SP lamivudine tab 100 mg (hbv) SP MAVYRET TAB 100-40MG QL (168 tabs / year); SP PEGASYS INJ PA; SP PEGASYS INJ 180MCG/M PA; SP PEGASYS INJ PROCLICK PA; SP cap 200 mg SP TYZEKA TAB 600MG SP HERPES AGENTS acyclovir cap 200 mg acyclovir susp 200 mg/5ml acyclovir tab 400 mg acyclovir tab 800 mg tab 125 mg famciclovir tab 250 mg famciclovir tab 500 mg valacyclovir hcl tab 1 gm valacyclovir hcl tab 500 mg AGENTS phosphate cap 30 mg (base equiv) QL (20 caps / 180 days) oseltamivir phosphate cap 45 mg (base equiv) QL (10 caps / 180 days) oseltamivir phosphate cap 75 mg (base equiv) QL (10 caps / 180 days) oseltamivir phosphate for susp 6 mg/ml (base QL (180 mL / 180 days) equiv) RELENZA MIS DISKHALE QL (1 inhaler / 180 days) hydrochloride tab 100 mg BETA BLOCKERS ALPHA-BETA BLOCKERS tab 3.125 mg Rx4L carvedilol tab 6.25 mg Rx4L carvedilol tab 12.5 mg Rx4L carvedilol tab 25 mg Rx4L hcl tab 100 mg

OTC - Over the counter PA - Prior Authorization; refer to Prior Authorization section QL 50 - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program

Drug Name Requirements/Limits labetalol hcl tab 200 mg labetalol hcl tab 300 mg BETA BLOCKERS CARDIO-SELECTIVE hcl cap 200 mg acebutolol hcl cap 400 mg atenolol tab 25 mg Rx4L atenolol tab 50 mg Rx4L atenolol tab 100 mg Rx4L bisoprolol fumarate tab 5 mg bisoprolol fumarate tab 10 mg metoprolol succinate tab er 24hr 25 mg (tartrate Rx4L equiv) metoprolol succinate tab er 24hr 50 mg (tartrate Rx4L equiv) metoprolol succinate tab er 24hr 100 mg (tartrate Rx4L equiv) metoprolol succinate tab er 24hr 200 mg (tartrate equiv) metoprolol tartrate tab 25 mg Rx4L metoprolol tartrate tab 50 mg Rx4L metoprolol tartrate tab 75 mg metoprolol tartrate tab 100 mg Rx4L BETA BLOCKERS NON-SELECTIVE tab 20 mg nadolol tab 40 mg nadolol tab 80 mg tab 5 mg pindolol tab 10 mg hcl cap er 24hr 60 mg propranolol hcl cap er 24hr 80 mg propranolol hcl cap er 24hr 120 mg propranolol hcl cap er 24hr 160 mg propranolol hcl oral soln 20 mg/5ml propranolol hcl oral soln 40 mg/5ml propranolol hcl tab 10 mg Rx4L propranolol hcl tab 20 mg Rx4L propranolol hcl tab 40 mg Rx4L propranolol hcl tab 60 mg propranolol hcl tab 80 mg Rx4L hcl (afib/afl) tab 80 mg sotalol hcl (afib/afl) tab 120 mg sotalol hcl (afib/afl) tab 160 mg sotalol hcl tab 80 mg sotalol hcl tab 120 mg

OTC - Over the counter PA - Prior Authorization; refer to Prior Authorization section QL 51 - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program

Drug Name Requirements/Limits sotalol hcl tab 160 mg sotalol hcl tab 240 mg maleate tab 5 mg timolol maleate tab 10 mg timolol maleate tab 20 mg BLOCKERS CALCIUM CHANNEL BLOCKERS amlodipine besylate tab 2.5 mg (base equivalent) Rx4L amlodipine besylate tab 5 mg (base equivalent) Rx4L amlodipine besylate tab 10 mg (base equivalent) Rx4L cap 240mg cd diltiazem cap 300mg cd diltiazem hcl cap er 12hr 60 mg diltiazem hcl cap er 12hr 90 mg diltiazem hcl cap er 12hr 120 mg diltiazem hcl cap er 24hr 120 mg diltiazem hcl cap er 24hr 180 mg diltiazem hcl cap er 24hr 240 mg diltiazem hcl coated beads cap er 24hr 120 mg diltiazem hcl coated beads cap er 24hr 180 mg diltiazem hcl coated beads cap er 24hr 360 mg diltiazem hcl extended release beads cap er 24hr 120 mg diltiazem hcl extended release beads cap er 24hr 180 mg diltiazem hcl extended release beads cap er 24hr 240 mg diltiazem hcl extended release beads cap er 24hr 300 mg diltiazem hcl extended release beads cap er 24hr 360 mg diltiazem hcl extended release beads cap er 24hr 420 mg diltiazem hcl tab 30 mg Rx4L diltiazem hcl tab 60 mg Rx4L diltiazem hcl tab 90 mg Rx4L diltiazem hcl tab 120 mg Rx4L tab er 24hr 2.5 mg felodipine tab er 24hr 5 mg felodipine tab er 24hr 10 mg matzim la tab 180mg/24 matzim la tab 240mg/24 matzim la tab 300mg/24 matzim la tab 360mg/24

OTC - Over the counter PA - Prior Authorization; refer to Prior Authorization section QL 52 - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program

Drug Name Requirements/Limits matzim la tab 420mg/24 tab er 24hr 30 mg nifedipine tab er 24hr 60 mg nifedipine tab er 24hr 90 mg nifedipine tab er 24hr osmotic release 30 mg nifedipine tab er 24hr osmotic release 60 mg nifedipine tab er 24hr osmotic release 90 mg hcl cap er 24hr 100 mg verapamil hcl cap er 24hr 120 mg verapamil hcl cap er 24hr 180 mg verapamil hcl cap er 24hr 200 mg verapamil hcl cap er 24hr 240 mg verapamil hcl cap er 24hr 300 mg verapamil hcl cap er 24hr 360 mg verapamil hcl tab 40 mg verapamil hcl tab 80 mg Rx4L verapamil hcl tab 120 mg Rx4L verapamil hcl tab er 120 mg verapamil hcl tab er 180 mg verapamil hcl tab er 240 mg CARDIOTONICS CARDIAC digitek tab 0.25mg digitek tab 0.125mg inj 0.25 mg/ml digoxin oral soln 0.05 mg/ml LANOXIN TAB 0.0625MG LANOXIN TAB 0.1875MG CARDIOVASCULAR AGENTS - MISC. CARDIOVASCULAR AGENTS MISC. - COMBINATIONS ENTRESTO TAB 24-26MG ENTRESTO TAB 49-51MG ENTRESTO TAB 97-103MG VASODILATORS epoprostenol sodium for inj 0.5 mg SP epoprostenol sodium for inj 1.5 mg SP ORENITRAM TAB 0.25MG PA; SP ORENITRAM TAB 0.125MG PA; SP ORENITRAM TAB 1MG PA; SP ORENITRAM TAB 2.5MG PA; SP inj soln 20 mg/20ml (1 mg/ml) PA treprostinil inj soln 50 mg/20ml (2.5 mg/ml) PA treprostinil inj soln 100 mg/20ml (5 mg/ml) PA

OTC - Over the counter PA - Prior Authorization; refer to Prior Authorization section QL 53 - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program

Drug Name Requirements/Limits treprostinil inj soln 200 mg/20ml (10 mg/ml) PA TYVASO START SOL 0.6MG/ML SP VENTAVIS SOL 10MCG/ML SP VENTAVIS SOL 20MCG/ML SP PULMONARY - ENDOTHELIN RECEPTOR ANTAGONISTS tab 5 mg PA; SP ambrisentan tab 10 mg PA; SP tab 62.5 mg PA; SP bosentan tab 125 mg PA; SP OPSUMIT TAB 10MG PA; SP TRACLEER TAB 32MG PA; SP PULMONARY HYPERTENSION - PHOSPHODIESTERASE INHIBITORS REVATIO INJ PA; SP citrate for suspension 10 mg/ml PA; SP sildenafil citrate iv soln 10 mg/12.5ml (base PA; SP equivalent) sildenafil citrate tab 20 mg PA; SP tab 20 mg (pah) PA; SP PULMONARY HYPERTENSION - RECEPTOR UPTRAVI TAB 200MCG PA; SP UPTRAVI TAB 400MCG PA; SP UPTRAVI TAB 600MCG PA; SP UPTRAVI TAB 800MCG PA; SP UPTRAVI TAB 1000MCG PA; SP UPTRAVI TAB 1200MCG PA; SP UPTRAVI TAB 1400MCG PA; SP UPTRAVI TAB 1600MCG PA; SP PULMONARY HYPERTENSION - SOL GUANYLATE CYCLASE STIMULATOR ADEMPAS TAB 0.5MG PA; SP ADEMPAS TAB 1.5MG PA; SP ADEMPAS TAB 1MG PA; SP ADEMPAS TAB 2.5MG PA; SP ADEMPAS TAB 2MG PA; SP SINUS NODE INHIBITORS CORLANOR TAB 5MG CORLANOR TAB 7.5MG STABILIZERS VYNDAMAX CAP 61MG PA; SP VYNDAQEL CAP 20MG PA; SP

OTC - Over the counter PA - Prior Authorization; refer to Prior Authorization section QL 54 - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program

Drug Name Requirements/Limits CEPHALOSPORINS - 1ST GENERATION cefadroxil cap 500 mg cefadroxil for susp 250 mg/5ml cefadroxil for susp 500 mg/5ml cefadroxil tab 1 gm cephalexin cap 250 mg cephalexin cap 500 mg cephalexin for susp 125 mg/5ml cephalexin for susp 250 mg/5ml cephalexin tab 250 mg cephalexin tab 500 mg CEPHALOSPORINS - 2ND GENERATION cefaclor cap 250 mg cefaclor cap 500 mg cefaclor for susp 125 mg/5ml cefaclor for susp 250 mg/5ml cefaclor for susp 375 mg/5ml cefprozil for susp 125 mg/5ml cefprozil for susp 250 mg/5ml cefprozil tab 250 mg cefprozil tab 500 mg CEFTIN SUS 250/5ML axetil tab 250 mg cefuroxime axetil tab 500 mg CEPHALOSPORINS - 3RD GENERATION cefdinir cap 300 mg cefdinir for susp 125 mg/5ml cefdinir for susp 250 mg/5ml CONTRACEPTIVES COMBINATION CONTRACEPTIVES - ORAL blisovi 24 tab fe 1/20 caziant pak desogest-eth estrad & eth estrad tab 0.15- 0.02/0.01 mg(21/5) & ethinyl tab 0.15 mg-30 mcg -ethinyl estradiol tab 3-0.02 mg drospirenone-ethinyl estradiol tab 3-0.03 mg leena tab levonorg-eth est tab 0.1-0.02mg(84) & eth est tab 0.01mg(7) levonorg-eth est tab 0.15-0.03mg(84) & eth est tab 0.01mg(7)

OTC - Over the counter PA - Prior Authorization; refer to Prior Authorization section QL 55 - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program

Drug Name Requirements/Limits & ethinyl estradiol (91-day) tab 0.15-0.03 mg levonorgestrel & ethinyl estradiol tab 0.1 mg-20 mcg levonorgestrel & ethinyl estradiol tab 0.15 mg-30 mcg levonorgestrel-eth estra tab 0.05-30/0.075- 40/0.125-30mg-mcg levonorgestrel-ethinyl estradiol (continuous) tab 90-20 mcg LO LOESTRIN TAB 1-10-10 low-ogestrel tab microgestin tab 1.5/30 microgestin tab fe1.5/30 necon tab 0.5/35 necon tab 1/35 necon tab 1/50-28 necon tab 7/7/7 norethindrone ace & ethinyl estradiol tab 1 mg-20 mcg norethindrone ace & ethinyl estradiol-fe tab 1 mg- 20 mcg norethindrone ace-eth estradiol-fe chew tab 1 mg- 20 mcg (24) & ethinyl estradiol tab 0.25 mg-35 mcg norgestimate-eth estrad tab 0.18-25/0.215- 25/0.25-25 mg-mcg norgestimate-eth estrad tab 0.18-35/0.215- 35/0.25-35 mg-mcg ogestrel tab tilia fe tab zenchent tab zovia 1/35e tab zovia 1/50e tab COMBINATION CONTRACEPTIVES - TRANSDERMAL xulane dis 150-35 COMBINATION CONTRACEPTIVES - VAGINAL eluryng mis QL (1 ring / 30 days); ACA EMERGENCY CONTRACEPTIVES ELLA TAB 30MG my way tab 1.5mg OTC; QL PROGESTIN CONTRACEPTIVES - INJECTABLE DEPO-SQ PROV INJ 104 Max day supply of 364 acetate im susp 150 mg/ml Max day supply of 364

OTC - Over the counter PA - Prior Authorization; refer to Prior Authorization section QL 56 - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program

Drug Name Requirements/Limits medroxyprogesterone acetate im susp prefilled syr Max day supply of 364 150 mg/ml PROGESTIN CONTRACEPTIVES - ORAL lyza tab 0.35mg GLUCOCORTICOSTEROIDS budesonide delayed release particles cap 3 mg DEXAMETHASON CON 1MG/ML elixir 0.5 mg/5ml dexamethasone sodium phosphate inj 4 mg/ml dexamethasone sodium phosphate inj 20 mg/5ml dexamethasone soln 0.5 mg/5ml dexamethasone tab 0.5 mg dexamethasone tab 0.75 mg dexamethasone tab 1 mg dexamethasone tab 1.5 mg dexamethasone tab 2 mg dexamethasone tab 4 mg dexamethasone tab 6 mg hydrocortisone tab 5 mg hydrocortisone tab 10 mg hydrocortisone tab 20 mg MEDROL TAB 2MG tab 4 mg methylprednisolone tab 8 mg methylprednisolone tab 16 mg methylprednisolone tab 32 mg methylprednisolone tab therapy pack 4 mg (21) sod phos orally disintegr tab 10 mg (base eq) prednisolone sod phos orally disintegr tab 15 mg (base eq) prednisolone sod phos orally disintegr tab 30 mg (base eq) prednisolone sod phosph oral soln 6.7 mg/5ml (5 mg/5ml base) prednisolone sod phosphate oral soln 15 mg/5ml (base equiv) prednisolone sodium phosphate oral soln 25 mg/5ml (base eq) prednisolone syrup 15 mg/5ml (usp solution equivalent) oral soln 5 mg/5ml prednisone tab 1 mg

OTC - Over the counter PA - Prior Authorization; refer to Prior Authorization section QL 57 - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program

Drug Name Requirements/Limits prednisone tab 2.5 mg prednisone tab 5 mg Rx4L prednisone tab 10 mg Rx4L prednisone tab 20 mg prednisone tab 50 mg prednisone tab therapy pack 5 mg (21) prednisone tab therapy pack 5 mg (48) prednisone tab therapy pack 10 mg (21) prednisone tab therapy pack 10 mg (48) SOLU-CORTEF INJ 100MG acetate tab 0.1 mg COUGH/COLD/ ANTITUSSIVES benzonatate cap 100 mg benzonatate cap 200 mg MISC. RESPIRATORY INHALANTS nebusal neb 3% sodium soln nebu 0.9% soln nebu 7% sodium chloride soln nebu 10% DERMATOLOGICALS PRODUCTS adapalene gel 0.1% QL (45 gm / 30 days) adapalene gel 0.3% QL (45 gm / 30 days) claravis cap 10mg QL (300 caps / year) claravis cap 20mg QL (300 caps / year) claravis cap 30mg QL (300 caps / year) claravis cap 40mg QL (300 caps / year) clindamycin phosphate gel 1% clindamycin phosphate lotion 1% clindamycin phosphate soln 1% dapsone gel 5% QL (60 gm / 30 days) gel 2% erythromycin soln 2% isotretinoin cap 10 mg QL (300 caps / year) isotretinoin cap 20 mg QL (300 caps / year) isotretinoin cap 30 mg QL (300 caps / year) isotretinoin cap 40 mg QL (300 caps / year) tretinoin cream 0.1% PA; PA applies to ages 40+ tretinoin cream 0.05% PA; PA applies to ages 40+ tretinoin cream 0.025% PA; PA applies to ages 40+ tretinoin gel 0.01% PA; PA applies to ages 40+

OTC - Over the counter PA - Prior Authorization; refer to Prior Authorization section QL 58 - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program

Drug Name Requirements/Limits tretinoin gel 0.025% PA; PA applies to ages 40+ ANTI-INFLAMMATORY AGENTS - TOPICAL diclofenac sodium gel 1% QL (1000 gm / 30 days) - TOPICAL sulfate cream 0.1% gentamicin sulfate oint 0.1% oint 2% ANTIFUNGALS - TOPICAL gel 0.77% ciclopirox olamine cream 0.77% (base equiv) ciclopirox olamine susp 0.77% (base equiv) ciclopirox shampoo 1% ciclopirox solution 8% cream 1% clotrimazole soln 1% clotrimazole w/ cream 1-0.05% clotrimazole w/ betamethasone lotion 1-0.05% cream 1% ketoconazole cream 2% ketoconazole shampoo 2% nystatin cream 100000 unit/gm nystatin oint 100000 unit/gm nystatin topical powder 100000 unit/gm ANTINEOPLASTIC OR PREMALIGNANT LESION AGENTS - TOPICAL fluorouracil cream 5% fluorouracil soln 2% fluorouracil soln 5% VALCHLOR GEL 0.016% PA ANTIPSORIATICS calcipotriene oint 0.005% calcipotriene soln 0.005% (50 mcg/ml) COSENTYX INJ 150MG/ML PA, QL ; SP COSENTYX INJ 300DOSE PA, QL ; SP COSENTYX PEN INJ 150MG/ML PA, QL ; SP COSENTYX PEN INJ 300DOSE PA, QL ; SP TALTZ INJ 80MG/ML PA, QL ; SP cream 0.1% PA TAZORAC CRE 0.05% PA TAZORAC GEL 0.1% PA TAZORAC GEL 0.05% PA BURN PRODUCTS silver cream 1%

OTC - Over the counter PA - Prior Authorization; refer to Prior Authorization section QL 59 - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program

Drug Name Requirements/Limits CORTICOSTEROIDS - TOPICAL dipropionate oint 0.05% betamethasone dipropionate augmented cream 0.05% betamethasone dipropionate augmented gel 0.05% betamethasone dipropionate augmented lotion 0.05% betamethasone dipropionate augmented oint 0.05% betamethasone dipropionate cream 0.05% betamethasone dipropionate lotion 0.05% betamethasone dipropionate oint 0.05% cream 0.1% (base equivalent) betamethasone valerate lotion 0.1% (base equivalent) betamethasone valerate oint 0.1% (base equivalent) propionate cream 0.05% foam 0.05% clobetasol propionate gel 0.05% clobetasol propionate oint 0.05% clobetasol propionate shampoo 0.05% clobetasol propionate soln 0.05% cream 0.05% QL (60 gm / 30 days) desonide lotion 0.05% QL (59 mL / 30 days) desonide oint 0.05% QL (60 gm / 30 days) acetonide oil 0.01% (scalp oil) cream 0.05% fluocinonide gel 0.05% fluocinonide oint 0.05% fluocinonide soln 0.05% cream 0.05% fluticasone propionate oint 0.005% halobetasol propionate cream 0.05% QL (50 gm / 30 days) halobetasol propionate oint 0.05% QL (50 gm / 30 days) cream 0.1% hydrocortisone butyrate oint 0.1% hydrocortisone butyrate soln 0.1% hydrocortisone cream 2.5% hydrocortisone lotion 2.5% hydrocortisone oint 1% QL hydrocortisone oint 2.5% furoate cream 0.1%

OTC - Over the counter PA - Prior Authorization; refer to Prior Authorization section QL 60 - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program

Drug Name Requirements/Limits mometasone furoate oint 0.1% mometasone furoate solution 0.1% (lotion) acetonide cream 0.1% cream 0.5% triamcinolone acetonide cream 0.025% triamcinolone acetonide lotion 0.1% triamcinolone acetonide lotion 0.025% triamcinolone acetonide oint 0.1% triamcinolone acetonide oint 0.5% triamcinolone acetonide oint 0.025% EMOLLIENTS (ammonium lactate) cream 12% lactic acid (ammonium lactate) lotion 12% - TOPICAL SANTYL OIN 250/GM QL (30 gm / 30 days) IMMUNOMODULATING AGENTS - TOPICAL cream 5% IMMUNOSUPPRESSIVE AGENTS - TOPICAL pimecrolimus cream 1% QL (30 gm / 30 days) oint 0.1% QL (30 gm / 30 days) tacrolimus oint 0.03% QL (30 gm / 30 days) KERATOLYTIC/ANTIMITOTIC AGENTS podofilox soln 0.5% LOCAL - TOPICAL hcl soln 4% lidocaine oint 5% QL (30 gm / 30 days) lidocaine patch 5% QL (90 patches / 30 days) lidocaine- cream 2.5-2.5% ROSACEA AGENTS gel 15% metronidazole cream 0.75% metronidazole gel 0.75% metronidazole gel 1% metronidazole lotion 0.75% SCABICIDES & PEDICULICIDES malathion lotion 0.5% QL (59 mL / 28 days) cream 5% DIAGNOSTIC PRODUCTS DIAGNOSTIC TESTS BREEZE 2 MIS TEST QL (100 ea / 30 days), OTC; QL CONTOUR TES BLD GLUC QL (100 strips / 30 days), OTC

OTC - Over the counter PA - Prior Authorization; refer to Prior Authorization section QL 61 - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program

Drug Name Requirements/Limits CONTOUR TES NEXT QL (100 strips / 30 days), OTC ONETOUCH TES ULTRA QL (100 strips / 30 days), OTC ONETOUCH TES VERIO QL (100 strips / 30 days), OTC DIGESTIVE AIDS DIGESTIVE ENZYMES CREON CAP 3000UNIT CREON CAP 6000UNIT CREON CAP 12000UNT CREON CAP 24000UNT CREON CAP 36000UNT PANCREAZE CAP PANCREAZE CAP 4200UNIT PANCREAZE CAP 10500UNT PANCREAZE CAP 16800UNT PANCREAZE CAP 21000UNT CARBONIC ANHYDRASE INHIBITORS cap er 12hr 500 mg acetazolamide tab 125 mg acetazolamide tab 250 mg methazolamide tab 25 mg methazolamide tab 50 mg COMBINATIONS & hydrochlorothiazide tab 5-50 mg & hydrochlorothiazide tab 25-25 mg & hydrochlorothiazide cap 37.5-25 mg Rx4L triamterene & hydrochlorothiazide cap 50-25 mg triamterene & hydrochlorothiazide tab 37.5-25 mg Rx4L triamterene & hydrochlorothiazide tab 75-50 mg Rx4L LOOP DIURETICS tab 0.5 mg Rx4L bumetanide tab 1 mg Rx4L bumetanide tab 2 mg Rx4L oral soln 10 mg/ml furosemide tab 20 mg Rx4L furosemide tab 40 mg Rx4L furosemide tab 80 mg Rx4L torsemide tab 5 mg torsemide tab 10 mg torsemide tab 20 mg

OTC - Over the counter PA - Prior Authorization; refer to Prior Authorization section QL 62 - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program

Drug Name Requirements/Limits torsemide tab 100 mg POTASSIUM SPARING DIURETICS amiloride hcl tab 5 mg CAROSPIR SUS 25MG/5ML spironolactone tab 25 mg Rx4L spironolactone tab 50 mg Rx4L spironolactone tab 100 mg AND -LIKE DIURETICS chlorthalidone tab 25 mg chlorthalidone tab 50 mg hydrochlorothiazide cap 12.5 mg Rx4L hydrochlorothiazide tab 12.5 mg hydrochlorothiazide tab 25 mg Rx4L hydrochlorothiazide tab 50 mg Rx4L tab 1.25 mg indapamide tab 2.5 mg tab 2.5 mg metolazone tab 5 mg metolazone tab 10 mg ENDOCRINE AND METABOLIC AGENTS - MISC. DENSITY REGULATORS alendronate sodium tab 5 mg alendronate sodium tab 10 mg alendronate sodium tab 35 mg Rx4L alendronate sodium tab 40 mg alendronate sodium tab 70 mg Rx4L (salmon) nasal soln 200 unit/act NATPARA INJ 25MCG PA; SP NATPARA INJ 50MCG PA; SP NATPARA INJ 75MCG PA; SP NATPARA INJ 100MCG PA; SP TYMLOS INJ PA; SP FERTILITY REGULATORS clomiphene citrate tab 50 mg PA GNRH/LHRH ANTAGONISTS ORILISSA TAB 150MG PA ORILISSA TAB 200MG PA GROWTH NORDITROPIN INJ 5/1.5ML PA; SP NORDITROPIN INJ 10/1.5ML PA; SP NORDITROPIN INJ 15/1.5ML PA; SP NORDITROPIN INJ 30/3ML PA; SP

OTC - Over the counter PA - Prior Authorization; refer to Prior Authorization section QL 63 - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program

Drug Name Requirements/Limits RECEPTOR MODULATORS hcl tab 60 mg LHRH/GNRH AGONIST ANALOG PITUITARY SUPPRESSANTS LUPANETA KIT 3.75-5 PA; SP LUPANETA KIT 11.25-5 PA; SP SYNAREL SOL 2MG/ML PA METABOLIC MODIFIERS cap 0.5 mcg calcitriol cap 0.25 mcg calcitriol inj 1 mcg/ml calcitriol oral soln 1 mcg/ml cap 0.5 mcg doxercalciferol cap 1 mcg doxercalciferol cap 2.5 mcg levocarnitine oral soln 1 gm/10ml (10%) paricalcitol cap 1 mcg paricalcitol cap 2 mcg paricalcitol cap 4 mcg sapropterin dihydrochloride powder packet 100 mg PA; SP sapropterin dihydrochloride powder packet 500 mg PA; SP sapropterin dihydrochloride tab 100 mg PA; SP STRENSIQ INJ 18/0.45 PA; SP STRENSIQ INJ 28/0.7ML PA; SP STRENSIQ INJ 40MG/ML PA; SP STRENSIQ INJ 80/0.8ML PA; SP HORMONES desmopressin acetate nasal soln 0.01% (refrigerated) desmopressin acetate soln 0.01% desmopressin acetate nasal spray soln 0.01% (refrigerated) desmopressin acetate tab 0.1 mg desmopressin acetate tab 0.2 mg NOCDURNA SUB 27.7MCG PA NOCDURNA SUB 55.3MCG PA NOCTIVA EMU 0.83/0.1 PA NOCTIVA SPR 1.66/0.1 PA STIMATE SOL 1.5MG/ML PA; SP INHIBITORS tab 0.5 mg RECEPTOR ANTAGONISTS tab 30 mg SP

OTC - Over the counter PA - Prior Authorization; refer to Prior Authorization section QL 64 - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program

Drug Name Requirements/Limits COMBINATIONS CLIMARA PRO DIS WEEKLY estradiol & norethindrone acetate tab 0.5-0.1 mg estradiol & norethindrone acetate tab 1-0.5 mg fyavolv tab 1-5 jevantique l tab 0.5-2.5 PREFEST TAB PREMPHASE TAB PREMPRO TAB PREMPRO TAB 0.3-1.5 PREMPRO TAB 0.45-1.5 PREMPRO TAB 0.625-5 ESTROGENS estradiol tab 0.5 mg estradiol tab 1 mg estradiol tab 2 mg estradiol td patch twice weekly 0.1 mg/24hr estradiol td patch weekly 0.1 mg/24hr estradiol td patch weekly 0.05 mg/24hr estradiol td patch weekly 0.06 mg/24hr estradiol td patch weekly 0.025 mg/24hr estradiol td patch weekly 0.075 mg/24hr estradiol td patch weekly 0.0375 mg/24hr (37.5 mcg/24hr) estropipate tab 0.75 mg estropipate tab 1.5 mg estropipate tab 3 mg PREMARIN TAB 0.3MG PREMARIN TAB 0.9MG PREMARIN TAB 0.45MG PREMARIN TAB 0.625MG PREMARIN TAB 1.25MG FLUOROQUINOLONES FLUOROQUINOLONES hcl tab 100 mg (base equiv) ciprofloxacin hcl tab 250 mg (base equiv) ciprofloxacin hcl tab 500 mg (base equiv) ciprofloxacin hcl tab 750 mg (base equiv) ciprofloxacin-ciprofloxacin hcl tab er 24hr 500 mg (base eq) ciprofloxacin-ciprofloxacin hcl tab er 24hr 1000 mg(base eq) oral soln 25 mg/ml

OTC - Over the counter PA - Prior Authorization; refer to Prior Authorization section QL 65 - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program

Drug Name Requirements/Limits levofloxacin tab 250 mg levofloxacin tab 500 mg levofloxacin tab 750 mg GASTROINTESTINAL AGENTS - MISC. 5-HT4 RECEPTOR AGONISTS MOTEGRITY TAB 1MG PA MOTEGRITY TAB 2MG PA AGENTS FOR CHRONIC IDIOPATHIC (CIC) TRULANCE TAB 3MG PA GALLSTONE SOLUBILIZING AGENTS ursodiol cap 300 mg ursodiol tab 250 mg ursodiol tab 500 mg GASTROINTESTINAL ACTIVATORS lubiprostone cap 8 mcg PA lubiprostone cap 24 mcg PA GASTROINTESTINAL STIMULANTS hcl soln 5 mg/5ml (10 mg/10ml) (base equiv) metoclopramide hcl tab 5 mg (base equivalent) metoclopramide hcl tab 10 mg (base equivalent) INFLAMMATORY BOWEL AGENTS ASACOL HD TAB 800MG balsalazide disodium cap 750 mg DIPENTUM CAP 250MG mesalamine cap er 24hr 0.375 gm mesalamine enema 4 gm mesalamine rectal enema 4 gm & cleanser wipe kit mesalamine suppos 1000 mg mesalamine tab delayed release 1.2 gm mesalamine tab delayed release 800 mg PENTASA CAP 250MG CR PENTASA CAP 500MG CR sulfasalazine tab 500 mg sulfasalazine tab delayed release 500 mg INTESTINAL lactulose (encephalopathy) solution 10 gm/15ml (IBS) AGENTS LINZESS CAP 72MCG PA LINZESS CAP 145MCG PA LINZESS CAP 290MCG PA ZELNORM TAB 6MG PA

OTC - Over the counter PA - Prior Authorization; refer to Prior Authorization section QL 66 - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program

Drug Name Requirements/Limits PERIPHERAL ANTAGONISTS MOVANTIK TAB 12.5MG PA, QL (30 tabs / 30 days) MOVANTIK TAB 25MG PA, QL (30 tabs / 30 days) SYMPROIC TAB 0.2MG PA PHOSPHATE BINDER AGENTS calcium acetate (phosphate binder) cap 667 mg (169 mg ca) sevelamer carbonate packet 0.8 gm sevelamer carbonate packet 2.4 gm sevelamer carbonate tab 800 mg GENITOURINARY AGENTS - MISCELLANEOUS ACIDIFIERS K-PHOS TAB NO 2 ALKALINIZERS potassium citrate & soln 1100-334 mg/5ml potassium citrate tab er 5 meq (540 mg) potassium citrate tab er 10 meq (1080 mg) potassium citrate tab er 15 meq (1620 mg) PROSTATIC HYPERTROPHY AGENTS hcl tab er 24hr 10 mg finasteride tab 5 mg hcl cap 0.4 mg URINARY ANALGESICS hcl tab 100 mg phenazopyridine hcl tab 200 mg AGENTS GOUT AGENTS allopurinol tab 100 mg Rx4L allopurinol tab 300 mg Rx4L colchicine tab 0.6 mg QL (60 tabs / 30 days) URICOSURICS probenecid tab 500 mg HEMATOLOGICAL AGENTS - MISC. COMPLEMENT INHIBITORS SOLIRIS INJ 10MG/ML PA; SP PLASMA KALLIKREIN INHIBITORS TAKHZYRO INJ 300/2ML PA; SP AGGREGATION INHIBITORS anagrelide hcl cap 0.5 mg anagrelide hcl cap 1 mg BRILINTA TAB 60MG

OTC - Over the counter PA - Prior Authorization; refer to Prior Authorization section QL 67 - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program

Drug Name Requirements/Limits BRILINTA TAB 90MG tab 50 mg cilostazol tab 100 mg bisulfate tab 75 mg (base equiv) clopidogrel bisulfate tab 300 mg (base equiv) tab 25 mg dipyridamole tab 50 mg dipyridamole tab 75 mg hcl tab 5 mg (base equiv) QL (30 tabs / 30 days) prasugrel hcl tab 10 mg (base equiv) QL (30 tabs / 30 days) HEMATOPOIETIC AGENTS AGENTS FOR SICKLE CELL DROXIA CAP 200MG DROXIA CAP 300MG DROXIA CAP 400MG COBALAMINS inj 1000 mcg/ml FOLIC ACID/ folic acid tab 1 mg Rx4L HEMATOPOIETIC GROWTH FACTORS ARANESP INJ 10MCG PA; SP ARANESP INJ 25MCG PA; SP ARANESP INJ 40MCG PA; SP ARANESP INJ 60MCG PA; SP ARANESP INJ 100MCG PA; SP ARANESP INJ 150MCG PA; SP ARANESP INJ 200MCG PA; SP ARANESP INJ 300MCG PA; SP ARANESP INJ 500MCG PA; SP DOPTELET TAB 20MG PA; SP GRANIX INJ 300/0.5 PA; SP GRANIX INJ 300/1ML PA; SP GRANIX INJ 480/0.8 PA; SP GRANIX INJ 480/1.6 PA; SP MULPLETA TAB 3MG PA; SP NEULASTA INJ 6MG/0.6M PA; SP NEULASTA KIT 6MG/0.6M PA; SP NEUPOGEN INJ 300/0.5 PA; SP NEUPOGEN INJ 300MCG PA; SP NEUPOGEN INJ 480/0.8 PA; SP NEUPOGEN INJ 480MCG PA; SP PROCRIT INJ 2000/ML PA; SP PROCRIT INJ 3000/ML PA; SP

OTC - Over the counter PA - Prior Authorization; refer to Prior Authorization section QL 68 - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program

Drug Name Requirements/Limits PROCRIT INJ 4000/ML PA; SP PROCRIT INJ 10000/ML PA; SP PROCRIT INJ 20000/ML PA; SP PROCRIT INJ 40000/ML PA; SP PROMACTA PAK 25MG PA; SP PROMACTA POW 12.5MG PA; SP PROMACTA TAB 12.5MG PA; SP PROMACTA TAB 25MG PA; SP PROMACTA TAB 50MG PA; SP PROMACTA TAB 75MG PA; SP ZARXIO INJ 300/0.5 PA; SP ZARXIO INJ 480/0.8 PA; SP HEMATOPOIETIC MIXTURES av-vite fb tab 2.5-25-1 fabb tab 2.2-25-1 folplex 2.2 tab HEMOSTATICS HEMOSTATICS - SYSTEMIC aminocaproic acid tab 1000 mg tranexamic acid tab 650 mg QL (30 tabs / 30 days) // DISORDER AGENTS HYPNOTICS elixir 20 mg/5ml phenobarbital tab 15 mg phenobarbital tab 16.2 mg phenobarbital tab 30 mg phenobarbital tab 32.4 mg phenobarbital tab 60 mg phenobarbital tab 64.8 mg phenobarbital tab 97.2 mg phenobarbital tab 100 mg NON-BARBITURATE HYPNOTICS tab 1 mg QL (30 tabs / 30 days) eszopiclone tab 2 mg QL (30 tabs / 30 days) eszopiclone tab 3 mg QL (30 tabs / 30 days) cap 15 mg QL (30 ea / 30 days) temazepam cap 30 mg QL (30 ea / 30 days) cap 5 mg QL (30 caps / 30 days) zaleplon cap 10 mg QL (30 caps / 30 days) tartrate tab 5 mg QL (30 ea / 30 days) zolpidem tartrate tab 10 mg QL (30 ea / 30 days) zolpidem tartrate tab er 6.25 mg QL (30 ea / 30 days) zolpidem tartrate tab er 12.5 mg QL (30 ea / 30 days)

OTC - Over the counter PA - Prior Authorization; refer to Prior Authorization section QL 69 - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program

Drug Name Requirements/Limits SELECTIVE RECEPTOR AGONISTS tab 8 mg QL (30 tabs / 30 days) COMBINATIONS gavilyte-h kit GOLYTELY SOL peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240 gm peg 3350-kcl-sod bicarb-nacl for soln 420 gm SUPREP BOWEL SOL PREP KIT LAXATIVES - MISCELLANEOUS constulose sol 10gm/15 MACROLIDES AZITHROMYCIN azithromycin for susp 100 mg/5ml azithromycin for susp 200 mg/5ml azithromycin powd pack for susp 1 gm azithromycin tab 250 mg azithromycin tab 500 mg azithromycin tab 600 mg clarithromycin for susp 125 mg/5ml clarithromycin for susp 250 mg/5ml clarithromycin tab 250 mg clarithromycin tab 500 mg clarithromycin tab er 24hr 500 mg e.e.s. 400 tab 400mg erythrocin tab 250mg erythromycin ethylsuccinate for susp 200 mg/5ml erythromycin tab 250 mg erythromycin tab 500 mg erythromycin w/ delayed release particles cap 250 mg MEDICAL DEVICES AND SUPPLIES DIABETIC SUPPLIES LANCETS MIS ORIGINAL OTC OMNIPOD MIS 5 PACK QL (2 boxes / 30 days) ONE TOUCH KIT VERIO FL OTC ONETOUCH KIT ULTRA 2 OTC ONETOUCH KIT VERIO RE OTC

OTC - Over the counter PA - Prior Authorization; refer to Prior Authorization section QL 70 - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program

Drug Name Requirements/Limits RESPIRATORY THERAPY SUPPLIES AEROCHAMBER MIS PLUS FLEXICHAMBER MIS MASK SM INSPIREASE MIS MOUTHPCE INSPIREASE MIS RES BAG PRODUCTS MIGRAINE PRODUCTS - MONOCLONAL ANTIBODIES AIMOVIG INJ 70MG/ML PA AIMOVIG INJ 140MG/ML PA NURTEC TAB 75MG ODT PA, QL (15 tabs / 30 days) UBRELVY TAB 50MG PA, QL (16 tabs / 30 days) UBRELVY TAB 100MG PA, QL (16 tabs / 30 days) SEROTONIN AGONISTS hydrobromide tab 20 mg (base QL (12 tabs / 30 days) equivalent) eletriptan hydrobromide tab 40 mg (base QL (12 tabs / 30 days) equivalent) hcl tab 1 mg (base equiv) QL (12 tabs / 30 days) naratriptan hcl tab 2.5 mg (base equiv) QL (12 tabs / 30 days) REYVOW TAB 50MG PA, QL (4 tabs / 30 days) REYVOW TAB 100MG PA, QL (8 tabs / 30 days) benzoate oral disintegrating tab 5 mg QL (12 tabs / 30 days) (base eq) rizatriptan benzoate oral disintegrating tab 10 mg QL (12 tabs / 30 days) (base eq) rizatriptan benzoate tab 5 mg (base equivalent) QL (12 tabs / 30 days) rizatriptan benzoate tab 10 mg (base equivalent) QL (12 tabs / 30 days) nasal spray 5 mg/act QL (6 inhalers / 30 days) sumatriptan nasal spray 20 mg/act QL (6 inhalers / 30 days) sumatriptan succinate inj 6 mg/0.5ml QL (10 injections / 30 days) sumatriptan succinate solution auto-injector 4 QL (10 injections / 30 days) mg/0.5ml sumatriptan succinate solution auto-injector 6 QL (10 injections / 30 days) mg/0.5ml sumatriptan succinate solution cartridge 4 QL (10 injections / 30 days) mg/0.5ml sumatriptan succinate solution cartridge 6 QL (10 injections / 30 days) mg/0.5ml sumatriptan succinate solution prefilled syringe 6 QL (10 injections / 30 days) mg/0.5ml sumatriptan succinate tab 25 mg QL (12 tabs / 30 days) sumatriptan succinate tab 50 mg QL (12 tabs / 30 days) sumatriptan succinate tab 100 mg QL (12 tabs / 30 days) tab 2.5 mg QL (12 tabs / 30 days)

OTC - Over the counter PA - Prior Authorization; refer to Prior Authorization section QL 71 - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program

Drug Name Requirements/Limits zolmitriptan tab 5 mg QL (12 tabs / 30 days) & ELECTROLYTES flura-drops dro 0.25mg f flura-drops dro 0.125mg ludent chw 0.5mg f ludent chw 0.25mg f ludent chw 1mg f sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml naf) sodium fluoride tab 0.5 mg f (from 1.1 mg naf) sodium fluoride tab 1 mg f (from 2.2 mg naf) PHOSPHATE K-PHOS TAB virt-phos tab 250 neut POTASSIUM klor-con 8 tab 8meq er klor-con m15 tab 15meq er KLOR-CON/25 POW 25MEQ potassium bicarbonate effer tab 25 meq potassium chloride cap er 8 meq potassium chloride cap er 10 meq potassium chloride microencapsulated crys er tab 10 meq potassium chloride microencapsulated crys er tab 20 meq potassium chloride oral soln 10% (20 meq/15ml) potassium chloride oral soln 20% (40 meq/15ml) potassium chloride powder packet 20 meq potassium chloride tab er 10 meq potassium chloride tab er 20 meq (1500 mg) SODIUM sodium chloride tab 1 gm OTC MISCELLANEOUS THERAPEUTIC CLASSES IMMUNOMODULATORS REVLIMID CAP 2.5MG PA; SP REVLIMID CAP 5MG PA; SP REVLIMID CAP 10MG PA; SP REVLIMID CAP 15MG PA; SP REVLIMID CAP 20MG PA; SP REVLIMID CAP 25MG PA; SP THALOMID CAP 50MG PA; SP; PA for new starts only

OTC - Over the counter PA - Prior Authorization; refer to Prior Authorization section QL 72 - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program

Drug Name Requirements/Limits THALOMID CAP 100MG PA; SP; PA for new starts only THALOMID CAP 150MG PA; SP; PA for new starts only THALOMID CAP 200MG PA; SP; PA for new starts only IMMUNOSUPPRESSIVE AGENTS AZASAN TAB 75 MG AZASAN TAB 100MG azathioprine tab 50 mg cyclosporine cap 25 mg SP cyclosporine cap 100 mg SP cyclosporine modified cap 25 mg SP cyclosporine modified cap 50 mg cyclosporine modified cap 100 mg SP cyclosporine modified oral soln 100 mg/ml SP ENSPRYNG INJ PA; SP mycophenolate mofetil cap 250 mg SP mycophenolate mofetil for oral susp 200 mg/ml SP mycophenolate mofetil tab 500 mg SP SANDIMMUNE CAP 25MG SP SANDIMMUNE CAP 100MG SP SANDIMMUNE SOL 100MG/ML SP oral soln 1 mg/ml SP sirolimus tab 0.5 mg SP sirolimus tab 1 mg SP sirolimus tab 2 mg SP tacrolimus cap 0.5 mg SP tacrolimus cap 1 mg SP tacrolimus cap 5 mg SP POTASSIUM REMOVING AGENTS sps sus 15gm/60 VELTASSA POW 8.4GM VELTASSA POW 16.8GM VELTASSA POW 25.2GM SYSTEMIC LUPUS ERYTHEMATOSUS AGENTS BENLYSTA INJ 200MG/ML PA; SP MOUTH/THROAT/DENTAL AGENTS ANESTHETICS TOPICAL ORAL FIRST-MOUTHW SUS BLM lidocaine hcl viscous soln 2% ANTI-INFECTIVES - THROAT clotrimazole troche 10 mg

OTC - Over the counter PA - Prior Authorization; refer to Prior Authorization section QL 73 - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program

Drug Name Requirements/Limits nystatin susp 100000 unit/ml - MOUTH/THROAT chlorhexidine gluconate soln 0.12% DENTAL PRODUCTS cavarest gel 1.1% sf 5000 plus cre 1.1% sod fluoride sol 0.2% STEROIDS - MOUTH/THROAT triamcinolone acetonide dental paste 0.1% THROAT PRODUCTS - MISC. hcl tab 5 mg pilocarpine hcl tab 7.5 mg B-COMPLEX W/ FOLIC ACID nephronex tab PED MULTI W/FL & FE ESCAVITE CHW multi-vit/fe dro /fl 0.25 tri-vit/fe dro /fl 0.25 PED MULTIPLE VITAMINS W/ MINERALS vitamax ped dro QL (300 mL / 30 days) PED MV W/ FLUORIDE multi-vit/fl dro 0.5mg/ml multi-vit/fl dro 0.25mg mvc-fluoride chw 0.5mg mvc-fluoride chw 0.25mg mvc-fluoride chw 1mg tri-vit/fluo dro 0.5mg tri-vit/fluo dro 0.25mg PRENATAL VITAMINS CITRANATAL MIS 90 DHA CITRANATAL PAK ASSURE CITRANATAL PAK DHA CITRANATAL PAK ESSENCE CITRANATAL TAB RX inatal adv tab PRENAISSANCE CAP BALANCE prenatal 19 chw tab prenatal 19 tab OTC VINACAL B MIS

OTC - Over the counter PA - Prior Authorization; refer to Prior Authorization section QL 74 - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program

Drug Name Requirements/Limits MUSCULOSKELETAL THERAPY AGENTS CENTRAL MUSCLE RELAXANTS tab 10 mg baclofen tab 20 mg tab 500 mg hcl tab 5 mg cyclobenzaprine hcl tab 10 mg tab 500 mg methocarbamol tab 750 mg citrate tab er 12hr 100 mg hcl tab 2 mg (base equivalent) tizanidine hcl tab 4 mg (base equivalent) DIRECT MUSCLE RELAXANTS dantrolene sodium cap 25 mg dantrolene sodium cap 50 mg dantrolene sodium cap 100 mg COMBINATIONS orphenadrine w/ aspirin & caffeine tab 50-770-60 mg NASAL AGENTS - SYSTEMIC AND TOPICAL NASAL ANTI-INFECTIVES BACTROBAN OIN NASAL 2% NASAL ANTIALLERGY hcl nasal spray 0.1% (137 mcg/spray) QL (2 bottles / 30 days) azelastine hcl nasal spray 0.15% (205.5 QL (1 bottle / 30 days) mcg/spray) hcl nasal soln 0.6% NASAL ANTICHOLINERGICS nasal soln 0.03% (21 mcg/spray) ipratropium bromide nasal soln 0.06% (42 mcg/spray) NASAL STEROIDS fluticasone propionate nasal susp 50 mcg/act QL (1 bottle / 30 days) mometasone furoate nasal susp 50 mcg/act NUTRIENTS PROTEINS cap 600 mg OPHTHALMIC AGENTS BETA-BLOCKERS - OPHTHALMIC hcl ophth soln 0.5% BETIMOL SOL 0.5% BETIMOL SOL 0.25%

OTC - Over the counter PA - Prior Authorization; refer to Prior Authorization section QL 75 - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program

Drug Name Requirements/Limits BETOPTIC-S SUS 0.25% OP COMBIGAN SOL 0.2/0.5% dorzolamide hcl-timolol maleate ophth sol 22.3-6.8 mg/ml pf dorzolamide hcl-timolol maleate ophth soln 22.3- 6.8 mg/ml hcl ophth soln 0.5% ophth soln 0.3% timolol maleate ophth gel forming soln 0.5% timolol maleate ophth gel forming soln 0.25% timolol maleate ophth soln 0.5% timolol maleate ophth soln 0.25% CYCLOPLEGIC MYDRIATICS atropine sul sol 1% op ISOPTO ATROP SOL 1% OP MIOTICS pilocarpine hcl ophth soln 1% pilocarpine hcl ophth soln 2% pilocarpine hcl ophth soln 4% OPHTHALMIC AGENTS tartrate ophth soln 0.2% brimonidine tartrate ophth soln 0.15% OPHTHALMIC ANTI-INFECTIVES ophth oint 500 unit/gm bacitracin-polymyxin b ophth oint ciprofloxacin hcl ophth soln 0.3% (base equivalent) erythromycin ophth oint 5 mg/gm gentamicin sulfate ophth oint 0.3% gentamicin sulfate ophth soln 0.3% levofloxacin ophth soln 0.5% hcl ophth soln 0.5% (base equiv) NATACYN SUS 5% OP neo-polycin oin op neomycin-polymy-gramicid op sol 1.75-10000- 0.025mg-unt-mg/ml ophth soln 0.3% polymyxin b-trimethoprim ophth soln 10000 unit/ml-0.1% sodium ophth soln 10% tobramycin ophth soln 0.3% trifluridine ophth soln 1%

OTC - Over the counter PA - Prior Authorization; refer to Prior Authorization section QL 76 - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program

Drug Name Requirements/Limits OPHTHALMIC STEROIDS dexamethasone sodium phosphate ophth soln 0.1% ophth susp 0.1% neo-polycin oin hc 1%op neomycin-polymyxin-dexamethasone ophth oint 0.1% neomycin-polymyxin-dexamethasone ophth susp 0.1% neomycin-polymyxin-hc ophth susp PRED MILD SUS 0.12% OP PRED SOD PHO SOL 1% OP ophth susp 1% sulfacetamide sodium-prednisolone ophth soln 10- 0.23(0.25)% tobramycin-dexamethasone ophth susp 0.3-0.1% OPHTHALMICS - MISC. azelastine hcl ophth soln 0.05% cromolyn sodium ophth soln 4% diclofenac sodium ophth soln 0.1% dorzolamide hcl ophth soln 2% ketorolac tromethamine ophth soln 0.4% ketorolac tromethamine ophth soln 0.5% olopatadine hcl ophth soln 0.1% (base equivalent) - OPHTHALMIC latanoprost ophth soln 0.005% OTIC AGENTS OTIC AGENTS - MISCELLANEOUS 2% in aluminum acetate otic soln acetic acid otic soln 2% OTIC ANTI-INFECTIVES ofloxacin otic soln 0.3% OTIC COMBINATIONS ciprofloxacin-dexamethasone otic susp 0.3-0.1% neomycin-polymyxin-hc otic soln 1% neomycin-polymyxin-hc otic susp 3.5 mg/ml- 10000 unit/ml-1% OTIC STEROIDS (otic) oil 0.01% QL (20 mL / 30 days) OXYTOCICS OXYTOCICS METHERGINE TAB 0.2MG

OTC - Over the counter PA - Prior Authorization; refer to Prior Authorization section QL 77 - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program

Drug Name Requirements/Limits PASSIVE IMMUNIZING AND TREATMENT AGENTS MONOCLONAL ANTIBODIES SYNAGIS INJ 50MG PA; ^, SP SYNAGIS INJ 100MG/ML PA; ^, SP AMINOPENICILLINS amoxicillin (trihydrate) cap 250 mg amoxicillin (trihydrate) cap 500 mg amoxicillin (trihydrate) chew tab 125 mg amoxicillin (trihydrate) chew tab 250 mg amoxicillin (trihydrate) for susp 125 mg/5ml amoxicillin (trihydrate) for susp 200 mg/5ml amoxicillin (trihydrate) for susp 250 mg/5ml amoxicillin (trihydrate) for susp 400 mg/5ml amoxicillin (trihydrate) tab 500 mg amoxicillin (trihydrate) tab 875 mg ampicillin cap 250 mg ampicillin cap 500 mg ampicillin for susp 125 mg/5ml ampicillin for susp 250 mg/5ml NATURAL PENICILLINS v potassium for soln 125 mg/5ml penicillin v potassium for soln 250 mg/5ml penicillin v potassium tab 250 mg penicillin v potassium tab 500 mg PENICILLIN COMBINATIONS amoxicillin & k clavulanate chew tab 200-28.5 mg amoxicillin & k clavulanate chew tab 400-57 mg amoxicillin & k clavulanate for susp 200-28.5 mg/5ml amoxicillin & k clavulanate for susp 250-62.5 mg/5ml amoxicillin & k clavulanate for susp 400-57 mg/5ml amoxicillin & k clavulanate for susp 600-42.9 mg/5ml amoxicillin & k clavulanate tab 250-125 mg amoxicillin & k clavulanate tab 500-125 mg amoxicillin & k clavulanate tab 875-125 mg AUGMENTIN SUS 125/5ML PENICILLINASE-RESISTANT PENICILLINS sodium cap 250 mg dicloxacillin sodium cap 500 mg

OTC - Over the counter PA - Prior Authorization; refer to Prior Authorization section QL 78 - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program

Drug Name Requirements/Limits PROGESTINS PROGESTINS medroxyprogesterone acetate tab 2.5 mg medroxyprogesterone acetate tab 5 mg medroxyprogesterone acetate tab 10 mg norethindrone acetate tab 5 mg cap 100 mg progesterone cap 200 mg PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. AGENTS FOR CHEMICAL DEPENDENCY acamprosate calcium tab delayed release 333 mg disulfiram tab 250 mg disulfiram tab 500 mg ANTI-CATAPLECTIC AGENTS XYREM SOL 500MG/ML PA ANTIDEMENTIA AGENTS ARICEPT TAB 23MG donepezil hydrochloride orally disintegrating tab 5 mg donepezil hydrochloride orally disintegrating tab 10 mg donepezil hydrochloride tab 5 mg donepezil hydrochloride tab 10 mg donepezil hydrochloride tab 23 mg galantamine hydrobromide cap er 24hr 8 mg galantamine hydrobromide cap er 24hr 16 mg galantamine hydrobromide cap er 24hr 24 mg galantamine hydrobromide oral soln 4 mg/ml galantamine hydrobromide tab 4 mg galantamine hydrobromide tab 8 mg galantamine hydrobromide tab 12 mg hcl oral solution 2 mg/ml memantine hcl tab 5 mg memantine hcl tab 10 mg memantine hcl tab 28 x 5 mg & 21 x 10 mg titration pack rivastigmine tartrate cap 1.5 mg (base equivalent) rivastigmine tartrate cap 3 mg (base equivalent) rivastigmine tartrate cap 4.5 mg (base equivalent) rivastigmine tartrate cap 6 mg (base equivalent) rivastigmine td patch 24hr 4.6 mg/24hr PA rivastigmine td patch 24hr 9.5 mg/24hr PA rivastigmine td patch 24hr 13.3 mg/24hr PA

OTC - Over the counter PA - Prior Authorization; refer to Prior Authorization section QL 79 - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program

Drug Name Requirements/Limits COMBINATION PSYCHOTHERAPEUTICS perphenazine-amitriptyline tab 2-10 mg perphenazine-amitriptyline tab 2-25 mg perphenazine-amitriptyline tab 4-10 mg perphenazine-amitriptyline tab 4-25 mg perphenazine-amitriptyline tab 4-50 mg AGENTS SAVELLA MIS TITR PAK QL (60 tabs / 30 days) SAVELLA TAB 12.5MG QL (60 tabs / 30 days) SAVELLA TAB 25MG QL (60 tabs / 30 days) SAVELLA TAB 50MG QL (60 tabs / 30 days) SAVELLA TAB 100MG QL (60 tabs / 30 days) MULTIPLE SCLEROSIS AGENTS AUBAGIO TAB 7MG PA; SP AUBAGIO TAB 14MG PA; SP AVONEX KIT 30MCG PA; SP AVONEX PEN KIT 30MCG PA; SP AVONEX PREFL KIT 30MCG PA; SP COPAXONE INJ 40MG/ML PA; SP dimethyl fumarate capsule delayed release 120 mg PA; SP dimethyl fumarate capsule delayed release 240 mg PA; SP dimethyl fumarate capsule dr starter pack 120 mg PA; SP & 240 mg EXTAVIA INJ 0.3MG PA; SP GILENYA CAP 0.5MG PA; SP glatiramer acetate soln prefilled syringe 40 mg/ml PA; SP glatopa inj 20mg/ml PA; SP MAVENCLAD PAK 10MG (4) PA; SP; RxC/M MAVENCLAD PAK 10MG (5) PA; SP; RxC/M MAVENCLAD PAK 10MG (6) PA; SP; RxC/M MAVENCLAD PAK 10MG (7) PA; SP; RxC/M MAVENCLAD PAK 10MG (8) PA; SP; RxC/M MAVENCLAD PAK 10MG (9) PA; SP; RxC/M MAVENCLAD PAK 10MG(10) PA; SP; RxC/M MAYZENT TAB 0.25MG PA; SP; RxC/M MAYZENT TAB 2MG PA; SP; RxC/M REBIF INJ 22/0.5 PA; SP REBIF INJ 44/0.5 PA; SP REBIF REBIDO INJ 22/0.5 PA; SP REBIF REBIDO INJ 44/0.5 PA; SP REBIF REBIDO INJ TITRATN PA; SP REBIF TITRTN INJ PACK PA; SP ZEPOSIA 7DAY CAP STR PACK PA; SP ZEPOSIA CAP .92MG PA; SP

OTC - Over the counter PA - Prior Authorization; refer to Prior Authorization section QL 80 - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program

Drug Name Requirements/Limits ZEPOSIA CAP STR KIT PA; SP PSEUDOBULBAR AFFECT (PBA) AGENTS NUEDEXTA CAP 20-10MG PA SMOKING DETERRENTS bupropion hcl (smoking deterrent) tab er 12hr 150 mg CHANTIX PAK 0.5& 1MG CHANTIX PAK 1MG CHANTIX TAB 0.5MG NICOTROL INH NICOTROL NS SPR 10MG/ML RESPIRATORY AGENTS - MISC. AGENTS KALYDECO PAK 25MG PA; SP KALYDECO PAK 50MG PA; SP KALYDECO PAK 75MG PA; SP KALYDECO TAB 150MG PA; SP ORKAMBI GRA 100-125 PA; SP ORKAMBI GRA 150-188 PA; SP ORKAMBI TAB 100-125 PA; SP ORKAMBI TAB 200-125 PA; SP PULMOZYME SOL 1MG/ML PA; SP SYMDEKO TAB 50-75MG PA; SP SYMDEKO TAB 100-150 PA; SP TRIKAFTA TAB PA; SP PULMONARY FIBROSIS AGENTS ESBRIET CAP 267MG PA; SP ESBRIET TAB 267MG PA; SP ESBRIET TAB 801MG PA; SP OFEV CAP 100MG PA; SP OFEV CAP 150MG PA; SP TETRACYCLINES doxycycline hyclate cap 50 mg doxycycline hyclate cap 100 mg doxycycline hyclate tab 20 mg doxycycline hyclate tab 100 mg doxycycline monohydrate for susp 25 mg/5ml QL (60 mL / 30 days) hcl cap 50 mg minocycline hcl cap 75 mg minocycline hcl cap 100 mg minocycline hcl tab 50 mg minocycline hcl tab 75 mg

OTC - Over the counter PA - Prior Authorization; refer to Prior Authorization section QL 81 - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program

Drug Name Requirements/Limits minocycline hcl tab 100 mg hcl cap 250 mg tetracycline hcl cap 500 mg AGENTS ANTITHYROID AGENTS methimazole tab 5 mg methimazole tab 10 mg tab 50 mg ARMOUR THYRO TAB 15MG ARMOUR THYRO TAB 30MG ARMOUR THYRO TAB 60MG ARMOUR THYRO TAB 90MG ARMOUR THYRO TAB 120MG ARMOUR THYRO TAB 180MG ARMOUR THYRO TAB 240MG ARMOUR THYRO TAB 300MG sodium tab 25 mcg levothyroxine sodium tab 50 mcg levothyroxine sodium tab 75 mcg levothyroxine sodium tab 88 mcg levothyroxine sodium tab 100 mcg levothyroxine sodium tab 112 mcg levothyroxine sodium tab 125 mcg levothyroxine sodium tab 137 mcg levothyroxine sodium tab 150 mcg levothyroxine sodium tab 175 mcg levothyroxine sodium tab 200 mcg levothyroxine sodium tab 300 mcg levoxyl tab 25mcg levoxyl tab 50mcg levoxyl tab 75mcg levoxyl tab 88mcg levoxyl tab 100mcg levoxyl tab 112mcg levoxyl tab 125mcg levoxyl tab 137mcg levoxyl tab 150mcg levoxyl tab 175mcg levoxyl tab 200mcg sodium tab 5 mcg liothyronine sodium tab 25 mcg liothyronine sodium tab 50 mcg np thyroid tab 15mg

OTC - Over the counter PA - Prior Authorization; refer to Prior Authorization section QL 82 - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program

Drug Name Requirements/Limits np thyroid tab 30mg np thyroid tab 60mg np thyroid tab 90mg np thyroid tab 120mg SYNTHROID TAB 25MCG SYNTHROID TAB 50MCG SYNTHROID TAB 75MCG SYNTHROID TAB 88MCG SYNTHROID TAB 100MCG SYNTHROID TAB 112MCG SYNTHROID TAB 125MCG SYNTHROID TAB 137MCG SYNTHROID TAB 150MCG SYNTHROID TAB 175MCG SYNTHROID TAB 200MCG SYNTHROID TAB 300MCG ULCER DRUGS CUVPOSA SOL 1MG/5ML PA dicyclomine hcl cap 10 mg dicyclomine hcl oral soln 10 mg/5ml dicyclomine hcl tab 20 mg glycopyrrolate tab 1 mg glycopyrrolate tab 2 mg H-2 ANTAGONISTS hcl soln 300 mg/5ml cimetidine tab 300 mg cimetidine tab 400 mg cimetidine tab 800 mg for susp 40 mg/5ml famotidine tab 20 mg QL (60 tabs / 30 days) famotidine tab 40 mg cap 150 mg nizatidine cap 300 mg nizatidine oral soln 15 mg/ml hcl syrup 15 mg/ml (75 mg/5ml) ranitidine hcl tab 150 mg QL (60 tabs / 30 days) ranitidine hcl tab 300 mg MISC. ANTI-ULCER susp 1 gm/10ml sucralfate tab 1 gm PUMP INHIBITORS lansoprazole cap delayed release 30 mg QL (60 caps / 30 days)

OTC - Over the counter PA - Prior Authorization; refer to Prior Authorization section QL 83 - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program

Drug Name Requirements/Limits LANSOPRAZOLE SUS 3MG/ML lansoprazole tab delayed release orally Covered for members age 6 disintegrating 15 mg and under lansoprazole tab delayed release orally Covered for members age 6 disintegrating 30 mg and under + SUS SYRSPEND omeprazole cap delayed release 10 mg omeprazole cap delayed release 20 mg omeprazole cap delayed release 40 mg pantoprazole sodium ec tab 20 mg (base equiv) QL (30 tabs / 30 days) pantoprazole sodium ec tab 40 mg (base equiv) QL (60 tabs / 30 days) rabeprazole sodium ec tab 20 mg ULCER DRUGS - PROSTAGLANDINS misoprostol tab 100 mcg misoprostol tab 200 mcg ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS ANTISPASMODICS sulfate elixir 0.125 mg/5ml hyoscyamine sulfate sl tab 0.125 mg hyoscyamine sulfate soln 0.125 mg/ml hyoscyamine sulfate tab 0.125 mg hyoscyamine sulfate tab disint 0.125 mg PROTON PUMP INHIBITORS esomepra mag cap 40mg dr QL (60 caps / 30 days) cap delayed release 20 QL (60 caps / 30 days) mg (base eq) URINARY ANTI-INFECTIVES URINARY ANTI-INFECTIVES METHENAMINE HIPPURATE TAB 1 GM macrocrystalline cap 25 mg nitrofurantoin macrocrystalline cap 50 mg nitrofurantoin macrocrystalline cap 100 mg nitrofurantoin monohydrate macrocrystalline cap 100 mg nitrofurantoin susp 25 mg/5ml URINARY ANTISPASMODICS URINARY - ANTIMUSCARINICS (ANTICHOLINERGIC) chloride syrup 5 mg/5ml oxybutynin chloride tab 5 mg oxybutynin chloride tab er 24hr 5 mg oxybutynin chloride tab er 24hr 10 mg oxybutynin chloride tab er 24hr 15 mg

OTC - Over the counter PA - Prior Authorization; refer to Prior Authorization section QL 84 - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program

Drug Name Requirements/Limits succinate tab 5 mg solifenacin succinate tab 10 mg tartrate cap er 24hr 2 mg tolterodine tartrate cap er 24hr 4 mg tolterodine tartrate tab 1 mg tolterodine tartrate tab 2 mg cap er 24hr 60 mg trospium chloride tab 20 mg URINARY ANTISPASMODICS - CHOLINERGIC AGONISTS chloride tab 5 mg bethanechol chloride tab 10 mg bethanechol chloride tab 25 mg bethanechol chloride tab 50 mg VAGINAL PRODUCTS VAGINAL ANTI-INFECTIVES CLEOCIN SUP 100MG clindamycin phosphate vaginal cream 2% clotrimazole vaginal cream 2% OTC metronidazole vaginal gel 0.75% 3 sup 200mg vaginal cream 0.4% terconazole vaginal cream 0.8% terconazole vaginal suppos 80 mg VAGINAL ESTROGENS estradiol vaginal cream 0.1 mg/gm FEMRING MIS 0.1MG/24 FEMRING MIS 0.05/24H PREMARIN VAG CRE 0.625MG YUVAFEM TAB 10MCG VASOPRESSORS THERAPY AGENTS epinephrine solution auto-injector 0.3 mg/0.3ml QL (4 pens / year) (1:1000) epinephrine solution auto-injector 0.15 mg/0.3ml QL (4 pens / year) (1:2000) epinephrine solution auto-injector 0.15 mg/0.15ml QL (4 pens / year) (1:1000) EPIPEN 2-PAK INJ 0.3MG QL (4 pens / year) EPIPEN-JR INJ 0.15MG QL (4 pens / year) VASOPRESSORS hcl tab 2.5 mg midodrine hcl tab 5 mg midodrine hcl tab 10 mg

OTC - Over the counter PA - Prior Authorization; refer to Prior Authorization section QL 85 - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program

Drug Name Requirements/Limits VITAMINS OIL SOLUBLE VITAMINS cap 1.25 mg (50000 unit) phytonadione tab 5 mg

OTC - Over the counter PA - Prior Authorization; refer to Prior Authorization section QL 86 - Quantity Limitations; refer to Prescription Quantity Management section RX4L - Rx4Less list RxC/M - Pharmacy Care Management Program

Index A ADEMPAS TAB 2MG ...... 54 abacavir sulfate soln 20 mg/ml (base ADMELOG INJ 100U/ML ...... 27 equiv) ...... 47 ADMELOG SOLO INJ 100U/ML ...... 27 abacavir sulfate tab 300 mg (base AEMCOLO TAB 194MG ...... 14 equiv) ...... 47 AEROCHAMBER MIS PLUS ...... 71 abacavir sulfate-lamivudine tab 600- AFINITOR TAB 10MG ...... 37 300 mg ...... 47 AIMOVIG INJ 140MG/ML ...... 71 abacavir sulfate-lamivudine-zidovudine AIMOVIG INJ 70MG/ML ...... 71 tab 300-150-300 mg ...... 47 albendazole tab 200 mg ...... 13 ABILIFY MAIN INJ 300MG ...... 46 albuterol sulfate inhal aero 108 ABILIFY MAIN INJ 400MG ...... 46 mcg/act (90mcg base equiv) ...... 18 acamprosate calcium tab delayed albuterol sulfate soln nebu 0.083% release 333 mg ...... 79 (2.5 mg/3ml) ...... 18 acarbose tab 100 mg ...... 25 albuterol sulfate soln nebu 0.5% (5 acarbose tab 25 mg ...... 25 mg/ml) ...... 18 acarbose tab 50 mg ...... 25 albuterol sulfate soln nebu 0.63 acebutolol hcl cap 200 mg ...... 51 mg/3ml (base equiv) ...... 18 acebutolol hcl cap 400 mg ...... 51 albuterol sulfate soln nebu 1.25 acetaminophen w/ codeine soln 120-12 mg/3ml (base equiv) ...... 18 mg/5ml ...... 12 albuterol sulfate syrup 2 mg/5ml ..... 18 acetaminophen w/ codeine tab 300-15 albuterol sulfate tab 2 mg ...... 18 mg ...... 12 albuterol sulfate tab 4 mg ...... 18 acetaminophen w/ codeine tab 300-30 albuterol sulfate tab er 12hr 4 mg .... 18 mg ...... 12 albuterol sulfate tab er 12hr 8 mg .... 18 acetaminophen w/ codeine tab 300-60 alclometasone dipropionate oint 0.05% mg ...... 12 ...... 60 acetazolamide cap er 12hr 500 mg ... 62 alendronate sodium tab 10 mg ...... 63 acetazolamide tab 125 mg...... 62 alendronate sodium tab 35 mg ...... 63 acetazolamide tab 250 mg...... 62 alendronate sodium tab 40 mg ...... 63 acetic acid 2% in aluminum acetate alendronate sodium tab 5 mg ...... 63 otic soln ...... 77 alendronate sodium tab 70 mg ...... 63 acetic acid otic soln 2% ...... 77 alfuzosin hcl tab er 24hr 10 mg ...... 67 acetylcysteine cap 600 mg ...... 75 allopurinol tab 100 mg ...... 67 ACTEMRA INJ 162/0.9 ...... 9 allopurinol tab 300 mg ...... 67 ACTEMRA INJ ACTPEN ...... 9 alogliptin benzoate tab 12.5 mg (base acyclovir cap 200 mg ...... 50 equiv) ...... 26 acyclovir susp 200 mg/5ml ...... 50 alogliptin benzoate tab 25 mg (base acyclovir tab 400 mg ...... 50 equiv) ...... 26 acyclovir tab 800 mg ...... 50 alogliptin benzoate tab 6.25 mg (base adapalene gel 0.1% ...... 58 equiv) ...... 26 adapalene gel 0.3% ...... 58 alogliptin-metformin hcl tab 12.5-1000 adefovir dipivoxil tab 10 mg ...... 50 mg ...... 25 ADEMPAS TAB 0.5MG ...... 54 alogliptin-metformin hcl tab 12.5-500 ADEMPAS TAB 1.5MG ...... 54 mg ...... 25 ADEMPAS TAB 1MG ...... 54 alprazolam orally disintegrating tab ADEMPAS TAB 2.5MG ...... 54 0.25 mg ...... 15 87 alprazolam orally disintegrating tab 0.5 amlodipine besylate-benazepril hcl cap mg ...... 15 5-20 mg ...... 33 alprazolam orally disintegrating tab 1 amlodipine besylate-benazepril hcl cap mg ...... 15 5-40 mg ...... 33 alprazolam orally disintegrating tab 2 amoxapine tab 100 mg ...... 25 mg ...... 15 amoxapine tab 150 mg ...... 25 alprazolam tab 0.25 mg ...... 15 amoxapine tab 25 mg ...... 24 alprazolam tab 0.5 mg ...... 15 amoxapine tab 50 mg ...... 24 alprazolam tab 0.5mg xr ...... 15 amoxicillin & k clavulanate chew tab alprazolam tab 1 mg ...... 15 200-28.5 mg ...... 78 alprazolam tab 1mg xr ...... 15 amoxicillin & k clavulanate chew tab alprazolam tab 2 mg ...... 16 400-57 mg ...... 78 alprazolam tab 2mg xr ...... 16 amoxicillin & k clavulanate for susp alprazolam tab 3mg xr ...... 16 200-28.5 mg/5ml ...... 78 ALVESCO AER 160MCG ...... 17 amoxicillin & k clavulanate for susp ALVESCO AER 80MCG ...... 17 250-62.5 mg/5ml ...... 78 amantadine hcl cap 100 mg ...... 41 amoxicillin & k clavulanate for susp amantadine hcl syrup 50 mg/5ml ..... 41 400-57 mg/5ml ...... 78 amantadine hcl tab 100 mg ...... 41 amoxicillin & k clavulanate for susp ambrisentan tab 10 mg ...... 54 600-42.9 mg/5ml ...... 78 ambrisentan tab 5 mg ...... 54 amoxicillin & k clavulanate tab 250-125 amiloride & hydrochlorothiazide tab 5- mg ...... 78 50 mg ...... 62 amoxicillin & k clavulanate tab 500-125 amiloride hcl tab 5 mg ...... 63 mg ...... 78 aminocaproic acid tab 1000 mg ...... 69 amoxicillin & k clavulanate tab 875-125 amiodarone hcl tab 200 mg ...... 16 mg ...... 78 amiodarone hcl tab 400 mg ...... 16 amoxicillin (trihydrate) cap 250 mg .. 78 amitriptyline hcl tab 10 mg ...... 24 amoxicillin (trihydrate) cap 500 mg .. 78 amitriptyline hcl tab 100 mg ...... 24 amoxicillin (trihydrate) chew tab 125 amitriptyline hcl tab 150 mg ...... 24 mg ...... 78 amitriptyline hcl tab 25 mg ...... 24 amoxicillin (trihydrate) chew tab 250 amitriptyline hcl tab 50 mg ...... 24 mg ...... 78 amitriptyline hcl tab 75 mg ...... 24 amoxicillin (trihydrate) for susp 125 amlodipine besylate tab 10 mg (base mg/5ml ...... 78 equivalent) ...... 52 amoxicillin (trihydrate) for susp 200 amlodipine besylate tab 2.5 mg (base mg/5ml ...... 78 equivalent) ...... 52 amoxicillin (trihydrate) for susp 250 amlodipine besylate tab 5 mg (base mg/5ml ...... 78 equivalent) ...... 52 amoxicillin (trihydrate) for susp 400 amlodipine besylate-benazepril hcl cap mg/5ml ...... 78 10-20 mg ...... 33 amoxicillin (trihydrate) tab 500 mg .. 78 amlodipine besylate-benazepril hcl cap amoxicillin (trihydrate) tab 875 mg .. 78 10-40 mg ...... 33 amphetamine-dextroamphetamine cap amlodipine besylate-benazepril hcl cap er 24hr 10 mg ...... 6 2.5-10 mg ...... 33 amphetamine-dextroamphetamine cap amlodipine besylate-benazepril hcl cap er 24hr 15 mg ...... 6 5-10 mg ...... 33 88 amphetamine-dextroamphetamine cap ARANESP INJ 500MCG ...... 68 er 24hr 20 mg ...... 6 ARANESP INJ 60MCG ...... 68 amphetamine-dextroamphetamine cap ARICEPT TAB 23MG ...... 79 er 24hr 25 mg ...... 6 aripiprazole oral solution 1 mg/ml .... 46 amphetamine-dextroamphetamine cap aripiprazole orally disintegrating tab 10 er 24hr 30 mg ...... 6 mg ...... 46 amphetamine-dextroamphetamine cap aripiprazole orally disintegrating tab 15 er 24hr 5 mg ...... 6 mg ...... 46 amphetamine-dextroamphetamine tab aripiprazole tab 10 mg ...... 46 10 mg ...... 6 aripiprazole tab 15 mg ...... 46 amphetamine-dextroamphetamine tab aripiprazole tab 2 mg ...... 46 12.5 mg ...... 6 aripiprazole tab 20 mg ...... 46 amphetamine-dextroamphetamine tab aripiprazole tab 30 mg ...... 46 15 mg ...... 6 aripiprazole tab 5 mg ...... 46 amphetamine-dextroamphetamine tab ARISTADA INJ 1064MG ...... 46 20 mg ...... 6 ARISTADA INJ 441MG/1...... 46 amphetamine-dextroamphetamine tab ARISTADA INJ 662MG/2 ...... 46 30 mg ...... 6 ARISTADA INJ 882MG/3 ...... 46 amphetamine-dextroamphetamine tab ARISTADA INJ INITIO ...... 46 5 mg ...... 6 armodafinil tab 150 mg ...... 7 amphetamine-dextroamphetamine tab armodafinil tab 200 mg ...... 7 7.5 mg ...... 6 armodafinil tab 250 mg ...... 7 ampicillin cap 250 mg ...... 78 armodafinil tab 50 mg ...... 7 ampicillin cap 500 mg ...... 78 ARMOUR THYRO TAB 120MG ...... 82 ampicillin for susp 125 mg/5ml ...... 78 ARMOUR THYRO TAB 15MG ...... 82 ampicillin for susp 250 mg/5ml ...... 78 ARMOUR THYRO TAB 180MG ...... 82 anagrelide hcl cap 0.5 mg ...... 67 ARMOUR THYRO TAB 240MG ...... 82 anagrelide hcl cap 1 mg ...... 67 ARMOUR THYRO TAB 300MG ...... 82 anastrozole tab 1 mg ...... 36 ARMOUR THYRO TAB 30MG ...... 82 ANDRODERM DIS 2MG/24HR ...... 13 ARMOUR THYRO TAB 60MG ...... 82 ANDRODERM DIS 4MG/24HR ...... 13 ARMOUR THYRO TAB 90MG ...... 82 ANORO ELLIPT AER 62.5-25 ...... 18 ARNUITY ELPT INH 100MCG ...... 17 APOKYN INJ 10MG/ML...... 41 ARNUITY ELPT INH 200MCG ...... 17 aprepitant capsule 125 mg ...... 29 ARNUITY ELPT INH 50MCG ...... 17 aprepitant capsule 40 mg ...... 29 ASACOL HD TAB 800MG ...... 66 aprepitant capsule 80 mg ...... 29 ASMANEX 120 AER 220MCG ...... 17 aprepitant capsule therapy pack 80 & ASMANEX 30 AER 110MCG ...... 17 125 mg ...... 29 ASMANEX HFA AER 100 MCG ...... 17 APTIVUS CAP 250MG ...... 47 ASMANEX HFA AER 200 MCG ...... 17 APTIVUS SOL ...... 47 ASMANEX HFA AER 50MCG ...... 17 ARANESP INJ 100MCG ...... 68 atazanavir sulfate cap 150 mg (base ARANESP INJ 10MCG ...... 68 equiv) ...... 47 ARANESP INJ 150MCG ...... 68 atazanavir sulfate cap 200 mg (base ARANESP INJ 200MCG ...... 68 equiv) ...... 47 ARANESP INJ 25MCG ...... 68 atazanavir sulfate cap 300 mg (base ARANESP INJ 300MCG ...... 68 equiv) ...... 47 ARANESP INJ 40MCG ...... 68 89 atenolol & chlorthalidone tab 100-25 AZASAN TAB 75 MG ...... 73 mg ...... 33 azathioprine tab 50 mg ...... 73 atenolol & chlorthalidone tab 50-25 mg azelaic acid gel 15% ...... 61 ...... 33 azelastine hcl nasal spray 0.1% (137 atenolol tab 100 mg ...... 51 mcg/spray) ...... 75 atenolol tab 25 mg ...... 51 azelastine hcl nasal spray 0.15% atenolol tab 50 mg ...... 51 (205.5 mcg/spray) ...... 75 atomoxetine hcl cap 10 mg (base azelastine hcl ophth soln 0.05% ...... 77 equiv) ...... 6 azithromycin for susp 100 mg/5ml ... 70 atomoxetine hcl cap 100 mg (base azithromycin for susp 200 mg/5ml ... 70 equiv) ...... 6 azithromycin powd pack for susp 1 gm atomoxetine hcl cap 18 mg (base ...... 70 equiv) ...... 6 azithromycin tab 250 mg ...... 70 atomoxetine hcl cap 25 mg (base azithromycin tab 500 mg ...... 70 equiv) ...... 6 azithromycin tab 600 mg ...... 70 atomoxetine hcl cap 40 mg (base B equiv) ...... 6 bac tab ...... 10 atomoxetine hcl cap 60 mg (base bacitracin ophth oint 500 unit/gm .... 76 equiv) ...... 6 bacitracin-polymyxin b ophth oint .... 76 atomoxetine hcl cap 80 mg (base baclofen tab 10 mg ...... 75 equiv) ...... 6 baclofen tab 20 mg ...... 75 atorvastatin calcium tab 10 mg (base BACTROBAN OIN NASAL 2% ...... 75 equivalent) ...... 30 balsalazide disodium cap 750 mg ..... 66 atorvastatin calcium tab 20 mg (base BALVERSA TAB 3MG ...... 38 equivalent) ...... 30 BALVERSA TAB 4MG ...... 38 atorvastatin calcium tab 40 mg (base BALVERSA TAB 5MG ...... 38 equivalent) ...... 30 BANZEL TAB 200MG ...... 20 atorvastatin calcium tab 80 mg (base BANZEL TAB 400MG ...... 20 equivalent) ...... 31 BAQSIMI ONE POW 3MG/DOSE ...... 26 atovaquone susp 750 mg/5ml ...... 14 BARACLUDE SOL ...... 50 atovaquone-proguanil hcl tab 250-100 BASAGLAR INJ 100UNIT ...... 27 mg ...... 35 benazepril & hydrochlorothiazide tab atovaquone-proguanil hcl tab 62.5-25 10-12.5 mg ...... 33 mg ...... 35 benazepril & hydrochlorothiazide tab atropine sul sol 1% op ...... 76 20-12.5 mg ...... 33 ATROVENT HFA AER 17MCG ...... 17 benazepril & hydrochlorothiazide tab AUBAGIO TAB 14MG ...... 80 20-25 mg ...... 33 AUBAGIO TAB 7MG ...... 80 benazepril & hydrochlorothiazide tab 5- AUGMENTIN SUS 125/5ML ...... 78 6.25 mg ...... 33 AVONEX KIT 30MCG ...... 80 benazepril hcl tab 10 mg ...... 31 AVONEX PEN KIT 30MCG ...... 80 benazepril hcl tab 20 mg ...... 31 AVONEX PREFL KIT 30MCG ...... 80 benazepril hcl tab 40 mg ...... 31 av-vite fb tab 2.5-25-1 ...... 69 benazepril hcl tab 5 mg ...... 31 AYVAKIT TAB 100MG ...... 37 BENLYSTA INJ 200MG/ML ...... 73 AYVAKIT TAB 200MG ...... 37 benzonatate cap 100 mg ...... 58 AYVAKIT TAB 300MG ...... 37 benzonatate cap 200 mg ...... 58 AZASAN TAB 100MG ...... 73 benztropine mesylate tab 0.5 mg ..... 41 90 benztropine mesylate tab 1 mg ...... 41 BOSULIF TAB 500MG ...... 38 benztropine mesylate tab 2 mg ...... 41 BREEZE 2 MIS TEST ...... 61 betamethasone dipropionate BRILINTA TAB 60MG ...... 67 augmented cream 0.05% ...... 60 BRILINTA TAB 90MG ...... 68 betamethasone dipropionate brimonidine tartrate ophth soln 0.15% augmented gel 0.05% ...... 60 ...... 76 betamethasone dipropionate brimonidine tartrate ophth soln 0.2%76 augmented lotion 0.05% ...... 60 bromocriptine mesylate cap 5 mg (base betamethasone dipropionate equivalent) ...... 41 augmented oint 0.05% ...... 60 bromocriptine mesylate tab 2.5 mg betamethasone dipropionate cream (base equivalent) ...... 41 0.05% ...... 60 BRUKINSA CAP 80MG ...... 38 betamethasone dipropionate lotion budesonide delayed release particles 0.05% ...... 60 cap 3 mg ...... 57 betamethasone dipropionate oint budesonide inhalation susp 0.25 0.05% ...... 60 mg/2ml ...... 17 betamethasone valerate cream 0.1% budesonide inhalation susp 0.5 mg/2ml (base equivalent) ...... 60 ...... 17 betamethasone valerate lotion 0.1% budesonide inhalation susp 1 mg/2ml (base equivalent) ...... 60 ...... 17 betamethasone valerate oint 0.1% budesonide-formoterol fumarate dihyd (base equivalent) ...... 60 aerosol 160-4.5 mcg/act ...... 18 betaxolol hcl ophth soln 0.5% ...... 75 budesonide-formoterol fumarate dihyd bethanechol chloride tab 10 mg ...... 85 aerosol 80-4.5 mcg/act ...... 18 bethanechol chloride tab 25 mg ...... 85 bumetanide tab 0.5 mg ...... 62 bethanechol chloride tab 5 mg ...... 85 bumetanide tab 1 mg ...... 62 bethanechol chloride tab 50 mg ...... 85 bumetanide tab 2 mg ...... 62 BETIMOL SOL 0.25% ...... 76 buprenorphine hcl sl tab 2 mg (base BETIMOL SOL 0.5% ...... 75 equiv) ...... 12 BETOPTIC-S SUS 0.25% OP ...... 76 buprenorphine hcl sl tab 8 mg (base bexarotene cap 75 mg ...... 40 equiv) ...... 12 bicalutamide tab 50 mg ...... 36 buprenorphine hcl-naloxone hcl sl film BIKTARVY TAB ...... 47 12-3 mg (base equiv) ...... 12 bisoprolol & hydrochlorothiazide tab buprenorphine hcl-naloxone hcl sl film 10-6.25 mg ...... 33 2-0.5 mg (base equiv) ...... 12 bisoprolol & hydrochlorothiazide tab buprenorphine hcl-naloxone hcl sl film 2.5-6.25 mg ...... 33 4-1 mg (base equiv) ...... 12 bisoprolol & hydrochlorothiazide tab 5- buprenorphine hcl-naloxone hcl sl film 6.25 mg ...... 33 8-2 mg (base equiv) ...... 12 bisoprolol fumarate tab 10 mg ...... 51 buprenorphine hcl-naloxone hcl sl tab bisoprolol fumarate tab 5 mg ...... 51 2-0.5 mg (base equiv) ...... 13 blisovi 24 tab fe 1/20 ...... 55 buprenorphine hcl-naloxone hcl sl tab BONJESTA TAB 20-20MG ...... 29 8-2 mg (base equiv) ...... 13 bosentan tab 125 mg ...... 54 buprenorphine td patch weekly 10 bosentan tab 62.5 mg ...... 54 mcg/hr ...... 13 BOSULIF TAB 100MG ...... 38 buprenorphine td patch weekly 15 BOSULIF TAB 400MG ...... 38 mcg/hr ...... 13 91 buprenorphine td patch weekly 20 capecitabine tab 500 mg ...... 36 mcg/hr ...... 13 CAPLYTA CAP 42MG ...... 42 buprenorphine td patch weekly 5 CAPRELSA TAB 100MG ...... 38 mcg/hr ...... 13 CAPRELSA TAB 300MG ...... 38 bupropion hcl (smoking deterrent) tab captopril tab 100 mg ...... 32 er 12hr 150 mg ...... 81 captopril tab 12.5 mg ...... 31 bupropion hcl tab 100 mg ...... 23 captopril tab 25 mg ...... 32 bupropion hcl tab 75 mg ...... 23 captopril tab 50 mg ...... 32 bupropion hcl tab er 12hr 100 mg .... 23 carbamazepine cap er 12hr 100 mg .. 20 bupropion hcl tab er 12hr 150 mg .... 23 carbamazepine cap er 12hr 200 mg .. 20 bupropion hcl tab er 12hr 200 mg .... 23 carbamazepine cap er 12hr 300 mg .. 20 bupropion hcl tab er 24hr 150 mg .... 23 carbamazepine chew tab 100 mg ..... 20 bupropion hcl tab er 24hr 300 mg .... 23 carbamazepine susp 100 mg/5ml ..... 20 buspirone hcl tab 10 mg ...... 15 carbamazepine tab 200 mg ...... 20 buspirone hcl tab 15 mg ...... 15 carbamazepine tab er 12hr 100 mg .. 21 buspirone hcl tab 30 mg ...... 15 carbamazepine tab er 12hr 200 mg .. 21 buspirone hcl tab 5 mg ...... 15 carbamazepine tab er 12hr 400 mg .. 21 buspirone hcl tab 7.5 mg ...... 15 carbidopa & levodopa orally butalbital-acetaminophen-caff w/ cod disintegrating tab 10-100 mg ...... 41 cap 50-325-40-30 mg ...... 12 carbidopa & levodopa orally butalbital-acetaminophen-caffeine cap disintegrating tab 25-100 mg ...... 41 50-300-40 mg ...... 60 carbidopa & levodopa orally butalbital-acetaminophen-caffeine cap disintegrating tab 25-250 mg ...... 41 50-325-40 mg ...... 10 carbidopa & levodopa tab 10-100 mg 41 butalbital-aspirin-caffeine cap 50-325- carbidopa & levodopa tab 25-100 mg 41 40 mg ...... 10 carbidopa & levodopa tab 25-250 mg 41 C carbidopa & levodopa tab er 25-100 cabergoline tab 0.5 mg ...... 64 mg ...... 41 CABOMETYX TAB 20MG ...... 38 carbidopa & levodopa tab er 50-200 CABOMETYX TAB 40MG ...... 38 mg ...... 41 CABOMETYX TAB 60MG ...... 38 carbidopa-levodopa-entacapone tabs calcipotriene oint 0.005% ...... 59 12.5-50-200 mg ...... 41 calcipotriene soln 0.005% (50 mcg/ml) carbidopa-levodopa-entacapone tabs ...... 59 18.75-75-200 mg ...... 41 calcitonin (salmon) nasal soln 200 carbidopa-levodopa-entacapone tabs unit/act ...... 63 25-100-200 mg ...... 41 calcitriol cap 0.25 mcg ...... 64 carbidopa-levodopa-entacapone tabs calcitriol cap 0.5 mcg ...... 64 31.25-125-200 mg ...... 41 calcitriol inj 1 mcg/ml ...... 64 carbidopa-levodopa-entacapone tabs calcitriol oral soln 1 mcg/ml ...... 64 37.5-150-200 mg ...... 41 calcium acetate (phosphate binder) cap carbidopa-levodopa-entacapone tabs 667 mg (169 mg ca) ...... 67 50-200-200 mg ...... 42 candesartan cilexetil tab 16 mg ...... 32 CAROSPIR SUS 25MG/5ML ...... 63 candesartan cilexetil tab 32 mg ...... 32 carvedilol tab 12.5 mg ...... 50 candesartan cilexetil tab 4 mg ...... 32 carvedilol tab 25 mg ...... 50 candesartan cilexetil tab 8 mg ...... 32 carvedilol tab 3.125 mg ...... 50 capecitabine tab 150 mg ...... 36 carvedilol tab 6.25 mg ...... 50 92 cavarest gel 1.1% ...... 74 chlorthalidone tab 25 mg ...... 63 caziant pak ...... 55 chlorthalidone tab 50 mg ...... 63 cefaclor cap 250 mg ...... 55 chlorzoxazone tab 500 mg...... 75 cefaclor cap 500 mg ...... 55 cholestyramine light powder 4 gm/dose cefaclor for susp 125 mg/5ml ...... 55 ...... 30 cefaclor for susp 250 mg/5ml ...... 55 cholestyramine light powder packets 4 cefaclor for susp 375 mg/5ml ...... 55 gm ...... 30 cefadroxil cap 500 mg ...... 55 cholestyramine powder 4 gm/dose ... 30 cefadroxil for susp 250 mg/5ml ...... 55 cholestyramine powder packets 4 gm30 cefadroxil for susp 500 mg/5ml ...... 55 ciclopirox gel 0.77% ...... 59 cefadroxil tab 1 gm ...... 55 ciclopirox olamine cream 0.77% (base cefdinir cap 300 mg ...... 55 equiv) ...... 59 cefdinir for susp 125 mg/5ml ...... 55 ciclopirox olamine susp 0.77% (base cefdinir for susp 250 mg/5ml ...... 55 equiv) ...... 59 cefprozil for susp 125 mg/5ml ...... 55 ciclopirox shampoo 1% ...... 59 cefprozil for susp 250 mg/5ml ...... 55 ciclopirox solution 8% ...... 59 cefprozil tab 250 mg ...... 55 cilostazol tab 100 mg ...... 68 cefprozil tab 500 mg ...... 55 cilostazol tab 50 mg ...... 68 CEFTIN SUS 250/5ML ...... 55 CIMDUO TAB 300-300 ...... 47 cefuroxime axetil tab 250 mg ...... 55 cimetidine hcl soln 300 mg/5ml ...... 83 cefuroxime axetil tab 500 mg ...... 55 cimetidine tab 300 mg ...... 83 celecoxib cap 100 mg ...... 9 cimetidine tab 400 mg ...... 83 celecoxib cap 200 mg ...... 9 cimetidine tab 800 mg ...... 83 celecoxib cap 400 mg ...... 9 ciprofloxacin hcl ophth soln 0.3% (base celecoxib cap 50 mg ...... 9 equivalent) ...... 76 cephalexin cap 250 mg ...... 55 ciprofloxacin hcl tab 100 mg (base cephalexin cap 500 mg ...... 55 equiv) ...... 65 cephalexin for susp 125 mg/5ml ...... 55 ciprofloxacin hcl tab 250 mg (base cephalexin for susp 250 mg/5ml ...... 55 equiv) ...... 65 cephalexin tab 250 mg ...... 55 ciprofloxacin hcl tab 500 mg (base cephalexin tab 500 mg ...... 55 equiv) ...... 65 cetirizine hcl oral soln 1 mg/ml (5 ciprofloxacin hcl tab 750 mg (base mg/5ml) ...... 29 equiv) ...... 65 CHANTIX PAK 0.5& 1MG ...... 81 ciprofloxacin-ciprofloxacin hcl tab er CHANTIX PAK 1MG ...... 81 24hr 1000 mg(base eq) ...... 65 CHANTIX TAB 0.5MG ...... 81 ciprofloxacin-ciprofloxacin hcl tab er chlordiazepoxide hcl cap 10 mg ...... 16 24hr 500 mg (base eq) ...... 65 chlordiazepoxide hcl cap 25 mg ...... 16 ciprofloxacin-dexamethasone otic susp chlordiazepoxide hcl cap 5 mg ...... 16 0.3-0.1% ...... 77 chlorhexidine gluconate soln 0.12% .. 74 citalopram hydrobromide oral soln 10 chloroquine phosphate tab 250 mg ... 35 mg/5ml ...... 23 chloroquine phosphate tab 500 mg ... 35 citalopram hydrobromide tab 10 mg chlorpromazine hcl tab 10 mg ...... 45 (base equiv) ...... 23 chlorpromazine hcl tab 100 mg ...... 45 citalopram hydrobromide tab 20 mg chlorpromazine hcl tab 200 mg ...... 46 (base equiv) ...... 23 chlorpromazine hcl tab 25 mg ...... 45 citalopram hydrobromide tab 40 mg chlorpromazine hcl tab 50 mg ...... 45 (base equiv) ...... 23 93

CITRANATAL MIS 90 DHA ...... 74 clonazepam orally disintegrating tab 1 CITRANATAL PAK ASSURE ...... 74 mg ...... 20 CITRANATAL PAK DHA ...... 74 clonazepam orally disintegrating tab 2 CITRANATAL PAK ESSENCE ...... 74 mg ...... 20 CITRANATAL TAB RX...... 74 clonazepam tab 0.5 mg ...... 20 claravis cap 10mg ...... 58 clonazepam tab 1 mg ...... 20 claravis cap 20mg ...... 58 clonazepam tab 2 mg ...... 20 claravis cap 30mg ...... 58 clonidine hcl tab 0.1 mg ...... 33 claravis cap 40mg ...... 58 clonidine hcl tab 0.2 mg ...... 33 clarithromycin for susp 125 mg/5ml . 70 clonidine hcl tab 0.3 mg ...... 33 clarithromycin for susp 250 mg/5ml . 70 clonidine hcl tab er 12hr 0.1 mg ...... 6 clarithromycin tab 250 mg ...... 70 clonidine td patch weekly 0.1 mg/24hr clarithromycin tab 500 mg ...... 70 ...... 33 clarithromycin tab er 24hr 500 mg ... 70 clonidine td patch weekly 0.2 mg/24hr clemastine fumarate tab 2.68 mg ..... 29 ...... 33 CLEOCIN SUP 100MG ...... 85 clonidine td patch weekly 0.3 mg/24hr CLIMARA PRO DIS WEEKLY...... 65 ...... 33 clindamycin hcl cap 150 mg ...... 14 clopidogrel bisulfate tab 300 mg (base clindamycin hcl cap 300 mg ...... 14 equiv) ...... 68 clindamycin palmitate hcl for soln 75 clopidogrel bisulfate tab 75 mg (base mg/5ml (base equiv) ...... 14 equiv) ...... 68 clindamycin phosphate gel 1% ...... 58 clotrimazole cream 1% ...... 59 clindamycin phosphate lotion 1% ..... 58 clotrimazole soln 1% ...... 59 clindamycin phosphate soln 1% ...... 58 clotrimazole troche 10 mg ...... 74 clindamycin phosphate vaginal cream clotrimazole vaginal cream 2% ...... 85 2% ...... 85 clotrimazole w/ betamethasone cream clobazam suspension 2.5 mg/ml ...... 20 1-0.05% ...... 59 clobazam tab 10 mg ...... 20 clotrimazole w/ betamethasone lotion clobazam tab 20 mg ...... 20 1-0.05% ...... 59 clobetasol propionate cream 0.05% .. 60 clozapine orally disintegrating tab 100 clobetasol propionate foam 0.05% ... 60 mg ...... 44 clobetasol propionate gel 0.05% ...... 60 clozapine orally disintegrating tab 12.5 clobetasol propionate oint 0.05% ..... 60 mg ...... 44 clobetasol propionate shampoo 0.05% clozapine orally disintegrating tab 150 ...... 60 mg ...... 44 clobetasol propionate soln 0.05% ..... 60 clozapine orally disintegrating tab 200 clomiphene citrate tab 50 mg ...... 63 mg ...... 44 clomipramine hcl cap 25 mg ...... 25 clozapine orally disintegrating tab 25 clomipramine hcl cap 50 mg ...... 25 mg ...... 44 clomipramine hcl cap 75 mg ...... 25 clozapine tab 100 mg ...... 44 clonazepam orally disintegrating tab clozapine tab 200 mg ...... 44 0.125 mg ...... 20 clozapine tab 25 mg ...... 44 clonazepam orally disintegrating tab clozapine tab 50 mg ...... 44 0.25 mg ...... 20 COARTEM TAB 20-120MG ...... 35 clonazepam orally disintegrating tab colchicine tab 0.6 mg ...... 67 0.5 mg ...... 20 colestipol hcl granule packets 5 gm .. 30 colestipol hcl granules 5 gm ...... 30 94 colestipol hcl tab 1 gm ...... 30 danazol cap 200 mg ...... 13 COMBIGAN SOL 0.2/0.5% ...... 76 danazol cap 50 mg ...... 13 COMBIVENT AER 20-100 ...... 18 dantrolene sodium cap 100 mg ...... 75 COMETRIQ KIT 100MG ...... 38 dantrolene sodium cap 25 mg ...... 75 COMETRIQ KIT 140MG ...... 38 dantrolene sodium cap 50 mg ...... 75 COMETRIQ KIT 60MG ...... 38 dapsone gel 5% ...... 58 COMPLERA TAB ...... 47 dapsone tab 100 mg ...... 14 compro sup 25mg ...... 46 dapsone tab 25 mg ...... 14 constulose sol 10gm/15 ...... 70 DEPO-SQ PROV INJ 104 ...... 56 CONTOUR TES BLD GLUC ...... 62 DESCOVY TAB 200/25MG ...... 47 CONTOUR TES NEXT ...... 62 desipramine hcl tab 10 mg ...... 25 COPAXONE INJ 40MG/ML ...... 80 desipramine hcl tab 100 mg ...... 25 CORLANOR TAB 5MG ...... 54 desipramine hcl tab 150 mg ...... 25 CORLANOR TAB 7.5MG ...... 54 desipramine hcl tab 25 mg ...... 25 CORTIFOAM AER 90MG ...... 13 desipramine hcl tab 50 mg ...... 25 COSENTYX INJ 150MG/ML ...... 59 desipramine hcl tab 75 mg ...... 25 COSENTYX INJ 300DOSE ...... 59 desmopressin acetate nasal soln 0.01% COSENTYX PEN INJ 150MG/ML ...... 59 (refrigerated) ...... 64 COSENTYX PEN INJ 300DOSE ...... 59 desmopressin acetate nasal spray soln COTELLIC TAB 20MG ...... 38 0.01% ...... 64 CREON CAP 12000UNT ...... 62 desmopressin acetate nasal spray soln CREON CAP 24000UNT ...... 62 0.01% (refrigerated) ...... 64 CREON CAP 3000UNIT ...... 62 desmopressin acetate tab 0.1 mg ..... 64 CREON CAP 36000UNT ...... 62 desmopressin acetate tab 0.2 mg ..... 64 CREON CAP 6000UNIT ...... 62 desogest-eth estrad & eth estrad tab CRIXIVAN CAP 200MG ...... 47 0.15-0.02/0.01 mg(21/5) ...... 55 CRIXIVAN CAP 400MG ...... 47 desogestrel & ethinyl estradiol tab 0.15 cromolyn sodium ophth soln 4% ...... 77 mg-30 mcg ...... 55 cromolyn sodium soln nebu 20 mg/2ml desonide cream 0.05% ...... 60 ...... 17 desonide lotion 0.05% ...... 60 CUVPOSA SOL 1MG/5ML ...... 83 desonide oint 0.05%...... 60 cyanocobalamin inj 1000 mcg/ml ..... 68 desvenlafaxine succinate tab er 24hr cyclobenzaprine hcl tab 10 mg ...... 75 100 mg (base equiv)...... 24 cyclobenzaprine hcl tab 5 mg ...... 75 desvenlafaxine succinate tab er 24hr cyclophosphamide cap 25 mg ...... 35 25 mg (base equiv) ...... 24 cyclophosphamide cap 50 mg ...... 35 desvenlafaxine succinate tab er 24hr cyclosporine cap 100 mg ...... 73 50 mg (base equiv) ...... 24 cyclosporine cap 25 mg ...... 73 DEXAMETHASON CON 1MG/ML ...... 57 cyclosporine modified cap 100 mg .... 73 dexamethasone elixir 0.5 mg/5ml .... 57 cyclosporine modified cap 25 mg ...... 73 dexamethasone sodium phosphate inj cyclosporine modified cap 50 mg ...... 73 20 mg/5ml ...... 57 cyclosporine modified oral soln 100 dexamethasone sodium phosphate inj mg/ml ...... 73 4 mg/ml ...... 57 cyproheptadine hcl syrup 2 mg/5ml .. 30 dexamethasone sodium phosphate cyproheptadine hcl tab 4 mg ...... 30 ophth soln 0.1% ...... 77 D dexamethasone soln 0.5 mg/5ml ..... 57 danazol cap 100 mg ...... 13 dexamethasone tab 0.5 mg ...... 57 95 dexamethasone tab 0.75 mg ...... 57 diclofenac sodium tab delayed release dexamethasone tab 1 mg ...... 57 25 mg ...... 9 dexamethasone tab 1.5 mg ...... 57 diclofenac sodium tab delayed release dexamethasone tab 2 mg ...... 57 50 mg ...... 9 dexamethasone tab 4 mg ...... 57 diclofenac sodium tab delayed release dexamethasone tab 6 mg ...... 57 75 mg ...... 9 dexmethylphenidate hcl cap er 24 hr diclofenac sodium tab er 24hr 100 mg 9 10 mg ...... 7 dicloxacillin sodium cap 250 mg ...... 78 dexmethylphenidate hcl cap er 24 hr dicloxacillin sodium cap 500 mg ...... 78 15 mg ...... 7 dicyclomine hcl cap 10 mg ...... 83 dexmethylphenidate hcl cap er 24 hr dicyclomine hcl oral soln 10 mg/5ml . 83 20 mg ...... 7 dicyclomine hcl tab 20 mg ...... 83 dexmethylphenidate hcl cap er 24 hr didanosine delayed release capsule 125 25 mg ...... 7 mg ...... 47 dexmethylphenidate hcl cap er 24 hr didanosine delayed release capsule 200 30 mg ...... 7 mg ...... 47 dexmethylphenidate hcl cap er 24 hr didanosine delayed release capsule 250 35 mg ...... 7 mg ...... 47 dexmethylphenidate hcl cap er 24 hr didanosine delayed release capsule 400 40 mg ...... 7 mg ...... 47 dexmethylphenidate hcl cap er 24 hr 5 diflunisal tab 500 mg ...... 10 mg ...... 7 digitek tab 0.125mg ...... 53 dexmethylphenidate hcl tab 10 mg .... 7 digitek tab 0.25mg ...... 53 dexmethylphenidate hcl tab 2.5 mg ... 7 digoxin inj 0.25 mg/ml ...... 53 dexmethylphenidate hcl tab 5 mg ...... 7 digoxin oral soln 0.05 mg/ml ...... 53 dextroamphetamine sulfate cap er 24hr DILANTIN CAP 30MG ...... 22 10 mg ...... 6 diltiazem cap 240mg cd ...... 52 dextroamphetamine sulfate cap er 24hr diltiazem cap 300mg cd ...... 52 15 mg ...... 6 diltiazem hcl cap er 12hr 120 mg ..... 52 dextroamphetamine sulfate cap er 24hr diltiazem hcl cap er 12hr 60 mg ...... 52 5 mg ...... 6 diltiazem hcl cap er 12hr 90 mg ...... 52 dextroamphetamine sulfate tab 10 mg 6 diltiazem hcl cap er 24hr 120 mg ..... 52 dextroamphetamine sulfate tab 5 mg 6 diltiazem hcl cap er 24hr 180 mg ..... 52 diazepam oral soln 1 mg/ml ...... 16 diltiazem hcl cap er 24hr 240 mg ..... 52 diazepam rectal gel delivery system 10 diltiazem hcl coated beads cap er 24hr mg ...... 20 120 mg ...... 52 diazepam rectal gel delivery system 2.5 diltiazem hcl coated beads cap er 24hr mg ...... 20 180 mg ...... 52 diazepam rectal gel delivery system 20 diltiazem hcl coated beads cap er 24hr mg ...... 20 360 mg ...... 52 diazepam tab 10 mg ...... 16 diltiazem hcl extended release beads diazepam tab 2 mg ...... 16 cap er 24hr 120 mg ...... 52 diazepam tab 5 mg ...... 16 diltiazem hcl extended release beads diclofenac potassium tab 50 mg ...... 9 cap er 24hr 180 mg ...... 52 diclofenac sodium gel 1% ...... 59 diltiazem hcl extended release beads diclofenac sodium ophth soln 0.1% ... 77 cap er 24hr 240 mg ...... 52

96 diltiazem hcl extended release beads donepezil hydrochloride orally cap er 24hr 300 mg ...... 52 disintegrating tab 5 mg ...... 79 diltiazem hcl extended release beads donepezil hydrochloride tab 10 mg ... 79 cap er 24hr 360 mg ...... 52 donepezil hydrochloride tab 23 mg ... 79 diltiazem hcl extended release beads donepezil hydrochloride tab 5 mg ..... 79 cap er 24hr 420 mg ...... 52 DOPTELET TAB 20MG...... 68 diltiazem hcl tab 120 mg ...... 52 dorzolamide hcl ophth soln 2% ...... 77 diltiazem hcl tab 30 mg ...... 52 dorzolamide hcl-timolol maleate ophth diltiazem hcl tab 60 mg ...... 52 sol 22.3-6.8 mg/ml pf ...... 76 diltiazem hcl tab 90 mg ...... 52 dorzolamide hcl-timolol maleate ophth dimethyl fumarate capsule delayed soln 22.3-6.8 mg/ml ...... 76 release 120 mg ...... 80 DOVATO TAB 50-300MG ...... 47 dimethyl fumarate capsule delayed doxazosin mesylate tab 1 mg ...... 33 release 240 mg ...... 80 doxazosin mesylate tab 2 mg ...... 33 dimethyl fumarate capsule dr starter doxazosin mesylate tab 4 mg ...... 33 pack 120 mg & 240 mg ...... 80 doxazosin mesylate tab 8 mg ...... 33 DIPENTUM CAP 250MG ...... 66 doxepin hcl cap 10 mg ...... 25 diphenhydramine hcl elixir 12.5 doxepin hcl cap 100 mg ...... 25 mg/5ml ...... 29 doxepin hcl cap 150 mg ...... 25 diphenoxylate w/ atropine liq 2.5-0.025 doxepin hcl cap 25 mg ...... 25 mg/5ml ...... 28 doxepin hcl cap 50 mg ...... 25 diphenoxylate w/ atropine tab 2.5- doxepin hcl cap 75 mg ...... 25 0.025 mg ...... 28 doxepin hcl conc 10 mg/ml ...... 25 dipyridamole tab 25 mg ...... 68 doxercalciferol cap 0.5 mcg ...... 64 dipyridamole tab 50 mg ...... 68 doxercalciferol cap 1 mcg ...... 64 dipyridamole tab 75 mg ...... 68 doxercalciferol cap 2.5 mcg ...... 64 disopyramide phosphate cap 100 mg 16 doxycycline hyclate cap 100 mg ...... 81 disopyramide phosphate cap 150 mg 16 doxycycline hyclate cap 50 mg ...... 81 disulfiram tab 250 mg ...... 79 doxycycline hyclate tab 100 mg ...... 81 disulfiram tab 500 mg ...... 79 doxycycline hyclate tab 20 mg ...... 81 divalproex sodium cap delayed release doxycycline monohydrate for susp 25 sprinkle 125 mg ...... 22 mg/5ml ...... 81 divalproex sodium tab delayed release doxylamine-pyridoxine tab delayed 125 mg ...... 22 release 10-10 mg ...... 29 divalproex sodium tab delayed release dronabinol cap 10 mg ...... 29 250 mg ...... 22 dronabinol cap 2.5 mg ...... 29 divalproex sodium tab delayed release dronabinol cap 5 mg ...... 29 500 mg ...... 22 drospirenone-ethinyl estradiol tab 3- divalproex sodium tab er 24 hr 250 mg 0.02 mg ...... 55 ...... 22 drospirenone-ethinyl estradiol tab 3- divalproex sodium tab er 24 hr 500 mg 0.03 mg ...... 55 ...... 22 DROXIA CAP 200MG ...... 68 dofetilide cap 125 mcg (0.125 mg) ... 16 DROXIA CAP 300MG ...... 68 dofetilide cap 250 mcg (0.25 mg) ..... 16 DROXIA CAP 400MG ...... 68 dofetilide cap 500 mcg (0.5 mg) ...... 16 duloxetine hcl enteric coated pellets donepezil hydrochloride orally cap 20 mg (base eq) ...... 24 disintegrating tab 10 mg ...... 79 97 duloxetine hcl enteric coated pellets ENBREL INJ 50MG/ML ...... 10 cap 30 mg (base eq) ...... 24 ENBREL MINI INJ 50MG/ML ...... 10 duloxetine hcl enteric coated pellets ENBREL SRCLK INJ 50MG/ML ...... 10 cap 60 mg (base eq) ...... 24 enoxaparin sodium inj 100 mg/ml .... 19 E enoxaparin sodium inj 120 mg/0.8ml 19 e.e.s. 400 tab 400mg ...... 70 enoxaparin sodium inj 150 mg/ml .... 19 econazole nitrate cream 1% ...... 59 enoxaparin sodium inj 30 mg/0.3ml . 19 EDURANT TAB 25MG ...... 47 enoxaparin sodium inj 300 mg/3ml .. 20 efavirenz cap 200 mg ...... 47 enoxaparin sodium inj 40 mg/0.4ml . 19 efavirenz cap 50 mg ...... 47 enoxaparin sodium inj 60 mg/0.6ml . 19 efavirenz tab 600 mg ...... 47 enoxaparin sodium inj 80 mg/0.8ml . 19 efavirenz-emtricitabine-tenofovir df tab ENSPRYNG INJ ...... 73 600-200-300 mg ...... 47 entacapone tab 200 mg ...... 41 efavirenz-lamivudine-tenofovir df tab entecavir tab 0.5 mg ...... 50 400-300-300 mg ...... 47 entecavir tab 1 mg ...... 50 efavirenz-lamivudine-tenofovir df tab ENTRESTO TAB 24-26MG ...... 53 600-300-300 mg ...... 47 ENTRESTO TAB 49-51MG ...... 53 eletriptan hydrobromide tab 20 mg ENTRESTO TAB 97-103MG ...... 53 (base equivalent) ...... 71 epinephrine solution auto-injector 0.15 eletriptan hydrobromide tab 40 mg mg/0.15ml (1:1000) ...... 85 (base equivalent) ...... 71 epinephrine solution auto-injector 0.15 ELIQUIS TAB 2.5MG ...... 19 mg/0.3ml (1:2000) ...... 85 ELIQUIS TAB 5MG ...... 19 epinephrine solution auto-injector 0.3 ELIXOPHYLLIN ELX 80/15ML ...... 19 mg/0.3ml (1:1000) ...... 85 ELLA TAB 30MG ...... 56 EPIPEN 2-PAK INJ 0.3MG ...... 85 eluryng mis ...... 56 EPIPEN-JR INJ 0.15MG ...... 85 EMEND SUS 125MG ...... 29 EPIVIR HBV SOL 5MG/ML ...... 50 emtricitabine caps 200 mg ...... 47 eplerenone tab 25 mg ...... 34 emtricitabine-tenofovir disoproxil eplerenone tab 50 mg ...... 34 fumarate tab 100-150 mg ...... 48 epoprostenol sodium for inj 0.5 mg .. 53 emtricitabine-tenofovir disoproxil epoprostenol sodium for inj 1.5 mg .. 53 fumarate tab 133-200 mg ...... 48 ergocalciferol cap 1.25 mg (50000 unit) emtricitabine-tenofovir disoproxil ...... 86 fumarate tab 167-250 mg ...... 48 ERIVEDGE CAP 150MG ...... 36 emtricitabine-tenofovir disoproxil erlotinib hcl tab 100 mg (base fumarate tab 200-300 mg ...... 48 equivalent) ...... 38 EMTRIVA SOL 10MG/ML ...... 48 erlotinib hcl tab 150 mg (base enalapril maleate & hydrochlorothiazide equivalent) ...... 38 tab 10-25 mg ...... 33 erlotinib hcl tab 25 mg (base enalapril maleate & hydrochlorothiazide equivalent) ...... 38 tab 5-12.5 mg ...... 33 erythrocin tab 250mg ...... 70 enalapril maleate tab 10 mg ...... 32 erythromycin ethylsuccinate for susp enalapril maleate tab 2.5 mg ...... 32 200 mg/5ml ...... 70 enalapril maleate tab 20 mg ...... 32 erythromycin gel 2% ...... 58 enalapril maleate tab 5 mg ...... 32 erythromycin ophth oint 5 mg/gm .... 76 ENBREL INJ 25/0.5ML ...... 10 erythromycin soln 2% ...... 58 ENBREL INJ 25MG ...... 10 erythromycin tab 250 mg ...... 70 98 erythromycin tab 500 mg ...... 70 ethambutol hcl tab 400 mg...... 35 erythromycin w/ delayed release ethosuximide cap 250 mg ...... 22 particles cap 250 mg ...... 70 ethosuximide soln 250 mg/5ml ...... 22 ESBRIET CAP 267MG ...... 81 etodolac cap 200 mg ...... 9 ESBRIET TAB 267MG ...... 81 etodolac cap 300 mg ...... 9 ESBRIET TAB 801MG ...... 81 etodolac tab 400 mg ...... 9 ESCAVITE CHW ...... 74 etodolac tab 500 mg ...... 9 escitalopram oxalate soln 5 mg/5ml etoposide cap 50 mg ...... 41 (base equiv) ...... 23 everolimus tab 2.5 mg ...... 38 escitalopram oxalate tab 10 mg (base everolimus tab 5 mg ...... 38 equiv) ...... 23 everolimus tab 7.5 mg ...... 38 escitalopram oxalate tab 20 mg (base EVOTAZ TAB 300-150 ...... 48 equiv) ...... 23 exemestane tab 25 mg ...... 36 escitalopram oxalate tab 5 mg (base EXTAVIA INJ 0.3MG ...... 80 equiv) ...... 23 ezetimibe tab 10 mg ...... 31 esomepra mag cap 40mg dr ...... 84 F esomeprazole magnesium cap delayed fabb tab 2.2-25-1 ...... 69 release 20 mg (base eq) ...... 84 famciclovir tab 125 mg ...... 50 estradiol & norethindrone acetate tab famciclovir tab 250 mg ...... 50 0.5-0.1 mg ...... 65 famciclovir tab 500 mg ...... 50 estradiol & norethindrone acetate tab famotidine for susp 40 mg/5ml ...... 83 1-0.5 mg ...... 65 famotidine tab 20 mg ...... 83 estradiol tab 0.5 mg ...... 65 famotidine tab 40 mg ...... 83 estradiol tab 1 mg ...... 65 FANAPT PAK ...... 43 estradiol tab 2 mg ...... 65 FANAPT TAB 10MG ...... 43 estradiol td patch twice weekly 0.1 FANAPT TAB 12MG ...... 43 mg/24hr ...... 65 FANAPT TAB 1MG ...... 43 estradiol td patch weekly 0.025 FANAPT TAB 2MG ...... 43 mg/24hr ...... 65 FANAPT TAB 4MG ...... 43 estradiol td patch weekly 0.0375 FANAPT TAB 6MG ...... 43 mg/24hr (37.5 mcg/24hr) ...... 65 FANAPT TAB 8MG ...... 43 estradiol td patch weekly 0.05 mg/24hr felodipine tab er 24hr 10 mg ...... 52 ...... 65 felodipine tab er 24hr 2.5 mg ...... 52 estradiol td patch weekly 0.06 mg/24hr felodipine tab er 24hr 5 mg ...... 52 ...... 65 FEMRING MIS 0.05/24H ...... 85 estradiol td patch weekly 0.075 FEMRING MIS 0.1MG/24 ...... 85 mg/24hr ...... 65 fenofibrate micronized cap 134 mg ... 30 estradiol td patch weekly 0.1 mg/24hr fenofibrate micronized cap 200 mg ... 30 ...... 65 fenofibrate micronized cap 67 mg..... 30 estradiol vaginal cream 0.1 mg/gm .. 85 fenofibrate tab 145 mg ...... 30 estropipate tab 0.75 mg ...... 65 fenofibrate tab 160 mg ...... 30 estropipate tab 1.5 mg ...... 65 fenofibrate tab 48 mg ...... 30 estropipate tab 3 mg ...... 65 fenofibrate tab 54 mg ...... 30 eszopiclone tab 1 mg ...... 69 fentanyl citrate lozenge on a handle eszopiclone tab 2 mg ...... 69 1200 mcg ...... 10 eszopiclone tab 3 mg ...... 69 fentanyl citrate lozenge on a handle ethambutol hcl tab 100 mg ...... 35 1600 mcg ...... 10 99 fentanyl citrate lozenge on a handle fluorouracil soln 5%...... 59 200 mcg ...... 10 fluoxetine hcl cap 10 mg ...... 23 fentanyl citrate lozenge on a handle fluoxetine hcl cap 20 mg ...... 23 400 mcg ...... 10 fluoxetine hcl cap 40 mg ...... 23 fentanyl citrate lozenge on a handle fluoxetine hcl solution 20 mg/5ml .... 23 600 mcg ...... 10 fluphenazine decanoate inj 25 mg/ml 46 fentanyl citrate lozenge on a handle fluphenazine hcl elixir 2.5 mg/5ml .... 46 800 mcg ...... 10 fluphenazine hcl inj 2.5 mg/ml ...... 46 fentanyl td patch 72hr 100 mcg/hr ... 11 fluphenazine hcl oral conc 5 mg/ml .. 46 fentanyl td patch 72hr 12 mcg/hr ..... 10 fluphenazine hcl tab 1 mg ...... 46 fentanyl td patch 72hr 25 mcg/hr ..... 10 fluphenazine hcl tab 10 mg ...... 46 fentanyl td patch 72hr 50 mcg/hr ..... 11 fluphenazine hcl tab 2.5 mg ...... 46 fentanyl td patch 72hr 75 mcg/hr ..... 11 fluphenazine hcl tab 5 mg ...... 46 FERPRX 2-DAY TAB 1000MG ...... 28 flura-drops dro 0.125mg ...... 72 finasteride tab 5 mg ...... 67 flura-drops dro 0.25mg f ...... 72 FINTEPLA SOL 2.2MG/ML ...... 21 flurbiprofen tab 100 mg ...... 9 FIRMAGON INJ 120MG ...... 36 flurbiprofen tab 50 mg ...... 9 FIRMAGON INJ 80MG ...... 36 flutamide cap 125 mg ...... 37 FIRST-MOUTHW SUS BLM ...... 73 fluticasone propionate cream 0.05% . 60 flecainide acetate tab 100 mg ...... 16 fluticasone propionate nasal susp 50 flecainide acetate tab 150 mg ...... 16 mcg/act ...... 75 flecainide acetate tab 50 mg ...... 16 fluticasone propionate oint 0.005% .. 60 FLEXICHAMBER MIS MASK SM ...... 71 fluticasone-salmeterol aer powder ba FLOVENT DISK AER 100MCG ...... 17 100-50 mcg/dose ...... 18 FLOVENT DISK AER 250MCG ...... 17 fluticasone-salmeterol aer powder ba FLOVENT DISK AER 50MCG ...... 17 113-14 mcg/act ...... 18 FLOVENT HFA AER 110MCG ...... 17 fluticasone-salmeterol aer powder ba FLOVENT HFA AER 220MCG ...... 17 232-14 mcg/act ...... 18 FLOVENT HFA AER 44MCG ...... 17 fluticasone-salmeterol aer powder ba fluconazole for susp 10 mg/ml ...... 29 250-50 mcg/dose ...... 18 fluconazole for susp 40 mg/ml ...... 29 fluticasone-salmeterol aer powder ba fluconazole tab 100 mg ...... 29 500-50 mcg/dose ...... 18 fluconazole tab 150 mg ...... 29 fluticasone-salmeterol aer powder ba fluconazole tab 200 mg ...... 29 55-14 mcg/act ...... 18 fluconazole tab 50 mg ...... 29 fluvoxamine maleate tab 100 mg ..... 23 fludrocortisone acetate tab 0.1 mg ... 58 fluvoxamine maleate tab 25 mg ...... 23 fluocinolone acetonide (otic) oil 0.01% fluvoxamine maleate tab 50 mg ...... 23 ...... 77 folic acid tab 1 mg ...... 68 fluocinolone acetonide oil 0.01% (scalp folplex 2.2 tab ...... 69 oil) ...... 60 fondaparinux sodium subcutaneous inj fluocinonide cream 0.05% ...... 60 10 mg/0.8ml...... 20 fluocinonide gel 0.05% ...... 60 fondaparinux sodium subcutaneous inj fluocinonide oint 0.05% ...... 60 2.5 mg/0.5ml...... 20 fluocinonide soln 0.05% ...... 60 fondaparinux sodium subcutaneous inj fluorometholone ophth susp 0.1% .... 77 5 mg/0.4ml ...... 20 fluorouracil cream 5% ...... 59 fondaparinux sodium subcutaneous inj fluorouracil soln 2% ...... 59 7.5 mg/0.6ml...... 20 100 fosamprenavir calcium tab 700 mg glatiramer acetate soln prefilled syringe (base equiv) ...... 48 40 mg/ml ...... 80 fosinopril sodium & hydrochlorothiazide glatopa inj 20mg/ml ...... 80 tab 10-12.5 mg ...... 34 glimepiride tab 1 mg ...... 28 fosinopril sodium & hydrochlorothiazide glimepiride tab 2 mg ...... 28 tab 20-12.5 mg ...... 34 glimepiride tab 4 mg ...... 28 fosinopril sodium tab 10 mg ...... 32 glipizide tab 10 mg ...... 28 fosinopril sodium tab 20 mg ...... 32 glipizide tab 5 mg ...... 28 fosinopril sodium tab 40 mg ...... 32 glipizide tab er 24hr 10 mg...... 28 fulvestrant inj 250 mg/5ml ...... 37 glipizide tab er 24hr 5 mg ...... 28 furosemide oral soln 10 mg/ml...... 62 glipizide xl tab 2.5mg ...... 28 furosemide tab 20 mg ...... 62 glipizide-metformin hcl tab 2.5-250 mg furosemide tab 40 mg ...... 62 ...... 25 furosemide tab 80 mg ...... 62 glipizide-metformin hcl tab 2.5-500 mg FUZEON INJ 90MG ...... 48 ...... 25 fyavolv tab 1-5 ...... 65 glipizide-metformin hcl tab 5-500 mg25 G GLUCAGEN INJ HYPOKIT ...... 26 gabapentin cap 100 mg ...... 21 GLUCAGON KIT 1MG ...... 26 gabapentin cap 300 mg ...... 21 glyburide micronized tab 1.5 mg ...... 28 gabapentin cap 400 mg ...... 21 glyburide micronized tab 3 mg ...... 28 gabapentin oral soln 250 mg/5ml ..... 21 glyburide micronized tab 6 mg ...... 28 gabapentin tab 600 mg ...... 21 glyburide tab 1.25 mg ...... 28 gabapentin tab 800 mg ...... 21 glyburide tab 2.5 mg ...... 28 galantamine hydrobromide cap er 24hr glyburide tab 5 mg ...... 28 16 mg ...... 79 glyburide-metformin tab 1.25-250 mg galantamine hydrobromide cap er 24hr ...... 25 24 mg ...... 79 glyburide-metformin tab 2.5-500 mg 26 galantamine hydrobromide cap er 24hr glyburide-metformin tab 5-500 mg ... 26 8 mg ...... 79 glycopyrrolate tab 1 mg ...... 83 galantamine hydrobromide oral soln 4 glycopyrrolate tab 2 mg ...... 83 mg/ml ...... 79 GLYXAMBI TAB 10-5 MG ...... 26 galantamine hydrobromide tab 12 mg GLYXAMBI TAB 25-5 MG ...... 26 ...... 79 GOLYTELY SOL ...... 70 galantamine hydrobromide tab 4 mg 79 granisetron hcl tab 1 mg ...... 28 galantamine hydrobromide tab 8 mg 79 GRANIX INJ 300/0.5 ...... 68 gavilyte-h kit ...... 70 GRANIX INJ 300/1ML ...... 68 GAVRETO CAP 100MG ...... 38 GRANIX INJ 480/0.8 ...... 68 gemfibrozil tab 600 mg ...... 30 GRANIX INJ 480/1.6 ...... 68 gentamicin sulfate cream 0.1% ...... 59 griseofulvin microsize susp 125 mg/5ml gentamicin sulfate oint 0.1% ...... 59 ...... 29 gentamicin sulfate ophth oint 0.3% .. 76 griseofulvin ultramicrosize tab 125 mg gentamicin sulfate ophth soln 0.3% .. 76 ...... 29 GENVOYA TAB ...... 48 griseofulvin ultramicrosize tab 250 mg GILENYA CAP 0.5MG ...... 80 ...... 29 GILOTRIF TAB 20MG ...... 38 guanfacine hcl tab 1 mg ...... 33 GILOTRIF TAB 30MG ...... 38 guanfacine hcl tab 2 mg ...... 33 GILOTRIF TAB 40MG ...... 38 101 guanfacine hcl tab er 24hr 1 mg (base HUMULIN R INJ U-100 ...... 27 equiv) ...... 6 HUMULIN R INJ U-500 ...... 27 guanfacine hcl tab er 24hr 2 mg (base hydralazine hcl tab 10 mg ...... 35 equiv) ...... 7 hydralazine hcl tab 100 mg ...... 35 guanfacine hcl tab er 24hr 3 mg (base hydralazine hcl tab 25 mg ...... 35 equiv) ...... 7 hydralazine hcl tab 50 mg ...... 35 guanfacine hcl tab er 24hr 4 mg (base hydrochlorothiazide cap 12.5 mg ...... 63 equiv) ...... 7 hydrochlorothiazide tab 12.5 mg ...... 63 H hydrochlorothiazide tab 25 mg ...... 63 HALDOL DECAN INJ 100MG/ML ...... 44 hydrochlorothiazide tab 50 mg ...... 63 HALDOL DECAN INJ 50MG/ML ...... 44 hydrocodone-acetaminophen soln 7.5- halobetasol propionate cream 0.05% 60 325 mg/15ml ...... 12 halobetasol propionate oint 0.05% ... 60 hydrocodone-acetaminophen tab 10- haloperidol decanoate im soln 100 325 mg ...... 12 mg/ml ...... 44 hydrocodone-acetaminophen tab 5-325 haloperidol decanoate im soln 50 mg ...... 12 mg/ml ...... 44 hydrocodone-acetaminophen tab 7.5- haloperidol lactate inj 5 mg/ml ...... 44 325 mg ...... 12 haloperidol lactate oral conc 2 mg/ml44 hydrocodone-ibuprofen tab 7.5-200 mg haloperidol tab 0.5 mg ...... 44 ...... 12 haloperidol tab 1 mg ...... 44 hydrocortisone butyrate cream 0.1% 60 haloperidol tab 10 mg ...... 44 hydrocortisone butyrate oint 0.1% ... 60 haloperidol tab 2 mg ...... 44 hydrocortisone butyrate soln 0.1% ... 60 haloperidol tab 20 mg ...... 44 hydrocortisone cream 2.5% ...... 60 haloperidol tab 5 mg ...... 44 hydrocortisone enema 100 mg/60ml 13 heparin sodium (porcine) inj 5000 hydrocortisone lotion 2.5% ...... 60 unit/ml ...... 20 hydrocortisone oint 1% ...... 60 HEXALEN CAP 50MG ...... 35 hydrocortisone oint 2.5% ...... 61 HUMALOG MIX INJ 50/50 ...... 27 hydrocortisone perianal cream 1% ... 13 HUMALOG MIX INJ 50/50KWP ...... 27 hydrocortisone perianal cream 2.5% 13 HUMALOG MIX INJ 75/25KWP ...... 27 hydrocortisone tab 10 mg ...... 57 HUMALOG MIX SUS 75/25 ...... 27 hydrocortisone tab 20 mg ...... 57 HUMIRA INJ 10/0.1ML ...... 8 hydrocortisone tab 5 mg ...... 57 HUMIRA INJ 10MG/0.2 ...... 8 hydromorphone hcl liqd 1 mg/ml ...... 11 HUMIRA INJ 20/0.2ML ...... 8 hydromorphone hcl tab 2 mg ...... 11 HUMIRA INJ 40/0.4ML ...... 8 hydromorphone hcl tab 4 mg ...... 11 HUMIRA KIT 20MG/0.4 ...... 8 hydromorphone hcl tab 8 mg ...... 11 HUMIRA KIT 40MG/0.8 ...... 8 hydromorphone hcl tab er 24hr 12 mg HUMIRA PEDIA INJ CROHNS ...... 8 ...... 11 HUMIRA PEN INJ 40/0.4ML ...... 8 hydromorphone hcl tab er 24hr 16 mg HUMIRA PEN INJ 40MG/0.8 ...... 8 ...... 11 HUMIRA PEN KIT CD/UC/HS ...... 8 hydromorphone hcl tab er 24hr 32 mg HUMIRA PEN KIT PS/UV ...... 8 ...... 11 HUMULIN INJ 70/30 ...... 27 hydromorphone hcl tab er 24hr 8 mg 11 HUMULIN INJ 70/30KWP ...... 27 hydroxychloroquine sulfate tab 200 mg HUMULIN N INJ U-100 ...... 27 ...... 35 HUMULIN N INJ U-100KWP ...... 27 hydroxyurea cap 500 mg ...... 40 102 hydroxyzine hcl syrup 10 mg/5ml ..... 15 inatal adv tab ...... 74 hydroxyzine hcl tab 10 mg ...... 15 INBRIJA CAP 42MG ...... 42 hydroxyzine hcl tab 25 mg ...... 15 INCRUSE ELPT INH 62.5MCG ...... 17 hydroxyzine hcl tab 50 mg ...... 15 indapamide tab 1.25 mg ...... 63 hydroxyzine pamoate cap 100 mg .... 15 indapamide tab 2.5 mg ...... 63 hydroxyzine pamoate cap 25 mg ...... 15 indomethacin cap 25 mg ...... 9 hydroxyzine pamoate cap 50 mg ...... 15 indomethacin cap 50 mg ...... 9 hyoscyamine sulfate elixir 0.125 indomethacin cap er 75 mg ...... 9 mg/5ml ...... 84 INSPIREASE MIS MOUTHPCE ...... 71 hyoscyamine sulfate sl tab 0.125 mg 84 INSPIREASE MIS RES BAG ...... 71 hyoscyamine sulfate soln 0.125 mg/ml INTELENCE TAB 100MG ...... 48 ...... 84 INTELENCE TAB 200MG ...... 48 hyoscyamine sulfate tab 0.125 mg ... 84 INTELENCE TAB 25MG ...... 48 hyoscyamine sulfate tab disint 0.125 INTRON A INJ 10MU ...... 40 mg ...... 84 INTRON A INJ 18MU ...... 40 I INTRON A INJ 25MU ...... 40 IBRANCE CAP 100MG ...... 38 INTRON A INJ 50MU ...... 40 IBRANCE CAP 125MG ...... 38 INVEGA SUST INJ 117/0.75 ...... 43 IBRANCE CAP 75MG ...... 38 INVEGA SUST INJ 156MG/ML ...... 43 IBRANCE TAB 100MG ...... 38 INVEGA SUST INJ 234/1.5 ...... 43 IBRANCE TAB 125MG ...... 38 INVEGA SUST INJ 39/0.25 ...... 43 IBRANCE TAB 75MG ...... 38 INVEGA SUST INJ 78/0.5ML ...... 43 ibuprofen susp 100 mg/5ml ...... 9 INVEGA TRINZ INJ 273MG...... 43 ibuprofen tab 400 mg ...... 9 INVEGA TRINZ INJ 410MG...... 43 ibuprofen tab 600 mg ...... 9 INVEGA TRINZ INJ 546MG...... 43 ibuprofen tab 800 mg ...... 9 INVEGA TRINZ INJ 819MG...... 43 ICLUSIG TAB 10MG ...... 38 INVIRASE CAP 200MG ...... 48 ICLUSIG TAB 15MG ...... 38 INVIRASE TAB 500MG ...... 48 ICLUSIG TAB 30MG ...... 38 INVOKAMET TAB 150-1000 ...... 26 ICLUSIG TAB 45MG ...... 38 INVOKAMET TAB 150-500 ...... 26 icosapent ethyl cap 1 gm...... 30 INVOKAMET TAB 50-1000 ...... 26 ILARIS INJ 150MG ...... 9 INVOKAMET TAB 50-500MG ...... 26 ILARIS INJ 150MG/ML ...... 9 INVOKANA TAB 100MG ...... 27 imatinib mesylate tab 100 mg (base INVOKANA TAB 300MG ...... 27 equivalent) ...... 38 ipratropium bromide inhal soln 0.02% imatinib mesylate tab 400 mg (base ...... 17 equivalent) ...... 38 ipratropium bromide nasal soln 0.03% IMBRUVICA CAP 140MG ...... 38 (21 mcg/spray) ...... 75 IMBRUVICA CAP 70MG ...... 38 ipratropium bromide nasal soln 0.06% IMBRUVICA TAB 140MG ...... 38 (42 mcg/spray) ...... 75 IMBRUVICA TAB 280MG ...... 38 ipratropium-albuterol nebu soln 0.5- IMBRUVICA TAB 420MG ...... 38 2.5(3) mg/3ml ...... 18 IMBRUVICA TAB 560MG ...... 38 irbesartan tab 150 mg ...... 32 imipramine hcl tab 10 mg ...... 25 irbesartan tab 300 mg ...... 32 imipramine hcl tab 25 mg ...... 25 irbesartan tab 75 mg ...... 32 imipramine hcl tab 50 mg ...... 25 irbesartan-hydrochlorothiazide tab imiquimod cream 5% ...... 61 150-12.5 mg ...... 34 103 irbesartan-hydrochlorothiazide tab JENTADUETO TAB XR ...... 26 300-12.5 mg ...... 34 jevantique l tab 0.5-2.5 ...... 65 ISENTRESS CHW 100MG ...... 48 JULUCA TAB 50-25MG...... 48 ISENTRESS CHW 25MG ...... 48 K ISENTRESS HD TAB 600MG ...... 48 KALETRA TAB 100-25MG ...... 48 ISENTRESS POW 100MG ...... 48 KALETRA TAB 200-50MG ...... 48 ISENTRESS TAB 400MG ...... 48 KALYDECO PAK 25MG ...... 81 isoniazid syrup 50 mg/5ml ...... 35 KALYDECO PAK 50MG ...... 81 isoniazid tab 100 mg ...... 35 KALYDECO PAK 75MG ...... 81 isoniazid tab 300 mg ...... 35 KALYDECO TAB 150MG ...... 81 ISOPTO ATROP SOL 1% OP ...... 76 ketoconazole cream 2% ...... 59 isosorbide dinitrate tab 10 mg ...... 14 ketoconazole shampoo 2% ...... 59 isosorbide dinitrate tab 20 mg ...... 14 ketoconazole tab 200 mg ...... 29 isosorbide dinitrate tab 30 mg ...... 14 ketoprofen cap 50 mg ...... 9 isosorbide dinitrate tab 5 mg ...... 14 ketoprofen cap 75 mg ...... 9 isosorbide dinitrate tab er 40 mg ...... 14 ketorolac tromethamine ophth soln isosorbide mononitrate tab 10 mg .... 14 0.4% ...... 77 isosorbide mononitrate tab 20 mg .... 14 ketorolac tromethamine ophth soln isosorbide mononitrate tab er 24hr 120 0.5% ...... 77 mg ...... 15 ketorolac tromethamine tab 10 mg .... 9 isosorbide mononitrate tab er 24hr 30 KEVZARA INJ 150/1.14 ...... 9 mg ...... 14 KEVZARA INJ 200/1.14 ...... 9 isosorbide mononitrate tab er 24hr 60 klor-con 8 tab 8meq er ...... 72 mg ...... 15 klor-con m15 tab 15meq er ...... 72 isotretinoin cap 10 mg ...... 58 KLOR-CON/25 POW 25MEQ ...... 72 isotretinoin cap 20 mg ...... 58 KORLYM TAB 300MG ...... 26 isotretinoin cap 30 mg ...... 58 K-PHOS TAB ...... 72 isotretinoin cap 40 mg ...... 58 K-PHOS TAB NO 2 ...... 67 ISTODAX INJ 10MG ...... 39 L itraconazole cap 100 mg ...... 29 labetalol hcl tab 100 mg ...... 50 ivermectin tab 3 mg ...... 13 labetalol hcl tab 200 mg ...... 51 J labetalol hcl tab 300 mg ...... 51 JAKAFI TAB 10MG ...... 39 lactic acid (ammonium lactate) cream JAKAFI TAB 15MG ...... 39 12% ...... 61 JAKAFI TAB 20MG ...... 39 lactic acid (ammonium lactate) lotion JAKAFI TAB 25MG ...... 39 12% ...... 61 JAKAFI TAB 5MG ...... 39 lactulose (encephalopathy) solution 10 JANUMET TAB 50-1000 ...... 26 gm/15ml ...... 66 JANUMET TAB 50-500MG ...... 26 lamivudine oral soln 10 mg/ml ...... 48 JANUVIA TAB 100MG ...... 26 lamivudine tab 100 mg (hbv) ...... 50 JANUVIA TAB 25MG ...... 26 lamivudine tab 150 mg ...... 48 JANUVIA TAB 50MG ...... 26 lamivudine tab 300 mg ...... 48 JARDIANCE TAB 10MG ...... 28 lamivudine-zidovudine tab 150-300 mg JARDIANCE TAB 25MG ...... 28 ...... 48 JENTADUETO TAB 2.5-1000 ...... 26 lamotrigine orally disintegrating tab JENTADUETO TAB 2.5-500...... 26 100 mg ...... 21 JENTADUETO TAB 2.5-850...... 26 104 lamotrigine orally disintegrating tab leucovorin calcium tab 5 mg ...... 40 200 mg ...... 21 LEUKERAN TAB 2MG ...... 35 lamotrigine orally disintegrating tab 25 leuprolide acetate inj kit 5 mg/ml ..... 37 mg ...... 21 levalbuterol tartrate inhal aerosol 45 lamotrigine orally disintegrating tab 50 mcg/act (base equiv) ...... 18 mg ...... 21 levetiracetam oral soln 100 mg/ml ... 21 lamotrigine tab 100 mg ...... 21 levetiracetam tab 1000 mg ...... 21 lamotrigine tab 150 mg ...... 21 levetiracetam tab 250 mg ...... 21 lamotrigine tab 200 mg ...... 21 levetiracetam tab 500 mg ...... 21 lamotrigine tab 25 mg ...... 21 levetiracetam tab 750 mg ...... 21 lamotrigine tab chewable dispersible 25 levetiracetam tab er 24hr 500 mg .... 21 mg ...... 21 levetiracetam tab er 24hr 750 mg .... 21 lamotrigine tab chewable dispersible 5 levobunolol hcl ophth soln 0.5% ...... 76 mg ...... 21 levocarnitine oral soln 1 gm/10ml LANCETS MIS ORIGINAL ...... 70 (10%) ...... 64 LANOXIN TAB 0.0625MG ...... 53 levocetirizine dihydrochloride soln 2.5 LANOXIN TAB 0.1875MG ...... 53 mg/5ml (0.5 mg/ml) ...... 30 lansoprazole cap delayed release 30 levocetirizine dihydrochloride tab 5 mg mg ...... 83 ...... 30 LANSOPRAZOLE SUS 3MG/ML ...... 84 levofloxacin ophth soln 0.5% ...... 76 lansoprazole tab delayed release orally levofloxacin oral soln 25 mg/ml...... 65 disintegrating 15 mg ...... 84 levofloxacin tab 250 mg ...... 66 lansoprazole tab delayed release orally levofloxacin tab 500 mg ...... 66 disintegrating 30 mg ...... 84 levofloxacin tab 750 mg ...... 66 lapatinib ditosylate tab 250 mg (base levonorgestrel & ethinyl estradiol (91- equiv) ...... 39 day) tab 0.15-0.03 mg ...... 56 latanoprost ophth soln 0.005% ...... 77 levonorgestrel & ethinyl estradiol tab LATUDA TAB 120MG ...... 42 0.1 mg-20 mcg ...... 56 LATUDA TAB 20MG ...... 42 levonorgestrel & ethinyl estradiol tab LATUDA TAB 40MG ...... 42 0.15 mg-30 mcg ...... 56 LATUDA TAB 60MG ...... 42 levonorgestrel-eth estra tab 0.05- LATUDA TAB 80MG ...... 42 30/0.075-40/0.125-30mg-mcg ..... 56 leena tab ...... 55 levonorgestrel-ethinyl estradiol leflunomide tab 10 mg ...... 10 (continuous) tab 90-20 mcg ...... 56 leflunomide tab 20 mg ...... 10 levonorg-eth est tab 0.1-0.02mg(84) & LENVIMA CAP 10 MG ...... 39 eth est tab 0.01mg(7) ...... 55 LENVIMA CAP 12MG ...... 39 levonorg-eth est tab 0.15-0.03mg(84) LENVIMA CAP 14 MG ...... 39 & eth est tab 0.01mg(7) ...... 55 LENVIMA CAP 18 MG ...... 39 levothyroxine sodium tab 100 mcg ... 82 LENVIMA CAP 20 MG ...... 39 levothyroxine sodium tab 112 mcg ... 82 LENVIMA CAP 24 MG ...... 39 levothyroxine sodium tab 125 mcg ... 82 LENVIMA CAP 4MG ...... 39 levothyroxine sodium tab 137 mcg ... 82 LENVIMA CAP 8 MG ...... 39 levothyroxine sodium tab 150 mcg ... 82 letrozole tab 2.5 mg ...... 37 levothyroxine sodium tab 175 mcg ... 82 leucovorin calcium tab 10 mg ...... 40 levothyroxine sodium tab 200 mcg ... 82 leucovorin calcium tab 15 mg ...... 41 levothyroxine sodium tab 25 mcg ..... 82 leucovorin calcium tab 25 mg ...... 41 levothyroxine sodium tab 300 mcg ... 82 105 levothyroxine sodium tab 50 mcg ..... 82 LO LOESTRIN TAB 1-10-10 ...... 56 levothyroxine sodium tab 75 mcg ..... 82 lomustine cap 10 mg ...... 35 levothyroxine sodium tab 88 mcg ..... 82 lomustine cap 100 mg ...... 36 levoxyl tab 100mcg ...... 82 lomustine cap 40 mg ...... 35 levoxyl tab 112mcg ...... 82 LONSURF TAB 15-6.14 ...... 37 levoxyl tab 125mcg ...... 82 LONSURF TAB 20-8.19 ...... 37 levoxyl tab 137mcg ...... 82 loperamide hcl cap 2 mg ...... 28 levoxyl tab 150mcg ...... 82 lopinavir-ritonavir soln 400-100 levoxyl tab 175mcg ...... 82 mg/5ml (80-20 mg/ml) ...... 48 levoxyl tab 200mcg ...... 82 lorazepam conc 2 mg/ml ...... 16 levoxyl tab 25mcg ...... 82 lorazepam tab 0.5 mg ...... 16 levoxyl tab 50mcg ...... 82 lorazepam tab 1 mg ...... 16 levoxyl tab 75mcg ...... 82 lorazepam tab 2 mg ...... 16 levoxyl tab 88mcg ...... 82 losartan potassium & LEXIVA SUS 50MG/ML ...... 48 hydrochlorothiazide tab 100-12.5 mg lidocaine hcl soln 4% ...... 61 ...... 34 lidocaine hcl viscous soln 2% ...... 74 losartan potassium & lidocaine oint 5% ...... 61 hydrochlorothiazide tab 100-25 mg 34 lidocaine patch 5% ...... 61 losartan potassium & lidocaine-prilocaine cream 2.5-2.5% . 61 hydrochlorothiazide tab 50-12.5 mg linezolid for susp 100 mg/5ml ...... 14 ...... 34 linezolid tab 600 mg ...... 14 losartan potassium tab 100 mg ...... 32 LINZESS CAP 145MCG ...... 66 losartan potassium tab 25 mg ...... 32 LINZESS CAP 290MCG ...... 66 losartan potassium tab 50 mg ...... 32 LINZESS CAP 72MCG ...... 66 lovastatin tab 10 mg ...... 31 liothyronine sodium tab 25 mcg ...... 82 lovastatin tab 20 mg ...... 31 liothyronine sodium tab 5 mcg ...... 82 lovastatin tab 40 mg ...... 31 liothyronine sodium tab 50 mcg ...... 82 low-ogestrel tab ...... 56 lisinopril & hydrochlorothiazide tab 10- loxapine succinate cap 10 mg ...... 44 12.5 mg ...... 34 loxapine succinate cap 25 mg ...... 44 lisinopril & hydrochlorothiazide tab 20- loxapine succinate cap 5 mg ...... 44 12.5 mg ...... 34 loxapine succinate cap 50 mg ...... 44 lisinopril & hydrochlorothiazide tab 20- lubiprostone cap 24 mcg ...... 66 25 mg ...... 34 lubiprostone cap 8 mcg ...... 66 lisinopril tab 10 mg ...... 32 ludent chw 0.25mg f ...... 72 lisinopril tab 2.5 mg ...... 32 ludent chw 0.5mg f ...... 72 lisinopril tab 20 mg ...... 32 ludent chw 1mg f ...... 72 lisinopril tab 30 mg ...... 32 LUPANETA KIT 11.25-5 ...... 64 lisinopril tab 40 mg ...... 32 LUPANETA KIT 3.75-5 ...... 64 lisinopril tab 5 mg ...... 32 LUPRON DEPOT INJ 11.25MG ...... 37 lithium carbonate cap 150 mg ...... 42 LUPRON DEPOT INJ 22.5MG ...... 37 lithium carbonate cap 300 mg ...... 42 LUPRON DEPOT INJ 3.75MG ...... 37 lithium carbonate cap 600 mg ...... 42 LUPRON DEPOT INJ 30MG ...... 37 lithium carbonate tab 300 mg ...... 42 LUPRON DEPOT INJ 45MG ...... 37 lithium carbonate tab er 300 mg ...... 42 LUPRON DEPOT INJ 7.5MG ...... 37 lithium carbonate tab er 450 mg ...... 42 LYSODREN TAB 500MG ...... 37 LITHIUM SOL 8MEQ/5ML ...... 42 lyza tab 0.35mg ...... 57 106

M mesalamine rectal enema 4 gm & malathion lotion 0.5%...... 61 cleanser wipe kit ...... 66 MARPLAN TAB 10MG ...... 23 mesalamine suppos 1000 mg...... 66 MATULANE CAP 50MG ...... 40 mesalamine tab delayed release 1.2 matzim la tab 180mg/24 ...... 52 gm ...... 66 matzim la tab 240mg/24 ...... 52 mesalamine tab delayed release 800 matzim la tab 300mg/24 ...... 52 mg ...... 66 matzim la tab 360mg/24 ...... 52 metformin hcl tab 1000 mg ...... 26 matzim la tab 420mg/24 ...... 53 metformin hcl tab 500 mg ...... 26 MAVENCLAD PAK 10MG (4) ...... 80 metformin hcl tab 850 mg ...... 26 MAVENCLAD PAK 10MG (5) ...... 80 metformin hcl tab er 24hr 500 mg .... 26 MAVENCLAD PAK 10MG (6) ...... 80 metformin hcl tab er 24hr 750 mg .... 26 MAVENCLAD PAK 10MG (7) ...... 80 methadone hcl tab 10 mg ...... 11 MAVENCLAD PAK 10MG (8) ...... 80 methadone hcl tab 5 mg ...... 11 MAVENCLAD PAK 10MG (9) ...... 80 methazolamide tab 25 mg ...... 62 MAVENCLAD PAK 10MG(10) ...... 80 methazolamide tab 50 mg ...... 62 MAVYRET TAB 100-40MG ...... 50 METHENAMINE HIPPURATE TAB 1 GM MAYZENT TAB 0.25MG ...... 80 ...... 84 MAYZENT TAB 2MG ...... 80 METHERGINE TAB 0.2MG ...... 77 meclizine hcl tab 12.5 mg ...... 28 methimazole tab 10 mg ...... 82 meclizine hcl tab 25 mg ...... 28 methimazole tab 5 mg ...... 82 MEDROL TAB 2MG ...... 57 methocarbamol tab 500 mg ...... 75 medroxyprogesterone acetate im susp methocarbamol tab 750 mg ...... 75 150 mg/ml ...... 56 methotrexate sodium inj 250 mg/10ml medroxyprogesterone acetate im susp (25 mg/ml) ...... 36 prefilled syr 150 mg/ml ...... 57 methotrexate sodium inj 50 mg/2ml medroxyprogesterone acetate tab 10 (25 mg/ml) ...... 36 mg ...... 79 methotrexate sodium inj pf 100 medroxyprogesterone acetate tab 2.5 mg/4ml (25 mg/ml) ...... 36 mg ...... 79 methotrexate sodium inj pf 1000 medroxyprogesterone acetate tab 5 mg mg/40ml (25 mg/ml) ...... 36 ...... 79 methotrexate sodium inj pf 200 mefloquine hcl tab 250 mg ...... 35 mg/8ml (25 mg/ml) ...... 36 megestrol acetate susp 40 mg/ml .... 37 methotrexate sodium inj pf 250 megestrol acetate tab 20 mg ...... 37 mg/10ml (25 mg/ml) ...... 36 megestrol acetate tab 40 mg ...... 37 methotrexate sodium inj pf 50 mg/2ml meloxicam tab 15 mg ...... 9 (25 mg/ml) ...... 36 meloxicam tab 7.5 mg ...... 9 methotrexate sodium tab 2.5 mg (base melphalan tab 2 mg ...... 36 equiv) ...... 36 memantine hcl oral solution 2 mg/ml 79 methyldopa tab 250 mg ...... 33 memantine hcl tab 10 mg ...... 79 methyldopa tab 500 mg ...... 33 memantine hcl tab 28 x 5 mg & 21 x methylphenidate hcl cap er 10 mg (cd) 10 mg titration pack ...... 79 ...... 7 memantine hcl tab 5 mg ...... 79 methylphenidate hcl cap er 20 mg (cd) mercaptopurine tab 50 mg ...... 36 ...... 7 mesalamine cap er 24hr 0.375 gm ... 66 methylphenidate hcl cap er 24hr 20 mg mesalamine enema 4 gm ...... 66 (la) ...... 7 107 methylphenidate hcl cap er 24hr 30 mg metoclopramide hcl tab 10 mg (base (la) ...... 7 equivalent) ...... 66 methylphenidate hcl cap er 24hr 40 mg metoclopramide hcl tab 5 mg (base (la) ...... 7 equivalent) ...... 66 methylphenidate hcl cap er 30 mg (cd) metolazone tab 10 mg ...... 63 ...... 7 metolazone tab 2.5 mg ...... 63 methylphenidate hcl cap er 40 mg (cd) metolazone tab 5 mg ...... 63 ...... 7 metoprolol & hydrochlorothiazide tab methylphenidate hcl cap er 50 mg (cd) 100-25 mg ...... 34 ...... 7 metoprolol & hydrochlorothiazide tab methylphenidate hcl cap er 60 mg (cd) 100-50 mg ...... 34 ...... 7 metoprolol & hydrochlorothiazide tab methylphenidate hcl chew tab 10 mg . 7 50-25 mg ...... 34 methylphenidate hcl chew tab 2.5 mg 7 metoprolol succinate tab er 24hr 100 methylphenidate hcl chew tab 5 mg ... 7 mg (tartrate equiv) ...... 51 methylphenidate hcl soln 10 mg/5ml . 7 metoprolol succinate tab er 24hr 200 methylphenidate hcl soln 5 mg/5ml ... 7 mg (tartrate equiv) ...... 51 methylphenidate hcl tab 10 mg ...... 7 metoprolol succinate tab er 24hr 25 mg methylphenidate hcl tab 20 mg ...... 7 (tartrate equiv) ...... 51 methylphenidate hcl tab 5 mg ...... 7 metoprolol succinate tab er 24hr 50 mg methylphenidate hcl tab er 10 mg ..... 7 (tartrate equiv) ...... 51 methylphenidate hcl tab er 20 mg ..... 7 metoprolol tartrate tab 100 mg ...... 51 methylphenidate hcl tab er 24hr 18 mg metoprolol tartrate tab 25 mg ...... 51 ...... 7 metoprolol tartrate tab 50 mg ...... 51 methylphenidate hcl tab er 24hr 27 mg metoprolol tartrate tab 75 mg ...... 51 ...... 7 metronidazole cap 375 mg ...... 14 methylphenidate hcl tab er 24hr 36 mg metronidazole cream 0.75% ...... 61 ...... 7 metronidazole gel 0.75% ...... 61 methylphenidate hcl tab er 24hr 54 mg metronidazole gel 1% ...... 61 ...... 7 metronidazole lotion 0.75% ...... 61 methylphenidate hcl tab er osmotic metronidazole tab 250 mg ...... 14 release (osm) 18 mg ...... 7 metronidazole tab 500 mg ...... 14 methylphenidate hcl tab er osmotic metronidazole vaginal gel 0.75% ..... 85 release (osm) 27 mg ...... 8 miconazole 3 sup 200mg ...... 85 methylphenidate hcl tab er osmotic microgestin tab 1.5/30 ...... 56 release (osm) 36 mg ...... 8 microgestin tab fe1.5/30 ...... 56 methylphenidate hcl tab er osmotic midodrine hcl tab 10 mg ...... 85 release (osm) 54 mg ...... 8 midodrine hcl tab 2.5 mg ...... 85 methylprednisolone tab 16 mg ...... 57 midodrine hcl tab 5 mg ...... 85 methylprednisolone tab 32 mg ...... 57 minocycline hcl cap 100 mg ...... 81 methylprednisolone tab 4 mg ...... 57 minocycline hcl cap 50 mg ...... 81 methylprednisolone tab 8 mg ...... 57 minocycline hcl cap 75 mg ...... 81 methylprednisolone tab therapy pack 4 minocycline hcl tab 100 mg ...... 82 mg (21) ...... 57 minocycline hcl tab 50 mg ...... 81 metipranolol ophth soln 0.3% ...... 76 minocycline hcl tab 75 mg ...... 81 metoclopramide hcl soln 5 mg/5ml (10 minoxidil tab 10 mg ...... 35 mg/10ml) (base equiv) ...... 66 minoxidil tab 2.5 mg ...... 35 108 mirtazapine orally disintegrating tab 15 MULPLETA TAB 3MG ...... 68 mg ...... 23 multi-vit/fe dro /fl 0.25 ...... 74 mirtazapine orally disintegrating tab 30 multi-vit/fl dro 0.25mg ...... 74 mg ...... 23 multi-vit/fl dro 0.5mg/ml ...... 74 mirtazapine orally disintegrating tab 45 mupirocin oint 2% ...... 59 mg ...... 23 mvc-fluoride chw 0.25mg ...... 74 mirtazapine tab 15 mg ...... 23 mvc-fluoride chw 0.5mg ...... 74 mirtazapine tab 30 mg ...... 23 mvc-fluoride chw 1mg ...... 74 mirtazapine tab 45 mg ...... 23 my way tab 1.5mg ...... 56 mirtazapine tab 7.5 mg ...... 23 mycophenolate mofetil cap 250 mg .. 73 misoprostol tab 100 mcg ...... 84 mycophenolate mofetil for oral susp misoprostol tab 200 mcg ...... 84 200 mg/ml ...... 73 mometasone furoate cream 0.1% .... 61 mycophenolate mofetil tab 500 mg... 73 mometasone furoate nasal susp 50 MYLERAN TAB 2MG...... 36 mcg/act ...... 75 N mometasone furoate oint 0.1% ...... 61 nabumetone tab 500 mg ...... 9 mometasone furoate solution 0.1% nabumetone tab 750 mg ...... 9 (lotion) ...... 61 nadolol tab 20 mg ...... 51 montelukast sodium chew tab 4 mg nadolol tab 40 mg ...... 51 (base equiv) ...... 17 nadolol tab 80 mg ...... 51 montelukast sodium chew tab 5 mg naloxone hcl soln prefilled syringe 2 (base equiv) ...... 17 mg/2ml ...... 28 montelukast sodium oral granules naltrexone hcl tab 50 mg ...... 28 packet 4 mg (base equiv) ...... 17 naproxen dr tab 375mg ...... 9 montelukast sodium tab 10 mg (base naproxen dr tab 500mg ...... 9 equiv) ...... 17 naproxen sodium tab 275 mg ...... 9 morphine sulfate oral soln 10 mg/5ml naproxen sodium tab 550 mg ...... 9 ...... 11 naproxen susp 125 mg/5ml ...... 10 morphine sulfate oral soln 100 mg/5ml naproxen tab 250 mg ...... 10 (20 mg/ml) ...... 11 naproxen tab 375 mg ...... 10 morphine sulfate oral soln 20 mg/5ml naproxen tab 500 mg ...... 10 ...... 11 naratriptan hcl tab 1 mg (base equiv) morphine sulfate suppos 10 mg ...... 11 ...... 71 morphine sulfate suppos 20 mg ...... 11 naratriptan hcl tab 2.5 mg (base equiv) MORPHINE SULFATE SUPPOS 30 MG . 11 ...... 71 morphine sulfate suppos 5 mg ...... 11 NARCAN SPR ...... 28 morphine sulfate tab 15 mg ...... 11 NATACYN SUS 5% OP ...... 76 morphine sulfate tab 30 mg ...... 11 nateglinide tab 120 mg ...... 27 morphine sulfate tab er 15 mg ...... 11 nateglinide tab 60 mg ...... 27 morphine sulfate tab er 30 mg ...... 11 NATPARA INJ 100MCG ...... 63 morphine sulfate tab er 60 mg ...... 11 NATPARA INJ 25MCG ...... 63 MOTEGRITY TAB 1MG ...... 66 NATPARA INJ 50MCG ...... 63 MOTEGRITY TAB 2MG ...... 66 NATPARA INJ 75MCG ...... 63 MOVANTIK TAB 12.5MG ...... 67 NAYZILAM SPR 5MG ...... 20 MOVANTIK TAB 25MG ...... 67 nebusal neb 3% ...... 58 moxifloxacin hcl ophth soln 0.5% (base necon tab 0.5/35 ...... 56 equiv) ...... 76 necon tab 1/35 ...... 56 109 necon tab 1/50-28...... 56 NITRO-BID OIN 2% ...... 15 necon tab 7/7/7 ...... 56 nitrofurantoin macrocrystalline cap 100 neomycin sulfate tab 500 mg ...... 8 mg ...... 84 neomycin-polymy-gramicid op sol nitrofurantoin macrocrystalline cap 25 1.75-10000-0.025mg-unt-mg/ml .. 76 mg ...... 84 neomycin-polymyxin-dexamethasone nitrofurantoin macrocrystalline cap 50 ophth oint 0.1% ...... 77 mg ...... 84 neomycin-polymyxin-dexamethasone nitrofurantoin monohydrate ophth susp 0.1% ...... 77 macrocrystalline cap 100 mg ...... 84 neomycin-polymyxin-hc ophth susp .. 77 nitrofurantoin susp 25 mg/5ml ...... 84 neomycin-polymyxin-hc otic soln 1% 77 nitroglycerin cap er 6.5 mg...... 15 neomycin-polymyxin-hc otic susp 3.5 nitroglycerin cap er 9 mg ...... 15 mg/ml-10000 unit/ml-1%...... 77 nitroglycerin sl tab 0.3 mg...... 15 neo-polycin oin hc 1%op ...... 77 nitroglycerin sl tab 0.4 mg...... 15 neo-polycin oin op ...... 76 nitroglycerin sl tab 0.6 mg...... 15 nephronex tab ...... 74 nitroglycerin td patch 24hr 0.1 mg/hr NEULASTA INJ 6MG/0.6M ...... 68 ...... 15 NEULASTA KIT 6MG/0.6M ...... 68 nitroglycerin td patch 24hr 0.2 mg/hr NEUPOGEN INJ 300/0.5 ...... 68 ...... 15 NEUPOGEN INJ 300MCG ...... 68 nitroglycerin td patch 24hr 0.4 mg/hr NEUPOGEN INJ 480/0.8 ...... 68 ...... 15 NEUPOGEN INJ 480MCG ...... 68 nitroglycerin td patch 24hr 0.6 mg/hr nevirapine susp 50 mg/5ml ...... 48 ...... 15 nevirapine tab 200 mg ...... 48 nizatidine cap 150 mg ...... 83 nevirapine tab er 24hr 100 mg ...... 48 nizatidine cap 300 mg ...... 83 nevirapine tab er 24hr 400 mg ...... 48 nizatidine oral soln 15 mg/ml ...... 83 NEXAVAR TAB 200MG ...... 39 NOCDURNA SUB 27.7MCG ...... 64 niacin tab er 1000 mg NOCDURNA SUB 55.3MCG ...... 64 (antihyperlipidemic) ...... 31 NOCTIVA EMU 0.83/0.1 ...... 64 niacin tab er 500 mg NOCTIVA SPR 1.66/0.1 ...... 64 (antihyperlipidemic) ...... 31 NORDITROPIN INJ 10/1.5ML ...... 63 niacin tab er 750 mg NORDITROPIN INJ 15/1.5ML ...... 63 (antihyperlipidemic) ...... 31 NORDITROPIN INJ 30/3ML ...... 63 NICOTROL INH ...... 81 NORDITROPIN INJ 5/1.5ML ...... 63 NICOTROL NS SPR 10MG/ML ...... 81 norethindrone ace & ethinyl estradiol nifedipine tab er 24hr 30 mg ...... 53 tab 1 mg-20 mcg ...... 56 nifedipine tab er 24hr 60 mg ...... 53 norethindrone ace & ethinyl estradiol-fe nifedipine tab er 24hr 90 mg ...... 53 tab 1 mg-20 mcg ...... 56 nifedipine tab er 24hr osmotic release norethindrone ace-eth estradiol-fe 30 mg ...... 53 chew tab 1 mg-20 mcg (24) ...... 56 nifedipine tab er 24hr osmotic release norethindrone acetate tab 5 mg ...... 79 60 mg ...... 53 norgestimate & ethinyl estradiol tab nifedipine tab er 24hr osmotic release 0.25 mg-35 mcg ...... 56 90 mg ...... 53 norgestimate-eth estrad tab 0.18- NINLARO CAP 2.3MG ...... 39 25/0.215-25/0.25-25 mg-mcg ...... 56 NINLARO CAP 3MG ...... 39 norgestimate-eth estrad tab 0.18- NINLARO CAP 4MG ...... 39 35/0.215-35/0.25-35 mg-mcg ...... 56 110

NORPACE CAP 100MG CR ...... 16 olanzapine orally disintegrating tab 15 nortriptyline hcl cap 10 mg ...... 25 mg ...... 44 nortriptyline hcl cap 25 mg ...... 25 olanzapine orally disintegrating tab 20 nortriptyline hcl cap 50 mg ...... 25 mg ...... 44 nortriptyline hcl cap 75 mg ...... 25 olanzapine orally disintegrating tab 5 nortriptyline hcl soln 10 mg/5ml ...... 25 mg ...... 44 NORVIR CAP 100MG ...... 48 olanzapine tab 10 mg ...... 45 NORVIR SOL 80MG/ML ...... 48 olanzapine tab 15 mg ...... 45 NOVOLIN INJ 70/30 ...... 27 olanzapine tab 2.5 mg ...... 44 NOVOLIN INJ 70/30 FP ...... 27 olanzapine tab 20 mg ...... 45 NOVOLIN N INJ U-100 ...... 27 olanzapine tab 5 mg ...... 44 NOVOLIN R INJ U-100...... 27 olanzapine tab 7.5 mg ...... 45 NOVOLOG MIX INJ 70/30 ...... 27 olmesartan medoxomil tab 20 mg .... 32 NOVOLOG MIX INJ FLEXPEN ...... 27 olmesartan medoxomil tab 40 mg .... 32 np thyroid tab 120mg ...... 83 olmesartan medoxomil tab 5 mg ...... 32 np thyroid tab 15mg ...... 82 olmesartan medoxomil- np thyroid tab 30mg ...... 83 hydrochlorothiazide tab 20-12.5 mg np thyroid tab 60mg ...... 83 ...... 34 np thyroid tab 90mg ...... 83 olmesartan medoxomil- NUBEQA TAB 300MG ...... 37 hydrochlorothiazide tab 40-12.5 mg NUCYNTA ER TAB 100MG ...... 11 ...... 34 NUCYNTA ER TAB 150MG ...... 11 olmesartan medoxomil- NUCYNTA ER TAB 200MG ...... 11 hydrochlorothiazide tab 40-25 mg . 34 NUCYNTA ER TAB 250MG ...... 11 olmesartan-amlodipine- NUCYNTA ER TAB 50MG ...... 11 hydrochlorothiazide tab 20-5-12.5 NUCYNTA TAB 100MG ...... 11 mg ...... 34 NUCYNTA TAB 50MG ...... 11 olmesartan-amlodipine- NUCYNTA TAB 75MG ...... 11 hydrochlorothiazide tab 40-10-12.5 NUEDEXTA CAP 20-10MG ...... 81 mg ...... 34 NURTEC TAB 75MG ODT ...... 71 olmesartan-amlodipine- nystatin cream 100000 unit/gm ...... 59 hydrochlorothiazide tab 40-10-25 mg nystatin oint 100000 unit/gm...... 59 ...... 34 nystatin oral powder ...... 29 olmesartan-amlodipine- nystatin susp 100000 unit/ml ...... 74 hydrochlorothiazide tab 40-5-12.5 nystatin tab 500000 unit ...... 29 mg ...... 34 nystatin topical powder 100000 olmesartan-amlodipine- unit/gm ...... 59 hydrochlorothiazide tab 40-5-25 mg O ...... 34 ODEFSEY TAB ...... 48 olopatadine hcl nasal soln 0.6% ...... 75 ODOMZO CAP 200MG ...... 36 olopatadine hcl ophth soln 0.1% (base OFEV CAP 100MG ...... 81 equivalent) ...... 77 OFEV CAP 150MG ...... 81 omega-3-acid ethyl esters cap 1 gm . 30 ofloxacin ophth soln 0.3% ...... 76 OMEPRAZOLE + SUS SYRSPEND ...... 84 ofloxacin otic soln 0.3% ...... 77 omeprazole cap delayed release 10 mg ogestrel tab ...... 56 ...... 84 olanzapine orally disintegrating tab 10 omeprazole cap delayed release 20 mg mg ...... 44 ...... 84 111 omeprazole cap delayed release 40 mg oxcarbazepine tab 300 mg ...... 21 ...... 84 oxcarbazepine tab 600 mg ...... 21 OMNIPOD MIS 5 PACK ...... 70 oxybutynin chloride syrup 5 mg/5ml . 84 ondansetron hcl oral soln 4 mg/5ml .. 28 oxybutynin chloride tab 5 mg ...... 84 ondansetron hcl tab 24 mg ...... 28 oxybutynin chloride tab er 24hr 10 mg ondansetron hcl tab 4 mg ...... 28 ...... 84 ondansetron hcl tab 8 mg ...... 28 oxybutynin chloride tab er 24hr 15 mg ondansetron orally disintegrating tab 4 ...... 84 mg ...... 28 oxybutynin chloride tab er 24hr 5 mg ondansetron orally disintegrating tab 8 ...... 84 mg ...... 28 oxycodone hcl cap 5 mg ...... 11 ONE TOUCH KIT VERIO FL ...... 70 oxycodone hcl soln 5 mg/5ml ...... 11 ONETOUCH KIT ULTRA 2 ...... 70 oxycodone hcl tab 10 mg ...... 11 ONETOUCH KIT VERIO RE ...... 70 oxycodone hcl tab 15 mg ...... 11 ONETOUCH TES ULTRA ...... 62 oxycodone hcl tab 20 mg ...... 11 ONETOUCH TES VERIO ...... 62 oxycodone hcl tab 30 mg ...... 11 OPSUMIT TAB 10MG ...... 54 oxycodone hcl tab 5 mg ...... 11 ORENITRAM TAB 0.125MG ...... 53 oxycodone hcl tab er 12hr deter 10 mg ORENITRAM TAB 0.25MG ...... 53 ...... 11 ORENITRAM TAB 1MG ...... 53 oxycodone hcl tab er 12hr deter 20 mg ORENITRAM TAB 2.5MG ...... 53 ...... 11 ORILISSA TAB 150MG ...... 63 oxycodone hcl tab er 12hr deter 40 mg ORILISSA TAB 200MG ...... 63 ...... 11 ORKAMBI GRA 100-125 ...... 81 oxycodone hcl tab er 12hr deter 80 mg ORKAMBI GRA 150-188 ...... 81 ...... 11 ORKAMBI TAB 100-125 ...... 81 oxycodone w/ acetaminophen tab 10- ORKAMBI TAB 200-125 ...... 81 325 mg ...... 12 orphenadrine citrate tab er 12hr 100 oxycodone w/ acetaminophen tab 2.5- mg ...... 75 325 mg ...... 12 orphenadrine w/ aspirin & caffeine tab oxycodone w/ acetaminophen tab 5- 50-770-60 mg ...... 75 325 mg ...... 12 oseltamivir phosphate cap 30 mg (base oxycodone w/ acetaminophen tab 7.5- equiv) ...... 50 325 mg ...... 12 oseltamivir phosphate cap 45 mg (base oxycodone-aspirin tab 4.8355-325 mg equiv) ...... 50 ...... 12 oseltamivir phosphate cap 75 mg (base oxycodone-ibuprofen tab 5-400 mg .. 12 equiv) ...... 50 oxymorphone hcl tab 10 mg ...... 12 oseltamivir phosphate for susp 6 oxymorphone hcl tab 5 mg ...... 12 mg/ml (base equiv) ...... 50 oxymorphone hcl tab er 12hr 10 mg . 12 OTEZLA TAB 10/20/30 ...... 10 oxymorphone hcl tab er 12hr 15 mg . 12 OTEZLA TAB 30MG ...... 10 oxymorphone hcl tab er 12hr 20 mg . 12 oxazepam cap 10 mg ...... 16 oxymorphone hcl tab er 12hr 30 mg . 12 oxazepam cap 15 mg ...... 16 oxymorphone hcl tab er 12hr 40 mg . 12 oxazepam cap 30 mg ...... 16 oxymorphone hcl tab er 12hr 5 mg ... 12 oxcarbazepine susp 300 mg/5ml (60 oxymorphone hcl tab er 12hr 7.5 mg 12 mg/ml) ...... 21 OZEMPIC INJ 2/1.5ML ...... 26 oxcarbazepine tab 150 mg ...... 21 112

P penicillin v potassium for soln 125 PALFORZIA CAP ESCALAT ...... 8 mg/5ml ...... 78 PALFORZIA CAP LEVEL 1 ...... 8 penicillin v potassium for soln 250 PALFORZIA CAP LEVEL 10 ...... 8 mg/5ml ...... 78 PALFORZIA CAP LEVEL 2 ...... 8 penicillin v potassium tab 250 mg .... 78 PALFORZIA CAP LEVEL 3 ...... 8 penicillin v potassium tab 500 mg .... 78 PALFORZIA CAP LEVEL 4 ...... 8 PENTASA CAP 250MG CR ...... 66 PALFORZIA CAP LEVEL 5 ...... 8 PENTASA CAP 500MG CR ...... 66 PALFORZIA CAP LEVEL 6 ...... 8 permethrin cream 5% ...... 61 PALFORZIA CAP LEVEL 7 ...... 8 perphenazine tab 16 mg ...... 46 PALFORZIA CAP LEVEL 8 ...... 8 perphenazine tab 2 mg ...... 46 PALFORZIA CAP LEVEL 9 ...... 8 perphenazine tab 4 mg ...... 46 PALFORZIA POW LEVEL 11 ...... 8 perphenazine tab 8 mg ...... 46 paliperidone tab er 24hr 1.5 mg ...... 43 perphenazine-amitriptyline tab 2-10 paliperidone tab er 24hr 3 mg ...... 43 mg ...... 80 paliperidone tab er 24hr 6 mg ...... 43 perphenazine-amitriptyline tab 2-25 paliperidone tab er 24hr 9 mg ...... 43 mg ...... 80 PANCREAZE CAP ...... 62 perphenazine-amitriptyline tab 4-10 PANCREAZE CAP 10500UNT ...... 62 mg ...... 80 PANCREAZE CAP 16800UNT ...... 62 perphenazine-amitriptyline tab 4-25 PANCREAZE CAP 21000UNT ...... 62 mg ...... 80 PANCREAZE CAP 4200UNIT ...... 62 perphenazine-amitriptyline tab 4-50 pantoprazole sodium ec tab 20 mg mg ...... 80 (base equiv) ...... 84 phenazopyridine hcl tab 100 mg ...... 67 pantoprazole sodium ec tab 40 mg phenazopyridine hcl tab 200 mg ...... 67 (base equiv) ...... 84 phenelzine sulfate tab 15 mg ...... 23 paricalcitol cap 1 mcg ...... 64 phenergan sup 12.5mg ...... 30 paricalcitol cap 2 mcg ...... 64 phenergan sup 25mg ...... 30 paricalcitol cap 4 mcg ...... 64 phenergan sup 50mg ...... 30 paroxetine hcl tab 10 mg ...... 23 phenobarbital elixir 20 mg/5ml ...... 69 paroxetine hcl tab 20 mg ...... 23 phenobarbital tab 100 mg ...... 69 paroxetine hcl tab 30 mg ...... 23 phenobarbital tab 15 mg ...... 69 paroxetine hcl tab 40 mg ...... 23 phenobarbital tab 16.2 mg ...... 69 paroxetine hcl tab er 24hr 12.5 mg .. 23 phenobarbital tab 30 mg ...... 69 paroxetine hcl tab er 24hr 25 mg ..... 23 phenobarbital tab 32.4 mg ...... 69 paroxetine hcl tab er 24hr 37.5 mg .. 24 phenobarbital tab 60 mg ...... 69 PAXIL SUS 10MG/5ML ...... 24 phenobarbital tab 64.8 mg ...... 69 peg 3350-kcl-na bicarb-nacl-na sulfate phenobarbital tab 97.2 mg ...... 69 for soln 236 gm ...... 70 phenytoin chew tab 50 mg ...... 22 peg 3350-kcl-na bicarb-nacl-na sulfate phenytoin sodium extended cap 100 for soln 240 gm ...... 70 mg ...... 22 peg 3350-kcl-sod bicarb-nacl for soln phenytoin sodium extended cap 200 420 gm ...... 70 mg ...... 22 PEGASYS INJ ...... 50 phenytoin sodium extended cap 300 PEGASYS INJ 180MCG/M ...... 50 mg ...... 22 PEGASYS INJ PROCLICK ...... 50 phenytoin susp 125 mg/5ml ...... 22 phytonadione tab 5 mg ...... 86 113 pilocarpine hcl ophth soln 1% ...... 76 potassium citrate tab er 10 meq (1080 pilocarpine hcl ophth soln 2% ...... 76 mg) ...... 67 pilocarpine hcl ophth soln 4% ...... 76 potassium citrate tab er 15 meq (1620 pilocarpine hcl tab 5 mg ...... 74 mg) ...... 67 pilocarpine hcl tab 7.5 mg ...... 74 potassium citrate tab er 5 meq (540 pimecrolimus cream 1% ...... 61 mg) ...... 67 pindolol tab 10 mg ...... 51 pramipexole dihydrochloride tab 0.125 pindolol tab 5 mg ...... 51 mg ...... 42 pioglitazone hcl tab 15 mg (base equiv) pramipexole dihydrochloride tab 0.25 ...... 27 mg ...... 42 pioglitazone hcl tab 30 mg (base equiv) pramipexole dihydrochloride tab 0.5 ...... 27 mg ...... 42 pioglitazone hcl tab 45 mg (base equiv) pramipexole dihydrochloride tab 0.75 ...... 27 mg ...... 42 pioglitazone hcl-glimepiride tab 30-2 pramipexole dihydrochloride tab 1 mg mg ...... 26 ...... 42 pioglitazone hcl-glimepiride tab 30-4 pramipexole dihydrochloride tab 1.5 mg ...... 26 mg ...... 42 pioglitazone hcl-metformin hcl tab 15- prasugrel hcl tab 10 mg (base equiv) 68 500 mg ...... 26 prasugrel hcl tab 5 mg (base equiv) . 68 pioglitazone hcl-metformin hcl tab 15- pravastatin sodium tab 10 mg ...... 31 850 mg ...... 26 pravastatin sodium tab 20 mg ...... 31 PIQRAY 200MG TAB DOSE ...... 39 pravastatin sodium tab 40 mg ...... 31 PIQRAY 250MG TAB DOSE ...... 39 pravastatin sodium tab 80 mg ...... 31 PIQRAY 300MG TAB DOSE ...... 39 prazosin hcl cap 1 mg ...... 33 podofilox soln 0.5% ...... 61 prazosin hcl cap 2 mg ...... 33 polymyxin b-trimethoprim ophth soln prazosin hcl cap 5 mg ...... 33 10000 unit/ml-0.1% ...... 76 PRED MILD SUS 0.12% OP ...... 77 potassium bicarbonate effer tab 25 PRED SOD PHO SOL 1% OP ...... 77 meq ...... 72 prednisolone acetate ophth susp 1% 77 potassium chloride cap er 10 meq .... 72 prednisolone sod phos orally disintegr potassium chloride cap er 8 meq ...... 72 tab 10 mg (base eq) ...... 57 potassium chloride microencapsulated prednisolone sod phos orally disintegr crys er tab 10 meq ...... 72 tab 15 mg (base eq) ...... 57 potassium chloride microencapsulated prednisolone sod phos orally disintegr crys er tab 20 meq ...... 72 tab 30 mg (base eq) ...... 57 potassium chloride oral soln 10% (20 prednisolone sod phosph oral soln 6.7 meq/15ml) ...... 72 mg/5ml (5 mg/5ml base) ...... 57 potassium chloride oral soln 20% (40 prednisolone sod phosphate oral soln meq/15ml) ...... 72 15 mg/5ml (base equiv) ...... 57 potassium chloride powder packet 20 prednisolone sodium phosphate oral meq ...... 72 soln 25 mg/5ml (base eq) ...... 57 potassium chloride tab er 10 meq..... 72 prednisolone syrup 15 mg/5ml (usp potassium chloride tab er 20 meq solution equivalent) ...... 57 (1500 mg) ...... 72 prednisone oral soln 5 mg/5ml ...... 57 potassium citrate & citric acid soln prednisone tab 1 mg ...... 57 1100-334 mg/5ml ...... 67 prednisone tab 10 mg ...... 58 114 prednisone tab 2.5 mg ...... 58 probenecid tab 500 mg ...... 67 prednisone tab 20 mg ...... 58 prochlorperazine maleate tab 10 mg prednisone tab 5 mg ...... 58 (base equivalent) ...... 46 prednisone tab 50 mg ...... 58 prochlorperazine maleate tab 5 mg prednisone tab therapy pack 10 mg (base equivalent) ...... 46 (21) ...... 58 PROCRIT INJ 10000/ML ...... 69 prednisone tab therapy pack 10 mg PROCRIT INJ 2000/ML ...... 68 (48) ...... 58 PROCRIT INJ 20000/ML ...... 69 prednisone tab therapy pack 5 mg (21) PROCRIT INJ 3000/ML ...... 68 ...... 58 PROCRIT INJ 4000/ML ...... 69 prednisone tab therapy pack 5 mg (48) PROCRIT INJ 40000/ML ...... 69 ...... 58 progesterone cap 100 mg ...... 79 PREFEST TAB ...... 65 progesterone cap 200 mg ...... 79 pregabalin cap 100 mg ...... 21 PROMACTA PAK 25MG ...... 69 pregabalin cap 150 mg ...... 21 PROMACTA POW 12.5MG ...... 69 pregabalin cap 200 mg ...... 21 PROMACTA TAB 12.5MG ...... 69 pregabalin cap 225 mg ...... 21 PROMACTA TAB 25MG ...... 69 pregabalin cap 25 mg ...... 21 PROMACTA TAB 50MG ...... 69 pregabalin cap 300 mg ...... 21 PROMACTA TAB 75MG ...... 69 pregabalin cap 50 mg ...... 21 promethazine hcl syrup 6.25 mg/5ml 30 pregabalin cap 75 mg ...... 21 promethazine hcl tab 12.5 mg ...... 30 pregabalin soln 20 mg/ml ...... 21 promethazine hcl tab 25 mg ...... 30 PREMARIN TAB 0.3MG ...... 65 promethazine hcl tab 50 mg ...... 30 PREMARIN TAB 0.45MG ...... 65 propafenone hcl cap er 12hr 225 mg 16 PREMARIN TAB 0.625MG ...... 65 propafenone hcl cap er 12hr 325 mg 16 PREMARIN TAB 0.9MG ...... 65 propafenone hcl cap er 12hr 425 mg 16 PREMARIN TAB 1.25MG ...... 65 propafenone hcl tab 150 mg ...... 16 PREMARIN VAG CRE 0.625MG ...... 85 propafenone hcl tab 225 mg ...... 16 PREMPHASE TAB ...... 65 propafenone hcl tab 300 mg ...... 16 PREMPRO TAB ...... 65 propranolol hcl cap er 24hr 120 mg .. 51 PREMPRO TAB 0.3-1.5 ...... 65 propranolol hcl cap er 24hr 160 mg .. 51 PREMPRO TAB 0.45-1.5 ...... 65 propranolol hcl cap er 24hr 60 mg .... 51 PREMPRO TAB 0.625-5 ...... 65 propranolol hcl cap er 24hr 80 mg .... 51 PRENAISSANCE CAP BALANCE ...... 74 propranolol hcl oral soln 20 mg/5ml . 51 prenatal 19 chw tab ...... 74 propranolol hcl oral soln 40 mg/5ml . 51 prenatal 19 tab ...... 74 propranolol hcl tab 10 mg ...... 51 PRETOMANID TAB 200MG ...... 35 propranolol hcl tab 20 mg ...... 51 PREVYMIS TAB 240MG ...... 50 propranolol hcl tab 40 mg ...... 51 PREVYMIS TAB 480MG ...... 50 propranolol hcl tab 60 mg ...... 51 PREZCOBIX TAB 800-150 ...... 48 propranolol hcl tab 80 mg ...... 51 PREZISTA SUS 100MG/ML ...... 48 propylthiouracil tab 50 mg...... 82 PREZISTA TAB 150MG ...... 48 protriptyline hcl tab 10 mg ...... 25 PREZISTA TAB 600MG ...... 48 protriptyline hcl tab 5 mg ...... 25 PREZISTA TAB 75MG ...... 48 PULMICORT INH 180MCG ...... 17 PREZISTA TAB 800MG ...... 49 PULMICORT INH 90MCG ...... 17 primidone tab 250 mg...... 21 PULMOZYME SOL 1MG/ML ...... 81 primidone tab 50 mg ...... 21 PURIXAN SUS 20MG/ML ...... 36 115 pyrazinamide tab 500 mg ...... 35 ranolazine tab er 12hr 1000 mg ...... 14 pyridostigmine bromide tab 60 mg ... 35 ranolazine tab er 12hr 500 mg ...... 14 pyridostigmine bromide tab er 180 mg rasagiline mesylate tab 0.5 mg (base ...... 35 equiv) ...... 42 Q rasagiline mesylate tab 1 mg (base quetiapine fumarate tab 100 mg ...... 45 equiv) ...... 42 quetiapine fumarate tab 200 mg ...... 45 REBIF INJ 22/0.5 ...... 80 quetiapine fumarate tab 25 mg ...... 45 REBIF INJ 44/0.5 ...... 80 quetiapine fumarate tab 300 mg ...... 45 REBIF REBIDO INJ 22/0.5 ...... 80 quetiapine fumarate tab 400 mg ...... 45 REBIF REBIDO INJ 44/0.5 ...... 80 quetiapine fumarate tab 50 mg ...... 45 REBIF REBIDO INJ TITRATN ...... 80 quetiapine fumarate tab er 24hr 150 REBIF TITRTN INJ PACK ...... 80 mg ...... 45 RELENZA MIS DISKHALE ...... 50 quetiapine fumarate tab er 24hr 200 repaglinide tab 0.5 mg ...... 27 mg ...... 45 repaglinide tab 1 mg...... 27 quetiapine fumarate tab er 24hr 300 repaglinide tab 2 mg...... 27 mg ...... 45 REPATHA PUSH INJ 420/3.5 ...... 31 quetiapine fumarate tab er 24hr 400 REPATHA SURE INJ 140MG/ML ...... 31 mg ...... 45 RESCRIPTOR TAB 100 MG ...... 49 quetiapine fumarate tab er 24hr 50 mg RESCRIPTOR TAB 200MG ...... 49 ...... 45 RETEVMO CAP 40MG ...... 39 quinapril hcl tab 10 mg ...... 32 RETEVMO CAP 80MG ...... 39 quinapril hcl tab 20 mg ...... 32 REVATIO INJ ...... 54 quinapril hcl tab 40 mg ...... 32 REVLIMID CAP 10MG ...... 72 quinapril hcl tab 5 mg ...... 32 REVLIMID CAP 15MG ...... 72 quinapril-hydrochlorothiazide tab 10- REVLIMID CAP 2.5MG ...... 72 12.5 mg ...... 34 REVLIMID CAP 20MG ...... 73 quinapril-hydrochlorothiazide tab 20- REVLIMID CAP 25MG ...... 73 12.5 mg ...... 34 REVLIMID CAP 5MG ...... 72 quinapril-hydrochlorothiazide tab 20-25 REXULTI TAB 0.25MG ...... 47 mg ...... 34 REXULTI TAB 0.5MG ...... 46 QVAR AER 40MCG ...... 17 REXULTI TAB 1MG ...... 47 QVAR AER 80MCG ...... 17 REXULTI TAB 2MG ...... 47 QVAR REDIHA AER 80MCG ...... 18 REXULTI TAB 3MG ...... 47 QVAR REDIHAL AER 40MCG ...... 18 REXULTI TAB 4MG ...... 47 R REYATAZ POW 50MG ...... 49 rabeprazole sodium ec tab 20 mg ..... 84 REYVOW TAB 100MG ...... 71 raloxifene hcl tab 60 mg ...... 64 REYVOW TAB 50MG ...... 71 ramelteon tab 8 mg ...... 70 ribavirin cap 200 mg ...... 50 ramipril cap 1.25 mg ...... 32 rifabutin cap 150 mg ...... 35 ramipril cap 10 mg ...... 32 rifampin cap 150 mg ...... 35 ramipril cap 2.5 mg ...... 32 rifampin cap 300 mg ...... 35 ramipril cap 5 mg ...... 32 rimantadine hydrochloride tab 100 mg ranitidine hcl syrup 15 mg/ml (75 ...... 50 mg/5ml) ...... 83 RINVOQ TAB 15MG ER ...... 8 ranitidine hcl tab 150 mg ...... 83 RISPERDAL INJ 12.5MG ...... 43 ranitidine hcl tab 300 mg ...... 83 RISPERDAL INJ 25MG ...... 43 116

RISPERDAL INJ 37.5MG ...... 43 ropinirole hydrochloride tab 2 mg ..... 42 RISPERDAL INJ 50MG ...... 43 ropinirole hydrochloride tab 3 mg ..... 42 risperidone orally disintegrating tab ropinirole hydrochloride tab 4 mg ..... 42 0.25 mg ...... 43 ropinirole hydrochloride tab 5 mg ..... 42 risperidone orally disintegrating tab 0.5 rosuvastatin calcium tab 10 mg ...... 31 mg ...... 43 rosuvastatin calcium tab 20 mg ...... 31 risperidone orally disintegrating tab 1 rosuvastatin calcium tab 40 mg ...... 31 mg ...... 43 rosuvastatin calcium tab 5 mg ...... 31 risperidone orally disintegrating tab 2 ROZLYTREK CAP 100MG ...... 39 mg ...... 43 ROZLYTREK CAP 200MG ...... 39 risperidone orally disintegrating tab 3 RUBRACA TAB 200MG ...... 39 mg ...... 43 RUBRACA TAB 250MG ...... 39 risperidone orally disintegrating tab 4 RUBRACA TAB 300MG ...... 39 mg ...... 43 rufinamide susp 40 mg/ml ...... 21 risperidone soln 1 mg/ml ...... 43 RUKOBIA TAB 600MG ER ...... 49 risperidone tab 0.25 mg ...... 43 RYBELSUS TAB 14MG ...... 27 risperidone tab 0.5 mg ...... 43 RYBELSUS TAB 3MG ...... 27 risperidone tab 1 mg ...... 44 RYBELSUS TAB 7MG ...... 27 risperidone tab 2 mg ...... 44 RYDAPT CAP 25MG ...... 39 risperidone tab 3 mg ...... 44 S risperidone tab 4 mg ...... 44 SANDIMMUNE CAP 100MG...... 73 ritonavir tab 100 mg ...... 49 SANDIMMUNE CAP 25MG ...... 73 rivastigmine tartrate cap 1.5 mg (base SANDIMMUNE SOL 100MG/ML ...... 73 equivalent) ...... 79 SANTYL OIN 250/GM ...... 61 rivastigmine tartrate cap 3 mg (base SAPHRIS SUB 10MG ...... 45 equivalent) ...... 79 SAPHRIS SUB 2.5MG ...... 45 rivastigmine tartrate cap 4.5 mg (base SAPHRIS SUB 5MG ...... 45 equivalent) ...... 79 sapropterin dihydrochloride powder rivastigmine tartrate cap 6 mg (base packet 100 mg ...... 64 equivalent) ...... 79 sapropterin dihydrochloride powder rivastigmine td patch 24hr 13.3 packet 500 mg ...... 64 mg/24hr ...... 79 sapropterin dihydrochloride tab 100 mg rivastigmine td patch 24hr 4.6 mg/24hr ...... 64 ...... 79 SAVELLA MIS TITR PAK ...... 80 rivastigmine td patch 24hr 9.5 mg/24hr SAVELLA TAB 100MG ...... 80 ...... 79 SAVELLA TAB 12.5MG ...... 80 rizatriptan benzoate oral disintegrating SAVELLA TAB 25MG ...... 80 tab 10 mg (base eq) ...... 71 SAVELLA TAB 50MG ...... 80 rizatriptan benzoate oral disintegrating scopolamine td patch 72hr 1 mg/3days tab 5 mg (base eq) ...... 71 ...... 28 rizatriptan benzoate tab 10 mg (base SECUADO DIS 3.8MG ...... 45 equivalent) ...... 71 SECUADO DIS 5.7MG ...... 45 rizatriptan benzoate tab 5 mg (base SECUADO DIS 7.6MG ...... 45 equivalent) ...... 71 selegiline hcl cap 5 mg ...... 42 ropinirole hydrochloride tab 0.25 mg 42 selegiline hcl tab 5 mg ...... 42 ropinirole hydrochloride tab 0.5 mg .. 42 SELZENTRY SOL 20MG/ML ...... 49 ropinirole hydrochloride tab 1 mg ..... 42 SELZENTRY TAB 150MG ...... 49 117

SELZENTRY TAB 25MG ...... 49 sotalol hcl (afib/afl) tab 80 mg ...... 51 SELZENTRY TAB 300MG ...... 49 sotalol hcl tab 120 mg ...... 51 SELZENTRY TAB 75MG ...... 49 sotalol hcl tab 160 mg ...... 52 SEREVENT DIS AER 50MCG ...... 18 sotalol hcl tab 240 mg ...... 52 sertraline hcl oral concentrate for sotalol hcl tab 80 mg ...... 51 solution 20 mg/ml ...... 24 SPIRIVA AER 1.25MCG ...... 17 sertraline hcl tab 100 mg ...... 24 SPIRIVA SPR 2.5MCG ...... 17 sertraline hcl tab 25 mg ...... 24 spironolactone & hydrochlorothiazide sertraline hcl tab 50 mg ...... 24 tab 25-25 mg ...... 62 sevelamer carbonate packet 0.8 gm . 67 spironolactone tab 100 mg ...... 63 sevelamer carbonate packet 2.4 gm . 67 spironolactone tab 25 mg ...... 63 sevelamer carbonate tab 800 mg ..... 67 spironolactone tab 50 mg ...... 63 sf 5000 plus cre 1.1% ...... 74 SPORANOX SOL 10MG/ML ...... 29 sildenafil citrate for suspension 10 SPRYCEL TAB 100MG ...... 39 mg/ml ...... 54 SPRYCEL TAB 140MG ...... 39 sildenafil citrate iv soln 10 mg/12.5ml SPRYCEL TAB 20MG ...... 39 (base equivalent) ...... 54 SPRYCEL TAB 50MG ...... 39 sildenafil citrate tab 20 mg ...... 54 SPRYCEL TAB 70MG ...... 39 cream 1% ...... 59 SPRYCEL TAB 80MG ...... 39 simvastatin tab 10 mg ...... 31 sps sus 15gm/60...... 73 simvastatin tab 20 mg ...... 31 stavudine cap 15 mg ...... 49 simvastatin tab 40 mg ...... 31 stavudine cap 20 mg ...... 49 simvastatin tab 5 mg ...... 31 stavudine cap 30 mg ...... 49 simvastatin tab 80 mg ...... 31 stavudine cap 40 mg ...... 49 sirolimus oral soln 1 mg/ml ...... 73 stavudine for oral soln 1 mg/ml ...... 49 sirolimus tab 0.5 mg ...... 73 STIMATE SOL 1.5MG/ML ...... 64 sirolimus tab 1 mg ...... 73 STIOLTO AER 2.5-2.5 ...... 18 sirolimus tab 2 mg ...... 73 STIVARGA TAB 40MG ...... 39 SIRTURO TAB 100MG ...... 35 STRENSIQ INJ 18/0.45 ...... 64 SIRTURO TAB 20MG ...... 35 STRENSIQ INJ 28/0.7ML ...... 64 sod fluoride sol 0.2% ...... 74 STRENSIQ INJ 40MG/ML ...... 64 sodium chloride soln nebu 0.9% ...... 58 STRENSIQ INJ 80/0.8ML ...... 64 sodium chloride soln nebu 10% ...... 58 STRIBILD TAB ...... 49 sodium chloride soln nebu 7% ...... 58 sucralfate susp 1 gm/10ml ...... 83 sodium chloride tab 1 gm ...... 72 sucralfate tab 1 gm ...... 83 sodium fluoride soln 0.5 mg/ml f (from sulfacetamide sodium ophth soln 10% 1.1 mg/ml naf) ...... 72 ...... 76 sodium fluoride tab 0.5 mg f (from 1.1 sulfacetamide sodium-prednisolone mg naf) ...... 72 ophth soln 10-0.23(0.25)% ...... 77 sodium fluoride tab 1 mg f (from 2.2 sulfamethoxazole-trimethoprim susp mg naf) ...... 72 200-40 mg/5ml ...... 14 solifenacin succinate tab 10 mg ...... 85 sulfamethoxazole-trimethoprim tab solifenacin succinate tab 5 mg ...... 85 400-80 mg ...... 14 SOLIRIS INJ 10MG/ML ...... 67 sulfamethoxazole-trimethoprim tab SOLU-CORTEF INJ 100MG ...... 58 800-160 mg ...... 14 sotalol hcl (afib/afl) tab 120 mg ...... 51 sulfasalazine tab 500 mg ...... 66 sotalol hcl (afib/afl) tab 160 mg ...... 51 118 sulfasalazine tab delayed release 500 SYNTHROID TAB 300MCG ...... 83 mg ...... 66 SYNTHROID TAB 50MCG ...... 83 sulindac tab 150 mg ...... 10 SYNTHROID TAB 75MCG ...... 83 sulindac tab 200 mg ...... 10 SYNTHROID TAB 88MCG ...... 83 sumatriptan nasal spray 20 mg/act .. 71 T sumatriptan nasal spray 5 mg/act .... 71 TABRECTA TAB 150MG ...... 40 sumatriptan succinate inj 6 mg/0.5ml TABRECTA TAB 200MG ...... 40 ...... 71 tacrolimus cap 0.5 mg ...... 73 sumatriptan succinate solution auto- tacrolimus cap 1 mg ...... 73 injector 4 mg/0.5ml ...... 71 tacrolimus cap 5 mg ...... 73 sumatriptan succinate solution auto- tacrolimus oint 0.03% ...... 61 injector 6 mg/0.5ml ...... 71 tacrolimus oint 0.1% ...... 61 sumatriptan succinate solution tadalafil tab 20 mg (pah) ...... 54 cartridge 4 mg/0.5ml ...... 71 TAFINLAR CAP 50MG ...... 40 sumatriptan succinate solution TAFINLAR CAP 75MG ...... 40 cartridge 6 mg/0.5ml ...... 71 TAGRISSO TAB 40MG ...... 40 sumatriptan succinate solution prefilled TAGRISSO TAB 80MG ...... 40 syringe 6 mg/0.5ml ...... 71 TAKHZYRO INJ 300/2ML ...... 67 sumatriptan succinate tab 100 mg .... 72 TALTZ INJ 80MG/ML ...... 59 sumatriptan succinate tab 25 mg ..... 72 TALZENNA CAP 0.25MG ...... 40 sumatriptan succinate tab 50 mg ..... 72 TALZENNA CAP 1MG ...... 40 SUPREP BOWEL SOL PREP KIT ...... 70 tamoxifen citrate tab 10 mg (base SUTENT CAP 12.5MG ...... 39 equivalent) ...... 37 SUTENT CAP 25MG ...... 39 tamoxifen citrate tab 20 mg (base SUTENT CAP 37.5MG ...... 39 equivalent) ...... 37 SUTENT CAP 50MG ...... 40 tamsulosin hcl cap 0.4 mg ...... 67 SYMDEKO TAB 100-150 ...... 81 TASIGNA CAP 150MG ...... 40 SYMDEKO TAB 50-75MG ...... 81 TASIGNA CAP 200MG ...... 40 SYMLINPEN 60 INJ 1000MCG ...... 25 TASIGNA CAP 50MG ...... 40 SYMLNPEN 120 INJ 1000MCG ...... 25 tazarotene cream 0.1% ...... 59 SYMPROIC TAB 0.2MG ...... 67 TAZORAC CRE 0.05% ...... 59 SYMTUZA TAB ...... 49 TAZORAC GEL 0.05% ...... 59 SYNAGIS INJ 100MG/ML ...... 78 TAZORAC GEL 0.1% ...... 59 SYNAGIS INJ 50MG ...... 78 TAZVERIK TAB 200MG ...... 40 SYNAREL SOL 2MG/ML ...... 64 temazepam cap 15 mg ...... 69 SYNJARDY TAB...... 26 temazepam cap 30 mg ...... 69 SYNJARDY TAB 12.5-500 ...... 26 temozolomide cap 100 mg ...... 36 SYNJARDY TAB 5-1000MG ...... 26 temozolomide cap 140 mg ...... 36 SYNJARDY TAB 5-500MG ...... 26 temozolomide cap 180 mg ...... 36 SYNTHROID TAB 100MCG...... 83 temozolomide cap 20 mg ...... 36 SYNTHROID TAB 112MCG...... 83 temozolomide cap 250 mg ...... 36 SYNTHROID TAB 125MCG...... 83 temozolomide cap 5 mg ...... 36 SYNTHROID TAB 137MCG...... 83 tenofovir disoproxil fumarate tab 300 SYNTHROID TAB 150MCG...... 83 mg ...... 49 SYNTHROID TAB 175MCG...... 83 terazosin hcl cap 1 mg (base SYNTHROID TAB 200MCG...... 83 equivalent) ...... 33 SYNTHROID TAB 25MCG ...... 83 119 terazosin hcl cap 10 mg (base thioridazine hcl tab 100 mg ...... 46 equivalent) ...... 33 thioridazine hcl tab 25 mg ...... 46 terazosin hcl cap 2 mg (base thioridazine hcl tab 50 mg ...... 46 equivalent) ...... 33 thiothixene cap 1 mg ...... 47 terazosin hcl cap 5 mg (base thiothixene cap 10 mg ...... 47 equivalent) ...... 33 thiothixene cap 2 mg ...... 47 terbinafine hcl tab 250 mg...... 29 thiothixene cap 5 mg ...... 47 terbutaline sulfate tab 2.5 mg ...... 18 tiagabine hcl tab 12 mg ...... 22 terbutaline sulfate tab 5 mg ...... 18 tiagabine hcl tab 16 mg ...... 22 terconazole vaginal cream 0.4% ...... 85 tiagabine hcl tab 2 mg ...... 22 terconazole vaginal cream 0.8% ...... 85 tiagabine hcl tab 4 mg ...... 22 terconazole vaginal suppos 80 mg .... 85 tilia fe tab ...... 56 testosterone cypionate im inj in oil 100 timolol maleate ophth gel forming soln mg/ml ...... 13 0.25% ...... 76 testosterone cypionate im inj in oil 200 timolol maleate ophth gel forming soln mg/ml ...... 13 0.5% ...... 76 testosterone enanthate im inj in oil 200 timolol maleate ophth soln 0.25% .... 76 mg/ml ...... 13 timolol maleate ophth soln 0.5% ...... 76 testosterone td gel 12.5 mg/act (1%) timolol maleate tab 10 mg ...... 52 ...... 13 timolol maleate tab 20 mg ...... 52 testosterone td gel 20.25 mg/1.25gm timolol maleate tab 5 mg ...... 52 (1.62%) ...... 13 TIVICAY PD TAB 5MG ...... 49 testosterone td gel 20.25 mg/act TIVICAY TAB 10MG...... 49 (1.62%) ...... 13 TIVICAY TAB 25MG...... 49 testosterone td gel 25 mg/2.5gm (1%) TIVICAY TAB 50MG...... 49 ...... 13 tizanidine hcl tab 2 mg (base testosterone td gel 40.5 mg/2.5gm equivalent) ...... 75 (1.62%) ...... 13 tizanidine hcl tab 4 mg (base testosterone td gel 50 mg/5gm (1%) 13 equivalent) ...... 75 tetracycline hcl cap 250 mg ...... 82 tobramycin nebu soln 300 mg/5ml .... 8 tetracycline hcl cap 500 mg ...... 82 tobramycin ophth soln 0.3% ...... 76 THALOMID CAP 100MG ...... 73 tobramycin-dexamethasone ophth susp THALOMID CAP 150MG ...... 73 0.3-0.1% ...... 77 THALOMID CAP 200MG ...... 73 tolterodine tartrate cap er 24hr 2 mg 85 THALOMID CAP 50MG ...... 73 tolterodine tartrate cap er 24hr 4 mg 85 THEO-24 CAP 100MG CR ...... 19 tolterodine tartrate tab 1 mg ...... 85 THEO-24 CAP 200MG CR ...... 19 tolterodine tartrate tab 2 mg ...... 85 THEO-24 CAP 300MG CR ...... 19 tolvaptan tab 30 mg ...... 64 THEO-24 CAP 400MG ER ...... 19 topiramate sprinkle cap 15 mg ...... 21 theophylline soln 80 mg/15ml ...... 19 topiramate sprinkle cap 25 mg ...... 22 theophylline tab er 12hr 100 mg ...... 19 topiramate tab 100 mg ...... 22 theophylline tab er 12hr 200 mg ...... 19 topiramate tab 200 mg ...... 22 theophylline tab er 12hr 300 mg ...... 19 topiramate tab 25 mg ...... 22 theophylline tab er 12hr 450 mg ...... 19 topiramate tab 50 mg ...... 22 theophylline tab er 24hr 400 mg ...... 19 toremifene citrate tab 60 mg (base theophylline tab er 24hr 600 mg ...... 19 equivalent) ...... 37 thioridazine hcl tab 10 mg ...... 46 torsemide tab 10 mg ...... 62 120 torsemide tab 100 mg ...... 63 triamcinolone acetonide dental paste torsemide tab 20 mg ...... 63 0.1% ...... 74 torsemide tab 5 mg ...... 62 triamcinolone acetonide lotion 0.025% TRACLEER TAB 32MG ...... 54 ...... 61 TRADJENTA TAB 5MG ...... 26 triamcinolone acetonide lotion 0.1% . 61 tramadol hcl tab 50 mg ...... 12 triamcinolone acetonide oint 0.025% 61 tramadol hcl tab er 24hr 100 mg ...... 12 triamcinolone acetonide oint 0.1% ... 61 tramadol hcl tab er 24hr 200 mg ...... 12 triamcinolone acetonide oint 0.5% ... 61 tramadol hcl tab er 24hr 300 mg ...... 12 triamterene & hydrochlorothiazide cap tramadol-acetaminophen tab 37.5-325 37.5-25 mg ...... 62 mg ...... 12 triamterene & hydrochlorothiazide cap trandolapril tab 1 mg ...... 32 50-25 mg ...... 62 trandolapril tab 2 mg ...... 32 triamterene & hydrochlorothiazide tab trandolapril tab 4 mg ...... 32 37.5-25 mg ...... 62 tranexamic acid tab 650 mg ...... 69 triamterene & hydrochlorothiazide tab tranylcypromine sulfate tab 10 mg ... 23 75-50 mg ...... 62 trazodone hcl tab 100 mg ...... 24 trifluoperazine hcl tab 1 mg (base trazodone hcl tab 150 mg ...... 24 equivalent) ...... 46 trazodone hcl tab 300 mg ...... 24 trifluoperazine hcl tab 10 mg (base trazodone hcl tab 50 mg ...... 24 equivalent) ...... 46 TRELEGY AER ELLIPTA ...... 18 trifluoperazine hcl tab 2 mg (base TRELSTAR INJ 11.25MG ...... 37 equivalent) ...... 46 TRELSTAR INJ 3.75MG ...... 37 trifluoperazine hcl tab 5 mg (base TRELSTAR MIX INJ 22.5MG ...... 37 equivalent) ...... 46 treprostinil inj soln 100 mg/20ml (5 trifluridine ophth soln 1% ...... 76 mg/ml) ...... 53 trihexyphenidyl hcl oral soln 0.4 mg/ml treprostinil inj soln 20 mg/20ml (1 ...... 41 mg/ml) ...... 53 trihexyphenidyl hcl tab 2 mg ...... 41 treprostinil inj soln 200 mg/20ml (10 trihexyphenidyl hcl tab 5 mg ...... 41 mg/ml) ...... 54 TRIKAFTA TAB ...... 81 treprostinil inj soln 50 mg/20ml (2.5 trimethobenzamide hcl cap 300 mg .. 29 mg/ml) ...... 53 trimethoprim tab 100 mg ...... 14 tretinoin cap 10 mg ...... 40 TRIUMEQ TAB ...... 49 tretinoin cream 0.025% ...... 58 tri-vit/fe dro /fl 0.25 ...... 74 tretinoin cream 0.05% ...... 58 tri-vit/fluo dro 0.25mg ...... 74 tretinoin cream 0.1% ...... 58 tri-vit/fluo dro 0.5mg ...... 74 tretinoin gel 0.01% ...... 58 TRIZIVIR TAB ...... 49 tretinoin gel 0.025% ...... 59 trospium chloride cap er 24hr 60 mg 85 TREXALL TAB 10MG ...... 36 trospium chloride tab 20 mg ...... 85 TREXALL TAB 15MG ...... 36 TRULANCE TAB 3MG ...... 66 TREXALL TAB 5MG ...... 36 TRULICITY INJ 0.75/0.5 ...... 27 TREXALL TAB 7.5MG ...... 36 TRULICITY INJ 1.5/0.5 ...... 27 triamcinolone acetonide cream 0.025% TRULICITY INJ 3/0.5 ...... 27 ...... 61 TRULICITY INJ 4.5/0.5 ...... 27 triamcinolone acetonide cream 0.1% 61 TRUVADA TAB 100-150 ...... 49 triamcinolone acetonide cream 0.5% 61 TRUVADA TAB 133-200 ...... 49 TRUVADA TAB 167-250 ...... 49 121

TRUVADA TAB 200-300 ...... 49 vancomycin hcl cap 125 mg (base TURALIO CAP 200MG ...... 40 equivalent) ...... 14 TYBOST TAB 150MG ...... 49 vancomycin hcl cap 250 mg (base TYMLOS INJ ...... 63 equivalent) ...... 14 TYVASO START SOL 0.6MG/ML ...... 54 VARUBI TAB 90MG ...... 29 TYZEKA TAB 600MG ...... 50 VELTASSA POW 16.8GM ...... 73 U VELTASSA POW 25.2GM ...... 73 UBRELVY TAB 100MG ...... 71 VELTASSA POW 8.4GM ...... 73 UBRELVY TAB 50MG ...... 71 VENCLEXTA TAB 100MG ...... 36 UPTRAVI TAB 1000MCG ...... 54 VENCLEXTA TAB 10MG...... 36 UPTRAVI TAB 1200MCG ...... 54 VENCLEXTA TAB 50MG...... 36 UPTRAVI TAB 1400MCG ...... 54 VENCLEXTA TAB START PK ...... 36 UPTRAVI TAB 1600MCG ...... 54 venlafaxine hcl cap er 24hr 150 mg UPTRAVI TAB 200MCG ...... 54 (base equivalent) ...... 24 UPTRAVI TAB 400MCG ...... 54 venlafaxine hcl cap er 24hr 37.5 mg UPTRAVI TAB 600MCG ...... 54 (base equivalent) ...... 24 UPTRAVI TAB 800MCG ...... 54 venlafaxine hcl cap er 24hr 75 mg ursodiol cap 300 mg ...... 66 (base equivalent) ...... 24 ursodiol tab 250 mg ...... 66 venlafaxine hcl tab 100 mg (base ursodiol tab 500 mg ...... 66 equivalent) ...... 24 V venlafaxine hcl tab 25 mg (base valacyclovir hcl tab 1 gm ...... 50 equivalent) ...... 24 valacyclovir hcl tab 500 mg ...... 50 venlafaxine hcl tab 37.5 mg (base VALCHLOR GEL 0.016% ...... 59 equivalent) ...... 24 valganciclovir hcl for soln 50 mg/ml venlafaxine hcl tab 50 mg (base (base equiv) ...... 50 equivalent) ...... 24 valganciclovir hcl tab 450 mg (base venlafaxine hcl tab 75 mg (base equivalent) ...... 50 equivalent) ...... 24 valproate sodium oral soln 250 mg/5ml VENTAVIS SOL 10MCG/ML ...... 54 (base equiv) ...... 22 VENTAVIS SOL 20MCG/ML ...... 54 valproic acid cap 250 mg ...... 22 VENTOLIN HFA AER ...... 18 valsartan tab 160 mg ...... 32 verapamil hcl cap er 24hr 100 mg .... 53 valsartan tab 320 mg ...... 33 verapamil hcl cap er 24hr 120 mg .... 53 valsartan tab 40 mg ...... 32 verapamil hcl cap er 24hr 180 mg .... 53 valsartan tab 80 mg ...... 32 verapamil hcl cap er 24hr 200 mg .... 53 valsartan-hydrochlorothiazide tab 160- verapamil hcl cap er 24hr 240 mg .... 53 12.5 mg ...... 34 verapamil hcl cap er 24hr 300 mg .... 53 valsartan-hydrochlorothiazide tab 160- verapamil hcl cap er 24hr 360 mg .... 53 25 mg ...... 34 verapamil hcl tab 120 mg ...... 53 valsartan-hydrochlorothiazide tab 320- verapamil hcl tab 40 mg ...... 53 12.5 mg ...... 34 verapamil hcl tab 80 mg ...... 53 valsartan-hydrochlorothiazide tab 80- verapamil hcl tab er 120 mg ...... 53 12.5 mg ...... 34 verapamil hcl tab er 180 mg ...... 53 VALTOCO LIQ 15MG ...... 20 verapamil hcl tab er 240 mg ...... 53 VALTOCO LIQ 20MG ...... 20 VERSACLOZ SUS 50MG/ML ...... 45 VALTOCO SPR 10MG ...... 20 VERZENIO TAB 100MG ...... 40 VALTOCO SPR 5MG ...... 20 VERZENIO TAB 150MG ...... 40 122

VERZENIO TAB 200MG ...... 40 W VERZENIO TAB 50MG ...... 40 warfarin sodium tab 1 mg ...... 19 VICTOZA INJ 18MG/3ML...... 27 warfarin sodium tab 10 mg ...... 19 VIDEX EC CAP 400MG ...... 49 warfarin sodium tab 2 mg ...... 19 VIDEX SOL 2GM ...... 49 warfarin sodium tab 2.5 mg ...... 19 VIDEX SOL 4GM ...... 49 warfarin sodium tab 3 mg ...... 19 vigabatrin powd pack 500 mg ...... 22 warfarin sodium tab 4 mg ...... 19 vigabatrin tab 500 mg ...... 22 warfarin sodium tab 5 mg ...... 19 VIMPAT SOL 10MG/ML ...... 22 warfarin sodium tab 6 mg ...... 19 VIMPAT TAB 100MG ...... 22 warfarin sodium tab 7.5 mg ...... 19 VIMPAT TAB 150MG ...... 22 wixela inhub aer 100/50 ...... 19 VIMPAT TAB 200MG ...... 22 wixela inhub aer 250/50 ...... 19 VIMPAT TAB 50MG ...... 22 wixela inhub aer 500/50 ...... 19 VINACAL B MIS ...... 75 X VIRACEPT TAB 250MG ...... 49 XALKORI CAP 200MG ...... 40 VIRACEPT TAB 625MG ...... 49 XALKORI CAP 250MG ...... 40 VIRAMUNE XR TAB 100MG ...... 49 XARELTO STAR TAB 15/20MG ...... 19 VIREAD TAB 150MG ...... 49 XARELTO TAB 10MG ...... 19 VIREAD TAB 200MG ...... 49 XARELTO TAB 15MG ...... 19 VIREAD TAB 250MG ...... 49 XARELTO TAB 2.5MG ...... 19 virt-phos tab 250 neut ...... 72 XARELTO TAB 20MG ...... 19 vitamax ped dro ...... 74 XELJANZ SOL 1MG/ML ...... 8 VITEKTA TAB 150MG ...... 49 XELJANZ TAB 10MG ...... 8 VITEKTA TAB 85MG ...... 49 XELJANZ TAB 5MG ...... 8 VIVITROL INJ 380MG ...... 28 XELJANZ XR TAB 11MG ...... 9 VIZIMPRO TAB 15MG ...... 40 XELJANZ XR TAB 22MG ...... 9 VIZIMPRO TAB 30MG ...... 40 XIFAXAN TAB 200MG ...... 14 VIZIMPRO TAB 45MG ...... 40 XIFAXAN TAB 550MG ...... 14 voriconazole for susp 40 mg/ml ...... 29 XOLAIR INJ 150MG/ML ...... 17 voriconazole tab 200 mg ...... 29 XOLAIR INJ 75/0.5 ...... 17 voriconazole tab 50 mg ...... 29 XOLAIR SOL 150MG ...... 17 VOTRIENT TAB 200MG ...... 40 XOSPATA TAB 40MG ...... 40 VRAYLAR CAP 1.5-3MG ...... 42 XPOVIO PAK 100MG ...... 37 VRAYLAR CAP 1.5MG ...... 42 XPOVIO PAK 40MG ...... 37 VRAYLAR CAP 3MG ...... 42 XPOVIO PAK 50MG ...... 37 VRAYLAR CAP 4.5MG ...... 42 XPOVIO PAK 60MG ...... 37 VRAYLAR CAP 6MG ...... 42 XPOVIO PAK 80MG ...... 37 VYNDAMAX CAP 61MG ...... 54 XTANDI CAP 40MG ...... 37 VYNDAQEL CAP 20MG ...... 54 XTANDI TAB 40MG ...... 37 VYVANSE CAP 10MG ...... 6 XTANDI TAB 80MG ...... 37 VYVANSE CAP 20MG ...... 6 xulane dis 150-35 ...... 56 VYVANSE CAP 30MG ...... 6 XYREM SOL 500MG/ML ...... 79 VYVANSE CAP 40MG ...... 6 Y VYVANSE CAP 50MG ...... 6 YUVAFEM TAB 10MCG ...... 85 VYVANSE CAP 60MG ...... 6 Z VYVANSE CAP 70MG ...... 6 zaleplon cap 10 mg ...... 69 zaleplon cap 5 mg ...... 69 123

ZARXIO INJ 300/0.5 ...... 69 zolpidem tartrate tab 5 mg ...... 69 ZARXIO INJ 480/0.8 ...... 69 zolpidem tartrate tab er 12.5 mg ..... 69 ZEJULA CAP 100MG ...... 40 zolpidem tartrate tab er 6.25 mg ..... 69 ZELBORAF TAB 240MG ...... 40 zonisamide cap 100 mg ...... 22 ZELNORM TAB 6MG ...... 66 zonisamide cap 25 mg ...... 22 zenchent tab ...... 56 zonisamide cap 50 mg ...... 22 ZEPOSIA 7DAY CAP STR PACK ...... 80 zovia 1/35e tab ...... 56 ZEPOSIA CAP .92MG ...... 80 zovia 1/50e tab ...... 56 ZEPOSIA CAP STR KIT ...... 81 ZUBSOLV SUB 0.7-0.18 ...... 13 zidovudine cap 100 mg ...... 49 ZUBSOLV SUB 1.4-0.36 ...... 13 zidovudine syrup 10 mg/ml ...... 49 ZUBSOLV SUB 11.4-2.9 ...... 13 zidovudine tab 300 mg ...... 49 ZUBSOLV SUB 2.9-0.71 ...... 13 ziprasidone hcl cap 20 mg ...... 42 ZUBSOLV SUB 5.7-1.4 ...... 13 ziprasidone hcl cap 40 mg ...... 43 ZUBSOLV SUB 8.6-2.1 ...... 13 ziprasidone hcl cap 60 mg ...... 43 ZYDELIG TAB 100MG ...... 40 ziprasidone hcl cap 80 mg ...... 43 ZYDELIG TAB 150MG ...... 40 ZOLADEX IMP 10.8MG ...... 37 ZYKADIA CAP 150MG ...... 40 ZOLADEX IMP 3.6MG ...... 37 ZYKADIA TAB 150MG ...... 40 ZOLINZA CAP 100MG ...... 40 ZYPREXA RELP INJ 210MG ...... 45 zolmitriptan tab 2.5 mg ...... 72 ZYPREXA RELP INJ 300MG ...... 45 zolmitriptan tab 5 mg ...... 72 ZYPREXA RELP INJ 405MG ...... 45 zolpidem tartrate tab 10 mg ...... 69

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