2021 FORMULARY GUIDE (Small Group Plans)

Pharmacy Benefits Management Table of Contents

Overview...... iii Important Phone Numbers ...... iii Understanding Coverage and Cost‐Sharing ...... iii Formulary ...... iii Understanding Our Symbols ...... iv Prior Authorization ...... iv Step Therapy ...... iv Quantity Limits ...... iv About Generic Drugs ...... iv How to Fill Your Prescription Medications ...... v Medication Supplies Not Covered by IU Health Plans...... vi Formulary Listing ...... 1

ii iuhealthplans.org

Pharmacy Benefits Management Overview This guide provides an overview of your pharmacy benefit. It explains the tiers for drug coverage, the process for getting certain drugs covered, your options for filling prescriptions, important phone numbers, and more.

Important Phone Numbers Pharmacy Services ‐ 844.432.0704.

Understanding Coverage and Cost‐Sharing Formulary The Formulary, also known as your Preferred Drug List, is a list of prescription drugs that are covered under your plan. The inclusion of specific medications on the IU Health Plans formulary is based on the medication's effectiveness, safety, and value.

The formulary offers a wide selection of generic and brand name prescription drugs suggested by the Pharmacy and Therapeutics (P&T) Committee, a group of physicians and pharmacists who researches and evaluates medications. The formulary is periodically reviewed and updated throughout the year in order to ensure that our benefits package consistently and adequately meets your needs.

When you need a prescription medication, you and your doctor can choose from five different levels of the formulary. These are Preferred Generics – Tier 1, Generics – Tier 2, Preferred Brands – Tier 3, Non‐ Preferred Brands – Tier 4 and Specialty – Tier 5. Each level has a different copayment. This gives you and your doctor the freedom to choose the medication that is right for you. At the same time, this will help you to better budget your health care dollars.

Preferred Generic Medications – Tier 1 have the lowest copayment/co‐insurance. Generic drugs offer the same level of safety and quality as their brand‐name equivalents. They have the same amount of active ingredients as brand‐name medications. You are required to use a generic version of the drug if one is available.

Generic Medications – Tier 2 have low copayment/co‐insurance. Generic drugs offer the same level of safety and quality as their brand‐name equivalents. They have the same amount of active ingredients as brand‐name medications. You are required to use a generic version of the drug if one is available.

Preferred‐Brand medications – Tier 3 have the middle level copayment/co‐insurance. These drugs are brand medications and “preferred” because of their value and effectiveness.

Non‐Preferred Brand and Generic medications – Tier 4 have a higher copayment/co‐insurance level. These medications are brand and generic drugs that are more expensive and have similar effectiveness as tier 3 medications.

iii

Pharmacy Benefits Management Specialty and High cost medications – Tier 5 have the highest copayment/co‐insurance level. These also include Specialty medications which usually treat complex and rare conditions. These drugs can be high‐cost medications and biologicals regardless of how they are administered (injectable, oral, transdermal, or inhalant).

Affordable Care Act/Zero Cost Share Preventative Drugs – Tier 6 have a zero cost share copay/co- insurance. These medications are brand and generic preventative drugs that may be covered at $0 copay provided that certain clinical conditions are met.

Non‐Formulary medications may be covered if the formulary medications do not work for you. If you require a Non‐Formulary medication, your doctor may request coverage for the Tier 4 or Tier 5 copayment by making a request for an exception. Understanding Our Symbols Prior Authorization You will see the symbol “PA” or “MNPA” next to certain drugs on our formulary tables. This is called prior authorization or medical necessity prior authorization, respectively. Prior authorization helps ensure that you’re using the best drugs in the safest way.

If you are currently taking or recently prescribed one of these drugs, please discuss possible alternatives or have your doctor request authorization by calling 844.432.0704.

Drugs that require prior authorization are often:  Newer drugs for which the Health Plan wants to track usage.  Non‐formulary drugs which require the use of formulary drugs prior to coverage. These drugs are not used as a standard first option in treating a medical condition.  Drugs with potential side effects that the Health Plan wants to monitor for patient safety.  Drugs categorized as specialty medications.

Step Therapy You will see the symbol “ST” (Step Therapy) next to certain drugs on the formulary tables in this booklet. Step therapy ensures you are taking the most effective medication at the best cost. This means trying the least expensive medications usually generic medications or drugs that are considered as the standard first‐line treatment.

How step therapy works Step 1: When your prescribed drug is impacted by step therapy, first you will be asked to try generic or first‐line treatment drugs. The drug recommended will be approved by the Food and Drug Administration (FDA) as providing the same health benefit at a much lower cost. Step 2: If the generic drug in step 1 does not work for you, then you will have coverage for a brand‐name drug. For more information on step therapy call 844.432.0704.

Pharmacy Benefits Management Quantity Limits The symbol “QL” next to the drugs in this formulary booklet stands for Quantity Limits. To ensure you are getting the most cost‐effective dose for your medication, a quantity limit or dose duration may be placed on certain drugs. These limits are based on FDA guidelines, clinical literature, and manufacturer’s instructions. Quantity limits promote appropriate use of the drug, prevent waste, and help control costs.

For some drugs, the dosing guidelines may recommend that patients take the drug one time a day in a larger dose instead of several times a day in smaller doses. The quantity limits follow the guidelines and cover one larger dose per day.

Prescriptions for specialty medications are limited to a 30‐day supply. For more information on quantity limits or dose durations call 844.432.0704. About Generic Drugs Generic drugs have the same active ingredients as their brand‐name equivalents, but cost significantly less. Not all drugs have a generic equivalent. Generally, new drugs receive patent protection for 20 years. Once the patent expires, other pharmaceutical companies can produce the same drug in a generic formulation. Companies that make generic drugs do not have to invest large amounts of money in research, since the company making the brand‐name equivalent has already done this. Also, generic companies do not need to advertise their drugs. As a result, generic drug makers can pass these savings on to you.

Generic drugs have the same active ingredients as brand‐name drugs, but their inactive ingredients can vary. This is why the generic drug might look different from the brand‐name drug. Inactive ingredients can be dyes used to color the drug or powders used to shape the tablets. Inactive ingredients do not affect how the generic drug works.

The FDA regulates generic drug manufacturers just as it regulates the makers of brand‐name medications. The generic drug must pass strict FDA measurements to ensure that it delivers the same amount of the active ingredient in the same time frame as its brand‐name counterpart. The manufacturer of the generic drug must prove that it produces its product under the same strict guidelines as the brand‐name drug.

How to Fill Your Prescription Medications Short‐term medications These are drugs you need immediately. This includes medications used to treat short term infections, or to relieve pain temporarily. You can fill these prescriptions at network pharmacies accepting CVS prescriptions. Locate the nearest retail network pharmacy by calling 844.432.0704. To fill your prescription, present your member ID card and written prescription and pay your copayment/co‐ insurance as described above.

Long‐term medications These are drugs you take on a regular basis. These could be drugs to treat asthma, high blood pressure, diabetes, etc. These medications can be mailed to your home for up to a 90‐day supply.

Pharmacy Benefits Management Specialty medications Specialty medications treat specific medical conditions such as cancer, hemophilia, hepatitis, multiple sclerosis, psoriasis, pulmonary arterial hypertension, respiratory syncytial virus, rheumatoid arthritis, and more. You can fill these prescriptions:

 Through IU Health Pharmacy o Advanced Therapies Pharmacy is a mail-order pharmacy that provides specialty medications. Please call 844.678.7100 to learn more about filling your specialty medication. o All IU Health Retail pharmacies provide specialty medications. Visit myiuhealthplans.com to find a location nearest you.  Through CVS Specialty Pharmacy o CVS Specialty Pharmacy is a pharmacy that provides specialty medications. Please call 844.432.0704 to learn more about filling your specialty medication

Filling Your Prescription When Traveling When you travel outside of your local area, thousands of pharmacies across the country will honor your IU Health Plans member ID card.

To locate a participating pharmacy, contact your member services team at the phone number listed on the back of your member ID card or on 1 page of this booklet.

To fill a prescription at a participating out‐of‐area pharmacy, present your IU Health Plans member ID card. Some pharmacies may ask you to pay the full price of the medication. If that happens:  Submit a Direct Reimbursement Claim form to IU Health Plans at: CVS Caremark - RxClaim P.O Box 52136 Phoenix, AZ 85072-2136  Or you may call your member services team for assistance  If your claim is approved, you will be reimbursed the amount that you paid for the medication, less the appropriate copayment.

If you will be away from home for an extended period of time, or if you will be traveling outside of the country, you may want to use our mail‐order service so that you receive a 90‐day supply before you leave home.

Medication Supplies Not Covered by IU Health Plans No authorizations will be provided for medications that are reported by the member, provider, or pharmacy to be lost, misplaced, stolen, destroyed, or damaged.

Pharmacy Benefits Management Medications received at no charge to the member (workers’ compensation, medications purchased with a manufacturer’s coupon, etc.) will not be covered.

Prescriptions that are written more than a year ago will not be covered. Your doctor will need to write a new prescription.

vii

Pharmacy Benefits Management List of Abbreviations

ACA: Affordable Care Act.

LA: Limited Availability. This prescription may be available only at certain pharmacies. For more information, please call Customer Service.

OTC: Over the Counter. An OTC drug is a non-prescription drug.

PA: Prior Authorization. The Plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval before you fill your prescriptions. If you don’t get approval, we may not cover the drug.

MNPA: Medical Necessity Prior Authorization. The Plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval for the medical necessity of the drug before you fill your prescriptions. If you don’t get approval, we may not cover the drug.

QL: Quantity Limit. For certain drugs, the Plan limits the amount of the drug that we will cover.

ST: Step Therapy. In some cases, the Plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B.

viii

2021 IUH eff 01/01/2021 Drug Name Drug Tier Requirements/Limits ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS AMPHETAMINES amphetamine sulfate tab 5 mg 4 QL amphetamine sulfate tab 10 mg 4 QL dextroamphetamine sulfate oral solution 5 2 QL mg/5ml ANALEPTICS caffeine citrate oral soln 60 mg/3ml (10 2 mg/ml base equiv) STIMULANTS - MISC. armodafinil tab 50 mg 5 PA; QL armodafinil tab 150 mg 5 PA; QL armodafinil tab 200 mg 5 PA; QL armodafinil tab 250 mg 5 PA; QL ALLERGENIC EXTRACTS ALLERGENIC EXTRACTS GRASTEK SUB 2800BAU 5 PA; QL RAGWITEK SUB 5 PA; QL MIXED ALLERGENIC EXTRACTS ORALAIR SUB 300 IR 5 PA; QL ALLERGENIC EXTRACTS/BIOLOGICALS MISC ALLERGENIC EXTRACTS ODACTRA SUB 5 PA; QL ANABOLIC STEROIDS ANABOLIC STEROIDS ANADROL-50 TAB 50MG 4 PA oxandrolone tab 2.5 mg 2 PA oxandrolone tab 10 mg 2 PA ANALGESICS COX-II INHIBITORS celecoxib cap 50 mg 4 ST celecoxib cap 100 mg 4 ST; QL celecoxib cap 200 mg 4 ST; QL celecoxib cap 400 mg 4 ST; QL GOUT allopurinol tab 100 mg 2 allopurinol tab 300 mg 2 KRYSTEXXA INJ 8MG/ML 5 PA; QL LOCAL ANESTHETICS lidocaine hcl local inj 1% 2 lidocaine hcl local inj 2% 2

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 1 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits lidocaine hcl local preservative free (pf) inj 2 0.5% lidocaine hcl local preservative free (pf) inj 2 1% lidocaine hcl local preservative free (pf) inj 2 2% lidocaine hcl local preservative free (pf) inj 2 4% lidocaine inj 0.5% w/ epinephrine- 2 1:200000 lidocaine inj 1% w/ epinephrine-1:100000 2 lidocaine inj 2% w/ epinephrine-1:100000 2 NON-OPIOID ANALGESICS butalbital-acetaminophen tab 50-325 mg 2 butalbital-acetaminophen-caffeine cap 50- 2 325-40 mg butalbital-acetaminophen-caffeine tab 50- 2 325-40 mg butalbital-aspirin-caffeine cap 50-325-40 2 mg NSAIDS aspirin chew tab 81 mg 6 ASPIRIN TAB 81MG 6 aspirin tab 325 mg 6 aspirin tab delayed release 81 mg 6 aspirin tab delayed release 325 mg 6 CALDOLOR INJ 800/8ML 4 choline & magnesium salicylates liq 500 2 mg/5ml diclofenac potassium tab 50 mg 2 diclofenac sodium tab delayed release 25 2 mg diclofenac sodium tab delayed release 50 2 mg diclofenac sodium tab delayed release 75 2 mg diclofenac sodium tab er 24hr 100 mg 2 diflunisal tab 500 mg 2 etodolac cap 200 mg 2 etodolac cap 300 mg 2 etodolac tab 400 mg 2 etodolac tab 500 mg 2 fenoprofen calcium tab 600 mg 4 PA flurbiprofen tab 50 mg 2 flurbiprofen tab 100 mg 2 HALFPRIN TAB 162MG EC 6

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 2 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits ibuprofen tab 400 mg 2 ibuprofen tab 600 mg 2 ibuprofen tab 800 mg 2 indomethacin cap 25 mg 2 indomethacin cap 50 mg 2 indomethacin cap er 75 mg 2 ketoprofen cap 50 mg 2 ketoprofen cap 75 mg 2 ketorolac tromethamine im inj 60 mg/2ml 2 QL (30 mg/ml) ketorolac tromethamine inj 15 mg/ml 2 QL ketorolac tromethamine inj 30 mg/ml 2 QL ketorolac tromethamine inj 300 mg/10ml 2 QL (30 mg/ml) ketorolac tromethamine tab 10 mg 2 QL meclofenamate sodium cap 50 mg 4 PA mefenamic acid cap 250 mg 4 PA meloxicam susp 7.5 mg/5ml 4 meloxicam tab 7.5 mg 1 meloxicam tab 15 mg 1 nabumetone tab 500 mg 2 nabumetone tab 750 mg 2 naproxen susp 125 mg/5ml 2 PA naproxen tab 250 mg 2 naproxen tab 375 mg 2 naproxen tab 500 mg 2 naproxen tab ec 375 mg 2 naproxen tab ec 500 mg 2 oxaprozin tab 600 mg 2 piroxicam cap 10 mg 4 piroxicam cap 20 mg 4 salsalate tab 500 mg 2 salsalate tab 750 mg 2 ST JOSEPH CHW 75MG ADU 6 sulindac tab 150 mg 2 sulindac tab 200 mg 2 tolmetin sodium cap 400 mg 2 tolmetin sodium tab 200 mg 4 PA tolmetin sodium tab 600 mg 2 NSAIDS, COMBINATIONS diclofenac w/ misoprostol tab delayed 2 PA release 50-0.2 mg diclofenac w/ misoprostol tab delayed 2 PA release 75-0.2 mg

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 3 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits NSAIDS, TOPICAL NOVOCLAIR CRE 4 OPIOID ANALGESICS acetaminophen w/ codeine soln 120-12 2 ST, PA mg/5ml acetaminophen w/ codeine tab 300-15 mg 2 ST, PA acetaminophen w/ codeine tab 300-30 mg 2 ST, PA acetaminophen w/ codeine tab 300-60 mg 2 ST, PA aspirin-caffeine-dihydrocodeine cap 356.4- 2 ST 30-16 mg butalbital-acetaminophen-caff w/ cod cap 2 ST, PA 50-300-40-30 mg butalbital-acetaminophen-caff w/ cod cap 2 ST, PA 50-325-40-30 mg butalbital-aspirin-caff w/ codeine cap 50- 2 ST, PA 325-40-30 mg butorphanol tartrate inj 1 mg/ml 2 ST butorphanol tartrate inj 2 mg/ml 2 ST butorphanol tartrate nasal soln 10 mg/ml 2 ST, PA; QL codeine sulfate tab 15 mg 2 ST, PA codeine sulfate tab 30 mg 2 ST, PA codeine sulfate tab 60 mg 2 ST, PA DEMEROL INJ 25MG/0.5 4 ST DEMEROL INJ 75MG/1.5 4 ST DEMEROL INJ 75MG/ML 4 ST DEMEROL INJ 100/2ML 4 ST EMBEDA CAP 20-0.8MG 4 ST, PA; QL EMBEDA CAP 30-1.2MG 4 ST, PA; QL EMBEDA CAP 50-2MG 4 ST, PA; QL EMBEDA CAP 60-2.4MG 4 ST, PA; QL EMBEDA CAP 80-3.2MG 4 ST, PA; QL EMBEDA CAP 100-4MG 4 ST, PA; QL fentanyl citrate lozenge on a handle 200 5 ST, PA; QL mcg fentanyl citrate lozenge on a handle 400 5 ST, PA; QL mcg fentanyl citrate lozenge on a handle 600 5 ST, PA; QL mcg fentanyl citrate lozenge on a handle 800 5 ST, PA; QL mcg fentanyl citrate lozenge on a handle 1200 5 ST, PA; QL mcg fentanyl citrate lozenge on a handle 1600 5 ST, PA; QL mcg fentanyl citrate pf soln cartridge 100 2 ST, PA mcg/2ml

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 4 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits fentanyl td patch 72hr 12 mcg/hr 2 ST, PA; QL fentanyl td patch 72hr 25 mcg/hr 2 ST, PA; QL fentanyl td patch 72hr 50 mcg/hr 2 ST, PA; QL fentanyl td patch 72hr 75 mcg/hr 2 ST, PA; QL fentanyl td patch 72hr 100 mcg/hr 2 ST, PA; QL hydrocodone-acetaminophen soln 7.5-325 2 ST, PA mg/15ml hydrocodone-acetaminophen soln 10-325 2 ST mg/15ml hydrocodone-acetaminophen tab 2.5-325 2 ST, PA mg hydrocodone-acetaminophen tab 5-325 mg 2 ST, PA hydrocodone-acetaminophen tab 7.5-325 2 ST, PA mg hydrocodone-acetaminophen tab 10-325 2 ST, PA mg hydrocodone-ibuprofen tab 5-200 mg 2 ST, PA hydrocodone-ibuprofen tab 5-200 mg 2 ST, PA; QL hydrocodone-ibuprofen tab 7.5-200 mg 2 ST, PA; QL hydrocodone-ibuprofen tab 10-200 mg 2 ST, PA; QL HYDROMORPHON SUP 3MG 2 ST, PA hydromorphone hcl inj 1 mg/ml 2 ST hydromorphone hcl inj 2 mg/ml 2 ST hydromorphone hcl inj 4 mg/ml 2 ST hydromorphone hcl tab 2 mg 2 ST, PA hydromorphone hcl tab 4 mg 2 ST, PA hydromorphone hcl tab 8 mg 2 ST, PA hydromorphone hcl tab er 24hr deter 8 mg 2 ST, PA; QL hydromorphone hcl tab er 24hr deter 12 2 ST, PA; QL mg hydromorphone hcl tab er 24hr deter 16 2 ST, PA; QL mg hydromorphone hcl tab er 24hr deter 32 2 ST, PA; QL mg levorphanol tartrate tab 2 mg 2 ST, PA meperidine hcl inj 10 mg/ml 2 ST meperidine hcl oral soln 50 mg/5ml 2 ST, PA meperidine hcl tab 50 mg 2 ST, PA meperidine hcl tab 100 mg 2 ST, PA methadone hcl conc 10 mg/ml 2 ST, PA methadone hcl soln 5 mg/5ml 2 ST, PA methadone hcl soln 10 mg/5ml 2 ST, PA methadone hcl tab 5 mg 2 ST, PA methadone hcl tab 10 mg 2 ST, PA methadone hcl tab for oral susp 40 mg 2 ST, PA MORPHINE SUL INJ 2MG/ML 2 ST

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 5 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits MORPHINE SUL INJ 4MG/ML 2 ST MORPHINE SUL INJ 5MG/ML 2 ST MORPHINE SUL INJ 10/0.7ML 2 ST MORPHINE SUL INJ 150/30ML 2 ST MORPHINE SUL SUP 30MG 2 ST, PA morphine sulfate inj 8 mg/ml 2 ST morphine sulfate inj 10 mg/ml 2 ST morphine sulfate inj 15 mg/ml 2 ST morphine sulfate inj pf 0.5 mg/ml 2 ST morphine sulfate inj pf 1 mg/ml 2 ST morphine sulfate iv soln 1 mg/ml 2 ST morphine sulfate iv soln 25 mg/ml 2 ST morphine sulfate iv soln 50 mg/ml 2 ST morphine sulfate iv soln pf 10 mg/ml 2 ST morphine sulfate iv soln pf 15 mg/ml 2 ST morphine sulfate oral soln 10 mg/5ml 2 ST, PA morphine sulfate oral soln 20 mg/5ml 2 ST, PA morphine sulfate oral soln 100 mg/5ml (20 2 ST, PA mg/ml) morphine sulfate suppos 5 mg 2 ST, PA morphine sulfate suppos 10 mg 2 ST, PA morphine sulfate suppos 20 mg 2 ST, PA morphine sulfate tab 15 mg 2 ST, PA; QL morphine sulfate tab 30 mg 2 ST, PA morphine sulfate tab er 15 mg 2 ST, PA morphine sulfate tab er 15 mg 2 ST, PA; QL morphine sulfate tab er 30 mg 2 ST, PA; QL morphine sulfate tab er 60 mg 2 ST, PA morphine sulfate tab er 60 mg 2 ST, PA; QL morphine sulfate tab er 100 mg 2 ST, PA morphine sulfate tab er 100 mg 2 ST, PA; QL morphine sulfate tab er 100 mg 2 ST morphine sulfate tab er 200 mg 2 ST, PA; QL nalbuphine hcl inj 10 mg/ml 2 ST nalbuphine hcl inj 20 mg/ml 2 ST NUCYNTA ER TAB 50MG 4 ST, PA; QL NUCYNTA ER TAB 100MG 4 ST, PA; QL NUCYNTA ER TAB 150MG 4 ST, PA; QL NUCYNTA ER TAB 200MG 4 ST, PA; QL NUCYNTA ER TAB 250MG 4 ST, PA; QL NUCYNTA TAB 50MG 4 ST, PA; QL NUCYNTA TAB 75MG 4 ST, PA; QL NUCYNTA TAB 100MG 4 ST, PA; QL oxycodone hcl cap 5 mg 2 ST, PA

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 6 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits oxycodone hcl conc 100 mg/5ml (20 2 ST, PA mg/ml) oxycodone hcl soln 5 mg/5ml 2 ST, PA oxycodone hcl tab 5 mg 2 ST, PA oxycodone hcl tab 10 mg 2 ST, PA oxycodone hcl tab 15 mg 2 ST, PA oxycodone hcl tab 20 mg 2 ST, PA oxycodone hcl tab 30 mg 2 ST, PA oxycodone hcl tab er 12hr deter 10 mg 4 ST, PA; QL oxycodone hcl tab er 12hr deter 15 mg 4 ST, PA; QL oxycodone hcl tab er 12hr deter 20 mg 4 ST, PA; QL oxycodone hcl tab er 12hr deter 30 mg 4 ST, PA; QL oxycodone hcl tab er 12hr deter 40 mg 4 ST, PA; QL oxycodone hcl tab er 12hr deter 60 mg 4 ST, PA; QL oxycodone hcl tab er 12hr deter 80 mg 4 ST, PA; QL oxycodone w/ acetaminophen tab 2.5-325 2 ST, PA mg oxycodone w/ acetaminophen tab 5-325 2 ST, PA mg oxycodone w/ acetaminophen tab 7.5-325 2 ST, PA mg oxycodone w/ acetaminophen tab 10-325 2 ST, PA mg oxycodone-aspirin tab 4.8355-325 mg 2 ST, PA oxycodone-ibuprofen tab 5-400 mg 2 ST, PA; QL oxymorphone hcl tab 5 mg 2 ST, PA oxymorphone hcl tab 10 mg 2 ST, PA oxymorphone hcl tab er 12hr 5 mg 2 ST, PA; QL oxymorphone hcl tab er 12hr 7.5 mg 2 ST, PA; QL oxymorphone hcl tab er 12hr 10 mg 2 ST, PA; QL oxymorphone hcl tab er 12hr 15 mg 2 ST, PA; QL oxymorphone hcl tab er 12hr 20 mg 2 ST, PA; QL oxymorphone hcl tab er 12hr 30 mg 2 ST, PA; QL oxymorphone hcl tab er 12hr 40 mg 2 ST, PA; QL pentazocine w/ naloxone tab 50-0.5 mg 2 ST, PA REPREXAIN TAB 2.5-200 2 ST; QL TALWIN INJ 30MG/ML 4 ST tramadol hcl tab 50 mg 2 ST, PA; QL tramadol hcl tab er 24hr 100 mg 2 ST, PA; QL tramadol hcl tab er 24hr 200 mg 2 ST, PA; QL tramadol hcl tab er 24hr 300 mg 2 ST, PA; QL tramadol hcl tab er 24hr biphasic release 2 ST, PA; QL 100 mg tramadol hcl tab er 24hr biphasic release 2 ST, PA; QL 200 mg

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 7 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits tramadol hcl tab er 24hr biphasic release 2 ST, PA; QL 300 mg tramadol-acetaminophen tab 37.5-325 mg 2 ST, PA; QL XARTEMIS XR TAB 7.5-325 4 ST, PA; QL VISCOSUPPLEMENTS EUFLEXXA INJ 10MG/ML 5 PA; QL ANALGESICS - ANTI-INFLAMMATORY ANTI-TNF-ALPHA - MONOCLONAL ANTIBODIES HUMIRA INJ 10/0.1ML 5 PA; QL HUMIRA INJ 20/0.2ML 5 PA; QL HUMIRA INJ 40/0.4ML 5 PA; QL HUMIRA PEDIA INJ CROHNS 5 PA; QL HUMIRA PEN INJ 40/0.4ML 5 PA; QL HUMIRA PEN KIT CD/UC/HS 5 PA; QL HUMIRA PEN KIT PS/UV 5 PA; QL ANTIRHEUMATIC - ENZYME INHIBITORS XELJANZ TAB 5MG 5 PA; QL XELJANZ TAB 10MG 5 PA; QL XELJANZ XR TAB 11MG 5 PA; QL INTERLEUKIN-1 RECEPTOR ANTAGONIST (IL-1RA) KINERET INJ 5 MNPA NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS) ketoprofen cap er 24hr 200 mg 2 SOLUBLE TUMOR NECROSIS FACTOR RECEPTOR AGENTS ENBREL MINI INJ 50MG/ML 5 PA; QL ANALGESICS - OPIOID OPIOID AGONISTS hydrocodone bitartrate cap er 12hr abuse- 4 QL (2 caps per day) deterrent 10 mg hydrocodone bitartrate cap er 12hr abuse- 4 QL (2 caps per day) deterrent 15 mg hydrocodone bitartrate cap er 12hr abuse- 4 QL (2 caps per day) deterrent 20 mg hydrocodone bitartrate cap er 12hr abuse- 4 QL (2 caps per day) deterrent 30 mg hydrocodone bitartrate cap er 12hr abuse- 4 QL (2 caps per day) deterrent 40 mg hydrocodone bitartrate cap er 12hr abuse- 4 QL (2 caps per day) deterrent 50 mg OPIOID PARTIAL AGONISTS buprenorphine td patch weekly 5 mcg/hr 4 PA; QL buprenorphine td patch weekly 7.5 mcg/hr 4 PA; QL buprenorphine td patch weekly 10 mcg/hr 4 PA; QL buprenorphine td patch weekly 15 mcg/hr 4 PA; QL

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 8 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits buprenorphine td patch weekly 20 mcg/hr 4 PA; QL ANDROGENS-ANABOLIC ANDROGENS testosterone td gel 20.25 mg/act (1.62%) 2 PA ANTHELMINTICS ANTHELMINTICS praziquantel tab 600 mg 2 ANTI-INFECTIVE AGENTS - MISC. ANTI-INFECTIVE AGENTS - MISC. pentamidine isethionate for nebulization 2 soln 300 mg GLYCOPEPTIDES FIRVANQ SOL 25MG/ML 3 QL FIRVANQ SOL 50MG/ML 3 QL PLEUROMUTILINS XENLETA TAB 600MG 5 PA; QL ANTI-INFECTIVES AMINOGLYCOSIDES amikacin sulfate inj 1 gm/4ml (250 mg/ml) 2 amikacin sulfate inj 500 mg/2ml (250 2 mg/ml) GENTAM/NACL INJ 0.9MG/ML 2 GENTAM/NACL INJ 1.4MG/ML 2 gentamicin in saline inj 0.8 mg/ml 2 gentamicin in saline inj 1 mg/ml 2 gentamicin in saline inj 1.2 mg/ml 2 gentamicin in saline inj 1.6 mg/ml 2 gentamicin in saline inj 2 mg/ml 2 gentamicin sulfate inj 10 mg/ml 2 gentamicin sulfate inj 40 mg/ml 2 gentamicin sulfate iv soln 10 mg/ml 2 neomycin sulfate tab 500 mg 2 paromomycin sulfate cap 250 mg 2 streptomycin sulfate for inj 1 gm 4 tobramycin sulfate for inj 1.2 gm 2 tobramycin sulfate inj 1.2 gm/30ml (40 2 mg/ml) (base equiv) tobramycin sulfate inj 2 gm/50ml (40 2 mg/ml) (base equiv) tobramycin sulfate inj 10 mg/ml (base 2 equivalent) tobramycin sulfate inj 80 mg/2ml (40 2 mg/ml) (base equiv)

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 9 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits ANTIBACTERIALS, CARBAPENEMS imipenem-cilastatin intravenous for soln 2 250 mg imipenem-cilastatin intravenous for soln 2 500 mg INVANZ INJ 1GM 4 meropenem iv for soln 1 gm 2 meropenem iv for soln 500 mg 2 ANTIBACTERIALS, CEPHALOSPORINS 1ST GEN cefadroxil cap 500 mg 2 cefadroxil for susp 250 mg/5ml 2 cefadroxil for susp 500 mg/5ml 2 cefadroxil tab 1 gm 2 CEFAZOL/DEX SOL 1GM 2 CEFAZOL/DEX SOL 2GM 2 CEFAZOLIN INJ 1GM/50ML 2 CEFAZOLIN INJ 100GM 2 CEFAZOLIN INJ 300GM 2 cefazolin sodium for inj 1 gm 2 cefazolin sodium for inj 10 gm 2 cefazolin sodium for inj 20 gm 2 cefazolin sodium for inj 500 mg 2 cefazolin sodium for iv soln 1 gm 2 cephalexin cap 250 mg 1 cephalexin cap 500 mg 1 cephalexin cap 750 mg 2 cephalexin for susp 125 mg/5ml 2 cephalexin for susp 250 mg/5ml 2 cephalexin tab 250 mg 2 cephalexin tab 500 mg 2 ANTIBACTERIALS, CEPHALOSPORINS, 2ND GEN cefaclor cap 250 mg 2 cefaclor cap 500 mg 2 CEFACLOR ER TAB 500MG 2 cefaclor for susp 250 mg/5ml 2 cefaclor for susp 375 mg/5ml 2 cefotetan disodium for inj 1 gm 2 cefotetan disodium for inj 2 gm 2 cefotetan disodium for inj 10 gm 2 CEFOXITIN INJ 1GM 2 CEFOXITIN INJ 2GM 2 cefoxitin sodium for inj 10 gm 2 cefoxitin sodium for iv soln 1 gm 2 cefoxitin sodium for iv soln 2 gm 2 cefprozil for susp 125 mg/5ml 2

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 10 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits cefprozil for susp 250 mg/5ml 2 cefprozil tab 250 mg 2 cefprozil tab 500 mg 2 CEFTIN SUS 125/5ML 4 CEFTIN SUS 250/5ML 4 cefuroxime axetil tab 250 mg 2 cefuroxime axetil tab 500 mg 2 cefuroxime sodium for inj 7.5 gm 2 cefuroxime sodium for inj 750 mg 2 cefuroxime sodium for iv soln 1.5 gm 2 ZINACEF/H20 INJ 1.5GM PB 4 ANTIBACTERIALS, CEPHALOSPORINS, 3RD GEN cefdinir cap 300 mg 2 cefdinir for susp 125 mg/5ml 2 cefdinir for susp 250 mg/5ml 2 cefditoren pivoxil tab 200 mg (base 2 equivalent) cefditoren pivoxil tab 400 mg (base 2 equivalent) cefixime for susp 100 mg/5ml 2 cefixime for susp 200 mg/5ml 2 cefotaxime sodium for inj 1 gm 2 cefotaxime sodium for inj 2 gm 2 cefotaxime sodium for inj 10 gm 2 cefotaxime sodium for inj 500 mg 2 cefpodoxime proxetil for susp 50 mg/5ml 2 cefpodoxime proxetil for susp 100 mg/5ml 2 cefpodoxime proxetil tab 100 mg 2 cefpodoxime proxetil tab 200 mg 2 ceftazidime for inj 1 gm 2 ceftazidime for inj 2 gm 2 ceftazidime for inj 6 gm 2 CEFTAZIDIME/ SOL D5W 1GM 4 CEFTAZIDIME/ SOL D5W 2GM 4 ceftibuten cap 400 mg 2 ceftibuten for susp 180 mg/5ml 2 CEFTRIAX/DEX INJ 1GM 4 CEFTRIAX/DEX INJ 2GM 4 ceftriaxone sodium for inj 1 gm 2 ceftriaxone sodium for inj 2 gm 2 ceftriaxone sodium for inj 10 gm 2 ceftriaxone sodium for inj 250 mg 2 ceftriaxone sodium for inj 500 mg 2 ceftriaxone sodium for iv soln 1 gm 2 ceftriaxone sodium for iv soln 2 gm 2

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 11 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits ceftriaxone sodium in dextrose inj 20 2 mg/ml ceftriaxone sodium in dextrose inj 40 2 mg/ml CLAFORAN INJ 1GM 4 CLAFORAN INJ 2GM 4 SPECTRACEF TAB 200MG 4 SUPRAX CAP 400MG 4 SUPRAX CHW 100MG 4 SUPRAX CHW 200MG 4 SUPRAX SUS 500/5ML 4 ANTIBACTERIALS, CEPHALOSPORINS, 4TH GEN cefepime hcl for inj 1 gm 2 cefepime hcl for inj 2 gm 2 CEFEPIME INJ 1GM 2 CEFEPIME INJ 2G/100ML 2 CEFEPIME/DEX INJ 1GM 4 CEFEPIME/DEX INJ 2GM 2 MAXIPIME INJ 1GM 4 MAXIPIME INJ 2GM 4 ANTIBACTERIALS, CEPHALOSPORINS, 5TH GEN TEFLARO INJ 400MG 4 TEFLARO INJ 600MG 4 ANTIBACTERIALS, ERYTHROMYCINS/MACROLIDES azithromycin for susp 100 mg/5ml 2 azithromycin for susp 200 mg/5ml 2 azithromycin iv for soln 500 mg 2 azithromycin powd pack for susp 1 gm 2 azithromycin tab 250 mg 2 azithromycin tab 500 mg 2 azithromycin tab 600 mg 2 clarithromycin for susp 125 mg/5ml 2 clarithromycin for susp 250 mg/5ml 2 clarithromycin tab 250 mg 2 clarithromycin tab 500 mg 2 clarithromycin tab er 24hr 500 mg 2 DIFICID TAB 200MG 5 ST; QL ERYTHROCIN INJ 500MG 4 erythromycin ethylsuccinate tab 400 mg 4 PA erythromycin stearate tab 250 mg 4 PA erythromycin tab 250 mg 4 PA erythromycin tab 500 mg 4 PA erythromycin tab delayed release 250 mg 4 PA erythromycin tab delayed release 333 mg 4 PA

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 12 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits erythromycin w/ delayed release particles 2 cap 250 mg ANTIBACTERIALS, FLUOROQUINOLONES CIPRO (5%) SUS 250MG/5 4 ciprofloxacin 200 mg/100ml in d5w 2 ciprofloxacin 400 mg/200ml in d5w 2 ciprofloxacin for oral susp 250 mg/5ml 2 (5%) (5 gm/100ml) ciprofloxacin for oral susp 500 mg/5ml 2 (10%) (10 gm/100ml) ciprofloxacin hcl tab 100 mg (base equiv) 2 ciprofloxacin hcl tab 250 mg (base equiv) 1 ciprofloxacin hcl tab 500 mg (base equiv) 1 ciprofloxacin hcl tab 750 mg (base equiv) 2 ciprofloxacin iv soln 200 mg/20ml (1%) 2 ciprofloxacin iv soln 400 mg/40ml (1%) 2 ciprofloxacin-ciprofloxacin hcl tab er 24hr 2 QL 500 mg (base eq) ciprofloxacin-ciprofloxacin hcl tab er 24hr 2 QL 1000 mg(base eq) FACTIVE TAB 320MG 4 QL levofloxacin in d5w iv soln 250 mg/50ml 2 levofloxacin in d5w iv soln 500 mg/100ml 2 levofloxacin in d5w iv soln 750 mg/150ml 2 levofloxacin iv soln 25 mg/ml 2 levofloxacin oral soln 25 mg/ml 2 levofloxacin tab 250 mg 2 levofloxacin tab 500 mg 2 levofloxacin tab 750 mg 2 moxifloxacin hcl tab 400 mg (base equiv) 2 MOXIFLOXACIN INJ 400/250 4 NOROXIN TAB 400MG 4 ofloxacin tab 400 mg 2 ANTIBACTERIALS, KETOLIDES KETEK TAB 300MG 4 QL KETEK TAB 400MG 4 QL ANTIBACTERIALS, PENICILLINS amoxicillin & k clavulanate chew tab 200- 2 28.5 mg amoxicillin & k clavulanate chew tab 400- 2 57 mg amoxicillin & k clavulanate for susp 200- 2 28.5 mg/5ml amoxicillin & k clavulanate for susp 250- 2 62.5 mg/5ml

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 13 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits amoxicillin & k clavulanate for susp 400-57 2 mg/5ml amoxicillin & k clavulanate for susp 600- 2 42.9 mg/5ml amoxicillin & k clavulanate tab 250-125 mg 2 amoxicillin & k clavulanate tab 500-125 mg 2 amoxicillin & k clavulanate tab 875-125 mg 2 amoxicillin & k clavulanate tab er 12hr 2 1000-62.5 mg amoxicillin (trihydrate) cap 250 mg 1 amoxicillin (trihydrate) cap 500 mg 1 amoxicillin (trihydrate) chew tab 125 mg 2 amoxicillin (trihydrate) chew tab 250 mg 2 amoxicillin (trihydrate) for susp 125 2 mg/5ml amoxicillin (trihydrate) for susp 200 2 mg/5ml amoxicillin (trihydrate) for susp 250 2 mg/5ml amoxicillin (trihydrate) for susp 400 2 mg/5ml amoxicillin (trihydrate) tab 500 mg 2 amoxicillin (trihydrate) tab 875 mg 2 ampicillin & sulbactam sodium for inj 1.5 2 (1-0.5) gm ampicillin & sulbactam sodium for inj 3 (2- 2 1) gm ampicillin & sulbactam sodium for iv soln 2 15 (10-5) gm ampicillin cap 250 mg 1 ampicillin cap 500 mg 1 ampicillin for susp 125 mg/5ml 2 ampicillin for susp 250 mg/5ml 2 ampicillin sodium for inj 1 gm 2 ampicillin sodium for inj 2 gm 2 ampicillin sodium for inj 125 mg 2 ampicillin sodium for inj 250 mg 2 ampicillin sodium for inj 500 mg 2 ampicillin sodium for iv soln 1 gm 2 ampicillin sodium for iv soln 2 gm 2 ampicillin sodium for iv soln 10 gm 2 AUGMENTIN SUS 125/5ML 4 BICILLIN C-R INJ 900/300 4 BICILLIN C-R INJ 1200000 4 BICILLIN L-A INJ 600000 4 BICILLIN L-A INJ 1200000 4

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 14 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits BICILLIN L-A INJ 2400000 4 dicloxacillin sodium cap 250 mg 2 dicloxacillin sodium cap 500 mg 2 NAFCILLIN INJ 1GM/50ML 2 NAFCILLIN INJ 2GM/100 2 nafcillin sodium for inj 1 gm 2 nafcillin sodium for inj 2 gm 2 nafcillin sodium for iv soln 1 gm 2 nafcillin sodium for iv soln 2 gm 2 nafcillin sodium for iv soln 10 gm 2 OXACILLIN INJ 1GM 2 OXACILLIN INJ 2GM 2 oxacillin sodium for inj 1 gm (base 2 equivalent) oxacillin sodium for inj 2 gm (base 2 equivalent) oxacillin sodium for iv soln 10 gm (base 2 equivalent) PEN G PROC INJ 600000 2 PEN GK/DEXTR INJ 20000/ML 4 PEN GK/DEXTR INJ 40000/ML 4 PEN GK/DEXTR INJ 60000/ML 4 penicillin g potassium for inj 5000000 unit 2 penicillin g potassium for inj 20000000 unit 2 penicillin g sodium for inj 5000000 unit 2 penicillin v potassium for soln 125 mg/5ml 2 penicillin v potassium for soln 250 mg/5ml 2 penicillin v potassium tab 250 mg 1 penicillin v potassium tab 500 mg 2 piperacillin sod-tazobactam na for inj 3.375 2 gm (3-0.375 gm) piperacillin sod-tazobactam sod for inj 2.25 2 gm (2-0.25 gm) piperacillin sod-tazobactam sod for inj 4.5 2 gm (4-0.5 gm) piperacillin sod-tazobactam sod for inj 40.5 2 gm (36-4.5 gm) ANTIBACTERIALS, SULFONAMIDES SULFADIAZINE TAB 500MG 2 sulfamethoxazole-trimethoprim iv soln 2 400-80 mg/5ml sulfamethoxazole-trimethoprim susp 200- 2 40 mg/5ml sulfamethoxazole-trimethoprim tab 400-80 2 mg

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 15 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits sulfamethoxazole-trimethoprim tab 800- 2 160 mg ANTIBACTERIALS, TETRACYCLINES demeclocycline hcl tab 150 mg 2 demeclocycline hcl tab 300 mg 2 doxycycline hyclate cap 50 mg 2 doxycycline hyclate cap 100 mg 2 doxycycline hyclate for inj 100 mg 2 doxycycline hyclate tab 20 mg 2 doxycycline hyclate tab 100 mg 2 doxycycline monohydrate cap 50 mg 2 doxycycline monohydrate cap 100 mg 2 doxycycline monohydrate for susp 25 2 mg/5ml doxycycline monohydrate tab 50 mg 2 doxycycline monohydrate tab 75 mg 2 doxycycline monohydrate tab 100 mg 2 doxycycline monohydrate tab 150 mg 2 MINOCIN INJ 100MG 4 minocycline hcl cap 50 mg 2 minocycline hcl cap 75 mg 2 minocycline hcl cap 100 mg 2 minocycline hcl tab 50 mg 2 minocycline hcl tab 75 mg 2 minocycline hcl tab 100 mg 2 tetracycline hcl cap 250 mg 2 tetracycline hcl cap 500 mg 2 ANTIFUNGALS ABELCET INJ 5MG/ML 4 AMBISOME INJ 50MG 4 amphotericin b for iv soln 50 mg 2 clotrimazole troche 10 mg 2 CRESEMBA CAP 186 MG 5 PA; QL CRESEMBA INJ 372MG 5 PA; QL ERAXIS INJ 50MG 4 ERAXIS INJ 100MG 4 fluconazole for susp 10 mg/ml 2 fluconazole for susp 40 mg/ml 2 fluconazole in nacl 0.9% inj 200 mg/100ml 2 fluconazole in nacl 0.9% inj 400 mg/200ml 2 fluconazole tab 50 mg 2 QL fluconazole tab 100 mg 2 QL fluconazole tab 150 mg 2 QL fluconazole tab 200 mg 2 QL FLUCONAZOLE/ INJ NACL 100 2

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 16 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits flucytosine cap 250 mg 5 PA flucytosine cap 500 mg 5 PA griseofulvin microsize susp 125 mg/5ml 2 griseofulvin microsize tab 500 mg 2 griseofulvin ultramicrosize tab 125 mg 2 griseofulvin ultramicrosize tab 250 mg 2 itraconazole cap 100 mg 2 PA; QL ketoconazole tab 200 mg 2 MYCAMINE INJ 50MG 4 MYCAMINE INJ 100MG 4 NOXAFIL SUS 40MG/ML 5 PA *nystatin oral powder* 2 nystatin susp 100000 unit/ml 2 nystatin tab 500000 unit 2 ONMEL TAB 200MG 4 PA; QL ORAVIG TAB 50MG 4 PA; QL terbinafine hcl tab 250 mg 2 QL voriconazole for inj 200 mg 2 QL voriconazole for susp 40 mg/ml 5 QL voriconazole tab 50 mg 5 QL voriconazole tab 200 mg 5 QL ANTIMALARIALS atovaquone-proguanil hcl tab 62.5-25 mg 2 PA atovaquone-proguanil hcl tab 250-100 mg 2 PA COARTEM TAB 20-120MG 3 ANTIRETROVIRALS, ANTIRETROVIRAL ADJUVANTS TYBOST TAB 150MG 3 QL ANTIRETROVIRALS, ANTIRETROVIRAL COMBINATIONS abacavir sulfate-lamivudine-zidovudine tab 2 QL 300-150-300 mg COMPLERA TAB 5 QL EVOTAZ TAB 300-150 5 QL GENVOYA TAB 5 QL lamivudine-zidovudine tab 150-300 mg 2 QL PREZCOBIX TAB 800-150 5 QL STRIBILD TAB 5 QL TRIUMEQ TAB 5 QL TRUVADA TAB 200-300 5 QL ANTIRETROVIRALS, CHEMOKINE RECEPTOR ANTAGONISTS SELZENTRY SOL 20MG/ML 3 PA; QL SELZENTRY TAB 150MG 5 PA; QL SELZENTRY TAB 300MG 5 PA; QL ANTIRETROVIRALS, FUSION INHIBITORS FUZEON INJ 90MG 5 QL

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 17 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits ANTIRETROVIRALS, INTEGRASE INHIBITORS ISENTRESS CHW 25MG 5 QL ISENTRESS CHW 100MG 5 QL ISENTRESS HD TAB 600MG 5 QL ISENTRESS POW 100MG 5 QL ISENTRESS TAB 400MG 5 QL TIVICAY TAB 50MG 5 QL VITEKTA TAB 85MG 5 QL VITEKTA TAB 150MG 5 QL ANTIRETROVIRALS, PROTEASE INHIBITORS APTIVUS CAP 250MG 5 QL APTIVUS SOL 5 QL atazanavir sulfate cap 150 mg (base equiv) 2 QL atazanavir sulfate cap 200 mg (base equiv) 2 QL atazanavir sulfate cap 300 mg (base equiv) 2 QL CRIXIVAN CAP 200MG 3 QL CRIXIVAN CAP 400MG 3 QL fosamprenavir calcium tab 700 mg (base 2 QL equiv) INVIRASE CAP 200MG 5 QL INVIRASE TAB 500MG 5 QL KALETRA TAB 100-25MG 5 QL KALETRA TAB 200-50MG 5 QL LEXIVA SUS 50MG/ML 5 QL lopinavir-ritonavir soln 400-100 mg/5ml 2 QL (80-20 mg/ml) NORVIR CAP 100MG 3 QL NORVIR SOL 80MG/ML 3 QL PREZISTA SUS 100MG/ML 5 QL PREZISTA TAB 75MG 5 QL PREZISTA TAB 150MG 5 QL PREZISTA TAB 600MG 5 QL PREZISTA TAB 800MG 5 QL REYATAZ POW 50MG 5 QL ritonavir tab 100 mg 2 QL VIRACEPT TAB 250MG 5 QL VIRACEPT TAB 625MG 5 QL ANTIRETROVIRALS, REVERSE TRANSCRIPTASE INHIBITORS - NON- NUCLEOSIDE EDURANT TAB 25MG 5 QL INTELENCE TAB 25MG 5 PA; QL INTELENCE TAB 100MG 5 PA; QL INTELENCE TAB 200MG 5 PA; QL nevirapine susp 50 mg/5ml 2 QL nevirapine tab 200 mg 2 QL MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 18 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits nevirapine tab er 24hr 100 mg 2 QL nevirapine tab er 24hr 400 mg 2 QL RESCRIPTOR TAB 100 MG 3 QL RESCRIPTOR TAB 200MG 3 QL ANTIRETROVIRALS, REVERSE TRANSCRIPTASE INHIBITORS - NUCLEOSIDE abacavir sulfate soln 20 mg/ml (base 2 QL equiv) abacavir sulfate tab 300 mg (base equiv) 2 QL didanosine delayed release capsule 125 mg 2 QL didanosine delayed release capsule 200 mg 2 QL didanosine delayed release capsule 250 mg 2 QL didanosine delayed release capsule 400 mg 2 QL EMTRIVA CAP 200MG 3 QL EMTRIVA SOL 10MG/ML 3 QL lamivudine oral soln 10 mg/ml 2 QL lamivudine tab 150 mg 2 QL lamivudine tab 300 mg 2 QL RETROVIR INJ 10MG/ML 5 stavudine cap 15 mg 2 QL stavudine cap 20 mg 2 QL stavudine cap 30 mg 2 QL stavudine cap 40 mg 2 QL stavudine for oral soln 1 mg/ml 2 QL VIDEX SOL 2GM 3 QL zidovudine cap 100 mg 2 QL zidovudine syrup 10 mg/ml 2 QL zidovudine tab 300 mg 2 QL ANTIRETROVIRALS, REVERSE TRANSCRIPTASE INHIBITORS - NUCLEOTIDE VIREAD POW 40MG/GM 5 QL VIREAD TAB 150MG 5 QL VIREAD TAB 200MG 5 QL VIREAD TAB 250MG 5 QL ANTITUBERCULAR AGENTS CAPASTAT SUL INJ 1GM 4 cycloserine cap 250 mg 4 ethambutol hcl tab 100 mg 2 ethambutol hcl tab 400 mg 2 isoniazid inj 100 mg/ml 2 isoniazid syrup 50 mg/5ml 2 isoniazid tab 100 mg 2 isoniazid tab 300 mg 2 PASER GRA 4GM 3

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 19 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits PRIFTIN TAB 150MG 4 pyrazinamide tab 500 mg 2 RIFAMATE CAP 4 rifampin cap 150 mg 2 rifampin cap 300 mg 2 rifampin for inj 600 mg 2 RIFATER TAB 4 SIRTURO TAB 100MG 5 PA TRECATOR TAB 250MG 4 ANTIVIRALS, CMV AGENTS cidofovir iv inj 75 mg/ml 2 ganciclovir sodium for inj 500 mg 2 VALCYTE TAB 450MG 4 valganciclovir hcl for soln 50 mg/ml (base 4 QL equiv) valganciclovir hcl tab 450 mg (base 2 equivalent) ANTIVIRALS, HEPATITIS AGENTS - HEPATITIS B adefovir dipivoxil tab 10 mg 5 PA BARACLUDE SOL 5 PA entecavir tab 0.5 mg 5 PA entecavir tab 1 mg 5 PA EPIVIR HBV SOL 5MG/ML 3 PA lamivudine tab 100 mg (hbv) 2 TYZEKA TAB 600MG 4 PA ANTIVIRALS, HEPATITIS AGENTS - HEPATITIS C EPCLUSA TAB 400-100 5 PA; QL HARVONI TAB 90-400MG 5 PA; QL OLYSIO CAP 150MG 5 PA; QL REBETOL SOL 40MG/ML 5 RIBAPAK PAK 1000/DAY 5 ribavirin cap 200 mg 5 QL ribavirin tab 200 mg 5 QL ribavirin tab 600 mg 5 QL SOVALDI TAB 400MG 5 PA; QL VOSEVI TAB 5 PA; QL ANTIVIRALS, HERPES AGENTS acyclovir cap 200 mg 2 acyclovir sodium for inj 500 mg 2 acyclovir sodium for inj 1000 mg 2 acyclovir sodium iv soln 50 mg/ml 2 acyclovir susp 200 mg/5ml 2 acyclovir tab 400 mg 2 acyclovir tab 800 mg 2

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 20 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits famciclovir tab 125 mg 2 QL famciclovir tab 250 mg 2 QL famciclovir tab 500 mg 2 QL valacyclovir hcl tab 1 gm 2 QL valacyclovir hcl tab 500 mg 2 QL ANTIVIRALS, INFLUENZA AGENTS oseltamivir phosphate cap 30 mg (base 2 QL (20 caps / 135 equiv) days); QL oseltamivir phosphate cap 45 mg (base 2 QL equiv) oseltamivir phosphate cap 75 mg (base 2 QL equiv) RELENZA MIS DISKHALE 4 QL rimantadine hydrochloride tab 100 mg 2 TAMIFLU CAP 30MG 4 QL (20 caps / 135 days); QL TAMIFLU CAP 45MG 4 QL TAMIFLU CAP 75MG 4 QL TAMIFLU SUS 6MG/ML 4 QL MISCELLANEOUS albendazole tab 200 mg 2 ALINIA SUS 100/5ML 5 PA ALINIA TAB 500MG 5 PA atovaquone susp 750 mg/5ml 2 AZACTAM/DEX INJ 1GM 4 AZACTAM/DEX INJ 2GM 4 aztreonam for inj 1 gm 2 aztreonam for inj 2 gm 2 bacitracin intramuscular for soln 50000 2 unit chloramphenicol sodium succinate for iv inj 2 1 gm clindamycin hcl cap 75 mg 2 clindamycin hcl cap 150 mg 2 clindamycin hcl cap 300 mg 2 clindamycin palmitate hcl for soln 75 2 mg/5ml (base equiv) clindamycin phosphate in d5w iv soln 300 2 mg/50ml clindamycin phosphate in d5w iv soln 600 2 mg/50ml clindamycin phosphate in d5w iv soln 900 2 mg/50ml clindamycin phosphate inj 300 mg/2ml 2 clindamycin phosphate inj 600 mg/4ml 2 clindamycin phosphate iv soln 300 mg/2ml 2

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 21 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits colistimethate sod for inj 150 mg (colistin 2 base activity) dapsone tab 25 mg 2 dapsone tab 100 mg 2 ivermectin tab 3 mg 2 linezolid for susp 100 mg/5ml 4 QL linezolid in sodium chloride iv soln 600 2 mg/300ml-0.9% linezolid tab 600 mg 4 QL METRONIDAZOL INJ 5MG/ML 2 metronidazole cap 375 mg 2 metronidazole in nacl 0.79% iv soln 500 2 mg/100ml metronidazole tab 250 mg 2 metronidazole tab 500 mg 2 nitrofurantoin macrocrystalline cap 50 mg 2 nitrofurantoin macrocrystalline cap 100 mg 2 nitrofurantoin monohydrate 2 macrocrystalline cap 100 mg polymyxin b sulfate for inj 500000 unit 2 rifabutin cap 150 mg 2 STROMECTOL TAB 3MG 3 tinidazole tab 250 mg 2 tinidazole tab 500 mg 2 trimethoprim tab 100 mg 2 VANCOMYC/D5W INJ 500MG 4 VANCOMYC/D5W INJ 750MG 4 vancomycin hcl cap 125 mg 5 vancomycin hcl cap 250 mg 5 vancomycin hcl for inj 1000 mg 2 vancomycin hcl for iv soln 5 gm (base 2 equivalent) vancomycin hcl for iv soln 10 gm (base 2 equivalent) vancomycin hcl for iv soln 500 mg (base 2 equivalent) VANCOMYCIN INJ 750MG 2 VIBATIV INJ 250MG 4 VIBATIV INJ 750MG 4 XIFAXAN TAB 200MG 5 PA; QL XIFAXAN TAB 550MG 5 PA; QL ZYVOX SOL 2MG/ML 4 ANTIANGINAL AGENTS ANTIANGINALS-OTHER ranolazine tab er 12hr 500 mg 2

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 22 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits ranolazine tab er 12hr 1000 mg 2 ANTIASTHMATIC AND BRONCHODILATOR AGENTS ANTIASTHMATIC - MONOCLONAL ANTIBODIES NUCALA INJ 100MG/ML 5 PA, QL (1 / 28 days) XOLAIR INJ 75/0.5 5 PA; QL XOLAIR INJ 150MG/ML 5 PA; QL BRONCHODILATORS - ANTICHOLINERGICS INCRUSE ELPT INH 62.5MCG 3 LEUKOTRIENE MODULATORS zileuton tab er 12hr 600 mg 5 ST; QL STEROID INHALANTS QVAR REDIHA AER 80MCG 3 QVAR REDIHAL AER 40MCG 3 SYMPATHOMIMETICS albuterol sulfate inhal aero 108 mcg/act 2 QL (90mcg base equiv) levalbuterol tartrate inhal aerosol 45 4 mcg/act (base equiv) MAXAIR AUTOH AER 200MCG 4 ANTICONVULSANTS ANTICONVULSANTS - MISC. carbamazepine tab er 12hr 100 mg 2 DIACOMIT CAP 250MG 5 PA; QL DIACOMIT CAP 500MG 5 PA; QL DIACOMIT PAK 250MG 5 PA; QL DIACOMIT PAK 500MG 5 PA; QL EPIDIOLEX SOL 100MG/ML 5 PA LAMICTAL CHW 2MG 2 lamotrigine orally disintegrating tab 25 mg 4 lamotrigine orally disintegrating tab 50 mg 4 lamotrigine orally disintegrating tab 100 4 mg lamotrigine orally disintegrating tab 200 4 mg lamotrigine tab er 24hr 50 mg 2 lamotrigine tab er 24hr 250 mg 2 GABA MODULATORS vigabatrin tab 500 mg 5 PA; QL ANTIDEPRESSANTS N-METHYL-D-ASPARTIC ACID (NMDA) RECEPTOR ANTAGONISTS SPRAVATO SOL 56MG DOS 5 PA; QL SPRAVATO SOL 84MG DOS 5 PA; QL

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 23 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits ANTIDIABETICS ANTIDIABETIC COMBINATIONS QTERN TAB 10MG/5MG 3 ST; QL SOLIQUA INJ 100/33 4 ST; QL SYNJARDY XR TAB 3 ST; QL SYNJARDY XR TAB 5-1000MG 3 ST; QL SYNJARDY XR TAB 10-1000 3 ST; QL SYNJARDY XR TAB 25-1000 3 ST; QL XIGDUO XR TAB 2.5-1000 3 ST; QL XIGDUO XR TAB 5-500MG 3 ST; QL XIGDUO XR TAB 5-1000MG 3 ST; QL XIGDUO XR TAB 10-500MG 3 ST; QL XIGDUO XR TAB 10-1000 3 ST; QL XULTOPHY INJ 100/3.6 4 ST; QL BIGUANIDES RIOMET SOL 500/5ML 4 DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS alogliptin benzoate tab 6.25 mg (base 4 ST equiv) alogliptin benzoate tab 25 mg (base equiv) 4 ST INCRETIN MIMETIC AGENTS (GLP-1 RECEPTOR AGONISTS) OZEMPIC INJ 2/1.5ML 3 ST; QL INSULIN TRESIBA INJ 100UNIT 3 QL SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITORS FARXIGA TAB 5MG 3 ST; QL FARXIGA TAB 10MG 3 ST; QL ANTIDOTES AND SPECIFIC ANTAGONISTS ANTIDOTES - CHELATING AGENTS deferasirox tab 90 mg 5 deferasirox tab 180 mg 5 PA deferasirox tab 360 mg 5 deferasirox tab for oral susp 125 mg 5 deferasirox tab for oral susp 250 mg 5 deferasirox tab for oral susp 500 mg 5 ANTIEMETICS 5-HT3 RECEPTOR ANTAGONISTS palonosetron hcl iv soln 0.25 mg/5ml (base 2 equivalent) SUBSTANCE P/NEUROKININ 1 (NK1) RECEPTOR ANTAGONISTS aprepitant capsule 40 mg 3 QL aprepitant capsule 80 mg 3 QL aprepitant capsule 125 mg 3 QL

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 24 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits aprepitant capsule therapy pack 80 & 125 3 QL mg fosaprepitant dimeglumine for iv infusion 3 QL (1 tab per 30 days) 150 mg (base eq) ANTIFUNGALS IMIDAZOLE-RELATED ANTIFUNGALS itraconazole oral soln 10 mg/ml 2 PA; QL posaconazole tab delayed release 100 mg 5 PA ANTIHYPERLIPIDEMICS ANTIHYPERLIPIDEMICS - MISC. VASCEPA CAP 0.5GM 3 PA BILE ACID SEQUESTRANTS colesevelam hcl packet for susp 3.75 gm 4 PA ANTIHYPERTENSIVES ANGIOTENSIN II RECEPTOR ANTAGONISTS olmesartan medoxomil tab 5 mg 4 olmesartan medoxomil tab 20 mg 4 olmesartan medoxomil tab 40 mg 4 DIRECT RENIN INHIBITORS aliskiren fumarate tab 150 mg (base 2 equivalent) aliskiren fumarate tab 300 mg (base 2 equivalent) ANTIMALARIALS ANTIMALARIALS chloroquine phosphate tab 250 mg 2 chloroquine phosphate tab 500 mg 2 DARAPRIM TAB 25MG 4 PA mefloquine hcl tab 250 mg 2 PA PRIMAQUINE TAB 26.3MG 4 PA quinine sulfate cap 324 mg 2 PA ANTIMYCOBACTERIAL AGENTS ANTIMYCOBACTERIAL AGENTS PRETOMANID TAB 200MG 5 PA; QL ANTINEOPLASTIC AGENTS ALKYLATING AGENTS carboplatin iv soln 600 mg/60ml 5 cisplatin inj 50 mg/50ml (1 mg/ml) 5 cyclophosphamide for inj 1 gm 5 cyclophosphamide for inj 2 gm 5 cyclophosphamide for inj 500 mg 5 dacarbazine for inj 100 mg 5 dacarbazine for inj 200 mg 5

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 25 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits EMCYT CAP 140MG 5 PA GLEOSTINE CAP 5MG 5 PA GLEOSTINE CAP 10MG 5 PA GLEOSTINE CAP 40MG 5 PA GLEOSTINE CAP 100MG 5 PA HEXALEN CAP 50MG 5 ifosfamide for inj 1 gm 5 IFOSFAMIDE INJ 3GM 5 ifosfamide iv inj 1 gm/20ml (50 mg/ml) 5 ifosfamide iv inj 3 gm/60ml (50 mg/ml) 5 LEUKERAN TAB 2MG 5 melphalan hcl for inj 50 mg (base equiv) 5 melphalan tab 2 mg 5 MUSTARGEN INJ 10MG 5 MYLERAN TAB 2MG 5 oxaliplatin for iv inj 50 mg 5 oxaliplatin for iv inj 100 mg 5 oxaliplatin iv soln 50 mg/10ml 5 oxaliplatin iv soln 100 mg/20ml 5 TEMODAR INJ 100MG 5 temozolomide cap 5 mg 5 PA temozolomide cap 20 mg 5 PA temozolomide cap 100 mg 5 PA temozolomide cap 140 mg 5 PA temozolomide cap 180 mg 5 PA temozolomide cap 250 mg 5 PA TREANDA INJ 25MG 5 TREANDA INJ 45/0.5ML 5 TREANDA INJ 100MG 5 TREANDA INJ 180/2ML 5 VALCHLOR GEL 0.016% 5 PA ZANOSAR INJ 1GM 5 ANTIMETABOLITES ALIMTA INJ 100MG 5 ALIMTA INJ 500MG 5 capecitabine tab 150 mg 5 PA capecitabine tab 500 mg 5 PA cladribine iv soln 10 mg/10ml (1 mg/ml) 5 cytarabine inj 20 mg/ml 5 cytarabine inj pf 20 mg/ml 5 cytarabine inj pf 100 mg/ml 5 floxuridine for inj 0.5 gm 5 fludarabine phosphate for inj 50 mg 5 fludarabine phosphate inj 25 mg/ml 5 fluorouracil iv soln 1 gm/20ml (50 mg/ml) 5

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 26 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits fluorouracil iv soln 2.5 gm/50ml (50 5 mg/ml) fluorouracil iv soln 5 gm/100ml (50 mg/ml) 5 fluorouracil iv soln 500 mg/10ml (50 5 mg/ml) gemcitabine hcl for inj 1 gm 5 gemcitabine hcl for inj 2 gm 5 gemcitabine hcl for inj 200 mg 5 gemcitabine hcl inj 200 mg/5.26ml (38 5 mg/ml) (base equiv) gemcitabine inj 1gm 5 gemcitabine inj 2gm 5 mercaptopurine tab 50 mg 2 methotrexate sodium for inj 1 gm 5 methotrexate sodium inj 50 mg/2ml (25 5 mg/ml) methotrexate sodium inj pf 50 mg/2ml (25 5 mg/ml) methotrexate sodium tab 2.5 mg (base 2 equiv) TABLOID TAB 40MG 5 PA HORMONAL ANTINEOPLASTICS, ANTIANDROGENS bicalutamide tab 50 mg 2 flutamide cap 125 mg 2 nilutamide tab 150 mg 2 PA tamoxifen citrate tab 10 mg (base 6 PA equivalent) tamoxifen citrate tab 20 mg (base 6 PA equivalent) XTANDI CAP 40MG 5 PA; QL HORMONAL ANTINEOPLASTICS, ANTIESTROGENS FASLODEX INJ 250/5ML 5 HORMONAL ANTINEOPLASTICS, AROMATASE INHIBITORS anastrozole tab 1 mg 2 exemestane tab 25 mg 2 letrozole tab 2.5 mg 2 HORMONAL ANTINEOPLASTICS, GONADOTROPIN RELEASING HORMONE ANTAGONISTS abiraterone acetate tab 250 mg 5 PA; QL FIRMAGON INJ 80MG 5 PA; QL FIRMAGON INJ 120MG 5 PA; QL ZYTIGA TAB 500MG 5 PA; QL HORMONAL ANTINEOPLASTICS, LUTEINIZING HORMONE- RELEASING HORMONE (LHRH) AGONISTS ELIGARD INJ 7.5MG 5 PA; QL

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 27 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits ELIGARD INJ 22.5MG 5 PA; QL ELIGARD INJ 30MG 5 PA; QL ELIGARD INJ 45MG 5 PA; QL leuprolide acetate inj kit 5 mg/ml 5 PA; QL LUPRON DEPOT INJ 3.75MG 5 PA; QL LUPRON DEPOT INJ 7.5MG 5 PA; QL LUPRON DEPOT INJ 11.25MG 5 PA; QL LUPRON DEPOT INJ 22.5MG 5 PA; QL LUPRON DEPOT INJ 30MG 5 PA; QL LUPRON DEPOT INJ 45MG 5 PA; QL TRELSTAR INJ 3.75MG 5 PA; QL TRELSTAR INJ 11.25MG 5 PA; QL TRELSTAR MIX INJ 22.5MG 5 PA; QL VANTAS KIT 50MG 5 PA; QL ZOLADEX IMP 3.6MG 5 PA; QL ZOLADEX IMP 10.8MG 5 PA; QL HORMONAL ANTINEOPLASTICS, PROGESTINS megestrol acetate susp 40 mg/ml 2 megestrol acetate tab 20 mg 2 megestrol acetate tab 40 mg 2 IMMUNOMODULATORS POMALYST CAP 1MG 5 PA; QL POMALYST CAP 2MG 5 PA; QL POMALYST CAP 3MG 5 PA; QL POMALYST CAP 4MG 5 PA; QL REVLIMID CAP 2.5MG 5 PA; QL REVLIMID CAP 5MG 5 PA; QL REVLIMID CAP 10MG 5 PA; QL REVLIMID CAP 15MG 5 PA; QL REVLIMID CAP 20MG 5 PA; QL REVLIMID CAP 25MG 5 PA; QL THALOMID CAP 50MG 5 PA; QL THALOMID CAP 100MG 5 PA; QL THALOMID CAP 150MG 5 PA; QL THALOMID CAP 200MG 5 PA; QL KINASE INHIBITORS AFINITOR DIS TAB 2MG 5 PA; QL AFINITOR DIS TAB 3MG 5 PA; QL AFINITOR DIS TAB 5MG 5 PA; QL AFINITOR TAB 10MG 5 PA; QL ALECENSA CAP 150MG 5 PA; QL BOSULIF TAB 100MG 5 PA; QL BOSULIF TAB 500MG 5 PA; QL CAPRELSA TAB 100MG 5 PA; QL

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 28 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits CAPRELSA TAB 300MG 5 PA; QL COMETRIQ KIT 60MG 5 PA; QL COMETRIQ KIT 100MG 5 PA; QL COMETRIQ KIT 140MG 5 PA; QL COTELLIC TAB 20MG 5 PA; QL GILOTRIF TAB 20MG 5 PA; QL GILOTRIF TAB 30MG 5 PA; QL GILOTRIF TAB 40MG 5 PA; QL IBRANCE CAP 75MG 5 PA; QL IBRANCE CAP 100MG 5 PA; QL IBRANCE CAP 125MG 5 PA; QL ICLUSIG TAB 15MG 5 PA; QL ICLUSIG TAB 45MG 5 PA; QL IMBRUVICA CAP 140MG 5 PA; QL IMBRUVICA TAB 140MG 5 PA; QL IMBRUVICA TAB 280MG 5 PA; QL IMBRUVICA TAB 420MG 5 PA; QL IMBRUVICA TAB 560MG 5 PA; QL INLYTA TAB 1MG 5 PA; QL INLYTA TAB 5MG 5 PA; QL IRESSA TAB 250MG 5 PA; QL JAKAFI TAB 5MG 5 PA; QL JAKAFI TAB 10MG 5 PA; QL JAKAFI TAB 15MG 5 PA; QL JAKAFI TAB 20MG 5 PA; QL JAKAFI TAB 25MG 5 PA; QL KISQALI 200 PAK FEMARA 5 PA; QL KISQALI 400 PAK FEMARA 5 PA; QL KISQALI 600 PAK FEMARA 5 PA; QL KISQALI TAB 200DOSE 5 PA; QL KISQALI TAB 400DOSE 5 PA; QL KISQALI TAB 600DOSE 5 PA; QL LENVIMA CAP 10 MG 5 PA; QL LENVIMA CAP 14 MG 5 PA; QL LENVIMA CAP 20 MG 5 PA; QL LENVIMA CAP 24 MG 5 PA; QL MEKINIST TAB 0.5MG 5 PA; QL MEKINIST TAB 2MG 5 PA; QL NEXAVAR TAB 200MG 5 PA; QL SPRYCEL TAB 20MG 5 PA; QL SPRYCEL TAB 50MG 5 PA; QL SPRYCEL TAB 70MG 5 PA; QL SPRYCEL TAB 80MG 5 PA; QL SPRYCEL TAB 100MG 5 PA; QL SPRYCEL TAB 140MG 5 PA; QL

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 29 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits STIVARGA TAB 40MG 5 PA; QL SUTENT CAP 12.5MG 5 PA; QL SUTENT CAP 25MG 5 PA; QL SUTENT CAP 37.5MG 5 PA; QL SUTENT CAP 50MG 5 PA; QL TAFINLAR CAP 50MG 5 PA; QL TAFINLAR CAP 75MG 5 PA; QL TAGRISSO TAB 40MG 5 PA; QL TAGRISSO TAB 80MG 5 PA; QL TARCEVA TAB 25MG 5 PA TARCEVA TAB 100MG 5 PA; QL TARCEVA TAB 150MG 5 PA; QL TASIGNA CAP 150MG 5 PA; QL TASIGNA CAP 200MG 5 PA; QL TYKERB TAB 250MG 5 PA; QL VOTRIENT TAB 200MG 5 PA; QL XALKORI CAP 200MG 5 PA; QL XALKORI CAP 250MG 5 PA; QL ZELBORAF TAB 240MG 5 PA; QL ZYDELIG TAB 100MG 5 PA; QL ZYDELIG TAB 150MG 5 PA; QL ZYKADIA CAP 150MG 5 PA; QL MISCELLANEOUS ABRAXANE INJ 100MG 5 amifostine for inj 500 mg 5 ARRANON INJ 5MG/ML 5 ARZERRA CON 100/5ML 5 PA AVASTIN INJ 5 bexarotene cap 75 mg 5 PA bleomycin sulfate for inj 15 unit 5 bleomycin sulfate for inj 30 unit 5 daunorubicin hcl iv soln 20 mg/4ml (base 5 equiv) DAUNOXOME INJ 2MG/ML 5 dexrazoxane hcl for inj 250 mg (base 5 equivalent) dexrazoxane hcl for inj 500 mg (base 5 equivalent) doxorubicin hcl for inj 10 mg 5 doxorubicin hcl for inj 50 mg 5 doxorubicin hcl inj 2 mg/ml 5 ELITEK INJ 1.5MG 5 ELITEK INJ 7.5MG 5 epirubicin hcl iv soln 50 mg/25ml (2 5 mg/ml)

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 30 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits epirubicin hcl iv soln 200 mg/100ml (2 5 mg/ml) ERBITUX INJ 100MG 5 ERBITUX INJ 200MG 5 ERIVEDGE CAP 150MG 5 PA; QL ETOPOPHOS INJ 100MG 5 etoposide cap 50 mg 5 PA etoposide inj 1 gm/50ml (20 mg/ml) 5 etoposide inj 100 mg/5ml (20 mg/ml) 5 PA etoposide inj 500 mg/25ml (20 mg/ml) 5 PA FARYDAK CAP 10MG 5 PA; QL FARYDAK CAP 15MG 5 PA; QL FARYDAK CAP 20MG 5 PA; QL FLUORAC CRE 5-1% 4 HERCEPTIN INJ 150MG 5 HERCEPTIN INJ 440MG 5 hydroxyurea cap 500 mg 2 idarubicin hcl iv inj 5 mg/5ml (1 mg/ml) 5 IXEMPRA KIT INJ 15MG 5 IXEMPRA KIT INJ 45MG 5 leucovorin calcium tab 5 mg 5 leucovorin calcium tab 10 mg 5 leucovorin calcium tab 15 mg 5 leucovorin calcium tab 25 mg 5 LONSURF TAB 15-6.14 5 PA LONSURF TAB 20-8.19 5 PA LYNPARZA CAP 50MG 5 PA; QL LYSODREN TAB 500MG 5 PA MATULANE CAP 50MG 5 mesna inj 100 mg/ml 5 MESNEX TAB 400MG 5 mitomycin for iv soln 5 mg 5 mitomycin for iv soln 20 mg 5 mitomycin for iv soln 40 mg 5 mitoxantrone hcl inj conc 25 mg/12.5ml (2 5 mg/ml) NINLARO CAP 2.3MG 5 PA; QL NINLARO CAP 3MG 5 PA; QL NINLARO CAP 4MG 5 PA; QL ODOMZO CAP 200MG 5 PA; QL ONCASPAR INJ 750/ML 5 paclitaxel iv conc 30 mg/5ml (6 mg/ml) 5 PHOTOFRIN INJ 75MG 5 PROLEUKIN INJ 22MU 5 RITUXAN INJ 100MG 5 PA; QL

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 31 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits TARGRETIN GEL 1% 5 PA tretinoin cap 10 mg 5 TRISENOX SOL 10MG/10M 5 UVADEX INJ 20MCG/ML 4 VENCLEXTA TAB 10MG 5 PA; QL VENCLEXTA TAB 50MG 5 PA; QL VENCLEXTA TAB 100MG 5 PA; QL vinblastine sulfate inj 1 mg/ml 5 vincristine sulfate iv soln 1 mg/ml 5 vinorelbine tartrate inj 10 mg/ml (base 5 equiv) vinorelbine tartrate inj 50 mg/5ml (10 5 mg/ml) (base equiv) VORAXAZE INJ 1000UNIT 5 PA ZOLINZA CAP 100MG 5 PA; QL TOPOISOMERASE INHIBITORS HYCAMTIN CAP 0.25MG 5 PA HYCAMTIN CAP 1MG 5 PA irinotecan hcl inj 40 mg/2ml (20 mg/ml) 5 irinotecan hcl inj 100 mg/5ml (20 mg/ml) 5 irinotecan hcl inj 500 mg/25ml (20 mg/ml) 5 TOPOTECAN INJ 4MG/4ML 5 ANTINEOPLASTIC ENZYME INHIBITORS POLY (ADP-RIBOSE) POLYMERASE (PARP) INHIBITORS RUBRACA TAB 200MG 5 PA; QL RUBRACA TAB 250MG 5 PA; QL RUBRACA TAB 300MG 5 PA; QL ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES ALKYLATING AGENTS CYCLOPHOSPHAMIDE CAP 25 MG 5 PA CYCLOPHOSPHAMIDE CAP 50 MG 5 PA ANTINEOPLASTIC - BCL-2 INHIBITORS VENCLEXTA TAB 10MG 5 PA; QL VENCLEXTA TAB 50MG 5 PA; QL VENCLEXTA TAB 100MG 5 PA; QL VENCLEXTA TAB START PK 5 PA; QL ANTINEOPLASTIC - HEDGEHOG PATHWAY INHIBITORS DAURISMO TAB 25MG 5 PA; QL DAURISMO TAB 100MG 5 PA; QL ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS ERLEADA TAB 60MG 5 PA; QL fulvestrant inj 250 mg/5ml 5 NUBEQA TAB 300MG 5 PA; QL

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 32 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits toremifene citrate tab 60 mg (base 5 PA equivalent) ANTINEOPLASTIC - XPO1 INHIBITORS XPOVIO PAK 60MG 5 PA; QL XPOVIO PAK 80MG 5 PA; QL XPOVIO PAK 100MG 5 PA; QL ANTINEOPLASTIC ENZYME INHIBITORS ALUNBRIG PAK 5 PA; QL ALUNBRIG TAB 30MG 5 PA; QL ALUNBRIG TAB 90MG 5 PA; QL ALUNBRIG TAB 180MG 5 PA; QL AYVAKIT TAB 100MG 5 PA, QL (1 per day) AYVAKIT TAB 200MG 5 PA, QL (1 per day) AYVAKIT TAB 300MG 5 PA, QL (1 per day) BALVERSA TAB 3MG 5 PA; QL BALVERSA TAB 4MG 5 PA; QL BALVERSA TAB 5MG 5 PA; QL BRAFTOVI CAP 50MG 5 PA; QL BRAFTOVI CAP 75MG 5 PA; QL BRUKINSA CAP 80MG 5 PA, QL (120 caps / 30 days) CABOMETYX TAB 20MG 5 PA; QL CABOMETYX TAB 40MG 5 PA; QL CABOMETYX TAB 60MG 5 PA; QL CALQUENCE CAP 100MG 5 PA; QL COPIKTRA CAP 15MG 5 PA; QL COPIKTRA CAP 25MG 5 PA; QL erlotinib hcl tab 25 mg (base equivalent) 5 PA erlotinib hcl tab 100 mg (base equivalent) 5 PA erlotinib hcl tab 150 mg (base equivalent) 5 PA everolimus tab 2.5 mg 5 PA, QL (1 tab / 1 day) everolimus tab 5 mg 5 PA, QL (1 tab / 1 day) everolimus tab 5 mg 5 PA, QL (1 tab per day) everolimus tab 7.5 mg 5 PA, QL (1 tab per day) IBRANCE TAB 75MG 5 PA, QL (21 tabs / 21 days) IBRANCE TAB 100MG 5 PA, QL (21 tabs / 21 days) IBRANCE TAB 125MG 5 PA, QL (21 tabs / 21 days) IDHIFA TAB 50MG 5 PA; QL IDHIFA TAB 100MG 5 PA; QL imatinib mesylate tab 100 mg (base 5 PA; QL equivalent)

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 33 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits imatinib mesylate tab 400 mg (base 5 PA; QL equivalent) INREBIC CAP 100MG 5 PA; QL KOSELUGO CAP 10MG 5 PA, QL (240 caps / 30 days) KOSELUGO CAP 25MG 5 PA, QL (120 caps / 30 days) LENVIMA CAP 8 MG 5 PA; QL LENVIMA CAP 18 MG 5 PA; QL LORBRENA TAB 25MG 5 PA; QL LORBRENA TAB 100MG 5 PA; QL MEKTOVI TAB 15MG 5 PA; QL NERLYNX TAB 40MG 5 PA; QL PEMAZYRE TAB 4.5MG 5 PA, QL (14 tabs / 21 days) PEMAZYRE TAB 9MG 5 PA, QL (14 tabs / 21 days) PEMAZYRE TAB 13.5MG 5 PA, QL (14 tabs / 21 days) PIQRAY 200MG TAB DOSE 5 PA; QL PIQRAY 250MG TAB DOSE 5 PA; QL PIQRAY 300MG TAB DOSE 5 PA; QL QINLOCK TAB 50MG 5 PA, QL (90 tabs / 30 days) RETEVMO CAP 40MG 5 PA, QL (180 caps / 30 days) RETEVMO CAP 80MG 5 PA, QL (120 caps / 30 days) ROZLYTREK CAP 100MG 5 PA; QL ROZLYTREK CAP 200MG 5 PA; QL RYDAPT CAP 25MG 5 PA; QL TABRECTA TAB 150MG 5 PA, QL (120 tabs / 30 days) TABRECTA TAB 200MG 5 PA, QL (120 tabs / 30 days) TALZENNA CAP 0.25MG 5 PA; QL TALZENNA CAP 1MG 5 PA; QL TASIGNA CAP 50MG 5 PA; QL TAZVERIK TAB 200MG 5 PA, QL (8 per day) TIBSOVO TAB 250MG 5 PA; QL TUKYSA TAB 50MG 5 PA, QL (360 tabs / 30 days) TUKYSA TAB 150MG 5 PA, QL (120 tabs / 30 days) TURALIO CAP 200MG 5 PA; QL VERZENIO TAB 50MG 5 PA; QL

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 34 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits VERZENIO TAB 100MG 5 PA; QL VERZENIO TAB 150MG 5 PA; QL VERZENIO TAB 200MG 5 PA; QL VITRAKVI CAP 25MG 5 PA; QL VITRAKVI CAP 100MG 5 PA; QL VITRAKVI SOL 20MG/ML 5 PA; QL VIZIMPRO TAB 15MG 5 PA; QL VIZIMPRO TAB 30MG 5 PA; QL VIZIMPRO TAB 45MG 5 PA; QL XOSPATA TAB 40MG 5 PA; QL ZEJULA CAP 100MG 5 PA; QL ANTIPARKINSON AND RELATED THERAPY AGENTS ANTIPARKINSON MONOAMINE OXIDASE INHIBITORS rasagiline mesylate tab 0.5 mg (base 4 ST equiv) rasagiline mesylate tab 1 mg (base equiv) 4 ST ANTIPSYCHOTICS/ANTIMANIC AGENTS DIBENZAPINES quetiapine fumarate tab er 24hr 50 mg 2 QL quetiapine fumarate tab er 24hr 150 mg 2 QL quetiapine fumarate tab er 24hr 200 mg 2 QL quetiapine fumarate tab er 24hr 300 mg 2 QL quetiapine fumarate tab er 24hr 400 mg 2 QL DIHYDROINDOLONES molindone hcl tab 5 mg 2 molindone hcl tab 10 mg 2 molindone hcl tab 25 mg 2 ANTIVIRALS ANTIRETROVIRALS abacavir sulfate-lamivudine tab 600-300 2 QL mg BIKTARVY TAB 5 QL CIMDUO TAB 300-300 5 QL DOVATO TAB 50-300MG 5 QL efavirenz cap 50 mg 2 QL efavirenz cap 200 mg 2 QL efavirenz tab 600 mg 2 QL SYMFI LO TAB 5 QL SYMFI TAB 5 QL tenofovir disoproxil fumarate tab 300 mg 2 QL HEPATITIS AGENTS DAKLINZA TAB 30MG 5 QL (1 tab per day); MNPA

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 35 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits DAKLINZA TAB 60MG 5 QL (1 tab per day); MNPA ribavirin tab 400 mg 5 QL (1 tab per day) VEMLIDY TAB 25MG 4 PA INFLUENZA AGENTS oseltamivir phosphate for susp 6 mg/ml 2 QL (base equiv) BACTERIAL VACCINES BACTERIAL VACCINE COMBINATIONS MENHIBRIX INJ 6 BACTERIAL VACCINES ACTHIB INJ 6 BEXSERO INJ 6 HIBERIX SOL 10MCG 6 MENACTRA INJ 6 MENOMUNE INJ A/C/Y/W 6 MENVEO INJ 6 PEDVAX HIB INJ 6 PNEUMOVAX 23 INJ 25/0.5 6 PREVNAR 13 INJ 6 TRUMENBA INJ 6 CALCIUM CHANNEL BLOCKERS CALCIUM CHANNEL BLOCKERS diltiazem hcl cap er 24hr 120 mg 2 diltiazem hcl cap er 24hr 180 mg 2 diltiazem hcl cap er 24hr 240 mg 2 diltiazem hcl coated beads cap er 24hr 120 2 mg diltiazem hcl coated beads cap er 24hr 180 2 mg diltiazem hcl coated beads cap er 24hr 240 2 mg diltiazem hcl coated beads cap er 24hr 300 2 mg diltiazem hcl extended release beads cap 2 er 24hr 120 mg diltiazem hcl extended release beads cap 2 er 24hr 180 mg diltiazem hcl extended release beads cap 2 er 24hr 240 mg diltiazem hcl extended release beads cap 2 er 24hr 300 mg diltiazem hcl extended release beads cap 2 er 24hr 360 mg

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 36 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits diltiazem hcl extended release beads cap 2 er 24hr 420 mg diltiazem hcl tab 30 mg 2 diltiazem hcl tab 60 mg 2 diltiazem hcl tab 90 mg 2 diltiazem hcl tab 120 mg 2 CARDIOVASCULAR ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS amlodipine besylate-benazepril hcl cap 2.5- 2 10 mg amlodipine besylate-benazepril hcl cap 5- 2 10 mg amlodipine besylate-benazepril hcl cap 5- 2 20 mg amlodipine besylate-benazepril hcl cap 5- 2 40 mg amlodipine besylate-benazepril hcl cap 10- 2 20 mg amlodipine besylate-benazepril hcl cap 10- 2 40 mg trandolapril-verapamil hcl tab er 1-240 mg 2 trandolapril-verapamil hcl tab er 2-180 mg 2 trandolapril-verapamil hcl tab er 2-240 mg 2 trandolapril-verapamil hcl tab er 4-240 mg 2 ACE INHIBITOR/DIURETIC COMBINATIONS benazepril & hydrochlorothiazide tab 5- 4 6.25 mg benazepril & hydrochlorothiazide tab 10- 4 12.5 mg benazepril & hydrochlorothiazide tab 20- 4 12.5 mg benazepril & hydrochlorothiazide tab 20-25 4 mg captopril & hydrochlorothiazide tab 25-15 4 mg captopril & hydrochlorothiazide tab 25-25 4 mg captopril & hydrochlorothiazide tab 50-15 4 mg captopril & hydrochlorothiazide tab 50-25 4 mg enalapril maleate & hydrochlorothiazide tab 2 5-12.5 mg enalapril maleate & hydrochlorothiazide tab 2 10-25 mg

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 37 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits fosinopril sodium & hydrochlorothiazide tab 2 10-12.5 mg fosinopril sodium & hydrochlorothiazide tab 2 20-12.5 mg lisinopril & hydrochlorothiazide tab 10-12.5 1 mg lisinopril & hydrochlorothiazide tab 20-12.5 1 mg lisinopril & hydrochlorothiazide tab 20-25 1 mg moexipril-hydrochlorothiazide tab 7.5-12.5 2 mg moexipril-hydrochlorothiazide tab 15-12.5 2 mg moexipril-hydrochlorothiazide tab 15-25 2 mg quinapril-hydrochlorothiazide tab 10-12.5 2 mg quinapril-hydrochlorothiazide tab 20-12.5 2 mg quinapril-hydrochlorothiazide tab 20-25 mg 2 ACE INHIBITORS benazepril hcl tab 5 mg 1 benazepril hcl tab 10 mg 1 benazepril hcl tab 20 mg 1 benazepril hcl tab 40 mg 1 captopril tab 12.5 mg 4 captopril tab 25 mg 4 captopril tab 50 mg 4 captopril tab 100 mg 4 enalapril maleate tab 2.5 mg 2 enalapril maleate tab 5 mg 2 enalapril maleate tab 10 mg 2 enalapril maleate tab 20 mg 2 enalaprilat iv inj 1.25 mg/ml 2 fosinopril sodium tab 10 mg 2 fosinopril sodium tab 20 mg 2 fosinopril sodium tab 40 mg 2 lisinopril tab 2.5 mg 1 lisinopril tab 5 mg 1 lisinopril tab 10 mg 1 lisinopril tab 20 mg 1 lisinopril tab 30 mg 1 lisinopril tab 40 mg 1 moexipril hcl tab 7.5 mg 2 moexipril hcl tab 15 mg 2

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 38 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits perindopril erbumine tab 2 mg 2 perindopril erbumine tab 4 mg 2 perindopril erbumine tab 8 mg 2 quinapril hcl tab 5 mg 2 quinapril hcl tab 10 mg 2 quinapril hcl tab 20 mg 2 quinapril hcl tab 40 mg 2 ramipril cap 1.25 mg 2 ramipril cap 2.5 mg 2 ramipril cap 5 mg 2 ramipril cap 10 mg 2 trandolapril tab 1 mg 2 trandolapril tab 2 mg 2 trandolapril tab 4 mg 2 ADRENOLYTICS, CENTRAL clonidine hcl tab 0.1 mg 2 clonidine hcl tab 0.2 mg 2 clonidine hcl tab 0.3 mg 2 clonidine td patch weekly 0.1 mg/24hr 2 clonidine td patch weekly 0.2 mg/24hr 2 clonidine td patch weekly 0.3 mg/24hr 2 guanfacine hcl tab 1 mg 2 guanfacine hcl tab 2 mg 2 AGENTS FOR PHEOCHROMOCYTOMA DEMSER CAP 250MG 5 PA phenoxybenzamine hcl cap 10 mg 5 PA PHENTOLAMINE INJ 5MG 2 ALDOSTERONE RECEPTOR ANTAGONISTS eplerenone tab 25 mg 2 eplerenone tab 50 mg 2 spironolactone tab 25 mg 1 spironolactone tab 50 mg 2 spironolactone tab 100 mg 2 ALPHA BLOCKERS doxazosin mesylate tab 1 mg 2 doxazosin mesylate tab 2 mg 2 doxazosin mesylate tab 4 mg 2 doxazosin mesylate tab 8 mg 2 prazosin hcl cap 1 mg 2 prazosin hcl cap 2 mg 2 prazosin hcl cap 5 mg 2 terazosin hcl cap 1 mg (base equivalent) 2 terazosin hcl cap 2 mg (base equivalent) 2 terazosin hcl cap 5 mg (base equivalent) 2

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 39 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits terazosin hcl cap 10 mg (base equivalent) 2 ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER COMBINATIONS EDARBYCLOR TAB 40-12.5 4 ST EDARBYCLOR TAB 40-25MG 4 ST ANGIOTENSIN II RECEPTOR ANTAGONIST/DIURETIC COMBINATIONS candesartan cilexetil-hydrochlorothiazide 2 tab 16-12.5 mg candesartan cilexetil-hydrochlorothiazide 2 tab 32-12.5 mg candesartan cilexetil-hydrochlorothiazide 2 tab 32-25 mg irbesartan-hydrochlorothiazide tab 150- 2 12.5 mg irbesartan-hydrochlorothiazide tab 300- 2 12.5 mg losartan potassium & hydrochlorothiazide 2 tab 50-12.5 mg losartan potassium & hydrochlorothiazide 2 tab 100-12.5 mg losartan potassium & hydrochlorothiazide 2 tab 100-25 mg telmisartan-hydrochlorothiazide tab 40- 2 12.5 mg telmisartan-hydrochlorothiazide tab 80- 2 12.5 mg telmisartan-hydrochlorothiazide tab 80-25 2 mg valsartan-hydrochlorothiazide tab 80-12.5 2 mg valsartan-hydrochlorothiazide tab 160-12.5 2 mg valsartan-hydrochlorothiazide tab 160-25 2 mg valsartan-hydrochlorothiazide tab 320-12.5 2 mg valsartan-hydrochlorothiazide tab 320-25 2 mg ANGIOTENSIN II RECEPTOR ANTAGONISTS candesartan cilexetil tab 4 mg 2 candesartan cilexetil tab 8 mg 2 candesartan cilexetil tab 16 mg 2 candesartan cilexetil tab 32 mg 2 EDARBI TAB 40MG 4 ST EDARBI TAB 80MG 4 ST

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 40 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits eprosartan mesylate tab 600 mg 2 irbesartan tab 75 mg 2 irbesartan tab 150 mg 2 irbesartan tab 300 mg 2 losartan potassium tab 25 mg 2 losartan potassium tab 50 mg 2 losartan potassium tab 100 mg 2 telmisartan tab 20 mg 2 telmisartan tab 40 mg 2 telmisartan tab 80 mg 2 valsartan tab 40 mg 2 valsartan tab 80 mg 2 valsartan tab 160 mg 2 valsartan tab 320 mg 2 ANTIARRHYTHMICS amiodarone hcl tab 100 mg 2 amiodarone hcl tab 200 mg 2 amiodarone hcl tab 400 mg 2 disopyramide phosphate cap 100 mg 2 disopyramide phosphate cap 150 mg 2 dofetilide cap 125 mcg (0.125 mg) 2 QL dofetilide cap 250 mcg (0.25 mg) 2 QL dofetilide cap 500 mcg (0.5 mg) 2 QL flecainide acetate tab 50 mg 2 flecainide acetate tab 100 mg 2 flecainide acetate tab 150 mg 2 mexiletine hcl cap 150 mg 2 mexiletine hcl cap 200 mg 2 mexiletine hcl cap 250 mg 2 MULTAQ TAB 400MG 3 procainamide hcl inj 100 mg/ml 2 PROCAINAMIDE INJ 500MG/ML 2 propafenone hcl cap er 12hr 225 mg 2 propafenone hcl cap er 12hr 325 mg 2 propafenone hcl cap er 12hr 425 mg 2 propafenone hcl tab 150 mg 2 propafenone hcl tab 225 mg 2 propafenone hcl tab 300 mg 2 QUINIDINE GL INJ 80MG/ML 2 quinidine gluconate tab er 324 mg 2 quinidine sulfate tab 200 mg 2 quinidine sulfate tab 300 mg 2 quinidine sulfate tab er 300 mg 2 sotalol hcl (afib/afl) tab 80 mg 2 sotalol hcl (afib/afl) tab 120 mg 2

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 41 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits sotalol hcl (afib/afl) tab 160 mg 2 SOTALOL HCL INJ 150/10ML 4 sotalol hcl tab 80 mg 2 sotalol hcl tab 120 mg 2 sotalol hcl tab 160 mg 2 sotalol hcl tab 240 mg 2 ANTILIPEMICS, BILE ACID RESINS cholestyramine light powder 4 gm/dose 4 cholestyramine light powder packets 4 gm 4 cholestyramine powder 4 gm/dose 4 cholestyramine powder packets 4 gm 4 colesevelam hcl tab 625 mg 4 PA colestipol hcl granule packets 5 gm 4 colestipol hcl granules 5 gm 4 colestipol hcl tab 1 gm 4 ANTILIPEMICS, CHOLESTEROL ABSORPTION INHIBITORS ezetimibe tab 10 mg 2 ANTILIPEMICS, FIBRATES choline fenofibrate cap dr 45 mg (fenofibric 4 acid equiv) choline fenofibrate cap dr 135 mg 4 (fenofibric acid equiv) fenofibrate micronized cap 43 mg 2 fenofibrate micronized cap 67 mg 2 fenofibrate micronized cap 134 mg 2 fenofibrate micronized cap 200 mg 4 fenofibrate tab 48 mg 2 fenofibrate tab 54 mg 2 fenofibrate tab 145 mg 2 fenofibrate tab 160 mg 2 fenofibric acid tab 35 mg 4 fenofibric acid tab 105 mg 4 gemfibrozil tab 600 mg 2 ANTILIPEMICS, HMG-COA REDUCTASE INHIBITORS/COMBINATIONS atorvastatin calcium tab 10 mg (base 2 equivalent) atorvastatin calcium tab 20 mg (base 2 equivalent) atorvastatin calcium tab 40 mg (base 2 equivalent) atorvastatin calcium tab 80 mg (base 2 equivalent) fluvastatin sodium cap 20 mg (base 4 equivalent)

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 42 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits fluvastatin sodium cap 40 mg (base 4 equivalent) LIVALO TAB 1MG 4 PA LIVALO TAB 2MG 4 PA LIVALO TAB 4MG 4 PA lovastatin tab 10 mg 1 lovastatin tab 20 mg 1 lovastatin tab 40 mg 1 pravastatin sodium tab 10 mg 2 pravastatin sodium tab 20 mg 2 pravastatin sodium tab 40 mg 2 pravastatin sodium tab 80 mg 2 rosuvastatin calcium tab 5 mg 2 rosuvastatin calcium tab 10 mg 2 rosuvastatin calcium tab 20 mg 2 rosuvastatin calcium tab 40 mg 2 simvastatin tab 5 mg 1 simvastatin tab 10 mg 1 simvastatin tab 20 mg 1 simvastatin tab 40 mg 1 simvastatin tab 80 mg 1 ANTILIPEMICS, MISCELLANEOUS JUXTAPID CAP 5MG 5 PA; QL JUXTAPID CAP 10MG 5 PA; QL JUXTAPID CAP 20MG 5 PA; QL JUXTAPID CAP 30MG 5 PA; QL JUXTAPID CAP 40MG 5 PA; QL JUXTAPID CAP 60MG 5 PA; QL KYNAMRO INJ 200MG/ML 5 PA; QL ANTILIPEMICS, NIACINS/COMBINATIONS niacin tab er 500 mg (antihyperlipidemic) 4 niacin tab er 750 mg (antihyperlipidemic) 4 niacin tab er 1000 mg (antihyperlipidemic) 4 ANTILIPEMICS, OMEGA-3 FATTY ACIDS omega-3-acid ethyl esters cap 1 gm 3 VASCEPA CAP 1GM 3 PA ANTILIPEMICS, PCSK9 INHIBITORS PRALUENT INJ 75MG/ML 5 PA; QL PRALUENT INJ 150MG/ML 5 PA; QL BETA-BLOCKER/DIURETIC COMBINATIONS atenolol & chlorthalidone tab 50-25 mg 1 atenolol & chlorthalidone tab 100-25 mg 1 bisoprolol & hydrochlorothiazide tab 2.5- 1 6.25 mg

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 43 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits bisoprolol & hydrochlorothiazide tab 5-6.25 1 mg bisoprolol & hydrochlorothiazide tab 10- 1 6.25 mg metoprolol & hydrochlorothiazide tab 50- 2 25 mg metoprolol & hydrochlorothiazide tab 100- 2 25 mg metoprolol & hydrochlorothiazide tab 100- 2 50 mg nadolol & bendroflumethiazide tab 40-5 mg 2 nadolol & bendroflumethiazide tab 80-5 mg 2 propranolol & hydrochlorothiazide tab 40- 2 25 mg propranolol & hydrochlorothiazide tab 80- 2 25 mg BETA-BLOCKERS acebutolol hcl cap 200 mg 2 acebutolol hcl cap 400 mg 2 atenolol tab 25 mg 1 atenolol tab 50 mg 1 atenolol tab 100 mg 1 betaxolol hcl tab 10 mg 2 betaxolol hcl tab 20 mg 2 bisoprolol fumarate tab 5 mg 2 bisoprolol fumarate tab 10 mg 2 BYSTOLIC TAB 2.5MG 4 ST BYSTOLIC TAB 5MG 4 ST BYSTOLIC TAB 10MG 4 ST BYSTOLIC TAB 20MG 4 ST carvedilol tab 3.125 mg 1 carvedilol tab 6.25 mg 1 carvedilol tab 12.5 mg 1 carvedilol tab 25 mg 1 esmolol hcl inj 100 mg/10ml 2 HEMANGEOL SOL 4.28/ML 4 PA; QL labetalol hcl iv soln 5 mg/ml 2 labetalol hcl tab 100 mg 2 labetalol hcl tab 200 mg 2 labetalol hcl tab 300 mg 2 LEVATOL TAB 20MG 4 ST metoprolol succinate tab er 24hr 25 mg 2 (tartrate equiv) metoprolol succinate tab er 24hr 50 mg 2 (tartrate equiv)

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 44 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits metoprolol succinate tab er 24hr 100 mg 2 (tartrate equiv) metoprolol succinate tab er 24hr 200 mg 2 (tartrate equiv) metoprolol tartrate iv soln 5 mg/5ml 2 metoprolol tartrate tab 25 mg 1 metoprolol tartrate tab 50 mg 1 metoprolol tartrate tab 100 mg 1 nadolol tab 20 mg 2 nadolol tab 40 mg 2 nadolol tab 80 mg 2 pindolol tab 5 mg 2 pindolol tab 10 mg 2 propranolol hcl cap er 24hr 60 mg 2 propranolol hcl cap er 24hr 80 mg 2 propranolol hcl cap er 24hr 120 mg 2 propranolol hcl cap er 24hr 160 mg 2 propranolol hcl inj 1 mg/ml 2 propranolol hcl oral soln 20 mg/5ml 2 propranolol hcl oral soln 40 mg/5ml 2 propranolol hcl tab 10 mg 1 propranolol hcl tab 20 mg 1 propranolol hcl tab 40 mg 1 propranolol hcl tab 60 mg 2 propranolol hcl tab 80 mg 1 timolol maleate tab 5 mg 2 timolol maleate tab 10 mg 2 timolol maleate tab 20 mg 2 CALCIUM CHANNEL BLOCKERS, DIHYDROPYRIDINES amlodipine besylate tab 2.5 mg (base 1 equivalent) amlodipine besylate tab 5 mg (base 1 equivalent) amlodipine besylate tab 10 mg (base 1 equivalent) CLEVIPREX EMU 50/100ML 4 felodipine tab er 24hr 2.5 mg 2 felodipine tab er 24hr 5 mg 2 felodipine tab er 24hr 10 mg 2 isradipine cap 2.5 mg 2 isradipine cap 5 mg 2 nicardipine hcl cap 20 mg 2 nicardipine hcl cap 30 mg 2 nicardipine hcl iv soln 2.5 mg/ml 2 nifedipine cap 10 mg 2

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 45 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits nifedipine cap 20 mg 2 nifedipine tab er 24hr 30 mg 2 nifedipine tab er 24hr 60 mg 2 nifedipine tab er 24hr 90 mg 2 nifedipine tab er 24hr osmotic release 30 2 mg nifedipine tab er 24hr osmotic release 60 2 mg nifedipine tab er 24hr osmotic release 90 2 mg nimodipine cap 30 mg 2 nisoldipine tab er 24hr 8.5 mg 2 ST nisoldipine tab er 24hr 17 mg 2 ST nisoldipine tab er 24hr 20 mg 2 ST nisoldipine tab er 24hr 25.5 mg 2 ST nisoldipine tab er 24hr 30 mg 2 ST nisoldipine tab er 24hr 34 mg 2 ST nisoldipine tab er 24hr 40 mg 2 ST CALCIUM CHANNEL BLOCKERS, NON DIHYDROPYRIDINES diltiazem hcl coated beads cap er 24hr 120 2 mg verapamil hcl cap er 24hr 120 mg 2 verapamil hcl cap er 24hr 180 mg 2 verapamil hcl cap er 24hr 240 mg 2 verapamil hcl iv soln 2.5 mg/ml 2 verapamil hcl tab 40 mg 2 verapamil hcl tab 80 mg 2 verapamil hcl tab 120 mg 2 verapamil hcl tab er 120 mg 2 verapamil hcl tab er 180 mg 2 verapamil hcl tab er 240 mg 2 DIGITALIS GLYCOSIDES digoxin inj 0.25 mg/ml 2 digoxin oral soln 0.05 mg/ml 2 digoxin tab 125 mcg (0.125 mg) 2 digoxin tab 250 mcg (0.25 mg) 2 DIRECT RENIN INHIBITORS/DIURETIC COMBINATIONS TEKTURNA HCT TAB 150-12.5 3 ST TEKTURNA HCT TAB 150-25MG 3 ST TEKTURNA HCT TAB 300-12.5 3 ST TEKTURNA HCT TAB 300-25MG 3 ST TEKTURNA TAB 150MG 3 ST TEKTURNA TAB 300MG 3 ST

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 46 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits DIURETICS amiloride & hydrochlorothiazide tab 5-50 2 mg amiloride hcl tab 5 mg 2 bumetanide inj 0.25 mg/ml 2 bumetanide tab 0.5 mg 1 bumetanide tab 1 mg 1 bumetanide tab 2 mg 2 chlorothiazide sodium for inj 500 mg 2 chlorothiazide tab 250 mg 2 chlorothiazide tab 500 mg 2 chlorthalidone tab 25 mg 2 chlorthalidone tab 50 mg 2 DIURIL SUS 250/5ML 4 DYRENIUM CAP 50MG 4 ST DYRENIUM CAP 100MG 4 ST furosemide inj 10 mg/ml 2 furosemide oral soln 8 mg/ml 2 furosemide oral soln 10 mg/ml 2 furosemide tab 20 mg 1 furosemide tab 40 mg 1 furosemide tab 80 mg 1 hydrochlorothiazide cap 12.5 mg 1 hydrochlorothiazide tab 12.5 mg 2 hydrochlorothiazide tab 25 mg 1 hydrochlorothiazide tab 50 mg 1 indapamide tab 1.25 mg 2 indapamide tab 2.5 mg 2 methyclothiazide tab 5 mg 2 metolazone tab 2.5 mg 2 metolazone tab 5 mg 2 metolazone tab 10 mg 2 spironolactone & hydrochlorothiazide tab 2 25-25 mg torsemide tab 5 mg 2 torsemide tab 10 mg 2 torsemide tab 20 mg 2 torsemide tab 100 mg 2 triamterene & hydrochlorothiazide cap 1 37.5-25 mg triamterene & hydrochlorothiazide cap 50- 2 25 mg triamterene & hydrochlorothiazide tab 1 37.5-25 mg

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 47 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits triamterene & hydrochlorothiazide tab 75- 1 50 mg MISCELLANEOUS atropine sulfate inj 0.4 mg/ml 2 atropine sulfate inj 1 mg/ml 2 atropine sulfate soln prefill syr 0.25 2 mg/5ml (0.05 mg/ml) atropine sulfate soln prefill syr 1 mg/10ml 2 (0.1 mg/ml) CORLANOR TAB 5MG 4 PA; QL CORLANOR TAB 7.5MG 4 PA; QL hydralazine hcl inj 20 mg/ml 2 hydralazine hcl tab 10 mg 2 hydralazine hcl tab 25 mg 2 hydralazine hcl tab 50 mg 2 hydralazine hcl tab 100 mg 2 isoxsuprine hcl tab 10 mg 2 isoxsuprine hcl tab 20 mg 2 methyldopa & hydrochlorothiazide tab 250- 2 15 mg methyldopa & hydrochlorothiazide tab 250- 2 25 mg methyldopa tab 250 mg 2 methyldopa tab 500 mg 2 methyldopate hcl inj 250 mg/5ml 2 midodrine hcl tab 2.5 mg 2 midodrine hcl tab 5 mg 2 midodrine hcl tab 10 mg 2 minoxidil tab 2.5 mg 2 minoxidil tab 10 mg 2 NORTHERA CAP 100MG 5 PA; QL NORTHERA CAP 200MG 5 PA; QL NORTHERA CAP 300MG 5 PA; QL papaverine hcl inj 30 mg/ml 2 reserpine tab 0.1 mg 2 reserpine tab 0.25 mg 2 NEPRILYSIN INHIBITOR / ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS ENTRESTO TAB 24-26MG 3 PA; QL ENTRESTO TAB 49-51MG 3 PA; QL ENTRESTO TAB 97-103MG 3 PA; QL NITRATES, INJECTABLE NITROGLYCER INJ 5MG/ML 2 nitroglycerin iv soln 100 mcg/ml in d5w 2 nitroglycerin iv soln 200 mcg/ml in d5w 2

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 48 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits nitroglycerin iv soln 400 mcg/ml in d5w 2 NITRATES, ORAL isosorbide dinitrate tab 5 mg 2 isosorbide dinitrate tab 10 mg 2 isosorbide dinitrate tab 20 mg 2 isosorbide dinitrate tab 30 mg 2 isosorbide dinitrate tab er 40 mg 2 isosorbide mononitrate tab 10 mg 2 isosorbide mononitrate tab 20 mg 2 isosorbide mononitrate tab er 24hr 30 mg 2 isosorbide mononitrate tab er 24hr 60 mg 2 isosorbide mononitrate tab er 24hr 120 mg 2 nitroglycerin cap er 2.5 mg 2 nitroglycerin cap er 6.5 mg 2 nitroglycerin cap er 9 mg 2 NITRATES, SUBLINGUAL/TRANSLINGUAL nitroglycerin lingual aerosol 400 mcg/spray 2 nitroglycerin sl tab 0.3 mg 2 nitroglycerin sl tab 0.4 mg 2 nitroglycerin sl tab 0.6 mg 2 nitroglycerin tl soln 0.4 mg/spray (400 2 mcg/spray) NITRATES, TRANSDERMAL NITRO-BID OIN 2% 2 NITRO-DUR DIS 0.3MG/HR 4 NITRO-DUR DIS 0.8MG/HR 4 nitroglycerin td patch 24hr 0.1 mg/hr 2 nitroglycerin td patch 24hr 0.2 mg/hr 2 nitroglycerin td patch 24hr 0.4 mg/hr 2 nitroglycerin td patch 24hr 0.6 mg/hr 2 PULMONARY ARTERIAL HYPERTENSION, ENDOTHELIN RECEPTOR ANTAGONIST BOSENTAN TAB 62.5 MG 5 PA; QL BOSENTAN TAB 125 MG 5 PA; QL OPSUMIT TAB 10MG 5 PA; QL PULMONARY ARTERIAL HYPERTENSION, PHOSPHODIESTERASE INHIBITOR sildenafil citrate tab 20 mg 5 PA; QL PULMONARY ARTERIAL HYPERTENSION, PROSTAGLANDIN VASODILATORS epoprostenol sodium for inj 0.5 mg 5 PA epoprostenol sodium for inj 1.5 mg 5 PA ORENITRAM TAB 0.25MG 5 PA ORENITRAM TAB 0.125MG 5 PA

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 49 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits ORENITRAM TAB 1MG 5 PA ORENITRAM TAB 2.5MG 5 PA ORENITRAM TAB 5MG 5 PA VENTAVIS SOL 10MCG/ML 5 PA VENTAVIS SOL 20MCG/ML 5 PA PULMONARY ARTERIAL HYPERTENSION, SOLUBLE GUANYLATE CYCLASE STIMULATORS ADEMPAS TAB 0.5MG 5 PA; QL ADEMPAS TAB 1.5MG 5 PA; QL ADEMPAS TAB 1MG 5 PA; QL ADEMPAS TAB 2.5MG 5 PA; QL ADEMPAS TAB 2MG 5 PA; QL CARDIOVASCULAR AGENTS - MISC. IMPOTENCE AGENTS tadalafil tab 2.5 mg 4 PA, QL (1 tab per day) tadalafil tab 5 mg 4 PA, QL (1 tab per day) PROSTAGLANDIN VASODILATORS treprostinil inj soln 20 mg/20ml (1 mg/ml) 5 PA treprostinil inj soln 50 mg/20ml (2.5 5 PA mg/ml) treprostinil inj soln 100 mg/20ml (5 5 PA mg/ml) treprostinil inj soln 200 mg/20ml (10 5 PA mg/ml) PULMONARY HYPERTENSION - ENDOTHELIN RECEPTOR ANTAGONISTS ambrisentan tab 5 mg 5 PA; QL ambrisentan tab 10 mg 5 PA; QL PULMONARY HYPERTENSION - PROSTACYCLIN RECEPTOR AGONIST UPTRAVI TAB 200/800 5 PA; QL UPTRAVI TAB 200MCG 5 PA; QL UPTRAVI TAB 400MCG 5 PA; QL UPTRAVI TAB 600MCG 5 PA; QL UPTRAVI TAB 800MCG 5 PA; QL UPTRAVI TAB 1000MCG 5 PA; QL UPTRAVI TAB 1200MCG 5 PA; QL UPTRAVI TAB 1400MCG 5 PA; QL UPTRAVI TAB 1600MCG 5 PA; QL TRANSTHYRETIN STABILIZERS VYNDAMAX CAP 61MG 5 PA; QL VYNDAQEL CAP 20MG 5 PA; QL CENTRAL NERVOUS SYSTEM ANTIANXIETY, BENZODIAZEPINES ALPRAZOLAM CON 1 MG/ML 2

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 50 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits alprazolam orally disintegrating tab 0.5 mg 2 ST alprazolam orally disintegrating tab 0.25 2 ST mg alprazolam orally disintegrating tab 1 mg 2 ST alprazolam orally disintegrating tab 2 mg 2 ST alprazolam tab 0.5 mg 2 alprazolam tab 0.25 mg 2 alprazolam tab 1 mg 2 alprazolam tab 2 mg 2 alprazolam tab er 24hr 0.5 mg 2 alprazolam tab er 24hr 1 mg 2 alprazolam tab er 24hr 2 mg 2 alprazolam tab er 24hr 3 mg 2 chlordiazepoxide hcl cap 5 mg 2 chlordiazepoxide hcl cap 10 mg 2 chlordiazepoxide hcl cap 25 mg 2 clonazepam orally disintegrating tab 0.5 2 mg clonazepam orally disintegrating tab 0.25 2 mg clonazepam orally disintegrating tab 0.125 2 mg clonazepam orally disintegrating tab 1 mg 2 clonazepam orally disintegrating tab 2 mg 2 clonazepam tab 0.5 mg 2 clonazepam tab 1 mg 2 clonazepam tab 2 mg 2 clorazepate dipotassium tab 3.75 mg 2 clorazepate dipotassium tab 7.5 mg 2 clorazepate dipotassium tab 15 mg 2 diazepam conc 5 mg/ml 2 diazepam inj 5 mg/ml 2 DIAZEPAM INJ 10MG/2ML 2 diazepam oral soln 1 mg/ml 2 diazepam tab 2 mg 2 diazepam tab 5 mg 2 diazepam tab 10 mg 2 lorazepam conc 2 mg/ml 2 lorazepam inj 2 mg/ml 2 lorazepam inj 4 mg/ml 2 lorazepam tab 0.5 mg 2 lorazepam tab 1 mg 2 lorazepam tab 2 mg 2 oxazepam cap 10 mg 2 oxazepam cap 15 mg 2

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 51 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits oxazepam cap 30 mg 2 ANTIANXIETY, MISCELLANEOUS buspirone hcl tab 5 mg 2 buspirone hcl tab 7.5 mg 2 buspirone hcl tab 10 mg 2 buspirone hcl tab 15 mg 2 buspirone hcl tab 30 mg 2 clomipramine hcl cap 25 mg 4 ST clomipramine hcl cap 50 mg 4 ST clomipramine hcl cap 75 mg 4 ST fluvoxamine maleate tab 25 mg 2 fluvoxamine maleate tab 50 mg 2 fluvoxamine maleate tab 100 mg 2 meprobamate tab 200 mg 2 meprobamate tab 400 mg 2 ANTICONVULSANTS APTIOM TAB 200MG 4 PA; QL APTIOM TAB 400MG 4 PA; QL APTIOM TAB 600MG 4 PA; QL APTIOM TAB 800MG 4 PA; QL BANZEL SUS 40MG/ML 4 PA BANZEL TAB 200MG 4 PA BANZEL TAB 400MG 4 PA carbamazepine cap er 12hr 100 mg 2 carbamazepine cap er 12hr 200 mg 2 carbamazepine cap er 12hr 300 mg 2 carbamazepine chew tab 100 mg 2 carbamazepine susp 100 mg/5ml 2 carbamazepine tab 200 mg 2 carbamazepine tab er 12hr 200 mg 2 carbamazepine tab er 12hr 400 mg 2 CELONTIN CAP 300MG 3 clobazam suspension 2.5 mg/ml 4 PA; QL clobazam tab 10 mg 4 PA; QL clobazam tab 20 mg 4 PA; QL diazepam rectal gel delivery system 2.5 2 mg diazepam rectal gel delivery system 10 mg 2 diazepam rectal gel delivery system 20 mg 2 QL DILANTIN CAP 30MG 3 divalproex sodium cap delayed release 2 sprinkle 125 mg divalproex sodium tab delayed release 125 2 mg

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 52 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits divalproex sodium tab delayed release 250 2 mg divalproex sodium tab delayed release 500 2 mg divalproex sodium tab er 24 hr 250 mg 2 divalproex sodium tab er 24 hr 500 mg 2 ethosuximide cap 250 mg 2 ethosuximide soln 250 mg/5ml 2 felbamate susp 600 mg/5ml 2 felbamate tab 400 mg 2 felbamate tab 600 mg 2 fosphenytoin sodium inj 100 mg/2ml 2 (phenytoin equiv) fosphenytoin sodium inj 500 mg/10ml 2 (phenytoin equiv) FYCOMPA SUS 0.5MG/ML 4 QL FYCOMPA TAB 2MG 4 PA; QL FYCOMPA TAB 4MG 4 PA; QL FYCOMPA TAB 6MG 4 PA; QL FYCOMPA TAB 8MG 4 PA; QL FYCOMPA TAB 10MG 4 PA; QL FYCOMPA TAB 12MG 4 PA; QL gabapentin cap 100 mg 2 gabapentin cap 300 mg 2 gabapentin cap 400 mg 2 gabapentin oral soln 250 mg/5ml 2 gabapentin tab 600 mg 2 gabapentin tab 800 mg 2 lamotrigine tab 25 mg 2 lamotrigine tab 100 mg 2 lamotrigine tab 150 mg 2 lamotrigine tab 200 mg 2 lamotrigine tab chewable dispersible 5 mg 2 lamotrigine tab chewable dispersible 25 mg 2 levetiracetam inj 500 mg/5ml (100 mg/ml) 2 levetiracetam oral soln 100 mg/ml 2 levetiracetam tab 250 mg 2 levetiracetam tab 500 mg 2 levetiracetam tab 750 mg 2 levetiracetam tab 1000 mg 2 levetiracetam tab er 24hr 500 mg 2 QL levetiracetam tab er 24hr 750 mg 2 QL oxcarbazepine susp 300 mg/5ml (60 2 mg/ml) oxcarbazepine tab 150 mg 2

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 53 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits oxcarbazepine tab 300 mg 2 oxcarbazepine tab 600 mg 2 PEGANONE TAB 250MG 4 PA phenobarbital elixir 20 mg/5ml 2 phenobarbital tab 15 mg 2 phenobarbital tab 16.2 mg 2 phenobarbital tab 30 mg 2 phenobarbital tab 32.4 mg 2 phenobarbital tab 60 mg 2 phenobarbital tab 64.8 mg 2 phenobarbital tab 97.2 mg 2 phenobarbital tab 100 mg 2 phenytoin chew tab 50 mg 2 phenytoin sodium extended cap 100 mg 2 phenytoin sodium extended cap 200 mg 2 phenytoin sodium extended cap 300 mg 2 phenytoin sodium inj 50 mg/ml 2 phenytoin susp 125 mg/5ml 2 POTIGA TAB 50MG 4 PA; QL POTIGA TAB 200MG 4 PA; QL POTIGA TAB 300MG 4 PA; QL POTIGA TAB 400MG 4 PA; QL primidone tab 50 mg 2 primidone tab 250 mg 2 tiagabine hcl tab 2 mg 2 tiagabine hcl tab 4 mg 2 tiagabine hcl tab 12 mg 2 tiagabine hcl tab 16 mg 2 topiramate cap er 24hr sprinkle 25 mg 2 topiramate cap er 24hr sprinkle 50 mg 2 topiramate cap er 24hr sprinkle 100 mg 2 topiramate cap er 24hr sprinkle 150 mg 2 topiramate cap er 24hr sprinkle 200 mg 2 topiramate sprinkle cap 15 mg 2 QL topiramate sprinkle cap 25 mg 2 QL topiramate tab 25 mg 2 topiramate tab 25 mg 2 QL topiramate tab 50 mg 2 topiramate tab 100 mg 2 topiramate tab 200 mg 2 valproate sodium inj 100 mg/ml 2 valproate sodium oral soln 250 mg/5ml 2 (base equiv) valproic acid cap 250 mg 2 vigabatrin powd pack 500 mg 5 PA; QL

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 54 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits VIMPAT INJ 200MG/20 4 PA VIMPAT SOL 10MG/ML 4 PA VIMPAT TAB 50MG 4 PA VIMPAT TAB 100MG 4 PA VIMPAT TAB 150MG 4 PA VIMPAT TAB 200MG 4 PA zonisamide cap 25 mg 2 zonisamide cap 50 mg 2 zonisamide cap 100 mg 2 ANTIDEMENTIA donepezil hydrochloride orally 2 disintegrating tab 5 mg donepezil hydrochloride orally 2 disintegrating tab 10 mg donepezil hydrochloride tab 5 mg 2 donepezil hydrochloride tab 10 mg 2 galantamine hydrobromide cap er 24hr 8 2 mg galantamine hydrobromide cap er 24hr 16 2 mg galantamine hydrobromide cap er 24hr 24 2 mg galantamine hydrobromide oral soln 4 2 mg/ml galantamine hydrobromide tab 4 mg 2 galantamine hydrobromide tab 8 mg 2 galantamine hydrobromide tab 12 mg 2 memantine hcl oral solution 2 mg/ml 2 memantine hcl tab 5 mg 2 memantine hcl tab 10 mg 2 memantine hcl tab 28 x 5 mg & 21 x 10 2 mg titration pack rivastigmine tartrate cap 1.5 mg (base 2 equivalent) rivastigmine tartrate cap 3 mg (base 2 equivalent) rivastigmine tartrate cap 4.5 mg (base 2 equivalent) rivastigmine tartrate cap 6 mg (base 2 equivalent) rivastigmine td patch 24hr 4.6 mg/24hr 2 rivastigmine td patch 24hr 9.5 mg/24hr 2 rivastigmine td patch 24hr 13.3 mg/24hr 2 ANTIDEPRESSANTS, MAOIS EMSAM DIS 6MG/24HR 4 PA; QL EMSAM DIS 9MG/24HR 4 PA; QL

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 55 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits EMSAM DIS 12MG/24H 4 PA; QL MARPLAN TAB 10MG 4 phenelzine sulfate tab 15 mg 2 tranylcypromine sulfate tab 10 mg 2 ANTIDEPRESSANTS, MISCELLANEOUS bupropion hcl tab 75 mg 2 bupropion hcl tab 100 mg 2 bupropion hcl tab er 12hr 100 mg 2 bupropion hcl tab er 12hr 150 mg 2 bupropion hcl tab er 12hr 200 mg 2 bupropion hcl tab er 24hr 150 mg 2 QL bupropion hcl tab er 24hr 300 mg 2 QL chlordiazepoxide-amitriptyline tab 5-12.5 2 mg chlordiazepoxide-amitriptyline tab 10-25 2 mg maprotiline hcl tab 25 mg 2 maprotiline hcl tab 50 mg 2 maprotiline hcl tab 75 mg 2 mirtazapine orally disintegrating tab 15 mg 2 mirtazapine orally disintegrating tab 30 mg 2 mirtazapine orally disintegrating tab 45 mg 2 mirtazapine tab 7.5 mg 2 mirtazapine tab 15 mg 2 mirtazapine tab 30 mg 2 mirtazapine tab 45 mg 2 nefazodone hcl tab 50 mg 4 nefazodone hcl tab 100 mg 4 nefazodone hcl tab 150 mg 4 nefazodone hcl tab 200 mg 4 nefazodone hcl tab 250 mg 4 trazodone hcl tab 50 mg 2 trazodone hcl tab 100 mg 2 trazodone hcl tab 150 mg 2 trazodone hcl tab 300 mg 2 ANTIDEPRESSANTS, SNRIS DESVENLAFAX TAB 50MG ER 4 ST; QL DESVENLAFAX TAB 100MG ER 4 ST; QL desvenlafaxine succinate tab er 24hr 25 4 ST; QL mg (base equiv) desvenlafaxine succinate tab er 24hr 50 4 ST; QL mg (base equiv) desvenlafaxine succinate tab er 24hr 100 4 ST; QL mg (base equiv)

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 56 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits duloxetine hcl enteric coated pellets cap 20 2 QL mg (base eq) duloxetine hcl enteric coated pellets cap 30 2 QL mg (base eq) duloxetine hcl enteric coated pellets cap 60 2 QL mg (base eq) FETZIMA CAP 20MG 4 PA; QL FETZIMA CAP 40MG 4 PA; QL FETZIMA CAP 80MG 4 PA; QL FETZIMA CAP 120MG 4 PA; QL FETZIMA CAP TITRATIO 4 PA; QL venlafaxine hcl cap er 24hr 37.5 mg (base 2 QL equivalent) venlafaxine hcl cap er 24hr 75 mg (base 2 QL equivalent) venlafaxine hcl cap er 24hr 150 mg (base 2 QL equivalent) venlafaxine hcl tab 25 mg (base 2 equivalent) venlafaxine hcl tab 37.5 mg (base 2 equivalent) venlafaxine hcl tab 50 mg (base 2 equivalent) venlafaxine hcl tab 75 mg (base 2 equivalent) venlafaxine hcl tab 100 mg (base 2 equivalent) ANTIDEPRESSANTS, SSRIS citalopram hydrobromide oral soln 10 2 mg/5ml citalopram hydrobromide tab 10 mg (base 1 QL equiv) citalopram hydrobromide tab 20 mg (base 1 QL equiv) citalopram hydrobromide tab 40 mg (base 1 QL equiv) escitalopram oxalate soln 5 mg/5ml (base 2 QL equiv) escitalopram oxalate tab 5 mg (base 2 QL equiv) escitalopram oxalate tab 10 mg (base 2 QL equiv) escitalopram oxalate tab 20 mg (base 2 QL equiv) fluoxetine hcl (pmdd) cap 10 mg 1 ST fluoxetine hcl (pmdd) cap 20 mg 1 ST fluoxetine hcl cap 10 mg 1

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 57 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits fluoxetine hcl cap 20 mg 1 fluoxetine hcl cap 40 mg 2 fluoxetine hcl solution 20 mg/5ml 2 fluoxetine hcl tab 10 mg 2 ST paroxetine hcl tab 10 mg 1 QL paroxetine hcl tab 20 mg 1 QL paroxetine hcl tab 30 mg 2 QL paroxetine hcl tab 40 mg 2 QL sertraline hcl oral concentrate for solution 2 20 mg/ml sertraline hcl tab 25 mg 1 sertraline hcl tab 50 mg 1 sertraline hcl tab 100 mg 1 TRINTELLIX TAB 5MG 4 PA; QL TRINTELLIX TAB 10MG 4 PA; QL TRINTELLIX TAB 20MG 4 PA; QL VIIBRYD KIT STARTER 4 PA; QL VIIBRYD TAB 10MG 4 PA; QL VIIBRYD TAB 20MG 4 PA; QL VIIBRYD TAB 40MG 4 PA; QL ANTIDEPRESSANTS, TCAS amitriptyline hcl tab 10 mg 2 amitriptyline hcl tab 25 mg 2 amitriptyline hcl tab 50 mg 2 amitriptyline hcl tab 75 mg 2 amitriptyline hcl tab 100 mg 2 amitriptyline hcl tab 150 mg 2 amoxapine tab 25 mg 2 amoxapine tab 50 mg 2 amoxapine tab 100 mg 2 amoxapine tab 150 mg 2 desipramine hcl tab 10 mg 2 desipramine hcl tab 25 mg 2 desipramine hcl tab 50 mg 2 desipramine hcl tab 75 mg 2 desipramine hcl tab 100 mg 2 desipramine hcl tab 150 mg 2 doxepin hcl cap 10 mg 2 doxepin hcl cap 25 mg 2 doxepin hcl cap 50 mg 2 doxepin hcl cap 75 mg 2 doxepin hcl cap 100 mg 2 doxepin hcl cap 150 mg 2 doxepin hcl conc 10 mg/ml 2 imipramine hcl tab 10 mg 2

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 58 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits imipramine hcl tab 25 mg 2 imipramine hcl tab 50 mg 2 nortriptyline hcl cap 10 mg 2 nortriptyline hcl cap 25 mg 2 nortriptyline hcl cap 50 mg 2 nortriptyline hcl cap 75 mg 2 nortriptyline hcl soln 10 mg/5ml 2 protriptyline hcl tab 5 mg 2 protriptyline hcl tab 10 mg 2 trimipramine maleate cap 25 mg 2 trimipramine maleate cap 50 mg 2 trimipramine maleate cap 100 mg 2 ANTIPARKINSONIAN AGENTS amantadine hcl cap 100 mg 2 amantadine hcl syrup 50 mg/5ml 2 amantadine hcl tab 100 mg 2 APOKYN INJ 10MG/ML 5 PA; QL benztropine mesylate inj 1 mg/ml 2 benztropine mesylate tab 0.5 mg 2 benztropine mesylate tab 1 mg 2 benztropine mesylate tab 2 mg 2 bromocriptine mesylate cap 5 mg (base 2 equivalent) bromocriptine mesylate tab 2.5 mg (base 2 equivalent) carbidopa & levodopa orally disintegrating 2 tab 10-100 mg carbidopa & levodopa orally disintegrating 2 tab 25-100 mg carbidopa & levodopa orally disintegrating 2 tab 25-250 mg carbidopa & levodopa tab 10-100 mg 2 carbidopa & levodopa tab 25-100 mg 2 carbidopa & levodopa tab 25-250 mg 2 carbidopa & levodopa tab er 25-100 mg 2 carbidopa & levodopa tab er 50-200 mg 2 carbidopa tab 25 mg 2 entacapone tab 200 mg 2 pramipexole dihydrochloride tab 0.5 mg 2 pramipexole dihydrochloride tab 0.25 mg 2 pramipexole dihydrochloride tab 0.75 mg 2 pramipexole dihydrochloride tab 0.125 mg 2 pramipexole dihydrochloride tab 1 mg 2 pramipexole dihydrochloride tab 1.5 mg 2 ropinirole hydrochloride tab 0.5 mg 2

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 59 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits ropinirole hydrochloride tab 0.25 mg 2 ropinirole hydrochloride tab 1 mg 2 ropinirole hydrochloride tab 2 mg 2 ropinirole hydrochloride tab 3 mg 2 ropinirole hydrochloride tab 4 mg 2 ropinirole hydrochloride tab 5 mg 2 ropinirole hydrochloride tab er 24hr 2 mg 2 ST (base equivalent) ropinirole hydrochloride tab er 24hr 4 mg 2 ST (base equivalent) ropinirole hydrochloride tab er 24hr 6 mg 2 ST (base equivalent) ropinirole hydrochloride tab er 24hr 8 mg 2 ST (base equivalent) ropinirole hydrochloride tab er 24hr 12 mg 2 ST (base equivalent) selegiline hcl cap 5 mg 2 selegiline hcl tab 5 mg 2 tolcapone tab 100 mg 2 ST trihexyphenidyl hcl oral soln 0.4 mg/ml 2 trihexyphenidyl hcl tab 2 mg 2 trihexyphenidyl hcl tab 5 mg 2 ANTIPSYCHOTICS, ATYPICALS ABILIFY MAIN INJ 300MG 5 PA; QL ABILIFY MAIN INJ 400MG 5 PA; QL aripiprazole oral solution 1 mg/ml 4 ST; QL aripiprazole orally disintegrating tab 10 mg 2 ST; QL aripiprazole orally disintegrating tab 15 mg 2 ST; QL aripiprazole tab 2 mg 2 ST; QL aripiprazole tab 5 mg 2 ST; QL aripiprazole tab 10 mg 2 ST; QL aripiprazole tab 15 mg 2 ST; QL aripiprazole tab 20 mg 2 ST; QL aripiprazole tab 30 mg 2 ST; QL clozapine orally disintegrating tab 12.5 mg 2 QL clozapine orally disintegrating tab 25 mg 2 QL clozapine orally disintegrating tab 100 mg 2 QL clozapine orally disintegrating tab 150 mg 4 QL clozapine orally disintegrating tab 200 mg 4 QL clozapine tab 25 mg 2 clozapine tab 50 mg 2 clozapine tab 100 mg 2 clozapine tab 200 mg 2 FANAPT TAB 1MG 4 PA; QL FANAPT TAB 2MG 4 PA; QL

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 60 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits FANAPT TAB 4MG 4 PA; QL FANAPT TAB 6MG 4 PA; QL FANAPT TAB 8MG 4 PA; QL FANAPT TAB 10MG 4 PA; QL FANAPT TAB 12MG 4 PA; QL GEODON INJ 20MG 4 PA INVEGA SUST INJ 39/0.25 5 PA; QL INVEGA SUST INJ 78/0.5ML 5 PA; QL INVEGA SUST INJ 117/0.75 5 PA; QL INVEGA SUST INJ 156MG/ML 5 PA; QL INVEGA SUST INJ 234/1.5 5 PA; QL INVEGA TRINZ INJ 273MG 5 PA; QL INVEGA TRINZ INJ 410MG 5 PA; QL INVEGA TRINZ INJ 546MG 5 PA; QL INVEGA TRINZ INJ 819MG 5 PA; QL LATUDA TAB 20MG 4 ST; QL LATUDA TAB 40MG 4 ST; QL LATUDA TAB 60MG 4 ST; QL LATUDA TAB 80MG 4 ST; QL LATUDA TAB 120MG 4 ST; QL loxapine succinate cap 5 mg 2 loxapine succinate cap 10 mg 2 loxapine succinate cap 25 mg 2 loxapine succinate cap 50 mg 2 NUPLAZID TAB 17MG 5 PA; QL olanzapine for im inj 10 mg 2 PA; QL olanzapine orally disintegrating tab 5 mg 2 QL olanzapine orally disintegrating tab 10 mg 2 QL olanzapine orally disintegrating tab 15 mg 2 QL olanzapine orally disintegrating tab 20 mg 2 QL olanzapine tab 2.5 mg 2 QL olanzapine tab 5 mg 2 QL olanzapine tab 7.5 mg 2 QL olanzapine tab 10 mg 2 QL olanzapine tab 15 mg 2 QL olanzapine tab 20 mg 2 QL paliperidone tab er 24hr 1.5 mg 4 QL paliperidone tab er 24hr 3 mg 4 QL paliperidone tab er 24hr 6 mg 4 QL paliperidone tab er 24hr 9 mg 4 QL quetiapine fumarate tab 25 mg 2 QL quetiapine fumarate tab 50 mg 2 QL quetiapine fumarate tab 100 mg 2 QL quetiapine fumarate tab 200 mg 2 QL quetiapine fumarate tab 300 mg 2 QL

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 61 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits quetiapine fumarate tab 400 mg 2 QL REXULTI TAB 0.5MG 4 ST; QL REXULTI TAB 0.25MG 4 ST; QL REXULTI TAB 1MG 4 ST; QL REXULTI TAB 2MG 4 ST; QL REXULTI TAB 3MG 4 ST; QL REXULTI TAB 4MG 4 ST; QL RISPERDAL INJ 12.5MG 5 PA; QL RISPERDAL INJ 25MG 5 PA; QL RISPERDAL INJ 37.5MG 5 PA; QL RISPERDAL INJ 50MG 5 PA; QL risperidone orally disintegrating tab 0.5 mg 2 QL risperidone orally disintegrating tab 0.25 2 QL mg risperidone orally disintegrating tab 1 mg 2 QL risperidone orally disintegrating tab 2 mg 2 QL risperidone orally disintegrating tab 3 mg 2 QL risperidone orally disintegrating tab 4 mg 2 QL risperidone soln 1 mg/ml 2 QL risperidone tab 0.5 mg 2 QL risperidone tab 0.25 mg 2 QL risperidone tab 1 mg 2 QL risperidone tab 2 mg 2 QL risperidone tab 3 mg 2 QL risperidone tab 4 mg 2 QL SAPHRIS SUB 2.5MG 4 ST; QL SAPHRIS SUB 5MG 4 ST; QL ziprasidone hcl cap 20 mg 2 QL ziprasidone hcl cap 40 mg 2 QL ziprasidone hcl cap 60 mg 2 QL ziprasidone hcl cap 80 mg 2 QL ZYPREXA RELP INJ 210MG 5 PA; QL ZYPREXA RELP INJ 300MG 5 PA; QL ZYPREXA RELP INJ 405MG 5 PA; QL ANTIPSYCHOTICS, MISCELLANEOUS CHLORPROMAZINE HCL INJ 25 MG/ML 2 chlorpromazine hcl tab 10 mg 2 chlorpromazine hcl tab 25 mg 2 chlorpromazine hcl tab 50 mg 2 chlorpromazine hcl tab 100 mg 2 chlorpromazine hcl tab 200 mg 2 fluphenazine decanoate inj 25 mg/ml 2 fluphenazine hcl elixir 2.5 mg/5ml 2 fluphenazine hcl inj 2.5 mg/ml 2 fluphenazine hcl oral conc 5 mg/ml 2

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 62 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits fluphenazine hcl tab 1 mg 2 fluphenazine hcl tab 2.5 mg 2 fluphenazine hcl tab 5 mg 2 fluphenazine hcl tab 10 mg 2 haloperidol decanoate im soln 50 mg/ml 5 haloperidol decanoate im soln 100 mg/ml 5 haloperidol lactate inj 5 mg/ml 2 haloperidol lactate oral conc 2 mg/ml 2 haloperidol tab 0.5 mg 2 haloperidol tab 1 mg 2 haloperidol tab 2 mg 2 haloperidol tab 5 mg 2 haloperidol tab 10 mg 2 haloperidol tab 20 mg 2 olanzapine-fluoxetine hcl cap 3-25 mg 4 PA; QL olanzapine-fluoxetine hcl cap 6-25 mg 4 PA; QL olanzapine-fluoxetine hcl cap 6-50 mg 4 PA; QL olanzapine-fluoxetine hcl cap 12-25 mg 4 PA; QL olanzapine-fluoxetine hcl cap 12-50 mg 4 PA; QL perphenazine tab 2 mg 2 perphenazine tab 4 mg 2 perphenazine tab 8 mg 2 perphenazine tab 16 mg 2 perphenazine-amitriptyline tab 2-10 mg 2 perphenazine-amitriptyline tab 2-25 mg 2 perphenazine-amitriptyline tab 4-10 mg 2 perphenazine-amitriptyline tab 4-25 mg 2 perphenazine-amitriptyline tab 4-50 mg 2 pimozide tab 1 mg 2 pimozide tab 2 mg 2 thioridazine hcl tab 10 mg 2 thioridazine hcl tab 25 mg 2 thioridazine hcl tab 50 mg 2 thioridazine hcl tab 100 mg 2 thiothixene cap 1 mg 2 thiothixene cap 2 mg 2 thiothixene cap 5 mg 2 thiothixene cap 10 mg 2 trifluoperazine hcl tab 1 mg (base 2 equivalent) trifluoperazine hcl tab 2 mg (base 2 equivalent) trifluoperazine hcl tab 5 mg (base 2 equivalent)

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 63 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits trifluoperazine hcl tab 10 mg (base 2 equivalent) ATTENTION DEFICIT HYPERACTIVITY DISORDER amphetamine-dextroamphetamine cap er 2 QL 24hr 5 mg amphetamine-dextroamphetamine cap er 2 QL 24hr 10 mg amphetamine-dextroamphetamine cap er 2 QL 24hr 15 mg amphetamine-dextroamphetamine cap er 2 QL 24hr 20 mg amphetamine-dextroamphetamine cap er 2 QL 24hr 25 mg amphetamine-dextroamphetamine cap er 2 QL 24hr 30 mg amphetamine-dextroamphetamine tab 5 2 QL mg amphetamine-dextroamphetamine tab 7.5 2 QL mg amphetamine-dextroamphetamine tab 10 2 QL mg amphetamine-dextroamphetamine tab 2 QL 12.5 mg amphetamine-dextroamphetamine tab 15 2 QL mg amphetamine-dextroamphetamine tab 20 2 QL mg amphetamine-dextroamphetamine tab 30 2 QL mg atomoxetine hcl cap 10 mg (base equiv) 2 QL atomoxetine hcl cap 18 mg (base equiv) 2 QL atomoxetine hcl cap 25 mg (base equiv) 2 QL atomoxetine hcl cap 40 mg (base equiv) 2 QL atomoxetine hcl cap 60 mg (base equiv) 2 QL atomoxetine hcl cap 80 mg (base equiv) 2 QL atomoxetine hcl cap 100 mg (base equiv) 2 QL clonidine hcl tab er 12hr 0.1 mg 2 QL dexmethylphenidate hcl cap er 24 hr 5 mg 4 QL dexmethylphenidate hcl cap er 24 hr 10 4 QL mg dexmethylphenidate hcl cap er 24 hr 15 4 QL mg dexmethylphenidate hcl cap er 24 hr 20 4 QL mg dexmethylphenidate hcl cap er 24 hr 30 4 QL mg

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 64 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits dexmethylphenidate hcl cap er 24 hr 40 4 QL mg dexmethylphenidate hcl tab 2.5 mg 2 QL dexmethylphenidate hcl tab 5 mg 2 QL dexmethylphenidate hcl tab 10 mg 2 QL dextroamphetamine sulfate cap er 24hr 5 4 QL mg dextroamphetamine sulfate cap er 24hr 10 4 QL mg dextroamphetamine sulfate cap er 24hr 15 4 QL mg dextroamphetamine sulfate tab 5 mg 2 dextroamphetamine sulfate tab 5 mg 2 QL dextroamphetamine sulfate tab 10 mg 2 QL guanfacine hcl tab er 24hr 1 mg (base 2 QL equiv) guanfacine hcl tab er 24hr 2 mg (base 2 QL equiv) guanfacine hcl tab er 24hr 3 mg (base 2 QL equiv) guanfacine hcl tab er 24hr 4 mg (base 2 QL equiv) methylphenidate hcl cap er 10 mg (cd) 2 QL methylphenidate hcl cap er 20 mg (cd) 2 QL methylphenidate hcl cap er 24hr 20 mg 2 QL (la) methylphenidate hcl cap er 24hr 30 mg 2 QL (la) methylphenidate hcl cap er 24hr 40 mg 2 QL (la) methylphenidate hcl cap er 30 mg (cd) 2 QL methylphenidate hcl cap er 40 mg (cd) 2 QL methylphenidate hcl cap er 50 mg (cd) 2 QL methylphenidate hcl cap er 60 mg (cd) 2 QL methylphenidate hcl chew tab 2.5 mg 2 QL methylphenidate hcl chew tab 5 mg 2 QL methylphenidate hcl chew tab 10 mg 2 QL methylphenidate hcl soln 5 mg/5ml 4 QL methylphenidate hcl soln 10 mg/5ml 4 QL methylphenidate hcl tab 5 mg 2 QL methylphenidate hcl tab 10 mg 2 QL methylphenidate hcl tab 20 mg 2 QL methylphenidate hcl tab er 10 mg 4 QL methylphenidate hcl tab er 20 mg 2 methylphenidate hcl tab er 20 mg 2 QL methylphenidate hcl tab er 24hr 27 mg 4 QL

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 65 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits methylphenidate hcl tab er 24hr 36 mg 4 QL methylphenidate hcl tab er 24hr 54 mg 4 QL methylphenidate hcl tab er osmotic release 4 QL (osm) 18 mg methylphenidate hcl tab er osmotic release 4 QL (osm) 27 mg methylphenidate hcl tab er osmotic release 4 QL (osm) 36 mg methylphenidate hcl tab er osmotic release 4 QL (osm) 54 mg VYVANSE CAP 10MG 4 PA; QL VYVANSE CAP 20MG 4 PA; QL VYVANSE CAP 30MG 4 PA; QL VYVANSE CAP 40MG 4 PA; QL VYVANSE CAP 50MG 4 PA; QL VYVANSE CAP 60MG 4 PA; QL VYVANSE CAP 70MG 4 PA; QL FIBROMYALGIA pregabalin cap 25 mg 2 PA; QL pregabalin cap 50 mg 2 PA; QL pregabalin cap 75 mg 2 PA; QL pregabalin cap 100 mg 2 PA; QL pregabalin cap 150 mg 2 PA; QL pregabalin cap 200 mg 2 PA; QL pregabalin cap 225 mg 2 PA; QL pregabalin cap 300 mg 2 PA; QL pregabalin soln 20 mg/ml 2 PA; QL SAVELLA MIS TITR PAK 4 PA; QL SAVELLA TAB 12.5MG 4 PA; QL SAVELLA TAB 25MG 4 PA; QL SAVELLA TAB 50MG 4 PA; QL SAVELLA TAB 100MG 4 PA; QL HUNTINGTON'S DISEASE AGENTS tetrabenazine tab 12.5 mg 5 PA; QL tetrabenazine tab 25 mg 5 PA; QL HYPNOTICS, BENZODIAZEPINES estazolam tab 1 mg 2 estazolam tab 2 mg 2 flurazepam hcl cap 15 mg 2 flurazepam hcl cap 30 mg 2 midazolam hcl syrup 2 mg/ml (base 2 equivalent) temazepam cap 15 mg 2 temazepam cap 30 mg 2 triazolam tab 0.25 mg 2

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 66 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits triazolam tab 0.125 mg 2 HYPNOTICS, NON-BENZODIAZEPINES eszopiclone tab 1 mg 2 QL eszopiclone tab 2 mg 2 QL eszopiclone tab 3 mg 2 QL HETLIOZ CAP 20MG 5 PA; QL ROZEREM TAB 8MG 4 PA; QL zaleplon cap 5 mg 2 QL zaleplon cap 10 mg 2 QL zolpidem tartrate tab 5 mg 2 QL zolpidem tartrate tab 10 mg 2 QL MIGRAINE, ERGOTAMINE DERIVATIVES dihydroergotamine mesylate nasal spray 4 4 PA mg/ml ERGOMAR SUB 2MG 4 PA; QL MIGRAINE, MISCELLANEOUS isometheptene-dichloral-acetaminophen 2 cap 65-100-325 mg MIGRAINE, SELECTIVE SEROTONIN AGONISTS almotriptan malate tab 6.25 mg 4 ST; QL almotriptan malate tab 12.5 mg 4 ST; QL naratriptan hcl tab 1 mg (base equiv) 4 QL naratriptan hcl tab 2.5 mg (base equiv) 4 QL rizatriptan benzoate oral disintegrating tab 4 QL 5 mg (base eq) rizatriptan benzoate oral disintegrating tab 2 QL 10 mg (base eq) rizatriptan benzoate tab 5 mg (base 4 QL equivalent) rizatriptan benzoate tab 10 mg (base 4 QL equivalent) sumatriptan nasal spray 5 mg/act 4 QL sumatriptan nasal spray 20 mg/act 4 QL sumatriptan succinate inj 6 mg/0.5ml 3 QL sumatriptan succinate solution auto- 4 QL injector 4 mg/0.5ml sumatriptan succinate solution auto- 4 QL injector 6 mg/0.5ml sumatriptan succinate solution cartridge 4 4 QL mg/0.5ml sumatriptan succinate solution cartridge 6 4 QL mg/0.5ml sumatriptan succinate solution prefilled 3 QL syringe 6 mg/0.5ml sumatriptan succinate tab 25 mg 2 QL

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 67 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits sumatriptan succinate tab 50 mg 2 QL sumatriptan succinate tab 100 mg 2 QL zolmitriptan orally disintegrating tab 2.5 4 QL mg zolmitriptan orally disintegrating tab 5 mg 4 QL zolmitriptan tab 2.5 mg 4 QL zolmitriptan tab 5 mg 4 QL ZOMIG SPR 2.5MG 4 QL ZOMIG SPR 5MG 4 QL MISCELLANEOUS BOTOX INJ 100UNIT 5 PA; QL BOTOX INJ 200UNIT 5 PA; QL DYSPORT INJ 500UNIT 5 PA; QL ergoloid mesylates tab 1 mg 2 GUANIDINE TAB 125MG 2 MYOBLOC INJ 2500/0.5 5 PA; QL MYOBLOC INJ 5000/ML 5 PA; QL MYOBLOC INJ 10000/2 5 PA; QL REGONOL INJ 5MG/ML 2 riluzole tab 50 mg 5 PA; QL XEOMIN INJ 50 UNIT 5 PA; QL XEOMIN INJ 100UNIT 5 PA; QL MOOD STABILIZERS lithium carbonate cap 150 mg 1 lithium carbonate cap 300 mg 1 lithium carbonate cap 600 mg 2 lithium carbonate tab 300 mg 2 lithium carbonate tab er 300 mg 2 lithium carbonate tab er 450 mg 2 LITHIUM SOL 8MEQ/5ML 2 MULTIPLE SCLEROSIS AUBAGIO TAB 7MG 5 PA; QL AUBAGIO TAB 14MG 5 PA; QL BETASERON INJ 0.3MG 5 PA; QL COPAXONE INJ 20MG/ML 5 PA; QL COPAXONE INJ 40MG/ML 5 PA; QL dalfampridine tab er 12hr 10 mg 5 PA; QL dimethyl fumarate capsule delayed release 5 PA, QL (60 caps / 30 120 mg days) dimethyl fumarate capsule delayed release 5 PA, QL (60 caps / 30 240 mg days) dimethyl fumarate capsule dr starter pack 5 PA, QL (1 kit in lifetime) 120 mg & 240 mg GILENYA CAP 0.5MG 5 PA; QL LEMTRADA INJ 12/1.2ML 5 PA

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 68 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits REBIF INJ 22/0.5 5 PA; QL REBIF INJ 44/0.5 5 PA; QL REBIF REBIDO INJ 22/0.5 5 PA; QL REBIF REBIDO INJ 44/0.5 5 PA; QL REBIF REBIDO INJ TITRATN 5 PA; QL REBIF TITRTN INJ PACK 5 PA; QL TYSABRI INJ 300/15ML 5 PA; QL MUSCULOSKELETAL THERAPY AGENTS baclofen tab 10 mg 2 baclofen tab 20 mg 2 carisoprodol tab 350 mg 2 QL carisoprodol w/ aspirin tab 200-325 mg 4 chlorzoxazone tab 500 mg 2 cyclobenzaprine hcl tab 5 mg 2 cyclobenzaprine hcl tab 10 mg 2 dantrolene sodium cap 25 mg 2 dantrolene sodium cap 50 mg 2 dantrolene sodium cap 100 mg 2 metaxalone tab 800 mg 4 PA; QL methocarbamol tab 500 mg 2 methocarbamol tab 750 mg 2 orphenadrine citrate inj 30 mg/ml 2 orphenadrine citrate tab er 12hr 100 mg 2 tizanidine hcl cap 2 mg (base equivalent) 2 ST tizanidine hcl cap 4 mg (base equivalent) 2 ST tizanidine hcl cap 6 mg (base equivalent) 2 ST tizanidine hcl tab 2 mg (base equivalent) 2 tizanidine hcl tab 4 mg (base equivalent) 2 MYASTHENIA GRAVIS pyridostigmine bromide tab 60 mg 2 NARCOLEPSY/CATAPLEXY modafinil tab 100 mg 4 PA; QL modafinil tab 200 mg 4 PA; QL XYREM SOL 500MG/ML 5 PA; QL POSTHERPETIC NEURALGIA GRALISE STAR MIS 300/600 4 PA; QL GRALISE TAB 300MG 4 PA; QL GRALISE TAB 600MG 4 PA; QL PSYCHOTHERAPEUTIC-MISC, ALCOHOL DETERRENTS acamprosate calcium tab delayed release 2 333 mg CAMPRAL TAB 333MG 2 disulfiram tab 250 mg 2 disulfiram tab 500 mg 2

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 69 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits VIVITROL INJ 380MG 5 PSYCHOTHERAPEUTIC-MISC, OPIOID ANTAGONIST EVZIO INJ 5 PA; QL naloxone hcl inj 0.4 mg/ml 2 naloxone hcl soln prefilled syringe 2 2 mg/2ml naltrexone hcl tab 50 mg 2 NARCAN SPR 4 QL PSYCHOTHERAPEUTIC-MISC, PARTIAL OPIOID AGONIST/OPIOID ANTAGONIST COMBINATIONS BUNAVAIL MIS 2.1-0.3 4 PA; QL BUNAVAIL MIS 4.2-0.7 4 PA; QL BUNAVAIL MIS 6.3-1MG 4 PA; QL buprenorphine hcl-naloxone hcl sl film 2- 2 PA; QL 0.5 mg (base equiv) buprenorphine hcl-naloxone hcl sl film 4-1 2 PA; QL mg (base equiv) buprenorphine hcl-naloxone hcl sl film 8-2 2 PA; QL mg (base equiv) buprenorphine hcl-naloxone hcl sl film 12-3 2 PA; QL mg (base equiv) buprenorphine hcl-naloxone hcl sl tab 2- 2 QL 0.5 mg (base equiv) buprenorphine hcl-naloxone hcl sl tab 8-2 2 QL mg (base equiv) ZUBSOLV SUB 0.7-0.18 4 PA; QL ZUBSOLV SUB 1.4-0.36 4 PA; QL ZUBSOLV SUB 2.9-0.71 4 PA; QL ZUBSOLV SUB 5.7-1.4 4 PA; QL ZUBSOLV SUB 8.6-2.1 4 PA; QL ZUBSOLV SUB 11.4-2.9 4 PA; QL PSYCHOTHERAPEUTIC-MISC, PARTIAL OPIOID AGONISTS buprenorphine hcl sl tab 2 mg (base equiv) 2 QL buprenorphine hcl sl tab 8 mg (base equiv) 2 QL PSYCHOTHERAPEUTIC-MISC, PSEUDOBULBAR AFFECT NUEDEXTA CAP 20-10MG 5 PA; QL PSYCHOTHERAPEUTIC-MISC, SMOKING DETERRENTS bupropion hcl (smoking deterrent) tab er 6 QL 12hr 150 mg CHANTIX PAK 0.5& 1MG 6 QL CHANTIX PAK 1MG 6 QL CHANTIX TAB 0.5MG 6 QL nicotine polacrilex gum 2 mg 6 nicotine polacrilex gum 4 mg 6 nicotine polacrilex lozenge 2 mg 6

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 70 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits nicotine polacrilex lozenge 4 mg 6 NICOTINE SYS KIT TRANSDER 6 QL nicotine td patch 24hr 7 mg/24hr 6 nicotine td patch 24hr 14 mg/24hr 6 nicotine td patch 24hr 21 mg/24hr 6 NICOTROL INH 6 QL NICOTROL NS SPR 10MG/ML 6 QL RESTLESS LEG SYNDROME (RLS) AGENTS HORIZANT TAB 300MG ER 4 PA; QL HORIZANT TAB 600MG ER 4 PA; QL CEPHALOSPORINS CEPHALOSPORINS - 3RD GENERATION cefixime cap 400 mg 2 COMBINATION CONTRACEPTIVES - ORAL BIPHASIC CONTRACEPTIVES - ORAL desogest-eth estrad & eth estrad tab 0.15- 6 0.02/0.01 mg(21/5) LO LOESTRIN TAB 1-10-10 6 PA NECON TAB 10/11-28 6 COMBINATION CONTRACEPTIVES - ORAL desogestrel & ethinyl estradiol tab 0.15 6 mg-30 mcg drospirenone-ethinyl estrad-levomefolate 6 PA tab 3-0.02-0.451 mg drospirenone-ethinyl estradiol tab 3-0.02 6 mg drospirenone-ethinyl estradiol tab 3-0.03 6 mg ethynodiol diacetate & ethinyl estradiol tab 6 1 mg-35 mcg ethynodiol diacetate & ethinyl estradiol tab 6 1 mg-50 mcg FALESSA KIT 6 GENERESS FE CHW 6 levonorgestrel & ethinyl estradiol tab 0.1 6 mg-20 mcg levonorgestrel & ethinyl estradiol tab 0.15 6 mg-30 mcg norethindrone & ethinyl estradiol tab 0.4 6 mg-35 mcg norethindrone & ethinyl estradiol tab 0.5 6 mg-35 mcg norethindrone & ethinyl estradiol tab 1 mg- 6 35 mcg

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 71 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits norethindrone & ethinyl estradiol-fe chew 6 tab 0.4 mg-35 mcg norethindrone & ethinyl estradiol-fe chew 6 tab 0.8 mg-25 mcg norethindrone & mestranol tab 1 mg-50 6 mcg norethindrone ace & ethinyl estradiol tab 1 6 mg-20 mcg norethindrone ace & ethinyl estradiol tab 6 1.5 mg-30 mcg norethindrone ace & ethinyl estradiol-fe 6 tab 1 mg-20 mcg norethindrone ace & ethinyl estradiol-fe 6 tab 1.5 mg-30 mcg norethindrone ace-eth estradiol-fe chew 6 PA tab 1 mg-20 mcg (24) norethindrone ace-ethinyl estradiol-fe tab 6 1 mg-20 mcg (24) norgestimate & ethinyl estradiol tab 0.25 6 mg-35 mcg norgestrel & ethinyl estradiol tab 0.3 mg- 6 30 mcg norgestrel & ethinyl estradiol tab 0.5 mg- 6 50 mcg NORINYL TAB 1+50-28 6 SAFYRAL TAB 6 TAYTULLA CAP 1MG/20MC 6 PA CONTINUOUS CONTRACEPTIVES - ORAL levonorgestrel-ethinyl estradiol 6 (continuous) tab 90-20 mcg EXTENDED-CYCLE CONTRACEPTIVES - ORAL levonorg-eth est tab 0.1-0.02mg(84) & eth 4 est tab 0.01mg(7) levonorg-eth est tab 0.15-0.03mg(84) & 4 eth est tab 0.01mg(7) levonorgestrel & ethinyl estradiol (91-day) 4 tab 0.15-0.03 mg QUARTETTE TAB 4 FOUR PHASE CONTRACEPTIVES - ORAL NATAZIA TAB 6 PA TRIPHASIC CONTRACEPTIVES - ORAL desogest-ethin est tab 0.1-0.025/0.125- 6 0.025/0.15-0.025mg-mg levonorgestrel-eth estra tab 0.05- 6 30/0.075-40/0.125-30mg-mcg

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 72 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits norethindrone ac-ethinyl estrad-fe tab 1- 6 20/1-30/1-35 mg-mcg norethindrone-eth estradiol tab 0.5- 6 35/0.75-35/1-35 mg-mcg norethindrone-eth estradiol tab 0.5-35/1- 6 35/0.5-35 mg-mcg norgestimate-eth estrad tab 0.18- 6 25/0.215-25/0.25-25 mg-mcg norgestimate-eth estrad tab 0.18- 6 35/0.215-35/0.25-35 mg-mcg COMBINATION CONTRACEPTIVES - TRANSDERMAL COMBINATION CONTRACEPTIVES - TRANSDERMAL norelgestromin-ethinyl estradiol td ptwk 6 QL 150-35 mcg/24hr CONTRACEPTIVES CERVICAL CAPS FEMCAP MIS 26MM 6 FEMCAP MIS 30MM 6 PRENTIF MIS 22MM 6 PRENTIF MIS 25MM 6 PRENTIF MIS 28MM 6 PRENTIF MIS 31MM 6 PRENTIF MIS FITTING 6 COMBINATION CONTRACEPTIVES - VAGINAL etonogestrel-ethinyl estradiol va ring 2 0.120-0.015 mg/24hr CONDOMS - FEMALE FC FEMALE MIS CONDOM 6 DIAPHRAGMS CAYA DPR 6 OMNIFLEX DPR 6 ORTHO COIL DPR KIT 50 6 ORTHO COIL DPR KIT 100 6 ORTHO COIL DPR KIT 105 6 ORTHO FLAT DPR KIT 55 6 ORTHO FLAT DPR KIT 60 6 ORTHO FLAT DPR KIT 65 6 ORTHO FLAT DPR KIT 70 6 ORTHO FLAT DPR KIT 75 6 ORTHO FLAT DPR KIT 80 6 ORTHO FLAT DPR KIT 85 6 ORTHO FLAT DPR KIT 90 6 ORTHO FLAT DPR KIT 95 6 WIDE-SEAL DPR KIT 60 6 WIDE-SEAL DPR KIT 65 6

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 73 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits WIDE-SEAL DPR KIT 70 6 WIDE-SEAL DPR KIT 75 6 WIDE-SEAL DPR KIT 80 6 WIDE-SEAL DPR KIT 85 6 WIDE-SEAL DPR KIT 90 6 WIDE-SEAL DPR KIT 95 6 COPPER CONTRACEPTIVES - IUD COPPER CONTRACEPTIVES - IUD PARAGARD IUD T380A 6 CORTICOSTEROIDS GLUCOCORTICOSTEROIDS budesonide tab er 24hr 9 mg 5 PA methylprednisolone acetate inj susp 40 4 mg/ml COUGH/COLD/ALLERGY COUGH/COLD/ALLERGY COMBINATIONS TUZISTRA XR SUS 4 DERMATOLOGICALS ACNE PRODUCTS dapsone gel 5% 2 PA FABIOR AER 0.1% 4 PA ANTIFUNGALS - TOPICAL JUBLIA SOL 10% 4 ST, PA luliconazole cream 1% 4 PA naftifine hcl gel 1% 4 PA ANTINEOPLASTIC OR PREMALIGNANT LESION AGENTS - TOPICAL PICATO GEL 0.05% 5 PA PICATO GEL 0.015% 5 PA ANTIPSORIATICS tazarotene cream 0.1% 2 PA CORTICOSTEROIDS - TOPICAL clocortolone pivalate cream 0.1% 4 CORDRAN OIN 0.025% 4 HALOG OIN 0.1% 4 LOCAL ANESTHETICS - TOPICAL lidocaine hcl urethral/mucosal gel 2% 2 QL ROSACEA AGENTS azelaic acid gel 15% 2 PA SCABICIDES & PEDICULICIDES crotamiton lotion 10% 4 ULESFIA LOT 5% 4

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 74 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits DIAGNOSTIC PRODUCTS DIAGNOSTIC TESTS CHEMSTRIP K TES 3 DIURETICS LOOP DIURETICS ethacrynic acid tab 25 mg 2 PA; QL OSMOTIC DIURETICS mannitol iv soln 20% 2 POTASSIUM SPARING DIURETICS triamterene cap 50 mg 2 ST triamterene cap 100 mg 2 ST EMERGENCY CONTRACEPTIVES EMERGENCY CONTRACEPTIVES ELLA TAB 30MG 6 levonorgestrel tab 0.75 mg 6 levonorgestrel tab 1.5 mg 6 levonorgestrel tab 1.5 mg 6 ENDOCRINE AND METABOLIC ANDROGENS ANDROXY TAB 10MG 2 PA AVEED INJ 750/3ML 4 PA AXIRON SOL 30MG/ACT 3 PA METHITEST TAB 10MG 4 PA methyltestosterone cap 10 mg 5 PA STRIANT MIS 30MG 4 PA testosterone cypionate im inj in oil 100 2 mg/ml testosterone cypionate im inj in oil 200 2 mg/ml testosterone enanthate im inj in oil 200 2 mg/ml testosterone td gel 10mg/act (2%) 2 PA testosterone td gel 12.5 mg/act (1%) 2 PA testosterone td gel 25 mg/2.5gm (1%) 2 PA testosterone td gel 50 mg/5gm (1%) 2 PA ANTIDIABETICS, ALPHA-GLUCOSIDASE INHIBITOR acarbose tab 25 mg 2 acarbose tab 50 mg 2 acarbose tab 100 mg 2 MIGLITOL TAB 25 MG 2 MIGLITOL TAB 50 MG 2 MIGLITOL TAB 100 MG 2 ANTIDIABETICS, AMYLIN ANALOGS SYMLINPEN 60 INJ 1000MCG 3 ST; QL

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 75 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits SYMLNPEN 120 INJ 1000MCG 3 ST; QL ANTIDIABETICS, BIGUANIDE/SULFONYLUREA COMBINATIONS glipizide-metformin hcl tab 2.5-250 mg 2 glipizide-metformin hcl tab 2.5-500 mg 2 glipizide-metformin hcl tab 5-500 mg 2 glyburide-metformin tab 1.25-250 mg 2 glyburide-metformin tab 2.5-500 mg 2 glyburide-metformin tab 5-500 mg 2 ANTIDIABETICS, BIGUANIDES metformin hcl tab 500 mg 1 metformin hcl tab 850 mg 2 metformin hcl tab 1000 mg 1 metformin hcl tab er 24hr 500 mg 2 metformin hcl tab er 24hr 750 mg 2 ANTIDIABETICS, DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS JANUVIA TAB 25MG 3 ST JANUVIA TAB 50MG 3 ST JANUVIA TAB 100MG 3 ST ANTIDIABETICS, DPP-4 INHIBITOR COMBINATIONS JANUMET TAB 50-500MG 3 ST JANUMET TAB 50-1000 3 ST JANUMET XR TAB 50-500MG 3 ST JANUMET XR TAB 50-1000 3 ST JANUMET XR TAB 100-1000 3 ST ANTIDIABETICS, INCRETIN MIMETIC AGENTS TRULICITY INJ 0.75/0.5 3 ST; QL TRULICITY INJ 1.5/0.5 3 ST; QL VICTOZA INJ 18MG/3ML 3 ST, QL (9mL per 30 days) VICTOZA INJ 18MG/3ML 3 ST; QL ANTIDIABETICS, INSULIN SENSITIZER/BIGUANIDE COMBINATION AVANDAMET TAB 2-500MG 5 AVANDAMET TAB 2-1000MG 5 AVANDAMET TAB 4-500MG 5 ANTIDIABETICS, INSULIN SENSITIZERS AVANDIA TAB 2MG 5 AVANDIA TAB 4MG 5 AVANDIA TAB 8MG 5 pioglitazone hcl tab 15 mg (base equiv) 2 pioglitazone hcl tab 30 mg (base equiv) 2 pioglitazone hcl tab 45 mg (base equiv) 2 ANTIDIABETICS, INSULINS HUMULIN R INJ U-500 3 QL HUMULIN R INJ U-500 3 QL (54 mL in 68 days)

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 76 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits LANTUS INJ 100/ML 3 QL LANTUS SOLOS INJ 100/ML 3 QL LEVEMIR INJ 3 QL LEVEMIR INJ FLEXTOUC 3 QL NOVOLIN INJ 70/30 3 QL NOVOLIN N INJ U-100 3 QL NOVOLIN R INJ U-100 3 QL NOVOLOG INJ 100/ML 3 QL NOVOLOG INJ FLEXPEN 3 QL NOVOLOG INJ PENFILL 3 QL NOVOLOG MIX INJ 70/30 3 QL NOVOLOG MIX INJ FLEXPEN 3 QL ANTIDIABETICS, MEGLITINIDE nateglinide tab 60 mg 2 nateglinide tab 120 mg 2 repaglinide tab 0.5 mg 2 repaglinide tab 1 mg 2 repaglinide tab 2 mg 2 ANTIDIABETICS, MEGLITINIDE/BIGUANIDE COMBINATIONS repaglinide-metformin hcl tab 1-500 mg 2 repaglinide-metformin hcl tab 2-500 mg 2 ANTIDIABETICS, SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITOR/BIGUANIDE COMBINATIONS SYNJARDY TAB 3 ST; QL SYNJARDY TAB 5-500MG 3 ST; QL SYNJARDY TAB 5-1000MG 3 ST; QL SYNJARDY TAB 12.5-500 3 ST; QL ANTIDIABETICS, SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITORS JARDIANCE TAB 10MG 3 ST; QL JARDIANCE TAB 25MG 3 ST; QL ANTIDIABETICS, SODIUM-GLUCOSE CO-TRANSPORTER 2 INHIBITOR/DPP-4 INHIBITOR COMBINATIONS GLYXAMBI TAB 10-5 MG 3 ST; QL GLYXAMBI TAB 25-5 MG 3 ST; QL ANTIDIABETICS, SULFONYLUREAS chlorpropamide tab 100 mg 2 chlorpropamide tab 250 mg 2 glimepiride tab 1 mg 2 glimepiride tab 2 mg 2 glimepiride tab 4 mg 2 glipizide tab 5 mg 2 glipizide tab 10 mg 2 glipizide tab er 24hr 2.5 mg 2

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 77 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits glipizide tab er 24hr 5 mg 2 glipizide tab er 24hr 10 mg 2 glyburide micronized tab 1.5 mg 2 glyburide micronized tab 3 mg 2 glyburide micronized tab 6 mg 2 glyburide tab 1.25 mg 2 glyburide tab 2.5 mg 2 glyburide tab 5 mg 2 tolazamide tab 250 mg 2 tolazamide tab 500 mg 2 tolbutamide tab 500 mg 2 ANTIDIABETICS, SUPPLIES ADVOCATE MIS LANCETS 3 QL AUTOSHIELD MIS 29X3/16" 3 AUTOSHIELD MIS 29X5/16" 3 AUTOSHIELD MIS 30GX5MM 3 BD NEEDLES MIS 18GX1.5" 3 FINGERSTIX MIS LANCETS 3 QL GLUCOLET 2 MIS LANCING 3 QL HYPO NEEDLE MIS 18GX1" 3 HYPO NEEDLE MIS 18GX1.5" 3 MONOJECTOR MIS END CAPS 3 QL ONE TCH SLVR KIT ULT MINI 3 ONETOUCH KIT ULT MINI 3 ONETOUCH KIT ULTRA 2 3 ONETOUCH KIT ULTRALNK 3 ONETOUCH KIT VERIO 3 ONETOUCH KIT VERIO IQ 3 ONETOUCH TES ULTRA 3 QL ONETOUCH TES ULTRA BL 3 ONETOUCH TES ULTRA BL 3 QL ONETOUCH TES VERIO 3 QL ONETOUCH VER KIT SYNC 3 SYMPATH NDL MIS 18GX6" 3 TECHLITE MIS LANCETS 3 QL ANTIDOTES flumazenil iv soln 1 mg/10ml (0.1 mg/ml) 2 CALCIUM REGULATORS, BISPHOSPHONATES alendronate sodium oral soln 70 mg/75ml 2 QL alendronate sodium tab 5 mg 2 alendronate sodium tab 10 mg 2 alendronate sodium tab 35 mg 1 alendronate sodium tab 40 mg 2 alendronate sodium tab 70 mg 1

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 78 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits etidronate disodium tab 200 mg 2 etidronate disodium tab 400 mg 2 FOSAMAX + D TAB 70-2800 4 PA; QL FOSAMAX + D TAB 70-5600 4 PA; QL ibandronate sodium iv soln 3 mg/3ml 4 QL (base equivalent) ibandronate sodium tab 150 mg (base 2 QL equivalent) pamidronate disodium for inj 30 mg 5 pamidronate disodium for inj 90 mg 5 pamidronate disodium iv soln 3 mg/ml 5 pamidronate disodium iv soln 9 mg/ml 5 PAMIDRONATE INJ 6MG/ML 5 risedronate sodium tab 5 mg 4 QL risedronate sodium tab 30 mg 4 QL risedronate sodium tab 35 mg 4 QL risedronate sodium tab 150 mg 4 QL risedronate sodium tab delayed release 35 4 QL mg zoledronic acid inj conc for iv infusion 4 5 QL mg/5ml zoledronic acid iv soln 5 mg/100ml 5 QL ZOLEDRONIC INJ 4MG 5 QL ZOMETA INJ 4MG/100 5 QL CALCIUM REGULATORS, CALCITONINS calcitonin (salmon) nasal soln 200 unit/act 2 FORTICAL SPR 200/ACT 2 CALCIUM REGULATORS, PARATHYROID HORMONES FORTEO SOL 600/2.4 5 PA; QL NATPARA INJ 25MCG 5 PA; QL NATPARA INJ 50MCG 5 PA; QL NATPARA INJ 75MCG 5 PA; QL NATPARA INJ 100MCG 5 PA; QL CALCIUM REGULATORS, RANK LIGAND INHIBITORS PROLIA SOL 60MG/ML 5 PA; QL XGEVA INJ 5 PA; QL ENDOMETRIOSIS danazol cap 50 mg 2 PA danazol cap 100 mg 2 PA danazol cap 200 mg 2 PA LUPANETA KIT 3.75-5 5 PA; QL LUPANETA KIT 11.25-5 5 PA; QL SYNAREL SOL 2MG/ML 5 PA; QL

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 79 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits ESTROGEN/PROGESTIN, ORAL estradiol & norethindrone acetate tab 0.5- 2 0.1 mg estradiol & norethindrone acetate tab 1-0.5 2 mg norethindrone acetate-ethinyl estradiol tab 2 0.5 mg-2.5 mcg norethindrone acetate-ethinyl estradiol tab 2 1 mg-5 mcg PREMPHASE TAB 3 PREMPRO TAB 3 PREMPRO TAB 0.3-1.5 3 PREMPRO TAB 0.45-1.5 3 PREMPRO TAB 0.625-5 3 ESTROGEN/PROGESTIN, TRANSDERMAL COMBIPATCH DIS 4 QL COMBIPATCH DIS .05/.14 4 QL ESTROGEN/SELECTIVE ESTROGEN RECEPTOR MODULATOR COMBINATIONS DUAVEE TAB 0.45-20 3 ESTROGENS, INJECTABLE DEPO-ESTRADI INJ 5MG/ML 4 estradiol valerate im in oil 20 mg/ml 2 estradiol valerate im in oil 40 mg/ml 2 PREMARIN INJ 25MG 4 ESTROGENS, ORAL ENJUVIA TAB 0.3MG 4 ST ENJUVIA TAB 0.9MG 4 ST ENJUVIA TAB 0.45MG 4 ST ENJUVIA TAB 0.625MG 4 ST ENJUVIA TAB 1.25MG 4 ST esterified estrogens & methyltestosterone 2 tab 0.625-1.25 mg esterified estrogens & methyltestosterone 2 tab 1.25-2.5 mg estradiol tab 0.5 mg 2 estradiol tab 1 mg 2 estradiol tab 2 mg 2 estropipate tab 0.75 mg 2 estropipate tab 1.5 mg 2 estropipate tab 3 mg 2 MENEST TAB 0.3MG 4 MENEST TAB 0.625MG 4 MENEST TAB 1.25MG 4 MENEST TAB 2.5MG 4

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 80 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits PREMARIN TAB 0.3MG 4 PREMARIN TAB 0.9MG 4 PREMARIN TAB 0.45MG 4 PREMARIN TAB 0.625MG 4 PREMARIN TAB 1.25MG 4 ESTROGENS, TRANSDERMAL estradiol td patch twice weekly 0.1 2 QL mg/24hr estradiol td patch twice weekly 0.05 2 QL mg/24hr estradiol td patch twice weekly 0.025 2 QL mg/24hr estradiol td patch twice weekly 0.075 2 QL mg/24hr estradiol td patch twice weekly 0.0375 2 QL mg/24hr estradiol td patch weekly 0.1 mg/24hr 2 QL estradiol td patch weekly 0.05 mg/24hr 2 QL estradiol td patch weekly 0.06 mg/24hr 2 QL estradiol td patch weekly 0.025 mg/24hr 2 QL estradiol td patch weekly 0.075 mg/24hr 2 QL estradiol td patch weekly 0.0375 mg/24hr 2 QL (37.5 mcg/24hr) ESTROGEL GEL 4 QL MENOSTAR DIS 14MCG 4 QL ESTROGENS, VAGINAL FEMRING MIS 0.1MG/24 4 FEMRING MIS 0.05/24H 4 PREMARIN VAG CRE 0.625MG 4 GLUCOCORTICOIDS cortisone acetate tab 25 mg 2 DEXAMETHASON CON 1MG/ML 2 dexamethasone elixir 0.5 mg/5ml 2 dexamethasone soln 0.5 mg/5ml 2 dexamethasone tab 0.5 mg 2 dexamethasone tab 0.75 mg 2 dexamethasone tab 1 mg 2 dexamethasone tab 1.5 mg 2 dexamethasone tab 2 mg 2 dexamethasone tab 4 mg 2 dexamethasone tab 6 mg 2 fludrocortisone acetate tab 0.1 mg 2 hydrocortisone tab 5 mg 2 hydrocortisone tab 10 mg 2 hydrocortisone tab 20 mg 2

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 81 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits methylprednisolone tab 4 mg 2 methylprednisolone tab 8 mg 2 methylprednisolone tab 16 mg 2 methylprednisolone tab 32 mg 2 methylprednisolone tab therapy pack 4 mg 2 (21) prednisolone sod phosph oral soln 6.7 2 mg/5ml (5 mg/5ml base) prednisolone sod phosphate oral soln 15 2 mg/5ml (base equiv) prednisolone sodium phosphate oral soln 2 25 mg/5ml (base eq) prednisolone syrup 15 mg/5ml (usp 2 solution equivalent) PREDNISONE CON 5MG/ML 2 prednisone oral soln 5 mg/5ml 2 prednisone tab 1 mg 2 prednisone tab 2.5 mg 2 prednisone tab 5 mg 2 prednisone tab 10 mg 2 prednisone tab 20 mg 2 prednisone tab 50 mg 2 prednisone tab therapy pack 5 mg (21) 2 prednisone tab therapy pack 10 mg (21) 2 GLUCOSE ELEVATING AGENT GLUCAGEN INJ 1MG 3 QL GLUCAGEN INJ HYPOKIT 3 QL GLUCAGON KIT 1MG 3 QL PROGLYCEM SUS 50MG/ML 4 HUMAN GROWTH HORMONES SEROSTIM INJ 4MG 5 PA SEROSTIM INJ 5MG 5 PA SEROSTIM INJ 6MG 5 PA ZORBTIVE INJ 8.8MG 5 PA HYPERPARATHYROID TREATMENT, VITAMIN D ANALOGS calcitriol cap 0.5 mcg 2 calcitriol cap 0.25 mcg 2 calcitriol inj 1 mcg/ml 2 calcitriol oral soln 1 mcg/ml 2 doxercalciferol cap 0.5 mcg 2 doxercalciferol cap 1 mcg 2 doxercalciferol cap 2.5 mcg 2 doxercalciferol inj 4 mcg/2ml (2 mcg/ml) 2 HECTOROL INJ 2MCG/ML 4 paricalcitol cap 1 mcg 2

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 82 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits paricalcitol cap 2 mcg 2 paricalcitol cap 4 mcg 2 INSULIN-LIKE GROWTH FACTOR INCRELEX INJ 40MG/4ML 5 PA LYSOSOMAL STORAGE DISORDERS ALDURAZYME INJ 2.9MG/5M 5 PA CERDELGA CAP 84MG 5 PA; QL CEREZYME INJ 400UNIT 5 PA ELAPRASE INJ 6MG/3ML 5 PA ELELYSO INJ 200UNIT 5 PA FABRAZYME INJ 5MG 5 PA FABRAZYME INJ 35MG 5 PA MYOZYME INJ 50MG 5 PA NAGLAZYME INJ 1MG/ML 5 PA VIMIZIM INJ 5MG/5ML 5 PA VPRIV INJ 400UNIT 5 PA MISCELLANEOUS ACTHAR INJ 80UNIT 5 PA; QL ADAGEN INJ 250/ML 5 PA cabergoline tab 0.5 mg 2 CARBAGLU TAB 200MG 5 PA chorionic gonadotropin for im inj 10000 5 unit chorionic gonadotropin for im inj 10000 5 PA unit CYSTADANE POW 5 PA KORLYM TAB 300MG 5 PA; QL levocarnitine inj 200 mg/ml 2 levocarnitine oral soln 1 gm/10ml (10%) 2 levocarnitine tab 330 mg 2 LUPR DEP-PED INJ 3M 30MG 5 PA; QL LUPR DEP-PED INJ 7.5MG 5 PA; QL LUPR DEP-PED INJ 11.25MG 5 PA; QL LUPR DEP-PED INJ 15MG 5 PA; QL methylergonovine maleate tab 0.2 mg 2 MYALEPT INJ 11.3MG 5 PA; QL octreotide acetate inj 50 mcg/ml (0.05 5 mg/ml) octreotide acetate inj 100 mcg/ml (0.1 5 mg/ml) octreotide acetate inj 200 mcg/ml (0.2 5 mg/ml) octreotide acetate inj 500 mcg/ml (0.5 5 mg/ml)

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 83 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits octreotide acetate inj 1000 mcg/ml (1 5 mg/ml) ORFADIN CAP 2MG 5 PA ORFADIN CAP 5MG 5 PA ORFADIN CAP 10MG 5 PA OSPHENA TAB 60MG 4 PA; QL raloxifene hcl tab 60 mg 6 PA RAVICTI LIQ 1.1GM/ML 5 PA; QL SANDOSTATIN KIT LAR 10MG 5 PA; QL SANDOSTATIN KIT LAR 20MG 5 PA; QL SANDOSTATIN KIT LAR 30MG 5 PA; QL SIGNIFOR INJ 0.3MG/ML 5 PA; QL SIGNIFOR INJ 0.6MG/ML 5 PA; QL SIGNIFOR INJ 0.9MG/ML 5 PA; QL SIGNIFOR LAR INJ 20MG 5 PA; QL SIGNIFOR LAR INJ 40MG 5 PA; QL SIGNIFOR LAR INJ 60MG 5 PA; QL SOMATULINE INJ 60/0.2ML 5 PA; QL SOMATULINE INJ 90/0.3ML 5 PA; QL SOMATULINE INJ 120/.5ML 5 PA; QL SOMAVERT INJ 10MG 5 PA; QL SOMAVERT INJ 15MG 5 PA; QL SOMAVERT INJ 20MG 5 PA; QL SOMAVERT INJ 25MG 5 PA; QL SOMAVERT INJ 30MG 5 PA; QL SUPPRELIN LA KIT 50MG 5 PA; QL trientine hcl cap 250 mg 5 PA PHENYLKETONURIA TREATMENT AGENTS KUVAN POW 500MG 5 PA KUVAN TAB 100MG 5 PA PHOSPHATE BINDER AGENTS AURYXIA TAB 210MG 3 calcium acetate (phosphate binder) cap 2 667 mg (169 mg ca) calcium acetate (phosphate binder) tab 2 667 mg FOSRENOL POW 750MG 4 ST FOSRENOL POW 1000MG 4 ST lanthanum carbonate chew tab 500 mg 2 (elemental) lanthanum carbonate chew tab 750 mg 2 (elemental) lanthanum carbonate chew tab 1000 mg 2 (elemental) RENAGEL TAB 400MG 3

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 84 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits sevelamer carbonate packet 0.8 gm 2 sevelamer carbonate packet 2.4 gm 2 VELPHORO CHW 500MG 4 ST PROGESTINS, INJECTABLE MAKENA INJ 250MG/ML 5 PA PROGESTINS, ORAL medroxyprogesterone acetate tab 2.5 mg 2 medroxyprogesterone acetate tab 5 mg 2 medroxyprogesterone acetate tab 10 mg 2 norethindrone acetate tab 5 mg 2 progesterone micronized cap 100 mg 2 progesterone micronized cap 200 mg 2 PROGESTINS, VAGINAL CRINONE GEL 4% VAG 4 THYROID AGENTS, ANTITHYROID AGENTS methimazole tab 5 mg 2 methimazole tab 10 mg 2 propylthiouracil tab 50 mg 2 SSKI SOL 1GM/ML 4 THYROID SUPPLEMENTS ARMOUR THYRO TAB 15MG 4 ARMOUR THYRO TAB 30MG 4 ARMOUR THYRO TAB 60MG 4 ARMOUR THYRO TAB 90MG 4 ARMOUR THYRO TAB 120MG 4 ARMOUR THYRO TAB 180MG 4 ARMOUR THYRO TAB 240MG 4 ARMOUR THYRO TAB 300MG 4 levothyroxine sodium for iv inj 100 mcg 2 LEVOTHYROXINE SODIUM FOR IV INJ 200 2 MCG levothyroxine sodium for iv inj 500 mcg 2 levothyroxine sodium tab 25 mcg 2 levothyroxine sodium tab 50 mcg 2 levothyroxine sodium tab 75 mcg 2 levothyroxine sodium tab 88 mcg 2 levothyroxine sodium tab 100 mcg 2 levothyroxine sodium tab 112 mcg 2 levothyroxine sodium tab 125 mcg 2 levothyroxine sodium tab 137 mcg 2 levothyroxine sodium tab 150 mcg 2 levothyroxine sodium tab 175 mcg 2 levothyroxine sodium tab 200 mcg 2 levothyroxine sodium tab 300 mcg 2

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 85 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits liothyronine sodium iv soln 10 mcg/ml 2 liothyronine sodium tab 5 mcg 2 liothyronine sodium tab 25 mcg 2 liothyronine sodium tab 50 mcg 2 NATURE THROI TAB 162.5MG 2 NATURE-THROI TAB 16.25MG 2 NATURE-THROI TAB 32.5MG 2 NATURE-THROI TAB 48.75MG 2 NATURE-THROI TAB 65MG 2 NATURE-THROI TAB 81.25MG 2 NATURE-THROI TAB 97.5MG 2 NATURE-THROI TAB 113.75MG 2 NATURE-THROI TAB 130MG 2 NATURE-THROI TAB 146.25MG 2 NATURE-THROI TAB 195MG 2 NATURE-THROI TAB 260MG 2 NATURE-THROI TAB 325MG 2 SYNTHROID TAB 25MCG 4 SYNTHROID TAB 50MCG 4 SYNTHROID TAB 75MCG 4 SYNTHROID TAB 88MCG 4 SYNTHROID TAB 100MCG 4 SYNTHROID TAB 112MCG 4 SYNTHROID TAB 125MCG 4 SYNTHROID TAB 137MCG 4 SYNTHROID TAB 150MCG 4 SYNTHROID TAB 175MCG 4 SYNTHROID TAB 200MCG 4 SYNTHROID TAB 300MCG 4 thyroid tab 30 mg (1/2 grain) 2 thyroid tab 60 mg (1 grain) 2 thyroid tab 90 mg (1 1/2 grain) 2 TIROSINT CAP 13MCG 4 TIROSINT CAP 25MCG 4 TIROSINT CAP 50MCG 4 TIROSINT CAP 75MCG 4 TIROSINT CAP 88MCG 4 TIROSINT CAP 100MCG 4 TIROSINT CAP 112MCG 4 TIROSINT CAP 125MCG 4 TIROSINT CAP 137MCG 4 TIROSINT CAP 150MCG 4 WESTHROID TAB 16.25MG 2 WESTHROID TAB 32.5MG 2 WESTHROID TAB 48.75MG 2

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 86 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits WESTHROID TAB 65MG 2 WESTHROID TAB 81.25MG 2 WESTHROID TAB 97.5MG 2 WESTHROID TAB 113.75MG 2 WESTHROID TAB 130MG 2 VASOPRESSIN RECEPTOR ANTAGONISTS SAMSCA TAB 15MG 5 PA; QL SAMSCA TAB 30MG 5 PA; QL VASOPRESSINS desmopressin acetate nasal soln 0.01% 2 (refrigerated) desmopressin acetate nasal spray soln 2 0.01% (refrigerated) desmopressin acetate tab 0.1 mg 2 desmopressin acetate tab 0.2 mg 2 ENDOCRINE AND METABOLIC AGENTS - MISC. ADRENAL STEROID INHIBITORS ISTURISA TAB 1MG 5 PA, QL (6 per day) ISTURISA TAB 1MG 5 PA, QL (6 tablets per day) ISTURISA TAB 5MG 5 PA, QL (6 per day) ISTURISA TAB 5MG 5 PA, QL (6 tablets per day) ISTURISA TAB 10MG 5 PA, QL (6 per day) ISTURISA TAB 10MG 5 PA, QL (6 tablets per day) GROWTH HORMONES GENOTROPIN INJ 0.2MG 5 PA GENOTROPIN INJ 0.4MG 5 PA GENOTROPIN INJ 0.6MG 5 PA GENOTROPIN INJ 0.8MG 5 PA GENOTROPIN INJ 1.2MG 5 PA GENOTROPIN INJ 1.4MG 5 PA GENOTROPIN INJ 1.6MG 5 PA GENOTROPIN INJ 1MG 5 PA GENOTROPIN INJ 5MG 5 PA GENOTROPIN INJ 12MG 5 PA METABOLIC MODIFIERS cinacalcet hcl tab 30 mg (base equiv) 5 cinacalcet hcl tab 60 mg (base equiv) 5 cinacalcet hcl tab 90 mg (base equiv) 5 GALAFOLD CAP 123MG 5 PA; QL PALYNZIQ INJ 2.5/0.5 5 PA; QL PALYNZIQ INJ 10/0.5ML 5 PA; QL PALYNZIQ INJ 20MG/ML 5 PA; QL MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 87 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits REVCOVI INJ 1.6MG/ML 5 PA sodium phenylbutyrate tab 500 mg 5 PA; QL VASOPRESSIN RECEPTOR ANTAGONISTS JYNARQUE PAK 45-15MG 5 PA; QL JYNARQUE PAK 60-30MG 5 PA; QL JYNARQUE PAK 90-30MG 5 PA; QL ENZYMES ENZYMES VITRASE INJ 200/ML 4 ESTROGENS ESTROGENS CENESTIN TAB 0.3MG 4 FLUOROQUINOLONES FLUOROQUINOLONES BAXDELA TAB 450MG 4 PA; QL GASTROINTESTINAL ANTIDIARRHEALS diphenoxylate w/ atropine liq 2.5-0.025 2 mg/5ml diphenoxylate w/ atropine tab 2.5-0.025 2 mg FULYZAQ TAB 125MG 5 PA; QL loperamide hcl cap 2 mg 2 paregoric tincture 2 mg/5ml (morphine 2 equivalent) ANTIEMETICS AKYNZEO CAP 300-0.5 4 QL ALOXI INJ 0.25MG/5 4 ST ANZEMET INJ 20MG/ML 4 ST ANZEMET TAB 50MG 4 ST; QL ANZEMET TAB 100MG 4 ST; QL CESAMET CAP 1MG 4 ST DIMENHYDRIN INJ 50MG/ML 2 dronabinol cap 2.5 mg 4 dronabinol cap 5 mg 4 dronabinol cap 10 mg 4 droperidol inj 2.5 mg/ml 2 granisetron hcl inj 0.1 mg/ml 2 QL granisetron hcl inj 1 mg/ml 2 QL granisetron hcl inj 4 mg/4ml (1 mg/ml) 2 QL granisetron hcl tab 1 mg 4 QL meclizine hcl tab 12.5 mg 2 meclizine hcl tab 25 mg 2

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 88 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits metoclopramide hcl inj 5 mg/ml (base 2 equivalent) metoclopramide hcl soln 5 mg/5ml (10 2 mg/10ml) (base equiv) metoclopramide hcl tab 5 mg (base 1 equivalent) metoclopramide hcl tab 10 mg (base 1 equivalent) ondansetron hcl inj 4 mg/2ml (2 mg/ml) 2 ondansetron hcl inj 40 mg/20ml (2 mg/ml) 2 ondansetron hcl oral soln 4 mg/5ml 2 ondansetron hcl tab 4 mg 2 QL ondansetron hcl tab 8 mg 2 QL ondansetron hcl tab 24 mg 2 QL ondansetron orally disintegrating tab 4 mg 2 QL ondansetron orally disintegrating tab 8 mg 2 QL prochlorperazine edisylate inj 10 mg/2ml 2 prochlorperazine maleate tab 5 mg (base 2 equivalent) prochlorperazine maleate tab 10 mg (base 2 equivalent) prochlorperazine suppos 25 mg 2 promethazine hcl inj 25 mg/ml 2 promethazine hcl inj 50 mg/ml 2 promethazine hcl suppos 12.5 mg 2 promethazine hcl suppos 25 mg 2 promethazine hcl suppos 50 mg 4 promethazine hcl syrup 6.25 mg/5ml 2 promethazine hcl tab 12.5 mg 2 promethazine hcl tab 25 mg 2 promethazine hcl tab 50 mg 2 SANCUSO DIS 3.1MG 4 ST; QL scopolamine td patch 72hr 1 mg/3days 2 TIGAN INJ 100MG/ML 4 trimethobenzamide hcl cap 300 mg 2 ANTISPASMODICS BELLA/OPIUM SUP 16.2-30 2 ST BELLA/OPIUM SUP 16.2-60 2 ST CANTIL TAB 25MG 4 CUVPOSA SOL 1MG/5ML 5 PA dicyclomine hcl cap 10 mg 2 dicyclomine hcl oral soln 10 mg/5ml 2 dicyclomine hcl tab 20 mg 2 glycopyrrolate inj 1 mg/5ml (0.2 mg/ml) 2 glycopyrrolate tab 1 mg 2

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 89 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits glycopyrrolate tab 2 mg 2 hyoscyamine sulfate elixir 0.125 mg/5ml 2 hyoscyamine sulfate sl tab 0.125 mg 2 hyoscyamine sulfate soln 0.125 mg/ml 2 hyoscyamine sulfate tab 0.125 mg 2 hyoscyamine sulfate tab disint 0.125 mg 2 hyoscyamine sulfate tab er 12hr 0.375 mg 2 methscopolamine bromide tab 2.5 mg 2 methscopolamine bromide tab 5 mg 2 pb-hyoscy-atrop-scopol tab 16.2-0.1037- 2 0.0194-0.0065 mg propantheline bromide tab 15 mg 2 CHOLELITHOLYTICS ursodiol cap 300 mg 2 ursodiol tab 250 mg 2 ursodiol tab 500 mg 2 H2-RECEPTOR ANTAGONISTS cimetidine hcl soln 300 mg/5ml 2 cimetidine tab 300 mg 2 cimetidine tab 400 mg 2 cimetidine tab 800 mg 2 famotidine for susp 40 mg/5ml 2 famotidine in nacl 0.9% iv soln 20 2 mg/50ml famotidine inj 20 mg/2ml 2 famotidine inj 40 mg/4ml 2 famotidine tab 40 mg 2 nizatidine cap 150 mg 2 nizatidine cap 300 mg 2 nizatidine oral soln 15 mg/ml 2 ranitidine hcl inj 50 mg/2ml (25 mg/ml) 2 ranitidine hcl inj 150 mg/6ml (25 mg/ml) 2 ranitidine hcl syrup 15 mg/ml (75 mg/5ml) 2 ranitidine hcl tab 150 mg 1 ranitidine hcl tab 300 mg 1 INFLAMMATORY BOWEL DISEASE, ORAL AGENTS balsalazide disodium cap 750 mg 2 budesonide delayed release particles cap 3 2 mg DELZICOL CAP 400MG 3 DIPENTUM CAP 250MG 4 ST *mesalamine rectal enema 4 gm & 2 cleanser wipe kit** sulfasalazine tab 500 mg 2 sulfasalazine tab delayed release 500 mg 2

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 90 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits INFLAMMATORY BOWEL DISEASE, RECTAL AGENTS hydrocortisone enema 100 mg/60ml 2 mesalamine enema 4 gm 2 mesalamine suppos 1000 mg 2 IRRITABLE BOWEL SYNDROME WITH CONSTIPATION AMITIZA CAP 8MCG 4 ST; QL AMITIZA CAP 24MCG 4 ST; QL LINZESS CAP 145MCG 3 QL LINZESS CAP 290MCG 3 QL IRRITABLE BOWEL SYNDROME WITH DIARRHEA alosetron hcl tab 0.5 mg (base equiv) 5 PA; QL alosetron hcl tab 1 mg (base equiv) 5 PA; QL VIBERZI TAB 75MG 5 PA; QL VIBERZI TAB 100MG 5 PA; QL LAXATIVES/STOOL SOFTENERS bisacodyl tab & peg 3350-kcl-sod bicarb- 6 nacl for soln kit bisacodyl tab delayed release 5 mg 6 lactulose solution 10 gm/15ml 2 MILK OF MAGN SUS 2400MG 6 MOVIPREP SOL 6 PA OSMOPREP TAB 1.5GM 4 peg 3350-kcl-na bicarb-nacl-na sulfate for 6 soln 236 gm peg 3350-kcl-na bicarb-nacl-na sulfate for 6 soln 240 gm peg 3350-kcl-sod bicarb-nacl for soln 420 6 gm polyethylene glycol 3350 oral powder 17 6 gm/scoop PREPOPIK PAK 6 SUCLEAR KIT 6 SUPREP BOWEL SOL PREP KIT 6 PA MISCELLANEOUS CARAFATE SUS 1GM/10ML 2 cromolyn sodium oral conc 100 mg/5ml 2 GATTEX KIT 5MG 5 PA; QL KEPIVANCE INJ 6.25MG 5 lactulose (encephalopathy) solution 10 2 gm/15ml RECTIV OIN 0.4% 4 PA sodium phenylbutyrate oral powder 3 5 PA gm/teaspoonful SUCRAID SOL 8500/ML 5 PA sucralfate tab 1 gm 2

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 91 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits OPIOID-INDUCED CONSTIPATION MOVANTIK TAB 12.5MG 3 QL MOVANTIK TAB 25MG 3 QL PANCREATIC ENZYMES CREON CAP 3000UNIT 3 CREON CAP 6000UNIT 3 CREON CAP 12000UNT 3 CREON CAP 24000UNT 3 CREON CAP 36000UNT 3 ZENPEP CAP 3000UNIT 4 ST ZENPEP CAP 10000UNT 4 ST ZENPEP CAP 15000UNT 4 ST ZENPEP CAP 20000UNT 4 ST ZENPEP CAP 25000UNT 4 ST ZENPEP CAP 40000UNT 4 ST PROSTAGLANDINS misoprostol tab 100 mcg 2 misoprostol tab 200 mcg 2 PROTON PUMP INHIBITORS (PPI) DEXILANT CAP 30MG DR 4 ST, PA; QL DEXILANT CAP 60MG DR 4 ST, PA; QL esomeprazole magnesium cap delayed 2 ST, PA; QL release 20 mg (base eq) esomeprazole magnesium cap delayed 2 ST, PA; QL release 40 mg (base eq) esomeprazole sodium for intravenous soln 2 QL 20 mg (base equiv) esomeprazole sodium for intravenous soln 2 QL 40 mg (base equiv) lansoprazole cap delayed release 15 mg 2 QL lansoprazole cap delayed release 30 mg 2 QL omeprazole cap delayed release 10 mg 2 QL omeprazole cap delayed release 20 mg 2 QL omeprazole cap delayed release 40 mg 2 QL pantoprazole sodium ec tab 20 mg (base 2 QL equiv) pantoprazole sodium ec tab 40 mg (base 2 QL equiv) rabeprazole sodium ec tab 20 mg 2 PA; QL SALIVA STIMULANTS cevimeline hcl cap 30 mg 2 pilocarpine hcl tab 5 mg 2 pilocarpine hcl tab 7.5 mg 2

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 92 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits STEROIDS, RECTAL hydrocortisone acetate w/ pramoxine 2 perianal cream 1-1% hydrocortisone acetate w/ pramoxine 2 perianal cream 2.5-1% hydrocortisone perianal cream 2.5% 2 lidocaine-hydrocortisone acetate perianal 2 cream 3-0.5% ULCER THERAPY COMBINATION amoxicillin cap-clarithro tab-lansopraz cap 4 dr therapy pack omeprazole-sodium bicarbonate cap 20- 2 ST, PA; QL 1100 mg omeprazole-sodium bicarbonate cap 40- 2 ST, PA; QL 1100 mg GASTROINTESTINAL AGENTS - MISC. INFLAMMATORY BOWEL AGENTS mesalamine cap dr 400 mg 2 mesalamine cap er 24hr 0.375 gm 2 mesalamine tab delayed release 1.2 gm 2 mesalamine tab delayed release 800 mg 2 REMICADE INJ 100MG 5 PA IRRITABLE BOWEL SYNDROME (IBS) AGENTS LINZESS CAP 72MCG 3 PHOSPHATE BINDER AGENTS sevelamer carbonate tab 800 mg 2 sevelamer hcl tab 800 mg 2 GENITOURINARY BENIGN PROSTATIC HYPERPLASIA alfuzosin hcl tab er 24hr 10 mg 2 dutasteride cap 0.5 mg 4 dutasteride-tamsulosin hcl cap 0.5-0.4 mg 2 finasteride tab 5 mg 2 silodosin cap 4 mg 2 ST, PA; QL silodosin cap 8 mg 2 ST, PA; QL tamsulosin hcl cap 0.4 mg 2 GENITOURINARY IRRIGANTS acetic acid irrigation soln 0.25% 2 neomycin-polymyxin b gu irrigation soln 2 MISCELLANEOUS bethanechol chloride tab 5 mg 2 bethanechol chloride tab 10 mg 2 bethanechol chloride tab 25 mg 2 bethanechol chloride tab 50 mg 2

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 93 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits CYSTAGON CAP 50MG 5 CYSTAGON CAP 150MG 5 ELMIRON CAP 100MG 4 PA methenamine hippurate tab 1 gm 2 methenamine mandelate tab 0.5 gm 2 methenamine mandelate tab 1 gm 2 *methenamine-hyos-meth blue-sod phos- 2 phen sal tab 81.6 mg*** *methenamine-hyoscamine-meth blue-sod 2 phos tab 81.6 mg*** MONUROL PAK GRANULES 4 PA nitrofurantoin macrocrystalline cap 25 mg 2 phenazopyridine hcl tab 100 mg 2 phenazopyridine hcl tab 200 mg 2 pot & sod citrates w/ cit ac soln 550-500- 2 334 mg/5ml pot & sod citrates w/ cit ac syrup 550-500- 2 334 mg/5ml potassium citrate & citric acid powder pack 2 3300-1002 mg potassium citrate & citric acid soln 1100- 2 334 mg/5ml potassium citrate tab er 5 meq (540 mg) 2 potassium citrate tab er 10 meq (1080 mg) 2 potassium citrate tab er 15 meq (1620 mg) 2 PROCYSBI CAP 25MG 5 PA; QL PROCYSBI CAP 75MG 5 PA; QL sodium citrate & citric acid soln 500-334 2 mg/5ml THIOLA TAB 100MG 5 PA URINARY ANTISPASMODICS flavoxate hcl tab 100 mg 2 MYRBETRIQ TAB 25MG 4 QL MYRBETRIQ TAB 50MG 4 QL oxybutynin chloride syrup 5 mg/5ml 2 oxybutynin chloride tab 5 mg 2 oxybutynin chloride tab er 24hr 5 mg 2 oxybutynin chloride tab er 24hr 10 mg 2 oxybutynin chloride tab er 24hr 15 mg 2 tolterodine tartrate cap er 24hr 2 mg 2 tolterodine tartrate cap er 24hr 4 mg 2 tolterodine tartrate tab 1 mg 2 tolterodine tartrate tab 2 mg 2 trospium chloride cap er 24hr 60 mg 4 trospium chloride tab 20 mg 2

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 94 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits VESICARE TAB 5MG 4 VESICARE TAB 10MG 4 VAGINAL ANTI-INFECTIVES clindamycin phosphate vaginal cream 2% 2 GYNAZOLE-1 CRE 2% 4 metronidazole vaginal gel 0.75% 2 terconazole vaginal cream 0.4% 2 terconazole vaginal cream 0.8% 2 terconazole vaginal suppos 80 mg 2 GENITOURINARY AGENTS - MISCELLANEOUS PROSTATIC HYPERTROPHY AGENTS CARDURA XL TAB 4MG 3 ST CARDURA XL TAB 8MG 3 ST GOUT AGENT COMBINATIONS GOUT AGENT COMBINATIONS colchicine w/ probenecid tab 0.5-500 mg 2 GOUT AGENTS GOUT AGENTS febuxostat tab 40 mg 2 ST febuxostat tab 80 mg 2 ST HEMATOLOGIC ANTICOAGULANTS, INJECTABLE ARGATROBAN INJ 50/50ML 4 bivalirudin trifluoroacetate for iv soln 250 2 mg (base equiv) enoxaparin sodium inj 30 mg/0.3ml 5 enoxaparin sodium inj 40 mg/0.4ml 5 enoxaparin sodium inj 60 mg/0.6ml 5 enoxaparin sodium inj 80 mg/0.8ml 5 enoxaparin sodium inj 100 mg/ml 5 enoxaparin sodium inj 120 mg/0.8ml 5 enoxaparin sodium inj 150 mg/ml 5 enoxaparin sodium inj 300 mg/3ml 5 fondaparinux sodium subcutaneous inj 2.5 5 QL mg/0.5ml fondaparinux sodium subcutaneous inj 5 5 QL mg/0.4ml fondaparinux sodium subcutaneous inj 7.5 5 QL mg/0.6ml fondaparinux sodium subcutaneous inj 10 5 QL mg/0.8ml FRAGMIN INJ 2500/0.2 5 QL FRAGMIN INJ 5000/0.2 5 QL FRAGMIN INJ 7500/0.3 5 QL

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 95 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits FRAGMIN INJ 10000/ML 5 QL FRAGMIN INJ 12500UNT 5 QL FRAGMIN INJ 15000UNT 5 QL FRAGMIN INJ 18000UNT 5 QL FRAGMIN INJ 95000UNT 5 QL heparin sodium (porcine) inj 1000 unit/ml 2 heparin sodium (porcine) inj 5000 unit/ml 2 heparin sodium (porcine) inj 10000 unit/ml 2 heparin sodium (porcine) inj 20000 unit/ml 2 heparin sodium (porcine) pf inj 5000 2 unit/0.5ml ANTICOAGULANTS, ORAL ELIQUIS TAB 2.5MG 3 QL ELIQUIS TAB 5MG 3 QL warfarin sodium tab 1 mg 2 warfarin sodium tab 2 mg 2 warfarin sodium tab 2.5 mg 2 warfarin sodium tab 3 mg 2 warfarin sodium tab 4 mg 2 warfarin sodium tab 5 mg 2 warfarin sodium tab 6 mg 2 warfarin sodium tab 7.5 mg 2 warfarin sodium tab 10 mg 2 XARELTO STAR TAB 15/20MG 3 QL XARELTO TAB 2.5MG 3 QL XARELTO TAB 10MG 3 QL XARELTO TAB 15MG 3 QL XARELTO TAB 20MG 3 QL HEMATOPOIETIC GROWTH FACTORS ARANESP INJ 10MCG 5 PA ARANESP INJ 25MCG 5 PA ARANESP INJ 40MCG 5 PA ARANESP INJ 60MCG 5 PA ARANESP INJ 100MCG 5 PA ARANESP INJ 150MCG 5 PA ARANESP INJ 200MCG 5 PA ARANESP INJ 300MCG 5 PA ARANESP INJ 500MCG 5 PA EPOGEN INJ 2000/ML 5 PA EPOGEN INJ 3000/ML 5 PA EPOGEN INJ 4000/ML 5 PA EPOGEN INJ 10000/ML 5 PA EPOGEN INJ 20000/ML 5 PA GRANIX INJ 300/0.5 5 PA GRANIX INJ 480/0.8 5 PA

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 96 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits LEUKINE INJ 250MCG 5 NEULASTA INJ 6MG/0.6M 5 PA NEULASTA KIT 6MG/0.6M 5 PA NEUPOGEN INJ 300/0.5 5 PA NEUPOGEN INJ 300MCG 5 PA NEUPOGEN INJ 480/0.8 5 PA NEUPOGEN INJ 480MCG 5 PA PROCRIT INJ 40000/ML 5 PA ZARXIO INJ 300/0.5 5 PA ZARXIO INJ 480/0.8 5 PA HEMOSTATICS, SYSTEMIC aminocaproic acid inj 250 mg/ml 2 tranexamic acid iv soln 1000 mg/10ml 2 (100 mg/ml) tranexamic acid tab 650 mg 2 QL HEREDITARY ANGIOEDEMA AGENTS BERINERT INJ 500UNIT 5 PA; QL CINRYZE SOL 500 UNIT 5 PA; QL FIRAZYR INJ 30MG/3ML 5 PA; QL KALBITOR INJ 10MG/ML 5 PA RUCONEST INJ 2100UNIT 5 PA IDIOPATHIC THROMBOCYTOPENIC PURPURA NPLATE INJ 250MCG 5 PA NPLATE INJ 500MCG 5 PA PROMACTA TAB 12.5MG 5 PA; QL PROMACTA TAB 25MG 5 PA; QL PROMACTA TAB 50MG 5 PA; QL PROMACTA TAB 75MG 5 PA; QL MISCELLANEOUS CHEMET CAP 100MG 4 PA cilostazol tab 50 mg 2 cilostazol tab 100 mg 2 EXJADE TAB 125MG 5 PA EXJADE TAB 250MG 5 PA EXJADE TAB 500MG 5 PA FERRIPROX SOL 100MG/ML 5 PA FERRIPROX TAB 500MG 5 PA pentoxifylline tab er 400 mg 2 protamine sulfate inj 10 mg/ml 2 PAROXYSMAL NOCTURNAL HEMOGLOBINURIA (PNH) AGENTS SOLIRIS INJ 10MG/ML 5 PA PLATELET AGGREGATION INHIBITORS aspirin-dipyridamole cap er 12hr 25-200 2 mg

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 97 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits BRILINTA TAB 60MG 3 QL BRILINTA TAB 90MG 3 QL clopidogrel bisulfate tab 75 mg (base 2 equiv) clopidogrel bisulfate tab 300 mg (base 2 equiv) dipyridamole tab 25 mg 2 dipyridamole tab 50 mg 2 dipyridamole tab 75 mg 2 ticlopidine hcl tab 250 mg 2 ZONTIVITY TAB 2.08MG 4 PA; QL PLATELET SYNTHESIS INHIBITOR anagrelide hcl cap 0.5 mg 2 anagrelide hcl cap 1 mg 2 STEM CELL MOBILIZERS MOZOBIL INJ 5 PA; QL HEMATOLOGICAL AGENTS - MISC. AMINOLEVULINATE SYNTHASE 1-DIRECTED SIRNA GIVLAARI INJ 189MG/ML 5 PA, QL (1 vial / 30 days) PLATELET AGGREGATION INHIBITORS prasugrel hcl tab 5 mg (base equiv) 2 QL prasugrel hcl tab 10 mg (base equiv) 2 QL HEMATOPOIETIC AGENTS AGENTS FOR GAUCHER DISEASE miglustat cap 100 mg 5 PA AGENTS FOR SICKLE CELL ANEMIA OXBRYTA TAB 500MG 5 PA, QL (90 tabs / 30 days) HEMATOPOIETIC GROWTH FACTORS DOPTELET TAB 20MG 5 PA; QL GRANIX INJ 300/1ML 5 PA GRANIX INJ 480/1.6 5 PA MULPLETA TAB 3MG 5 PA; QL REBLOZYL INJ 25MG 5 PA REBLOZYL INJ 75MG 5 PA RETACRIT INJ 2000UNIT 5 PA RETACRIT INJ 3000UNIT 5 PA RETACRIT INJ 4000UNIT 5 PA RETACRIT INJ 10000UNT 5 PA RETACRIT INJ 40000UNT 5 PA IMMUNOLOGIC AGENTS BIOLOGIC DISEASE-MODIFYING AGENTS ENBREL INJ 25/0.5ML 5 PA; QL ENBREL INJ 25MG 5 PA; QL

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 98 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits ENBREL INJ 50MG/ML 5 PA; QL ENBREL SRCLK INJ 50MG/ML 5 PA; QL HUMIRA INJ 10MG/0.2 5 PA; QL HUMIRA KIT 20MG/0.4 5 PA; QL HUMIRA KIT 40MG/0.8 5 PA; QL HUMIRA PEN INJ 40MG/0.8 5 PA; QL SIMPONI ARIA SOL 50MG/4ML 5 ST, PA; QL DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDS) CUPRIMINE CAP 250MG 5 PA hydroxychloroquine sulfate tab 200 mg 2 leflunomide tab 10 mg 2 leflunomide tab 20 mg 2 OTREXUP INJ 7.5/0.4 5 PA; QL OTREXUP INJ 10MG 5 PA, QL (1.6 / 21 days); QL OTREXUP INJ 15MG 5 PA, QL (1.6 / 21 days); QL OTREXUP INJ 20MG 5 PA; QL OTREXUP INJ 25MG 5 PA; QL PENICILLAMIN POW 5 penicillamine cap 250 mg 5 PA RASUVO INJ 7.5MG 5 PA; QL RASUVO INJ 10MG 5 PA; QL RASUVO INJ 12.5MG 5 PA; QL RASUVO INJ 15MG 5 PA; QL RASUVO INJ 17.5MG 5 PA; QL RASUVO INJ 22.5MG 5 PA; QL RASUVO INJ 25MG 5 PA; QL RASUVO INJ 27.5MG 5 PA; QL RASUVO INJ 30MG 5 PA; QL RIDAURA CAP 3MG 5 IMMUNE GLOBULINS ATGAM INJ 250MG 5 CARIMUNE NF INJ 6GM 5 PA CARIMUNE NF INJ 12GM 5 PA CUVITRU INJ 2GM/10ML 5 PA CUVITRU INJ 4GM/20ML 5 PA CUVITRU SOL 1GM/5ML 5 PA FLEBOGAMMA INJ 20/400ML 5 PA GAMASTAN INJ 5 PA GAMMAGARD INJ 1GM/10ML 5 PA GAMMAGARD INJ 2.5GM/25 5 PA GAMMAGARD INJ 5GM/50ML 5 PA GAMMAGARD INJ 10GM/100 5 PA GAMMAGARD INJ 20GM/200 5 PA

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 99 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits GAMMAGARD SD INJ 5GM HU 5 PA GAMMAGARD SD INJ 10GM HU 5 PA GAMUNEX-C INJ 40/400ML 5 PA HIZENTRA INJ 10/50ML 5 PA OCTAGAM INJ 1GM 5 PA OCTAGAM INJ 2GM/20ML 5 PA PRIVIGEN INJ 5 GRAMS 5 PA THYMOGLOBULN INJ 25MG 5 IMMUNOMODULATORS, INTERFERONS ACTIMMUNE INJ 2MU/0.5 5 PA ALFERON N INJ 5MU/ML 5 PA INTRON A INJ 10MU 5 PA INTRON A INJ 18MU 5 PA INTRON A INJ 25MU 5 PA INTRON A INJ 50MU 5 PA PEG-INTRON KIT 50MCG RP 5 PA; QL PEG-INTRON KIT 80MCG 5 PA; QL PEG-INTRON KIT 120 RP 5 PA; QL PEG-INTRON KIT 150MCG 5 PA; QL PEGASYS INJ 5 PA; QL PEGASYS INJ 180MCG/M 5 PA; QL PEGASYS INJ PROCLICK 5 PA; QL SYLATRON KIT 200MCG 5 PA SYLATRON KIT 300MCG 5 PA SYLATRON KIT 600MCG 5 PA IMMUNOMODULATORS, MISCELLANEOUS ARCALYST INJ 220MG 5 PA; QL ILARIS INJ 150MG 5 PA; QL OTEZLA TAB 10/20/30 5 PA; QL OTEZLA TAB 30MG 5 PA; QL IMMUNOSUPPRESSANTS, ANTIMETABOLITES azathioprine tab 50 mg 2 mycophenolate mofetil cap 250 mg 2 mycophenolate mofetil for oral susp 200 5 mg/ml mycophenolate mofetil tab 500 mg 2 mycophenolate sodium tab dr 180 mg 2 (mycophenolic acid equiv) mycophenolate sodium tab dr 360 mg 2 (mycophenolic acid equiv) IMMUNOSUPPRESSANTS, CALCINEURIN INHIBITORS cyclosporine cap 25 mg 2 cyclosporine cap 100 mg 2 cyclosporine iv soln 50 mg/ml 5 cyclosporine modified cap 25 mg 2 MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 100 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits cyclosporine modified cap 50 mg 2 cyclosporine modified cap 100 mg 2 cyclosporine modified oral soln 100 mg/ml 2 PROGRAF INJ 5MG/ML 5 tacrolimus cap 0.5 mg 2 tacrolimus cap 1 mg 2 tacrolimus cap 5 mg 2 IMMUNOSUPPRESSANTS, MISCELLANEOUS BENLYSTA INJ 120MG 5 PA BENLYSTA INJ 200MG/ML 5 PA BENLYSTA INJ 400MG 5 PA NULOJIX INJ 250MG 5 PA SIMULECT INJ 10MG 5 SIMULECT INJ 20MG 5 IMMUNOSUPPRESSANTS, RAPAMYCIN DERIVATIVE RAPAMUNE SOL 1MG/ML 5 PA sirolimus tab 0.5 mg 2 PA sirolimus tab 1 mg 2 PA sirolimus tab 2 mg 2 PA ZORTRESS TAB 0.5MG 5 PA ZORTRESS TAB 0.25MG 5 PA ZORTRESS TAB 0.75MG 5 PA MONOCLONAL ANTIBODIES SYNAGIS INJ 50MG 5 PA; QL SYNAGIS INJ 100MG/ML 5 PA; QL INSULIN HUMAN INSULIN TOUJEO SOLO INJ 300IU/ML 3 QL TRESIBA FLEX INJ 100UNIT 3 TRESIBA FLEX INJ 200UNIT 3 LAXATIVES LAXATIVE COMBINATIONS peg 3350-kcl-na bicarb-nacl-na sulfate for 2 soln 236 gm peg 3350-kcl-na bicarb-nacl-na sulfate for 2 soln 240 gm peg 3350-kcl-sod bicarb-nacl for soln 420 2 gm LYMPHATIC AGENTS INTERLEUKIN-6 (IL-6) ANTAGONISTS SYLVANT SOL 100MG 5 PA SYLVANT SOL 400MG 5 PA

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 101 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits MACROLIDES ERYTHROMYCINS erythromycin ethylsuccinate for susp 200 4 PA mg/5ml erythromycin ethylsuccinate for susp 400 4 PA mg/5ml MIGRAINE PRODUCTS MIGRAINE COMBINATIONS ergotamine w/ caffeine tab 1-100 mg 4 PA, QL (40 tabs per 28 days) MIGRAINE PRODUCTS - MONOCLONAL ANTIBODIES AIMOVIG INJ 70MG/ML 5 PA; QL AIMOVIG INJ 140MG/ML 5 PA; QL AJOVY INJ 225/1.5 5 PA; QL EMGALITY INJ 100MG/ML 5 PA, QL (3 ml per 30 days) EMGALITY INJ 120MG/ML 5 PA; QL SEROTONIN AGONISTS eletriptan hydrobromide tab 20 mg (base 2 QL equivalent) eletriptan hydrobromide tab 40 mg (base 2 QL equivalent) frovatriptan succinate tab 2.5 mg (base 4 ST; QL equivalent) MISCELLANEOUS DIAGNOSTIC AGENTS GLUCAGON INJ 1MG 3 QL INFUSION SUPPLIES HEP SOD/NACL INJ 25000UNT 2 heparin sodium (porcine) 100 unit/ml in 2 d5w heparin sodium (porcine)-dextrose iv sol 2 20000 unit/500ml-5% heparin sodium (porcine)-dextrose iv sol 2 25000 unit/500ml-5% OTHER NEXAVIR INJ 4 MISCELLANEOUS THERAPEUTIC CLASSES CHELATING AGENTS penicillamine tab 250 mg 5 PA IMMUNOSUPPRESSIVE AGENTS sirolimus oral soln 1 mg/ml 2 PA IRRIGATION SOLUTIONS *irrigation solution, physiological** 4

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 102 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits POTASSIUM REMOVING AGENTS LOKELMA PAK 5GM 5 PA; QL LOKELMA PAK 10GM 5 PA; QL MIXED VACCINE COMBINATIONS MIXED VACCINE COMBINATIONS COMVAX INJ 6 MOUTH/THROAT/DENTAL AGENTS ANTISEPTICS - MOUTH/THROAT DEBACTEROL SOL 30-50% 4 MUSCULOSKELETAL THERAPY AGENTS CENTRAL MUSCLE RELAXANTS GABLOFEN INJ 50MCG/ML 5 GABLOFEN INJ 20000/20 5 NASAL AGENTS - SYSTEMIC AND TOPICAL NASAL STEROIDS OMNARIS SPR 4 ST triamcinolone acetonide nasal aerosol 4 suspension 55 mcg/act NUTRITIONAL / SUPPLEMENTS DIETARY MANAGEMENT PRODUCTS CEREFOLIN TAB 2 folbic tab 2 folic acid-pyridoxine-cyanocobalamin tab 2 2.5-25-2 mg L-METHYL- TAB B6-B12 2 L-METHYL-MC TAB 2 L-METHYL-MC TAB NAC 2 METAFOLBIC TAB 2 METAFOLBIC TAB PLUS 2 ELECTROLYTES, MISCELLANEOUS pot phos monobasic w/sod phos di & 2 monobas tab 155-852-130mg ELECTROLYTES, POTASSIUM KLOR-CON M15 TAB 15MEQ ER 2 pot bicarbonate & chloride effer tab 25 2 meq potassium bicarbonate effer tab 25 meq 2 potassium chloride cap er 8 meq 2 potassium chloride cap er 10 meq 2 potassium chloride microencapsulated crys 2 er tab 10 meq potassium chloride microencapsulated crys 2 er tab 20 meq potassium chloride tab er 8 meq (600 mg) 2

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 103 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits potassium chloride tab er 10 meq 2 potassium chloride tab er 20 meq (1500 2 mg) ELECTROLYTES, POTASSIUM-REMOVING AGENTS sodium polystyrene sulfonate oral susp 15 2 gm/60ml *sodium polystyrene sulfonate powder** 2 sodium polystyrene sulfonate rectal susp 2 30 gm/120ml VELTASSA POW 8.4GM 5 PA; QL VELTASSA POW 16.8GM 5 PA; QL VELTASSA POW 25.2GM 5 PA; QL VITAMINS AND MINERALS, FOLIC ACID / COMBINATIONS folic acid cap 0.8 mg 6 folic acid tab 1 mg 2 folic acid tab 400 mcg 6 folic acid tab 800 mcg 6 folic acid-vitamin b6-vitamin b12 tab 2.2- 2 25-0.5 mg folic acid-vitamin b6-vitamin b12 tab 2.2- 2 25-1 mg folic acid-vitamin b6-vitamin b12 tab 2.5- 2 25-1 mg VITAMINS AND MINERALS, MISCELLANEOUS *b-complex vitamin tab** 6 *b-complex w/ c & folic acid cap 1 mg*** 2 *b-complex w/ c & folic acid tab 1 mg*** 2 *b-complex w/ c & folic acid tab 5 mg*** 2 *b-complex w/ c & folic acid tab*** 6 *b-complex w/ c cap** 6 *b-complex w/ folic acid tab** 6 *b-complex w/biotin & folic acid tab*** 6 calcium citrate-vitamin d tab 315 mg-200 6 unit (elemental ca) calcium citrate-vitamin d tab 1500 mg-200 6 unit CALCIUM-FA WAF PLUS D 2 carbonyl iron susp 15 mg/1.25ml 6 (elemental iron) cholecalciferol cap 1.25 mg (50000 unit) 4 DIALYVITE/ TAB ZINC 2 ergocalciferol cap 1.25 mg (50000 unit) 2 *fe asp gly-fe polysacch-succ ac-c-threon 2 ac-b12-fa cap*** *fe asparto gly-fe fum-b12-fa-c-succinic ac 2 tab ther pack** MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 104 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits *fe fum-iron polysacch complex-fa-b 2 cmplx-c-zn-mn-cu cap*** fe fumarate w/ b12-vit c-fa-ifc cap 110- 2 0.015-75-0.5-240 mg fe fumarate-vit c-vit b12-fa cap 460 (151 2 fe)-60-0.01-1 mg FER-IN-SOL DRO 15MG/ML 6 FERRALET 90 TAB 2 FERRAPLUS 90 TAB 2 ferrous fumarate-folic acid tab 324-1 mg 2 FERROUS SUL LIQ 220/5ML 6 ferrous sulfate elixir 220 mg/5ml (44 6 mg/5ml elemental fe) ferrous sulfate soln 75 mg/ml (15 mg/ml 6 elemental fe) FERROUS SULFATE SYRUP 300 MG/5ML 6 (60 MG/5ML ELEMENTAL FE) FLUOR-A-DAY CHW 0.5MG F 6 FLUOR-A-DAY CHW 0.25MG F 6 FLUOR-A-DAY CHW 1MG F 2 FLUORABON DRO 6 FOCALGIN DSS TAB 90-1MG 2 FOLIVANE-F CAP 2 FOLIVANE-PLS CAP 2 FULL SPECT TAB B/ VIT C 6 FUSION PLUS CAP 4 GALZIN CAP 25MG 4 PA GALZIN CAP 50MG 4 PA HEMATOGEN FA CAP 2 ICAR PEDS SUS GRAPE 6 iron polysacch complex-vit b12-fa cap 150- 2 0.025-1 mg *iron-docusate-b12-folic acid-c-e-cu-biotin 2 tab 150-1 mg*** iron-folic acid-vit c-vit b6-vit b12-zinc tab 2 150-1.25 mg iron-vit c-vit b12-folic acid tab 100-250- 2 0.025-1 mg LOZI-FLUR LOZ 1MG F 2 LURIDE CHW 0.5MG F 6 LURIDE CHW 0.25MG F 6 LURIDE DRO 0.5MG/ML 6 MULTIGEN PLS TAB 2 MULTIGEN TAB 2 MULTIGEN TAB FOLIC 2 *multiple vitamin tab** 6

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 105 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits MYKIDZ IRON SUS 15/1.5ML 6 *pediatric multiple vitamins w/ fl-fe drops 6 0.25-10 mg/ml** *pediatric multiple vitamins w/ fluoride 6 chew tab 0.5 mg*** *pediatric multiple vitamins w/ fluoride 6 chew tab 0.25 mg*** *pediatric multiple vitamins w/ fluoride 2 chew tab 1 mg*** *pediatric multiple vitamins w/ fluoride 6 soln 0.5 mg/ml*** *pediatric multiple vitamins w/ fluoride 6 soln 0.25 mg/ml*** *pediatric multiple vitamins w/ iron drops 6 10 mg/ml** *pediatric vitamins acd fluoride & fe drops 6 0.25-10 mg/ml*** *pediatric vitamins acd w/ fluoride soln 0.5 6 mg/ml*** *pediatric vitamins acd w/ fluoride soln 6 0.25 mg/ml*** phytonadione tab 5 mg 4 sodium fluoride chew tab 0.5 mg f (from 6 1.1 mg naf) sodium fluoride chew tab 0.25 mg f (from 6 0.55 mg naf) sodium fluoride chew tab 1 mg f (from 2.2 2 mg naf) sodium fluoride soln 0.5 mg/ml f (from 1.1 6 mg/ml naf) sodium fluoride soln 0.25 mg/drop f (from 6 0.55 mg/drop naf) sodium fluoride soln 0.125 mg/drop f 6 (0.275 mg/drop naf) sodium fluoride tab 0.5 mg f (from 1.1 mg 6 naf) TARON FORTE CAP 2 OPHTHALMIC AGENTS BETA-BLOCKERS - OPHTHALMIC dorzolamide hcl-timolol maleate ophth sol 2 22.3-6.8 mg/ml pf OPHTHALMIC ANTI-INFECTIVES moxifloxacin hcl ophth soln 0.5% (base 2 equiv) OPHTHALMIC KINASE INHIBITORS RHOPRESSA SOL 0.02% 4 ST

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 106 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits OPHTHALMIC STEROIDS loteprednol etabonate ophth susp 0.5% 2 OPHTHALMICS - MISC. bromfenac sodium ophth soln 0.09% (base 4 equiv) (once-daily) PROSTAGLANDINS - OPHTHALMIC travoprost ophth soln 0.004% 2 (benzalkonium free) (bak free) PASSIVE IMMUNIZING AGENTS - COMBINATIONS PASSIVE IMMUNIZING AGENTS - COMBINATIONS HYQVIA INJ 2.5-200 5 PA HYQVIA INJ 5-400 5 PA HYQVIA INJ 10-800 5 PA HYQVIA INJ 20-1600 5 PA HYQVIA INJ 30-2400 5 PA PROGESTIN CONTRACEPTIVES - IMPLANTS PROGESTIN CONTRACEPTIVES - IMPLANTS IMPLANON IMP 68MG 6 PROGESTIN CONTRACEPTIVES - INJECTABLE PROGESTIN CONTRACEPTIVES - INJECTABLE DEPO-SQ PROV INJ 104 6 PA; QL KYLEENA IUD 19.5MG 6 QL medroxyprogesterone acetate im susp 150 6 QL mg/ml medroxyprogesterone acetate im susp 6 QL prefilled syr 150 mg/ml SKYLA IUD 13.5MG 6 PROGESTIN CONTRACEPTIVES - IUD PROGESTIN CONTRACEPTIVES - IUD LILETTA IUD 52MG 6 MIRENA IUD SYSTEM 6 PROGESTIN CONTRACEPTIVES - ORAL PROGESTIN CONTRACEPTIVES - ORAL norethindrone tab 0.35 mg 6 PROGESTINS PROGESTINS hydroxyprogesterone caproate im in oil 5 PA 250 mg/ml MAKENA INJ 275MG 5 PA progesterone im in oil 50 mg/ml 2 PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. AGENTS FOR CHEMICAL DEPENDENCY LUCEMYRA TAB 0.18MG 4 PA; QL

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 107 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits MULTIPLE SCLEROSIS AGENTS AVONEX KIT 30MCG 5 PA; QL glatiramer acetate soln prefilled syringe 20 5 PA; QL mg/ml glatiramer acetate soln prefilled syringe 40 5 PA; QL mg/ml TRANSTHYRETIN AMYLOIDOSIS AGENTS TEGSEDI INJ 284/1.5 5 PA; QL PULMONARY FIBROSIS AGENTS PULMONARY FIBROSIS AGENTS ESBRIET CAP 267MG 5 PA; QL PULMONARY FIBROSIS AGENTS - KINASE INHIBITORS OFEV CAP 100MG 5 PA; QL OFEV CAP 150MG 5 PA; QL RESPIRATORY ANAPHYLAXIS TREATMENT AGENTS ADRENALIN INJ 1MG/ML 2 ADRENALIN INJ 30/30ML 2 AUVI-Q INJ 0.3MG 3 QL epinephrine pf inj 1 mg/ml 2 epinephrine pf soln prefilled syringe 1 2 mg/10ml (0.1 mg/ml) epinephrine solution auto-injector 0.15 4 mg/0.15ml (1:1000) EPIPEN 2-PAK INJ 0.3MG 3 QL EPIPEN-JR INJ 0.15MG 3 QL ANTICHOLINERGIC/BETA AGONIST COMBINATIONS, LONG ACTING ANORO ELLIPT AER 62.5-25 3 STIOLTO AER 2.5-2.5 3 ANTICHOLINERGIC/BETA AGONIST COMBINATIONS, SHORT ACTING COMBIVENT AER 20-100 3 ipratropium-albuterol nebu soln 0.5-2.5(3) 2 mg/3ml ANTICHOLINERGICS ATROVENT HFA AER 17MCG 4 ipratropium bromide inhal soln 0.02% 2 SPIRIVA AER 1.25MCG 3 SPIRIVA CAP HANDIHLR 3 SPIRIVA SPR 2.5MCG 3 ANTIHISTAMINE/DECONGESTANT COMBINATIONS promethazine & phenylephrine syrup 6.25- 2 5 mg/5ml

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 108 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits ANTIHISTAMINES, LOW-SEDATING cetirizine hcl oral soln 1 mg/ml (5 mg/5ml) 2 desloratadine tab 5 mg 4 levocetirizine dihydrochloride soln 2.5 2 mg/5ml (0.5 mg/ml) levocetirizine dihydrochloride tab 5 mg 2 ANTIHISTAMINES, SEDATING carbinoxamine maleate soln 4 mg/5ml 2 carbinoxamine maleate tab 4 mg 2 clemastine fumarate tab 2.68 mg 2 cyproheptadine hcl syrup 2 mg/5ml 2 cyproheptadine hcl tab 4 mg 2 dexchlorpheniramine maleate syrup 2 4 mg/5ml diphenhydramine hcl inj 50 mg/ml 2 hydroxyzine hcl im soln 25 mg/ml 2 hydroxyzine hcl im soln 50 mg/ml 2 hydroxyzine hcl syrup 10 mg/5ml 2 hydroxyzine hcl tab 10 mg 2 hydroxyzine hcl tab 25 mg 2 hydroxyzine hcl tab 50 mg 2 hydroxyzine pamoate cap 25 mg 2 hydroxyzine pamoate cap 50 mg 2 hydroxyzine pamoate cap 100 mg 2 ANTITUSSIVE COMBINATIONS, NON-OPIOID phenylephrine-guaifenesin liqd 7.5-100 2 mg/5ml (1.5-20 mg/ml) promethazine-dm syrup 6.25-15 mg/5ml 2 pseudoephed-bromphen-dm syrup 30-2-10 2 mg/5ml ANTITUSSIVE COMBINATIONS, OPIOID FLOWTUSS SOL 2.5-200 4 guaifenesin-codeine soln 100-6.3 mg/5ml 2 guaifenesin-codeine soln 100-10 mg/5ml 2 hydrocod polst-chlorphen polst er susp 10- 2 QL 8 mg/5ml hydrocodone w/ homatropine syrup 5-1.5 2 ST mg/5ml hydrocodone w/ homatropine tab 5-1.5 mg 2 ST LORTUSS EX LIQ 2 PHENHIST DH LIQ 30-2-10 2 ST phenylephrine w/ dm-gg tab 10-20-400 2 mg promethazine w/ codeine syrup 6.25-10 2 ST mg/5ml

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 109 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits promethazine-phenylephrine-codeine syrup 2 ST 6.25-5-10 mg/5ml pseudoephedrine w/ cod-gg soln 30-10- 2 100 mg/5ml RYDEX LIQ 2 ST ANTITUSSIVES benzonatate cap 100 mg 2 benzonatate cap 200 mg 2 BETA AGONISTS, INHALANTS, LONG ACTING, Hand-held Active Inhalation ARCAPTA CAP 75MCG 4 ST FORADIL CAP AEROLIZE 3 SEREVENT DIS AER 50MCG 3 STRIVERDI AER 2.5MCG 4 BETA AGONISTS, INHALANTS, LONG ACTING, Nebulized Passive Inhalation BROVANA NEB 15MCG 4 PERFOROMIST NEB 20MCG 4 BETA AGONISTS, INHALANTS, SHORT ACTING albuterol sulfate soln nebu 0.5% (5 mg/ml) 2 albuterol sulfate soln nebu 0.63 mg/3ml 2 (base equiv) albuterol sulfate soln nebu 0.083% (2.5 2 mg/3ml) albuterol sulfate soln nebu 1.25 mg/3ml 2 (base equiv) levalbuterol hcl soln nebu 0.31 mg/3ml 2 (base equiv) levalbuterol hcl soln nebu 0.63 mg/3ml 2 (base equiv) levalbuterol hcl soln nebu 1.25 mg/3ml 2 (base equiv) levalbuterol hcl soln nebu conc 1.25 2 mg/0.5ml (base equiv) metaproterenol sulfate syrup 10 mg/5ml 2 metaproterenol sulfate tab 10 mg 2 metaproterenol sulfate tab 20 mg 2 PROAIR HFA AER 3 PA; QL PROVENTIL AER HFA 3 PA; QL VENTOLIN HFA AER 3 QL BETA AGONISTS, INJECTABLE terbutaline sulfate inj 1 mg/ml 2 BETA AGONISTS, ORAL AGENTS albuterol sulfate syrup 2 mg/5ml 2 albuterol sulfate tab 2 mg 2

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 110 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits albuterol sulfate tab 4 mg 2 albuterol sulfate tab er 12hr 4 mg 2 albuterol sulfate tab er 12hr 8 mg 2 terbutaline sulfate tab 2.5 mg 2 terbutaline sulfate tab 5 mg 2 CYSTIC FIBROSIS BETHKIS NEB 300/4ML 5 QL CAYSTON INH 75MG 5 QL KALYDECO PAK 50MG 5 PA; QL KALYDECO PAK 75MG 5 PA; QL KALYDECO TAB 150MG 5 PA; QL ORKAMBI TAB 200-125 5 PA; QL PULMOZYME SOL 1MG/ML 5 PA; QL tobramycin nebu soln 300 mg/5ml 5 QL LEUKOTRIENE MODIFIERS montelukast sodium chew tab 4 mg (base 2 QL equiv) montelukast sodium chew tab 5 mg (base 2 QL equiv) montelukast sodium oral granules packet 4 2 QL mg (base equiv) montelukast sodium tab 10 mg (base 2 QL equiv) zafirlukast tab 10 mg 2 zafirlukast tab 20 mg 2 ZYFLO TAB 600MG 5 MAST CELL STABILIZERS cromolyn sodium soln nebu 20 mg/2ml 2 MISCELLANEOUS acetylcysteine inhal soln 10% 2 acetylcysteine inhal soln 20% 2 ARALAST NP INJ 400MG 5 PA ARALAST NP INJ 500MG 5 ARALAST NP INJ 800MG 5 PA GLASSIA INJ 5 PA ipratropium bromide nasal soln 0.03% (21 2 mcg/spray) ipratropium bromide nasal soln 0.06% (42 2 mcg/spray) NEBUSAL NEB 6% 3 NUCALA INJ 100MG 5 PA; QL PROLASTIN-C INJ 1000MG 5 PA sodium chloride soln nebu 3% 2 sodium chloride soln nebu 7% 2 sodium chloride soln nebu 10% 2

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 111 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits XOLAIR SOL 150MG 5 PA; QL ZEMAIRA INJ 1000MG 5 PA NASAL ANTIHISTAMINES azelastine hcl nasal spray 0.1% (137 2 mcg/spray) azelastine hcl nasal spray 0.15% (205.5 2 mcg/spray) olopatadine hcl nasal soln 0.6% 2 ST NASAL STEROIDS / COMBINATIONS budesonide nasal susp 32 mcg/act 2 flunisolide nasal soln 25 mcg/act (0.025%) 2 fluticasone propionate nasal susp 50 2 mcg/act VERAMYST SPR 27.5MCG 3 PHOSPHODIESTERASE-4 INHIBITORS DALIRESP TAB 500MCG 4 PA STEROID INHALANTS ARNUITY ELPT INH 100MCG 3 ARNUITY ELPT INH 200MCG 3 budesonide inhalation susp 0.5 mg/2ml 2 budesonide inhalation susp 0.25 mg/2ml 2 budesonide inhalation susp 1 mg/2ml 2 FLOVENT DISK AER 50MCG 3 FLOVENT DISK AER 100MCG 3 FLOVENT DISK AER 250MCG 3 FLOVENT HFA AER 44MCG 3 FLOVENT HFA AER 110MCG 3 FLOVENT HFA AER 220MCG 3 PULMICORT INH 90MCG 3 PULMICORT INH 180MCG 3 QVAR AER 40MCG 3 QVAR AER 80MCG 3 STEROID/BETA AGONIST COMBINATIONS ADVAIR DISKU AER 100/50 3 ADVAIR DISKU AER 250/50 3 ADVAIR DISKU AER 500/50 3 ADVAIR HFA AER 45/21 3 ADVAIR HFA AER 115/21 3 ADVAIR HFA AER 230/21 3 BREO ELLIPTA INH 100-25 3 BREO ELLIPTA INH 200-25 3 SYMBICORT AER 80-4.5 3 SYMBICORT AER 160-4.5 3

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 112 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits TOPICAL DECONGESTANTS ADRENALIN SOL 1:1000 2 XANTHINES aminophylline inj 25 mg/ml 2 theophylline soln 80 mg/15ml 2 theophylline tab er 12hr 100 mg 2 theophylline tab er 12hr 200 mg 2 theophylline tab er 12hr 300 mg 2 theophylline tab er 12hr 450 mg 2 theophylline tab er 24hr 400 mg 2 theophylline tab er 24hr 600 mg 2 RESPIRATORY AGENTS - MISC. CYSTIC FIBROSIS AGENTS SYMDEKO TAB 100-150 5 PA; QL TRIKAFTA TAB 5 PA; QL SELECTIVE CGMP PHOSPHODIESTERASE TYPE 5 INHIBITORS SELECTIVE CGMP PHOSPHODIESTERASE TYPE 5 INHIBITORS CIALIS TAB 2.5MG 4 PA; QL CIALIS TAB 5MG 4 PA; QL SPERMICIDES SPERMICIDES CONCEPTROL GEL 4% 6 ENCARE SUP 100MG 6 GYNOL II GEL 3% 6 nonoxynol-9 gel 4% 6 SHUR-SEAL GEL 2% 6 TODAY SPONGE MIS 6 VCF VAGINAL AER CONTRACP 6 VCF VAGINAL MIS CONTRACP 6 THYROID AGENTS THYROID HORMONES THYROLAR-1 TAB 60MG 4 THYROLAR-1/2 TAB 30MG 4 THYROLAR-1/4 TAB 15MG 4 THYROLAR-2 TAB 120MG 4 THYROLAR-3 TAB 180MG 4 TOPICAL DERMATOLOGY, ACNE: ORAL CLARAVIS 4 DERMATOLOGY, ACNE: TOPICAL adapalene cream 0.1% 2 PA AVAR LS PAD 10-2% 4 PA AVAR PAD 9.5-5% 4 PA

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 113 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits clindamycin phosphate gel 1% 2 QL clindamycin phosphate lotion 1% 2 QL clindamycin phosphate soln 1% 2 QL clindamycin phosphate swab 1% 2 clindamycin phosphate-benzoyl peroxide 4 PA gel 1-5% CLINDAP-T CRE 4 erythromycin gel 2% 4 erythromycin pads 2% 2 erythromycin soln 2% 2 *sulfacetamide sod-sulfur wash 9-4.5% & 2 sunscreen kit*** sulfacetamide sodium lotion 10% (acne) 2 sulfacetamide sodium w/ sulfur emulsion 2 10-1% sulfacetamide sodium w/ sulfur emulsion 2 10-5% TAZORAC CRE 0.05% 4 PA TAZORAC GEL 0.1% 4 PA TAZORAC GEL 0.05% 4 PA tretinoin cream 0.1% 2 tretinoin cream 0.05% 2 tretinoin cream 0.025% 2 tretinoin gel 0.01% 2 tretinoin gel 0.025% 2 DERMATOLOGY, ACTINIC KERATOSIS fluorouracil cream 5% 2 fluorouracil soln 2% 2 fluorouracil soln 5% 2 DERMATOLOGY, ANTI-INFECTIVE/ANTI-INFLAMMATORY COMBINATIONS CORTISPORIN CRE 0.5% 4 CORTISPORIN OIN 1% 4 NEO-SYNALAR CRE 4 PA DERMATOLOGY, ANTIBIOTICS gentamicin sulfate cream 0.1% 2 gentamicin sulfate oint 0.1% 2 mupirocin calcium cream 2% 2 ST mupirocin oint 2% 2 silver sulfadiazine cream 1% 2 DERMATOLOGY, ANTIFUNGALS ciclopirox olamine cream 0.77% (base 2 equiv) ciclopirox solution 8% 2

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 114 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits clotrimazole w/ betamethasone cream 1- 2 0.05% clotrimazole w/ betamethasone lotion 1- 4 0.05% econazole nitrate cream 1% 4 PA ERTACZO CRE 2% 4 PA KERYDIN SOL 5% 5 PA ketoconazole cream 2% 2 ketoconazole shampoo 2% 2 MENTAX CRE 1% 4 PA NAFTIN GEL 1% 4 PA nystatin cream 100000 unit/gm 2 nystatin oint 100000 unit/gm 2 nystatin topical powder 100000 unit/gm 2 nystatin-triamcinolone cream 100000-0.1 2 unit/gm-% nystatin-triamcinolone oint 100000-0.1 2 unit/gm-% oxiconazole nitrate cream 1% 2 PA; QL DERMATOLOGY, ANTIPSORIATICS, INJECTABLE COSENTYX INJ 150MG/ML 5 PA; QL COSENTYX PEN INJ 300DOSE 5 PA; QL STELARA INJ 45MG/0.5 5 PA; QL STELARA INJ 90MG/ML 5 PA; QL DERMATOLOGY, ANTIPSORIATICS, ORAL acitretin cap 10 mg 5 ST acitretin cap 17.5 mg 5 ST acitretin cap 25 mg 5 ST methoxsalen rapid cap 10 mg 5 PA 8-MOP CAP 10MG 5 PA DERMATOLOGY, ANTIPSORIATICS, TOPICAL calcipotriene cream 0.005% 4 QL calcipotriene oint 0.005% 4 QL calcipotriene soln 0.005% (50 mcg/ml) 4 QL DRITHO-CREME CRE HP 1% 2 DERMATOLOGY, ANTISEBORRHEICS selenium sulfide lotion 2.5% 2 selenium sulfide shampoo 2.25% 2 sulfacetamide sodium liquid 10% 2 DERMATOLOGY, CORTICOSTEROIDS: HIGH POTENCY amcinonide cream 0.1% 4 amcinonide lotion 0.1% 4 AMCINONIDE OIN 0.1% 4 betamethasone dipropionate augmented 2 cream 0.05%

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 115 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits betamethasone dipropionate augmented 4 lotion 0.05% betamethasone dipropionate cream 0.05% 2 betamethasone dipropionate lotion 0.05% 2 betamethasone dipropionate oint 0.05% 2 desoximetasone cream 0.25% 4 QL desoximetasone gel 0.05% 4 PA; QL desoximetasone oint 0.25% 4 PA; QL fluocinonide cream 0.05% 2 QL fluocinonide emulsified base cream 0.05% 2 fluocinonide gel 0.05% 2 fluocinonide oint 0.05% 4 fluocinonide soln 0.05% 2 DERMATOLOGY, CORTICOSTEROIDS: LOW POTENCY alclometasone dipropionate cream 0.05% 2 PA alclometasone dipropionate oint 0.05% 2 PA desonide cream 0.05% 4 PA; QL desonide oint 0.05% 4 PA; QL fluocinolone acetonide cream 0.01% 2 fluocinolone acetonide oil 0.01% (body oil) 2 fluocinolone acetonide oil 0.01% (scalp oil) 2 fluocinolone acetonide soln 0.01% 2 hydrocortisone cream 2.5% 2 hydrocortisone lotion 2.5% 2 hydrocortisone oint 1% 2 hydrocortisone oint 2.5% 2 mometasone furoate cream 0.1% 2 mometasone furoate oint 0.1% 2 mometasone furoate solution 0.1% (lotion) 2 pramoxine-hc cream 1-2.5% 2 prednicarbate cream 0.1% 2 prednicarbate oint 0.1% 2 TACLONEX SUS 4 PA triamcinolone acetonide cream 0.1% 1 triamcinolone acetonide cream 0.5% 2 triamcinolone acetonide cream 0.025% 2 triamcinolone acetonide lotion 0.1% 2 triamcinolone acetonide lotion 0.025% 2 triamcinolone acetonide oint 0.1% 2 triamcinolone acetonide oint 0.5% 2 triamcinolone acetonide oint 0.025% 2 TRIDERMA CRE FORTE 4 DERMATOLOGY, CORTICOSTEROIDS: MEDIUM POTENCY betamethasone valerate cream 0.1% (base 2 equivalent)

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 116 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits betamethasone valerate lotion 0.1% (base 2 equivalent) betamethasone valerate oint 0.1% (base 2 equivalent) desoximetasone cream 0.05% 4 QL desoximetasone oint 0.05% 4 PA; QL fluocinolone acetonide cream 0.025% 2 fluocinolone acetonide oint 0.025% 2 fluticasone propionate cream 0.05% 2 fluticasone propionate oint 0.005% 2 DERMATOLOGY, CORTICOSTEROIDS: VERY HIGH POTENCY betamethasone dipropionate augmented 4 gel 0.05% betamethasone dipropionate augmented 4 oint 0.05% clobetasol propionate cream 0.05% 2 PA; QL clobetasol propionate gel 0.05% 2 PA; QL clobetasol propionate oint 0.05% 2 PA; QL clobetasol propionate soln 0.05% 2 PA; QL halobetasol propionate cream 0.05% 2 QL halobetasol propionate oint 0.05% 4 QL DERMATOLOGY, EMOLLIENTS lactic acid (ammonium lactate) cream 12% 2 lactic acid (ammonium lactate) lotion 10% 2 lactic acid (ammonium lactate) lotion 12% 2 lactic acid (ammonium lactate) lotion 12% 2 lactic acid w/ vitamin e cream 10%-3500 2 unit/30gm urea lotion 40% 2 DERMATOLOGY, IMMUNOMODULATORS pimecrolimus cream 1% 4 PA tacrolimus oint 0.1% 4 PA; QL tacrolimus oint 0.03% 4 PA; QL DERMATOLOGY, LOCAL ANALGESIC lidocaine patch 5% 4 PA; QL DERMATOLOGY, LOCAL ANESTHETICS lidocaine hcl soln 4% 2 PA; QL lidocaine hcl urethral/mucosal gel 2% 2 lidocaine hcl urethral/mucosal gel prefilled 2 syringe 2% lidocaine oint 5% 4 PA; QL lidocaine-prilocaine cream 2.5-2.5% 2 lidocaine-prilocaine cream 2.5-2.5% 2 PA; QL lidocaine-prilocaine cream kit 2.5-2.5% 2 PA QUTENZA KIT 8% 1-PCH 5 PA; QL

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 117 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits SYNERA DIS 70-70MG 4 PA DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE acyclovir oint 5% 4 PA; QL DENAVIR CRE 1% 4 PA; QL ethyl chloride aerosol spray 2 imiquimod cream 5% 2 PANRETIN GEL 0.1% 5 PA podofilox soln 0.5% 2 SALICYLIC AC LIQ 26% 2 salicylic acid cream 6% 2 salicylic acid film forming liquid 27.5% 2 salicylic acid lotion 6% 2 salicylic acid shampoo 6% 2 SANTYL OIN 250/GM 4 PA SILVER NITRA SOL 10% 2 silver nitrate-potassium nitrate applicator 2 75-25% SULFAMYLON CRE 85MG/GM 4 trypsin w/ castor oil & peruvian balsam 2 spray DERMATOLOGY, ROSACEA metronidazole cream 0.75% 2 metronidazole gel 0.75% 2 metronidazole gel 1% 2 metronidazole lotion 0.75% 2 MIRVASO GEL 0.33% 4 PA DERMATOLOGY, SCABICIDES AND PEDICULICIDES EURAX CRE 10% 4 lindane lotion 1% 2 lindane shampoo 1% 4 malathion lotion 0.5% 4 permethrin cream 5% 4 SKLICE LOT 0.5% 4 PA spinosad susp 0.9% 2 DERMATOLOGY, WOUND CARE PRODUCTS AVO CREAM EMU 2 BIAFINE EMU 2 PRUTECT EMU 2 REGRANEX GEL 0.01% 4 QL IRRIGATION SOLUTIONS lactated ringer's for irrigation 2 ringer's solution for irrigation 2 water for irrigation, sterile irrigation soln 2

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 118 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits MOUTH/THROAT/DENTAL AGENTS, MISCELLANEOUS chlorhexidine gluconate soln 0.12% 2 GELCLAIR GEL 4 lidocaine hcl viscous soln 2% 2 sodium fluoride cream 1.1% 2 sodium fluoride gel 1.1% (0.5% f) 2 sodium fluoride rinse 0.2% 2 sodium fluoride rinse 0.2% 2 triamcinolone acetonide dental paste 0.1% 2 MOUTH/THROAT/DENTAL AGENTS, PROTECTANTS ORAMAGICRX SUS 4 SALICEPT SUS 4 OPHTHALMIC, ANTI-INFECTIVE/ANTI-INFLAMMATORY COMBINATIONS bacitracin-polymyxin-neomycin-hc ophth 2 oint 1% BLEPHAMIDE OIN S.O.P. 4 BLEPHAMIDE SUS OP 4 neomycin-polymyxin-dexamethasone 2 ophth oint 0.1% neomycin-polymyxin-dexamethasone 2 ophth susp 0.1% neomycin-polymyxin-hc ophth susp 2 PRED-G S.O.P OIN OP 4 PRED-G SUS OP 4 sulfacetamide sodium-prednisolone ophth 2 soln 10-0.23(0.25)% TOBRADEX ST SUS 0.3-0.05 4 tobramycin-dexamethasone ophth susp 2 0.3-0.1% OPHTHALMIC, ANTI-INFECTIVES bacitracin ophth oint 500 unit/gm 2 bacitracin-polymyxin b ophth oint 2 BETADINE SOL 5% OP 4 CILOXAN OIN 0.3% OP 4 ciprofloxacin hcl ophth soln 0.3% (base 2 equivalent) erythromycin ophth oint 5 mg/gm 2 gatifloxacin ophth soln 0.5% 2 gentamicin sulfate ophth oint 0.3% 2 gentamicin sulfate ophth soln 0.3% 2 levofloxacin ophth soln 0.5% 2 neomycin-bacitrac zn-polymyx 5(3.5)mg- 2 400unt-10000unt op oin

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 119 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits neomycin-polymy-gramicid op sol 1.75- 2 10000-0.025mg-unt-mg/ml ofloxacin ophth soln 0.3% 2 polymyxin b-trimethoprim ophth soln 2 10000 unit/ml-0.1% sulfacetamide sodium ophth oint 10% 2 sulfacetamide sodium ophth soln 10% 2 tobramycin ophth soln 0.3% 2 OPHTHALMIC, ANTI-INFLAMMATORY: NONSTEROIDAL ACUVAIL SOL 0.45% 3 QL bromfenac sodium ophth soln 0.09% (base 2 equivalent) diclofenac sodium ophth soln 0.1% 2 flurbiprofen sodium ophth soln 0.03% 2 ILEVRO DRO 0.3% OP 4 ketorolac tromethamine ophth soln 0.4% 2 QL ketorolac tromethamine ophth soln 0.5% 2 QL NEVANAC SUS 0.1% 4 PROLENSA SOL 0.07% 4 OPHTHALMIC, ANTI-INFLAMMATORY: STEROIDAL ALREX SUS 0.2% 4 dexamethasone sodium phosphate ophth 2 soln 0.1% DUREZOL EMU 0.05% 3 FLAREX SUS 0.1% OP 4 fluorometholone ophth susp 0.1% 2 FML FORTE SUS 0.25% OP 3 FML OIN 0.1% OP 3 ILUVIEN IMP 0.19MG 5 PA; QL LOTEMAX GEL 0.5% 4 LOTEMAX OIN 0.5% 4 LOTEMAX SUS 0.5% 4 MAXIDEX SUS 0.1% OP 4 PRED MILD SUS 0.12% OP 3 PRED SOD PHO SOL 1% OP 2 prednisolone acetate ophth susp 1% 2 TRIESENCE INJ 40MG/ML 4 VEXOL SUS 1% OP 4 OPHTHALMIC, ANTIALLERGICS ALOCRIL SOL 2% 4 ST ALOMIDE SOL 0.1% OP 4 ST azelastine hcl ophth soln 0.05% 2 BEPREVE DRO 1.5% 4 ST cromolyn sodium ophth soln 4% 2 EMADINE SOL 0.05% OP 4 ST

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 120 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits epinastine hcl ophth soln 0.05% 2 LASTACAFT SOL 0.25% 3 olopatadine hcl ophth soln 0.1% (base 2 ST equivalent) OPHTHALMIC, ANTIFUNGALS NATACYN SUS 5% OP 4 OPHTHALMIC, ANTIVIRAL trifluridine ophth soln 1% 2 OPHTHALMIC, BETA-BLOCKERS: NONSELECTIVE carteolol hcl ophth soln 1% 2 levobunolol hcl ophth soln 0.5% 2 metipranolol ophth soln 0.3% 2 timolol maleate ophth gel forming soln 4 0.5% timolol maleate ophth gel forming soln 4 0.25% timolol maleate ophth soln 0.5% 2 timolol maleate ophth soln 0.25% 2 OPHTHALMIC, BETA-BLOCKERS: SELECTIVE betaxolol hcl ophth soln 0.5% 2 OPHTHALMIC, CARBONIC ANHYDRASE INHIBITOR/BETA-BLOCKER COMBINATIONS dorzolamide hcl-timolol maleate ophth soln 2 22.3-6.8 mg/ml OPHTHALMIC, CARBONIC ANHYDRASE INHIBITORS, INJECTABLE acetazolamide sodium for inj 500 mg 2 KEVEYIS TAB 50MG 5 PA; QL OPHTHALMIC, CARBONIC ANHYDRASE INHIBITORS: ORAL acetazolamide cap er 12hr 500 mg 2 acetazolamide tab 125 mg 2 acetazolamide tab 250 mg 2 methazolamide tab 25 mg 2 methazolamide tab 50 mg 2 OPHTHALMIC, CARBONIC ANHYDRASE INHIBITORS: TOPICAL AZOPT SUS 1% OP 4 dorzolamide hcl ophth soln 2% 2 OPHTHALMIC, DIAGNOSTIC PRODUCTS fluorescein w/ benoxinate ophth soln 0.25- 2 0.4% fluorescein w/ proparacaine ophth soln 2 0.25-0.5% OPHTHALMIC, DRY EYE DISEASE RESTASIS EMU 0.05% 3 QL

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 121 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits OPHTHALMIC, MISCELLANEOUS CYSTARAN SOL 0.44% 5 PA; QL EYLEA INJ 2/0.05ML 5 PA JETREA INJ 0.5/0.2 5 PA; QL LUCENTIS SOL 0.3MG 5 PA LUCENTIS SOL 0.5MG 5 PA MACUGEN INJ 5 PA naphazoline hcl ophth soln 0.1% 2 phenylephrine hcl ophth soln 2.5% 2 phenylephrine hcl ophth soln 10% 2 proparacaine hcl ophth soln 0.5% 2 tetracaine hcl ophth soln 0.5% 2 OPHTHALMIC, MYDRIATICS ATROPINE SUL OIN 1% OP 2 atropine sulfate ophth soln 1% 2 cyclopentolate hcl ophth soln 1% 2 cyclopentolate hcl ophth soln 2% 2 homatropine hbr ophth soln 5% 2 tropicamide ophth soln 0.5% 2 tropicamide ophth soln 1% 2 OPHTHALMIC, PARASYMPATHOMIMETICS MIOSTAT INJ 0.01% OP 2 pilocarpine hcl ophth soln 1% 2 pilocarpine hcl ophth soln 2% 2 pilocarpine hcl ophth soln 4% 2 OPHTHALMIC, PROSTAGLANDINS bimatoprost ophth soln 0.03% 3 latanoprost ophth soln 0.005% 2 LUMIGAN SOL 0.01% 3 RESCULA SOL 0.15% 4 travoprost ophth soln 0.004% 3 ZIOPTAN DRO 0.0015% 4 OPHTHALMIC, SYMPATHOMIMETIC/BETA-BLOCKER COMBINATIONS COMBIGAN SOL 0.2/0.5% 3 OPHTHALMIC, SYMPATHOMIMETICS ALPHAGAN P SOL 0.1% 3 apraclonidine hcl ophth soln 0.5% (base 2 equivalent) brimonidine tartrate ophth soln 0.2% 2 brimonidine tartrate ophth soln 0.15% 3 PHOSPHOLINE SOL 0.125%OP 4 OTIC ANALGESIC COMBINATIONS pramoxine-hc-chloroxylenol otic soln 10- 2 10-1 mg/ml

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 122 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits OTIC, ANTI-INFECTIVE/ANTI-INFLAMMATORY COMBINATIONS CIPRO HC SUS OTIC 3 CIPRODEX SUS 0.3-0.1% 3 COLY-MYCIN S SUS OTIC 4 hydrocortisone w/ acetic acid otic soln 1- 2 2% neomycin-polymyxin-hc otic soln 1% 2 neomycin-polymyxin-hc otic susp 3.5 2 mg/ml-10000 unit/ml-1% OTIC, ANTI-INFECTIVES acetic acid 2% in aluminum acetate otic 2 soln acetic acid otic soln 2% 2 ciprofloxacin hcl otic soln 0.2% (base 2 equivalent) ofloxacin otic soln 0.3% 2 OTIC, MISCELLANEOUS fluocinolone acetonide (otic) oil 0.01% 2 TOXOID COMBINATIONS TOXOID COMBINATIONS ADACEL INJ 6 BOOSTRIX INJ 6 DAPTACEL INJ 6 DIP/TET PED INJ 25-5LFU 6 INFANRIX INJ 6 PEDIARIX INJ 0.5ML 6 PENTACEL INJ 6 QUADRACEL INJ 6 TDVAX INJ 2-2 LF 6 TENIVAC INJ 5-2LF 6 TOXOIDS TOXOIDS TETANUS TOX INJ 5LF ADS 6 ULCER DRUGS H-2 ANTAGONISTS famotidine tab 20 mg 2 URICOSURICS URICOSURICS probenecid tab 500 mg 2 URINARY ANTISPASMODICS URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC) darifenacin hydrobromide tab er 24hr 7.5 2 mg (base equiv)

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 123 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits darifenacin hydrobromide tab er 24hr 15 2 mg (base equiv) solifenacin succinate tab 5 mg 2 solifenacin succinate tab 10 mg 2 VAGINAL AND RELATED PRODUCTS MISCELLANEOUS VAGINAL PRODUCTS INTRAROSA SUP 6.5MG 4 PA VAGINAL PRODUCTS MISCELLANEOUS VAGINAL PRODUCTS acetic acid-oxyquinoline vaginal gel 0.9- 4 0.025% VAGINAL ESTROGENS estradiol vaginal cream 0.1 mg/gm 2 estradiol vaginal tab 10 mcg 2 VASOPRESSORS ANAPHYLAXIS THERAPY AGENTS epinephrine solution auto-injector 0.3 2 mg/0.3ml (1:1000) epinephrine solution auto-injector 0.15 2 QL (2 per 30 days) mg/0.3ml (1:2000) VIRAL VACCINES VIRAL VACCINE COMBINATIONS M-M-R II INJ 6 PROQUAD INJ 6 TWINRIX INJ 6 VIRAL VACCINES AFLURIA INJ PF 14-15 6 CERVARIX INJ 6 ENGERIX-B INJ 10/0.5ML 6 ENGERIX-B INJ 20MCG/ML 6 EZ FLU SHOT INJ 2014-15 6 EZ FLU SHOT INJ PF 14-15 6 EZ FLU SHOT KIT 2015-16 6 EZ FLU SHOT KIT 2016-17 6 FLUAD INJ 2016-17 6 FLUBLOK SOL 2014-15 6 FLUCELVAX INJ 2014-15 6 FLUCLVX QUAD INJ 2016-17 6 FLULAVAL INJ 2014-15 6 FLULAVAL QUA INJ 2014-15 6 FLUMIST QUAD SUS 2014-15 6 FLUVIRIN INJ 2014-15 6 FLUVIRIN INJ 2015-16 6 FLUVIRIN PF INJ 2014-15 6

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 124 Limits ST - Step Therapy

Drug Name Drug Tier Requirements/Limits FLUZONE HD INJ PF 14-15 6 FLUZONE INJ INTRADRM 6 FLUZONE QUAD INJ 14-15 6 FLUZONE QUAD INJ 2015-16 6 GARDASIL 9 INJ 6 GARDASIL INJ 6 HAVRIX INJ 720UNIT 6 HAVRIX INJ 1440UNIT 6 IPOL INJ INACTIVE 6 RECOMBIVA HB INJ 5MCG/0.5 6 RECOMBIVA HB INJ 10MCG/ML 6 RECOMBIVA-HB INJ 40MCG/ML 6 ROTARIX SUS 6 ROTATEQ SOL 6 VAQTA INJ 25/0.5ML 6 VAQTA INJ 50UNT/ML 6 VARIVAX INJ 6 ZOSTAVAX INJ 6

MNPA - Medical Necessity Prior Authorization PA - Prior Authorization QL - Quantity 125 Limits ST - Step Therapy

Index * *pediatric vitamins acd w/ fluoride soln *b-complex vitamin tab** ...... 104 0.25 mg/ml*** ...... 106 *b-complex w/ c & folic acid cap 1 *pediatric vitamins acd w/ fluoride soln mg*** ...... 104 0.5 mg/ml*** ...... 106 *b-complex w/ c & folic acid tab 1 *sodium polystyrene sulfonate mg*** ...... 104 powder** ...... 104 *b-complex w/ c & folic acid tab 5 *sulfacetamide sod-sulfur wash 9-4.5% mg*** ...... 104 & sunscreen kit*** ...... 114 *b-complex w/ c & folic acid tab*** 104 8 *b-complex w/ c cap** ...... 104 8-MOP CAP 10MG ...... 115 *b-complex w/ folic acid tab**...... 104 A *b-complex w/biotin & folic acid tab*** abacavir sulfate soln 20 mg/ml (base ...... 104 equiv) ...... 19 *fe asp gly-fe polysacch-succ ac-c- abacavir sulfate tab 300 mg (base threon ac-b12-fa cap*** ...... 104 equiv) ...... 19 *fe asparto gly-fe fum-b12-fa-c- abacavir sulfate-lamivudine tab 600- succinic ac tab ther pack** ...... 104 300 mg ...... 35 *fe fum-iron polysacch complex-fa-b abacavir sulfate-lamivudine-zidovudine cmplx-c-zn-mn-cu cap*** ...... 105 tab 300-150-300 mg...... 17 *iron-docusate-b12-folic acid-c-e-cu- ABELCET INJ 5MG/ML ...... 16 biotin tab 150-1 mg*** ...... 105 ABILIFY MAIN INJ 300MG ...... 60 *irrigation solution, physiological** 102 ABILIFY MAIN INJ 400MG ...... 60 *mesalamine rectal enema 4 gm & abiraterone acetate tab 250 mg ...... 27 cleanser wipe kit** ...... 90 ABRAXANE INJ 100MG ...... 30 *methenamine-hyoscamine-meth blue- acamprosate calcium tab delayed sod phos tab 81.6 mg*** ...... 94 release 333 mg ...... 69 *methenamine-hyos-meth blue-sod acarbose tab 100 mg ...... 75 phos-phen sal tab 81.6 mg*** ...... 94 acarbose tab 25 mg ...... 75 *multiple vitamin tab** ...... 105 acarbose tab 50 mg ...... 75 *nystatin oral powder* ...... 17 acebutolol hcl cap 200 mg ...... 44 *pediatric multiple vitamins w/ fl-fe acebutolol hcl cap 400 mg ...... 44 drops 0.25-10 mg/ml** ...... 106 acetaminophen w/ codeine soln 120-12 *pediatric multiple vitamins w/ fluoride mg/5ml ...... 4 chew tab 0.25 mg*** ...... 106 acetaminophen w/ codeine tab 300-15 *pediatric multiple vitamins w/ fluoride mg ...... 4 chew tab 0.5 mg*** ...... 106 acetaminophen w/ codeine tab 300-30 *pediatric multiple vitamins w/ fluoride mg ...... 4 chew tab 1 mg*** ...... 106 acetaminophen w/ codeine tab 300-60 *pediatric multiple vitamins w/ fluoride mg ...... 4 soln 0.25 mg/ml***...... 106 acetazolamide cap er 12hr 500 mg . 121 *pediatric multiple vitamins w/ fluoride acetazolamide sodium for inj 500 mg soln 0.5 mg/ml*** ...... 106 ...... 121 *pediatric multiple vitamins w/ iron acetazolamide tab 125 mg ...... 121 drops 10 mg/ml** ...... 106 acetazolamide tab 250 mg ...... 121 *pediatric vitamins acd fluoride & fe acetic acid 2% in aluminum acetate drops 0.25-10 mg/ml*** ...... 106 otic soln ...... 123 126 acetic acid irrigation soln 0.25%...... 93 AJOVY INJ 225/1.5 ...... 102 acetic acid otic soln 2% ...... 123 AKYNZEO CAP 300-0.5...... 88 acetic acid-oxyquinoline vaginal gel albendazole tab 200 mg ...... 21 0.9-0.025% ...... 124 albuterol sulfate inhal aero 108 acetylcysteine inhal soln 10% ...... 111 mcg/act (90mcg base equiv)...... 23 acetylcysteine inhal soln 20% ...... 111 albuterol sulfate soln nebu 0.083% acitretin cap 10 mg ...... 115 (2.5 mg/3ml) ...... 110 acitretin cap 17.5 mg ...... 115 albuterol sulfate soln nebu 0.5% (5 acitretin cap 25 mg ...... 115 mg/ml) ...... 110 ACTHAR INJ 80UNIT ...... 83 albuterol sulfate soln nebu 0.63 ACTHIB INJ ...... 36 mg/3ml (base equiv) ...... 110 ACTIMMUNE INJ 2MU/0.5 ...... 100 albuterol sulfate soln nebu 1.25 ACUVAIL SOL 0.45% ...... 120 mg/3ml (base equiv) ...... 110 acyclovir cap 200 mg ...... 20 albuterol sulfate syrup 2 mg/5ml.... 110 acyclovir oint 5% ...... 118 albuterol sulfate tab 2 mg ...... 110 acyclovir sodium for inj 1000 mg ...... 20 albuterol sulfate tab 4 mg ...... 111 acyclovir sodium for inj 500 mg ...... 20 albuterol sulfate tab er 12hr 4 mg .. 111 acyclovir sodium iv soln 50 mg/ml .... 20 albuterol sulfate tab er 12hr 8 mg .. 111 acyclovir susp 200 mg/5ml ...... 20 alclometasone dipropionate cream acyclovir tab 400 mg ...... 20 0.05% ...... 116 acyclovir tab 800 mg ...... 20 alclometasone dipropionate oint 0.05% ADACEL INJ ...... 123 ...... 116 ADAGEN INJ 250/ML ...... 83 ALDURAZYME INJ 2.9MG/5M...... 83 adapalene cream 0.1% ...... 113 ALECENSA CAP 150MG...... 28 adefovir dipivoxil tab 10 mg ...... 20 alendronate sodium oral soln 70 ADEMPAS TAB 0.5MG...... 50 mg/75ml ...... 78 ADEMPAS TAB 1.5MG...... 50 alendronate sodium tab 10 mg ...... 78 ADEMPAS TAB 1MG ...... 50 alendronate sodium tab 35 mg ...... 78 ADEMPAS TAB 2.5MG...... 50 alendronate sodium tab 40 mg ...... 78 ADEMPAS TAB 2MG ...... 50 alendronate sodium tab 5 mg ...... 78 ADRENALIN INJ 1MG/ML ...... 108 alendronate sodium tab 70 mg ...... 78 ADRENALIN INJ 30/30ML ...... 108 ALFERON N INJ 5MU/ML ...... 100 ADRENALIN SOL 1:1000 ...... 113 alfuzosin hcl tab er 24hr 10 mg ...... 93 ADVAIR DISKU AER 100/50 ...... 112 ALIMTA INJ 100MG ...... 26 ADVAIR DISKU AER 250/50 ...... 112 ALIMTA INJ 500MG ...... 26 ADVAIR DISKU AER 500/50 ...... 112 ALINIA SUS 100/5ML ...... 21 ADVAIR HFA AER 115/21...... 112 ALINIA TAB 500MG...... 21 ADVAIR HFA AER 230/21...... 112 aliskiren fumarate tab 150 mg (base ADVAIR HFA AER 45/21 ...... 112 equivalent) ...... 25 ADVOCATE MIS LANCETS ...... 78 aliskiren fumarate tab 300 mg (base AFINITOR DIS TAB 2MG ...... 28 equivalent) ...... 25 AFINITOR DIS TAB 3MG ...... 28 allopurinol tab 100 mg ...... 1 AFINITOR DIS TAB 5MG ...... 28 allopurinol tab 300 mg ...... 1 AFINITOR TAB 10MG ...... 28 almotriptan malate tab 12.5 mg ...... 67 AFLURIA INJ PF 14-15...... 124 almotriptan malate tab 6.25 mg ...... 67 AIMOVIG INJ 140MG/ML ...... 102 ALOCRIL SOL 2% ...... 120 AIMOVIG INJ 70MG/ML ...... 102 127 alogliptin benzoate tab 25 mg (base amiloride & hydrochlorothiazide tab 5- equiv) ...... 24 50 mg ...... 47 alogliptin benzoate tab 6.25 mg (base amiloride hcl tab 5 mg ...... 47 equiv) ...... 24 aminocaproic acid inj 250 mg/ml ...... 97 ALOMIDE SOL 0.1% OP ...... 120 aminophylline inj 25 mg/ml ...... 113 alosetron hcl tab 0.5 mg (base equiv) amiodarone hcl tab 100 mg ...... 41 ...... 91 amiodarone hcl tab 200 mg ...... 41 alosetron hcl tab 1 mg (base equiv) .. 91 amiodarone hcl tab 400 mg ...... 41 ALOXI INJ 0.25MG/5 ...... 88 AMITIZA CAP 24MCG ...... 91 ALPHAGAN P SOL 0.1% ...... 122 AMITIZA CAP 8MCG ...... 91 ALPRAZOLAM CON 1 MG/ML ...... 50 amitriptyline hcl tab 10 mg ...... 58 alprazolam orally disintegrating tab amitriptyline hcl tab 100 mg ...... 58 0.25 mg ...... 51 amitriptyline hcl tab 150 mg ...... 58 alprazolam orally disintegrating tab 0.5 amitriptyline hcl tab 25 mg ...... 58 mg ...... 51 amitriptyline hcl tab 50 mg ...... 58 alprazolam orally disintegrating tab 1 amitriptyline hcl tab 75 mg ...... 58 mg ...... 51 amlodipine besylate tab 10 mg (base alprazolam orally disintegrating tab 2 equivalent) ...... 45 mg ...... 51 amlodipine besylate tab 2.5 mg (base alprazolam tab 0.25 mg ...... 51 equivalent) ...... 45 alprazolam tab 0.5 mg ...... 51 amlodipine besylate tab 5 mg (base alprazolam tab 1 mg ...... 51 equivalent) ...... 45 alprazolam tab 2 mg ...... 51 amlodipine besylate-benazepril hcl cap alprazolam tab er 24hr 0.5 mg ...... 51 10-20 mg ...... 37 alprazolam tab er 24hr 1 mg ...... 51 amlodipine besylate-benazepril hcl cap alprazolam tab er 24hr 2 mg ...... 51 10-40 mg ...... 37 alprazolam tab er 24hr 3 mg ...... 51 amlodipine besylate-benazepril hcl cap ALREX SUS 0.2% ...... 120 2.5-10 mg ...... 37 ALUNBRIG PAK ...... 33 amlodipine besylate-benazepril hcl cap ALUNBRIG TAB 180MG ...... 33 5-10 mg ...... 37 ALUNBRIG TAB 30MG ...... 33 amlodipine besylate-benazepril hcl cap ALUNBRIG TAB 90MG ...... 33 5-20 mg ...... 37 amantadine hcl cap 100 mg ...... 59 amlodipine besylate-benazepril hcl cap amantadine hcl syrup 50 mg/5ml ..... 59 5-40 mg ...... 37 amantadine hcl tab 100 mg ...... 59 amoxapine tab 100 mg ...... 58 AMBISOME INJ 50MG ...... 16 amoxapine tab 150 mg ...... 58 ambrisentan tab 10 mg ...... 50 amoxapine tab 25 mg ...... 58 ambrisentan tab 5 mg...... 50 amoxapine tab 50 mg ...... 58 amcinonide cream 0.1%...... 115 amoxicillin & k clavulanate chew tab amcinonide lotion 0.1% ...... 115 200-28.5 mg...... 13 AMCINONIDE OIN 0.1% ...... 115 amoxicillin & k clavulanate chew tab amifostine for inj 500 mg ...... 30 400-57 mg ...... 13 amikacin sulfate inj 1 gm/4ml (250 amoxicillin & k clavulanate for susp mg/ml) ...... 9 200-28.5 mg/5ml ...... 13 amikacin sulfate inj 500 mg/2ml (250 amoxicillin & k clavulanate for susp mg/ml) ...... 9 250-62.5 mg/5ml ...... 13

128 amoxicillin & k clavulanate for susp amphetamine-dextroamphetamine tab 400-57 mg/5ml ...... 14 12.5 mg ...... 64 amoxicillin & k clavulanate for susp amphetamine-dextroamphetamine tab 600-42.9 mg/5ml ...... 14 15 mg ...... 64 amoxicillin & k clavulanate tab 250-125 amphetamine-dextroamphetamine tab mg ...... 14 20 mg ...... 64 amoxicillin & k clavulanate tab 500-125 amphetamine-dextroamphetamine tab mg ...... 14 30 mg ...... 64 amoxicillin & k clavulanate tab 875-125 amphetamine-dextroamphetamine tab mg ...... 14 5 mg ...... 64 amoxicillin & k clavulanate tab er 12hr amphetamine-dextroamphetamine tab 1000-62.5 mg ...... 14 7.5 mg ...... 64 amoxicillin (trihydrate) cap 250 mg .. 14 amphotericin b for iv soln 50 mg ...... 16 amoxicillin (trihydrate) cap 500 mg .. 14 ampicillin & sulbactam sodium for inj amoxicillin (trihydrate) chew tab 125 1.5 (1-0.5) gm ...... 14 mg ...... 14 ampicillin & sulbactam sodium for inj 3 amoxicillin (trihydrate) chew tab 250 (2-1) gm ...... 14 mg ...... 14 ampicillin & sulbactam sodium for iv amoxicillin (trihydrate) for susp 125 soln 15 (10-5) gm ...... 14 mg/5ml ...... 14 ampicillin cap 250 mg ...... 14 amoxicillin (trihydrate) for susp 200 ampicillin cap 500 mg ...... 14 mg/5ml ...... 14 ampicillin for susp 125 mg/5ml ...... 14 amoxicillin (trihydrate) for susp 250 ampicillin for susp 250 mg/5ml ...... 14 mg/5ml ...... 14 ampicillin sodium for inj 1 gm ...... 14 amoxicillin (trihydrate) for susp 400 ampicillin sodium for inj 125 mg ...... 14 mg/5ml ...... 14 ampicillin sodium for inj 2 gm ...... 14 amoxicillin (trihydrate) tab 500 mg .. 14 ampicillin sodium for inj 250 mg ...... 14 amoxicillin (trihydrate) tab 875 mg .. 14 ampicillin sodium for inj 500 mg ...... 14 amoxicillin cap-clarithro tab-lansopraz ampicillin sodium for iv soln 1 gm .... 14 cap dr therapy pack ...... 93 ampicillin sodium for iv soln 10 gm ... 14 amphetamine sulfate tab 10 mg ...... 1 ampicillin sodium for iv soln 2 gm .... 14 amphetamine sulfate tab 5 mg...... 1 ANADROL-50 TAB 50MG...... 1 amphetamine-dextroamphetamine cap anagrelide hcl cap 0.5 mg ...... 98 er 24hr 10 mg ...... 64 anagrelide hcl cap 1 mg ...... 98 amphetamine-dextroamphetamine cap anastrozole tab 1 mg ...... 27 er 24hr 15 mg ...... 64 ANDROXY TAB 10MG ...... 75 amphetamine-dextroamphetamine cap ANORO ELLIPT AER 62.5-25 ...... 108 er 24hr 20 mg ...... 64 ANZEMET INJ 20MG/ML ...... 88 amphetamine-dextroamphetamine cap ANZEMET TAB 100MG ...... 88 er 24hr 25 mg ...... 64 ANZEMET TAB 50MG ...... 88 amphetamine-dextroamphetamine cap APOKYN INJ 10MG/ML ...... 59 er 24hr 30 mg ...... 64 apraclonidine hcl ophth soln 0.5% amphetamine-dextroamphetamine cap (base equivalent) ...... 122 er 24hr 5 mg ...... 64 aprepitant capsule 125 mg ...... 24 amphetamine-dextroamphetamine tab aprepitant capsule 40 mg ...... 24 10 mg ...... 64 aprepitant capsule 80 mg ...... 24

129 aprepitant capsule therapy pack 80 & ARNUITY ELPT INH 200MCG ...... 112 125 mg ...... 25 ARRANON INJ 5MG/ML ...... 30 APTIOM TAB 200MG ...... 52 ARZERRA CON 100/5ML ...... 30 APTIOM TAB 400MG ...... 52 aspirin chew tab 81 mg ...... 2 APTIOM TAB 600MG ...... 52 aspirin tab 325 mg ...... 2 APTIOM TAB 800MG ...... 52 ASPIRIN TAB 81MG ...... 2 APTIVUS CAP 250MG ...... 18 aspirin tab delayed release 325 mg ... 2 APTIVUS SOL ...... 18 aspirin tab delayed release 81 mg ..... 2 ARALAST NP INJ 400MG ...... 111 aspirin-caffeine-dihydrocodeine cap ARALAST NP INJ 500MG ...... 111 356.4-30-16 mg ...... 4 ARALAST NP INJ 800MG ...... 111 aspirin-dipyridamole cap er 12hr 25- ARANESP INJ 100MCG ...... 96 200 mg ...... 97 ARANESP INJ 10MCG ...... 96 atazanavir sulfate cap 150 mg (base ARANESP INJ 150MCG ...... 96 equiv) ...... 18 ARANESP INJ 200MCG ...... 96 atazanavir sulfate cap 200 mg (base ARANESP INJ 25MCG ...... 96 equiv) ...... 18 ARANESP INJ 300MCG ...... 96 atazanavir sulfate cap 300 mg (base ARANESP INJ 40MCG ...... 96 equiv) ...... 18 ARANESP INJ 500MCG ...... 96 atenolol & chlorthalidone tab 100-25 ARANESP INJ 60MCG ...... 96 mg ...... 43 ARCALYST INJ 220MG ...... 100 atenolol & chlorthalidone tab 50-25 mg ARCAPTA CAP 75MCG ...... 110 ...... 43 ARGATROBAN INJ 50/50ML ...... 95 atenolol tab 100 mg ...... 44 aripiprazole oral solution 1 mg/ml .... 60 atenolol tab 25 mg ...... 44 aripiprazole orally disintegrating tab 10 atenolol tab 50 mg ...... 44 mg ...... 60 ATGAM INJ 250MG ...... 99 aripiprazole orally disintegrating tab 15 atomoxetine hcl cap 10 mg (base mg ...... 60 equiv) ...... 64 aripiprazole tab 10 mg ...... 60 atomoxetine hcl cap 100 mg (base aripiprazole tab 15 mg ...... 60 equiv) ...... 64 aripiprazole tab 2 mg ...... 60 atomoxetine hcl cap 18 mg (base aripiprazole tab 20 mg ...... 60 equiv) ...... 64 aripiprazole tab 30 mg ...... 60 atomoxetine hcl cap 25 mg (base aripiprazole tab 5 mg ...... 60 equiv) ...... 64 armodafinil tab 150 mg ...... 1 atomoxetine hcl cap 40 mg (base armodafinil tab 200 mg ...... 1 equiv) ...... 64 armodafinil tab 250 mg ...... 1 atomoxetine hcl cap 60 mg (base armodafinil tab 50 mg...... 1 equiv) ...... 64 ARMOUR THYRO TAB 120MG ...... 85 atomoxetine hcl cap 80 mg (base ARMOUR THYRO TAB 15MG ...... 85 equiv) ...... 64 ARMOUR THYRO TAB 180MG ...... 85 atorvastatin calcium tab 10 mg (base ARMOUR THYRO TAB 240MG ...... 85 equivalent) ...... 42 ARMOUR THYRO TAB 300MG ...... 85 atorvastatin calcium tab 20 mg (base ARMOUR THYRO TAB 30MG ...... 85 equivalent) ...... 42 ARMOUR THYRO TAB 60MG ...... 85 atorvastatin calcium tab 40 mg (base ARMOUR THYRO TAB 90MG ...... 85 equivalent) ...... 42 ARNUITY ELPT INH 100MCG ...... 112 130 atorvastatin calcium tab 80 mg (base azelastine hcl nasal spray 0.15% equivalent) ...... 42 (205.5 mcg/spray) ...... 112 atovaquone susp 750 mg/5ml ...... 21 azelastine hcl ophth soln 0.05% ..... 120 atovaquone-proguanil hcl tab 250-100 azithromycin for susp 100 mg/5ml ... 12 mg ...... 17 azithromycin for susp 200 mg/5ml ... 12 atovaquone-proguanil hcl tab 62.5-25 azithromycin iv for soln 500 mg ...... 12 mg ...... 17 azithromycin powd pack for susp 1 gm ATROPINE SUL OIN 1% OP ...... 122 ...... 12 atropine sulfate inj 0.4 mg/ml ...... 48 azithromycin tab 250 mg ...... 12 atropine sulfate inj 1 mg/ml ...... 48 azithromycin tab 500 mg ...... 12 atropine sulfate ophth soln 1% ...... 122 azithromycin tab 600 mg ...... 12 atropine sulfate soln prefill syr 0.25 AZOPT SUS 1% OP ...... 121 mg/5ml (0.05 mg/ml) ...... 48 aztreonam for inj 1 gm ...... 21 atropine sulfate soln prefill syr 1 aztreonam for inj 2 gm ...... 21 mg/10ml (0.1 mg/ml) ...... 48 B ATROVENT HFA AER 17MCG ...... 108 bacitracin intramuscular for soln 50000 AUBAGIO TAB 14MG ...... 68 unit ...... 21 AUBAGIO TAB 7MG ...... 68 bacitracin ophth oint 500 unit/gm .. 119 AUGMENTIN SUS 125/5ML ...... 14 bacitracin-polymyxin b ophth oint .. 119 AURYXIA TAB 210MG ...... 84 bacitracin-polymyxin-neomycin-hc AUTOSHIELD MIS 29X3/16 ...... 78 ophth oint 1% ...... 119 AUTOSHIELD MIS 29X5/16 ...... 78 baclofen tab 10 mg ...... 69 AUTOSHIELD MIS 30GX5MM ...... 78 baclofen tab 20 mg ...... 69 AUVI-Q INJ 0.3MG ...... 108 balsalazide disodium cap 750 mg ..... 90 AVANDAMET TAB 2-1000MG ...... 76 BALVERSA TAB 3MG ...... 33 AVANDAMET TAB 2-500MG ...... 76 BALVERSA TAB 4MG ...... 33 AVANDAMET TAB 4-500MG ...... 76 BALVERSA TAB 5MG ...... 33 AVANDIA TAB 2MG ...... 76 BANZEL SUS 40MG/ML...... 52 AVANDIA TAB 4MG ...... 76 BANZEL TAB 200MG ...... 52 AVANDIA TAB 8MG ...... 76 BANZEL TAB 400MG ...... 52 AVAR LS PAD 10-2% ...... 113 BARACLUDE SOL ...... 20 AVAR PAD 9.5-5% ...... 113 BAXDELA TAB 450MG ...... 88 AVASTIN INJ ...... 30 BD NEEDLES MIS 18GX1.5 ...... 78 AVEED INJ 750/3ML...... 75 BELLA/OPIUM SUP 16.2-30...... 89 AVO CREAM EMU ...... 118 BELLA/OPIUM SUP 16.2-60...... 89 AVONEX KIT 30MCG ...... 108 benazepril & hydrochlorothiazide tab AXIRON SOL 30MG/ACT ...... 75 10-12.5 mg ...... 37 AYVAKIT TAB 100MG ...... 33 benazepril & hydrochlorothiazide tab AYVAKIT TAB 200MG ...... 33 20-12.5 mg ...... 37 AYVAKIT TAB 300MG ...... 33 benazepril & hydrochlorothiazide tab AZACTAM/DEX INJ 1GM ...... 21 20-25 mg ...... 37 AZACTAM/DEX INJ 2GM ...... 21 benazepril & hydrochlorothiazide tab 5- azathioprine tab 50 mg ...... 100 6.25 mg ...... 37 azelaic acid gel 15% ...... 74 benazepril hcl tab 10 mg ...... 38 azelastine hcl nasal spray 0.1% (137 benazepril hcl tab 20 mg ...... 38 mcg/spray) ...... 112 benazepril hcl tab 40 mg ...... 38 benazepril hcl tab 5 mg ...... 38 131

BENLYSTA INJ 120MG ...... 101 BICILLIN L-A INJ 1200000...... 14 BENLYSTA INJ 200MG/ML ...... 101 BICILLIN L-A INJ 2400000...... 15 BENLYSTA INJ 400MG ...... 101 BICILLIN L-A INJ 600000 ...... 14 benzonatate cap 100 mg ...... 110 BIKTARVY TAB ...... 35 benzonatate cap 200 mg ...... 110 bimatoprost ophth soln 0.03% ...... 122 benztropine mesylate inj 1 mg/ml .... 59 bisacodyl tab & peg 3350-kcl-sod benztropine mesylate tab 0.5 mg ..... 59 bicarb-nacl for soln kit ...... 91 benztropine mesylate tab 1 mg ...... 59 bisacodyl tab delayed release 5 mg .. 91 benztropine mesylate tab 2 mg ...... 59 bisoprolol & hydrochlorothiazide tab BEPREVE DRO 1.5% ...... 120 10-6.25 mg ...... 44 BERINERT INJ 500UNIT ...... 97 bisoprolol & hydrochlorothiazide tab BETADINE SOL 5% OP ...... 119 2.5-6.25 mg ...... 43 betamethasone dipropionate bisoprolol & hydrochlorothiazide tab 5- augmented cream 0.05% ...... 115 6.25 mg ...... 44 betamethasone dipropionate bisoprolol fumarate tab 10 mg ...... 44 augmented gel 0.05% ...... 117 bisoprolol fumarate tab 5 mg ...... 44 betamethasone dipropionate bivalirudin trifluoroacetate for iv soln augmented lotion 0.05% ...... 116 250 mg (base equiv)...... 95 betamethasone dipropionate bleomycin sulfate for inj 15 unit ...... 30 augmented oint 0.05%...... 117 bleomycin sulfate for inj 30 unit ...... 30 betamethasone dipropionate cream BLEPHAMIDE OIN S.O.P...... 119 0.05%...... 116 BLEPHAMIDE SUS OP ...... 119 betamethasone dipropionate lotion BOOSTRIX INJ ...... 123 0.05%...... 116 BOSENTAN TAB 125 MG ...... 49 betamethasone dipropionate oint BOSENTAN TAB 62.5 MG ...... 49 0.05%...... 116 BOSULIF TAB 100MG ...... 28 betamethasone valerate cream 0.1% BOSULIF TAB 500MG ...... 28 (base equivalent) ...... 116 BOTOX INJ 100UNIT ...... 68 betamethasone valerate lotion 0.1% BOTOX INJ 200UNIT ...... 68 (base equivalent) ...... 117 BRAFTOVI CAP 50MG ...... 33 betamethasone valerate oint 0.1% BRAFTOVI CAP 75MG ...... 33 (base equivalent) ...... 117 BREO ELLIPTA INH 100-25 ...... 112 BETASERON INJ 0.3MG ...... 68 BREO ELLIPTA INH 200-25 ...... 112 betaxolol hcl ophth soln 0.5% ...... 121 BRILINTA TAB 60MG ...... 98 betaxolol hcl tab 10 mg ...... 44 BRILINTA TAB 90MG ...... 98 betaxolol hcl tab 20 mg ...... 44 brimonidine tartrate ophth soln 0.15% bethanechol chloride tab 10 mg ...... 93 ...... 122 bethanechol chloride tab 25 mg ...... 93 brimonidine tartrate ophth soln 0.2% bethanechol chloride tab 5 mg ...... 93 ...... 122 bethanechol chloride tab 50 mg ...... 93 bromfenac sodium ophth soln 0.09% BETHKIS NEB 300/4ML ...... 111 (base equiv) (once-daily) ...... 107 bexarotene cap 75 mg ...... 30 bromfenac sodium ophth soln 0.09% BEXSERO INJ ...... 36 (base equivalent) ...... 120 BIAFINE EMU ...... 118 bromocriptine mesylate cap 5 mg (base bicalutamide tab 50 mg...... 27 equivalent) ...... 59 BICILLIN C-R INJ 1200000 ...... 14 bromocriptine mesylate tab 2.5 mg BICILLIN C-R INJ 900/300 ...... 14 (base equivalent) ...... 59 132

BROVANA NEB 15MCG ...... 110 bupropion hcl tab 100 mg ...... 56 BRUKINSA CAP 80MG ...... 33 bupropion hcl tab 75 mg ...... 56 budesonide delayed release particles bupropion hcl tab er 12hr 100 mg .... 56 cap 3 mg ...... 90 bupropion hcl tab er 12hr 150 mg .... 56 budesonide inhalation susp 0.25 bupropion hcl tab er 12hr 200 mg .... 56 mg/2ml ...... 112 bupropion hcl tab er 24hr 150 mg .... 56 budesonide inhalation susp 0.5 mg/2ml bupropion hcl tab er 24hr 300 mg .... 56 ...... 112 buspirone hcl tab 10 mg...... 52 budesonide inhalation susp 1 mg/2ml buspirone hcl tab 15 mg...... 52 ...... 112 buspirone hcl tab 30 mg...... 52 budesonide nasal susp 32 mcg/act . 112 buspirone hcl tab 5 mg ...... 52 budesonide tab er 24hr 9 mg ...... 74 buspirone hcl tab 7.5 mg ...... 52 bumetanide inj 0.25 mg/ml ...... 47 butalbital-acetaminophen tab 50-325 bumetanide tab 0.5 mg ...... 47 mg ...... 2 bumetanide tab 1 mg ...... 47 butalbital-acetaminophen-caff w/ cod bumetanide tab 2 mg ...... 47 cap 50-300-40-30 mg ...... 4 BUNAVAIL MIS 2.1-0.3 ...... 70 butalbital-acetaminophen-caff w/ cod BUNAVAIL MIS 4.2-0.7 ...... 70 cap 50-325-40-30 mg ...... 4 BUNAVAIL MIS 6.3-1MG ...... 70 butalbital-acetaminophen-caffeine cap buprenorphine hcl sl tab 2 mg (base 50-325-40 mg...... 2 equiv) ...... 70 butalbital-acetaminophen-caffeine tab buprenorphine hcl sl tab 8 mg (base 50-325-40 mg...... 2 equiv) ...... 70 butalbital-aspirin-caff w/ codeine cap buprenorphine hcl-naloxone hcl sl film 50-325-40-30 mg ...... 4 12-3 mg (base equiv) ...... 70 butalbital-aspirin-caffeine cap 50-325- buprenorphine hcl-naloxone hcl sl film 40 mg ...... 2 2-0.5 mg (base equiv) ...... 70 butorphanol tartrate inj 1 mg/ml ...... 4 buprenorphine hcl-naloxone hcl sl film butorphanol tartrate inj 2 mg/ml ...... 4 4-1 mg (base equiv) ...... 70 butorphanol tartrate nasal soln 10 buprenorphine hcl-naloxone hcl sl film mg/ml ...... 4 8-2 mg (base equiv) ...... 70 BYSTOLIC TAB 10MG ...... 44 buprenorphine hcl-naloxone hcl sl tab BYSTOLIC TAB 2.5MG ...... 44 2-0.5 mg (base equiv) ...... 70 BYSTOLIC TAB 20MG ...... 44 buprenorphine hcl-naloxone hcl sl tab BYSTOLIC TAB 5MG ...... 44 8-2 mg (base equiv) ...... 70 C buprenorphine td patch weekly 10 cabergoline tab 0.5 mg ...... 83 mcg/hr ...... 8 CABOMETYX TAB 20MG ...... 33 buprenorphine td patch weekly 15 CABOMETYX TAB 40MG ...... 33 mcg/hr ...... 8 CABOMETYX TAB 60MG ...... 33 buprenorphine td patch weekly 20 caffeine citrate oral soln 60 mg/3ml mcg/hr ...... 9 (10 mg/ml base equiv) ...... 1 buprenorphine td patch weekly 5 calcipotriene cream 0.005% ...... 115 mcg/hr ...... 8 calcipotriene oint 0.005% ...... 115 buprenorphine td patch weekly 7.5 calcipotriene soln 0.005% (50 mcg/ml) mcg/hr ...... 8 ...... 115 bupropion hcl (smoking deterrent) tab calcitonin (salmon) nasal soln 200 er 12hr 150 mg ...... 70 unit/act ...... 79 133 calcitriol cap 0.25 mcg ...... 82 CARBAGLU TAB 200MG ...... 83 calcitriol cap 0.5 mcg ...... 82 carbamazepine cap er 12hr 100 mg .. 52 calcitriol inj 1 mcg/ml ...... 82 carbamazepine cap er 12hr 200 mg .. 52 calcitriol oral soln 1 mcg/ml ...... 82 carbamazepine cap er 12hr 300 mg .. 52 calcium acetate (phosphate binder) cap carbamazepine chew tab 100 mg ..... 52 667 mg (169 mg ca) ...... 84 carbamazepine susp 100 mg/5ml ..... 52 calcium acetate (phosphate binder) tab carbamazepine tab 200 mg ...... 52 667 mg ...... 84 carbamazepine tab er 12hr 100 mg .. 23 calcium citrate-vitamin d tab 1500 mg- carbamazepine tab er 12hr 200 mg .. 52 200 unit ...... 104 carbamazepine tab er 12hr 400 mg .. 52 calcium citrate-vitamin d tab 315 mg- carbidopa & levodopa orally 200 unit (elemental ca) ...... 104 disintegrating tab 10-100 mg ...... 59 CALCIUM-FA WAF PLUS D...... 104 carbidopa & levodopa orally CALDOLOR INJ 800/8ML...... 2 disintegrating tab 25-100 mg ...... 59 CALQUENCE CAP 100MG ...... 33 carbidopa & levodopa orally CAMPRAL TAB 333MG ...... 69 disintegrating tab 25-250 mg ...... 59 candesartan cilexetil tab 16 mg ...... 40 carbidopa & levodopa tab 10-100 mg 59 candesartan cilexetil tab 32 mg ...... 40 carbidopa & levodopa tab 25-100 mg 59 candesartan cilexetil tab 4 mg ...... 40 carbidopa & levodopa tab 25-250 mg 59 candesartan cilexetil tab 8 mg ...... 40 carbidopa & levodopa tab er 25-100 candesartan cilexetil- mg ...... 59 hydrochlorothiazide tab 16-12.5 mg carbidopa & levodopa tab er 50-200 ...... 40 mg ...... 59 candesartan cilexetil- carbidopa tab 25 mg...... 59 hydrochlorothiazide tab 32-12.5 mg carbinoxamine maleate soln 4 mg/5ml ...... 40 ...... 109 candesartan cilexetil- carbinoxamine maleate tab 4 mg ... 109 hydrochlorothiazide tab 32-25 mg . 40 carbonyl iron susp 15 mg/1.25ml CANTIL TAB 25MG ...... 89 (elemental iron) ...... 104 CAPASTAT SUL INJ 1GM ...... 19 carboplatin iv soln 600 mg/60ml ...... 25 capecitabine tab 150 mg ...... 26 CARDURA XL TAB 4MG ...... 95 capecitabine tab 500 mg ...... 26 CARDURA XL TAB 8MG ...... 95 CAPRELSA TAB 100MG ...... 28 CARIMUNE NF INJ 12GM ...... 99 CAPRELSA TAB 300MG ...... 29 CARIMUNE NF INJ 6GM ...... 99 captopril & hydrochlorothiazide tab 25- carisoprodol tab 350 mg ...... 69 15 mg ...... 37 carisoprodol w/ aspirin tab 200-325 mg captopril & hydrochlorothiazide tab 25- ...... 69 25 mg ...... 37 carteolol hcl ophth soln 1% ...... 121 captopril & hydrochlorothiazide tab 50- carvedilol tab 12.5 mg ...... 44 15 mg ...... 37 carvedilol tab 25 mg ...... 44 captopril & hydrochlorothiazide tab 50- carvedilol tab 3.125 mg ...... 44 25 mg ...... 37 carvedilol tab 6.25 mg ...... 44 captopril tab 100 mg ...... 38 CAYA DPR ...... 73 captopril tab 12.5 mg ...... 38 CAYSTON INH 75MG ...... 111 captopril tab 25 mg ...... 38 cefaclor cap 250 mg ...... 10 captopril tab 50 mg ...... 38 cefaclor cap 500 mg ...... 10 CARAFATE SUS 1GM/10ML ...... 91 CEFACLOR ER TAB 500MG ...... 10 134 cefaclor for susp 250 mg/5ml ...... 10 cefpodoxime proxetil for susp 50 cefaclor for susp 375 mg/5ml ...... 10 mg/5ml ...... 11 cefadroxil cap 500 mg ...... 10 cefpodoxime proxetil tab 100 mg ..... 11 cefadroxil for susp 250 mg/5ml ...... 10 cefpodoxime proxetil tab 200 mg ..... 11 cefadroxil for susp 500 mg/5ml ...... 10 cefprozil for susp 125 mg/5ml...... 10 cefadroxil tab 1 gm ...... 10 cefprozil for susp 250 mg/5ml...... 11 CEFAZOL/DEX SOL 1GM ...... 10 cefprozil tab 250 mg ...... 11 CEFAZOL/DEX SOL 2GM ...... 10 cefprozil tab 500 mg ...... 11 CEFAZOLIN INJ 100GM ...... 10 ceftazidime for inj 1 gm ...... 11 CEFAZOLIN INJ 1GM/50ML ...... 10 ceftazidime for inj 2 gm ...... 11 CEFAZOLIN INJ 300GM ...... 10 ceftazidime for inj 6 gm ...... 11 cefazolin sodium for inj 1 gm ...... 10 CEFTAZIDIME/ SOL D5W 1GM ...... 11 cefazolin sodium for inj 10 gm ...... 10 CEFTAZIDIME/ SOL D5W 2GM ...... 11 cefazolin sodium for inj 20 gm ...... 10 ceftibuten cap 400 mg ...... 11 cefazolin sodium for inj 500 mg ...... 10 ceftibuten for susp 180 mg/5ml ...... 11 cefazolin sodium for iv soln 1 gm ..... 10 CEFTIN SUS 125/5ML ...... 11 cefdinir cap 300 mg ...... 11 CEFTIN SUS 250/5ML ...... 11 cefdinir for susp 125 mg/5ml ...... 11 CEFTRIAX/DEX INJ 1GM ...... 11 cefdinir for susp 250 mg/5ml ...... 11 CEFTRIAX/DEX INJ 2GM ...... 11 cefditoren pivoxil tab 200 mg (base ceftriaxone sodium for inj 1 gm...... 11 equivalent) ...... 11 ceftriaxone sodium for inj 10 gm ...... 11 cefditoren pivoxil tab 400 mg (base ceftriaxone sodium for inj 2 gm...... 11 equivalent) ...... 11 ceftriaxone sodium for inj 250 mg .... 11 cefepime hcl for inj 1 gm ...... 12 ceftriaxone sodium for inj 500 mg .... 11 cefepime hcl for inj 2 gm ...... 12 ceftriaxone sodium for iv soln 1 gm .. 11 CEFEPIME INJ 1GM ...... 12 ceftriaxone sodium for iv soln 2 gm .. 11 CEFEPIME INJ 2G/100ML ...... 12 ceftriaxone sodium in dextrose inj 20 CEFEPIME/DEX INJ 1GM ...... 12 mg/ml ...... 12 CEFEPIME/DEX INJ 2GM ...... 12 ceftriaxone sodium in dextrose inj 40 cefixime cap 400 mg...... 71 mg/ml ...... 12 cefixime for susp 100 mg/5ml ...... 11 cefuroxime axetil tab 250 mg ...... 11 cefixime for susp 200 mg/5ml ...... 11 cefuroxime axetil tab 500 mg ...... 11 cefotaxime sodium for inj 1 gm ...... 11 cefuroxime sodium for inj 7.5 gm ..... 11 cefotaxime sodium for inj 10 gm ...... 11 cefuroxime sodium for inj 750 mg .... 11 cefotaxime sodium for inj 2 gm ...... 11 cefuroxime sodium for iv soln 1.5 gm cefotaxime sodium for inj 500 mg .... 11 ...... 11 cefotetan disodium for inj 1 gm ...... 10 celecoxib cap 100 mg ...... 1 cefotetan disodium for inj 10 gm ...... 10 celecoxib cap 200 mg ...... 1 cefotetan disodium for inj 2 gm ...... 10 celecoxib cap 400 mg ...... 1 CEFOXITIN INJ 1GM ...... 10 celecoxib cap 50 mg ...... 1 CEFOXITIN INJ 2GM ...... 10 CELONTIN CAP 300MG ...... 52 cefoxitin sodium for inj 10 gm ...... 10 CENESTIN TAB 0.3MG ...... 88 cefoxitin sodium for iv soln 1 gm ...... 10 cephalexin cap 250 mg ...... 10 cefoxitin sodium for iv soln 2 gm ...... 10 cephalexin cap 500 mg ...... 10 cefpodoxime proxetil for susp 100 cephalexin cap 750 mg ...... 10 mg/5ml ...... 11 cephalexin for susp 125 mg/5ml ...... 10 cephalexin for susp 250 mg/5ml ...... 10 135 cephalexin tab 250 mg ...... 10 cholestyramine light powder packets 4 cephalexin tab 500 mg ...... 10 gm ...... 42 CERDELGA CAP 84MG ...... 83 cholestyramine powder 4 gm/dose ... 42 CEREFOLIN TAB ...... 103 cholestyramine powder packets 4 gm42 CEREZYME INJ 400UNIT ...... 83 choline & magnesium salicylates liq CERVARIX INJ ...... 124 500 mg/5ml ...... 2 CESAMET CAP 1MG ...... 88 choline fenofibrate cap dr 135 mg cetirizine hcl oral soln 1 mg/ml (5 (fenofibric acid equiv) ...... 42 mg/5ml) ...... 109 choline fenofibrate cap dr 45 mg cevimeline hcl cap 30 mg ...... 92 (fenofibric acid equiv) ...... 42 CHANTIX PAK 0.5& 1MG ...... 70 chorionic gonadotropin for im inj 10000 CHANTIX PAK 1MG ...... 70 unit ...... 83 CHANTIX TAB 0.5MG ...... 70 CIALIS TAB 2.5MG ...... 113 CHEMET CAP 100MG ...... 97 CIALIS TAB 5MG ...... 113 CHEMSTRIP K TES ...... 75 ciclopirox olamine cream 0.77% (base chloramphenicol sodium succinate for equiv) ...... 114 iv inj 1 gm ...... 21 ciclopirox solution 8% ...... 114 chlordiazepoxide hcl cap 10 mg ...... 51 cidofovir iv inj 75 mg/ml ...... 20 chlordiazepoxide hcl cap 25 mg ...... 51 cilostazol tab 100 mg ...... 97 chlordiazepoxide hcl cap 5 mg ...... 51 cilostazol tab 50 mg ...... 97 chlordiazepoxide-amitriptyline tab 10- CILOXAN OIN 0.3% OP ...... 119 25 mg ...... 56 CIMDUO TAB 300-300 ...... 35 chlordiazepoxide-amitriptyline tab 5- cimetidine hcl soln 300 mg/5ml ...... 90 12.5 mg ...... 56 cimetidine tab 300 mg ...... 90 chlorhexidine gluconate soln 0.12% 119 cimetidine tab 400 mg ...... 90 chloroquine phosphate tab 250 mg ... 25 cimetidine tab 800 mg ...... 90 chloroquine phosphate tab 500 mg ... 25 cinacalcet hcl tab 30 mg (base equiv) chlorothiazide sodium for inj 500 mg 47 ...... 87 chlorothiazide tab 250 mg ...... 47 cinacalcet hcl tab 60 mg (base equiv) chlorothiazide tab 500 mg ...... 47 ...... 87 CHLORPROMAZINE HCL INJ 25 MG/ML cinacalcet hcl tab 90 mg (base equiv) ...... 62 ...... 87 chlorpromazine hcl tab 10 mg ...... 62 CINRYZE SOL 500 UNIT ...... 97 chlorpromazine hcl tab 100 mg ...... 62 CIPRO (5%) SUS 250MG/5 ...... 13 chlorpromazine hcl tab 200 mg ...... 62 CIPRO HC SUS OTIC ...... 123 chlorpromazine hcl tab 25 mg ...... 62 CIPRODEX SUS 0.3-0.1% ...... 123 chlorpromazine hcl tab 50 mg ...... 62 ciprofloxacin 200 mg/100ml in d5w .. 13 chlorpropamide tab 100 mg ...... 77 ciprofloxacin 400 mg/200ml in d5w .. 13 chlorpropamide tab 250 mg ...... 77 ciprofloxacin for oral susp 250 mg/5ml chlorthalidone tab 25 mg...... 47 (5%) (5 gm/100ml) ...... 13 chlorthalidone tab 50 mg...... 47 ciprofloxacin for oral susp 500 mg/5ml chlorzoxazone tab 500 mg ...... 69 (10%) (10 gm/100ml) ...... 13 cholecalciferol cap 1.25 mg (50000 ciprofloxacin hcl ophth soln 0.3% (base unit) ...... 104 equivalent) ...... 119 cholestyramine light powder 4 gm/dose ciprofloxacin hcl otic soln 0.2% (base ...... 42 equivalent) ...... 123

136 ciprofloxacin hcl tab 100 mg (base clindamycin phosphate in d5w iv soln equiv) ...... 13 900 mg/50ml ...... 21 ciprofloxacin hcl tab 250 mg (base clindamycin phosphate inj 300 mg/2ml equiv) ...... 13 ...... 21 ciprofloxacin hcl tab 500 mg (base clindamycin phosphate inj 600 mg/4ml equiv) ...... 13 ...... 21 ciprofloxacin hcl tab 750 mg (base clindamycin phosphate iv soln 300 equiv) ...... 13 mg/2ml ...... 21 ciprofloxacin iv soln 200 mg/20ml (1%) clindamycin phosphate lotion 1% ... 114 ...... 13 clindamycin phosphate soln 1% ..... 114 ciprofloxacin iv soln 400 mg/40ml (1%) clindamycin phosphate swab 1% .... 114 ...... 13 clindamycin phosphate vaginal cream ciprofloxacin-ciprofloxacin hcl tab er 2% ...... 95 24hr 1000 mg(base eq)...... 13 clindamycin phosphate-benzoyl ciprofloxacin-ciprofloxacin hcl tab er peroxide gel 1-5% ...... 114 24hr 500 mg (base eq) ...... 13 CLINDAP-T CRE...... 114 cisplatin inj 50 mg/50ml (1 mg/ml) .. 25 clobazam suspension 2.5 mg/ml ...... 52 citalopram hydrobromide oral soln 10 clobazam tab 10 mg ...... 52 mg/5ml ...... 57 clobazam tab 20 mg ...... 52 citalopram hydrobromide tab 10 mg clobetasol propionate cream 0.05% 117 (base equiv) ...... 57 clobetasol propionate gel 0.05% .... 117 citalopram hydrobromide tab 20 mg clobetasol propionate oint 0.05% ... 117 (base equiv) ...... 57 clobetasol propionate soln 0.05% ... 117 citalopram hydrobromide tab 40 mg clocortolone pivalate cream 0.1% ..... 74 (base equiv) ...... 57 clomipramine hcl cap 25 mg ...... 52 cladribine iv soln 10 mg/10ml (1 clomipramine hcl cap 50 mg ...... 52 mg/ml) ...... 26 clomipramine hcl cap 75 mg ...... 52 CLAFORAN INJ 1GM ...... 12 clonazepam orally disintegrating tab CLAFORAN INJ 2GM ...... 12 0.125 mg ...... 51 CLARAVIS ...... 113 clonazepam orally disintegrating tab clarithromycin for susp 125 mg/5ml . 12 0.25 mg ...... 51 clarithromycin for susp 250 mg/5ml . 12 clonazepam orally disintegrating tab clarithromycin tab 250 mg ...... 12 0.5 mg ...... 51 clarithromycin tab 500 mg ...... 12 clonazepam orally disintegrating tab 1 clarithromycin tab er 24hr 500 mg ... 12 mg ...... 51 clemastine fumarate tab 2.68 mg ... 109 clonazepam orally disintegrating tab 2 CLEVIPREX EMU 50/100ML ...... 45 mg ...... 51 clindamycin hcl cap 150 mg ...... 21 clonazepam tab 0.5 mg ...... 51 clindamycin hcl cap 300 mg ...... 21 clonazepam tab 1 mg ...... 51 clindamycin hcl cap 75 mg...... 21 clonazepam tab 2 mg ...... 51 clindamycin palmitate hcl for soln 75 clonidine hcl tab 0.1 mg ...... 39 mg/5ml (base equiv) ...... 21 clonidine hcl tab 0.2 mg ...... 39 clindamycin phosphate gel 1% ...... 114 clonidine hcl tab 0.3 mg ...... 39 clindamycin phosphate in d5w iv soln clonidine hcl tab er 12hr 0.1 mg ...... 64 300 mg/50ml ...... 21 clonidine td patch weekly 0.1 mg/24hr clindamycin phosphate in d5w iv soln ...... 39 600 mg/50ml ...... 21 137 clonidine td patch weekly 0.2 mg/24hr COMBIPATCH DIS .05/.14 ...... 80 ...... 39 COMBIVENT AER 20-100 ...... 108 clonidine td patch weekly 0.3 mg/24hr COMETRIQ KIT 100MG ...... 29 ...... 39 COMETRIQ KIT 140MG ...... 29 clopidogrel bisulfate tab 300 mg (base COMETRIQ KIT 60MG...... 29 equiv) ...... 98 COMPLERA TAB ...... 17 clopidogrel bisulfate tab 75 mg (base COMVAX INJ ...... 103 equiv) ...... 98 CONCEPTROL GEL 4% ...... 113 clorazepate dipotassium tab 15 mg .. 51 COPAXONE INJ 20MG/ML ...... 68 clorazepate dipotassium tab 3.75 mg 51 COPAXONE INJ 40MG/ML ...... 68 clorazepate dipotassium tab 7.5 mg . 51 COPIKTRA CAP 15MG ...... 33 clotrimazole troche 10 mg ...... 16 COPIKTRA CAP 25MG ...... 33 clotrimazole w/ betamethasone cream CORDRAN OIN 0.025% ...... 74 1-0.05%...... 115 CORLANOR TAB 5MG ...... 48 clotrimazole w/ betamethasone lotion CORLANOR TAB 7.5MG ...... 48 1-0.05%...... 115 cortisone acetate tab 25 mg ...... 81 clozapine orally disintegrating tab 100 CORTISPORIN CRE 0.5%...... 114 mg ...... 60 CORTISPORIN OIN 1%...... 114 clozapine orally disintegrating tab 12.5 COSENTYX INJ 150MG/ML ...... 115 mg ...... 60 COSENTYX PEN INJ 300DOSE ...... 115 clozapine orally disintegrating tab 150 COTELLIC TAB 20MG ...... 29 mg ...... 60 CREON CAP 12000UNT...... 92 clozapine orally disintegrating tab 200 CREON CAP 24000UNT...... 92 mg ...... 60 CREON CAP 3000UNIT ...... 92 clozapine orally disintegrating tab 25 CREON CAP 36000UNT...... 92 mg ...... 60 CREON CAP 6000UNIT ...... 92 clozapine tab 100 mg...... 60 CRESEMBA CAP 186 MG ...... 16 clozapine tab 200 mg...... 60 CRESEMBA INJ 372MG ...... 16 clozapine tab 25 mg ...... 60 CRINONE GEL 4% VAG ...... 85 clozapine tab 50 mg ...... 60 CRIXIVAN CAP 200MG ...... 18 COARTEM TAB 20-120MG ...... 17 CRIXIVAN CAP 400MG ...... 18 codeine sulfate tab 15 mg ...... 4 cromolyn sodium ophth soln 4% .... 120 codeine sulfate tab 30 mg ...... 4 cromolyn sodium oral conc 100 mg/5ml codeine sulfate tab 60 mg ...... 4 ...... 91 colchicine w/ probenecid tab 0.5-500 cromolyn sodium soln nebu 20 mg/2ml mg ...... 95 ...... 111 colesevelam hcl packet for susp 3.75 crotamiton lotion 10% ...... 74 gm ...... 25 CUPRIMINE CAP 250MG ...... 99 colesevelam hcl tab 625 mg ...... 42 CUVITRU INJ 2GM/10ML ...... 99 colestipol hcl granule packets 5 gm .. 42 CUVITRU INJ 4GM/20ML ...... 99 colestipol hcl granules 5 gm...... 42 CUVITRU SOL 1GM/5ML ...... 99 colestipol hcl tab 1 gm ...... 42 CUVPOSA SOL 1MG/5ML ...... 89 colistimethate sod for inj 150 mg cyclobenzaprine hcl tab 10 mg ...... 69 (colistin base activity) ...... 22 cyclobenzaprine hcl tab 5 mg ...... 69 COLY-MYCIN S SUS OTIC ...... 123 cyclopentolate hcl ophth soln 1% ... 122 COMBIGAN SOL 0.2/0.5% ...... 122 cyclopentolate hcl ophth soln 2% ... 122 COMBIPATCH DIS ...... 80 CYCLOPHOSPHAMIDE CAP 25 MG ..... 32 138

CYCLOPHOSPHAMIDE CAP 50 MG ..... 32 DAURISMO TAB 100MG ...... 32 cyclophosphamide for inj 1 gm ...... 25 DAURISMO TAB 25MG ...... 32 cyclophosphamide for inj 2 gm ...... 25 DEBACTEROL SOL 30-50% ...... 103 cyclophosphamide for inj 500 mg ..... 25 deferasirox tab 180 mg ...... 24 cycloserine cap 250 mg ...... 19 deferasirox tab 360 mg ...... 24 cyclosporine cap 100 mg ...... 100 deferasirox tab 90 mg...... 24 cyclosporine cap 25 mg ...... 100 deferasirox tab for oral susp 125 mg 24 cyclosporine iv soln 50 mg/ml ...... 100 deferasirox tab for oral susp 250 mg 24 cyclosporine modified cap 100 mg .. 101 deferasirox tab for oral susp 500 mg 24 cyclosporine modified cap 25 mg .... 100 DELZICOL CAP 400MG ...... 90 cyclosporine modified cap 50 mg .... 101 demeclocycline hcl tab 150 mg ...... 16 cyclosporine modified oral soln 100 demeclocycline hcl tab 300 mg ...... 16 mg/ml ...... 101 DEMEROL INJ 100/2ML ...... 4 cyproheptadine hcl syrup 2 mg/5ml 109 DEMEROL INJ 25MG/0.5 ...... 4 cyproheptadine hcl tab 4 mg...... 109 DEMEROL INJ 75MG/1.5 ...... 4 CYSTADANE POW ...... 83 DEMEROL INJ 75MG/ML ...... 4 CYSTAGON CAP 150MG ...... 94 DEMSER CAP 250MG ...... 39 CYSTAGON CAP 50MG...... 94 DENAVIR CRE 1% ...... 118 CYSTARAN SOL 0.44% ...... 122 DEPO-ESTRADI INJ 5MG/ML ...... 80 cytarabine inj 20 mg/ml ...... 26 DEPO-SQ PROV INJ 104 ...... 107 cytarabine inj pf 100 mg/ml ...... 26 desipramine hcl tab 10 mg ...... 58 cytarabine inj pf 20 mg/ml ...... 26 desipramine hcl tab 100 mg ...... 58 D desipramine hcl tab 150 mg ...... 58 dacarbazine for inj 100 mg ...... 25 desipramine hcl tab 25 mg ...... 58 dacarbazine for inj 200 mg ...... 25 desipramine hcl tab 50 mg ...... 58 DAKLINZA TAB 30MG...... 35 desipramine hcl tab 75 mg ...... 58 DAKLINZA TAB 60MG...... 36 desloratadine tab 5 mg ...... 109 dalfampridine tab er 12hr 10 mg ...... 68 desmopressin acetate nasal soln 0.01% DALIRESP TAB 500MCG ...... 112 (refrigerated) ...... 87 danazol cap 100 mg ...... 79 desmopressin acetate nasal spray soln danazol cap 200 mg ...... 79 0.01% (refrigerated)...... 87 danazol cap 50 mg ...... 79 desmopressin acetate tab 0.1 mg ..... 87 dantrolene sodium cap 100 mg ...... 69 desmopressin acetate tab 0.2 mg ..... 87 dantrolene sodium cap 25 mg ...... 69 desogest-eth estrad & eth estrad tab dantrolene sodium cap 50 mg ...... 69 0.15-0.02/0.01 mg(21/5) ...... 71 dapsone gel 5% ...... 74 desogest-ethin est tab 0.1- dapsone tab 100 mg ...... 22 0.025/0.125-0.025/0.15-0.025mg- dapsone tab 25 mg...... 22 mg ...... 72 DAPTACEL INJ...... 123 desogestrel & ethinyl estradiol tab 0.15 DARAPRIM TAB 25MG ...... 25 mg-30 mcg ...... 71 darifenacin hydrobromide tab er 24hr desonide cream 0.05% ...... 116 15 mg (base equiv) ...... 124 desonide oint 0.05%...... 116 darifenacin hydrobromide tab er 24hr desoximetasone cream 0.05% ...... 117 7.5 mg (base equiv) ...... 123 desoximetasone cream 0.25% ...... 116 daunorubicin hcl iv soln 20 mg/4ml desoximetasone gel 0.05%...... 116 (base equiv) ...... 30 desoximetasone oint 0.05% ...... 117 DAUNOXOME INJ 2MG/ML ...... 30 desoximetasone oint 0.25% ...... 116 139

DESVENLAFAX TAB 100MG ER ...... 56 dextroamphetamine sulfate cap er 24hr DESVENLAFAX TAB 50MG ER ...... 56 5 mg ...... 65 desvenlafaxine succinate tab er 24hr dextroamphetamine sulfate oral 100 mg (base equiv) ...... 56 solution 5 mg/5ml ...... 1 desvenlafaxine succinate tab er 24hr dextroamphetamine sulfate tab 10 mg 25 mg (base equiv) ...... 56 ...... 65 desvenlafaxine succinate tab er 24hr dextroamphetamine sulfate tab 5 mg 65 50 mg (base equiv) ...... 56 DIACOMIT CAP 250MG ...... 23 DEXAMETHASON CON 1MG/ML ...... 81 DIACOMIT CAP 500MG ...... 23 dexamethasone elixir 0.5 mg/5ml .... 81 DIACOMIT PAK 250MG ...... 23 dexamethasone sodium phosphate DIACOMIT PAK 500MG ...... 23 ophth soln 0.1% ...... 120 DIALYVITE/ TAB ZINC ...... 104 dexamethasone soln 0.5 mg/5ml ..... 81 diazepam conc 5 mg/ml ...... 51 dexamethasone tab 0.5 mg ...... 81 DIAZEPAM INJ 10MG/2ML ...... 51 dexamethasone tab 0.75 mg ...... 81 diazepam inj 5 mg/ml ...... 51 dexamethasone tab 1 mg ...... 81 diazepam oral soln 1 mg/ml ...... 51 dexamethasone tab 1.5 mg ...... 81 diazepam rectal gel delivery system 10 dexamethasone tab 2 mg ...... 81 mg ...... 52 dexamethasone tab 4 mg ...... 81 diazepam rectal gel delivery system 2.5 dexamethasone tab 6 mg ...... 81 mg ...... 52 dexchlorpheniramine maleate syrup 2 diazepam rectal gel delivery system 20 mg/5ml ...... 109 mg ...... 52 DEXILANT CAP 30MG DR ...... 92 diazepam tab 10 mg ...... 51 DEXILANT CAP 60MG DR ...... 92 diazepam tab 2 mg...... 51 dexmethylphenidate hcl cap er 24 hr diazepam tab 5 mg...... 51 10 mg ...... 64 diclofenac potassium tab 50 mg ...... 2 dexmethylphenidate hcl cap er 24 hr diclofenac sodium ophth soln 0.1% 120 15 mg ...... 64 diclofenac sodium tab delayed release dexmethylphenidate hcl cap er 24 hr 25 mg ...... 2 20 mg ...... 64 diclofenac sodium tab delayed release dexmethylphenidate hcl cap er 24 hr 50 mg ...... 2 30 mg ...... 64 diclofenac sodium tab delayed release dexmethylphenidate hcl cap er 24 hr 75 mg ...... 2 40 mg ...... 65 diclofenac sodium tab er 24hr 100 mg 2 dexmethylphenidate hcl cap er 24 hr 5 diclofenac w/ misoprostol tab delayed mg ...... 64 release 50-0.2 mg ...... 3 dexmethylphenidate hcl tab 10 mg ... 65 diclofenac w/ misoprostol tab delayed dexmethylphenidate hcl tab 2.5 mg .. 65 release 75-0.2 mg ...... 3 dexmethylphenidate hcl tab 5 mg ..... 65 dicloxacillin sodium cap 250 mg ...... 15 dexrazoxane hcl for inj 250 mg (base dicloxacillin sodium cap 500 mg ...... 15 equivalent) ...... 30 dicyclomine hcl cap 10 mg...... 89 dexrazoxane hcl for inj 500 mg (base dicyclomine hcl oral soln 10 mg/5ml . 89 equivalent) ...... 30 dicyclomine hcl tab 20 mg ...... 89 dextroamphetamine sulfate cap er 24hr didanosine delayed release capsule 125 10 mg ...... 65 mg ...... 19 dextroamphetamine sulfate cap er 24hr didanosine delayed release capsule 200 15 mg ...... 65 mg ...... 19 140 didanosine delayed release capsule 250 DIP/TET PED INJ 25-5LFU ...... 123 mg ...... 19 DIPENTUM CAP 250MG ...... 90 didanosine delayed release capsule 400 diphenhydramine hcl inj 50 mg/ml . 109 mg ...... 19 diphenoxylate w/ atropine liq 2.5-0.025 DIFICID TAB 200MG ...... 12 mg/5ml ...... 88 diflunisal tab 500 mg ...... 2 diphenoxylate w/ atropine tab 2.5- digoxin inj 0.25 mg/ml ...... 46 0.025 mg ...... 88 digoxin oral soln 0.05 mg/ml ...... 46 dipyridamole tab 25 mg ...... 98 digoxin tab 125 mcg (0.125 mg) ...... 46 dipyridamole tab 50 mg ...... 98 digoxin tab 250 mcg (0.25 mg) ...... 46 dipyridamole tab 75 mg ...... 98 dihydroergotamine mesylate nasal disopyramide phosphate cap 100 mg 41 spray 4 mg/ml ...... 67 disopyramide phosphate cap 150 mg 41 DILANTIN CAP 30MG ...... 52 disulfiram tab 250 mg ...... 69 diltiazem hcl cap er 24hr 120 mg ..... 36 disulfiram tab 500 mg ...... 69 diltiazem hcl cap er 24hr 180 mg ..... 36 DIURIL SUS 250/5ML...... 47 diltiazem hcl cap er 24hr 240 mg ..... 36 divalproex sodium cap delayed release diltiazem hcl coated beads cap er 24hr sprinkle 125 mg ...... 52 120 mg ...... 36, 46 divalproex sodium tab delayed release diltiazem hcl coated beads cap er 24hr 125 mg ...... 52 180 mg ...... 36 divalproex sodium tab delayed release diltiazem hcl coated beads cap er 24hr 250 mg ...... 53 240 mg ...... 36 divalproex sodium tab delayed release diltiazem hcl coated beads cap er 24hr 500 mg ...... 53 300 mg ...... 36 divalproex sodium tab er 24 hr 250 mg diltiazem hcl extended release beads ...... 53 cap er 24hr 120 mg ...... 36 divalproex sodium tab er 24 hr 500 mg diltiazem hcl extended release beads ...... 53 cap er 24hr 180 mg ...... 36 dofetilide cap 125 mcg (0.125 mg) ... 41 diltiazem hcl extended release beads dofetilide cap 250 mcg (0.25 mg)..... 41 cap er 24hr 240 mg ...... 36 dofetilide cap 500 mcg (0.5 mg) ...... 41 diltiazem hcl extended release beads donepezil hydrochloride orally cap er 24hr 300 mg ...... 36 disintegrating tab 10 mg ...... 55 diltiazem hcl extended release beads donepezil hydrochloride orally cap er 24hr 360 mg ...... 36 disintegrating tab 5 mg ...... 55 diltiazem hcl extended release beads donepezil hydrochloride tab 10 mg ... 55 cap er 24hr 420 mg ...... 37 donepezil hydrochloride tab 5 mg ..... 55 diltiazem hcl tab 120 mg ...... 37 DOPTELET TAB 20MG...... 98 diltiazem hcl tab 30 mg ...... 37 dorzolamide hcl ophth soln 2% ...... 121 diltiazem hcl tab 60 mg ...... 37 dorzolamide hcl-timolol maleate ophth diltiazem hcl tab 90 mg ...... 37 sol 22.3-6.8 mg/ml pf ...... 106 DIMENHYDRIN INJ 50MG/ML ...... 88 dorzolamide hcl-timolol maleate ophth dimethyl fumarate capsule delayed soln 22.3-6.8 mg/ml ...... 121 release 120 mg ...... 68 DOVATO TAB 50-300MG ...... 35 dimethyl fumarate capsule delayed doxazosin mesylate tab 1 mg ...... 39 release 240 mg ...... 68 doxazosin mesylate tab 2 mg ...... 39 dimethyl fumarate capsule dr starter doxazosin mesylate tab 4 mg ...... 39 pack 120 mg & 240 mg ...... 68 doxazosin mesylate tab 8 mg ...... 39 141 doxepin hcl cap 10 mg ...... 58 duloxetine hcl enteric coated pellets doxepin hcl cap 100 mg ...... 58 cap 60 mg (base eq) ...... 57 doxepin hcl cap 150 mg ...... 58 DUREZOL EMU 0.05% ...... 120 doxepin hcl cap 25 mg ...... 58 dutasteride cap 0.5 mg ...... 93 doxepin hcl cap 50 mg ...... 58 dutasteride-tamsulosin hcl cap 0.5-0.4 doxepin hcl cap 75 mg ...... 58 mg ...... 93 doxepin hcl conc 10 mg/ml ...... 58 DYRENIUM CAP 100MG ...... 47 doxercalciferol cap 0.5 mcg ...... 82 DYRENIUM CAP 50MG ...... 47 doxercalciferol cap 1 mcg ...... 82 DYSPORT INJ 500UNIT...... 68 doxercalciferol cap 2.5 mcg ...... 82 E doxercalciferol inj 4 mcg/2ml (2 econazole nitrate cream 1% ...... 115 mcg/ml) ...... 82 EDARBI TAB 40MG ...... 40 doxorubicin hcl for inj 10 mg ...... 30 EDARBI TAB 80MG ...... 40 doxorubicin hcl for inj 50 mg ...... 30 EDARBYCLOR TAB 40-12.5 ...... 40 doxorubicin hcl inj 2 mg/ml ...... 30 EDARBYCLOR TAB 40-25MG ...... 40 doxycycline hyclate cap 100 mg ...... 16 EDURANT TAB 25MG...... 18 doxycycline hyclate cap 50 mg ...... 16 efavirenz cap 200 mg ...... 35 doxycycline hyclate for inj 100 mg ... 16 efavirenz cap 50 mg ...... 35 doxycycline hyclate tab 100 mg ...... 16 efavirenz tab 600 mg ...... 35 doxycycline hyclate tab 20 mg ...... 16 ELAPRASE INJ 6MG/3ML...... 83 doxycycline monohydrate cap 100 mg ELELYSO INJ 200UNIT ...... 83 ...... 16 eletriptan hydrobromide tab 20 mg doxycycline monohydrate cap 50 mg 16 (base equivalent) ...... 102 doxycycline monohydrate for susp 25 eletriptan hydrobromide tab 40 mg mg/5ml ...... 16 (base equivalent) ...... 102 doxycycline monohydrate tab 100 mg ELIGARD INJ 22.5MG ...... 28 ...... 16 ELIGARD INJ 30MG ...... 28 doxycycline monohydrate tab 150 mg ELIGARD INJ 45MG ...... 28 ...... 16 ELIGARD INJ 7.5MG ...... 27 doxycycline monohydrate tab 50 mg. 16 ELIQUIS TAB 2.5MG ...... 96 doxycycline monohydrate tab 75 mg. 16 ELIQUIS TAB 5MG ...... 96 DRITHO-CREME CRE HP 1% ...... 115 ELITEK INJ 1.5MG ...... 30 dronabinol cap 10 mg ...... 88 ELITEK INJ 7.5MG ...... 30 dronabinol cap 2.5 mg ...... 88 ELLA TAB 30MG ...... 75 dronabinol cap 5 mg ...... 88 ELMIRON CAP 100MG ...... 94 droperidol inj 2.5 mg/ml ...... 88 EMADINE SOL 0.05% OP ...... 120 drospirenone-ethinyl estradiol tab 3- EMBEDA CAP 100-4MG ...... 4 0.02 mg ...... 71 EMBEDA CAP 20-0.8MG ...... 4 drospirenone-ethinyl estradiol tab 3- EMBEDA CAP 30-1.2MG ...... 4 0.03 mg ...... 71 EMBEDA CAP 50-2MG ...... 4 drospirenone-ethinyl estrad- EMBEDA CAP 60-2.4MG ...... 4 levomefolate tab 3-0.02-0.451 mg 71 EMBEDA CAP 80-3.2MG ...... 4 DUAVEE TAB 0.45-20...... 80 EMCYT CAP 140MG ...... 26 duloxetine hcl enteric coated pellets EMGALITY INJ 100MG/ML ...... 102 cap 20 mg (base eq) ...... 57 EMGALITY INJ 120MG/ML ...... 102 duloxetine hcl enteric coated pellets EMSAM DIS 12MG/24H ...... 56 cap 30 mg (base eq) ...... 57 EMSAM DIS 6MG/24HR ...... 55 142

EMSAM DIS 9MG/24HR ...... 55 epinephrine solution auto-injector 0.15 EMTRIVA CAP 200MG ...... 19 mg/0.3ml (1:2000)...... 124 EMTRIVA SOL 10MG/ML ...... 19 epinephrine solution auto-injector 0.3 enalapril maleate & hydrochlorothiazide mg/0.3ml (1:1000)...... 124 tab 10-25 mg ...... 37 EPIPEN 2-PAK INJ 0.3MG ...... 108 enalapril maleate & hydrochlorothiazide EPIPEN-JR INJ 0.15MG ...... 108 tab 5-12.5 mg ...... 37 epirubicin hcl iv soln 200 mg/100ml (2 enalapril maleate tab 10 mg ...... 38 mg/ml) ...... 31 enalapril maleate tab 2.5 mg ...... 38 epirubicin hcl iv soln 50 mg/25ml (2 enalapril maleate tab 20 mg ...... 38 mg/ml) ...... 30 enalapril maleate tab 5 mg ...... 38 EPIVIR HBV SOL 5MG/ML ...... 20 enalaprilat iv inj 1.25 mg/ml ...... 38 eplerenone tab 25 mg ...... 39 ENBREL INJ 25/0.5ML ...... 98 eplerenone tab 50 mg ...... 39 ENBREL INJ 25MG ...... 98 EPOGEN INJ 10000/ML ...... 96 ENBREL INJ 50MG/ML ...... 99 EPOGEN INJ 2000/ML ...... 96 ENBREL MINI INJ 50MG/ML ...... 8 EPOGEN INJ 20000/ML ...... 96 ENBREL SRCLK INJ 50MG/ML ...... 99 EPOGEN INJ 3000/ML ...... 96 ENCARE SUP 100MG ...... 113 EPOGEN INJ 4000/ML ...... 96 ENGERIX-B INJ 10/0.5ML ...... 124 epoprostenol sodium for inj 0.5 mg .. 49 ENGERIX-B INJ 20MCG/ML ...... 124 epoprostenol sodium for inj 1.5 mg .. 49 ENJUVIA TAB 0.3MG ...... 80 eprosartan mesylate tab 600 mg ...... 41 ENJUVIA TAB 0.45MG ...... 80 ERAXIS INJ 100MG ...... 16 ENJUVIA TAB 0.625MG ...... 80 ERAXIS INJ 50MG ...... 16 ENJUVIA TAB 0.9MG ...... 80 ERBITUX INJ 100MG ...... 31 ENJUVIA TAB 1.25MG ...... 80 ERBITUX INJ 200MG ...... 31 enoxaparin sodium inj 100 mg/ml .... 95 ergocalciferol cap 1.25 mg (50000 unit) enoxaparin sodium inj 120 mg/0.8ml 95 ...... 104 enoxaparin sodium inj 150 mg/ml .... 95 ergoloid mesylates tab 1 mg ...... 68 enoxaparin sodium inj 30 mg/0.3ml . 95 ERGOMAR SUB 2MG ...... 67 enoxaparin sodium inj 300 mg/3ml .. 95 ergotamine w/ caffeine tab 1-100 mg enoxaparin sodium inj 40 mg/0.4ml . 95 ...... 102 enoxaparin sodium inj 60 mg/0.6ml . 95 ERIVEDGE CAP 150MG ...... 31 enoxaparin sodium inj 80 mg/0.8ml . 95 ERLEADA TAB 60MG ...... 32 entacapone tab 200 mg ...... 59 erlotinib hcl tab 100 mg (base entecavir tab 0.5 mg ...... 20 equivalent) ...... 33 entecavir tab 1 mg ...... 20 erlotinib hcl tab 150 mg (base ENTRESTO TAB 24-26MG ...... 48 equivalent) ...... 33 ENTRESTO TAB 49-51MG ...... 48 erlotinib hcl tab 25 mg (base ENTRESTO TAB 97-103MG...... 48 equivalent) ...... 33 EPCLUSA TAB 400-100...... 20 ERTACZO CRE 2% ...... 115 EPIDIOLEX SOL 100MG/ML ...... 23 ERYTHROCIN INJ 500MG ...... 12 epinastine hcl ophth soln 0.05% .... 121 erythromycin ethylsuccinate for susp epinephrine pf inj 1 mg/ml ...... 108 200 mg/5ml ...... 102 epinephrine pf soln prefilled syringe 1 erythromycin ethylsuccinate for susp mg/10ml (0.1 mg/ml) ...... 108 400 mg/5ml ...... 102 epinephrine solution auto-injector 0.15 erythromycin ethylsuccinate tab 400 mg/0.15ml (1:1000) ...... 108 mg ...... 12 143 erythromycin gel 2% ...... 114 estradiol td patch twice weekly 0.025 erythromycin ophth oint 5 mg/gm .. 119 mg/24hr ...... 81 erythromycin pads 2% ...... 114 estradiol td patch twice weekly 0.0375 erythromycin soln 2% ...... 114 mg/24hr ...... 81 erythromycin stearate tab 250 mg.... 12 estradiol td patch twice weekly 0.05 erythromycin tab 250 mg ...... 12 mg/24hr ...... 81 erythromycin tab 500 mg ...... 12 estradiol td patch twice weekly 0.075 erythromycin tab delayed release 250 mg/24hr ...... 81 mg ...... 12 estradiol td patch twice weekly 0.1 erythromycin tab delayed release 333 mg/24hr ...... 81 mg ...... 12 estradiol td patch weekly 0.025 erythromycin w/ delayed release mg/24hr ...... 81 particles cap 250 mg ...... 13 estradiol td patch weekly 0.0375 ESBRIET CAP 267MG ...... 108 mg/24hr (37.5 mcg/24hr) ...... 81 escitalopram oxalate soln 5 mg/5ml estradiol td patch weekly 0.05 mg/24hr (base equiv) ...... 57 ...... 81 escitalopram oxalate tab 10 mg (base estradiol td patch weekly 0.06 mg/24hr equiv) ...... 57 ...... 81 escitalopram oxalate tab 20 mg (base estradiol td patch weekly 0.075 equiv) ...... 57 mg/24hr ...... 81 escitalopram oxalate tab 5 mg (base estradiol td patch weekly 0.1 mg/24hr equiv) ...... 57 ...... 81 esmolol hcl inj 100 mg/10ml ...... 44 estradiol vaginal cream 0.1 mg/gm 124 esomeprazole magnesium cap delayed estradiol vaginal tab 10 mcg ...... 124 release 20 mg (base eq)...... 92 estradiol valerate im in oil 20 mg/ml 80 esomeprazole magnesium cap delayed estradiol valerate im in oil 40 mg/ml 80 release 40 mg (base eq)...... 92 ESTROGEL GEL ...... 81 esomeprazole sodium for intravenous estropipate tab 0.75 mg ...... 80 soln 20 mg (base equiv) ...... 92 estropipate tab 1.5 mg ...... 80 esomeprazole sodium for intravenous estropipate tab 3 mg ...... 80 soln 40 mg (base equiv) ...... 92 eszopiclone tab 1 mg ...... 67 estazolam tab 1 mg ...... 66 eszopiclone tab 2 mg ...... 67 estazolam tab 2 mg ...... 66 eszopiclone tab 3 mg ...... 67 esterified estrogens & ethacrynic acid tab 25 mg ...... 75 methyltestosterone tab 0.625-1.25 ethambutol hcl tab 100 mg...... 19 mg ...... 80 ethambutol hcl tab 400 mg...... 19 esterified estrogens & ethosuximide cap 250 mg ...... 53 methyltestosterone tab 1.25-2.5 mg ethosuximide soln 250 mg/5ml ...... 53 ...... 80 ethyl chloride aerosol spray ...... 118 estradiol & norethindrone acetate tab ethynodiol diacetate & ethinyl estradiol 0.5-0.1 mg ...... 80 tab 1 mg-35 mcg...... 71 estradiol & norethindrone acetate tab ethynodiol diacetate & ethinyl estradiol 1-0.5 mg ...... 80 tab 1 mg-50 mcg...... 71 estradiol tab 0.5 mg ...... 80 etidronate disodium tab 200 mg...... 79 estradiol tab 1 mg ...... 80 etidronate disodium tab 400 mg...... 79 estradiol tab 2 mg ...... 80 etodolac cap 200 mg ...... 2 etodolac cap 300 mg ...... 2 144 etodolac tab 400 mg ...... 2 FANAPT TAB 2MG ...... 60 etodolac tab 500 mg ...... 2 FANAPT TAB 4MG ...... 61 etonogestrel-ethinyl estradiol va ring FANAPT TAB 6MG ...... 61 0.120-0.015 mg/24hr ...... 73 FANAPT TAB 8MG ...... 61 ETOPOPHOS INJ 100MG ...... 31 FARXIGA TAB 10MG ...... 24 etoposide cap 50 mg ...... 31 FARXIGA TAB 5MG ...... 24 etoposide inj 1 gm/50ml (20 mg/ml) 31 FARYDAK CAP 10MG ...... 31 etoposide inj 100 mg/5ml (20 mg/ml) FARYDAK CAP 15MG ...... 31 ...... 31 FARYDAK CAP 20MG ...... 31 etoposide inj 500 mg/25ml (20 mg/ml) FASLODEX INJ 250/5ML ...... 27 ...... 31 FC FEMALE MIS CONDOM ...... 73 EUFLEXXA INJ 10MG/ML ...... 8 fe fumarate w/ b12-vit c-fa-ifc cap EURAX CRE 10% ...... 118 110-0.015-75-0.5-240 mg ...... 105 everolimus tab 2.5 mg ...... 33 fe fumarate-vit c-vit b12-fa cap 460 everolimus tab 5 mg ...... 33 (151 fe)-60-0.01-1 mg...... 105 everolimus tab 7.5 mg ...... 33 febuxostat tab 40 mg ...... 95 EVOTAZ TAB 300-150 ...... 17 febuxostat tab 80 mg ...... 95 EVZIO INJ ...... 70 felbamate susp 600 mg/5ml ...... 53 exemestane tab 25 mg ...... 27 felbamate tab 400 mg ...... 53 EXJADE TAB 125MG ...... 97 felbamate tab 600 mg ...... 53 EXJADE TAB 250MG ...... 97 felodipine tab er 24hr 10 mg ...... 45 EXJADE TAB 500MG ...... 97 felodipine tab er 24hr 2.5 mg ...... 45 EYLEA INJ 2/0.05ML ...... 122 felodipine tab er 24hr 5 mg ...... 45 EZ FLU SHOT INJ 2014-15 ...... 124 FEMCAP MIS 26MM ...... 73 EZ FLU SHOT INJ PF 14-15 ...... 124 FEMCAP MIS 30MM ...... 73 EZ FLU SHOT KIT 2015-16 ...... 124 FEMRING MIS 0.05/24H ...... 81 EZ FLU SHOT KIT 2016-17 ...... 124 FEMRING MIS 0.1MG/24 ...... 81 ezetimibe tab 10 mg ...... 42 fenofibrate micronized cap 134 mg ... 42 F fenofibrate micronized cap 200 mg ... 42 FABIOR AER 0.1% ...... 74 fenofibrate micronized cap 43 mg..... 42 FABRAZYME INJ 35MG ...... 83 fenofibrate micronized cap 67 mg..... 42 FABRAZYME INJ 5MG ...... 83 fenofibrate tab 145 mg ...... 42 FACTIVE TAB 320MG ...... 13 fenofibrate tab 160 mg ...... 42 FALESSA KIT ...... 71 fenofibrate tab 48 mg ...... 42 famciclovir tab 125 mg ...... 21 fenofibrate tab 54 mg ...... 42 famciclovir tab 250 mg ...... 21 fenofibric acid tab 105 mg ...... 42 famciclovir tab 500 mg ...... 21 fenofibric acid tab 35 mg ...... 42 famotidine for susp 40 mg/5ml ...... 90 fenoprofen calcium tab 600 mg ...... 2 famotidine in nacl 0.9% iv soln 20 fentanyl citrate lozenge on a handle mg/50ml ...... 90 1200 mcg ...... 4 famotidine inj 20 mg/2ml ...... 90 fentanyl citrate lozenge on a handle famotidine inj 40 mg/4ml ...... 90 1600 mcg ...... 4 famotidine tab 20 mg ...... 123 fentanyl citrate lozenge on a handle famotidine tab 40 mg ...... 90 200 mcg ...... 4 FANAPT TAB 10MG ...... 61 fentanyl citrate lozenge on a handle FANAPT TAB 12MG ...... 61 400 mcg ...... 4 FANAPT TAB 1MG ...... 60 145 fentanyl citrate lozenge on a handle FLOVENT HFA AER 220MCG ...... 112 600 mcg ...... 4 FLOVENT HFA AER 44MCG ...... 112 fentanyl citrate lozenge on a handle FLOWTUSS SOL 2.5-200 ...... 109 800 mcg ...... 4 floxuridine for inj 0.5 gm ...... 26 fentanyl citrate pf soln cartridge 100 FLUAD INJ 2016-17 ...... 124 mcg/2ml...... 4 FLUBLOK SOL 2014-15 ...... 124 fentanyl td patch 72hr 100 mcg/hr .... 5 FLUCELVAX INJ 2014-15 ...... 124 fentanyl td patch 72hr 12 mcg/hr ...... 5 FLUCLVX QUAD INJ 2016-17...... 124 fentanyl td patch 72hr 25 mcg/hr ...... 5 fluconazole for susp 10 mg/ml ...... 16 fentanyl td patch 72hr 50 mcg/hr ...... 5 fluconazole for susp 40 mg/ml ...... 16 fentanyl td patch 72hr 75 mcg/hr ...... 5 fluconazole in nacl 0.9% inj 200 FER-IN-SOL DRO 15MG/ML...... 105 mg/100ml ...... 16 FERRALET 90 TAB...... 105 fluconazole in nacl 0.9% inj 400 FERRAPLUS 90 TAB ...... 105 mg/200ml ...... 16 FERRIPROX SOL 100MG/ML ...... 97 fluconazole tab 100 mg ...... 16 FERRIPROX TAB 500MG ...... 97 fluconazole tab 150 mg ...... 16 ferrous fumarate-folic acid tab 324-1 fluconazole tab 200 mg ...... 16 mg ...... 105 fluconazole tab 50 mg...... 16 FERROUS SUL LIQ 220/5ML ...... 105 FLUCONAZOLE/ INJ NACL 100 ...... 16 ferrous sulfate elixir 220 mg/5ml (44 flucytosine cap 250 mg ...... 17 mg/5ml elemental fe) ...... 105 flucytosine cap 500 mg ...... 17 ferrous sulfate soln 75 mg/ml (15 fludarabine phosphate for inj 50 mg . 26 mg/ml elemental fe) ...... 105 fludarabine phosphate inj 25 mg/ml . 26 FERROUS SULFATE SYRUP 300 MG/5ML fludrocortisone acetate tab 0.1 mg ... 81 (60 MG/5ML ELEMENTAL FE) ...... 105 FLULAVAL INJ 2014-15 ...... 124 FETZIMA CAP 120MG ...... 57 FLULAVAL QUA INJ 2014-15 ...... 124 FETZIMA CAP 20MG ...... 57 flumazenil iv soln 1 mg/10ml (0.1 FETZIMA CAP 40MG ...... 57 mg/ml) ...... 78 FETZIMA CAP 80MG ...... 57 FLUMIST QUAD SUS 2014-15 ...... 124 FETZIMA CAP TITRATIO ...... 57 flunisolide nasal soln 25 mcg/act finasteride tab 5 mg ...... 93 (0.025%) ...... 112 FINGERSTIX MIS LANCETS ...... 78 fluocinolone acetonide (otic) oil 0.01% FIRAZYR INJ 30MG/3ML ...... 97 ...... 123 FIRMAGON INJ 120MG ...... 27 fluocinolone acetonide cream 0.01% FIRMAGON INJ 80MG ...... 27 ...... 116 FIRVANQ SOL 25MG/ML ...... 9 fluocinolone acetonide cream 0.025% FIRVANQ SOL 50MG/ML ...... 9 ...... 117 FLAREX SUS 0.1% OP ...... 120 fluocinolone acetonide oil 0.01% (body flavoxate hcl tab 100 mg ...... 94 oil) ...... 116 FLEBOGAMMA INJ 20/400ML...... 99 fluocinolone acetonide oil 0.01% (scalp flecainide acetate tab 100 mg ...... 41 oil) ...... 116 flecainide acetate tab 150 mg ...... 41 fluocinolone acetonide oint 0.025% 117 flecainide acetate tab 50 mg ...... 41 fluocinolone acetonide soln 0.01%.. 116 FLOVENT DISK AER 100MCG ...... 112 fluocinonide cream 0.05% ...... 116 FLOVENT DISK AER 250MCG ...... 112 fluocinonide emulsified base cream FLOVENT DISK AER 50MCG ...... 112 0.05% ...... 116 FLOVENT HFA AER 110MCG ...... 112 fluocinonide gel 0.05% ...... 116 146 fluocinonide oint 0.05% ...... 116 fluticasone propionate nasal susp 50 fluocinonide soln 0.05% ...... 116 mcg/act ...... 112 FLUORABON DRO ...... 105 fluticasone propionate oint 0.005% 117 FLUORAC CRE 5-1% ...... 31 fluvastatin sodium cap 20 mg (base FLUOR-A-DAY CHW 0.25MG F ...... 105 equivalent) ...... 42 FLUOR-A-DAY CHW 0.5MG F ...... 105 fluvastatin sodium cap 40 mg (base FLUOR-A-DAY CHW 1MG F ...... 105 equivalent) ...... 43 fluorescein w/ benoxinate ophth soln FLUVIRIN INJ 2014-15 ...... 124 0.25-0.4% ...... 121 FLUVIRIN INJ 2015-16 ...... 124 fluorescein w/ proparacaine ophth soln FLUVIRIN PF INJ 2014-15...... 124 0.25-0.5% ...... 121 fluvoxamine maleate tab 100 mg ..... 52 fluorometholone ophth susp 0.1% .. 120 fluvoxamine maleate tab 25 mg ...... 52 fluorouracil cream 5% ...... 114 fluvoxamine maleate tab 50 mg ...... 52 fluorouracil iv soln 1 gm/20ml (50 FLUZONE HD INJ PF 14-15 ...... 125 mg/ml) ...... 26 FLUZONE INJ INTRADRM ...... 125 fluorouracil iv soln 2.5 gm/50ml (50 FLUZONE QUAD INJ 14-15 ...... 125 mg/ml) ...... 27 FLUZONE QUAD INJ 2015-16 ...... 125 fluorouracil iv soln 5 gm/100ml (50 FML FORTE SUS 0.25% OP ...... 120 mg/ml) ...... 27 FML OIN 0.1% OP ...... 120 fluorouracil iv soln 500 mg/10ml (50 FOCALGIN DSS TAB 90-1MG...... 105 mg/ml) ...... 27 folbic tab ...... 103 fluorouracil soln 2% ...... 114 folic acid cap 0.8 mg...... 104 fluorouracil soln 5% ...... 114 folic acid tab 1 mg ...... 104 fluoxetine hcl (pmdd) cap 10 mg ...... 57 folic acid tab 400 mcg ...... 104 fluoxetine hcl (pmdd) cap 20 mg ...... 57 folic acid tab 800 mcg ...... 104 fluoxetine hcl cap 10 mg ...... 57 folic acid-pyridoxine-cyanocobalamin fluoxetine hcl cap 20 mg ...... 58 tab 2.5-25-2 mg...... 103 fluoxetine hcl cap 40 mg ...... 58 folic acid-vitamin b6-vitamin b12 tab fluoxetine hcl solution 20 mg/5ml ..... 58 2.2-25-0.5 mg ...... 104 fluoxetine hcl tab 10 mg...... 58 folic acid-vitamin b6-vitamin b12 tab fluphenazine decanoate inj 25 mg/ml62 2.2-25-1 mg ...... 104 fluphenazine hcl elixir 2.5 mg/5ml .... 62 folic acid-vitamin b6-vitamin b12 tab fluphenazine hcl inj 2.5 mg/ml ...... 62 2.5-25-1 mg ...... 104 fluphenazine hcl oral conc 5 mg/ml... 62 FOLIVANE-F CAP ...... 105 fluphenazine hcl tab 1 mg ...... 63 FOLIVANE-PLS CAP...... 105 fluphenazine hcl tab 10 mg ...... 63 fondaparinux sodium subcutaneous inj fluphenazine hcl tab 2.5 mg ...... 63 10 mg/0.8ml ...... 95 fluphenazine hcl tab 5 mg ...... 63 fondaparinux sodium subcutaneous inj flurazepam hcl cap 15 mg ...... 66 2.5 mg/0.5ml...... 95 flurazepam hcl cap 30 mg ...... 66 fondaparinux sodium subcutaneous inj flurbiprofen sodium ophth soln 0.03% 5 mg/0.4ml ...... 95 ...... 120 fondaparinux sodium subcutaneous inj flurbiprofen tab 100 mg ...... 2 7.5 mg/0.6ml...... 95 flurbiprofen tab 50 mg ...... 2 FORADIL CAP AEROLIZE ...... 110 flutamide cap 125 mg ...... 27 FORTEO SOL 600/2.4 ...... 79 fluticasone propionate cream 0.05% FORTICAL SPR 200/ACT ...... 79 ...... 117 FOSAMAX + D TAB 70-2800 ...... 79 147

FOSAMAX + D TAB 70-5600 ...... 79 G fosamprenavir calcium tab 700 mg gabapentin cap 100 mg ...... 53 (base equiv) ...... 18 gabapentin cap 300 mg ...... 53 fosaprepitant dimeglumine for iv gabapentin cap 400 mg ...... 53 infusion 150 mg (base eq) ...... 25 gabapentin oral soln 250 mg/5ml ..... 53 fosinopril sodium & hydrochlorothiazide gabapentin tab 600 mg ...... 53 tab 10-12.5 mg ...... 38 gabapentin tab 800 mg ...... 53 fosinopril sodium & hydrochlorothiazide GABLOFEN INJ 20000/20 ...... 103 tab 20-12.5 mg ...... 38 GABLOFEN INJ 50MCG/ML ...... 103 fosinopril sodium tab 10 mg ...... 38 GALAFOLD CAP 123MG ...... 87 fosinopril sodium tab 20 mg ...... 38 galantamine hydrobromide cap er 24hr fosinopril sodium tab 40 mg ...... 38 16 mg ...... 55 fosphenytoin sodium inj 100 mg/2ml galantamine hydrobromide cap er 24hr (phenytoin equiv) ...... 53 24 mg ...... 55 fosphenytoin sodium inj 500 mg/10ml galantamine hydrobromide cap er 24hr (phenytoin equiv) ...... 53 8 mg ...... 55 FOSRENOL POW 1000MG ...... 84 galantamine hydrobromide oral soln 4 FOSRENOL POW 750MG ...... 84 mg/ml ...... 55 FRAGMIN INJ 10000/ML ...... 96 galantamine hydrobromide tab 12 mg FRAGMIN INJ 12500UNT ...... 96 ...... 55 FRAGMIN INJ 15000UNT ...... 96 galantamine hydrobromide tab 4 mg 55 FRAGMIN INJ 18000UNT ...... 96 galantamine hydrobromide tab 8 mg 55 FRAGMIN INJ 2500/0.2 ...... 95 GALZIN CAP 25MG ...... 105 FRAGMIN INJ 5000/0.2 ...... 95 GALZIN CAP 50MG ...... 105 FRAGMIN INJ 7500/0.3 ...... 95 GAMASTAN INJ ...... 99 FRAGMIN INJ 95000UNT ...... 96 GAMMAGARD INJ 10GM/100 ...... 99 frovatriptan succinate tab 2.5 mg (base GAMMAGARD INJ 1GM/10ML ...... 99 equivalent) ...... 102 GAMMAGARD INJ 2.5GM/25 ...... 99 FULL SPECT TAB B/ VIT C ...... 105 GAMMAGARD INJ 20GM/200 ...... 99 fulvestrant inj 250 mg/5ml ...... 32 GAMMAGARD INJ 5GM/50ML ...... 99 FULYZAQ TAB 125MG ...... 88 GAMMAGARD SD INJ 10GM HU ...... 100 furosemide inj 10 mg/ml ...... 47 GAMMAGARD SD INJ 5GM HU ...... 100 furosemide oral soln 10 mg/ml...... 47 GAMUNEX-C INJ 40/400ML ...... 100 furosemide oral soln 8 mg/ml ...... 47 ganciclovir sodium for inj 500 mg ..... 20 furosemide tab 20 mg ...... 47 GARDASIL 9 INJ ...... 125 furosemide tab 40 mg ...... 47 GARDASIL INJ ...... 125 furosemide tab 80 mg ...... 47 gatifloxacin ophth soln 0.5% ...... 119 FUSION PLUS CAP ...... 105 GATTEX KIT 5MG ...... 91 FUZEON INJ 90MG ...... 17 GELCLAIR GEL ...... 119 FYCOMPA SUS 0.5MG/ML ...... 53 gemcitabine hcl for inj 1 gm ...... 27 FYCOMPA TAB 10MG ...... 53 gemcitabine hcl for inj 2 gm ...... 27 FYCOMPA TAB 12MG ...... 53 gemcitabine hcl for inj 200 mg ...... 27 FYCOMPA TAB 2MG...... 53 gemcitabine hcl inj 200 mg/5.26ml (38 FYCOMPA TAB 4MG...... 53 mg/ml) (base equiv) ...... 27 FYCOMPA TAB 6MG...... 53 gemcitabine inj 1gm ...... 27 FYCOMPA TAB 8MG...... 53 gemcitabine inj 2gm ...... 27 gemfibrozil tab 600 mg ...... 42 148

GENERESS FE CHW ...... 71 glipizide tab er 24hr 2.5 mg...... 77 GENOTROPIN INJ 0.2MG ...... 87 glipizide tab er 24hr 5 mg ...... 78 GENOTROPIN INJ 0.4MG ...... 87 glipizide-metformin hcl tab 2.5-250 mg GENOTROPIN INJ 0.6MG ...... 87 ...... 76 GENOTROPIN INJ 0.8MG ...... 87 glipizide-metformin hcl tab 2.5-500 mg GENOTROPIN INJ 1.2MG ...... 87 ...... 76 GENOTROPIN INJ 1.4MG ...... 87 glipizide-metformin hcl tab 5-500 mg76 GENOTROPIN INJ 1.6MG ...... 87 GLUCAGEN INJ 1MG ...... 82 GENOTROPIN INJ 12MG ...... 87 GLUCAGEN INJ HYPOKIT ...... 82 GENOTROPIN INJ 1MG ...... 87 GLUCAGON INJ 1MG ...... 102 GENOTROPIN INJ 5MG ...... 87 GLUCAGON KIT 1MG...... 82 GENTAM/NACL INJ 0.9MG/ML ...... 9 GLUCOLET 2 MIS LANCING ...... 78 GENTAM/NACL INJ 1.4MG/ML ...... 9 glyburide micronized tab 1.5 mg ...... 78 gentamicin in saline inj 0.8 mg/ml ..... 9 glyburide micronized tab 3 mg ...... 78 gentamicin in saline inj 1 mg/ml ...... 9 glyburide micronized tab 6 mg ...... 78 gentamicin in saline inj 1.2 mg/ml ..... 9 glyburide tab 1.25 mg ...... 78 gentamicin in saline inj 1.6 mg/ml ..... 9 glyburide tab 2.5 mg ...... 78 gentamicin in saline inj 2 mg/ml ...... 9 glyburide tab 5 mg ...... 78 gentamicin sulfate cream 0.1% ...... 114 glyburide-metformin tab 1.25-250 mg gentamicin sulfate inj 10 mg/ml ...... 9 ...... 76 gentamicin sulfate inj 40 mg/ml ...... 9 glyburide-metformin tab 2.5-500 mg 76 gentamicin sulfate iv soln 10 mg/ml .. 9 glyburide-metformin tab 5-500 mg ... 76 gentamicin sulfate oint 0.1% ...... 114 glycopyrrolate inj 1 mg/5ml (0.2 gentamicin sulfate ophth oint 0.3% 119 mg/ml) ...... 89 gentamicin sulfate ophth soln 0.3% 119 glycopyrrolate tab 1 mg ...... 89 GENVOYA TAB ...... 17 glycopyrrolate tab 2 mg ...... 90 GEODON INJ 20MG ...... 61 GLYXAMBI TAB 10-5 MG ...... 77 GILENYA CAP 0.5MG ...... 68 GLYXAMBI TAB 25-5 MG ...... 77 GILOTRIF TAB 20MG ...... 29 GRALISE STAR MIS 300/600...... 69 GILOTRIF TAB 30MG ...... 29 GRALISE TAB 300MG ...... 69 GILOTRIF TAB 40MG ...... 29 GRALISE TAB 600MG ...... 69 GIVLAARI INJ 189MG/ML...... 98 granisetron hcl inj 0.1 mg/ml...... 88 GLASSIA INJ ...... 111 granisetron hcl inj 1 mg/ml ...... 88 glatiramer acetate soln prefilled syringe granisetron hcl inj 4 mg/4ml (1 mg/ml) 20 mg/ml ...... 108 ...... 88 glatiramer acetate soln prefilled syringe granisetron hcl tab 1 mg ...... 88 40 mg/ml ...... 108 GRANIX INJ 300/0.5 ...... 96 GLEOSTINE CAP 100MG ...... 26 GRANIX INJ 300/1ML ...... 98 GLEOSTINE CAP 10MG ...... 26 GRANIX INJ 480/0.8 ...... 96 GLEOSTINE CAP 40MG ...... 26 GRANIX INJ 480/1.6 ...... 98 GLEOSTINE CAP 5MG ...... 26 GRASTEK SUB 2800BAU...... 1 glimepiride tab 1 mg...... 77 griseofulvin microsize susp 125 mg/5ml glimepiride tab 2 mg...... 77 ...... 17 glimepiride tab 4 mg...... 77 griseofulvin microsize tab 500 mg .... 17 glipizide tab 10 mg ...... 77 griseofulvin ultramicrosize tab 125 mg glipizide tab 5 mg ...... 77 ...... 17 glipizide tab er 24hr 10 mg ...... 78 149 griseofulvin ultramicrosize tab 250 mg heparin sodium (porcine) inj 1000 ...... 17 unit/ml ...... 96 guaifenesin-codeine soln 100-10 heparin sodium (porcine) inj 10000 mg/5ml ...... 109 unit/ml ...... 96 guaifenesin-codeine soln 100-6.3 heparin sodium (porcine) inj 20000 mg/5ml ...... 109 unit/ml ...... 96 guanfacine hcl tab 1 mg ...... 39 heparin sodium (porcine) inj 5000 guanfacine hcl tab 2 mg ...... 39 unit/ml ...... 96 guanfacine hcl tab er 24hr 1 mg (base heparin sodium (porcine) pf inj 5000 equiv) ...... 65 unit/0.5ml ...... 96 guanfacine hcl tab er 24hr 2 mg (base heparin sodium (porcine)-dextrose iv equiv) ...... 65 sol 20000 unit/500ml-5% ...... 102 guanfacine hcl tab er 24hr 3 mg (base heparin sodium (porcine)-dextrose iv equiv) ...... 65 sol 25000 unit/500ml-5% ...... 102 guanfacine hcl tab er 24hr 4 mg (base HERCEPTIN INJ 150MG ...... 31 equiv) ...... 65 HERCEPTIN INJ 440MG ...... 31 GUANIDINE TAB 125MG ...... 68 HETLIOZ CAP 20MG ...... 67 GYNAZOLE-1 CRE 2% ...... 95 HEXALEN CAP 50MG ...... 26 GYNOL II GEL 3% ...... 113 HIBERIX SOL 10MCG ...... 36 H HIZENTRA INJ 10/50ML ...... 100 HALFPRIN TAB 162MG EC ...... 2 homatropine hbr ophth soln 5% ..... 122 halobetasol propionate cream 0.05% HORIZANT TAB 300MG ER ...... 71 ...... 117 HORIZANT TAB 600MG ER ...... 71 halobetasol propionate oint 0.05% . 117 HUMIRA INJ 10/0.1ML ...... 8 HALOG OIN 0.1% ...... 74 HUMIRA INJ 10MG/0.2 ...... 99 haloperidol decanoate im soln 100 HUMIRA INJ 20/0.2ML ...... 8 mg/ml ...... 63 HUMIRA INJ 40/0.4ML ...... 8 haloperidol decanoate im soln 50 HUMIRA KIT 20MG/0.4 ...... 99 mg/ml ...... 63 HUMIRA KIT 40MG/0.8 ...... 99 haloperidol lactate inj 5 mg/ml...... 63 HUMIRA PEDIA INJ CROHNS ...... 8 haloperidol lactate oral conc 2 mg/ml63 HUMIRA PEN INJ 40/0.4ML ...... 8 haloperidol tab 0.5 mg ...... 63 HUMIRA PEN INJ 40MG/0.8 ...... 99 haloperidol tab 1 mg ...... 63 HUMIRA PEN KIT CD/UC/HS ...... 8 haloperidol tab 10 mg ...... 63 HUMIRA PEN KIT PS/UV ...... 8 haloperidol tab 2 mg ...... 63 HUMULIN R INJ U-500 ...... 76 haloperidol tab 20 mg ...... 63 HYCAMTIN CAP 0.25MG ...... 32 haloperidol tab 5 mg ...... 63 HYCAMTIN CAP 1MG ...... 32 HARVONI TAB 90-400MG ...... 20 hydralazine hcl inj 20 mg/ml ...... 48 HAVRIX INJ 1440UNIT ...... 125 hydralazine hcl tab 10 mg ...... 48 HAVRIX INJ 720UNIT ...... 125 hydralazine hcl tab 100 mg ...... 48 HECTOROL INJ 2MCG/ML ...... 82 hydralazine hcl tab 25 mg ...... 48 HEMANGEOL SOL 4.28/ML ...... 44 hydralazine hcl tab 50 mg ...... 48 HEMATOGEN FA CAP ...... 105 hydrochlorothiazide cap 12.5 mg ...... 47 HEP SOD/NACL INJ 25000UNT ...... 102 hydrochlorothiazide tab 12.5 mg ...... 47 heparin sodium (porcine) 100 unit/ml hydrochlorothiazide tab 25 mg ...... 47 in d5w ...... 102 hydrochlorothiazide tab 50 mg ...... 47

150 hydrocod polst-chlorphen polst er susp hydrocortisone tab 5 mg ...... 81 10-8 mg/5ml ...... 109 hydrocortisone w/ acetic acid otic soln hydrocodone bitartrate cap er 12hr 1-2% ...... 123 abuse-deterrent 10 mg ...... 8 HYDROMORPHON SUP 3MG ...... 5 hydrocodone bitartrate cap er 12hr hydromorphone hcl inj 1 mg/ml ...... 5 abuse-deterrent 15 mg ...... 8 hydromorphone hcl inj 2 mg/ml ...... 5 hydrocodone bitartrate cap er 12hr hydromorphone hcl inj 4 mg/ml ...... 5 abuse-deterrent 20 mg ...... 8 hydromorphone hcl tab 2 mg ...... 5 hydrocodone bitartrate cap er 12hr hydromorphone hcl tab 4 mg ...... 5 abuse-deterrent 30 mg ...... 8 hydromorphone hcl tab 8 mg ...... 5 hydrocodone bitartrate cap er 12hr hydromorphone hcl tab er 24hr deter abuse-deterrent 40 mg ...... 8 12 mg ...... 5 hydrocodone bitartrate cap er 12hr hydromorphone hcl tab er 24hr deter abuse-deterrent 50 mg ...... 8 16 mg ...... 5 hydrocodone w/ homatropine syrup 5- hydromorphone hcl tab er 24hr deter 1.5 mg/5ml ...... 109 32 mg ...... 5 hydrocodone w/ homatropine tab 5-1.5 hydromorphone hcl tab er 24hr deter 8 mg ...... 109 mg ...... 5 hydrocodone-acetaminophen soln 10- hydroxychloroquine sulfate tab 200 mg 325 mg/15ml ...... 5 ...... 99 hydrocodone-acetaminophen soln 7.5- hydroxyprogesterone caproate im in oil 325 mg/15ml ...... 5 250 mg/ml ...... 107 hydrocodone-acetaminophen tab 10- hydroxyurea cap 500 mg ...... 31 325 mg ...... 5 hydroxyzine hcl im soln 25 mg/ml .. 109 hydrocodone-acetaminophen tab 2.5- hydroxyzine hcl im soln 50 mg/ml .. 109 325 mg ...... 5 hydroxyzine hcl syrup 10 mg/5ml... 109 hydrocodone-acetaminophen tab 5-325 hydroxyzine hcl tab 10 mg ...... 109 mg ...... 5 hydroxyzine hcl tab 25 mg ...... 109 hydrocodone-acetaminophen tab 7.5- hydroxyzine hcl tab 50 mg ...... 109 325 mg ...... 5 hydroxyzine pamoate cap 100 mg .. 109 hydrocodone-ibuprofen tab 10-200 mg hydroxyzine pamoate cap 25 mg .... 109 ...... 5 hydroxyzine pamoate cap 50 mg .... 109 hydrocodone-ibuprofen tab 5-200 mg 5 hyoscyamine sulfate elixir 0.125 hydrocodone-ibuprofen tab 7.5-200 mg mg/5ml ...... 90 ...... 5 hyoscyamine sulfate sl tab 0.125 mg 90 hydrocortisone acetate w/ pramoxine hyoscyamine sulfate soln 0.125 mg/ml perianal cream 1-1% ...... 93 ...... 90 hydrocortisone acetate w/ pramoxine hyoscyamine sulfate tab 0.125 mg ... 90 perianal cream 2.5-1%...... 93 hyoscyamine sulfate tab disint 0.125 hydrocortisone cream 2.5% ...... 116 mg ...... 90 hydrocortisone enema 100 mg/60ml. 91 hyoscyamine sulfate tab er 12hr 0.375 hydrocortisone lotion 2.5% ...... 116 mg ...... 90 hydrocortisone oint 1% ...... 116 HYPO NEEDLE MIS 18GX1 ...... 78 hydrocortisone oint 2.5% ...... 116 HYPO NEEDLE MIS 18GX1.5 ...... 78 hydrocortisone perianal cream 2.5% . 93 HYQVIA INJ 10-800 ...... 107 hydrocortisone tab 10 mg...... 81 HYQVIA INJ 2.5-200 ...... 107 hydrocortisone tab 20 mg...... 81 HYQVIA INJ 20-1600 ...... 107 151

HYQVIA INJ 30-2400 ...... 107 imipramine hcl tab 50 mg...... 59 HYQVIA INJ 5-400 ...... 107 imiquimod cream 5%...... 118 I IMPLANON IMP 68MG ...... 107 ibandronate sodium iv soln 3 mg/3ml INCRELEX INJ 40MG/4ML ...... 83 (base equivalent) ...... 79 INCRUSE ELPT INH 62.5MCG ...... 23 ibandronate sodium tab 150 mg (base indapamide tab 1.25 mg ...... 47 equivalent) ...... 79 indapamide tab 2.5 mg ...... 47 IBRANCE CAP 100MG ...... 29 indomethacin cap 25 mg ...... 3 IBRANCE CAP 125MG ...... 29 indomethacin cap 50 mg ...... 3 IBRANCE CAP 75MG ...... 29 indomethacin cap er 75 mg ...... 3 IBRANCE TAB 100MG ...... 33 INFANRIX INJ ...... 123 IBRANCE TAB 125MG ...... 33 INLYTA TAB 1MG ...... 29 IBRANCE TAB 75MG ...... 33 INLYTA TAB 5MG ...... 29 ibuprofen tab 400 mg ...... 3 INREBIC CAP 100MG ...... 34 ibuprofen tab 600 mg ...... 3 INTELENCE TAB 100MG ...... 18 ibuprofen tab 800 mg ...... 3 INTELENCE TAB 200MG ...... 18 ICAR PEDS SUS GRAPE ...... 105 INTELENCE TAB 25MG ...... 18 ICLUSIG TAB 15MG ...... 29 INTRAROSA SUP 6.5MG ...... 124 ICLUSIG TAB 45MG ...... 29 INTRON A INJ 10MU ...... 100 idarubicin hcl iv inj 5 mg/5ml (1 INTRON A INJ 18MU ...... 100 mg/ml) ...... 31 INTRON A INJ 25MU ...... 100 IDHIFA TAB 100MG ...... 33 INTRON A INJ 50MU ...... 100 IDHIFA TAB 50MG ...... 33 INVANZ INJ 1GM ...... 10 ifosfamide for inj 1 gm ...... 26 INVEGA SUST INJ 117/0.75 ...... 61 IFOSFAMIDE INJ 3GM ...... 26 INVEGA SUST INJ 156MG/ML ...... 61 ifosfamide iv inj 1 gm/20ml (50 mg/ml) INVEGA SUST INJ 234/1.5...... 61 ...... 26 INVEGA SUST INJ 39/0.25...... 61 ifosfamide iv inj 3 gm/60ml (50 mg/ml) INVEGA SUST INJ 78/0.5ML ...... 61 ...... 26 INVEGA TRINZ INJ 273MG...... 61 ILARIS INJ 150MG ...... 100 INVEGA TRINZ INJ 410MG...... 61 ILEVRO DRO 0.3% OP...... 120 INVEGA TRINZ INJ 546MG...... 61 ILUVIEN IMP 0.19MG ...... 120 INVEGA TRINZ INJ 819MG...... 61 imatinib mesylate tab 100 mg (base INVIRASE CAP 200MG ...... 18 equivalent) ...... 33 INVIRASE TAB 500MG ...... 18 imatinib mesylate tab 400 mg (base IPOL INJ INACTIVE ...... 125 equivalent) ...... 34 ipratropium bromide inhal soln 0.02% IMBRUVICA CAP 140MG ...... 29 ...... 108 IMBRUVICA TAB 140MG ...... 29 ipratropium bromide nasal soln 0.03% IMBRUVICA TAB 280MG ...... 29 (21 mcg/spray) ...... 111 IMBRUVICA TAB 420MG ...... 29 ipratropium bromide nasal soln 0.06% IMBRUVICA TAB 560MG ...... 29 (42 mcg/spray) ...... 111 imipenem-cilastatin intravenous for ipratropium-albuterol nebu soln 0.5- soln 250 mg...... 10 2.5(3) mg/3ml ...... 108 imipenem-cilastatin intravenous for irbesartan tab 150 mg ...... 41 soln 500 mg...... 10 irbesartan tab 300 mg ...... 41 imipramine hcl tab 10 mg ...... 58 irbesartan tab 75 mg ...... 41 imipramine hcl tab 25 mg ...... 59 152 irbesartan-hydrochlorothiazide tab ISTURISA TAB 1MG ...... 87 150-12.5 mg ...... 40 ISTURISA TAB 5MG ...... 87 irbesartan-hydrochlorothiazide tab itraconazole cap 100 mg ...... 17 300-12.5 mg ...... 40 itraconazole oral soln 10 mg/ml ...... 25 IRESSA TAB 250MG ...... 29 ivermectin tab 3 mg ...... 22 irinotecan hcl inj 100 mg/5ml (20 IXEMPRA KIT INJ 15MG ...... 31 mg/ml) ...... 32 IXEMPRA KIT INJ 45MG ...... 31 irinotecan hcl inj 40 mg/2ml (20 J mg/ml) ...... 32 JAKAFI TAB 10MG ...... 29 irinotecan hcl inj 500 mg/25ml (20 JAKAFI TAB 15MG ...... 29 mg/ml) ...... 32 JAKAFI TAB 20MG ...... 29 iron polysacch complex-vit b12-fa cap JAKAFI TAB 25MG ...... 29 150-0.025-1 mg ...... 105 JAKAFI TAB 5MG ...... 29 iron-folic acid-vit c-vit b6-vit b12-zinc JANUMET TAB 50-1000 ...... 76 tab 150-1.25 mg ...... 105 JANUMET TAB 50-500MG ...... 76 iron-vit c-vit b12-folic acid tab 100- JANUMET XR TAB 100-1000...... 76 250-0.025-1 mg ...... 105 JANUMET XR TAB 50-1000 ...... 76 ISENTRESS CHW 100MG ...... 18 JANUMET XR TAB 50-500MG ...... 76 ISENTRESS CHW 25MG ...... 18 JANUVIA TAB 100MG ...... 76 ISENTRESS HD TAB 600MG ...... 18 JANUVIA TAB 25MG ...... 76 ISENTRESS POW 100MG ...... 18 JANUVIA TAB 50MG ...... 76 ISENTRESS TAB 400MG ...... 18 JARDIANCE TAB 10MG ...... 77 isometheptene-dichloral- JARDIANCE TAB 25MG ...... 77 acetaminophen cap 65-100-325 mg JETREA INJ 0.5/0.2 ...... 122 ...... 67 JUBLIA SOL 10% ...... 74 isoniazid inj 100 mg/ml ...... 19 JUXTAPID CAP 10MG ...... 43 isoniazid syrup 50 mg/5ml ...... 19 JUXTAPID CAP 20MG ...... 43 isoniazid tab 100 mg ...... 19 JUXTAPID CAP 30MG ...... 43 isoniazid tab 300 mg ...... 19 JUXTAPID CAP 40MG ...... 43 isosorbide dinitrate tab 10 mg ...... 49 JUXTAPID CAP 5MG ...... 43 isosorbide dinitrate tab 20 mg ...... 49 JUXTAPID CAP 60MG ...... 43 isosorbide dinitrate tab 30 mg ...... 49 JYNARQUE PAK 45-15MG ...... 88 isosorbide dinitrate tab 5 mg ...... 49 JYNARQUE PAK 60-30MG ...... 88 isosorbide dinitrate tab er 40 mg ...... 49 JYNARQUE PAK 90-30MG ...... 88 isosorbide mononitrate tab 10 mg .... 49 K isosorbide mononitrate tab 20 mg .... 49 KALBITOR INJ 10MG/ML ...... 97 isosorbide mononitrate tab er 24hr 120 KALETRA TAB 100-25MG ...... 18 mg ...... 49 KALETRA TAB 200-50MG ...... 18 isosorbide mononitrate tab er 24hr 30 KALYDECO PAK 50MG ...... 111 mg ...... 49 KALYDECO PAK 75MG ...... 111 isosorbide mononitrate tab er 24hr 60 KALYDECO TAB 150MG ...... 111 mg ...... 49 KEPIVANCE INJ 6.25MG ...... 91 isoxsuprine hcl tab 10 mg ...... 48 KERYDIN SOL 5% ...... 115 isoxsuprine hcl tab 20 mg ...... 48 KETEK TAB 300MG ...... 13 isradipine cap 2.5 mg ...... 45 KETEK TAB 400MG ...... 13 isradipine cap 5 mg ...... 45 ketoconazole cream 2% ...... 115 ISTURISA TAB 10MG ...... 87 ketoconazole shampoo 2% ...... 115 153 ketoconazole tab 200 mg ...... 17 lactulose (encephalopathy) solution 10 ketoprofen cap 50 mg ...... 3 gm/15ml ...... 91 ketoprofen cap 75 mg ...... 3 lactulose solution 10 gm/15ml ...... 91 ketoprofen cap er 24hr 200 mg ...... 8 LAMICTAL CHW 2MG...... 23 ketorolac tromethamine im inj 60 lamivudine oral soln 10 mg/ml ...... 19 mg/2ml (30 mg/ml) ...... 3 lamivudine tab 100 mg (hbv)...... 20 ketorolac tromethamine inj 15 mg/ml 3 lamivudine tab 150 mg ...... 19 ketorolac tromethamine inj 30 mg/ml 3 lamivudine tab 300 mg ...... 19 ketorolac tromethamine inj 300 lamivudine-zidovudine tab 150-300 mg mg/10ml (30 mg/ml) ...... 3 ...... 17 ketorolac tromethamine ophth soln lamotrigine orally disintegrating tab 0.4% ...... 120 100 mg ...... 23 ketorolac tromethamine ophth soln lamotrigine orally disintegrating tab 0.5% ...... 120 200 mg ...... 23 ketorolac tromethamine tab 10 mg .... 3 lamotrigine orally disintegrating tab 25 KEVEYIS TAB 50MG ...... 121 mg ...... 23 KINERET INJ ...... 8 lamotrigine orally disintegrating tab 50 KISQALI 200 PAK FEMARA ...... 29 mg ...... 23 KISQALI 400 PAK FEMARA ...... 29 lamotrigine tab 100 mg ...... 53 KISQALI 600 PAK FEMARA ...... 29 lamotrigine tab 150 mg ...... 53 KISQALI TAB 200DOSE ...... 29 lamotrigine tab 200 mg ...... 53 KISQALI TAB 400DOSE ...... 29 lamotrigine tab 25 mg ...... 53 KISQALI TAB 600DOSE ...... 29 lamotrigine tab chewable dispersible 25 KLOR-CON M15 TAB 15MEQ ER ...... 103 mg ...... 53 KORLYM TAB 300MG ...... 83 lamotrigine tab chewable dispersible 5 KOSELUGO CAP 10MG ...... 34 mg ...... 53 KOSELUGO CAP 25MG ...... 34 lamotrigine tab er 24hr 250 mg ...... 23 KRYSTEXXA INJ 8MG/ML ...... 1 lamotrigine tab er 24hr 50 mg ...... 23 KUVAN POW 500MG ...... 84 lansoprazole cap delayed release 15 KUVAN TAB 100MG...... 84 mg ...... 92 KYLEENA IUD 19.5MG ...... 107 lansoprazole cap delayed release 30 KYNAMRO INJ 200MG/ML ...... 43 mg ...... 92 L lanthanum carbonate chew tab 1000 labetalol hcl iv soln 5 mg/ml ...... 44 mg (elemental) ...... 84 labetalol hcl tab 100 mg ...... 44 lanthanum carbonate chew tab 500 mg labetalol hcl tab 200 mg ...... 44 (elemental)...... 84 labetalol hcl tab 300 mg ...... 44 lanthanum carbonate chew tab 750 mg lactated ringer's for irrigation ...... 118 (elemental)...... 84 lactic acid (ammonium lactate) cream LANTUS INJ 100/ML ...... 77 12% ...... 117 LANTUS SOLOS INJ 100/ML ...... 77 lactic acid (ammonium lactate) lotion LASTACAFT SOL 0.25%...... 121 10% ...... 117 latanoprost ophth soln 0.005% ...... 122 lactic acid (ammonium lactate) lotion LATUDA TAB 120MG ...... 61 12% ...... 117 LATUDA TAB 20MG ...... 61 lactic acid w/ vitamin e cream 10%- LATUDA TAB 40MG ...... 61 3500 unit/30gm ...... 117 LATUDA TAB 60MG ...... 61 LATUDA TAB 80MG ...... 61 154 leflunomide tab 10 mg ...... 99 levocetirizine dihydrochloride tab 5 mg leflunomide tab 20 mg ...... 99 ...... 109 LEMTRADA INJ 12/1.2ML ...... 68 levofloxacin in d5w iv soln 250 LENVIMA CAP 10 MG ...... 29 mg/50ml ...... 13 LENVIMA CAP 14 MG ...... 29 levofloxacin in d5w iv soln 500 LENVIMA CAP 18 MG ...... 34 mg/100ml ...... 13 LENVIMA CAP 20 MG ...... 29 levofloxacin in d5w iv soln 750 LENVIMA CAP 24 MG ...... 29 mg/150ml ...... 13 LENVIMA CAP 8 MG ...... 34 levofloxacin iv soln 25 mg/ml ...... 13 letrozole tab 2.5 mg ...... 27 levofloxacin ophth soln 0.5% ...... 119 leucovorin calcium tab 10 mg ...... 31 levofloxacin oral soln 25 mg/ml...... 13 leucovorin calcium tab 15 mg ...... 31 levofloxacin tab 250 mg ...... 13 leucovorin calcium tab 25 mg ...... 31 levofloxacin tab 500 mg ...... 13 leucovorin calcium tab 5 mg ...... 31 levofloxacin tab 750 mg ...... 13 LEUKERAN TAB 2MG ...... 26 levonorgestrel & ethinyl estradiol (91- LEUKINE INJ 250MCG ...... 97 day) tab 0.15-0.03 mg ...... 72 leuprolide acetate inj kit 5 mg/ml ..... 28 levonorgestrel & ethinyl estradiol tab levalbuterol hcl soln nebu 0.31 mg/3ml 0.1 mg-20 mcg ...... 71 (base equiv) ...... 110 levonorgestrel & ethinyl estradiol tab levalbuterol hcl soln nebu 0.63 mg/3ml 0.15 mg-30 mcg ...... 71 (base equiv) ...... 110 levonorgestrel tab 0.75 mg ...... 75 levalbuterol hcl soln nebu 1.25 mg/3ml levonorgestrel tab 1.5 mg ...... 75 (base equiv) ...... 110 levonorgestrel-eth estra tab 0.05- levalbuterol hcl soln nebu conc 1.25 30/0.075-40/0.125-30mg-mcg ..... 72 mg/0.5ml (base equiv) ...... 110 levonorgestrel-ethinyl estradiol levalbuterol tartrate inhal aerosol 45 (continuous) tab 90-20 mcg ...... 72 mcg/act (base equiv) ...... 23 levonorg-eth est tab 0.1-0.02mg(84) & LEVATOL TAB 20MG ...... 44 eth est tab 0.01mg(7) ...... 72 LEVEMIR INJ ...... 77 levonorg-eth est tab 0.15-0.03mg(84) LEVEMIR INJ FLEXTOUC ...... 77 & eth est tab 0.01mg(7) ...... 72 levetiracetam inj 500 mg/5ml (100 levorphanol tartrate tab 2 mg ...... 5 mg/ml) ...... 53 levothyroxine sodium for iv inj 100 mcg levetiracetam oral soln 100 mg/ml ... 53 ...... 85 levetiracetam tab 1000 mg ...... 53 LEVOTHYROXINE SODIUM FOR IV INJ levetiracetam tab 250 mg ...... 53 200 MCG ...... 85 levetiracetam tab 500 mg ...... 53 levothyroxine sodium for iv inj 500 mcg levetiracetam tab 750 mg ...... 53 ...... 85 levetiracetam tab er 24hr 500 mg .... 53 levothyroxine sodium tab 100 mcg ... 85 levetiracetam tab er 24hr 750 mg .... 53 levothyroxine sodium tab 112 mcg ... 85 levobunolol hcl ophth soln 0.5% ..... 121 levothyroxine sodium tab 125 mcg ... 85 levocarnitine inj 200 mg/ml ...... 83 levothyroxine sodium tab 137 mcg ... 85 levocarnitine oral soln 1 gm/10ml levothyroxine sodium tab 150 mcg ... 85 (10%) ...... 83 levothyroxine sodium tab 175 mcg ... 85 levocarnitine tab 330 mg ...... 83 levothyroxine sodium tab 200 mcg ... 85 levocetirizine dihydrochloride soln 2.5 levothyroxine sodium tab 25 mcg ..... 85 mg/5ml (0.5 mg/ml) ...... 109 levothyroxine sodium tab 300 mcg ... 85 levothyroxine sodium tab 50 mcg ..... 85 155 levothyroxine sodium tab 75 mcg ..... 85 liothyronine sodium tab 50 mcg ...... 86 levothyroxine sodium tab 88 mcg ..... 85 lisinopril & hydrochlorothiazide tab 10- LEXIVA SUS 50MG/ML ...... 18 12.5 mg ...... 38 lidocaine hcl local inj 1% ...... 1 lisinopril & hydrochlorothiazide tab 20- lidocaine hcl local inj 2% ...... 1 12.5 mg ...... 38 lidocaine hcl local preservative free (pf) lisinopril & hydrochlorothiazide tab 20- inj 0.5% ...... 2 25 mg ...... 38 lidocaine hcl local preservative free (pf) lisinopril tab 10 mg...... 38 inj 1% ...... 2 lisinopril tab 2.5 mg...... 38 lidocaine hcl local preservative free (pf) lisinopril tab 20 mg...... 38 inj 2% ...... 2 lisinopril tab 30 mg...... 38 lidocaine hcl local preservative free (pf) lisinopril tab 40 mg...... 38 inj 4% ...... 2 lisinopril tab 5 mg ...... 38 lidocaine hcl soln 4% ...... 117 lithium carbonate cap 150 mg...... 68 lidocaine hcl urethral/mucosal gel 2% lithium carbonate cap 300 mg...... 68 ...... 74, 117 lithium carbonate cap 600 mg...... 68 lidocaine hcl urethral/mucosal gel lithium carbonate tab 300 mg ...... 68 prefilled syringe 2% ...... 117 lithium carbonate tab er 300 mg ...... 68 lidocaine hcl viscous soln 2% ...... 119 lithium carbonate tab er 450 mg ...... 68 lidocaine inj 0.5% w/ epinephrine- LITHIUM SOL 8MEQ/5ML ...... 68 1:200000 ...... 2 LIVALO TAB 1MG...... 43 lidocaine inj 1% w/ epinephrine- LIVALO TAB 2MG...... 43 1:100000 ...... 2 LIVALO TAB 4MG...... 43 lidocaine inj 2% w/ epinephrine- L-METHYL- TAB B6-B12 ...... 103 1:100000 ...... 2 L-METHYL-MC TAB...... 103 lidocaine oint 5% ...... 117 L-METHYL-MC TAB NAC ...... 103 lidocaine patch 5% ...... 117 LO LOESTRIN TAB 1-10-10 ...... 71 lidocaine-hydrocortisone acetate LOKELMA PAK 10GM ...... 103 perianal cream 3-0.5%...... 93 LOKELMA PAK 5GM ...... 103 lidocaine-prilocaine cream 2.5-2.5% LONSURF TAB 15-6.14 ...... 31 ...... 117 LONSURF TAB 20-8.19 ...... 31 lidocaine-prilocaine cream kit 2.5-2.5% loperamide hcl cap 2 mg ...... 88 ...... 117 lopinavir-ritonavir soln 400-100 LILETTA IUD 52MG ...... 107 mg/5ml (80-20 mg/ml) ...... 18 lindane lotion 1% ...... 118 lorazepam conc 2 mg/ml ...... 51 lindane shampoo 1% ...... 118 lorazepam inj 2 mg/ml ...... 51 linezolid for susp 100 mg/5ml ...... 22 lorazepam inj 4 mg/ml ...... 51 linezolid in sodium chloride iv soln 600 lorazepam tab 0.5 mg ...... 51 mg/300ml-0.9% ...... 22 lorazepam tab 1 mg ...... 51 linezolid tab 600 mg ...... 22 lorazepam tab 2 mg ...... 51 LINZESS CAP 145MCG ...... 91 LORBRENA TAB 100MG ...... 34 LINZESS CAP 290MCG ...... 91 LORBRENA TAB 25MG ...... 34 LINZESS CAP 72MCG ...... 93 LORTUSS EX LIQ ...... 109 liothyronine sodium iv soln 10 mcg/ml losartan potassium & ...... 86 hydrochlorothiazide tab 100-12.5 mg liothyronine sodium tab 25 mcg ...... 86 ...... 40 liothyronine sodium tab 5 mcg ...... 86 156 losartan potassium & malathion lotion 0.5% ...... 118 hydrochlorothiazide tab 100-25 mg 40 mannitol iv soln 20% ...... 75 losartan potassium & maprotiline hcl tab 25 mg ...... 56 hydrochlorothiazide tab 50-12.5 mg maprotiline hcl tab 50 mg ...... 56 ...... 40 maprotiline hcl tab 75 mg ...... 56 losartan potassium tab 100 mg ...... 41 MARPLAN TAB 10MG ...... 56 losartan potassium tab 25 mg ...... 41 MATULANE CAP 50MG ...... 31 losartan potassium tab 50 mg ...... 41 MAXAIR AUTOH AER 200MCG ...... 23 LOTEMAX GEL 0.5% ...... 120 MAXIDEX SUS 0.1% OP ...... 120 LOTEMAX OIN 0.5% ...... 120 MAXIPIME INJ 1GM...... 12 LOTEMAX SUS 0.5% ...... 120 MAXIPIME INJ 2GM...... 12 loteprednol etabonate ophth susp 0.5% meclizine hcl tab 12.5 mg ...... 88 ...... 107 meclizine hcl tab 25 mg ...... 88 lovastatin tab 10 mg ...... 43 meclofenamate sodium cap 50 mg .... 3 lovastatin tab 20 mg ...... 43 medroxyprogesterone acetate im susp lovastatin tab 40 mg ...... 43 150 mg/ml ...... 107 loxapine succinate cap 10 mg ...... 61 medroxyprogesterone acetate im susp loxapine succinate cap 25 mg ...... 61 prefilled syr 150 mg/ml ...... 107 loxapine succinate cap 5 mg ...... 61 medroxyprogesterone acetate tab 10 loxapine succinate cap 50 mg ...... 61 mg ...... 85 LOZI-FLUR LOZ 1MG F ...... 105 medroxyprogesterone acetate tab 2.5 LUCEMYRA TAB 0.18MG ...... 107 mg ...... 85 LUCENTIS SOL 0.3MG ...... 122 medroxyprogesterone acetate tab 5 mg LUCENTIS SOL 0.5MG ...... 122 ...... 85 luliconazole cream 1% ...... 74 mefenamic acid cap 250 mg ...... 3 LUMIGAN SOL 0.01%...... 122 mefloquine hcl tab 250 mg ...... 25 LUPANETA KIT 11.25-5 ...... 79 megestrol acetate susp 40 mg/ml .... 28 LUPANETA KIT 3.75-5 ...... 79 megestrol acetate tab 20 mg ...... 28 LUPR DEP-PED INJ 11.25MG ...... 83 megestrol acetate tab 40 mg ...... 28 LUPR DEP-PED INJ 15MG...... 83 MEKINIST TAB 0.5MG ...... 29 LUPR DEP-PED INJ 3M 30MG ...... 83 MEKINIST TAB 2MG ...... 29 LUPR DEP-PED INJ 7.5MG...... 83 MEKTOVI TAB 15MG ...... 34 LUPRON DEPOT INJ 11.25MG ...... 28 meloxicam susp 7.5 mg/5ml ...... 3 LUPRON DEPOT INJ 22.5MG ...... 28 meloxicam tab 15 mg ...... 3 LUPRON DEPOT INJ 3.75MG ...... 28 meloxicam tab 7.5 mg ...... 3 LUPRON DEPOT INJ 30MG ...... 28 melphalan hcl for inj 50 mg (base LUPRON DEPOT INJ 45MG ...... 28 equiv) ...... 26 LUPRON DEPOT INJ 7.5MG ...... 28 melphalan tab 2 mg ...... 26 LURIDE CHW 0.25MG F ...... 105 memantine hcl oral solution 2 mg/ml 55 LURIDE CHW 0.5MG F ...... 105 memantine hcl tab 10 mg ...... 55 LURIDE DRO 0.5MG/ML ...... 105 memantine hcl tab 28 x 5 mg & 21 x LYNPARZA CAP 50MG ...... 31 10 mg titration pack ...... 55 LYSODREN TAB 500MG ...... 31 memantine hcl tab 5 mg ...... 55 M MENACTRA INJ...... 36 MACUGEN INJ ...... 122 MENEST TAB 0.3MG ...... 80 MAKENA INJ 250MG/ML ...... 85 MENEST TAB 0.625MG ...... 80 MAKENA INJ 275MG ...... 107 MENEST TAB 1.25MG ...... 80 157

MENEST TAB 2.5MG...... 80 methenamine mandelate tab 0.5 gm 94 MENHIBRIX INJ ...... 36 methenamine mandelate tab 1 gm ... 94 MENOMUNE INJ A/C/Y/W...... 36 methimazole tab 10 mg ...... 85 MENOSTAR DIS 14MCG ...... 81 methimazole tab 5 mg ...... 85 MENTAX CRE 1% ...... 115 METHITEST TAB 10MG ...... 75 MENVEO INJ ...... 36 methocarbamol tab 500 mg ...... 69 meperidine hcl inj 10 mg/ml ...... 5 methocarbamol tab 750 mg ...... 69 meperidine hcl oral soln 50 mg/5ml ... 5 methotrexate sodium for inj 1 gm .... 27 meperidine hcl tab 100 mg ...... 5 methotrexate sodium inj 50 mg/2ml meperidine hcl tab 50 mg ...... 5 (25 mg/ml) ...... 27 meprobamate tab 200 mg ...... 52 methotrexate sodium inj pf 50 mg/2ml meprobamate tab 400 mg ...... 52 (25 mg/ml) ...... 27 mercaptopurine tab 50 mg ...... 27 methotrexate sodium tab 2.5 mg (base meropenem iv for soln 1 gm ...... 10 equiv) ...... 27 meropenem iv for soln 500 mg ...... 10 methoxsalen rapid cap 10 mg ...... 115 mesalamine cap dr 400 mg ...... 93 methscopolamine bromide tab 2.5 mg mesalamine cap er 24hr 0.375 gm ... 93 ...... 90 mesalamine enema 4 gm ...... 91 methscopolamine bromide tab 5 mg . 90 mesalamine suppos 1000 mg ...... 91 methyclothiazide tab 5 mg ...... 47 mesalamine tab delayed release 1.2 methyldopa & hydrochlorothiazide tab gm ...... 93 250-15 mg ...... 48 mesalamine tab delayed release 800 methyldopa & hydrochlorothiazide tab mg ...... 93 250-25 mg ...... 48 mesna inj 100 mg/ml...... 31 methyldopa tab 250 mg ...... 48 MESNEX TAB 400MG ...... 31 methyldopa tab 500 mg ...... 48 METAFOLBIC TAB ...... 103 methyldopate hcl inj 250 mg/5ml ..... 48 METAFOLBIC TAB PLUS ...... 103 methylergonovine maleate tab 0.2 mg metaproterenol sulfate syrup 10 ...... 83 mg/5ml ...... 110 methylphenidate hcl cap er 10 mg (cd) metaproterenol sulfate tab 10 mg .. 110 ...... 65 metaproterenol sulfate tab 20 mg .. 110 methylphenidate hcl cap er 20 mg (cd) metaxalone tab 800 mg ...... 69 ...... 65 metformin hcl tab 1000 mg ...... 76 methylphenidate hcl cap er 24hr 20 mg metformin hcl tab 500 mg ...... 76 (la) ...... 65 metformin hcl tab 850 mg ...... 76 methylphenidate hcl cap er 24hr 30 mg metformin hcl tab er 24hr 500 mg .... 76 (la) ...... 65 metformin hcl tab er 24hr 750 mg .... 76 methylphenidate hcl cap er 24hr 40 mg methadone hcl conc 10 mg/ml ...... 5 (la) ...... 65 methadone hcl soln 10 mg/5ml ...... 5 methylphenidate hcl cap er 30 mg (cd) methadone hcl soln 5 mg/5ml ...... 5 ...... 65 methadone hcl tab 10 mg ...... 5 methylphenidate hcl cap er 40 mg (cd) methadone hcl tab 5 mg ...... 5 ...... 65 methadone hcl tab for oral susp 40 mg methylphenidate hcl cap er 50 mg (cd) ...... 5 ...... 65 methazolamide tab 25 mg ...... 121 methylphenidate hcl cap er 60 mg (cd) methazolamide tab 50 mg ...... 121 ...... 65 methenamine hippurate tab 1 gm..... 94 methylphenidate hcl chew tab 10 mg 65 158 methylphenidate hcl chew tab 2.5 mg metoprolol & hydrochlorothiazide tab ...... 65 100-50 mg ...... 44 methylphenidate hcl chew tab 5 mg.. 65 metoprolol & hydrochlorothiazide tab methylphenidate hcl soln 10 mg/5ml 65 50-25 mg ...... 44 methylphenidate hcl soln 5 mg/5ml .. 65 metoprolol succinate tab er 24hr 100 methylphenidate hcl tab 10 mg ...... 65 mg (tartrate equiv) ...... 45 methylphenidate hcl tab 20 mg ...... 65 metoprolol succinate tab er 24hr 200 methylphenidate hcl tab 5 mg ...... 65 mg (tartrate equiv) ...... 45 methylphenidate hcl tab er 10 mg .... 65 metoprolol succinate tab er 24hr 25 mg methylphenidate hcl tab er 20 mg .... 65 (tartrate equiv) ...... 44 methylphenidate hcl tab er 24hr 27 mg metoprolol succinate tab er 24hr 50 mg ...... 65 (tartrate equiv) ...... 44 methylphenidate hcl tab er 24hr 36 mg metoprolol tartrate iv soln 5 mg/5ml 45 ...... 66 metoprolol tartrate tab 100 mg ...... 45 methylphenidate hcl tab er 24hr 54 mg metoprolol tartrate tab 25 mg ...... 45 ...... 66 metoprolol tartrate tab 50 mg ...... 45 methylphenidate hcl tab er osmotic METRONIDAZOL INJ 5MG/ML ...... 22 release (osm) 18 mg ...... 66 metronidazole cap 375 mg ...... 22 methylphenidate hcl tab er osmotic metronidazole cream 0.75% ...... 118 release (osm) 27 mg ...... 66 metronidazole gel 0.75% ...... 118 methylphenidate hcl tab er osmotic metronidazole gel 1% ...... 118 release (osm) 36 mg ...... 66 metronidazole in nacl 0.79% iv soln methylphenidate hcl tab er osmotic 500 mg/100ml ...... 22 release (osm) 54 mg ...... 66 metronidazole lotion 0.75% ...... 118 methylprednisolone acetate inj susp 40 metronidazole tab 250 mg ...... 22 mg/ml ...... 74 metronidazole tab 500 mg ...... 22 methylprednisolone tab 16 mg ...... 82 metronidazole vaginal gel 0.75% ..... 95 methylprednisolone tab 32 mg ...... 82 mexiletine hcl cap 150 mg ...... 41 methylprednisolone tab 4 mg...... 82 mexiletine hcl cap 200 mg ...... 41 methylprednisolone tab 8 mg...... 82 mexiletine hcl cap 250 mg ...... 41 methylprednisolone tab therapy pack 4 midazolam hcl syrup 2 mg/ml (base mg (21) ...... 82 equivalent) ...... 66 methyltestosterone cap 10 mg ...... 75 midodrine hcl tab 10 mg ...... 48 metipranolol ophth soln 0.3% ...... 121 midodrine hcl tab 2.5 mg ...... 48 metoclopramide hcl inj 5 mg/ml (base midodrine hcl tab 5 mg ...... 48 equivalent) ...... 89 MIGLITOL TAB 100 MG ...... 75 metoclopramide hcl soln 5 mg/5ml (10 MIGLITOL TAB 25 MG ...... 75 mg/10ml) (base equiv) ...... 89 MIGLITOL TAB 50 MG ...... 75 metoclopramide hcl tab 10 mg (base miglustat cap 100 mg ...... 98 equivalent) ...... 89 MILK OF MAGN SUS 2400MG ...... 91 metoclopramide hcl tab 5 mg (base MINOCIN INJ 100MG ...... 16 equivalent) ...... 89 minocycline hcl cap 100 mg ...... 16 metolazone tab 10 mg ...... 47 minocycline hcl cap 50 mg ...... 16 metolazone tab 2.5 mg ...... 47 minocycline hcl cap 75 mg ...... 16 metolazone tab 5 mg ...... 47 minocycline hcl tab 100 mg ...... 16 metoprolol & hydrochlorothiazide tab minocycline hcl tab 50 mg ...... 16 100-25 mg ...... 44 minocycline hcl tab 75 mg ...... 16 159 minoxidil tab 10 mg ...... 48 montelukast sodium tab 10 mg (base minoxidil tab 2.5 mg ...... 48 equiv) ...... 111 MIOSTAT INJ 0.01% OP ...... 122 MONUROL PAK GRANULES ...... 94 MIRENA IUD SYSTEM ...... 107 MORPHINE SUL INJ 10/0.7ML ...... 6 mirtazapine orally disintegrating tab 15 MORPHINE SUL INJ 150/30ML ...... 6 mg ...... 56 MORPHINE SUL INJ 2MG/ML ...... 5 mirtazapine orally disintegrating tab 30 MORPHINE SUL INJ 4MG/ML ...... 6 mg ...... 56 MORPHINE SUL INJ 5MG/ML ...... 6 mirtazapine orally disintegrating tab 45 MORPHINE SUL SUP 30MG ...... 6 mg ...... 56 morphine sulfate inj 10 mg/ml ...... 6 mirtazapine tab 15 mg ...... 56 morphine sulfate inj 15 mg/ml ...... 6 mirtazapine tab 30 mg ...... 56 morphine sulfate inj 8 mg/ml ...... 6 mirtazapine tab 45 mg ...... 56 morphine sulfate inj pf 0.5 mg/ml ..... 6 mirtazapine tab 7.5 mg ...... 56 morphine sulfate inj pf 1 mg/ml ...... 6 MIRVASO GEL 0.33% ...... 118 morphine sulfate iv soln 1 mg/ml ...... 6 misoprostol tab 100 mcg ...... 92 morphine sulfate iv soln 25 mg/ml .... 6 misoprostol tab 200 mcg ...... 92 morphine sulfate iv soln 50 mg/ml .... 6 mitomycin for iv soln 20 mg ...... 31 morphine sulfate iv soln pf 10 mg/ml . 6 mitomycin for iv soln 40 mg ...... 31 morphine sulfate iv soln pf 15 mg/ml . 6 mitomycin for iv soln 5 mg ...... 31 morphine sulfate oral soln 10 mg/5ml 6 mitoxantrone hcl inj conc 25 morphine sulfate oral soln 100 mg/5ml mg/12.5ml (2 mg/ml) ...... 31 (20 mg/ml) ...... 6 M-M-R II INJ ...... 124 morphine sulfate oral soln 20 mg/5ml 6 modafinil tab 100 mg ...... 69 morphine sulfate suppos 10 mg ...... 6 modafinil tab 200 mg ...... 69 morphine sulfate suppos 20 mg ...... 6 moexipril hcl tab 15 mg ...... 38 morphine sulfate suppos 5 mg ...... 6 moexipril hcl tab 7.5 mg ...... 38 morphine sulfate tab 15 mg ...... 6 moexipril-hydrochlorothiazide tab 15- morphine sulfate tab 30 mg ...... 6 12.5 mg ...... 38 morphine sulfate tab er 100 mg ...... 6 moexipril-hydrochlorothiazide tab 15- morphine sulfate tab er 15 mg ...... 6 25 mg ...... 38 morphine sulfate tab er 200 mg ...... 6 moexipril-hydrochlorothiazide tab 7.5- morphine sulfate tab er 30 mg ...... 6 12.5 mg ...... 38 morphine sulfate tab er 60 mg ...... 6 molindone hcl tab 10 mg ...... 35 MOVANTIK TAB 12.5MG ...... 92 molindone hcl tab 25 mg ...... 35 MOVANTIK TAB 25MG ...... 92 molindone hcl tab 5 mg...... 35 MOVIPREP SOL ...... 91 mometasone furoate cream 0.1% .. 116 moxifloxacin hcl ophth soln 0.5% (base mometasone furoate oint 0.1% ...... 116 equiv) ...... 106 mometasone furoate solution 0.1% moxifloxacin hcl tab 400 mg (base (lotion) ...... 116 equiv) ...... 13 MONOJECTOR MIS END CAPS ...... 78 MOXIFLOXACIN INJ 400/250 ...... 13 montelukast sodium chew tab 4 mg MOZOBIL INJ ...... 98 (base equiv) ...... 111 MULPLETA TAB 3MG ...... 98 montelukast sodium chew tab 5 mg MULTAQ TAB 400MG...... 41 (base equiv) ...... 111 MULTIGEN PLS TAB ...... 105 montelukast sodium oral granules MULTIGEN TAB ...... 105 packet 4 mg (base equiv) ...... 111 MULTIGEN TAB FOLIC ...... 105 160 mupirocin calcium cream 2% ...... 114 naltrexone hcl tab 50 mg ...... 70 mupirocin oint 2% ...... 114 naphazoline hcl ophth soln 0.1% .... 122 MUSTARGEN INJ 10MG ...... 26 naproxen susp 125 mg/5ml ...... 3 MYALEPT INJ 11.3MG ...... 83 naproxen tab 250 mg ...... 3 MYCAMINE INJ 100MG ...... 17 naproxen tab 375 mg ...... 3 MYCAMINE INJ 50MG ...... 17 naproxen tab 500 mg ...... 3 mycophenolate mofetil cap 250 mg 100 naproxen tab ec 375 mg ...... 3 mycophenolate mofetil for oral susp naproxen tab ec 500 mg ...... 3 200 mg/ml ...... 100 naratriptan hcl tab 1 mg (base equiv) mycophenolate mofetil tab 500 mg . 100 ...... 67 mycophenolate sodium tab dr 180 mg naratriptan hcl tab 2.5 mg (base equiv) (mycophenolic acid equiv) ...... 100 ...... 67 mycophenolate sodium tab dr 360 mg NARCAN SPR ...... 70 (mycophenolic acid equiv) ...... 100 NATACYN SUS 5% OP ...... 121 MYKIDZ IRON SUS 15/1.5ML ...... 106 NATAZIA TAB ...... 72 MYLERAN TAB 2MG ...... 26 nateglinide tab 120 mg ...... 77 MYOBLOC INJ 10000/2 ...... 68 nateglinide tab 60 mg ...... 77 MYOBLOC INJ 2500/0.5 ...... 68 NATPARA INJ 100MCG ...... 79 MYOBLOC INJ 5000/ML ...... 68 NATPARA INJ 25MCG ...... 79 MYOZYME INJ 50MG ...... 83 NATPARA INJ 50MCG ...... 79 MYRBETRIQ TAB 25MG ...... 94 NATPARA INJ 75MCG ...... 79 MYRBETRIQ TAB 50MG ...... 94 NATURE THROI TAB 162.5MG ...... 86 N NATURE-THROI TAB 113.75MG ...... 86 nabumetone tab 500 mg ...... 3 NATURE-THROI TAB 130MG...... 86 nabumetone tab 750 mg ...... 3 NATURE-THROI TAB 146.25MG ...... 86 nadolol & bendroflumethiazide tab 40-5 NATURE-THROI TAB 16.25MG ...... 86 mg ...... 44 NATURE-THROI TAB 195MG...... 86 nadolol & bendroflumethiazide tab 80-5 NATURE-THROI TAB 260MG...... 86 mg ...... 44 NATURE-THROI TAB 32.5MG...... 86 nadolol tab 20 mg ...... 45 NATURE-THROI TAB 325MG...... 86 nadolol tab 40 mg ...... 45 NATURE-THROI TAB 48.75MG ...... 86 nadolol tab 80 mg ...... 45 NATURE-THROI TAB 65MG ...... 86 NAFCILLIN INJ 1GM/50ML ...... 15 NATURE-THROI TAB 81.25MG ...... 86 NAFCILLIN INJ 2GM/100 ...... 15 NATURE-THROI TAB 97.5MG...... 86 nafcillin sodium for inj 1 gm ...... 15 NEBUSAL NEB 6% ...... 111 nafcillin sodium for inj 2 gm ...... 15 NECON TAB 10/11-28 ...... 71 nafcillin sodium for iv soln 1 gm ...... 15 nefazodone hcl tab 100 mg ...... 56 nafcillin sodium for iv soln 10 gm ..... 15 nefazodone hcl tab 150 mg ...... 56 nafcillin sodium for iv soln 2 gm ...... 15 nefazodone hcl tab 200 mg ...... 56 naftifine hcl gel 1% ...... 74 nefazodone hcl tab 250 mg ...... 56 NAFTIN GEL 1% ...... 115 nefazodone hcl tab 50 mg ...... 56 NAGLAZYME INJ 1MG/ML ...... 83 neomycin sulfate tab 500 mg ...... 9 nalbuphine hcl inj 10 mg/ml ...... 6 neomycin-bacitrac zn-polymyx nalbuphine hcl inj 20 mg/ml ...... 6 5(3.5)mg-400unt-10000unt op oin naloxone hcl inj 0.4 mg/ml ...... 70 ...... 119 naloxone hcl soln prefilled syringe 2 neomycin-polymy-gramicid op sol mg/2ml ...... 70 1.75-10000-0.025mg-unt-mg/ml 120 161 neomycin-polymyxin b gu irrigation nifedipine tab er 24hr 30 mg ...... 46 soln ...... 93 nifedipine tab er 24hr 60 mg ...... 46 neomycin-polymyxin-dexamethasone nifedipine tab er 24hr 90 mg ...... 46 ophth oint 0.1% ...... 119 nifedipine tab er 24hr osmotic release neomycin-polymyxin-dexamethasone 30 mg ...... 46 ophth susp 0.1% ...... 119 nifedipine tab er 24hr osmotic release neomycin-polymyxin-hc ophth susp 119 60 mg ...... 46 neomycin-polymyxin-hc otic soln 1% nifedipine tab er 24hr osmotic release ...... 123 90 mg ...... 46 neomycin-polymyxin-hc otic susp 3.5 nilutamide tab 150 mg ...... 27 mg/ml-10000 unit/ml-1%...... 123 nimodipine cap 30 mg...... 46 NEO-SYNALAR CRE ...... 114 NINLARO CAP 2.3MG ...... 31 NERLYNX TAB 40MG ...... 34 NINLARO CAP 3MG ...... 31 NEULASTA INJ 6MG/0.6M ...... 97 NINLARO CAP 4MG ...... 31 NEULASTA KIT 6MG/0.6M ...... 97 nisoldipine tab er 24hr 17 mg ...... 46 NEUPOGEN INJ 300/0.5 ...... 97 nisoldipine tab er 24hr 20 mg ...... 46 NEUPOGEN INJ 300MCG ...... 97 nisoldipine tab er 24hr 25.5 mg ...... 46 NEUPOGEN INJ 480/0.8 ...... 97 nisoldipine tab er 24hr 30 mg ...... 46 NEUPOGEN INJ 480MCG ...... 97 nisoldipine tab er 24hr 34 mg ...... 46 NEVANAC SUS 0.1% ...... 120 nisoldipine tab er 24hr 40 mg ...... 46 nevirapine susp 50 mg/5ml ...... 18 nisoldipine tab er 24hr 8.5 mg ...... 46 nevirapine tab 200 mg ...... 18 NITRO-BID OIN 2% ...... 49 nevirapine tab er 24hr 100 mg ...... 19 NITRO-DUR DIS 0.3MG/HR ...... 49 nevirapine tab er 24hr 400 mg ...... 19 NITRO-DUR DIS 0.8MG/HR ...... 49 NEXAVAR TAB 200MG ...... 29 nitrofurantoin macrocrystalline cap 100 NEXAVIR INJ...... 102 mg ...... 22 niacin tab er 1000 mg nitrofurantoin macrocrystalline cap 25 (antihyperlipidemic) ...... 43 mg ...... 94 niacin tab er 500 mg nitrofurantoin macrocrystalline cap 50 (antihyperlipidemic) ...... 43 mg ...... 22 niacin tab er 750 mg nitrofurantoin monohydrate (antihyperlipidemic) ...... 43 macrocrystalline cap 100 mg ...... 22 nicardipine hcl cap 20 mg ...... 45 NITROGLYCER INJ 5MG/ML...... 48 nicardipine hcl cap 30 mg ...... 45 nitroglycerin cap er 2.5 mg...... 49 nicardipine hcl iv soln 2.5 mg/ml ...... 45 nitroglycerin cap er 6.5 mg...... 49 nicotine polacrilex gum 2 mg ...... 70 nitroglycerin cap er 9 mg ...... 49 nicotine polacrilex gum 4 mg ...... 70 nitroglycerin iv soln 100 mcg/ml in d5w nicotine polacrilex lozenge 2 mg ...... 70 ...... 48 nicotine polacrilex lozenge 4 mg ...... 71 nitroglycerin iv soln 200 mcg/ml in d5w NICOTINE SYS KIT TRANSDER ...... 71 ...... 48 nicotine td patch 24hr 14 mg/24hr ... 71 nitroglycerin iv soln 400 mcg/ml in d5w nicotine td patch 24hr 21 mg/24hr ... 71 ...... 49 nicotine td patch 24hr 7 mg/24hr ..... 71 nitroglycerin lingual aerosol 400 NICOTROL INH...... 71 mcg/spray ...... 49 NICOTROL NS SPR 10MG/ML ...... 71 nitroglycerin sl tab 0.3 mg...... 49 nifedipine cap 10 mg ...... 45 nitroglycerin sl tab 0.4 mg...... 49 nifedipine cap 20 mg ...... 46 nitroglycerin sl tab 0.6 mg...... 49 162 nitroglycerin td patch 24hr 0.1 mg/hr norethindrone tab 0.35 mg ...... 107 ...... 49 norethindrone-eth estradiol tab 0.5- nitroglycerin td patch 24hr 0.2 mg/hr 35/0.75-35/1-35 mg-mcg...... 73 ...... 49 norethindrone-eth estradiol tab 0.5- nitroglycerin td patch 24hr 0.4 mg/hr 35/1-35/0.5-35 mg-mcg ...... 73 ...... 49 norgestimate & ethinyl estradiol tab nitroglycerin td patch 24hr 0.6 mg/hr 0.25 mg-35 mcg ...... 72 ...... 49 norgestimate-eth estrad tab 0.18- nitroglycerin tl soln 0.4 mg/spray (400 25/0.215-25/0.25-25 mg-mcg ...... 73 mcg/spray) ...... 49 norgestimate-eth estrad tab 0.18- nizatidine cap 150 mg ...... 90 35/0.215-35/0.25-35 mg-mcg ...... 73 nizatidine cap 300 mg ...... 90 norgestrel & ethinyl estradiol tab 0.3 nizatidine oral soln 15 mg/ml ...... 90 mg-30 mcg ...... 72 nonoxynol-9 gel 4% ...... 113 norgestrel & ethinyl estradiol tab 0.5 norelgestromin-ethinyl estradiol td mg-50 mcg ...... 72 ptwk 150-35 mcg/24hr ...... 73 NORINYL TAB 1+50-28 ...... 72 norethindrone & ethinyl estradiol tab NOROXIN TAB 400MG ...... 13 0.4 mg-35 mcg ...... 71 NORTHERA CAP 100MG ...... 48 norethindrone & ethinyl estradiol tab NORTHERA CAP 200MG ...... 48 0.5 mg-35 mcg ...... 71 NORTHERA CAP 300MG ...... 48 norethindrone & ethinyl estradiol tab 1 nortriptyline hcl cap 10 mg ...... 59 mg-35 mcg ...... 71 nortriptyline hcl cap 25 mg ...... 59 norethindrone & ethinyl estradiol-fe nortriptyline hcl cap 50 mg ...... 59 chew tab 0.4 mg-35 mcg ...... 72 nortriptyline hcl cap 75 mg ...... 59 norethindrone & ethinyl estradiol-fe nortriptyline hcl soln 10 mg/5ml ...... 59 chew tab 0.8 mg-25 mcg ...... 72 NORVIR CAP 100MG ...... 18 norethindrone & mestranol tab 1 mg- NORVIR SOL 80MG/ML ...... 18 50 mcg ...... 72 NOVOCLAIR CRE ...... 4 norethindrone ace & ethinyl estradiol NOVOLIN INJ 70/30 ...... 77 tab 1 mg-20 mcg ...... 72 NOVOLIN N INJ U-100 ...... 77 norethindrone ace & ethinyl estradiol NOVOLIN R INJ U-100 ...... 77 tab 1.5 mg-30 mcg ...... 72 NOVOLOG INJ 100/ML ...... 77 norethindrone ace & ethinyl estradiol-fe NOVOLOG INJ FLEXPEN...... 77 tab 1 mg-20 mcg ...... 72 NOVOLOG INJ PENFILL ...... 77 norethindrone ace & ethinyl estradiol-fe NOVOLOG MIX INJ 70/30 ...... 77 tab 1.5 mg-30 mcg ...... 72 NOVOLOG MIX INJ FLEXPEN ...... 77 norethindrone ace-eth estradiol-fe NOXAFIL SUS 40MG/ML ...... 17 chew tab 1 mg-20 mcg (24) ...... 72 NPLATE INJ 250MCG ...... 97 norethindrone ace-ethinyl estradiol-fe NPLATE INJ 500MCG ...... 97 tab 1 mg-20 mcg (24)...... 72 NUBEQA TAB 300MG ...... 32 norethindrone acetate tab 5 mg ...... 85 NUCALA INJ 100MG ...... 111 norethindrone acetate-ethinyl estradiol NUCALA INJ 100MG/ML ...... 23 tab 0.5 mg-2.5 mcg ...... 80 NUCYNTA ER TAB 100MG ...... 6 norethindrone acetate-ethinyl estradiol NUCYNTA ER TAB 150MG ...... 6 tab 1 mg-5 mcg ...... 80 NUCYNTA ER TAB 200MG ...... 6 norethindrone ac-ethinyl estrad-fe tab NUCYNTA ER TAB 250MG ...... 6 1-20/1-30/1-35 mg-mcg ...... 73 NUCYNTA ER TAB 50MG ...... 6 163

NUCYNTA TAB 100MG ...... 6 olanzapine tab 2.5 mg ...... 61 NUCYNTA TAB 50MG ...... 6 olanzapine tab 20 mg ...... 61 NUCYNTA TAB 75MG ...... 6 olanzapine tab 5 mg ...... 61 NUEDEXTA CAP 20-10MG ...... 70 olanzapine tab 7.5 mg ...... 61 NULOJIX INJ 250MG ...... 101 olanzapine-fluoxetine hcl cap 12-25 mg NUPLAZID TAB 17MG ...... 61 ...... 63 nystatin cream 100000 unit/gm ..... 115 olanzapine-fluoxetine hcl cap 12-50 mg nystatin oint 100000 unit/gm...... 115 ...... 63 nystatin susp 100000 unit/ml ...... 17 olanzapine-fluoxetine hcl cap 3-25 mg nystatin tab 500000 unit ...... 17 ...... 63 nystatin topical powder 100000 olanzapine-fluoxetine hcl cap 6-25 mg unit/gm ...... 115 ...... 63 nystatin-triamcinolone cream 100000- olanzapine-fluoxetine hcl cap 6-50 mg 0.1 unit/gm-% ...... 115 ...... 63 nystatin-triamcinolone oint 100000-0.1 olmesartan medoxomil tab 20 mg .... 25 unit/gm-%...... 115 olmesartan medoxomil tab 40 mg .... 25 O olmesartan medoxomil tab 5 mg ...... 25 OCTAGAM INJ 1GM ...... 100 olopatadine hcl nasal soln 0.6% ..... 112 OCTAGAM INJ 2GM/20ML ...... 100 olopatadine hcl ophth soln 0.1% (base octreotide acetate inj 100 mcg/ml (0.1 equivalent) ...... 121 mg/ml) ...... 83 OLYSIO CAP 150MG ...... 20 octreotide acetate inj 1000 mcg/ml (1 omega-3-acid ethyl esters cap 1 gm . 43 mg/ml) ...... 84 omeprazole cap delayed release 10 mg octreotide acetate inj 200 mcg/ml (0.2 ...... 92 mg/ml) ...... 83 omeprazole cap delayed release 20 mg octreotide acetate inj 50 mcg/ml (0.05 ...... 92 mg/ml) ...... 83 omeprazole cap delayed release 40 mg octreotide acetate inj 500 mcg/ml (0.5 ...... 92 mg/ml) ...... 83 omeprazole-sodium bicarbonate cap ODACTRA SUB ...... 1 20-1100 mg...... 93 ODOMZO CAP 200MG ...... 31 omeprazole-sodium bicarbonate cap OFEV CAP 100MG ...... 108 40-1100 mg...... 93 OFEV CAP 150MG ...... 108 OMNARIS SPR...... 103 ofloxacin ophth soln 0.3% ...... 120 OMNIFLEX DPR ...... 73 ofloxacin otic soln 0.3% ...... 123 ONCASPAR INJ 750/ML ...... 31 ofloxacin tab 400 mg ...... 13 ondansetron hcl inj 4 mg/2ml (2 olanzapine for im inj 10 mg ...... 61 mg/ml) ...... 89 olanzapine orally disintegrating tab 10 ondansetron hcl inj 40 mg/20ml (2 mg ...... 61 mg/ml) ...... 89 olanzapine orally disintegrating tab 15 ondansetron hcl oral soln 4 mg/5ml .. 89 mg ...... 61 ondansetron hcl tab 24 mg ...... 89 olanzapine orally disintegrating tab 20 ondansetron hcl tab 4 mg...... 89 mg ...... 61 ondansetron hcl tab 8 mg...... 89 olanzapine orally disintegrating tab 5 ondansetron orally disintegrating tab 4 mg ...... 61 mg ...... 89 olanzapine tab 10 mg ...... 61 ondansetron orally disintegrating tab 8 olanzapine tab 15 mg ...... 61 mg ...... 89 164

ONE TCH SLVR KIT ULT MINI ...... 78 OSMOPREP TAB 1.5GM ...... 91 ONETOUCH KIT ULT MINI ...... 78 OSPHENA TAB 60MG ...... 84 ONETOUCH KIT ULTRA 2 ...... 78 OTEZLA TAB 10/20/30 ...... 100 ONETOUCH KIT ULTRALNK ...... 78 OTEZLA TAB 30MG ...... 100 ONETOUCH KIT VERIO ...... 78 OTREXUP INJ 10MG ...... 99 ONETOUCH KIT VERIO IQ ...... 78 OTREXUP INJ 15MG ...... 99 ONETOUCH TES ULTRA ...... 78 OTREXUP INJ 20MG ...... 99 ONETOUCH TES ULTRA BL ...... 78 OTREXUP INJ 25MG ...... 99 ONETOUCH TES VERIO ...... 78 OTREXUP INJ 7.5/0.4...... 99 ONETOUCH VER KIT SYNC ...... 78 OXACILLIN INJ 1GM ...... 15 ONMEL TAB 200MG ...... 17 OXACILLIN INJ 2GM ...... 15 OPSUMIT TAB 10MG ...... 49 oxacillin sodium for inj 1 gm (base ORALAIR SUB 300 IR ...... 1 equivalent) ...... 15 ORAMAGICRX SUS ...... 119 oxacillin sodium for inj 2 gm (base ORAVIG TAB 50MG ...... 17 equivalent) ...... 15 ORENITRAM TAB 0.125MG ...... 49 oxacillin sodium for iv soln 10 gm ORENITRAM TAB 0.25MG ...... 49 (base equivalent) ...... 15 ORENITRAM TAB 1MG ...... 50 oxaliplatin for iv inj 100 mg ...... 26 ORENITRAM TAB 2.5MG ...... 50 oxaliplatin for iv inj 50 mg ...... 26 ORENITRAM TAB 5MG ...... 50 oxaliplatin iv soln 100 mg/20ml ...... 26 ORFADIN CAP 10MG ...... 84 oxaliplatin iv soln 50 mg/10ml ...... 26 ORFADIN CAP 2MG ...... 84 oxandrolone tab 10 mg ...... 1 ORFADIN CAP 5MG ...... 84 oxandrolone tab 2.5 mg ...... 1 ORKAMBI TAB 200-125 ...... 111 oxaprozin tab 600 mg ...... 3 orphenadrine citrate inj 30 mg/ml .... 69 oxazepam cap 10 mg ...... 51 orphenadrine citrate tab er 12hr 100 oxazepam cap 15 mg ...... 51 mg ...... 69 oxazepam cap 30 mg ...... 52 ORTHO COIL DPR KIT 100 ...... 73 OXBRYTA TAB 500MG ...... 98 ORTHO COIL DPR KIT 105 ...... 73 oxcarbazepine susp 300 mg/5ml (60 ORTHO COIL DPR KIT 50 ...... 73 mg/ml) ...... 53 ORTHO FLAT DPR KIT 55 ...... 73 oxcarbazepine tab 150 mg ...... 53 ORTHO FLAT DPR KIT 60 ...... 73 oxcarbazepine tab 300 mg ...... 54 ORTHO FLAT DPR KIT 65 ...... 73 oxcarbazepine tab 600 mg ...... 54 ORTHO FLAT DPR KIT 70 ...... 73 oxiconazole nitrate cream 1% ...... 115 ORTHO FLAT DPR KIT 75 ...... 73 oxybutynin chloride syrup 5 mg/5ml . 94 ORTHO FLAT DPR KIT 80 ...... 73 oxybutynin chloride tab 5 mg ...... 94 ORTHO FLAT DPR KIT 85 ...... 73 oxybutynin chloride tab er 24hr 10 mg ORTHO FLAT DPR KIT 90 ...... 73 ...... 94 ORTHO FLAT DPR KIT 95 ...... 73 oxybutynin chloride tab er 24hr 15 mg oseltamivir phosphate cap 30 mg (base ...... 94 equiv) ...... 21 oxybutynin chloride tab er 24hr 5 mg oseltamivir phosphate cap 45 mg (base ...... 94 equiv) ...... 21 oxycodone hcl cap 5 mg ...... 6 oseltamivir phosphate cap 75 mg (base oxycodone hcl conc 100 mg/5ml (20 equiv) ...... 21 mg/ml) ...... 7 oseltamivir phosphate for susp 6 oxycodone hcl soln 5 mg/5ml ...... 7 mg/ml (base equiv) ...... 36 oxycodone hcl tab 10 mg ...... 7 165 oxycodone hcl tab 15 mg ...... 7 PALYNZIQ INJ 10/0.5ML ...... 87 oxycodone hcl tab 20 mg ...... 7 PALYNZIQ INJ 2.5/0.5...... 87 oxycodone hcl tab 30 mg ...... 7 PALYNZIQ INJ 20MG/ML ...... 87 oxycodone hcl tab 5 mg ...... 7 pamidronate disodium for inj 30 mg . 79 oxycodone hcl tab er 12hr deter 10 mg pamidronate disodium for inj 90 mg . 79 ...... 7 pamidronate disodium iv soln 3 mg/ml oxycodone hcl tab er 12hr deter 15 mg ...... 79 ...... 7 pamidronate disodium iv soln 9 mg/ml oxycodone hcl tab er 12hr deter 20 mg ...... 79 ...... 7 PAMIDRONATE INJ 6MG/ML ...... 79 oxycodone hcl tab er 12hr deter 30 mg PANRETIN GEL 0.1% ...... 118 ...... 7 pantoprazole sodium ec tab 20 mg oxycodone hcl tab er 12hr deter 40 mg (base equiv) ...... 92 ...... 7 pantoprazole sodium ec tab 40 mg oxycodone hcl tab er 12hr deter 60 mg (base equiv) ...... 92 ...... 7 papaverine hcl inj 30 mg/ml ...... 48 oxycodone hcl tab er 12hr deter 80 mg PARAGARD IUD T380A ...... 74 ...... 7 paregoric tincture 2 mg/5ml (morphine oxycodone w/ acetaminophen tab 10- equivalent) ...... 88 325 mg ...... 7 paricalcitol cap 1 mcg ...... 82 oxycodone w/ acetaminophen tab 2.5- paricalcitol cap 2 mcg ...... 83 325 mg ...... 7 paricalcitol cap 4 mcg ...... 83 oxycodone w/ acetaminophen tab 5- paromomycin sulfate cap 250 mg ...... 9 325 mg ...... 7 paroxetine hcl tab 10 mg ...... 58 oxycodone w/ acetaminophen tab 7.5- paroxetine hcl tab 20 mg ...... 58 325 mg ...... 7 paroxetine hcl tab 30 mg ...... 58 oxycodone-aspirin tab 4.8355-325 mg 7 paroxetine hcl tab 40 mg ...... 58 oxycodone-ibuprofen tab 5-400 mg ... 7 PASER GRA 4GM ...... 19 oxymorphone hcl tab 10 mg ...... 7 pb-hyoscy-atrop-scopol tab 16.2- oxymorphone hcl tab 5 mg ...... 7 0.1037-0.0194-0.0065 mg ...... 90 oxymorphone hcl tab er 12hr 10 mg .. 7 PEDIARIX INJ 0.5ML ...... 123 oxymorphone hcl tab er 12hr 15 mg .. 7 PEDVAX HIB INJ ...... 36 oxymorphone hcl tab er 12hr 20 mg .. 7 peg 3350-kcl-na bicarb-nacl-na sulfate oxymorphone hcl tab er 12hr 30 mg .. 7 for soln 236 gm ...... 91, 101 oxymorphone hcl tab er 12hr 40 mg .. 7 peg 3350-kcl-na bicarb-nacl-na sulfate oxymorphone hcl tab er 12hr 5 mg .... 7 for soln 240 gm ...... 91, 101 oxymorphone hcl tab er 12hr 7.5 mg . 7 peg 3350-kcl-sod bicarb-nacl for soln OZEMPIC INJ 2/1.5ML ...... 24 420 gm ...... 91, 101 P PEGANONE TAB 250MG ...... 54 paclitaxel iv conc 30 mg/5ml (6 mg/ml) PEGASYS INJ ...... 100 ...... 31 PEGASYS INJ 180MCG/M ...... 100 paliperidone tab er 24hr 1.5 mg ...... 61 PEGASYS INJ PROCLICK ...... 100 paliperidone tab er 24hr 3 mg ...... 61 PEG-INTRON KIT 120 RP ...... 100 paliperidone tab er 24hr 6 mg ...... 61 PEG-INTRON KIT 150MCG ...... 100 paliperidone tab er 24hr 9 mg ...... 61 PEG-INTRON KIT 50MCG RP ...... 100 palonosetron hcl iv soln 0.25 mg/5ml PEG-INTRON KIT 80MCG ...... 100 (base equivalent) ...... 24 PEMAZYRE TAB 13.5MG ...... 34 166

PEMAZYRE TAB 4.5MG ...... 34 phenazopyridine hcl tab 200 mg...... 94 PEMAZYRE TAB 9MG ...... 34 phenelzine sulfate tab 15 mg ...... 56 PEN G PROC INJ 600000 ...... 15 PHENHIST DH LIQ 30-2-10 ...... 109 PEN GK/DEXTR INJ 20000/ML ...... 15 phenobarbital elixir 20 mg/5ml ...... 54 PEN GK/DEXTR INJ 40000/ML ...... 15 phenobarbital tab 100 mg ...... 54 PEN GK/DEXTR INJ 60000/ML ...... 15 phenobarbital tab 15 mg ...... 54 PENICILLAMIN POW ...... 99 phenobarbital tab 16.2 mg ...... 54 penicillamine cap 250 mg ...... 99 phenobarbital tab 30 mg ...... 54 penicillamine tab 250 mg ...... 102 phenobarbital tab 32.4 mg ...... 54 penicillin g potassium for inj 20000000 phenobarbital tab 60 mg ...... 54 unit...... 15 phenobarbital tab 64.8 mg ...... 54 penicillin g potassium for inj 5000000 phenobarbital tab 97.2 mg ...... 54 unit...... 15 phenoxybenzamine hcl cap 10 mg .... 39 penicillin g sodium for inj 5000000 unit PHENTOLAMINE INJ 5MG...... 39 ...... 15 phenylephrine hcl ophth soln 10% .. 122 penicillin v potassium for soln 125 phenylephrine hcl ophth soln 2.5% . 122 mg/5ml ...... 15 phenylephrine w/ dm-gg tab 10-20-400 penicillin v potassium for soln 250 mg ...... 109 mg/5ml ...... 15 phenylephrine-guaifenesin liqd 7.5-100 penicillin v potassium tab 250 mg .... 15 mg/5ml (1.5-20 mg/ml) ...... 109 penicillin v potassium tab 500 mg .... 15 phenytoin chew tab 50 mg ...... 54 PENTACEL INJ ...... 123 phenytoin sodium extended cap 100 pentamidine isethionate for mg ...... 54 nebulization soln 300 mg ...... 9 phenytoin sodium extended cap 200 pentazocine w/ naloxone tab 50-0.5 mg ...... 54 mg ...... 7 phenytoin sodium extended cap 300 pentoxifylline tab er 400 mg ...... 97 mg ...... 54 PERFOROMIST NEB 20MCG ...... 110 phenytoin sodium inj 50 mg/ml...... 54 perindopril erbumine tab 2 mg ...... 39 phenytoin susp 125 mg/5ml ...... 54 perindopril erbumine tab 4 mg ...... 39 PHOSPHOLINE SOL 0.125%OP ...... 122 perindopril erbumine tab 8 mg ...... 39 PHOTOFRIN INJ 75MG ...... 31 permethrin cream 5% ...... 118 phytonadione tab 5 mg ...... 106 perphenazine tab 16 mg ...... 63 PICATO GEL 0.015% ...... 74 perphenazine tab 2 mg ...... 63 PICATO GEL 0.05% ...... 74 perphenazine tab 4 mg ...... 63 pilocarpine hcl ophth soln 1% ...... 122 perphenazine tab 8 mg ...... 63 pilocarpine hcl ophth soln 2% ...... 122 perphenazine-amitriptyline tab 2-10 pilocarpine hcl ophth soln 4% ...... 122 mg ...... 63 pilocarpine hcl tab 5 mg ...... 92 perphenazine-amitriptyline tab 2-25 pilocarpine hcl tab 7.5 mg ...... 92 mg ...... 63 pimecrolimus cream 1%...... 117 perphenazine-amitriptyline tab 4-10 pimozide tab 1 mg ...... 63 mg ...... 63 pimozide tab 2 mg ...... 63 perphenazine-amitriptyline tab 4-25 pindolol tab 10 mg ...... 45 mg ...... 63 pindolol tab 5 mg ...... 45 perphenazine-amitriptyline tab 4-50 pioglitazone hcl tab 15 mg (base equiv) mg ...... 63 ...... 76 phenazopyridine hcl tab 100 mg ...... 94 167 pioglitazone hcl tab 30 mg (base equiv) potassium chloride tab er 10 meq .. 104 ...... 76 potassium chloride tab er 20 meq pioglitazone hcl tab 45 mg (base equiv) (1500 mg) ...... 104 ...... 76 potassium chloride tab er 8 meq (600 piperacillin sod-tazobactam na for inj mg) ...... 103 3.375 gm (3-0.375 gm) ...... 15 potassium citrate & citric acid powder piperacillin sod-tazobactam sod for inj pack 3300-1002 mg...... 94 2.25 gm (2-0.25 gm) ...... 15 potassium citrate & citric acid soln piperacillin sod-tazobactam sod for inj 1100-334 mg/5ml ...... 94 4.5 gm (4-0.5 gm) ...... 15 potassium citrate tab er 10 meq (1080 piperacillin sod-tazobactam sod for inj mg) ...... 94 40.5 gm (36-4.5 gm) ...... 15 potassium citrate tab er 15 meq (1620 PIQRAY 200MG TAB DOSE ...... 34 mg) ...... 94 PIQRAY 250MG TAB DOSE ...... 34 potassium citrate tab er 5 meq (540 PIQRAY 300MG TAB DOSE ...... 34 mg) ...... 94 piroxicam cap 10 mg ...... 3 POTIGA TAB 200MG ...... 54 piroxicam cap 20 mg ...... 3 POTIGA TAB 300MG ...... 54 PNEUMOVAX 23 INJ 25/0.5...... 36 POTIGA TAB 400MG ...... 54 podofilox soln 0.5% ...... 118 POTIGA TAB 50MG ...... 54 polyethylene glycol 3350 oral powder PRALUENT INJ 150MG/ML...... 43 17 gm/scoop ...... 91 PRALUENT INJ 75MG/ML ...... 43 polymyxin b sulfate for inj 500000 unit pramipexole dihydrochloride tab 0.125 ...... 22 mg ...... 59 polymyxin b-trimethoprim ophth soln pramipexole dihydrochloride tab 0.25 10000 unit/ml-0.1% ...... 120 mg ...... 59 POMALYST CAP 1MG ...... 28 pramipexole dihydrochloride tab 0.5 POMALYST CAP 2MG ...... 28 mg ...... 59 POMALYST CAP 3MG ...... 28 pramipexole dihydrochloride tab 0.75 POMALYST CAP 4MG ...... 28 mg ...... 59 posaconazole tab delayed release 100 pramipexole dihydrochloride tab 1 mg mg ...... 25 ...... 59 pot & sod citrates w/ cit ac soln 550- pramipexole dihydrochloride tab 1.5 500-334 mg/5ml ...... 94 mg ...... 59 pot & sod citrates w/ cit ac syrup 550- pramoxine-hc cream 1-2.5% ...... 116 500-334 mg/5ml ...... 94 pramoxine-hc-chloroxylenol otic soln pot bicarbonate & chloride effer tab 25 10-10-1 mg/ml ...... 122 meq ...... 103 prasugrel hcl tab 10 mg (base equiv) 98 pot phos monobasic w/sod phos di & prasugrel hcl tab 5 mg (base equiv) . 98 monobas tab 155-852-130mg ..... 103 pravastatin sodium tab 10 mg ...... 43 potassium bicarbonate effer tab 25 pravastatin sodium tab 20 mg ...... 43 meq ...... 103 pravastatin sodium tab 40 mg ...... 43 potassium chloride cap er 10 meq .. 103 pravastatin sodium tab 80 mg ...... 43 potassium chloride cap er 8 meq .... 103 praziquantel tab 600 mg ...... 9 potassium chloride microencapsulated prazosin hcl cap 1 mg ...... 39 crys er tab 10 meq ...... 103 prazosin hcl cap 2 mg ...... 39 potassium chloride microencapsulated prazosin hcl cap 5 mg ...... 39 crys er tab 20 meq ...... 103 PRED MILD SUS 0.12% OP ...... 120 168

PRED SOD PHO SOL 1% OP ...... 120 PREMPRO TAB 0.625-5 ...... 80 PRED-G S.O.P OIN OP ...... 119 PRENTIF MIS 22MM ...... 73 PRED-G SUS OP ...... 119 PRENTIF MIS 25MM ...... 73 prednicarbate cream 0.1% ...... 116 PRENTIF MIS 28MM ...... 73 prednicarbate oint 0.1%...... 116 PRENTIF MIS 31MM ...... 73 prednisolone acetate ophth susp 1% PRENTIF MIS FITTING ...... 73 ...... 120 PREPOPIK PAK ...... 91 prednisolone sod phosph oral soln 6.7 PRETOMANID TAB 200MG ...... 25 mg/5ml (5 mg/5ml base) ...... 82 PREVNAR 13 INJ ...... 36 prednisolone sod phosphate oral soln PREZCOBIX TAB 800-150 ...... 17 15 mg/5ml (base equiv) ...... 82 PREZISTA SUS 100MG/ML ...... 18 prednisolone sodium phosphate oral PREZISTA TAB 150MG ...... 18 soln 25 mg/5ml (base eq) ...... 82 PREZISTA TAB 600MG ...... 18 prednisolone syrup 15 mg/5ml (usp PREZISTA TAB 75MG ...... 18 solution equivalent) ...... 82 PREZISTA TAB 800MG ...... 18 PREDNISONE CON 5MG/ML ...... 82 PRIFTIN TAB 150MG ...... 20 prednisone oral soln 5 mg/5ml ...... 82 PRIMAQUINE TAB 26.3MG ...... 25 prednisone tab 1 mg ...... 82 primidone tab 250 mg ...... 54 prednisone tab 10 mg ...... 82 primidone tab 50 mg ...... 54 prednisone tab 2.5 mg ...... 82 PRIVIGEN INJ 5 GRAMS ...... 100 prednisone tab 20 mg ...... 82 PROAIR HFA AER ...... 110 prednisone tab 5 mg ...... 82 probenecid tab 500 mg ...... 123 prednisone tab 50 mg ...... 82 procainamide hcl inj 100 mg/ml ...... 41 prednisone tab therapy pack 10 mg PROCAINAMIDE INJ 500MG/ML ...... 41 (21) ...... 82 prochlorperazine edisylate inj 10 prednisone tab therapy pack 5 mg (21) mg/2ml ...... 89 ...... 82 prochlorperazine maleate tab 10 mg pregabalin cap 100 mg ...... 66 (base equivalent) ...... 89 pregabalin cap 150 mg ...... 66 prochlorperazine maleate tab 5 mg pregabalin cap 200 mg ...... 66 (base equivalent) ...... 89 pregabalin cap 225 mg ...... 66 prochlorperazine suppos 25 mg...... 89 pregabalin cap 25 mg ...... 66 PROCRIT INJ 40000/ML...... 97 pregabalin cap 300 mg ...... 66 PROCYSBI CAP 25MG ...... 94 pregabalin cap 50 mg ...... 66 PROCYSBI CAP 75MG ...... 94 pregabalin cap 75 mg ...... 66 progesterone im in oil 50 mg/ml .... 107 pregabalin soln 20 mg/ml ...... 66 progesterone micronized cap 100 mg 85 PREMARIN INJ 25MG ...... 80 progesterone micronized cap 200 mg 85 PREMARIN TAB 0.3MG ...... 81 PROGLYCEM SUS 50MG/ML ...... 82 PREMARIN TAB 0.45MG...... 81 PROGRAF INJ 5MG/ML ...... 101 PREMARIN TAB 0.625MG ...... 81 PROLASTIN-C INJ 1000MG ...... 111 PREMARIN TAB 0.9MG ...... 81 PROLENSA SOL 0.07% ...... 120 PREMARIN TAB 1.25MG...... 81 PROLEUKIN INJ 22MU ...... 31 PREMARIN VAG CRE 0.625MG ...... 81 PROLIA SOL 60MG/ML ...... 79 PREMPHASE TAB ...... 80 PROMACTA TAB 12.5MG ...... 97 PREMPRO TAB ...... 80 PROMACTA TAB 25MG ...... 97 PREMPRO TAB 0.3-1.5 ...... 80 PROMACTA TAB 50MG ...... 97 PREMPRO TAB 0.45-1.5...... 80 PROMACTA TAB 75MG ...... 97 169 promethazine & phenylephrine syrup PRUTECT EMU ...... 118 6.25-5 mg/5ml ...... 108 pseudoephed-bromphen-dm syrup 30- promethazine hcl inj 25 mg/ml ...... 89 2-10 mg/5ml ...... 109 promethazine hcl inj 50 mg/ml ...... 89 pseudoephedrine w/ cod-gg soln 30- promethazine hcl suppos 12.5 mg .... 89 10-100 mg/5ml ...... 110 promethazine hcl suppos 25 mg ...... 89 PULMICORT INH 180MCG ...... 112 promethazine hcl suppos 50 mg ...... 89 PULMICORT INH 90MCG ...... 112 promethazine hcl syrup 6.25 mg/5ml 89 PULMOZYME SOL 1MG/ML ...... 111 promethazine hcl tab 12.5 mg ...... 89 pyrazinamide tab 500 mg ...... 20 promethazine hcl tab 25 mg ...... 89 pyridostigmine bromide tab 60 mg ... 69 promethazine hcl tab 50 mg ...... 89 Q promethazine w/ codeine syrup 6.25- QINLOCK TAB 50MG ...... 34 10 mg/5ml ...... 109 QTERN TAB 10MG/5MG ...... 24 promethazine-dm syrup 6.25-15 QUADRACEL INJ ...... 123 mg/5ml ...... 109 QUARTETTE TAB ...... 72 promethazine-phenylephrine-codeine quetiapine fumarate tab 100 mg ...... 61 syrup 6.25-5-10 mg/5ml ...... 110 quetiapine fumarate tab 200 mg ...... 61 propafenone hcl cap er 12hr 225 mg 41 quetiapine fumarate tab 25 mg ...... 61 propafenone hcl cap er 12hr 325 mg 41 quetiapine fumarate tab 300 mg ...... 61 propafenone hcl cap er 12hr 425 mg 41 quetiapine fumarate tab 400 mg ...... 62 propafenone hcl tab 150 mg ...... 41 quetiapine fumarate tab 50 mg ...... 61 propafenone hcl tab 225 mg ...... 41 quetiapine fumarate tab er 24hr 150 propafenone hcl tab 300 mg ...... 41 mg ...... 35 propantheline bromide tab 15 mg ..... 90 quetiapine fumarate tab er 24hr 200 proparacaine hcl ophth soln 0.5% .. 122 mg ...... 35 propranolol & hydrochlorothiazide tab quetiapine fumarate tab er 24hr 300 40-25 mg ...... 44 mg ...... 35 propranolol & hydrochlorothiazide tab quetiapine fumarate tab er 24hr 400 80-25 mg ...... 44 mg ...... 35 propranolol hcl cap er 24hr 120 mg .. 45 quetiapine fumarate tab er 24hr 50 mg propranolol hcl cap er 24hr 160 mg .. 45 ...... 35 propranolol hcl cap er 24hr 60 mg .... 45 quinapril hcl tab 10 mg ...... 39 propranolol hcl cap er 24hr 80 mg .... 45 quinapril hcl tab 20 mg ...... 39 propranolol hcl inj 1 mg/ml...... 45 quinapril hcl tab 40 mg ...... 39 propranolol hcl oral soln 20 mg/5ml.. 45 quinapril hcl tab 5 mg ...... 39 propranolol hcl oral soln 40 mg/5ml.. 45 quinapril-hydrochlorothiazide tab 10- propranolol hcl tab 10 mg ...... 45 12.5 mg ...... 38 propranolol hcl tab 20 mg ...... 45 quinapril-hydrochlorothiazide tab 20- propranolol hcl tab 40 mg ...... 45 12.5 mg ...... 38 propranolol hcl tab 60 mg ...... 45 quinapril-hydrochlorothiazide tab 20-25 propranolol hcl tab 80 mg ...... 45 mg ...... 38 propylthiouracil tab 50 mg ...... 85 QUINIDINE GL INJ 80MG/ML ...... 41 PROQUAD INJ ...... 124 quinidine gluconate tab er 324 mg ... 41 protamine sulfate inj 10 mg/ml ...... 97 quinidine sulfate tab 200 mg ...... 41 protriptyline hcl tab 10 mg ...... 59 quinidine sulfate tab 300 mg ...... 41 protriptyline hcl tab 5 mg ...... 59 quinidine sulfate tab er 300 mg...... 41 PROVENTIL AER HFA...... 110 quinine sulfate cap 324 mg...... 25 170

QUTENZA KIT 8% 1-PCH ...... 117 RECOMBIVA HB INJ 10MCG/ML ...... 125 QVAR AER 40MCG ...... 112 RECOMBIVA HB INJ 5MCG/0.5 ...... 125 QVAR AER 80MCG ...... 112 RECOMBIVA-HB INJ 40MCG/ML ...... 125 QVAR REDIHA AER 80MCG ...... 23 RECTIV OIN 0.4% ...... 91 QVAR REDIHAL AER 40MCG ...... 23 REGONOL INJ 5MG/ML ...... 68 R REGRANEX GEL 0.01% ...... 118 rabeprazole sodium ec tab 20 mg ..... 92 RELENZA MIS DISKHALE ...... 21 RAGWITEK SUB...... 1 REMICADE INJ 100MG ...... 93 raloxifene hcl tab 60 mg...... 84 RENAGEL TAB 400MG ...... 84 ramipril cap 1.25 mg ...... 39 repaglinide tab 0.5 mg ...... 77 ramipril cap 10 mg ...... 39 repaglinide tab 1 mg...... 77 ramipril cap 2.5 mg ...... 39 repaglinide tab 2 mg...... 77 ramipril cap 5 mg ...... 39 repaglinide-metformin hcl tab 1-500 ranitidine hcl inj 150 mg/6ml (25 mg ...... 77 mg/ml) ...... 90 repaglinide-metformin hcl tab 2-500 ranitidine hcl inj 50 mg/2ml (25 mg ...... 77 mg/ml) ...... 90 REPREXAIN TAB 2.5-200 ...... 7 ranitidine hcl syrup 15 mg/ml (75 RESCRIPTOR TAB 100 MG ...... 19 mg/5ml) ...... 90 RESCRIPTOR TAB 200MG ...... 19 ranitidine hcl tab 150 mg ...... 90 RESCULA SOL 0.15% ...... 122 ranitidine hcl tab 300 mg ...... 90 reserpine tab 0.1 mg ...... 48 ranolazine tab er 12hr 1000 mg ...... 23 reserpine tab 0.25 mg ...... 48 ranolazine tab er 12hr 500 mg ...... 22 RESTASIS EMU 0.05% ...... 121 RAPAMUNE SOL 1MG/ML ...... 101 RETACRIT INJ 10000UNT ...... 98 rasagiline mesylate tab 0.5 mg (base RETACRIT INJ 2000UNIT ...... 98 equiv) ...... 35 RETACRIT INJ 3000UNIT ...... 98 rasagiline mesylate tab 1 mg (base RETACRIT INJ 40000UNT ...... 98 equiv) ...... 35 RETACRIT INJ 4000UNIT ...... 98 RASUVO INJ 10MG ...... 99 RETEVMO CAP 40MG ...... 34 RASUVO INJ 12.5MG...... 99 RETEVMO CAP 80MG ...... 34 RASUVO INJ 15MG ...... 99 RETROVIR INJ 10MG/ML ...... 19 RASUVO INJ 17.5MG...... 99 REVCOVI INJ 1.6MG/ML ...... 88 RASUVO INJ 22.5MG...... 99 REVLIMID CAP 10MG ...... 28 RASUVO INJ 25MG ...... 99 REVLIMID CAP 15MG ...... 28 RASUVO INJ 27.5MG...... 99 REVLIMID CAP 2.5MG ...... 28 RASUVO INJ 30MG ...... 99 REVLIMID CAP 20MG ...... 28 RASUVO INJ 7.5MG ...... 99 REVLIMID CAP 25MG ...... 28 RAVICTI LIQ 1.1GM/ML ...... 84 REVLIMID CAP 5MG ...... 28 REBETOL SOL 40MG/ML ...... 20 REXULTI TAB 0.25MG ...... 62 REBIF INJ 22/0.5 ...... 69 REXULTI TAB 0.5MG ...... 62 REBIF INJ 44/0.5 ...... 69 REXULTI TAB 1MG ...... 62 REBIF REBIDO INJ 22/0.5 ...... 69 REXULTI TAB 2MG ...... 62 REBIF REBIDO INJ 44/0.5 ...... 69 REXULTI TAB 3MG ...... 62 REBIF REBIDO INJ TITRATN...... 69 REXULTI TAB 4MG ...... 62 REBIF TITRTN INJ PACK ...... 69 REYATAZ POW 50MG ...... 18 REBLOZYL INJ 25MG ...... 98 RHOPRESSA SOL 0.02% ...... 106 REBLOZYL INJ 75MG ...... 98 RIBAPAK PAK 1000/DAY ...... 20 171 ribavirin cap 200 mg ...... 20 rivastigmine tartrate cap 1.5 mg (base ribavirin tab 200 mg ...... 20 equivalent) ...... 55 ribavirin tab 400 mg ...... 36 rivastigmine tartrate cap 3 mg (base ribavirin tab 600 mg ...... 20 equivalent) ...... 55 RIDAURA CAP 3MG ...... 99 rivastigmine tartrate cap 4.5 mg (base rifabutin cap 150 mg ...... 22 equivalent) ...... 55 RIFAMATE CAP ...... 20 rivastigmine tartrate cap 6 mg (base rifampin cap 150 mg...... 20 equivalent) ...... 55 rifampin cap 300 mg...... 20 rivastigmine td patch 24hr 13.3 rifampin for inj 600 mg ...... 20 mg/24hr ...... 55 RIFATER TAB ...... 20 rivastigmine td patch 24hr 4.6 mg/24hr riluzole tab 50 mg ...... 68 ...... 55 rimantadine hydrochloride tab 100 mg rivastigmine td patch 24hr 9.5 mg/24hr ...... 21 ...... 55 ringer's solution for irrigation ...... 118 rizatriptan benzoate oral disintegrating RIOMET SOL 500/5ML ...... 24 tab 10 mg (base eq) ...... 67 risedronate sodium tab 150 mg ...... 79 rizatriptan benzoate oral disintegrating risedronate sodium tab 30 mg ...... 79 tab 5 mg (base eq) ...... 67 risedronate sodium tab 35 mg ...... 79 rizatriptan benzoate tab 10 mg (base risedronate sodium tab 5 mg ...... 79 equivalent) ...... 67 risedronate sodium tab delayed release rizatriptan benzoate tab 5 mg (base 35 mg ...... 79 equivalent) ...... 67 RISPERDAL INJ 12.5MG ...... 62 ropinirole hydrochloride tab 0.25 mg 60 RISPERDAL INJ 25MG ...... 62 ropinirole hydrochloride tab 0.5 mg .. 59 RISPERDAL INJ 37.5MG ...... 62 ropinirole hydrochloride tab 1 mg ..... 60 RISPERDAL INJ 50MG ...... 62 ropinirole hydrochloride tab 2 mg ..... 60 risperidone orally disintegrating tab ropinirole hydrochloride tab 3 mg ..... 60 0.25 mg ...... 62 ropinirole hydrochloride tab 4 mg ..... 60 risperidone orally disintegrating tab 0.5 ropinirole hydrochloride tab 5 mg ..... 60 mg ...... 62 ropinirole hydrochloride tab er 24hr 12 risperidone orally disintegrating tab 1 mg (base equivalent) ...... 60 mg ...... 62 ropinirole hydrochloride tab er 24hr 2 risperidone orally disintegrating tab 2 mg (base equivalent) ...... 60 mg ...... 62 ropinirole hydrochloride tab er 24hr 4 risperidone orally disintegrating tab 3 mg (base equivalent) ...... 60 mg ...... 62 ropinirole hydrochloride tab er 24hr 6 risperidone orally disintegrating tab 4 mg (base equivalent) ...... 60 mg ...... 62 ropinirole hydrochloride tab er 24hr 8 risperidone soln 1 mg/ml...... 62 mg (base equivalent) ...... 60 risperidone tab 0.25 mg ...... 62 rosuvastatin calcium tab 10 mg ...... 43 risperidone tab 0.5 mg ...... 62 rosuvastatin calcium tab 20 mg ...... 43 risperidone tab 1 mg ...... 62 rosuvastatin calcium tab 40 mg ...... 43 risperidone tab 2 mg ...... 62 rosuvastatin calcium tab 5 mg ...... 43 risperidone tab 3 mg ...... 62 ROTARIX SUS ...... 125 risperidone tab 4 mg ...... 62 ROTATEQ SOL...... 125 ritonavir tab 100 mg ...... 18 ROZEREM TAB 8MG ...... 67 RITUXAN INJ 100MG ...... 31 ROZLYTREK CAP 100MG ...... 34 172

ROZLYTREK CAP 200MG ...... 34 sertraline hcl tab 100 mg ...... 58 RUBRACA TAB 200MG ...... 32 sertraline hcl tab 25 mg ...... 58 RUBRACA TAB 250MG ...... 32 sertraline hcl tab 50 mg ...... 58 RUBRACA TAB 300MG ...... 32 sevelamer carbonate packet 0.8 gm . 85 RUCONEST INJ 2100UNIT...... 97 sevelamer carbonate packet 2.4 gm . 85 RYDAPT CAP 25MG ...... 34 sevelamer carbonate tab 800 mg ..... 93 RYDEX LIQ ...... 110 sevelamer hcl tab 800 mg ...... 93 S SHUR-SEAL GEL 2% ...... 113 SAFYRAL TAB ...... 72 SIGNIFOR INJ 0.3MG/ML ...... 84 SALICEPT SUS ...... 119 SIGNIFOR INJ 0.6MG/ML ...... 84 SALICYLIC AC LIQ 26% ...... 118 SIGNIFOR INJ 0.9MG/ML ...... 84 salicylic acid cream 6% ...... 118 SIGNIFOR LAR INJ 20MG...... 84 salicylic acid film forming liquid 27.5% SIGNIFOR LAR INJ 40MG...... 84 ...... 118 SIGNIFOR LAR INJ 60MG...... 84 salicylic acid lotion 6% ...... 118 sildenafil citrate tab 20 mg ...... 49 salicylic acid shampoo 6% ...... 118 silodosin cap 4 mg...... 93 salsalate tab 500 mg ...... 3 silodosin cap 8 mg...... 93 salsalate tab 750 mg ...... 3 SILVER NITRA SOL 10% ...... 118 SAMSCA TAB 15MG ...... 87 silver nitrate-potassium nitrate SAMSCA TAB 30MG ...... 87 applicator 75-25% ...... 118 SANCUSO DIS 3.1MG ...... 89 silver sulfadiazine cream 1% ...... 114 SANDOSTATIN KIT LAR 10MG ...... 84 SIMPONI ARIA SOL 50MG/4ML ...... 99 SANDOSTATIN KIT LAR 20MG ...... 84 SIMULECT INJ 10MG ...... 101 SANDOSTATIN KIT LAR 30MG ...... 84 SIMULECT INJ 20MG ...... 101 SANTYL OIN 250/GM ...... 118 simvastatin tab 10 mg ...... 43 SAPHRIS SUB 2.5MG ...... 62 simvastatin tab 20 mg ...... 43 SAPHRIS SUB 5MG ...... 62 simvastatin tab 40 mg ...... 43 SAVELLA MIS TITR PAK ...... 66 simvastatin tab 5 mg ...... 43 SAVELLA TAB 100MG ...... 66 simvastatin tab 80 mg ...... 43 SAVELLA TAB 12.5MG ...... 66 sirolimus oral soln 1 mg/ml ...... 102 SAVELLA TAB 25MG ...... 66 sirolimus tab 0.5 mg ...... 101 SAVELLA TAB 50MG ...... 66 sirolimus tab 1 mg ...... 101 scopolamine td patch 72hr 1 mg/3days sirolimus tab 2 mg ...... 101 ...... 89 SIRTURO TAB 100MG ...... 20 selegiline hcl cap 5 mg ...... 60 SKLICE LOT 0.5% ...... 118 selegiline hcl tab 5 mg ...... 60 SKYLA IUD 13.5MG ...... 107 selenium sulfide lotion 2.5% ...... 115 sodium chloride soln nebu 10% ..... 111 selenium sulfide shampoo 2.25% ... 115 sodium chloride soln nebu 3% ...... 111 SELZENTRY SOL 20MG/ML...... 17 sodium chloride soln nebu 7% ...... 111 SELZENTRY TAB 150MG ...... 17 sodium citrate & citric acid soln 500- SELZENTRY TAB 300MG ...... 17 334 mg/5ml ...... 94 SEREVENT DIS AER 50MCG ...... 110 sodium fluoride chew tab 0.25 mg f SEROSTIM INJ 4MG ...... 82 (from 0.55 mg naf) ...... 106 SEROSTIM INJ 5MG ...... 82 sodium fluoride chew tab 0.5 mg f SEROSTIM INJ 6MG ...... 82 (from 1.1 mg naf) ...... 106 sertraline hcl oral concentrate for sodium fluoride chew tab 1 mg f (from solution 20 mg/ml ...... 58 2.2 mg naf) ...... 106 173 sodium fluoride cream 1.1% ...... 119 spironolactone tab 25 mg ...... 39 sodium fluoride gel 1.1% (0.5% f) . 119 spironolactone tab 50 mg ...... 39 sodium fluoride rinse 0.2% ...... 119 SPRAVATO SOL 56MG DOS ...... 23 sodium fluoride soln 0.125 mg/drop f SPRAVATO SOL 84MG DOS ...... 23 (0.275 mg/drop naf) ...... 106 SPRYCEL TAB 100MG ...... 29 sodium fluoride soln 0.25 mg/drop f SPRYCEL TAB 140MG ...... 29 (from 0.55 mg/drop naf) ...... 106 SPRYCEL TAB 20MG ...... 29 sodium fluoride soln 0.5 mg/ml f (from SPRYCEL TAB 50MG ...... 29 1.1 mg/ml naf)...... 106 SPRYCEL TAB 70MG ...... 29 sodium fluoride tab 0.5 mg f (from 1.1 SPRYCEL TAB 80MG ...... 29 mg naf) ...... 106 SSKI SOL 1GM/ML ...... 85 sodium phenylbutyrate oral powder 3 ST JOSEPH CHW 75MG ADU ...... 3 gm/teaspoonful ...... 91 stavudine cap 15 mg ...... 19 sodium phenylbutyrate tab 500 mg .. 88 stavudine cap 20 mg ...... 19 sodium polystyrene sulfonate oral susp stavudine cap 30 mg ...... 19 15 gm/60ml ...... 104 stavudine cap 40 mg ...... 19 sodium polystyrene sulfonate rectal stavudine for oral soln 1 mg/ml ...... 19 susp 30 gm/120ml...... 104 STELARA INJ 45MG/0.5 ...... 115 solifenacin succinate tab 10 mg...... 124 STELARA INJ 90MG/ML ...... 115 solifenacin succinate tab 5 mg ...... 124 STIOLTO AER 2.5-2.5 ...... 108 SOLIQUA INJ 100/33 ...... 24 STIVARGA TAB 40MG ...... 30 SOLIRIS INJ 10MG/ML ...... 97 streptomycin sulfate for inj 1 gm...... 9 SOMATULINE INJ 120/.5ML ...... 84 STRIANT MIS 30MG ...... 75 SOMATULINE INJ 60/0.2ML ...... 84 STRIBILD TAB...... 17 SOMATULINE INJ 90/0.3ML ...... 84 STRIVERDI AER 2.5MCG ...... 110 SOMAVERT INJ 10MG...... 84 STROMECTOL TAB 3MG ...... 22 SOMAVERT INJ 15MG...... 84 SUCLEAR KIT ...... 91 SOMAVERT INJ 20MG...... 84 SUCRAID SOL 8500/ML ...... 91 SOMAVERT INJ 25MG...... 84 sucralfate tab 1 gm ...... 91 SOMAVERT INJ 30MG...... 84 sulfacetamide sodium liquid 10% ... 115 sotalol hcl (afib/afl) tab 120 mg ...... 41 sulfacetamide sodium lotion 10% sotalol hcl (afib/afl) tab 160 mg ...... 42 (acne) ...... 114 sotalol hcl (afib/afl) tab 80 mg ...... 41 sulfacetamide sodium ophth oint 10% SOTALOL HCL INJ 150/10ML ...... 42 ...... 120 sotalol hcl tab 120 mg ...... 42 sulfacetamide sodium ophth soln 10% sotalol hcl tab 160 mg ...... 42 ...... 120 sotalol hcl tab 240 mg ...... 42 sulfacetamide sodium w/ sulfur sotalol hcl tab 80 mg ...... 42 emulsion 10-1% ...... 114 SOVALDI TAB 400MG ...... 20 sulfacetamide sodium w/ sulfur SPECTRACEF TAB 200MG ...... 12 emulsion 10-5% ...... 114 spinosad susp 0.9%...... 118 sulfacetamide sodium-prednisolone SPIRIVA AER 1.25MCG ...... 108 ophth soln 10-0.23(0.25)% ...... 119 SPIRIVA CAP HANDIHLR ...... 108 SULFADIAZINE TAB 500MG ...... 15 SPIRIVA SPR 2.5MCG...... 108 sulfamethoxazole-trimethoprim iv soln spironolactone & hydrochlorothiazide 400-80 mg/5ml ...... 15 tab 25-25 mg ...... 47 sulfamethoxazole-trimethoprim susp spironolactone tab 100 mg ...... 39 200-40 mg/5ml ...... 15 174 sulfamethoxazole-trimethoprim tab SYMLINPEN 60 INJ 1000MCG ...... 75 400-80 mg ...... 15 SYMLNPEN 120 INJ 1000MCG ...... 76 sulfamethoxazole-trimethoprim tab SYMPATH NDL MIS 18GX6 ...... 78 800-160 mg ...... 16 SYNAGIS INJ 100MG/ML ...... 101 SULFAMYLON CRE 85MG/GM ...... 118 SYNAGIS INJ 50MG ...... 101 sulfasalazine tab 500 mg ...... 90 SYNAREL SOL 2MG/ML ...... 79 sulfasalazine tab delayed release 500 SYNERA DIS 70-70MG ...... 118 mg ...... 90 SYNJARDY TAB ...... 77 sulindac tab 150 mg ...... 3 SYNJARDY TAB 12.5-500 ...... 77 sulindac tab 200 mg ...... 3 SYNJARDY TAB 5-1000MG ...... 77 sumatriptan nasal spray 20 mg/act .. 67 SYNJARDY TAB 5-500MG ...... 77 sumatriptan nasal spray 5 mg/act .... 67 SYNJARDY XR TAB ...... 24 sumatriptan succinate inj 6 mg/0.5ml SYNJARDY XR TAB 10-1000 ...... 24 ...... 67 SYNJARDY XR TAB 25-1000 ...... 24 sumatriptan succinate solution auto- SYNJARDY XR TAB 5-1000MG ...... 24 injector 4 mg/0.5ml ...... 67 SYNTHROID TAB 100MCG ...... 86 sumatriptan succinate solution auto- SYNTHROID TAB 112MCG ...... 86 injector 6 mg/0.5ml ...... 67 SYNTHROID TAB 125MCG ...... 86 sumatriptan succinate solution SYNTHROID TAB 137MCG ...... 86 cartridge 4 mg/0.5ml ...... 67 SYNTHROID TAB 150MCG ...... 86 sumatriptan succinate solution SYNTHROID TAB 175MCG ...... 86 cartridge 6 mg/0.5ml ...... 67 SYNTHROID TAB 200MCG ...... 86 sumatriptan succinate solution prefilled SYNTHROID TAB 25MCG ...... 86 syringe 6 mg/0.5ml ...... 67 SYNTHROID TAB 300MCG ...... 86 sumatriptan succinate tab 100 mg .... 68 SYNTHROID TAB 50MCG ...... 86 sumatriptan succinate tab 25 mg ..... 67 SYNTHROID TAB 75MCG ...... 86 sumatriptan succinate tab 50 mg ..... 68 SYNTHROID TAB 88MCG ...... 86 SUPPRELIN LA KIT 50MG ...... 84 T SUPRAX CAP 400MG ...... 12 TABLOID TAB 40MG ...... 27 SUPRAX CHW 100MG ...... 12 TABRECTA TAB 150MG...... 34 SUPRAX CHW 200MG ...... 12 TABRECTA TAB 200MG...... 34 SUPRAX SUS 500/5ML ...... 12 TACLONEX SUS ...... 116 SUPREP BOWEL SOL PREP KIT ...... 91 tacrolimus cap 0.5 mg ...... 101 SUTENT CAP 12.5MG ...... 30 tacrolimus cap 1 mg ...... 101 SUTENT CAP 25MG ...... 30 tacrolimus cap 5 mg ...... 101 SUTENT CAP 37.5MG ...... 30 tacrolimus oint 0.03% ...... 117 SUTENT CAP 50MG ...... 30 tacrolimus oint 0.1% ...... 117 SYLATRON KIT 200MCG ...... 100 tadalafil tab 2.5 mg ...... 50 SYLATRON KIT 300MCG ...... 100 tadalafil tab 5 mg ...... 50 SYLATRON KIT 600MCG ...... 100 TAFINLAR CAP 50MG ...... 30 SYLVANT SOL 100MG...... 101 TAFINLAR CAP 75MG ...... 30 SYLVANT SOL 400MG...... 101 TAGRISSO TAB 40MG ...... 30 SYMBICORT AER 160-4.5 ...... 112 TAGRISSO TAB 80MG ...... 30 SYMBICORT AER 80-4.5 ...... 112 TALWIN INJ 30MG/ML ...... 7 SYMDEKO TAB 100-150 ...... 113 TALZENNA CAP 0.25MG ...... 34 SYMFI LO TAB ...... 35 TALZENNA CAP 1MG ...... 34 SYMFI TAB ...... 35 TAMIFLU CAP 30MG ...... 21 175

TAMIFLU CAP 45MG ...... 21 temozolomide cap 180 mg ...... 26 TAMIFLU CAP 75MG ...... 21 temozolomide cap 20 mg ...... 26 TAMIFLU SUS 6MG/ML ...... 21 temozolomide cap 250 mg ...... 26 tamoxifen citrate tab 10 mg (base temozolomide cap 5 mg ...... 26 equivalent) ...... 27 TENIVAC INJ 5-2LF ...... 123 tamoxifen citrate tab 20 mg (base tenofovir disoproxil fumarate tab 300 equivalent) ...... 27 mg ...... 35 tamsulosin hcl cap 0.4 mg ...... 93 terazosin hcl cap 1 mg (base TARCEVA TAB 100MG ...... 30 equivalent) ...... 39 TARCEVA TAB 150MG ...... 30 terazosin hcl cap 10 mg (base TARCEVA TAB 25MG ...... 30 equivalent) ...... 40 TARGRETIN GEL 1% ...... 32 terazosin hcl cap 2 mg (base TARON FORTE CAP ...... 106 equivalent) ...... 39 TASIGNA CAP 150MG...... 30 terazosin hcl cap 5 mg (base TASIGNA CAP 200MG...... 30 equivalent) ...... 39 TASIGNA CAP 50MG ...... 34 terbinafine hcl tab 250 mg ...... 17 TAYTULLA CAP 1MG/20MC ...... 72 terbutaline sulfate inj 1 mg/ml ...... 110 tazarotene cream 0.1%...... 74 terbutaline sulfate tab 2.5 mg ...... 111 TAZORAC CRE 0.05% ...... 114 terbutaline sulfate tab 5 mg ...... 111 TAZORAC GEL 0.05% ...... 114 terconazole vaginal cream 0.4% ...... 95 TAZORAC GEL 0.1% ...... 114 terconazole vaginal cream 0.8% ...... 95 TAZVERIK TAB 200MG ...... 34 terconazole vaginal suppos 80 mg .... 95 TDVAX INJ 2-2 LF ...... 123 testosterone cypionate im inj in oil 100 TECHLITE MIS LANCETS ...... 78 mg/ml ...... 75 TEFLARO INJ 400MG ...... 12 testosterone cypionate im inj in oil 200 TEFLARO INJ 600MG ...... 12 mg/ml ...... 75 TEGSEDI INJ 284/1.5 ...... 108 testosterone enanthate im inj in oil 200 TEKTURNA HCT TAB 150-12.5...... 46 mg/ml ...... 75 TEKTURNA HCT TAB 150-25MG ...... 46 testosterone td gel 10mg/act (2%)... 75 TEKTURNA HCT TAB 300-12.5...... 46 testosterone td gel 12.5 mg/act (1%) TEKTURNA HCT TAB 300-25MG ...... 46 ...... 75 TEKTURNA TAB 150MG ...... 46 testosterone td gel 20.25 mg/act TEKTURNA TAB 300MG ...... 46 (1.62%) ...... 9 telmisartan tab 20 mg ...... 41 testosterone td gel 25 mg/2.5gm (1%) telmisartan tab 40 mg ...... 41 ...... 75 telmisartan tab 80 mg ...... 41 testosterone td gel 50 mg/5gm (1%) 75 telmisartan-hydrochlorothiazide tab 40- TETANUS TOX INJ 5LF ADS ...... 123 12.5 mg ...... 40 tetrabenazine tab 12.5 mg ...... 66 telmisartan-hydrochlorothiazide tab 80- tetrabenazine tab 25 mg ...... 66 12.5 mg ...... 40 tetracaine hcl ophth soln 0.5% ...... 122 telmisartan-hydrochlorothiazide tab 80- tetracycline hcl cap 250 mg ...... 16 25 mg ...... 40 tetracycline hcl cap 500 mg ...... 16 temazepam cap 15 mg...... 66 THALOMID CAP 100MG ...... 28 temazepam cap 30 mg...... 66 THALOMID CAP 150MG ...... 28 TEMODAR INJ 100MG ...... 26 THALOMID CAP 200MG ...... 28 temozolomide cap 100 mg...... 26 THALOMID CAP 50MG ...... 28 temozolomide cap 140 mg...... 26 theophylline soln 80 mg/15ml ...... 113 176 theophylline tab er 12hr 100 mg .... 113 TIROSINT CAP 150MCG ...... 86 theophylline tab er 12hr 200 mg .... 113 TIROSINT CAP 25MCG ...... 86 theophylline tab er 12hr 300 mg .... 113 TIROSINT CAP 50MCG ...... 86 theophylline tab er 12hr 450 mg .... 113 TIROSINT CAP 75MCG ...... 86 theophylline tab er 24hr 400 mg .... 113 TIROSINT CAP 88MCG ...... 86 theophylline tab er 24hr 600 mg .... 113 TIVICAY TAB 50MG...... 18 THIOLA TAB 100MG ...... 94 tizanidine hcl cap 2 mg (base thioridazine hcl tab 10 mg ...... 63 equivalent) ...... 69 thioridazine hcl tab 100 mg ...... 63 tizanidine hcl cap 4 mg (base thioridazine hcl tab 25 mg ...... 63 equivalent) ...... 69 thioridazine hcl tab 50 mg ...... 63 tizanidine hcl cap 6 mg (base thiothixene cap 1 mg ...... 63 equivalent) ...... 69 thiothixene cap 10 mg ...... 63 tizanidine hcl tab 2 mg (base thiothixene cap 2 mg ...... 63 equivalent) ...... 69 thiothixene cap 5 mg ...... 63 tizanidine hcl tab 4 mg (base THYMOGLOBULN INJ 25MG ...... 100 equivalent) ...... 69 thyroid tab 30 mg (1/2 grain) ...... 86 TOBRADEX ST SUS 0.3-0.05 ...... 119 thyroid tab 60 mg (1 grain) ...... 86 tobramycin nebu soln 300 mg/5ml . 111 thyroid tab 90 mg (1 1/2 grain) ...... 86 tobramycin ophth soln 0.3% ...... 120 THYROLAR-1 TAB 60MG ...... 113 tobramycin sulfate for inj 1.2 gm ...... 9 THYROLAR-1/2 TAB 30MG ...... 113 tobramycin sulfate inj 1.2 gm/30ml (40 THYROLAR-1/4 TAB 15MG ...... 113 mg/ml) (base equiv) ...... 9 THYROLAR-2 TAB 120MG ...... 113 tobramycin sulfate inj 10 mg/ml (base THYROLAR-3 TAB 180MG ...... 113 equivalent) ...... 9 tiagabine hcl tab 12 mg ...... 54 tobramycin sulfate inj 2 gm/50ml (40 tiagabine hcl tab 16 mg ...... 54 mg/ml) (base equiv) ...... 9 tiagabine hcl tab 2 mg ...... 54 tobramycin sulfate inj 80 mg/2ml (40 tiagabine hcl tab 4 mg ...... 54 mg/ml) (base equiv) ...... 9 TIBSOVO TAB 250MG ...... 34 tobramycin-dexamethasone ophth susp ticlopidine hcl tab 250 mg ...... 98 0.3-0.1% ...... 119 TIGAN INJ 100MG/ML ...... 89 TODAY SPONGE MIS ...... 113 timolol maleate ophth gel forming soln tolazamide tab 250 mg ...... 78 0.25%...... 121 tolazamide tab 500 mg ...... 78 timolol maleate ophth gel forming soln tolbutamide tab 500 mg ...... 78 0.5% ...... 121 tolcapone tab 100 mg ...... 60 timolol maleate ophth soln 0.25% .. 121 tolmetin sodium cap 400 mg ...... 3 timolol maleate ophth soln 0.5% .... 121 tolmetin sodium tab 200 mg ...... 3 timolol maleate tab 10 mg ...... 45 tolmetin sodium tab 600 mg ...... 3 timolol maleate tab 20 mg ...... 45 tolterodine tartrate cap er 24hr 2 mg 94 timolol maleate tab 5 mg ...... 45 tolterodine tartrate cap er 24hr 4 mg 94 tinidazole tab 250 mg ...... 22 tolterodine tartrate tab 1 mg ...... 94 tinidazole tab 500 mg ...... 22 tolterodine tartrate tab 2 mg ...... 94 TIROSINT CAP 100MCG...... 86 topiramate cap er 24hr sprinkle 100 TIROSINT CAP 112MCG...... 86 mg ...... 54 TIROSINT CAP 125MCG...... 86 topiramate cap er 24hr sprinkle 150 TIROSINT CAP 137MCG...... 86 mg ...... 54 TIROSINT CAP 13MCG ...... 86 177 topiramate cap er 24hr sprinkle 200 travoprost ophth soln 0.004% ...... 122 mg ...... 54 travoprost ophth soln 0.004% topiramate cap er 24hr sprinkle 25 mg (benzalkonium free) (bak free).... 107 ...... 54 trazodone hcl tab 100 mg...... 56 topiramate cap er 24hr sprinkle 50 mg trazodone hcl tab 150 mg...... 56 ...... 54 trazodone hcl tab 300 mg...... 56 topiramate sprinkle cap 15 mg ...... 54 trazodone hcl tab 50 mg ...... 56 topiramate sprinkle cap 25 mg ...... 54 TREANDA INJ 100MG ...... 26 topiramate tab 100 mg ...... 54 TREANDA INJ 180/2ML ...... 26 topiramate tab 200 mg ...... 54 TREANDA INJ 25MG ...... 26 topiramate tab 25 mg ...... 54 TREANDA INJ 45/0.5ML ...... 26 topiramate tab 50 mg ...... 54 TRECATOR TAB 250MG ...... 20 TOPOTECAN INJ 4MG/4ML ...... 32 TRELSTAR INJ 11.25MG ...... 28 toremifene citrate tab 60 mg (base TRELSTAR INJ 3.75MG ...... 28 equivalent) ...... 33 TRELSTAR MIX INJ 22.5MG...... 28 torsemide tab 10 mg ...... 47 treprostinil inj soln 100 mg/20ml (5 torsemide tab 100 mg...... 47 mg/ml) ...... 50 torsemide tab 20 mg ...... 47 treprostinil inj soln 20 mg/20ml (1 torsemide tab 5 mg ...... 47 mg/ml) ...... 50 TOUJEO SOLO INJ 300IU/ML ...... 101 treprostinil inj soln 200 mg/20ml (10 tramadol hcl tab 50 mg ...... 7 mg/ml) ...... 50 tramadol hcl tab er 24hr 100 mg ...... 7 treprostinil inj soln 50 mg/20ml (2.5 tramadol hcl tab er 24hr 200 mg ...... 7 mg/ml) ...... 50 tramadol hcl tab er 24hr 300 mg ...... 7 TRESIBA FLEX INJ 100UNIT ...... 101 tramadol hcl tab er 24hr biphasic TRESIBA FLEX INJ 200UNIT ...... 101 release 100 mg ...... 7 TRESIBA INJ 100UNIT...... 24 tramadol hcl tab er 24hr biphasic tretinoin cap 10 mg ...... 32 release 200 mg ...... 7 tretinoin cream 0.025% ...... 114 tramadol hcl tab er 24hr biphasic tretinoin cream 0.05% ...... 114 release 300 mg ...... 8 tretinoin cream 0.1% ...... 114 tramadol-acetaminophen tab 37.5-325 tretinoin gel 0.01% ...... 114 mg ...... 8 tretinoin gel 0.025% ...... 114 trandolapril tab 1 mg ...... 39 triamcinolone acetonide cream 0.025% trandolapril tab 2 mg ...... 39 ...... 116 trandolapril tab 4 mg ...... 39 triamcinolone acetonide cream 0.1% trandolapril-verapamil hcl tab er 1-240 ...... 116 mg ...... 37 triamcinolone acetonide cream 0.5% trandolapril-verapamil hcl tab er 2-180 ...... 116 mg ...... 37 triamcinolone acetonide dental paste trandolapril-verapamil hcl tab er 2-240 0.1% ...... 119 mg ...... 37 triamcinolone acetonide lotion 0.025% trandolapril-verapamil hcl tab er 4-240 ...... 116 mg ...... 37 triamcinolone acetonide lotion 0.1% tranexamic acid iv soln 1000 mg/10ml ...... 116 (100 mg/ml) ...... 97 triamcinolone acetonide nasal aerosol tranexamic acid tab 650 mg ...... 97 suspension 55 mcg/act...... 103 tranylcypromine sulfate tab 10 mg ... 56 178 triamcinolone acetonide oint 0.025% TRULICITY INJ 0.75/0.5 ...... 76 ...... 116 TRULICITY INJ 1.5/0.5 ...... 76 triamcinolone acetonide oint 0.1% . 116 TRUMENBA INJ ...... 36 triamcinolone acetonide oint 0.5% . 116 TRUVADA TAB 200-300 ...... 17 triamterene & hydrochlorothiazide cap trypsin w/ castor oil & peruvian balsam 37.5-25 mg ...... 47 spray ...... 118 triamterene & hydrochlorothiazide cap TUKYSA TAB 150MG ...... 34 50-25 mg ...... 47 TUKYSA TAB 50MG ...... 34 triamterene & hydrochlorothiazide tab TURALIO CAP 200MG ...... 34 37.5-25 mg ...... 47 TUZISTRA XR SUS ...... 74 triamterene & hydrochlorothiazide tab TWINRIX INJ ...... 124 75-50 mg ...... 48 TYBOST TAB 150MG ...... 17 triamterene cap 100 mg ...... 75 TYKERB TAB 250MG ...... 30 triamterene cap 50 mg ...... 75 TYSABRI INJ 300/15ML ...... 69 triazolam tab 0.125 mg ...... 67 TYZEKA TAB 600MG ...... 20 triazolam tab 0.25 mg ...... 66 U TRIDERMA CRE FORTE ...... 116 ULESFIA LOT 5% ...... 74 trientine hcl cap 250 mg ...... 84 UPTRAVI TAB 1000MCG ...... 50 TRIESENCE INJ 40MG/ML ...... 120 UPTRAVI TAB 1200MCG ...... 50 trifluoperazine hcl tab 1 mg (base UPTRAVI TAB 1400MCG ...... 50 equivalent) ...... 63 UPTRAVI TAB 1600MCG ...... 50 trifluoperazine hcl tab 10 mg (base UPTRAVI TAB 200/800 ...... 50 equivalent) ...... 64 UPTRAVI TAB 200MCG ...... 50 trifluoperazine hcl tab 2 mg (base UPTRAVI TAB 400MCG ...... 50 equivalent) ...... 63 UPTRAVI TAB 600MCG ...... 50 trifluoperazine hcl tab 5 mg (base UPTRAVI TAB 800MCG ...... 50 equivalent) ...... 63 urea lotion 40% ...... 117 trifluridine ophth soln 1% ...... 121 ursodiol cap 300 mg ...... 90 trihexyphenidyl hcl oral soln 0.4 mg/ml ursodiol tab 250 mg ...... 90 ...... 60 ursodiol tab 500 mg ...... 90 trihexyphenidyl hcl tab 2 mg...... 60 UVADEX INJ 20MCG/ML ...... 32 trihexyphenidyl hcl tab 5 mg...... 60 V TRIKAFTA TAB ...... 113 valacyclovir hcl tab 1 gm ...... 21 trimethobenzamide hcl cap 300 mg .. 89 valacyclovir hcl tab 500 mg ...... 21 trimethoprim tab 100 mg ...... 22 VALCHLOR GEL 0.016% ...... 26 trimipramine maleate cap 100 mg .... 59 VALCYTE TAB 450MG ...... 20 trimipramine maleate cap 25 mg ...... 59 valganciclovir hcl for soln 50 mg/ml trimipramine maleate cap 50 mg ...... 59 (base equiv) ...... 20 TRINTELLIX TAB 10MG ...... 58 valganciclovir hcl tab 450 mg (base TRINTELLIX TAB 20MG ...... 58 equivalent) ...... 20 TRINTELLIX TAB 5MG ...... 58 valproate sodium inj 100 mg/ml...... 54 TRISENOX SOL 10MG/10M ...... 32 valproate sodium oral soln 250 mg/5ml TRIUMEQ TAB ...... 17 (base equiv) ...... 54 tropicamide ophth soln 0.5% ...... 122 valproic acid cap 250 mg...... 54 tropicamide ophth soln 1% ...... 122 valsartan tab 160 mg...... 41 trospium chloride cap er 24hr 60 mg 94 valsartan tab 320 mg...... 41 trospium chloride tab 20 mg ...... 94 valsartan tab 40 mg ...... 41 179 valsartan tab 80 mg ...... 41 venlafaxine hcl tab 100 mg (base valsartan-hydrochlorothiazide tab 160- equivalent) ...... 57 12.5 mg ...... 40 venlafaxine hcl tab 25 mg (base valsartan-hydrochlorothiazide tab 160- equivalent) ...... 57 25 mg ...... 40 venlafaxine hcl tab 37.5 mg (base valsartan-hydrochlorothiazide tab 320- equivalent) ...... 57 12.5 mg ...... 40 venlafaxine hcl tab 50 mg (base valsartan-hydrochlorothiazide tab 320- equivalent) ...... 57 25 mg ...... 40 venlafaxine hcl tab 75 mg (base valsartan-hydrochlorothiazide tab 80- equivalent) ...... 57 12.5 mg ...... 40 VENTAVIS SOL 10MCG/ML...... 50 VANCOMYC/D5W INJ 500MG ...... 22 VENTAVIS SOL 20MCG/ML...... 50 VANCOMYC/D5W INJ 750MG ...... 22 VENTOLIN HFA AER ...... 110 vancomycin hcl cap 125 mg ...... 22 VERAMYST SPR 27.5MCG ...... 112 vancomycin hcl cap 250 mg ...... 22 verapamil hcl cap er 24hr 120 mg .... 46 vancomycin hcl for inj 1000 mg ...... 22 verapamil hcl cap er 24hr 180 mg .... 46 vancomycin hcl for iv soln 10 gm (base verapamil hcl cap er 24hr 240 mg .... 46 equivalent) ...... 22 verapamil hcl iv soln 2.5 mg/ml ...... 46 vancomycin hcl for iv soln 5 gm (base verapamil hcl tab 120 mg ...... 46 equivalent) ...... 22 verapamil hcl tab 40 mg ...... 46 vancomycin hcl for iv soln 500 mg verapamil hcl tab 80 mg ...... 46 (base equivalent) ...... 22 verapamil hcl tab er 120 mg ...... 46 VANCOMYCIN INJ 750MG ...... 22 verapamil hcl tab er 180 mg ...... 46 VANTAS KIT 50MG ...... 28 verapamil hcl tab er 240 mg ...... 46 VAQTA INJ 25/0.5ML ...... 125 VERZENIO TAB 100MG ...... 35 VAQTA INJ 50UNT/ML ...... 125 VERZENIO TAB 150MG ...... 35 VARIVAX INJ...... 125 VERZENIO TAB 200MG ...... 35 VASCEPA CAP 0.5GM ...... 25 VERZENIO TAB 50MG ...... 34 VASCEPA CAP 1GM ...... 43 VESICARE TAB 10MG ...... 95 VCF VAGINAL AER CONTRACP ...... 113 VESICARE TAB 5MG...... 95 VCF VAGINAL MIS CONTRACP ...... 113 VEXOL SUS 1% OP ...... 120 VELPHORO CHW 500MG ...... 85 VIBATIV INJ 250MG ...... 22 VELTASSA POW 16.8GM ...... 104 VIBATIV INJ 750MG ...... 22 VELTASSA POW 25.2GM ...... 104 VIBERZI TAB 100MG...... 91 VELTASSA POW 8.4GM...... 104 VIBERZI TAB 75MG ...... 91 VEMLIDY TAB 25MG...... 36 VICTOZA INJ 18MG/3ML ...... 76 VENCLEXTA TAB 100MG ...... 32 VIDEX SOL 2GM ...... 19 VENCLEXTA TAB 10MG ...... 32 vigabatrin powd pack 500 mg ...... 54 VENCLEXTA TAB 50MG ...... 32 vigabatrin tab 500 mg ...... 23 VENCLEXTA TAB START PK ...... 32 VIIBRYD KIT STARTER ...... 58 venlafaxine hcl cap er 24hr 150 mg VIIBRYD TAB 10MG ...... 58 (base equivalent) ...... 57 VIIBRYD TAB 20MG ...... 58 venlafaxine hcl cap er 24hr 37.5 mg VIIBRYD TAB 40MG ...... 58 (base equivalent) ...... 57 VIMIZIM INJ 5MG/5ML ...... 83 venlafaxine hcl cap er 24hr 75 mg VIMPAT INJ 200MG/20 ...... 55 (base equivalent) ...... 57 VIMPAT SOL 10MG/ML ...... 55 VIMPAT TAB 100MG ...... 55 180

VIMPAT TAB 150MG ...... 55 warfarin sodium tab 3 mg ...... 96 VIMPAT TAB 200MG ...... 55 warfarin sodium tab 4 mg ...... 96 VIMPAT TAB 50MG ...... 55 warfarin sodium tab 5 mg ...... 96 vinblastine sulfate inj 1 mg/ml ...... 32 warfarin sodium tab 6 mg ...... 96 vincristine sulfate iv soln 1 mg/ml .... 32 warfarin sodium tab 7.5 mg ...... 96 vinorelbine tartrate inj 10 mg/ml (base water for irrigation, sterile irrigation equiv) ...... 32 soln ...... 118 vinorelbine tartrate inj 50 mg/5ml (10 WESTHROID TAB 113.75MG ...... 87 mg/ml) (base equiv) ...... 32 WESTHROID TAB 130MG ...... 87 VIRACEPT TAB 250MG ...... 18 WESTHROID TAB 16.25MG ...... 86 VIRACEPT TAB 625MG ...... 18 WESTHROID TAB 32.5MG ...... 86 VIREAD POW 40MG/GM ...... 19 WESTHROID TAB 48.75MG ...... 86 VIREAD TAB 150MG...... 19 WESTHROID TAB 65MG ...... 87 VIREAD TAB 200MG...... 19 WESTHROID TAB 81.25MG ...... 87 VIREAD TAB 250MG...... 19 WESTHROID TAB 97.5MG ...... 87 VITEKTA TAB 150MG ...... 18 WIDE-SEAL DPR KIT 60 ...... 73 VITEKTA TAB 85MG ...... 18 WIDE-SEAL DPR KIT 65 ...... 73 VITRAKVI CAP 100MG ...... 35 WIDE-SEAL DPR KIT 70 ...... 74 VITRAKVI CAP 25MG...... 35 WIDE-SEAL DPR KIT 75 ...... 74 VITRAKVI SOL 20MG/ML ...... 35 WIDE-SEAL DPR KIT 80 ...... 74 VITRASE INJ 200/ML ...... 88 WIDE-SEAL DPR KIT 85 ...... 74 VIVITROL INJ 380MG ...... 70 WIDE-SEAL DPR KIT 90 ...... 74 VIZIMPRO TAB 15MG ...... 35 WIDE-SEAL DPR KIT 95 ...... 74 VIZIMPRO TAB 30MG ...... 35 X VIZIMPRO TAB 45MG ...... 35 XALKORI CAP 200MG ...... 30 VORAXAZE INJ 1000UNIT ...... 32 XALKORI CAP 250MG ...... 30 voriconazole for inj 200 mg ...... 17 XARELTO STAR TAB 15/20MG ...... 96 voriconazole for susp 40 mg/ml ...... 17 XARELTO TAB 10MG ...... 96 voriconazole tab 200 mg ...... 17 XARELTO TAB 15MG ...... 96 voriconazole tab 50 mg ...... 17 XARELTO TAB 2.5MG ...... 96 VOSEVI TAB ...... 20 XARELTO TAB 20MG ...... 96 VOTRIENT TAB 200MG ...... 30 XARTEMIS XR TAB 7.5-325...... 8 VPRIV INJ 400UNIT ...... 83 XELJANZ TAB 10MG ...... 8 VYNDAMAX CAP 61MG ...... 50 XELJANZ TAB 5MG ...... 8 VYNDAQEL CAP 20MG ...... 50 XELJANZ XR TAB 11MG ...... 8 VYVANSE CAP 10MG ...... 66 XENLETA TAB 600MG ...... 9 VYVANSE CAP 20MG ...... 66 XEOMIN INJ 100UNIT ...... 68 VYVANSE CAP 30MG ...... 66 XEOMIN INJ 50 UNIT ...... 68 VYVANSE CAP 40MG ...... 66 XGEVA INJ ...... 79 VYVANSE CAP 50MG ...... 66 XIFAXAN TAB 200MG ...... 22 VYVANSE CAP 60MG ...... 66 XIFAXAN TAB 550MG ...... 22 VYVANSE CAP 70MG ...... 66 XIGDUO XR TAB 10-1000 ...... 24 W XIGDUO XR TAB 10-500MG ...... 24 warfarin sodium tab 1 mg ...... 96 XIGDUO XR TAB 2.5-1000 ...... 24 warfarin sodium tab 10 mg ...... 96 XIGDUO XR TAB 5-1000MG ...... 24 warfarin sodium tab 2 mg ...... 96 XIGDUO XR TAB 5-500MG ...... 24 warfarin sodium tab 2.5 mg ...... 96 XOLAIR INJ 150MG/ML...... 23 181

XOLAIR INJ 75/0.5 ...... 23 zoledronic acid iv soln 5 mg/100ml ... 79 XOLAIR SOL 150MG ...... 112 ZOLEDRONIC INJ 4MG ...... 79 XOSPATA TAB 40MG ...... 35 ZOLINZA CAP 100MG ...... 32 XPOVIO PAK 100MG ...... 33 zolmitriptan orally disintegrating tab XPOVIO PAK 60MG ...... 33 2.5 mg ...... 68 XPOVIO PAK 80MG ...... 33 zolmitriptan orally disintegrating tab 5 XTANDI CAP 40MG ...... 27 mg ...... 68 XULTOPHY INJ 100/3.6 ...... 24 zolmitriptan tab 2.5 mg ...... 68 XYREM SOL 500MG/ML ...... 69 zolmitriptan tab 5 mg ...... 68 Z zolpidem tartrate tab 10 mg ...... 67 zafirlukast tab 10 mg ...... 111 zolpidem tartrate tab 5 mg ...... 67 zafirlukast tab 20 mg ...... 111 ZOMETA INJ 4MG/100 ...... 79 zaleplon cap 10 mg ...... 67 ZOMIG SPR 2.5MG ...... 68 zaleplon cap 5 mg ...... 67 ZOMIG SPR 5MG ...... 68 ZANOSAR INJ 1GM ...... 26 zonisamide cap 100 mg ...... 55 ZARXIO INJ 300/0.5 ...... 97 zonisamide cap 25 mg ...... 55 ZARXIO INJ 480/0.8 ...... 97 zonisamide cap 50 mg ...... 55 ZEJULA CAP 100MG ...... 35 ZONTIVITY TAB 2.08MG ...... 98 ZELBORAF TAB 240MG ...... 30 ZORBTIVE INJ 8.8MG ...... 82 ZEMAIRA INJ 1000MG ...... 112 ZORTRESS TAB 0.25MG ...... 101 ZENPEP CAP 10000UNT ...... 92 ZORTRESS TAB 0.5MG ...... 101 ZENPEP CAP 15000UNT ...... 92 ZORTRESS TAB 0.75MG ...... 101 ZENPEP CAP 20000UNT ...... 92 ZOSTAVAX INJ ...... 125 ZENPEP CAP 25000UNT ...... 92 ZUBSOLV SUB 0.7-0.18 ...... 70 ZENPEP CAP 3000UNIT ...... 92 ZUBSOLV SUB 1.4-0.36 ...... 70 ZENPEP CAP 40000UNT ...... 92 ZUBSOLV SUB 11.4-2.9 ...... 70 zidovudine cap 100 mg ...... 19 ZUBSOLV SUB 2.9-0.71 ...... 70 zidovudine syrup 10 mg/ml ...... 19 ZUBSOLV SUB 5.7-1.4 ...... 70 zidovudine tab 300 mg...... 19 ZUBSOLV SUB 8.6-2.1 ...... 70 zileuton tab er 12hr 600 mg ...... 23 ZYDELIG TAB 100MG ...... 30 ZINACEF/H20 INJ 1.5GM PB ...... 11 ZYDELIG TAB 150MG ...... 30 ZIOPTAN DRO 0.0015% ...... 122 ZYFLO TAB 600MG ...... 111 ziprasidone hcl cap 20 mg ...... 62 ZYKADIA CAP 150MG ...... 30 ziprasidone hcl cap 40 mg ...... 62 ZYPREXA RELP INJ 210MG ...... 62 ziprasidone hcl cap 60 mg ...... 62 ZYPREXA RELP INJ 300MG ...... 62 ziprasidone hcl cap 80 mg ...... 62 ZYPREXA RELP INJ 405MG ...... 62 ZOLADEX IMP 10.8MG ...... 28 ZYTIGA TAB 500MG ...... 27 ZOLADEX IMP 3.6MG ...... 28 ZYVOX SOL 2MG/ML ...... 22 zoledronic acid inj conc for iv infusion 4 mg/5ml ...... 79

182