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EXCHANGE_VA_9 Drug Name Drug Tier Requirements/Limits ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS - cap sr 1 QL (90 caps / 25 days) 24hr 5 mg amphetamine-dextroamphetamine cap sr 1 QL (90 caps / 25 days) 24hr 10 mg amphetamine-dextroamphetamine cap sr 1 QL (30 caps / 25 days) 24hr 15 mg amphetamine-dextroamphetamine cap sr 1 QL (30 caps / 25 days) 24hr 20 mg amphetamine-dextroamphetamine cap sr 1 QL (30 caps / 25 days) 24hr 25 mg amphetamine-dextroamphetamine cap sr 1 QL (30 caps / 25 days) 24hr 30 mg amphetamine-dextroamphetamine tab 5 1 QL (90 tabs / 25 days) mg amphetamine-dextroamphetamine tab 7.5 1 QL (90 tabs / 25 days) mg amphetamine-dextroamphetamine tab 10 1 QL (90 tabs / 25 days) mg amphetamine-dextroamphetamine tab 1 QL (90 tabs / 25 days) 12.5 mg amphetamine-dextroamphetamine tab 15 1 QL (60 tabs / 25 days) mg amphetamine-dextroamphetamine tab 20 1 QL (60 tabs / 25 days) mg amphetamine-dextroamphetamine tab 30 1 QL (30 tabs / 25 days) mg dextroamphetamine sulfate cap sr 24hr 5 1 QL (120 caps / 25 days) mg dextroamphetamine sulfate cap sr 24hr 10 1 QL (120 caps / 25 days) mg dextroamphetamine sulfate cap sr 24hr 15 1 QL (60 tabs / 25 days) mg dextroamphetamine sulfate tab 5 mg 1 QL (120 tabs / 25 days) dextroamphetamine sulfate tab 10 mg 1 QL (120 tabs / 25 days) hcl tab 5 mg 1 QL (150 tabs / 25 days) VYVANSE CAP 20MG 3 PA VYVANSE CAP 30MG 3 PA VYVANSE CAP 40MG 3 PA VYVANSE CAP 50MG 3 PA VYVANSE CAP 60MG 3 PA VYVANSE CAP 70MG 3 PA Attention-Deficit/Hyperactivity Disorder (ADHD) Agents INTUNIV TAB 1MG 3 ST INTUNIV TAB 2MG 3 ST INTUNIV TAB 3MG 3 ST

1 Drug Name Drug Tier Requirements/Limits INTUNIV TAB 4MG 3 ST STRATTERA CAP 10MG 2 QL (120 caps / 25 days) STRATTERA CAP 18MG 2 QL (120 caps / 25 days) STRATTERA CAP 25MG 2 QL (120 caps / 25 days) STRATTERA CAP 40MG 2 QL (60 caps / 25 days) STRATTERA CAP 60MG 2 QL (30 caps / 25 days) STRATTERA CAP 80MG 2 QL (30 caps / 25 days) STRATTERA CAP 100MG 2 QL (30 caps / 25 days) Stimulants - Misc. DAYTRANA DIS 10MG/9HR 3 QL (30 patches per 25 days) DAYTRANA DIS 15MG/9HR 3 QL (30 patches per 25 days) DAYTRANA DIS 20MG/9HR 3 QL (30 patches per 25 days) DAYTRANA DIS 30MG/9HR 3 QL (30 patches per 25 days) dexmethylphenidate hcl tab 2.5 mg 1 QL (120 tabs / 25 days) dexmethylphenidate hcl tab 5 mg 1 QL (120 tabs / 25 days) dexmethylphenidate hcl tab 10 mg 1 QL (60 tabs / 25 days) FOCALIN XR CAP 5MG 3 QL (60 caps per 25 days) FOCALIN XR CAP 10MG 3 QL (60 caps per 25 days) FOCALIN XR CAP 15MG 3 QL (60 caps per 25 days) FOCALIN XR CAP 20MG 3 QL (60 caps per 25 days) FOCALIN XR CAP 25MG 3 QL (30 caps per 25 days) FOCALIN XR CAP 30MG 3 QL (30 caps per 25 days) FOCALIN XR CAP 35MG 3 QL (30 caps per 25 days) FOCALIN XR CAP 40MG 3 QL (30 caps per 25 days) metadate tab 20mg er 1 QL (90 tabs / 25 days) METHYLIN CHW 2.5MG 3 QL (180 tabs per 25 days) METHYLIN CHW 5MG 3 QL (180 tabs per 25 days) METHYLIN CHW 10MG 3 QL (180 tabs per 25 days) methylin tab 5mg 1 QL (180 tabs / 25 days)

2 Drug Name Drug Tier Requirements/Limits methylin tab 10mg 1 QL (180 tabs / 25 days) methylin tab 10mg er 1 QL (90 tabs / 25 days) methylin tab 20mg 1 QL (90 tabs / 25 days) methylin tab 20mg er 1 QL (90 tabs / 25 days) methylphenidate hcl cap sr 24hr 20 mg 1 QL (60 caps / 25 days) methylphenidate hcl cap sr 24hr 30 mg 1 QL (60 caps / 25 days) methylphenidate hcl cap sr 24hr 40 mg 1 QL (30 caps / 25 days) methylphenidate hcl soln 5 mg/5ml 1 QL (1800 ml / 25 days) methylphenidate hcl soln 10 mg/5ml 1 QL (900 ml / 25 days) methylphenidate hcl tab 5 mg 1 QL (180 tabs / 25 days) methylphenidate hcl tab 10 mg 1 QL (180 tabs / 25 days) methylphenidate hcl tab 20 mg 1 QL (90 tabs / 25 days) methylphenidate hcl tab cr 10 mg 1 QL (90 tabs / 25 days) methylphenidate hcl tab cr 20 mg 1 QL (90 tabs / 25 days) methylphenidate hcl tab sa osm 18 mg 1 QL (60 tabs / 25 days) methylphenidate hcl tab sa osm 27 mg 1 QL (60 tabs / 25 days) methylphenidate hcl tab sa osm 36 mg 1 QL (60 tabs / 25 days) methylphenidate hcl tab sa osm 54 mg 1 QL (30 tabs / 25 days) modafinil tab 100 mg 1 PA modafinil tab 200 mg 1 PA NUVIGIL TAB 50MG 2 PA NUVIGIL TAB 150MG 2 PA NUVIGIL TAB 250MG 2 PA RITALIN LA CAP 10MG 2 QL (60 caps / 25 days) AMINOGLYCOSIDES Aminoglycosides amikacin sulfate inj 100 mg/2ml (50 1 mg/ml) amikacin sulfate inj 500 mg/2ml (250 1 mg/ml) GENTAM/NACL INJ 0.9MG/ML 3 GENTAM/NACL INJ 1.4MG/ML 3 gentamicin in saline inj 0.8 mg/ml 1 gentamicin in saline inj 1 mg/ml 1 gentamicin in saline inj 1.2 mg/ml 1 gentamicin in saline inj 1.6 mg/ml 1 gentamicin in saline inj 2 mg/ml 1 gentamicin sulfate inj 10 mg/ml 1 gentamicin sulfate inj 40 mg/ml 1 kanamycin sulfate inj 333 mg/ml 1 NEO-FRADIN SOL 125/5ML 3 neomycin sulfate tab 500 mg 1 paromomycin sulfate cap 250 mg 1 streptomycin sulfate for inj 1 gm 1 TOBI NEB 300/5ML 4 PA

3 Drug Name Drug Tier Requirements/Limits TOBRA/NACL INJ 60/0.9 3 TOBRA/NACL INJ 80/0.9 3 tobramycin sulfate inj 10 mg/ml 1 tobramycin sulfate inj 80 mg/2ml (40 1 mg/ml) ANALGESICS - ANTI-INFLAMMATORY Anti-TNF-alpha - Monoclonoal Antibodies HUMIRA KIT 20MG/0.4 4 PA HUMIRA KIT 40MG/0.8 4 PA HUMIRA PEN KIT CROHNS 4 PA SIMPONI INJ 50MG 4 PA Antirheumatic Antimetabolites RHEUMATREX TAB 2.5MG 3 Interleukin-1 Blockers ARCALYST INJ 220MG 4 PA Interleukin-1 (IL-1Ra) KINERET INJ 4 PA Interleukin-6 Receptor Inhibitors ACTEMRA INJ 80MG/4ML 4 PA ACTEMRA INJ 200/10ML 4 PA ACTEMRA INJ 400/20ML 4 PA Nonsteroidal Anti-inflammatory Agents (NSAIDs) CELEBREX CAP 50MG 3 ST CELEBREX CAP 100MG 3 ST CELEBREX CAP 200MG 3 ST CELEBREX CAP 400MG 3 ST diclofenac potassium tab 50 mg 1 diclofenac sodium tab delayed release 25 1 mg diclofenac sodium tab delayed release 50 1 mg diclofenac sodium tab delayed release 75 1 mg diclofenac sodium tab sr 24hr 100 mg 1 diclofenac w/ misoprostol tab delayed 1 release 50-0.2 mg diclofenac w/ misoprostol tab delayed 1 release 75-0.2 mg etodolac cap 200 mg 1 etodolac cap 300 mg 1 etodolac tab 400 mg 1 etodolac tab 500 mg 1 etodolac tab sr 24hr 400 mg 1 etodolac tab sr 24hr 500 mg 1 etodolac tab sr 24hr 600 mg 1 fenoprofen calcium tab 600 mg 1

4 Drug Name Drug Tier Requirements/Limits flurbiprofen tab 50 mg 1 flurbiprofen tab 100 mg 1 ibuprofen sus 100/5ml 1 ibuprofen tab 400 mg 1 ibuprofen tab 600 mg 1 ibuprofen tab 800 mg 1 INDOCIN SUS 25MG/5ML 3 indomethacin cap 25 mg 1 indomethacin cap 50 mg 1 indomethacin cap cr 75 mg 1 ketoprofen cap 50 mg 1 ketoprofen cap 75 mg 1 ketoprofen cap sr 24hr 200 mg 1 ketorolac tromethamine im inj 30 mg/ml 1 ketorolac tromethamine im inj 60 mg/2ml 1 (30 mg/ml) ketorolac tromethamine inj 15 mg/ml 1 ketorolac tromethamine inj 30 mg/ml 1 ketorolac tromethamine inj 60 mg/2ml (30 1 mg/ml) ketorolac tromethamine inj 300 mg/10ml 1 (30 mg/ml) ketorolac tromethamine tab 10 mg 1 QL (20 tabs per 25 days) meclofenamate sodium cap 50 mg 1 meclofenamate sodium cap 100 mg 1 mefenamic acid cap 250 mg 1 meloxicam susp 7.5 mg/5ml 1 meloxicam tab 7.5 mg 1 meloxicam tab 15 mg 1 nabumetone tab 500 mg 1 nabumetone tab 750 mg 1 NALFON CAP 200MG 2 ST NALFON CAP 400MG 2 ST naproxen dr tab 375mg 1 naproxen dr tab 500mg 1 naproxen sodium tab 275 mg 1 naproxen sodium tab 550 mg 1 naproxen susp 125 mg/5ml 1 naproxen tab 250 mg 1 naproxen tab 375 mg 1 naproxen tab 500 mg 1 oxaprozin tab 600 mg 1 piroxicam cap 10 mg 1 piroxicam cap 20 mg 1 SPRIX SPR 15.75MG 3 QL (5 bottles / 25 days)

5 Drug Name Drug Tier Requirements/Limits sulindac tab 150 mg 1 sulindac tab 200 mg 1 tolmetin sodium cap 400 mg 1 tolmetin sodium tab 200 mg 1 tolmetin sodium tab 600 mg 1 ZIPSOR CAP 25MG 3 Pyrimidine Synthesis Inhibitors leflunomide tab 10 mg 1 leflunomide tab 20 mg 1 Selective Costimulation Modulators ORENCIA INJ 250MG 4 PA Soluble Tumor Necrosis Factor Receptor Agents ENBREL INJ 25/0.5ML 4 PA ENBREL INJ 25MG 4 PA ENBREL INJ 50MG/ML 4 PA ANALGESICS - NonNarcotic Salicylates ADULT ASA TAB 81MG QM 0 aspirin chew tab 81 mg 0 aspirin low tab 81mg ec 0 aspirin tab 81 mg 0 aspirin tab 325 mg 0 aspirin tab delayed release 325 mg 0 bayer low chw 81mg 0 diflunisal tab 500 mg 1 ECOTRIN TAB 325MG EC 0 HALFPRIN TAB 162MG EC 0 ST JOSEPH CHW 75MG ADU 0 ANALGESICS - Opioid ABSTRAL SUB 100MCG 3 PA ABSTRAL SUB 200MCG 3 PA ABSTRAL SUB 300MCG 3 PA ABSTRAL SUB 400MCG 3 PA ABSTRAL SUB 600MCG 3 PA ABSTRAL SUB 800MCG 3 PA astramorph inj 1mg/2ml 1 astramorph inj 2mg/2ml 1 AVINZA CAP 30MG 3 QL (60 ea / 25 days) AVINZA CAP 45MG 3 QL (60 ea / 25 days) AVINZA CAP 60MG 3 QL (60 ea / 25 days) AVINZA CAP 75MG 3 QL (60 ea / 25 days) AVINZA CAP 90MG 3 QL (60 ea / 25 days) AVINZA CAP 120MG 3 QL (60 ea / 25 days)

6 Drug Name Drug Tier Requirements/Limits SULF SOL 30MG/5ML 2 codeine sulfate tab 15 mg 1 QL (45 tabs / 25 days) codeine sulfate tab 30 mg 1 QL (45 tabs / 25 days) codeine sulfate tab 60 mg 1 QL (45 tabs / 25 days) CONZIP CAP 100MG 3 QL (30 caps per 25 days) CONZIP CAP 200MG 3 QL (30 caps per 25 days) CONZIP CAP 300MG 3 QL (30 caps per 25 days) DILAUDID-HP INJ 250MG 3 EMBEDA CAP 30-1.2MG 3 QL (60 caps per 25 days) EXALGO TAB 8MG 3 QL (60 tabs / 25 days) EXALGO TAB 12MG 3 QL (60 tabs / 25 days) EXALGO TAB 16MG 3 QL (60 tabs / 25 days) EXALGO TAB 32MG 3 QL (60 tabs / 25 days) citrate lollipop 200 mcg 1 PA fentanyl citrate lollipop 400 mcg 1 PA fentanyl citrate lollipop 600 mcg 1 PA fentanyl citrate lollipop 800 mcg 1 PA fentanyl citrate lollipop 1200 mcg 1 PA fentanyl citrate lollipop 1600 mcg 1 PA fentanyl td patch 72hr 12 mcg/hr 1 QL (10 patches / 25 days) fentanyl td patch 72hr 25 mcg/hr 1 QL (10 patches / 25 days) fentanyl td patch 72hr 50 mcg/hr 1 QL (10 patches / 25 days) fentanyl td patch 72hr 75 mcg/hr 1 QL (10 patches / 25 days) fentanyl td patch 72hr 100 mcg/hr 1 QL (10 patches / 25 days) FENTORA TAB 100MCG 3 PA FENTORA TAB 200MCG 3 PA FENTORA TAB 400MCG 3 PA FENTORA TAB 600MCG 3 PA FENTORA TAB 800MCG 3 PA HYDROMORPHON SUP 3MG 3 hcl inj 1 mg/ml 1 hydromorphone hcl inj 2 mg/ml 1 hydromorphone hcl inj 10 mg/ml 1 hydromorphone hcl liqd 1 mg/ml 1 QL (180 ml / 25 days) hydromorphone hcl preservative free (pf) 1 inj 1 mg/ml

7 Drug Name Drug Tier Requirements/Limits hydromorphone hcl preservative free (pf) 1 inj 2 mg/ml hydromorphone hcl preservative free (pf) 1 inj 4 mg/ml hydromorphone hcl preservative free (pf) 1 inj 10 mg/ml hydromorphone hcl tab 2 mg 1 QL (180 tabs / 25 days) hydromorphone hcl tab 4 mg 1 QL (180 tabs / 25 days) hydromorphone hcl tab 8 mg 1 QL (180 tabs / 25 days) KADIAN CAP 10MG CR 3 QL (60 caps per 25 days) KADIAN CAP 200MG CR 3 QL (60 caps per 25 days) LAZANDA SPR 100MCG 3 PA LAZANDA SPR 400MCG 3 PA tartrate tab 2 mg 1 QL (180 tabs / 25 days) meperidine hcl oral soln 50 mg/5ml 1 QL (30 ml / 25 days) meperidine hcl tab 50 mg 1 QL (15 tabs / 25 days) meperidine hcl tab 100 mg 1 QL (15 tabs / 25 days) hcl conc 10 mg/ml 1 methadone hcl soln 5 mg/5ml 1 methadone hcl soln 10 mg/5ml 1 methadone hcl tab 5 mg 1 QL (120 tabs / 25 days) methadone hcl tab 10 mg 1 QL (120 tabs / 25 days) methadone hcl tab for oral susp 40 mg 1 QL (30 tabs / 25 days) METHADONE INJ 10MG/ML 3 methadose con 10mg/ml 1 methadose tab 5mg 1 QL (120 tabs / 25 days) methadose tab 10mg 1 QL (120 tabs / 25 days) methadose tab 40mg 1 QL (30 tabs / 25 days) SUL INJ 4MG/ML 3 MORPHINE SUL INJ 5MG/ML 3 MORPHINE SUL SUP 30MG 2 QL (180 / 25 days) morphine sulfate (concentrate) oral soln 201 QL (180 ml / 25 days) mg/ml morphine sulfate cap sr 24hr 20 mg 1 QL (90 caps per 25 days) morphine sulfate cap sr 24hr 30 mg 1 QL (90 caps per 25 days) morphine sulfate cap sr 24hr 50 mg 1 QL (90 caps per 25 days) morphine sulfate cap sr 24hr 60 mg 1 QL (90 caps per 25 days) morphine sulfate cap sr 24hr 80 mg 1 QL (90 caps per 25 days)

8 Drug Name Drug Tier Requirements/Limits morphine sulfate cap sr 24hr 100 mg 1 QL (90 caps per 25 days) morphine sulfate inj 2 mg/ml 1 morphine sulfate inj 8 mg/ml 1 morphine sulfate inj 10 mg/ml 1 morphine sulfate inj 15 mg/ml 1 morphine sulfate inj pf 0.5 mg/ml 1 morphine sulfate inj pf 1 mg/ml 1 morphine sulfate oral soln 10 mg/5ml 1 QL (900 ml / 25 days) morphine sulfate oral soln 20 mg/5ml 1 QL (900 ml / 25 days) morphine sulfate suppos 5 mg 1 QL (180 / 25 days) morphine sulfate suppos 10 mg 1 QL (180 / 25 days) morphine sulfate suppos 20 mg 1 QL (180 / 25 days) morphine sulfate tab 15 mg 1 QL (180 tabs / 25 days) morphine sulfate tab 30 mg 1 QL (180 tabs / 25 days) morphine sulfate tab cr 15 mg 1 QL (90 tabs / 25 days) morphine sulfate tab cr 30 mg 1 QL (90 tabs / 25 days) morphine sulfate tab cr 100 mg 1 QL (90 tabs / 25 days) morphine sulfate tab cr 200 mg 1 QL (60 tabs / 25 days) morphine sulfate tab sr 12hr 60 mg 1 QL (90 tabs / 25 days) NUCYNTA ER TAB 50MG 3 QL (120 tabs / 25 days) NUCYNTA ER TAB 100MG 3 QL (120 tabs / 25 days) NUCYNTA ER TAB 150MG 3 QL (60 tabs / 25 days) NUCYNTA ER TAB 200MG 3 QL (60 tabs / 25 days) NUCYNTA ER TAB 250MG 3 QL (60 tabs / 25 days) NUCYNTA TAB 50MG 3 QL (360 tabs / 25 days) NUCYNTA TAB 75MG 3 QL (240 tabs / 25 days) NUCYNTA TAB 100MG 3 QL (180 tabs / 25 days) ONSOLIS MIS 200MCG 3 PA ONSOLIS MIS 400MCG 3 PA ONSOLIS MIS 600MCG 3 PA ONSOLIS MIS 800MCG 3 PA ONSOLIS MIS 1200MCG 3 PA OPANA ER TAB 5MG 3 QL (120 ea / 25 days) OPANA ER TAB 7.5MG 3 QL (120 ea / 25 days) OPANA ER TAB 10MG 3 QL (120 ea / 25 days) OPANA ER TAB 15MG 3 QL (120 ea / 25 days) OPANA ER TAB 20MG 3 QL (120 ea / 25 days) OPANA ER TAB 30MG 3 QL (120 ea / 25 days) OPANA ER TAB 40MG 3 QL (120 ea / 25 days) OXECTA TAB 5MG 3 QL (180 tabs per 25 days) OXECTA TAB 7.5MG 3 QL (180 tabs per 25 days) hcl cap 5 mg 1 QL (180 caps / 25 days)

9 Drug Name Drug Tier Requirements/Limits oxycodone hcl conc 20 mg/ml 1 QL (180 ml / 25 days) oxycodone hcl soln 5 mg/5ml 1 QL (180 ml / 25 days) oxycodone hcl tab 5 mg 1 QL (180 tabs / 25 days) oxycodone hcl tab 10 mg 1 QL (180 tabs / 25 days) oxycodone hcl tab 15 mg 1 QL (180 tabs / 25 days) oxycodone hcl tab 20 mg 1 QL (180 tabs / 25 days) oxycodone hcl tab 30 mg 1 QL (180 tabs / 25 days) OXYCONTIN TAB 10MG CR 2 QL (120 ea / 25 days) OXYCONTIN TAB 15MG CR 2 QL (120 ea / 25 days) OXYCONTIN TAB 20MG CR 2 QL (120 ea / 25 days) OXYCONTIN TAB 30MG CR 2 QL (120 ea / 25 days) OXYCONTIN TAB 40MG CR 2 QL (120 ea / 25 days) OXYCONTIN TAB 60MG CR 2 QL (120 ea / 25 days) OXYCONTIN TAB 80MG CR 2 QL (120 ea / 25 days) hcl tab 5 mg 1 QL (180 tabs / 25 days) oxymorphone hcl tab 10 mg 1 QL (180 tabs / 25 days) oxymorphone hcl tab sr 12hr 5 mg 1 QL (120 tabs / 25 days) oxymorphone hcl tab sr 12hr 7.5 mg 1 QL (120 tabs / 25 days) oxymorphone hcl tab sr 12hr 10 mg 1 QL (120 tabs / 25 days) oxymorphone hcl tab sr 12hr 15 mg 1 QL (120 tabs / 25 days) oxymorphone hcl tab sr 12hr 20 mg 1 QL (120 tabs / 25 days) oxymorphone hcl tab sr 12hr 30 mg 1 QL (120 tabs / 25 days) oxymorphone hcl tab sr 12hr 40 mg 1 QL (120 tabs / 25 days) SUBSYS SPR 100MCG 3 PA SUBSYS SPR 200MCG 3 PA SUBSYS SPR 400MCG 3 PA SUBSYS SPR 600MCG 3 PA SUBSYS SPR 800MCG 3 PA hcl tab 50 mg 1 QL (240 tabs / 25 days) tramadol hcl tab sr 24hr 100 mg 1 QL (30 tabs / 25 days) tramadol hcl tab sr 24hr 200 mg 1 QL (30 tabs / 25 days) tramadol hcl tab sr 24hr 300 mg 1 QL (30 tabs / 25 days) Opioid Combinations acetaminophen w/ codeine soln 120-12 1 QL (3750 ml / 25 days) mg/5ml acetaminophen w/ codeine tab 300-15 mg 1 QL (300 tabs / 25 days) acetaminophen w/ codeine tab 300-30 mg 1 QL (300 tabs / 25 days) acetaminophen w/ codeine tab 300-60 mg 1 QL (300 tabs / 25 days) CAPITAL/COD SUS 120-12/5 2 QL (3750 ml / 25 days) co-gesic tab 5-500mg 1 QL (180 tabs / 25 days) COCET PLUS TAB 650-60MG 2 QL (120 tabs / 25 days) COCET TAB 650-30MG 2 QL (120 tabs / 25 days) endocet tab 5-325mg 1 QL (300 tabs / 25 days) endocet tab 7.5-325 1 QL (300 tabs / 25 days) endocet tab 7.5-500m 1 QL (180 tabs / 25 days) endocet tab 10-325mg 1 QL (300 tabs / 25 days)

10 Drug Name Drug Tier Requirements/Limits endocet tab 10-650mg 1 QL (120 tabs / 25 days) HYDROCO/APAP SOL 10-325MG 2 QL (3750 ml / 25 days) -acetaminophen soln 7.5-325 1 QL (3750 ml / 25 days) mg/15ml hydrocodone-acetaminophen soln 7.5-500 1 QL (2250 ml / 25 days) mg/15ml hydrocodone-acetaminophen tab 2.5-500 1 QL (180 tabs / 25 days) mg hydrocodone-acetaminophen tab 5-300 mg1 QL (300 tabs / 25 days) hydrocodone-acetaminophen tab 5-325 mg1 QL (300 tabs / 25 days) hydrocodone-acetaminophen tab 5-500 mg1 QL (180 tabs / 25 days) hydrocodone-acetaminophen tab 7.5-300 1 QL (300 tabs / 25 days) mg hydrocodone-acetaminophen tab 7.5-325 1 QL (300 tabs / 25 days) mg hydrocodone-acetaminophen tab 7.5-500 1 QL (180 tabs / 25 days) mg hydrocodone-acetaminophen tab 7.5-650 1 QL (120 tabs / 25 days) mg hydrocodone-acetaminophen tab 7.5-750 1 QL (120 tabs / 25 days) mg hydrocodone-acetaminophen tab 10-300 1 QL (300 tabs / 25 days) mg hydrocodone-acetaminophen tab 10-325 1 QL (300 tabs / 25 days) mg hydrocodone-acetaminophen tab 10-500 1 QL (180 tabs / 25 days) mg hydrocodone-acetaminophen tab 10-650 1 QL (120 tabs / 25 days) mg hydrocodone-acetaminophen tab 10-660 1 QL (120 tabs / 25 days) mg hydrocodone-acetaminophen tab 10-750 1 QL (120 tabs / 25 days) mg hydrogesic cap 5-500mg 1 QL (180 caps / 25 days) MAGNACET TAB 7.5-400 2 QL (240 tabs / 25 days) margesic-h cap 5-500mg 1 QL (180 caps / 25 days) oxycodone w/ acetaminophen cap 5-500 1 QL (180 caps / 25 days) mg oxycodone w/ acetaminophen tab 2.5-325 1 QL (300 tabs / 25 days) mg oxycodone w/ acetaminophen tab 5-325 1 QL (300 tabs / 25 days) mg oxycodone w/ acetaminophen tab 7.5-325 1 QL (300 tabs / 25 days) mg oxycodone w/ acetaminophen tab 7.5-500 1 QL (180 tabs / 25 days) mg oxycodone w/ acetaminophen tab 10-325 1 QL (300 tabs / 25 days) mg oxycodone w/ acetaminophen tab 10-650 1 QL (120 tabs / 25 days) mg oxycodone-ibuprofen tab 5-400 mg 1 QL (28 tabs / 25 days)

11 Drug Name Drug Tier Requirements/Limits polygesic cap 5-500mg 1 QL (180 caps / 25 days) PRIMLEV TAB 5-300MG 2 QL (300 tabs / 25 days) PRIMLEV TAB 7.5-300 2 QL (300 tabs / 25 days) PRIMLEV TAB 10-300MG 2 QL (300 tabs / 25 days) ROXICET SOL 5-325/5 2 QL (1385 ml / 25 days) roxicet tab 5-325mg 1 QL (300 tabs / 25 days) ROXICET TAB 5-500MG 2 QL (180 tabs / 25 days) stagesic cap 5-500mg 1 QL (180 caps / 25 days) vicodin es tab 7.5-300 1 QL (300 tabs / 25 days) vicodin hp tab 10-300mg 1 QL (300 tabs / 25 days) vicodin hp tab 10-660mg 1 QL (120 tabs / 25 days) vicodin tab 5-300mg 1 QL (300 tabs / 25 days) XOLOX TAB 10-500MG 2 QL (180 tabs / 25 days) ZAMICET SOL 10-325MG 2 QL (3750 ml / 25 days) Opioid Partial Agonists hcl inj 0.3 mg/ml (base 1 equiv) buprenorphine hcl sl tab 2 mg (base equiv) 1 PA buprenorphine hcl sl tab 8 mg (base equiv) 1 PA tartrate inj 1 mg/ml 1 butorphanol tartrate inj 2 mg/ml 1 butorphanol tartrate nasal soln 10 mg/ml 1 QL (2 bottles / 25 days) BUTRANS DIS 5MCG/HR 3 PA BUTRANS DIS 10MCG/HR 3 PA BUTRANS DIS 20MCG/HR 3 PA hcl inj 10 mg/ml 1 nalbuphine hcl inj 20 mg/ml 1 SUBOXONE MIS 2-0.5MG 2 PA SUBOXONE MIS 4-1MG 2 PA SUBOXONE MIS 8-2MG 2 PA SUBOXONE MIS 12-3MG 2 PA TALWIN INJ 30MG/ML 3 QL (180 / 25 days) ANDROGENS-ANABOLIC Anabolic Steroids ANADROL-50 TAB 50MG 3 PA tab 2.5 mg 1 PA oxandrolone tab 10 mg 1 PA Androgens ANDRODERM DIS 2.5MG/24 2 PA ANDRODERM DIS 2MG/24HR 2 PA ANDRODERM DIS 4MG/24HR 2 PA ANDRODERM DIS 5MG/24HR 2 PA ANDROGEL GEL 1%(25MG) 3 PA ANDROGEL GEL 1.62% 3 PA android cap 10mg 1 PA

12 Drug Name Drug Tier Requirements/Limits ANDROXY TAB 10MG 3 PA AXIRON SOL 30MG/ACT 2 PA danazol cap 50 mg 1 PA danazol cap 100 mg 1 PA danazol cap 200 mg 1 PA FORTESTA GEL 10MG/ACT 2 PA METHITEST TAB 10MG 3 PA STRIANT MIS 30MG 3 PA TESTIM GEL 1%(50MG) 3 PA cypionate im in oil 100 mg/ml 1 PA testosterone cypionate im in oil 200 mg/ml 1 PA testosterone enanthate im in oil 200 mg/ml1 PA ANORECTAL AGENTS Intrarectal Steroids colocort ene 100mg 1 hydrocortisone enema 100 mg/60ml 1 Rectal Steroids anucort-hc sup 25mg 1 hemril-30 sup 30mg 1 hydrocortisone acetate suppos 25 mg 1 hydrocortisone acetate suppos 30 mg 1 procto-pak cre 1% 1 proctocream cre -hc 2.5% 1 proctosol hc cre 2.5% 1 proctozone cre -hc 2.5% 1 Vasodilating Agents RECTIV OIN 0.4% 3 ANTHELMINTICS Anthelmintics ALBENZA TAB 200MG 2 BILTRICIDE TAB 600MG 3 mebendazole chew tab 100 mg 1 STROMECTOL TAB 3MG 3 ANTI-INFECTIVE AGENTS - MISC. Anti-infective Agents - Misc. AZACTAM/DEX INJ 1GM 3 AZACTAM/DEX INJ 2GM 3 aztreonam for inj 1 gm 1 aztreonam for inj 2 gm 1 CAYSTON INH 75MG 4 PA FLAGYL ER TAB 750MG 3 metronidazole cap 375 mg 1 metronidazole in nacl 0.79% iv soln 500 1 mg/100ml

13 Drug Name Drug Tier Requirements/Limits metronidazole tab 250 mg 1 metronidazole tab 500 mg 1 NEBUPENT INH 300MG 3 PENTAM 300 INJ 300MG 3 PRIMSOL SOL 50MG/5ML 2 tinidazole tab 250 mg 1 tinidazole tab 500 mg 1 trimethoprim tab 100 mg 1 vancomycin hcl cap 125 mg 1 ST vancomycin hcl cap 250 mg 1 ST vancomycin hcl for inj 10 gm 1 vancomycin hcl for inj 500 mg 1 vancomycin hcl for inj 1000 mg 1 VIBATIV INJ 250MG 3 XIFAXAN TAB 200MG 2 XIFAXAN TAB 550MG 2 PA Anti-infective Misc. - Combinations e.s.p. sus 200-600 1 erythromycin-sulfisoxazole for susp 200- 1 600 mg/5ml sulfamethoxazole-trimethoprim iv soln 1 400-80 mg/5ml sulfamethoxazole-trimethoprim susp 200- 1 40 mg/5ml sulfamethoxazole-trimethoprim tab 400-80 1 mg sulfamethoxazole-trimethoprim tab 800- 1 160 mg Antiprotozoal Agents ALINIA SUS 100MG/5M 2 ALINIA TAB 500MG 2 MEPRON SUS 3 Carbapenems DORIBAX INJ 250MG 3 DORIBAX INJ 500MG 3 imipenem-cilastatin intravenous for soln 1 250 mg imipenem-cilastatin intravenous for soln 1 500 mg INVANZ INJ 1GM 3 meropenem iv for soln 500 mg 1 Chloramphenicols chloramphenicol sodium succinate for iv inj 1 1 gm Cyclic Lipopeptides CUBICIN SOL 500MG 3 Glycylcyclines

14 Drug Name Drug Tier Requirements/Limits TYGACIL INJ 50MG 3 Ketolides KETEK TAB 300MG 3 KETEK TAB 400MG 3 Leprostatics dapsone tab 25 mg 1 dapsone tab 100 mg 1 Lincosamides clindamycin hcl cap 75 mg 1 clindamycin hcl cap 150 mg 1 clindamycin hcl cap 300 mg 1 clindamycin palmitate hcl for soln 75 1 mg/5ml (base equiv) clindamycin phosphate inj 300 mg/2ml 1 LINCOCIN INJ 300MG/ML 3 Oxazolidinones ZYVOX SOL 2MG/ML 3 ZYVOX SUS 100MG/5M 2 ZYVOX TAB 600MG 2 Polymyxins polymyxin b sulfate for inj 500000 unit 1 AGENTS -Other RANEXA TAB 500MG 2 ST RANEXA TAB 1000MG 2 ST Nitrates DILATRATE SR CAP 40MG 3 isochron tab 40mg cr 1 isoditrate tab 40mg er 1 ISORDIL TAB 40MG 2 isosorbide dinitrate sl tab 2.5 mg 1 isosorbide dinitrate sl tab 5 mg 1 isosorbide dinitrate tab 5 mg 1 isosorbide dinitrate tab 10 mg 1 isosorbide dinitrate tab 20 mg 1 isosorbide dinitrate tab 30 mg 1 isosorbide dinitrate tab cr 40 mg 1 isosorbide mononitrate tab 10 mg 1 isosorbide mononitrate tab 20 mg 1 isosorbide mononitrate tab sr 24hr 30 mg 1 isosorbide mononitrate tab sr 24hr 60 mg 1 isosorbide mononitrate tab sr 24hr 120 mg 1 minitran dis 0.1mg/hr 1 minitran dis 0.2mg/hr 1 minitran dis 0.4mg/hr 1

15 Drug Name Drug Tier Requirements/Limits minitran dis 0.6mg/hr 1 NITRO-BID OIN 2% 3 NITRO-DUR DIS 0.3MG/HR 2 NITRO-DUR DIS 0.8MG/HR 2 NITROGLYCER INJ 5MG/ML 3 nitroglycerin iv soln 100 mcg/ml in d5w 1 nitroglycerin iv soln 200 mcg/ml in d5w 1 nitroglycerin iv soln 400 mcg/ml in d5w 1 nitroglycerin td patch 24hr 0.1 mg/hr 1 nitroglycerin td patch 24hr 0.2 mg/hr 1 nitroglycerin td patch 24hr 0.4 mg/hr 1 nitroglycerin td patch 24hr 0.6 mg/hr 1 nitroglycerin tl soln 0.4 mg/spray (400 1 mcg/spray) NITROMIST AER 400MCG 3 NITROSTAT SUB 0.3MG 2 NITROSTAT SUB 0.4MG 2 NITROSTAT SUB 0.6MG 2 ANTIANXIETY AGENTS Antianxiety Agents - Misc. hcl tab 5 mg 1 buspirone hcl tab 7.5 mg 1 buspirone hcl tab 10 mg 1 buspirone hcl tab 15 mg 1 buspirone hcl tab 30 mg 1 hcl im soln 25 mg/ml 1 PA; High Risk Medications require PA for members age 65 and older hydroxyzine hcl im soln 50 mg/ml 1 PA; High Risk Medications require PA for members age 65 and older hydroxyzine hcl syrup 10 mg/5ml 1 PA; High Risk Medications require PA for members age 65 and older hydroxyzine hcl tab 10 mg 1 PA; High Risk Medications require PA for members age 65 and older

16 Drug Name Drug Tier Requirements/Limits hydroxyzine hcl tab 25 mg 1 PA; High Risk Medications require PA for members age 65 and older hydroxyzine hcl tab 50 mg 1 PA; High Risk Medications require PA for members age 65 and older hydroxyzine pamoate cap 25 mg 1 PA; High Risk Medications require PA for members age 65 and older hydroxyzine pamoate cap 50 mg 1 PA; High Risk Medications require PA for members age 65 and older hydroxyzine pamoate cap 100 mg 1 PA; High Risk Medications require PA for members age 65 and older tab 200 mg 1 meprobamate tab 400 mg 1 CON 1 MG/ML 2 QL (120 ml / 25 days) alprazolam orally disintegrating tab 0.5 mg 1 QL (90 tabs / 25 days) alprazolam orally disintegrating tab 0.25 1 QL (90 tabs / 25 days) mg alprazolam orally disintegrating tab 1 mg 1 QL (90 tabs / 25 days) alprazolam orally disintegrating tab 2 mg 1 QL (60 tabs / 25 days) alprazolam tab 0.5 mg 1 QL (90 tabs / 25 days) alprazolam tab 0.25 mg 1 QL (90 tabs / 25 days) alprazolam tab 1 mg 1 QL (90 tabs / 25 days) alprazolam tab 2 mg 1 QL (60 tabs / 25 days) dipotassium tab 3.75 mg 1 QL (120 tabs / 25 days) clorazepate dipotassium tab 7.5 mg 1 QL (120 tabs / 25 days) clorazepate dipotassium tab 15 mg 1 QL (120 tabs / 25 days) CON 5MG/ML 2 QL (240 ml / 25 days) diazepam soln 1 mg/ml 1 QL (1200 ml / 25 days) diazepam tab 2 mg 1 QL (120 tabs / 25 days) diazepam tab 5 mg 1 QL (120 tabs / 25 days) diazepam tab 10 mg 1 QL (120 tabs / 25 days) conc 2 mg/ml 1 QL (90 ml / 25 days) lorazepam tab 0.5 mg 1 QL (150 tabs / 25 days) lorazepam tab 1 mg 1 QL (150 tabs / 25 days) lorazepam tab 2 mg 1 QL (150 tabs / 25 days)

17 Drug Name Drug Tier Requirements/Limits cap 10 mg 1 QL (120 caps / 25 days) oxazepam cap 15 mg 1 QL (120 caps / 25 days) oxazepam cap 30 mg 1 QL (120 caps / 25 days) ANTIARRHYTHMICS Antiarrhythmics Type I-A disopyramide phosphate cap 100 mg 1 disopyramide phosphate cap 150 mg 1 NORPACE CAP 100MG CR 2 NORPACE CAP 150MG CR 2 procainamide hcl inj 100 mg/ml 1 PROCAINAMIDE INJ 500MG/ML 3 gluconate tab cr 324 mg 1 quinidine sulfate tab cr 300 mg 1 Antiarrhythmics Type I-B lidocaine hcl iv inj 20 mg/ml 1 lidocaine iv infusion in d5w inj 4 mg/ml 1 lidocaine iv infusion in d5w inj 8 mg/ml 1 mexiletine hcl cap 150 mg 1 mexiletine hcl cap 200 mg 1 mexiletine hcl cap 250 mg 1 Antiarrhythmics Type I-C flecainide acetate tab 50 mg 1 flecainide acetate tab 100 mg 1 flecainide acetate tab 150 mg 1 hcl cap sr 12hr 225 mg 1 propafenone hcl cap sr 12hr 325 mg 1 propafenone hcl cap sr 12hr 425 mg 1 propafenone hcl tab 150 mg 1 propafenone hcl tab 225 mg 1 propafenone hcl tab 300 mg 1 Antiarrhythmics Type III amiodarone hcl inj 150 mg/3ml (50 1 mg/ml) amiodarone hcl tab 200 mg 1 amiodarone hcl tab 400 mg 1 MULTAQ TAB 400MG 3 PA NEXTERONE INJ 3 PACERONE TAB 100MG 2 pacerone tab 200mg 1 TIKOSYN CAP 125MCG 4 PA TIKOSYN CAP 250MCG 4 PA TIKOSYN CAP 500MCG 4 PA ANTIASTHMATIC AND BRONCHODILATOR AGENTS Anti-Inflammatory Agents cromolyn sodium soln nebu 20 mg/2ml 1 QL (240 mL / 25 days) 18 Drug Name Drug Tier Requirements/Limits Bronchodilators - ATROVENT HFA AER 17MCG 2 QL (2 inhalers per 25 days) ipratropium inhal soln 0.02% 1 QL (2 containers / 25 days) SPIRIVA CAP HANDIHLR 2 QL (30 caps / 25 days) Leukotriene Modulators montelukast sodium chew tab 4 mg (base 1 ST equiv) montelukast sodium chew tab 5 mg (base 1 ST equiv) montelukast sodium oral granules packet 4 1 ST mg (base equiv) montelukast sodium tab 10 mg (base 1 ST equiv) zafirlukast tab 10 mg 1 zafirlukast tab 20 mg 1 ZYFLO CR TAB 600MG 3 Selective Phosphodiesterase 4 (PDE4) Inhibitors DALIRESP TAB 500MCG 3 PA Steroid Inhalants ALVESCO AER 80MCG 3 QL (2 / 25 days) ALVESCO AER 160MCG 3 QL (2 / 25 days) ASMANEX 7 AER 110MCG 3 QL (2 inhalers per 25 days) ASMANEX 14 AER 220MCG 3 QL (1 inhaler / 25 days) ASMANEX 30 AER 110MCG 2 QL (2 inhalers / 25 days) ASMANEX 30 AER 220MCG 2 QL (1 inhaler / 25 days) ASMANEX 60 AER 220MCG 2 QL (1 inhaler / 25 days) ASMANEX 120 AER 220MCG 2 QL (1 inhaler / 25 days) budesonide inhalation susp 0.5 mg/2ml 1 QL (60 / 25 days) budesonide inhalation susp 0.25 mg/2ml 1 QL (60 / 25 days) FLOVENT DISK AER 50MCG 3 QL (2 inhalers per 25 days) FLOVENT DISK AER 100MCG 3 QL (2 inhalers per 25 days) FLOVENT DISK AER 250MCG 3 QL (4 inhalers per 25 days) FLOVENT HFA AER 44MCG 3 QL (1 inhaler per 25 days) FLOVENT HFA AER 110MCG 3 QL (1 inhaler per 25 days) FLOVENT HFA AER 220MCG 3 QL (2 inhalers per 25 days)

19 Drug Name Drug Tier Requirements/Limits PULMICORT INH 90MCG 2 QL (2 inhalers per 25 days) PULMICORT INH 180MCG 2 QL (2 / 25 days) PULMICORT SUS 1MG/2ML 2 QL (30 ea / 25 days) QVAR AER 40MCG 3 QL (2 inhalers per 25 days) QVAR AER 80MCG 3 QL (2 inhalers per 25 days) Sympathomimetics ADVAIR DISKU AER 100/50 2 ST albuterol sulfate soln nebu 0.5% (5 mg/ml)1 QL (60 / 25 days) albuterol sulfate soln nebu 0.63 mg/3ml 1 QL (125 / 25 days) (base equiv) albuterol sulfate soln nebu 0.083% (2.5 1 QL (125 / 25 days) mg/3ml) albuterol sulfate soln nebu 1.25 mg/3ml 1 QL (125 / 25 days) (base equiv) albuterol sulfate syrup 2 mg/5ml 1 albuterol sulfate tab 2 mg 1 albuterol sulfate tab 4 mg 1 albuterol sulfate tab sr 12hr 4 mg 1 albuterol sulfate tab sr 12hr 8 mg 1 ARCAPTA CAP 75MCG 3 QL (1 per 25 days) BROVANA NEB 15MCG 3 QL (60 / 25 days) COMBIVENT AER RESPIMAT 2 QL (2 inhalers / 25 days) DULERA AER 100-5MCG 2 ST DULERA AER 200-5MCG 2 ST epinephrine hcl inj 0.1 mg/ml 1 epinephrine hcl inj 1 mg/ml 1 FORADIL CAP AEROLIZE 2 QL (60 caps / 25 days) ipratropium-albuterol nebu soln 0.5-2.5(3) 1 QL (180 / 25 days) mg/3ml levalbuterol hcl soln nebu 0.31 mg/3ml 1 QL (4 boxes / 25 days) (base equiv) levalbuterol hcl soln nebu 0.63 mg/3ml 1 QL (4 boxes / 25 days) (base equiv) levalbuterol hcl soln nebu conc 1.25 1 QL (3 boxes / 25 days) mg/0.5ml (base equiv) MAXAIR AUTOH AER 200MCG 3 ST metaproterenol sulfate syrup 10 mg/5ml 1 metaproterenol sulfate tab 10 mg 1 metaproterenol sulfate tab 20 mg 1 PERFOROMIST NEB 20MCG 2 QL (60 ea / 25 days) PROAIR HFA AER 2 QL (2 inhalers per 25 days) PROVENTIL AER HFA 3 ST

20 Drug Name Drug Tier Requirements/Limits SEREVENT DIS AER 50MCG 3 QL (1 inhaler per 25 days) SYMBICORT AER 80-4.5 2 ST SYMBICORT AER 160-4.5 2 ST sulfate inj 1 mg/ml 1 terbutaline sulfate tab 2.5 mg 1 terbutaline sulfate tab 5 mg 1 VENTOLIN HFA AER 3 ST XOPENEX HFA AER 3 ST Xanthines aminophylline inj 25 mg/ml 1 ELIXOPHYLLIN ELX 80/15ML 3 LUFYLLIN TAB 200MG 3 LUFYLLIN TAB 400MG 3 THEO-24 CAP 100MG CR 3 THEO-24 CAP 200MG CR 3 THEO-24 CAP 300MG CR 3 THEO-24 CAP 400MG ER 3 theochron tab 100mg cr 1 theochron tab 200mg cr 1 theochron tab 300mg cr 1 theophylline soln 80 mg/15ml 1 theophylline tab sr 12hr 100 mg 1 theophylline tab sr 12hr 200 mg 1 theophylline tab sr 12hr 300 mg 1 theophylline tab sr 12hr 450 mg 1 theophylline tab sr 24hr 400 mg 1 theophylline tab sr 24hr 600 mg 1 ANTICOAGULANTS Coumarin Anticoagulants COUMADIN INJ 5 MG 3 jantoven tab 1mg 1 jantoven tab 2.5mg 1 jantoven tab 2mg 1 jantoven tab 3mg 1 jantoven tab 4mg 1 jantoven tab 5mg 1 jantoven tab 6mg 1 jantoven tab 7.5mg 1 jantoven tab 10mg 1 warfarin sodium tab 1 mg 1 warfarin sodium tab 2 mg 1 warfarin sodium tab 2.5 mg 1 warfarin sodium tab 3 mg 1 warfarin sodium tab 4 mg 1

21 Drug Name Drug Tier Requirements/Limits warfarin sodium tab 5 mg 1 warfarin sodium tab 6 mg 1 warfarin sodium tab 7.5 mg 1 warfarin sodium tab 10 mg 1 Direct Factor Xa Inhibitors ELIQUIS TAB 2.5MG 3 PA ELIQUIS TAB 5MG 3 PA XARELTO TAB 10MG 2 QL (35 tabs / 90 days) XARELTO TAB 15MG 2 QL (42 tabs / 90 days) XARELTO TAB 20MG 2 PA Heparins And Heparinoid-Like Agents enoxaparin sodium inj 30 mg/0.3ml 1 QL (60 ml / 180 days) enoxaparin sodium inj 40 mg/0.4ml 1 QL (60 ml / 180 days) enoxaparin sodium inj 60 mg/0.6ml 1 QL (60 ml / 180 days) enoxaparin sodium inj 80 mg/0.8ml 1 QL (60 ml / 180 days) enoxaparin sodium inj 100 mg/ml 1 QL (60 ml / 180 days) enoxaparin sodium inj 120 mg/0.8ml 1 QL (60 ml / 180 days) enoxaparin sodium inj 150 mg/ml 1 QL (60 ml / 180 days) enoxaparin sodium inj 300 mg/3ml 1 QL (20 ml / 180 days) fondaparinux sodium inj 2.5 mg/0.5ml 1 QL (30 ml / 180 days) fondaparinux sodium inj 5 mg/0.4ml 1 QL (30 ml / 180 days) fondaparinux sodium inj 7.5 mg/0.6ml 1 QL (30 ml / 180 days) fondaparinux sodium inj 10 mg/0.8ml 1 QL (30 ml / 180 days) FRAGMIN INJ 2500/0.2 3 QL (30 mL per 180 days) FRAGMIN INJ 5000/0.2 3 QL (30 mL per 180 days) FRAGMIN INJ 7500/0.3 3 QL (30 mL per 180 days) FRAGMIN INJ 10000/ML 3 QL (30 ml per 180 days) FRAGMIN INJ 12500UNT 3 QL (30 ml per 180 days) FRAGMIN INJ 15000UNT 3 QL (30 ml per 180 days) FRAGMIN INJ 18000UNT 3 QL (30 mL per 180 days) FRAGMIN INJ 25000/ML 3 QL (30 mL per 180 days) heparin sodium (porcine) inj 1000 unit/ml 1 heparin sodium (porcine) inj 10000 unit/ml 1 Thrombin Inhibitors argatroban inj 100 mg/ml (concentrate for 1 iv infusion) ARGATROBAN INJ 125/125 3 PRADAXA CAP 75MG 2 PRADAXA CAP 150MG 2

22 Drug Name Drug Tier Requirements/Limits Anticonvulsants - Benzodiazepines tab 0.5 mg 1 clonazepam tab 1 mg 1 clonazepam tab 2 mg 1 ONFI TAB 5MG 2 ONFI TAB 10MG 2 ONFI TAB 20MG 2 Anticonvulsants - Misc. BANZEL SUS 40MG/ML 2 BANZEL TAB 200MG 2 BANZEL TAB 400MG 2 cap sr 12hr 100 mg 1 carbamazepine cap sr 12hr 200 mg 1 carbamazepine cap sr 12hr 300 mg 1 carbamazepine chew tab 100 mg 1 carbamazepine susp 100 mg/5ml 1 carbamazepine tab 200 mg 1 carbamazepine tab sr 12hr 200 mg 1 carbamazepine tab sr 12hr 400 mg 1 epitol tab 200mg 1 cap 100 mg 1 gabapentin cap 300 mg 1 gabapentin cap 400 mg 1 gabapentin oral soln 250 mg/5ml 1 gabapentin tab 600 mg 1 gabapentin tab 800 mg 1 LAMICTAL CHW 2MG 2 LAMICTAL KIT START 35 3 LAMICTAL KIT START 49 3 LAMICTAL KIT START 98 3 LAMICTAL ODT KIT 3 LAMICTAL ODT TAB 25MG 3 LAMICTAL ODT TAB 50MG 3 LAMICTAL ODT TAB 100MG 3 LAMICTAL ODT TAB 200MG 3 LAMICTAL XR KIT 3 lamotrigine tab 25 mg 1 lamotrigine tab 100 mg 1 lamotrigine tab 150 mg 1 lamotrigine tab 200 mg 1 lamotrigine tab chewable dispersible 5 mg 1 lamotrigine tab chewable dispersible 25 mg1 lamotrigine tab sr 24hr 25 mg 1 lamotrigine tab sr 24hr 50 mg 1 lamotrigine tab sr 24hr 100 mg 1

23 Drug Name Drug Tier Requirements/Limits lamotrigine tab sr 24hr 200 mg 1 lamotrigine tab sr 24hr 250 mg 1 lamotrigine tab sr 24hr 300 mg 1 LEVETIRACETA INJ 5MG/ML 3 LEVETIRACETA INJ 10MG/ML 3 LEVETIRACETA INJ 15MG/ML 3 levetiracetam inj 500 mg/5ml (100 mg/ml) 1 levetiracetam oral soln 100 mg/ml 1 levetiracetam tab 250 mg 1 levetiracetam tab 500 mg 1 levetiracetam tab 750 mg 1 levetiracetam tab 1000 mg 1 levetiracetam tab sr 24hr 500 mg 1 levetiracetam tab sr 24hr 750 mg 1 LYRICA CAP 25MG 2 ST LYRICA CAP 50MG 2 ST LYRICA CAP 75MG 2 ST LYRICA CAP 100MG 2 ST LYRICA CAP 150MG 2 ST LYRICA CAP 200MG 2 ST LYRICA CAP 225MG 2 ST LYRICA CAP 300MG 2 ST LYRICA SOL 20MG/ML 2 ST susp 300 mg/5ml (60 1 mg/ml) oxcarbazepine tab 150 mg 1 oxcarbazepine tab 300 mg 1 oxcarbazepine tab 600 mg 1 POTIGA TAB 50MG 2 POTIGA TAB 200MG 2 POTIGA TAB 300MG 2 POTIGA TAB 400MG 2 primidone tab 50 mg 1 primidone tab 250 mg 1 TEGRETOL XR TAB 100MG 2 topiragen tab 25mg 1 topiragen tab 50mg 1 topiragen tab 100mg 1 topiragen tab 200mg 1 topiramate sprinkle cap 15 mg 1 topiramate sprinkle cap 25 mg 1 topiramate tab 25 mg 1 topiramate tab 50 mg 1 topiramate tab 100 mg 1 topiramate tab 200 mg 1 VIMPAT INJ 200MG/20 3 PA

24 Drug Name Drug Tier Requirements/Limits VIMPAT SOL 10MG/ML 2 VIMPAT TAB 50MG 2 VIMPAT TAB 100MG 2 VIMPAT TAB 150MG 2 VIMPAT TAB 200MG 2 zonisamide cap 25 mg 1 zonisamide cap 50 mg 1 zonisamide cap 100 mg 1 felbamate susp 600 mg/5ml 1 felbamate tab 400 mg 1 felbamate tab 600 mg 1 GABA Modulators GABITRIL TAB 12MG 2 GABITRIL TAB 16MG 2 SABRIL POW 500MG 4 PA SABRIL TAB 500MG 4 PA hcl tab 2 mg 1 tiagabine hcl tab 4 mg 1 Hydantoins DILANTIN CAP 30MG 3 fosphenytoin sodium inj 100 mg/2ml 1 (phenytoin equiv) PEGANONE TAB 250MG 3 phenytoin chew tab 50 mg 1 phenytoin sodium extended cap 100 mg 1 phenytoin sodium extended cap 200 mg 1 phenytoin sodium extended cap 300 mg 1 phenytoin sodium inj 50 mg/ml 1 phenytoin susp 125 mg/5ml 1 Succinimides CELONTIN CAP 300MG 3 ethosuximide cap 250 mg 1 ethosuximide soln 250 mg/5ml 1 Valproic Acid divalproex sodium cap sprinkle 125 mg 1 divalproex sodium tab delayed release 125 1 mg divalproex sodium tab delayed release 250 1 mg divalproex sodium tab delayed release 500 1 mg divalproex sodium tab sr 24 hr 250 mg 1 divalproex sodium tab sr 24 hr 500 mg 1 STAVZOR CAP 125MG 3 STAVZOR CAP 250MG 3

25 Drug Name Drug Tier Requirements/Limits STAVZOR CAP 500MG 3 valproate sodium inj 100 mg/ml 1 valproate sodium syrup 250 mg/5ml (base 1 equiv) valproic acid cap 250 mg 1 Alpha-2 Receptor Antagonists () mirtazapine orally disintegrating tab 15 mg 1 mirtazapine orally disintegrating tab 30 mg 1 mirtazapine orally disintegrating tab 45 mg 1 mirtazapine tab 7.5 mg 1 mirtazapine tab 15 mg 1 mirtazapine tab 30 mg 1 mirtazapine tab 45 mg 1 Antidepressants - Misc. APLENZIN TAB 174MG 3 APLENZIN TAB 348MG 3 APLENZIN TAB 522MG 3 budeprion tab 100mg sr 1 budeprion tab 150mg sr 1 budeprion xl tab 150mg 1 budeprion xl tab 300mg 1 hcl tab 75 mg 1 bupropion hcl tab 100 mg 1 bupropion hcl tab sr 12hr 100 mg 1 bupropion hcl tab sr 12hr 150 mg 1 bupropion hcl tab sr 12hr 200 mg 1 bupropion hcl tab sr 24hr 150 mg 1 bupropion hcl tab sr 24hr 300 mg 1 hcl tab 25 mg 1 maprotiline hcl tab 50 mg 1 maprotiline hcl tab 75 mg 1 Modified Cyclics hcl tab 100 mg 1 nefazodone hcl tab 200 mg 1 nefazodone hcl tab 250 mg 1 OLEPTRO TAB 24HR150 3 OLEPTRO TAB 24HR300 3 hcl tab 50 mg 1 trazodone hcl tab 100 mg 1 trazodone hcl tab 150 mg 1 trazodone hcl tab 300 mg 1 VIIBRYD KIT 3 ST VIIBRYD TAB 10MG 3 ST VIIBRYD TAB 20MG 3 ST

26 Drug Name Drug Tier Requirements/Limits VIIBRYD TAB 40MG 3 ST Inhibitors (MAOIs) EMSAM DIS 6MG/24HR 3 EMSAM DIS 9MG/24HR 3 EMSAM DIS 12MG/24H 3 MARPLAN TAB 10MG 3 sulfate tab 15 mg 1 sulfate tab 10 mg 1 Selective Inhibitors (SSRIs) hydrobromide oral soln 10 1 mg/5ml citalopram hydrobromide tab 10 mg (base 1 equiv) citalopram hydrobromide tab 20 mg (base 1 equiv) citalopram hydrobromide tab 40 mg (base 1 equiv) oxalate soln 5 mg/5ml (base 1 equiv) escitalopram oxalate tab 5 mg (base 1 equiv) escitalopram oxalate tab 10 mg (base 1 equiv) escitalopram oxalate tab 20 mg (base 1 equiv) hcl cap 10 mg 1 fluoxetine hcl cap 20 mg 1 fluoxetine hcl cap 40 mg 1 fluoxetine hcl cap delayed release 90 mg 1 fluoxetine hcl solution 20 mg/5ml 1 fluoxetine hcl tab 10 mg 1 fluoxetine hcl tab 20 mg 1 FLUOXETINE TAB 60MG 3 maleate tab 25 mg 1 fluvoxamine maleate tab 50 mg 1 fluvoxamine maleate tab 100 mg 1 LUVOX CR CAP 100MG 3 ST LUVOX CR CAP 150MG 3 ST hcl oral susp 10 mg/5ml (base 1 equiv) paroxetine hcl tab 10 mg 1 paroxetine hcl tab 20 mg 1 paroxetine hcl tab 30 mg 1 paroxetine hcl tab 40 mg 1 paroxetine hcl tab sr 24hr 12.5 mg 1 paroxetine hcl tab sr 24hr 25 mg 1 paroxetine hcl tab sr 24hr 37.5 mg 1 PAXIL SUS 10MG/5ML 2

27 Drug Name Drug Tier Requirements/Limits PEXEVA TAB 10MG 3 ST PEXEVA TAB 20MG 3 ST PEXEVA TAB 30MG 3 ST PEXEVA TAB 40MG 3 ST hcl oral conc 20 mg/ml 1 sertraline hcl tab 25 mg 1 sertraline hcl tab 50 mg 1 sertraline hcl tab 100 mg 1 Serotonin- Reuptake Inhibitors (SNRIs) CYMBALTA CAP 20MG 2 ST CYMBALTA CAP 30MG 2 ST CYMBALTA CAP 60MG 2 ST PRISTIQ TAB 50MG 3 ST PRISTIQ TAB 100MG 3 ST hcl cap sr 24hr 37.5 mg (base 1 equivalent) venlafaxine hcl cap sr 24hr 75 mg (base 1 equivalent) venlafaxine hcl cap sr 24hr 150 mg (base 1 equivalent) venlafaxine hcl tab 25 mg 1 venlafaxine hcl tab 37.5 mg 1 venlafaxine hcl tab 50 mg 1 venlafaxine hcl tab 75 mg 1 venlafaxine hcl tab 100 mg 1 venlafaxine hcl tab sr 24hr 37.5 mg (base 1 equivalent) venlafaxine hcl tab sr 24hr 75 mg (base 1 equivalent) venlafaxine hcl tab sr 24hr 150 mg (base 1 equivalent) venlafaxine hcl tab sr 24hr 225 mg (base 1 equivalent) Agents hcl tab 10 mg 1 QL (90 tabs / 25 days); QL applies to members age 65 and older amitriptyline hcl tab 25 mg 1 QL (30 tabs / 25 days); QL applies to members age 65 and older amitriptyline hcl tab 50 mg 1 QL (30 tabs / 25 days); QL applies to members age 65 and older amitriptyline hcl tab 75 mg 1 QL applies to members age 65 and older amitriptyline hcl tab 100 mg 1 QL applies to members age 65 and older

28 Drug Name Drug Tier Requirements/Limits amitriptyline hcl tab 150 mg 1 QL applies to members age 65 and older TAB 25MG 3 QL (90 tabs / 25 days); QL applies to members age 65 and older AMOXAPINE TAB 50MG 3 QL (90 tabs / 25 days); QL applies to members age 65 and older AMOXAPINE TAB 100MG 3 QL (30 tabs / 25 days); QL applies to members age 65 and older AMOXAPINE TAB 150MG 3 QL (30 tabs / 25 days); QL applies to members age 65 and older hcl cap 25 mg 1 QL (90 caps / 25 days); QL applies to members age 65 and older clomipramine hcl cap 50 mg 1 QL (90 caps / 25 days); QL applies to members age 65 and older clomipramine hcl cap 75 mg 1 QL (60 caps / 25 days); QL applies to members age 65 and older hcl tab 10 mg 1 QL (90 tabs / 25 days); QL applies to members age 65 and older desipramine hcl tab 25 mg 1 QL (90 tabs / 25 days); QL applies to members age 65 and older desipramine hcl tab 50 mg 1 QL (90 tabs / 25 days); QL applies to members age 65 and older desipramine hcl tab 75 mg 1 QL (60 tabs / 25 days); QL applies to members age 65 and older desipramine hcl tab 100 mg 1 QL (30 tabs / 25 days); QL applies to members age 65 and older desipramine hcl tab 150 mg 1 QL (30 tabs / 25 days); QL applies to members age 65 and older

29 Drug Name Drug Tier Requirements/Limits hcl cap 10 mg 1 QL (90 caps / 25 days); QL applies to members age 65 and older doxepin hcl cap 25 mg 1 QL (90 caps / 25 days); QL applies to members age 65 and older doxepin hcl cap 50 mg 1 QL (90 caps / 25 days); QL applies to members age 65 and older doxepin hcl cap 75 mg 1 QL (60 caps / 25 days); QL applies to members age 65 and older doxepin hcl cap 100 mg 1 QL (30 caps / 25 days); QL applies to members age 65 and older doxepin hcl cap 150 mg 1 QL (30 caps / 25 days); QL applies to members age 65 and older doxepin hcl conc 10 mg/ml 1 QL (360 ml / 25 days); QL applies to members age 65 and older hcl tab 10 mg 1 QL (60 tabs / 25 days); QL applies to members age 65 and older imipramine hcl tab 25 mg 1 QL (60 tabs / 25 days); QL applies to members age 65 and older imipramine hcl tab 50 mg 1 QL (60 tabs / 25 days); QL applies to members age 65 and older imipramine pamoate cap 75 mg 1 QL (30 caps / 25 days); QL applies to members age 65 and older imipramine pamoate cap 100 mg 1 QL (30 caps / 25 days); QL applies to members age 65 and older imipramine pamoate cap 125 mg 1 QL applies to members age 65 and older imipramine pamoate cap 150 mg 1 QL applies to members age 65 and older hcl cap 10 mg 1 QL (60 caps / 25 days); QL applies to members age 65 and older

30 Drug Name Drug Tier Requirements/Limits nortriptyline hcl cap 25 mg 1 QL (60 caps / 25 days); QL applies to members age 65 and older nortriptyline hcl cap 50 mg 1 QL (60 caps / 25 days); QL applies to members age 65 and older nortriptyline hcl cap 75 mg 1 QL (30 caps / 25 days); QL applies to members age 65 and older nortriptyline hcl soln 10 mg/5ml 1 QL (3 bottles per 25 days); QL applies to members age 65 and older hcl tab 5 mg 1 QL (60 tabs / 25 days); QL applies to members age 65 and older protriptyline hcl tab 10 mg 1 QL (60 tabs / 25 days); QL applies to members age 65 and older maleate cap 25 mg 1 QL (60 caps / 25 days); QL applies to members age 65 and older trimipramine maleate cap 50 mg 1 QL (60 caps / 25 days); QL applies to members age 65 and older trimipramine maleate cap 100 mg 1 QL (30 caps / 25 days); QL applies to members age 65 and older ANTIDIABETICS Alpha-Glucosidase Inhibitors acarbose tab 25 mg 1 acarbose tab 50 mg 1 acarbose tab 100 mg 1 GLYSET TAB 25MG 3 GLYSET TAB 50MG 3 GLYSET TAB 100MG 3 Antidiabetic - Amylin Analogs SYMLIN INJ 600MCG 3 PA SYMLINPEN 60 INJ 1000MCG 3 PA SYMLNPEN 120 INJ 1000MCG 3 PA Antidiabetic Combinations glipizide-metformin hcl tab 2.5-250 mg 1 glipizide-metformin hcl tab 2.5-500 mg 1

31 Drug Name Drug Tier Requirements/Limits glipizide-metformin hcl tab 5-500 mg 1 glyburide-metformin tab 1.25-250 mg 1 PA; High Risk Medications require PA for members age 65 and older glyburide-metformin tab 2.5-500 mg 1 PA; High Risk Medications require PA for members age 65 and older glyburide-metformin tab 5-500 mg 1 PA; High Risk Medications require PA for members age 65 and older JANUMET TAB 50-500MG 3 PA JANUMET TAB 50-1000 3 PA JANUMET XR TAB 50-500MG 3 PA JANUMET XR TAB 50-1000 3 PA JANUMET XR TAB 100-1000 3 PA JENTADUETO TAB 2.5-500 3 PA JENTADUETO TAB 2.5-850 3 PA JENTADUETO TAB 2.5-1000 3 PA pioglitazone hcl-glimepiride tab 30-2 mg 1 ST pioglitazone hcl-glimepiride tab 30-4 mg 1 ST pioglitazone hcl-metformin hcl tab 15-500 1 ST mg pioglitazone hcl-metformin hcl tab 15-850 1 ST mg Biguanides metformin hcl tab 500 mg 1 metformin hcl tab 850 mg 1 metformin hcl tab 1000 mg 1 metformin hcl tab sr 24hr 500 mg 1 metformin hcl tab sr 24hr 750 mg 1 metformin hcl tab sr 24hr osmotic 1000 1 mg RIOMET SOL 3 Diabetic Other GLUCAGEN INJ HYPOKIT 2 GLUCAGON KIT 1MG 2 PROGLYCEM SUS 50MG/ML 3 Dipeptidyl Peptidase-4 (DPP-4) Inhibitors JANUVIA TAB 25MG 2 ST JANUVIA TAB 50MG 2 ST JANUVIA TAB 100MG 2 ST ONGLYZA TAB 2.5MG 3 PA ONGLYZA TAB 5MG 3 PA 32 Drug Name Drug Tier Requirements/Limits TRADJENTA TAB 5MG 3 PA Receptor Agonists - Antidiabetic CYCLOSET TAB 0.8MG 3 Incretin Mimetic Agents (GLP-1 Receptor Agonists) BYDUREON INJ 2 ST BYETTA INJ 5MCG 2 ST BYETTA INJ 10MCG 2 ST VICTOZA INJ 18MG/3ML 3 PA Insulin APIDRA INJ SOLOSTAR 2 APIDRA INJ U-100 2 HUMALOG INJ 100/ML 3 HUMALOG MIX INJ 50/50 3 HUMALOG MIX INJ 50/50KWP 3 HUMALOG MIX INJ 75/25KWP 3 HUMALOG MIX SUS 75/25 3 HUMULIN INJ 70/30 3 HUMULIN N INJ U-100 3 HUMULIN N PN INJ U-100 3 HUMULIN PEN INJ 70/30 3 HUMULIN R INJ U-100 3 HUMULIN R INJ U-500 2 LANTUS INJ 100/ML 2 LANTUS INJ SOLOSTAR 2 LEVEMIR INJ 2 LEVEMIR INJ FLEXPEN 2 NOVOLIN INJ 70/30 2 NOVOLIN N INJ U-100 2 NOVOLIN R INJ U-100 2 NOVOLOG INJ 100/ML 2 NOVOLOG INJ PENFILL 2 NOVOLOG MIX INJ 70/30 2 NOVOLOG MIX INJ FLEXPEN 2 Insulin Sensitizing Agents AVANDIA TAB 2MG 3 AVANDIA TAB 4MG 3 AVANDIA TAB 8MG 3 pioglitazone hcl tab 15 mg (base equiv) 1 ST pioglitazone hcl tab 30 mg (base equiv) 1 ST pioglitazone hcl tab 45 mg (base equiv) 1 ST Meglitinide Analogues nateglinide tab 60 mg 1 nateglinide tab 120 mg 1 PRANDIN TAB 0.5MG 3 PRANDIN TAB 1MG 3

33 Drug Name Drug Tier Requirements/Limits PRANDIN TAB 2MG 3 Sulfonylureas chlorpropamide tab 100 mg 1 chlorpropamide tab 250 mg 1 glimepiride tab 1 mg 1 glimepiride tab 2 mg 1 glimepiride tab 4 mg 1 glipizide tab 5 mg 1 glipizide tab 10 mg 1 glipizide tab sr 24hr 2.5 mg 1 glipizide tab sr 24hr 5 mg 1 glipizide tab sr 24hr 10 mg 1 glyburide micronized tab 1.5 mg 1 PA; High Risk Medications require PA for members age 65 and older glyburide micronized tab 3 mg 1 PA; High Risk Medications require PA for members age 65 and older glyburide micronized tab 6 mg 1 PA; High Risk Medications require PA for members age 65 and older glyburide tab 1.25 mg 1 PA; High Risk Medications require PA for members age 65 and older glyburide tab 2.5 mg 1 PA; High Risk Medications require PA for members age 65 and older glyburide tab 5 mg 1 PA; High Risk Medications require PA for members age 65 and older glycron tab 1.5mg 1 PA; High Risk Medications require PA for members age 65 and older glycron tab 3mg 1 PA; High Risk Medications require PA for members age 65 and older

34 Drug Name Drug Tier Requirements/Limits GLYCRON TAB 4.5MG 2 PA; High Risk Medications require PA for members age 65 and older glycron tab 6mg 1 PA; High Risk Medications require PA for members age 65 and older tolazamide tab 250 mg 1 tolazamide tab 500 mg 1 tolbutamide tab 500 mg 1 ANTIDIARRHEALS Antiperistaltic Agents w/ liq 2.5-0.025 1 mg/5ml diphenoxylate w/ atropine tab 2.5-0.025 1 mg hcl cap 2 mg 1 loperamide hcl tab 2 mg 1 MOTOFEN TAB 3 Antidotes - Chelating Agents CHEMET CAP 100MG 3 EXJADE TAB 125MG 4 PA EXJADE TAB 250MG 4 PA EXJADE TAB 500MG 4 PA FERRIPROX TAB 500MG 4 PA Opioid Antagonists depade tab 50mg 1 hcl inj 0.4 mg/ml 1 naloxone hcl inj 1 mg/ml 1 hcl tab 50 mg 1 VIVITROL INJ 380MG 4 PA 5-HT3 Receptor Antagonists ALOXI INJ 3 QL (1 vial / 15 days) ALOXI INJ 0.25MG/5 3 QL (1 vial / 15 days) ANZEMET TAB 50MG 3 QL (3 tabs / 15 days) ANZEMET TAB 100MG 3 QL (3 tabs / 15 days) hcl inj 0.1 mg/ml 1 QL (1 mL / 15 days) granisetron hcl inj 1 mg/ml 1 QL (1 mL / 15 days) granisetron hcl tab 1 mg 1 QL (6 tabs / 15 days) GRANISOL SOL 2MG/10ML 3 QL (30 mL / 15 days)

35 Drug Name Drug Tier Requirements/Limits hcl and dextrose inj 32 1 mg/50ml ondansetron hcl inj 4 mg/2ml (2 mg/ml) 1 ondansetron hcl oral soln 4 mg/5ml 1 QL (2 bottles per 15 days) ondansetron hcl tab 4 mg 1 QL (12 tabs / 15 days) ondansetron hcl tab 8 mg 1 QL (12 tabs / 15 days) ondansetron hcl tab 24 mg 1 QL (1 tab / 15 days) ondansetron orally disintegrating tab 4 mg 1 QL (12 tabs / 15 days) ondansetron orally disintegrating tab 8 mg 1 QL (12 tabs / 15 days) SANCUSO DIS 3.1MG 3 QL (1 patch / 15 days) ZUPLENZ MIS 4MG 3 QL (12 ea / 15 days) ZUPLENZ MIS 8MG 3 QL (12 ea / 15 days) Antiemetics - ANTIVERT TAB 50MG 2 tab 50 mg 1 hcl tab 12.5 mg 1 meclizine hcl tab 25 mg 1 TRANSDERM-SC DIS 1.5MG 3 hcl cap 300 mg 1 PA; High Risk Medications require PA for members age 65 and older trimethobenzamide hcl inj 100 mg/ml 1 PA; High Risk Medications require PA for members age 65 and older univert tab 32mg 1 Antiemetics - Miscellaneous CESAMET CAP 1MG 3 QL (18 caps / 25 days) cap 2.5 mg 1 QL (60 caps / 25 days) dronabinol cap 5 mg 1 QL (60 caps / 25 days) dronabinol cap 10 mg 1 QL (60 caps / 25 days) Substance P/Neurokinin 1 (NK1) Receptor Antagonists EMEND CAP 40MG 3 QL (3 caps / 180 days) EMEND CAP 80MG 3 QL (2 caps / 15 days) EMEND CAP 125MG 3 QL (1 caps / 15 days) EMEND PAK 80 & 125 3 QL (1 caps / 25 days) ANTIFUNGALS Antifungal - Glucan Synthesis Inhibitors (Echinocandins) CANCIDAS INJ 50MG 3 CANCIDAS INJ 70MG 3 ERAXIS INJ 50MG 3 ERAXIS INJ 100MG 3 MYCAMINE INJ 50MG 3 36 Drug Name Drug Tier Requirements/Limits MYCAMINE INJ 100MG 3 Antifungals ABELCET INJ 5MG/ML 3 AMBISOME INJ 50MG 3 AMPHOTEC INJ 50MG 3 AMPHOTEC INJ 100MG 3 amphotericin b for inj 50 mg 1 BIO-STATIN CAP 500000 2 BIO-STATIN CAP 1000000 2 griseofulvin microsize susp 125 mg/5ml 1 griseofulvin microsize tab 500 mg 1 griseofulvin ultramicrosize tab 125 mg 1 griseofulvin ultramicrosize tab 250 mg 1 LAMISIL GRA 125MG 3 PA LAMISIL GRA 187.5MG 3 PA nystatin oral powder 1 nystatin tab 500000 unit 1 terbinafine hcl tab 250 mg 1 PA -Related Antifungals fluconazole for susp 10 mg/ml 1 fluconazole for susp 40 mg/ml 1 fluconazole in dextrose inj 200 mg/100ml 1 fluconazole in dextrose inj 400 mg/200ml 1 fluconazole in nacl 0.9% inj 200 mg/100ml 1 fluconazole in nacl 0.9% inj 400 mg/200ml 1 fluconazole tab 50 mg 1 fluconazole tab 100 mg 1 fluconazole tab 150 mg 1 fluconazole tab 200 mg 1 FLUCONAZOLE/ INJ NACL 100 3 cap 100 mg 1 PA ketoconazole tab 200 mg 1 NOXAFIL SUS 40MG/ML 2 SPORANOX SOL 10MG/ML 2 PA VFEND SUS 40MG/ML 2 PA voriconazole tab 50 mg 1 PA voriconazole tab 200 mg 1 PA Antihistamines - Alkylamines tannate chew tab 12 mg 1 maleate syrup 2 1 mg/5ml Antihistamines - Ethanolamines arbinoxa liq 4mg/5ml 1 maleate liquid 4 mg/5ml 1

37 Drug Name Drug Tier Requirements/Limits carbinoxamine maleate tab 4 mg 1 fumarate syrup 0.67 mg/5ml 1 PA; High Risk (0.5 mg/5ml base eq) Medications require PA for members age 65 and older clemastine fumarate tab 2.68 mg 1 PA; High Risk Medications require PA for members age 65 and older hcl cap 25 mg 1 diphenhydramine hcl cap 50 mg 1 diphenhydramine hcl elixir 12.5 mg/5ml 1 diphenhydramine hcl inj 50 mg/ml 1 Antihistamines - Non-Sedating CLARINEX SYP 0.5MG/ML 3 tab 5 mg 1 desloratadine tab orally disintegrating 2.5 1 mg desloratadine tab orally disintegrating 5 1 mg dihydrochloride soln 2.5 1 mg/5ml (0.5 mg/ml) levocetirizine dihydrochloride tab 5 mg 1 Antihistamines - phenadoz sup 12.5mg 1 phenadoz sup 25mg 1 hcl inj 25 mg/ml 1 promethazine hcl inj 50 mg/ml 1 promethazine hcl suppos 12.5 mg 1 promethazine hcl suppos 25 mg 1 promethazine hcl syrup 6.25 mg/5ml 1 PA; High Risk Medications require PA for members age 65 and older promethazine hcl tab 12.5 mg 1 PA; High Risk Medications require PA for members age 65 and older promethazine hcl tab 25 mg 1 PA; High Risk Medications require PA for members age 65 and older

38 Drug Name Drug Tier Requirements/Limits promethazine hcl tab 50 mg 1 PA; High Risk Medications require PA for members age 65 and older promethegan sup 12.5mg 1 promethegan sup 25mg 1 promethegan sup 50mg 1 Antihistamines - Piperidines hcl syrup 2 mg/5ml 1 cyproheptadine hcl tab 4 mg 1 ANTIHYPERLIPIDEMICS Antihyperlipidemics - Combinations VYTORIN TAB 10-10MG 3 ST VYTORIN TAB 10-20MG 3 ST VYTORIN TAB 10-40MG 3 ST VYTORIN TAB 10-80MG 3 ST Antihyperlipidemics - Misc. LOVAZA CAP 1GM 3 PA Bile Acid Sequestrants cholestyramine light powder 4 gm/dose 1 cholestyramine light powder packets 4 gm 1 cholestyramine powder 4 gm/dose 1 cholestyramine powder packets 4 gm 1 colestipol hcl granule packets 5 gm 1 colestipol hcl granules 5 gm 1 colestipol hcl tab 1 gm 1 prevalite pow 4gm 1 WELCHOL PAK 3.75GM 3 WELCHOL TAB 625MG 3 Fibric Acid Derivatives fenofibrate micronized cap 67 mg 1 fenofibrate micronized cap 134 mg 1 fenofibrate micronized cap 200 mg 1 fenofibrate tab 54 mg 1 fenofibrate tab 160 mg 1 fenofibric acid tab 35 mg 1 fenofibric acid tab 105 mg 1 FENOGLIDE TAB 40MG 3 gemfibrozil tab 600 mg 1 LIPOFEN CAP 50MG 3 LIPOFEN CAP 150MG 3 TRIGLIDE TAB 50MG 3 ST TRILIPIX CAP 45MG 3 ST TRILIPIX CAP 135MG 3 ST

39 Drug Name Drug Tier Requirements/Limits HMG CoA Reductase Inhibitors ALTOPREV TAB 20MG ER 3 ST ALTOPREV TAB 40MG ER 3 ST ALTOPREV TAB 60MG ER 3 ST atorvastatin calcium tab 10 mg (base 1 equivalent) atorvastatin calcium tab 20 mg (base 1 equivalent) atorvastatin calcium tab 40 mg (base 1 equivalent) atorvastatin calcium tab 80 mg (base 1 equivalent) CRESTOR TAB 5MG 3 ST CRESTOR TAB 10MG 3 ST CRESTOR TAB 20MG 3 ST CRESTOR TAB 40MG 3 fluvastatin sodium cap 20 mg 1 fluvastatin sodium cap 40 mg 1 LESCOL XL TAB 80MG 3 LIVALO TAB 1MG 3 ST LIVALO TAB 2MG 3 ST LIVALO TAB 4MG 3 ST lovastatin tab 10 mg 1 lovastatin tab 20 mg 1 lovastatin tab 40 mg 1 pravastatin sodium tab 10 mg 1 pravastatin sodium tab 20 mg 1 pravastatin sodium tab 40 mg 1 pravastatin sodium tab 80 mg 1 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 ST Intestinal Absorption Inhibitors ZETIA TAB 10MG 3 ST Nicotinic Acid Derivatives NIASPAN TAB 500MG ER 2 NIASPAN TAB 750MG ER 2 NIASPAN TAB 1000 ER 2 ANTIHYPERTENSIVES 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

40 Drug Name Drug Tier Requirements/Limits captopril tab 12.5 mg 1 captopril tab 25 mg 1 captopril tab 50 mg 1 captopril tab 100 mg 1 enalapril maleate tab 2.5 mg 1 enalapril maleate tab 5 mg 1 enalapril maleate tab 10 mg 1 enalapril maleate tab 20 mg 1 fosinopril sodium tab 10 mg 1 fosinopril sodium tab 20 mg 1 fosinopril sodium tab 40 mg 1 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 1 moexipril hcl tab 15 mg 1 perindopril erbumine tab 2 mg 1 perindopril erbumine tab 4 mg 1 perindopril erbumine tab 8 mg 1 quinapril hcl tab 5 mg 1 quinapril hcl tab 10 mg 1 quinapril hcl tab 20 mg 1 quinapril hcl tab 40 mg 1 ramipril cap 1.25 mg 1 ramipril cap 2.5 mg 1 ramipril cap 5 mg 1 ramipril cap 10 mg 1 trandolapril tab 1 mg 1 trandolapril tab 2 mg 1 trandolapril tab 4 mg 1 Agents for Pheochromocytoma DIBENZYLINE CAP 10MG 3 Angiotensin II Receptor Antagonists ATACAND TAB 4MG 3 ST ATACAND TAB 8MG 3 ST ATACAND TAB 16MG 3 ST ATACAND TAB 32MG 3 ST BENICAR TAB 5MG 3 ST BENICAR TAB 20MG 3 ST BENICAR TAB 40MG 3 ST DIOVAN TAB 40MG 2 ST DIOVAN TAB 80MG 2 ST

41 Drug Name Drug Tier Requirements/Limits DIOVAN TAB 160MG 2 ST DIOVAN TAB 320MG 2 ST EDARBI TAB 40MG 3 ST EDARBI TAB 80MG 3 ST eprosartan mesylate tab 600 mg 1 irbesartan tab 75 mg 1 irbesartan tab 150 mg 1 irbesartan tab 300 mg 1 losartan potassium tab 25 mg 1 losartan potassium tab 50 mg 1 losartan potassium tab 100 mg 1 MICARDIS TAB 20MG 3 ST MICARDIS TAB 40MG 3 ST MICARDIS TAB 80MG 3 ST TEVETEN TAB 400MG 3 ST Antiadrenergic Antihypertensives hcl tab 0.1 mg 1 clonidine hcl tab 0.2 mg 1 clonidine hcl tab 0.3 mg 1 clonidine hcl td patch weekly 0.1 mg/24hr 1 clonidine hcl td patch weekly 0.2 mg/24hr 1 clonidine hcl td patch weekly 0.3 mg/24hr 1 mesylate tab 1 mg 1 doxazosin mesylate tab 2 mg 1 doxazosin mesylate tab 4 mg 1 doxazosin mesylate tab 8 mg 1 hcl tab 1 mg 1 guanfacine hcl tab 2 mg 1 tab 250 mg 1 methyldopa tab 500 mg 1 methyldopate hcl inj 250 mg/5ml 1 hcl cap 1 mg 1 prazosin hcl cap 2 mg 1 prazosin hcl cap 5 mg 1 hcl cap 1 mg 1 terazosin hcl cap 2 mg 1 terazosin hcl cap 5 mg 1 terazosin hcl cap 10 mg 1 Antihypertensive Combinations amlodipine besylate-benazepril hcl cap 2.5-1 10 mg amlodipine besylate-benazepril hcl cap 5- 1 10 mg amlodipine besylate-benazepril hcl cap 5- 1 20 mg amlodipine besylate-benazepril hcl cap 5- 1 40 mg 42 Drug Name Drug Tier Requirements/Limits amlodipine besylate-benazepril hcl cap 10- 1 20 mg amlodipine besylate-benazepril hcl cap 10- 1 40 mg & chlorthalidone tab 50-25 mg 1 atenolol & chlorthalidone tab 100-25 mg 1 & hydrochlorothiazide tab 2.5- 1 6.25 mg bisoprolol & hydrochlorothiazide tab 5-6.25 1 mg bisoprolol & hydrochlorothiazide tab 10- 1 6.25 mg captopril & hydrochlorothiazide tab 25-15 1 mg captopril & hydrochlorothiazide tab 25-25 1 mg captopril & hydrochlorothiazide tab 50-15 1 mg captopril & hydrochlorothiazide tab 50-25 1 mg enalapril maleate & hydrochlorothiazide tab1 5-12.5 mg enalapril maleate & hydrochlorothiazide tab1 10-25 mg lisinopril & hydrochlorothiazide tab 10-12.5 1 mg lisinopril & hydrochlorothiazide tab 20-12.5 1 mg lisinopril & hydrochlorothiazide tab 20-25 1 mg losartan potassium & hydrochlorothiazide 1 tab 50-12.5 mg losartan potassium & hydrochlorothiazide 1 tab 100-12.5 mg losartan potassium & hydrochlorothiazide 1 tab 100-25 mg & hydrochlorothiazide tab 50-251 mg metoprolol & hydrochlorothiazide tab 100- 1 25 mg metoprolol & hydrochlorothiazide tab 100- 1 50 mg & bendroflumethiazide tab 40-5 mg1 nadolol & bendroflumethiazide tab 80-5 mg1 & hydrochlorothiazide tab 40- 1 25 mg propranolol & hydrochlorothiazide tab 80- 1 25 mg valsartan-hydrochlorothiazide tab 80-12.5 1 mg valsartan-hydrochlorothiazide tab 160-12.51 mg

43 Drug Name Drug Tier Requirements/Limits valsartan-hydrochlorothiazide tab 160-25 1 mg valsartan-hydrochlorothiazide tab 320-12.51 mg valsartan-hydrochlorothiazide tab 320-25 1 mg Direct Renin Inhibitors TEKTURNA TAB 150MG 3 ST TEKTURNA TAB 300MG 3 ST Selective Aldosterone Receptor Antagonists (SARAs) eplerenone tab 25 mg 1 eplerenone tab 50 mg 1 Vasodilators hydralazine hcl inj 20 mg/ml 1 hydralazine hcl tab 10 mg 1 hydralazine hcl tab 25 mg 1 hydralazine hcl tab 50 mg 1 hydralazine hcl tab 100 mg 1 minoxidil tab 2.5 mg 1 minoxidil tab 10 mg 1 ANTIMALARIALS Antimalarial Combinations atovaquone-proguanil hcl tab 62.5-25 mg 1 atovaquone-proguanil hcl tab 250-100 mg 1 COARTEM TAB 20-120MG 3 Antimalarials chloroquine phosphate tab 250 mg 1 chloroquine phosphate tab 500 mg 1 DARAPRIM TAB 25MG 3 HALFAN TAB 250MG 3 hydroxychloroquine sulfate tab 200 mg 1 mefloquine hcl tab 250 mg 1 PRIMAQUINE TAB 26.3MG 3 quinine sulfate cap 324 mg 1 ANTIMYASTHENIC AGENTS Antimyasthenic Agents GUANIDINE TAB 125MG 3 MESTINON SYP 60MG/5ML 2 MESTINON TAB TIMESPAN 3 MYTELASE TAB 10MG 3 pyridostigmine bromide tab 60 mg 1 REGONOL INJ 5MG/ML 3 ANTIMYCOBACTERIAL AGENTS Anti TB Combinations isonarif cap 1 44 Drug Name Drug Tier Requirements/Limits RIFATER TAB 2 Antimycobacterial Agents CAPASTAT SUL INJ 1GM 2 cap 250 mg 1 ethambutol hcl tab 100 mg 1 ethambutol hcl tab 400 mg 1 inj 100 mg/ml 1 isoniazid syrup 50 mg/5ml 1 isoniazid tab 100 mg 1 isoniazid tab 300 mg 1 MYCOBUTIN CAP 150MG 3 PASER GRA 4GM 3 PRIFTIN TAB 150MG 2 pyrazinamide tab 500 mg 1 rifampin cap 150 mg 1 rifampin cap 300 mg 1 rifampin for inj 600 mg 1 TRECATOR TAB 250MG 2 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Alkylating Agents ALKERAN TAB 2MG 2 BICNU INJ 100MG 2 BUSULFEX INJ 6MG/ML 2 carboplatin iv for inj 150 mg 1 carboplatin iv soln 50 mg/5ml 1 carboplatin iv soln 150 mg/15ml 1 carboplatin iv soln 450 mg/45ml 1 carboplatin iv soln 600 mg/60ml 1 CEENU CAP 10MG 2 CEENU CAP 40MG 2 CEENU CAP 100MG 2 cisplatin inj 50 mg/50ml (1 mg/ml) 1 cisplatin inj 100 mg/100ml (1 mg/ml) 1 cisplatin inj 200 mg/200ml (1 mg/ml) 1 CYCLOPHOSPH INJ 1GM 2 CYCLOPHOSPH INJ 2GM 2 CYCLOPHOSPH INJ 500MG 2 cyclophosphamide tab 25 mg 1 cyclophosphamide tab 50 mg 1 ELOXATIN INJ 200MG 2 GLIADEL WAF 7.7MG 2 HEXALEN CAP 50MG 2 ifosfamide for inj 1 gm 1 ifosfamide iv inj 1 gm/20ml (50 mg/ml) 1 ifosfamide iv inj 3 gm/60ml (50 mg/ml) 1

45 Drug Name Drug Tier Requirements/Limits LEUKERAN TAB 2MG 2 melphalan hcl for inj 50 mg (base equiv) 1 MYLERAN TAB 2MG 2 oxaliplatin for iv inj 50 mg 1 oxaliplatin for iv inj 100 mg 1 oxaliplatin iv soln 50 mg/10ml 1 oxaliplatin iv soln 100 mg/20ml 1 TEMODAR CAP 5MG 4 PA TEMODAR CAP 20MG 4 PA TEMODAR CAP 100MG 4 PA TEMODAR CAP 140MG 4 PA TEMODAR CAP 180MG 4 PA TEMODAR CAP 250MG 4 PA TEMODAR INJ 100MG 4 PA thiotepa for inj 15 mg 1 THIOTEPA INJ 15MG 2 ZANOSAR INJ 1GM 2 Antimetabolites adrucil inj 50mg/ml 1 ALIMTA INJ 100MG 2 ALIMTA INJ 500MG 2 ARRANON INJ 5MG/ML 2 cladribine inj 1 mg/ml 1 CLOLAR INJ 1MG/ML 2 cytarabine for inj 1 gm 1 cytarabine for inj 100 mg 1 cytarabine for inj 500 mg 1 cytarabine inj 20 mg/ml 1 cytarabine inj 100 mg/ml 1 cytarabine inj pf 20 mg/ml 1 DACOGEN INJ 50MG 4 PA DEPOCYT INJ 50MG/5ML 2 floxuridine for inj 0.5 gm 1 fludarabine phosphate for inj 50 mg 1 fludarabine phosphate inj 25 mg/ml 1 fluorouracil inj 1 gm/20ml (50 mg/ml) 1 fluorouracil inj 2.5 gm/50ml (50 mg/ml) 1 fluorouracil inj 5 gm/100ml (50 mg/ml) 1 fluorouracil inj 500 mg/10ml (50 mg/ml) 1 gemcitabine hcl for inj 1 gm 1 gemcitabine hcl for inj 2 gm 1 gemcitabine hcl for inj 200 mg 1 mercaptopurine tab 50 mg 1 methotrexate sodium for inj 1 gm 1 methotrexate sodium inj 25 mg/ml 1

46 Drug Name Drug Tier Requirements/Limits methotrexate sodium inj pf 25 mg/ml 1 methotrexate sodium tab 2.5 mg (base 1 equiv) TABLOID TAB 40MG 2 TREXALL TAB 5MG 3 TREXALL TAB 7.5MG 3 TREXALL TAB 10MG 3 TREXALL TAB 15MG 3 VIDAZA INJ 100MG 4 PA XELODA TAB 150MG 4 PA XELODA TAB 500MG 4 PA Antineoplastic - Antibodies ARZERRA CON 100/5ML 4 PA BEXXAR CON 14MG/ML 2 CAMPATH INJ 30MG/ML 2 ERBITUX INJ 100MG 4 PA ERBITUX INJ 200MG 4 PA RITUXAN INJ 100MG 4 PA YERVOY INJ 50MG 4 PA Antineoplastic - Hedgehog Pathway Inhibitors ERIVEDGE CAP 150MG 4 PA Antineoplastic - Hormonal and Related Agents anastrozole tab 1 mg 1 bicalutamide tab 50 mg 1 DEPO-PROVERA INJ 400/ML 3 ELIGARD INJ 7.5MG 4 PA ELIGARD INJ 22.5MG 4 PA ELIGARD INJ 30MG 4 PA ELIGARD INJ 45MG 4 PA EMCYT CAP 140MG 2 exemestane tab 25 mg 1 FARESTON TAB 60MG 2 FASLODEX INJ 250MG 2 FIRMAGON INJ 80MG 4 PA FIRMAGON INJ 120MG 4 PA flutamide cap 125 mg 1 letrozole tab 2.5 mg 1 leuprolide acetate inj kit 5 mg/ml 4 PA LUPRON DEPOT INJ 3.75MG 4 PA LUPRON DEPOT INJ 11.25MG 4 PA LUPRON DEPOT INJ 22.5MG 4 PA LUPRON DEPOT INJ 30MG 4 PA LUPRON DEPOT INJ 45MG 4 PA LYSODREN TAB 500MG 2 susp 40 mg/ml 1 megestrol acetate tab 20 mg 1 47 Drug Name Drug Tier Requirements/Limits megestrol acetate tab 40 mg 1 NILANDRON TAB 150MG 2 tamoxifen citrate tab 10 mg (base 1 equivalent) tamoxifen citrate tab 20 mg (base 1 equivalent) TRELSTAR DEP INJ 3.75MG 4 PA TRELSTAR LA INJ 11.25MG 4 PA TRELSTAR MIX INJ 22.5MG 4 PA XTANDI CAP 40MG 4 PA ZYTIGA TAB 250MG 4 PA Antineoplastic Antibiotics adriamycin inj 10mg 1 ADRIAMYCIN INJ 20MG 2 bleomycin sulfate for inj 15 unit 1 bleomycin sulfate for inj 30 unit 1 dactinomycin for inj 0.5 mg 1 daunorubicin hcl for inj 20 mg 1 daunorubicin hcl inj 5 mg/ml (base equiv) 1 DAUNOXOME INJ 2MG/ML 2 doxorubicin hcl for inj 10 mg 1 doxorubicin hcl for inj 50 mg 1 doxorubicin hcl inj 2 mg/ml 1 epirubicin hcl inj 10 mg/5ml (2 mg/ml) 1 epirubicin hcl inj 50 mg/25ml (2 mg/ml) 1 epirubicin hcl inj 150 mg/75ml (2 mg/ml) 1 epirubicin hcl inj 200 mg/100ml (2 mg/ml) 1 EPIRUBICIN INJ 50MG 2 EPIRUBICIN INJ 200MG 2 idarubicin hcl iv inj 5 mg/5ml (1 mg/ml) 1 idarubicin hcl iv inj 10 mg/10ml (1 mg/ml) 1 idarubicin hcl iv inj 20 mg/20ml (1 mg/ml) 1 lipodox 50 inj 2mg/ml 1 lipodox inj 2mg/ml 1 mitomycin for inj 5 mg 1 mitomycin for inj 20 mg 1 mitomycin for inj 40 mg 1 mitoxantrone hcl inj conc 20 mg/10ml (2 4 PA mg/ml) mitoxantrone hcl inj conc 25 mg/12.5ml (2 4 PA mg/ml) mitoxantrone hcl inj conc 30 mg/15ml (2 4 PA mg/ml) Antineoplastic Combinations ifosfamide & mesna inj kit 1000-1000 mg 1 Antineoplastic Inhibitors AFINITOR TAB 2.5MG 4 PA

48 Drug Name Drug Tier Requirements/Limits AFINITOR TAB 5MG 4 PA AFINITOR TAB 7.5MG 4 PA AFINITOR TAB 10MG 4 PA BOSULIF TAB 100MG 4 PA BOSULIF TAB 500MG 4 PA CAPRELSA TAB 100MG 4 PA CAPRELSA TAB 300MG 4 PA COMETRIQ KIT 60MG 4 PA COMETRIQ KIT 100MG 4 PA COMETRIQ KIT 140MG 4 PA GLEEVEC TAB 100MG 4 PA GLEEVEC TAB 400MG 4 PA ICLUSIG TAB 15MG 4 PA ICLUSIG TAB 45MG 4 PA INLYTA TAB 1MG 4 PA INLYTA TAB 5MG 4 PA JAKAFI TAB 5MG 4 PA JAKAFI TAB 10MG 4 PA JAKAFI TAB 15MG 4 PA JAKAFI TAB 20MG 4 PA JAKAFI TAB 25MG 4 PA NEXAVAR TAB 200MG 4 PA SPRYCEL TAB 20MG 4 PA SPRYCEL TAB 50MG 4 PA SPRYCEL TAB 70MG 4 PA SPRYCEL TAB 80MG 4 PA SPRYCEL TAB 100MG 4 PA SPRYCEL TAB 140MG 4 PA STIVARGA TAB 40MG 4 PA SUTENT CAP 12.5MG 4 PA SUTENT CAP 25MG 4 PA SUTENT CAP 50MG 4 PA TARCEVA TAB 25MG 4 PA TARCEVA TAB 100MG 4 PA TARCEVA TAB 150MG 4 PA TASIGNA CAP 150MG 4 PA TASIGNA CAP 200MG 4 PA TORISEL SOL 25MG/ML 4 PA TYKERB TAB 250MG 4 PA VANDETANIB TAB 100MG 4 PA VANDETANIB TAB 300MG 4 PA VOTRIENT TAB 200MG 4 PA XALKORI CAP 200MG 4 PA XALKORI CAP 250MG 4 PA ZELBORAF TAB 240MG 4 PA

49 Drug Name Drug Tier Requirements/Limits ZOLINZA CAP 100MG 4 PA Antineoplastic ELSPAR INJ 10000UNT 4 PA ONCASPAR INJ 750/ML 4 PA Antineoplastic Radiopharmaceuticals BEXXAR 131 I INJ 0.61/ML 2 BEXXAR 131 I INJ 5.6MCI/M 2 QUADRAMET INJ 2 Antineoplastics Misc. ACTIMMUNE INJ 2MU/0.5 4 PA ALFERON N INJ 5MU/ML 4 PA dacarbazine for inj 100 mg 1 dacarbazine for inj 200 mg 1 hydroxyurea cap 500 mg 1 INTRON-A INJ 3MU PEN 4 PA INTRON-A INJ 5MU PEN 4 PA INTRON-A INJ 10MU 4 PA INTRON-A INJ 10MU PEN 4 PA INTRON-A INJ 18MU 4 PA INTRON-A INJ 25MU 4 PA INTRON-A INJ 50MU 4 PA MATULANE CAP 50MG 2 ONTAK INJ 150/ML 2 pentostatin for inj 10 mg 1 PHOTOFRIN INJ 75MG 2 SYNRIBO INJ 3.5MG 4 PA TARGRETIN CAP 75MG 4 PA THERACYS INJ 2 TICE BCG INJ 2 tretinoin cap 10 mg 1 PA TRISENOX SOL 10MG/10M 2 UVADEX INJ 20MCG/ML 2 Adjuncts KEPIVANCE INJ 6.25MG 2 Chemotherapy Rescue/ Agents amifostine crystalline for inj 500 mg 1 dexrazoxane for inj 250 mg 1 dexrazoxane for inj 500 mg 1 leucovorin calcium for inj 50 mg 1 leucovorin calcium for inj 100 mg 1 leucovorin calcium for inj 200 mg 1 leucovorin calcium for inj 350 mg 1 leucovorin calcium inj 10 mg/ml 1 leucovorin calcium tab 5 mg 1 leucovorin calcium tab 10 mg 1

50 Drug Name Drug Tier Requirements/Limits leucovorin calcium tab 15 mg 1 leucovorin calcium tab 25 mg 1 LEUCOVORIN INJ CALCIUM 2 mesna inj 100 mg/ml 1 MESNEX TAB 400MG 2 Mitotic Inhibitors ABRAXANE INJ 100MG 2 DOCEFREZ INJ 20MG 2 DOCEFREZ INJ 80MG 2 docetaxel for inj conc 20 mg/ml 1 docetaxel for inj conc 80 mg/4ml (20 1 mg/ml) DOCETAXEL INJ 20/0.5ML 2 DOCETAXEL INJ 20MG/2ML 2 DOCETAXEL INJ 80MG/2ML 2 DOCETAXEL INJ 80MG/8ML 2 DOCETAXEL INJ 160/16ML 2 ETOPOPHOS INJ 100MG 2 etoposide cap 50 mg 1 etoposide inj 20 mg/ml 1 paclitaxel iv conc 30 mg/5ml (6 mg/ml) 1 paclitaxel iv conc 100 mg/16.7ml (6 1 mg/ml) paclitaxel iv conc 150 mg/25ml (6 mg/ml) 1 paclitaxel iv conc 300 mg/50ml (6 mg/ml) 1 TAXOTERE INJ 20/0.5ML 2 TAXOTERE INJ 80MG/2ML 2 toposar inj 100/5ml 1 VINBLASTINE INJ 10MG 2 vinblastine sulfate inj 1 mg/ml 1 vincasar pfs inj 1mg/ml 1 vincristine sulfate iv soln 1 mg/ml 1 vinorelbine tartrate inj 10 mg/ml 1 vinorelbine tartrate inj 50 mg/5ml (10 1 mg/ml) VUMON INJ 50MG/5ML 2 Topoisomerase I Inhibitors CAMPTOSAR INJ 300/15ML 2 HYCAMTIN CAP 0.25MG 4 PA HYCAMTIN CAP 1MG 4 PA irinotecan hcl inj 40 mg/2ml (20 mg/ml) 1 irinotecan hcl inj 100 mg/5ml (20 mg/ml) 1 irinotecan hcl inj 500 mg/25ml (20 mg/ml) 1 topotecan hcl for inj 4 mg 1 TOPOTECAN INJ 4MG/4ML 2 ANTIPARKINSON AGENTS

51 Drug Name Drug Tier Requirements/Limits Antiparkinson Adjuvants LODOSYN TAB 25MG 3 Antiparkinson Anticholinergics benztropine mesylate inj 1 mg/ml 1 benztropine mesylate tab 0.5 mg 1 benztropine mesylate tab 1 mg 1 benztropine mesylate tab 2 mg 1 hcl elixir 0.4 mg/ml 1 trihexyphenidyl hcl tab 2 mg 1 trihexyphenidyl hcl tab 5 mg 1 Antiparkinson COMT Inhibitors entacapone tab 200 mg 1 TASMAR TAB 100MG 3 Antiparkinson Dopaminergics amantadine hcl cap 100 mg 1 amantadine hcl syrup 50 mg/5ml 1 amantadine hcl tab 100 mg 1 APOKYN INJ 4 PA mesylate cap 5 mg 1 bromocriptine mesylate tab 2.5 mg 1 carbidopa & levodopa orally disintegrating 1 tab 10-100 mg carbidopa & levodopa orally disintegrating 1 tab 25-100 mg carbidopa & levodopa orally disintegrating 1 tab 25-250 mg carbidopa & levodopa tab 10-100 mg 1 carbidopa & levodopa tab 25-100 mg 1 carbidopa & levodopa tab 25-250 mg 1 carbidopa & levodopa tab cr 25-100 mg 1 carbidopa & levodopa tab cr 50-200 mg 1 carbidopa-levodopa-entacapone tabs 12.5- 1 50-200 mg carbidopa-levodopa-entacapone tabs 1 18.75-75-200 mg carbidopa-levodopa-entacapone tabs 25- 1 100-200 mg carbidopa-levodopa-entacapone tabs 1 31.25-125-200 mg carbidopa-levodopa-entacapone tabs 37.5- 1 150-200 mg carbidopa-levodopa-entacapone tabs 50- 1 200-200 mg MIRAPEX ER TAB 0.75MG 2 MIRAPEX ER TAB 0.375MG 2 MIRAPEX ER TAB 1.5MG 2 MIRAPEX ER TAB 2.25MG 2 MIRAPEX ER TAB 3.75MG 2

52 Drug Name Drug Tier Requirements/Limits MIRAPEX ER TAB 3MG 2 MIRAPEX ER TAB 4.5MG 2 pramipexole dihydrochloride tab 0.5 mg 1 pramipexole dihydrochloride tab 0.25 mg 1 pramipexole dihydrochloride tab 0.75 mg 1 pramipexole dihydrochloride tab 0.125 mg 1 pramipexole dihydrochloride tab 1 mg 1 pramipexole dihydrochloride tab 1.5 mg 1 hydrochloride tab 0.5 mg 1 ropinirole hydrochloride tab 0.25 mg 1 ropinirole hydrochloride tab 1 mg 1 ropinirole hydrochloride tab 2 mg 1 ropinirole hydrochloride tab 3 mg 1 ropinirole hydrochloride tab 4 mg 1 ropinirole hydrochloride tab 5 mg 1 Antiparkinson Monoamine Oxidase Inhibitors AZILECT TAB 0.5MG 2 AZILECT TAB 1MG 2 hcl cap 5 mg 1 selegiline hcl tab 5 mg 1 ZELAPAR TAB 1.25MG 3 /ANTIMANIC AGENTS Antimanic Agents carbonate cap 150 mg 1 cap 300 mg 1 lithium carbonate cap 600 mg 1 lithium carbonate tab 300 mg 1 lithium carbonate tab cr 300 mg 1 lithium carbonate tab cr 450 mg 1 LITHIUM CITR SOL 8MEQ/5ML 3 Antipsychotics - Misc. GEODON INJ 20MG 3 LATUDA TAB 20MG 2 ST LATUDA TAB 40MG 2 ST LATUDA TAB 80MG 2 ST LATUDA TAB 120MG 2 ST hcl cap 20 mg 1 ziprasidone hcl cap 40 mg 1 ziprasidone hcl cap 60 mg 1 ziprasidone hcl cap 80 mg 1 Benzisoxazoles FANAPT PAK 3 ST FANAPT TAB 1MG 3 ST FANAPT TAB 2MG 3 ST FANAPT TAB 4MG 3 ST

53 Drug Name Drug Tier Requirements/Limits FANAPT TAB 6MG 3 ST FANAPT TAB 8MG 3 ST FANAPT TAB 10MG 3 ST FANAPT TAB 12MG 3 ST INVEGA SUST INJ 39/0.25 3 PA INVEGA SUST INJ 78/0.5ML 3 PA INVEGA SUST INJ 117/0.75 3 PA INVEGA SUST INJ 156MG/ML 3 PA INVEGA SUST INJ 234/1.5 3 PA INVEGA TAB 1.5MG 2 ST INVEGA TAB 3MG 2 ST INVEGA TAB 6MG 2 ST INVEGA TAB 9MG 2 ST RISPERDAL INJ 12.5MG 2 PA RISPERDAL INJ 25MG 2 PA RISPERDAL INJ 37.5MG 2 PA RISPERDAL INJ 50MG 2 PA orally disintegrating tab 0.5 mg 1 risperidone orally disintegrating tab 0.25 1 mg risperidone orally disintegrating tab 1 mg 1 risperidone orally disintegrating tab 2 mg 1 risperidone orally disintegrating tab 3 mg 1 risperidone orally disintegrating tab 4 mg 1 risperidone soln 1 mg/ml 1 risperidone tab 0.5 mg 1 risperidone tab 0.25 mg 1 risperidone tab 1 mg 1 risperidone tab 2 mg 1 risperidone tab 3 mg 1 risperidone tab 4 mg 1 Butyrophenones decanoate im soln 50 mg/ml 1 im soln 100 mg/ml 1 haloperidol lactate inj 5 mg/ml 1 haloperidol lactate oral conc 2 mg/ml 1 haloperidol tab 0.5 mg 1 haloperidol tab 1 mg 1 haloperidol tab 2 mg 1 haloperidol tab 5 mg 1 haloperidol tab 10 mg 1 haloperidol tab 20 mg 1 Dibenzapines tab 25 mg 1 clozapine tab 50 mg 1 clozapine tab 100 mg 1

54 Drug Name Drug Tier Requirements/Limits clozapine tab 200 mg 1 succinate cap 5 mg 1 loxapine succinate cap 10 mg 1 loxapine succinate cap 25 mg 1 loxapine succinate cap 50 mg 1 for im inj 10 mg 1 olanzapine orally disintegrating tab 5 mg 1 olanzapine orally disintegrating tab 10 mg 1 olanzapine orally disintegrating tab 15 mg 1 olanzapine orally disintegrating tab 20 mg 1 olanzapine tab 2.5 mg 1 olanzapine tab 5 mg 1 olanzapine tab 7.5 mg 1 olanzapine tab 10 mg 1 olanzapine tab 15 mg 1 olanzapine tab 20 mg 1 fumarate tab 25 mg 1 quetiapine fumarate tab 50 mg 1 quetiapine fumarate tab 100 mg 1 quetiapine fumarate tab 200 mg 1 quetiapine fumarate tab 300 mg 1 quetiapine fumarate tab 400 mg 1 SAPHRIS SUB 5MG 3 ST SAPHRIS SUB 10MG 3 ST SEROQUEL XR TAB 50MG 2 ST SEROQUEL XR TAB 150MG 2 ST SEROQUEL XR TAB 200MG 2 ST SEROQUEL XR TAB 300MG 2 ST SEROQUEL XR TAB 400MG 2 ST Phenothiazines CHLORPROMAZ INJ 25MG/ML 3 hcl tab 10 mg 1 chlorpromazine hcl tab 25 mg 1 chlorpromazine hcl tab 50 mg 1 chlorpromazine hcl tab 100 mg 1 chlorpromazine hcl tab 200 mg 1 compro sup 25mg 1 decanoate inj 25 mg/ml 1 fluphenazine hcl elixir 2.5 mg/5ml 1 fluphenazine hcl inj 2.5 mg/ml 1 fluphenazine hcl oral conc 5 mg/ml 1 fluphenazine hcl tab 1 mg 1 fluphenazine hcl tab 2.5 mg 1 fluphenazine hcl tab 5 mg 1 fluphenazine hcl tab 10 mg 1

55 Drug Name Drug Tier Requirements/Limits tab 2 mg 1 perphenazine tab 4 mg 1 perphenazine tab 8 mg 1 perphenazine tab 16 mg 1 edisylate inj 5 mg/ml 1 prochlorperazine maleate tab 5 mg 1 prochlorperazine maleate tab 10 mg 1 prochlorperazine suppos 25 mg 1 hcl tab 10 mg 1 thioridazine hcl tab 25 mg 1 thioridazine hcl tab 50 mg 1 thioridazine hcl tab 100 mg 1 hcl tab 1 mg 1 trifluoperazine hcl tab 2 mg 1 trifluoperazine hcl tab 5 mg 1 trifluoperazine hcl tab 10 mg 1 Quinolinone Derivatives ABILIFY DISC TAB 10MG 3 ST ABILIFY DISC TAB 15MG 3 ST ABILIFY INJ 9.75MG 3 ST ABILIFY SOL 1MG/ML 2 ST ABILIFY TAB 2MG 2 ST ABILIFY TAB 5MG 2 ST ABILIFY TAB 10MG 2 ST ABILIFY TAB 15MG 2 ST ABILIFY TAB 20MG 2 ST ABILIFY TAB 30MG 2 ST NAVANE CAP 20MG 3 thiothixene cap 1 mg 1 thiothixene cap 2 mg 1 thiothixene cap 5 mg 1 thiothixene cap 10 mg 1 ANTISEPTICS DISINFECTANTS Chlorine Antiseptics PHISOHEX LIQ 3% 3 ANTIVIRALS Antiretrovirals abacavir sulfate tab 300 mg (base equiv) 1 APTIVUS CAP 250MG 2 APTIVUS SOL 2 ATRIPLA TAB 2 COMPLERA TAB 2 CRIXIVAN CAP 100MG 2

56 Drug Name Drug Tier Requirements/Limits CRIXIVAN CAP 200MG 2 CRIXIVAN CAP 400MG 2 didanosine delayed release capsule 125 mg1 didanosine delayed release capsule 200 mg1 didanosine delayed release capsule 250 mg1 didanosine delayed release capsule 400 mg1 EDURANT TAB 25MG 2 EMTRIVA CAP 200MG 2 EMTRIVA SOL 10MG/ML 2 EPIVIR HBV SOL 5MG/ML 2 EPIVIR HBV TAB 100MG 2 EPIVIR SOL 10MG/ML 2 EPZICOM TAB 600-300 2 FUZEON INJ 90MG 4 PA FUZEON KIT 4 PA INTELENCE TAB 25MG 2 INTELENCE TAB 100MG 2 INTELENCE TAB 200MG 2 INVIRASE CAP 200MG 2 INVIRASE TAB 500MG 2 ISENTRESS CHW 25MG 2 ISENTRESS CHW 100MG 2 ISENTRESS TAB 400MG 2 KALETRA SOL 2 KALETRA TAB 100-25MG 2 KALETRA TAB 200-50MG 2 lamivudine tab 150 mg 1 lamivudine tab 300 mg 1 lamivudine-zidovudine tab 150-300 mg 1 LEXIVA SUS 50MG/ML 2 LEXIVA TAB 700MG 2 nevirapine susp 50 mg/5ml 1 nevirapine tab 200 mg 1 NORVIR CAP 100MG 2 NORVIR SOL 80MG/ML 2 NORVIR TAB 100MG 2 PREZISTA TAB 75MG 2 PREZISTA TAB 150MG 2 PREZISTA TAB 400MG 2 PREZISTA TAB 600MG 2 PREZISTA TAB 800MG 2 RESCRIPTOR TAB 100 MG 2 RESCRIPTOR TAB 200MG 2 RETROVIR INJ 10MG/ML 3 REYATAZ CAP 100MG 2

57 Drug Name Drug Tier Requirements/Limits REYATAZ CAP 150MG 2 REYATAZ CAP 200MG 2 REYATAZ CAP 300MG 2 SELZENTRY TAB 150MG 2 SELZENTRY TAB 300MG 2 stavudine cap 15 mg 1 stavudine cap 20 mg 1 stavudine cap 30 mg 1 stavudine cap 40 mg 1 stavudine for oral soln 1 mg/ml 1 SUSTIVA CAP 50MG 2 SUSTIVA CAP 200MG 2 SUSTIVA TAB 600MG 2 TRIZIVIR TAB 2 TRUVADA TAB 200-300 2 VIDEX SOL 2GM 2 VIDEX SOL 4GM 2 VIRACEPT TAB 250MG 2 VIRACEPT TAB 625MG 2 VIRAMUNE XR TAB 400MG 2 VIREAD POW 40MG/GM 2 VIREAD TAB 150MG 2 VIREAD TAB 200MG 2 VIREAD TAB 250MG 2 VIREAD TAB 300MG 2 ZIAGEN SOL 20MG/ML 2 zidovudine cap 100 mg 1 zidovudine syrup 10 mg/ml 1 zidovudine tab 300 mg 1 CMV Agents cidofovir iv inj 75 mg/ml 1 foscarnet sodium inj 24 mg/ml 1 ganciclovir cap 250 mg 1 ganciclovir cap 500 mg 1 VALCYTE SOL 50MG/ML 3 VALCYTE TAB 450MG 3 Hepatitis Agents BARACLUDE SOL .05MG/ML 2 BARACLUDE TAB 0.5MG 2 BARACLUDE TAB 1MG 2 HEPSERA TAB 10MG 4 PA INCIVEK TAB 375MG 4 PA INFERGEN INJ 9MCG 4 PA INFERGEN INJ 15MCG 4 PA PEG-INTRON KIT 50MCG 4 PA

58 Drug Name Drug Tier Requirements/Limits PEG-INTRON KIT 50MCG RP 4 PA PEG-INTRON KIT 80MCG 4 PA PEG-INTRON KIT 80MCG RP 4 PA PEG-INTRON KIT 120 RP 4 PA PEG-INTRON KIT 120MCG 4 PA PEG-INTRON KIT 150 RP 4 PA PEG-INTRON KIT 150MCG 4 PA PEGASYS INJ 4 PA PEGASYS INJ 180MCG/M 4 PA PEGASYS INJ PROCLICK 4 PA PEGASYS KIT 4 PA REBETOL SOL 40MG/ML 4 PA RIBAPAK MIS 600/DAY 4 PA RIBAPAK PAK 1000/DAY 4 PA ribasphere cap 200mg 4 PA ribasphere tab 200mg 4 PA ribasphere tab 400mg 4 PA ribasphere tab 600mg 4 PA RIBATAB PAK 1000/DAY 4 PA ribavirin cap 200 mg 4 PA ribavirin tab 200 mg 4 PA TYZEKA TAB 600MG 4 PA VICTRELIS CAP 200MG 4 PA Herpes Agents acyclovir cap 200 mg 1 acyclovir sodium for inj 500 mg 1 acyclovir susp 200 mg/5ml 1 acyclovir tab 400 mg 1 acyclovir tab 800 mg 1 famciclovir tab 125 mg 1 famciclovir tab 250 mg 1 famciclovir tab 500 mg 1 valacyclovir hcl tab 1 gm 1 valacyclovir hcl tab 500 mg 1 Agents RELENZA MIS DISKHALE 2 QL (40 / 180 days) rimantadine hydrochloride tab 100 mg 1 TAMIFLU CAP 30MG 2 QL (28 caps / 180 days) TAMIFLU CAP 45MG 2 QL (14 caps / 180 days) TAMIFLU CAP 75MG 2 QL (14 caps / 180 days) TAMIFLU SUS 6MG/ML 2 QL (180 ml / 180 days) TAMIFLU SUS 12MG/ML 2 QL (180 ml / 180 days) Respiratory Syncytial Virus (RSV) Agents VIRAZOLE INH 6GM 3 ASSORTED CLASSES

59 Drug Name Drug Tier Requirements/Limits Chelating Agents DEPEN TITRA TAB 250MG 3 SYPRINE CAP 250MG 3 Immunomodulators REVLIMID CAP 2.5MG 4 PA REVLIMID CAP 5MG 4 PA REVLIMID CAP 10MG 4 PA REVLIMID CAP 15MG 4 PA REVLIMID CAP 25MG 4 PA THALOMID CAP 50MG 4 PA THALOMID CAP 100MG 4 PA THALOMID CAP 150MG 4 PA THALOMID CAP 200MG 4 PA Immunosuppressive Agents ATGAM INJ 250MG 3 AZASAN TAB 75 MG 3 AZASAN TAB 100MG 3 azathioprine sodium for inj 100 mg 1 azathioprine tab 50 mg 1 CELLCEPT IV INJ 500MG 3 CELLCEPT SUS 200MG/ML 2 cyclosporine cap 25 mg 1 cyclosporine cap 100 mg 1 cyclosporine iv soln 50 mg/ml 1 cyclosporine modified cap 25 mg 1 cyclosporine modified cap 50 mg 1 cyclosporine modified cap 100 mg 1 cyclosporine modified oral soln 100 mg/ml 1 gengraf cap 25mg 1 gengraf cap 100mg 1 gengraf sol 100mg/ml 1 mycophenolate mofetil cap 250 mg 1 mycophenolate mofetil tab 500 mg 1 MYFORTIC TAB 180MG 3 MYFORTIC TAB 360MG 3 NULOJIX INJ 250MG 3 PROGRAF INJ 5MG/ML 3 RAPAMUNE SOL 1MG/ML 2 RAPAMUNE TAB 0.5MG 2 RAPAMUNE TAB 1MG 2 RAPAMUNE TAB 2MG 2 SANDIMMUNE SOL 100MG/ML 3 SIMULECT INJ 10MG 3 SIMULECT INJ 20MG 3 tacrolimus cap 0.5 mg 1

60 Drug Name Drug Tier Requirements/Limits tacrolimus cap 1 mg 1 tacrolimus cap 5 mg 1 THYMOGLOBULN INJ 25MG 3 ZORTRESS TAB 0.5MG 2 ZORTRESS TAB 0.25MG 2 ZORTRESS TAB 0.75MG 2 Irrigation Solutions physiolyte sol 1 physiosol sol irrigat 1 tis-u-sol sol 1 Potassium Removing Resins kionex sus 15gm/60 1 sodium polystyrene sulfonate oral susp 15 1 gm/60ml sodium polystyrene sulfonate rectal susp 1 30 gm/120ml Systemic Lupus Erythematosus Agents BENLYSTA INJ 120MG 4 PA BETA BLOCKERS Alpha-Beta Blockers tab 3.125 mg 1 carvedilol tab 6.25 mg 1 carvedilol tab 12.5 mg 1 carvedilol tab 25 mg 1 COREG CR CAP 10MG 3 COREG CR CAP 20MG 3 COREG CR CAP 40MG 3 COREG CR CAP 80MG 3 hcl iv soln 5 mg/ml 1 labetalol hcl tab 100 mg 1 labetalol hcl tab 200 mg 1 labetalol hcl tab 300 mg 1 Beta Blockers Cardio-Selective hcl cap 200 mg 1 acebutolol hcl cap 400 mg 1 atenolol tab 25 mg 1 atenolol tab 50 mg 1 atenolol tab 100 mg 1 hcl tab 10 mg 1 betaxolol hcl tab 20 mg 1 bisoprolol fumarate tab 5 mg 1 bisoprolol fumarate tab 10 mg 1 BYSTOLIC TAB 2.5MG 3 BYSTOLIC TAB 5MG 3 BYSTOLIC TAB 10MG 3

61 Drug Name Drug Tier Requirements/Limits BYSTOLIC TAB 20MG 3 metoprolol succinate tab sr 24hr 25 mg 1 metoprolol succinate tab sr 24hr 50 mg 1 metoprolol succinate tab sr 24hr 100 mg 1 metoprolol succinate tab sr 24hr 200 mg 1 metoprolol tartrate inj 1 mg/ml 1 metoprolol tartrate tab 25 mg 1 metoprolol tartrate tab 50 mg 1 metoprolol tartrate tab 100 mg 1 Beta Blockers Non-Selective LEVATOL TAB 20MG 3 nadolol tab 20 mg 1 nadolol tab 40 mg 1 nadolol tab 80 mg 1 nadolol tab 160 mg 1 tab 5 mg 1 pindolol tab 10 mg 1 propranolol hcl cap sr 24hr 60 mg 1 propranolol hcl cap sr 24hr 80 mg 1 propranolol hcl cap sr 24hr 120 mg 1 propranolol hcl cap sr 24hr 160 mg 1 propranolol hcl inj 1 mg/ml 1 propranolol hcl oral soln 20 mg/5ml 1 propranolol hcl oral soln 40 mg/5ml 1 propranolol hcl tab 10 mg 1 propranolol hcl tab 20 mg 1 propranolol hcl tab 40 mg 1 propranolol hcl tab 60 mg 1 propranolol hcl tab 80 mg 1 sorine tab 80mg 1 sorine tab 120mg 1 sorine tab 160mg 1 sorine tab 240mg 1 hcl (afib/afl) tab 80 mg 1 sotalol hcl (afib/afl) tab 120 mg 1 sotalol hcl (afib/afl) tab 160 mg 1 SOTALOL HCL INJ 150/10ML 3 sotalol hcl tab 80 mg 1 sotalol hcl tab 120 mg 1 sotalol hcl tab 160 mg 1 sotalol hcl tab 240 mg 1 maleate tab 5 mg 1 timolol maleate tab 10 mg 1 timolol maleate tab 20 mg 1 BIOLOGICALS MISC

62 Drug Name Drug Tier Requirements/Limits Biologicals Misc ADAGEN INJ 250/ML 4 PA CALCIUM CHANNEL BLOCKERS Calcium Channel Blockers afeditab tab 30mg cr 1 afeditab tab 60mg cr 1 amlodipine besylate tab 2.5 mg 1 amlodipine besylate tab 5 mg 1 amlodipine besylate tab 10 mg 1 CARDENE IV INJ 40/200ML 3 CARDENE IV SOL 20/200ML 3 CARDIZEM LA TAB 120MG 2 cartia xt cap 120/24hr 1 cartia xt cap 180/24hr 1 cartia xt cap 240/24hr 1 cartia xt cap 300/24hr 1 dilt-cd cap 120mg 1 dilt-cd cap 180mg 1 dilt-cd cap 240mg 1 dilt-cd cap 300mg 1 diltiazem hcl cap sr 12hr 60 mg 1 diltiazem hcl cap sr 12hr 90 mg 1 diltiazem hcl cap sr 12hr 120 mg 1 diltiazem hcl cap sr 24hr 120 mg 1 diltiazem hcl cap sr 24hr 180 mg 1 diltiazem hcl cap sr 24hr 240 mg 1 diltiazem hcl coated beads cap sr 24hr 120 1 mg diltiazem hcl coated beads cap sr 24hr 180 1 mg diltiazem hcl coated beads cap sr 24hr 240 1 mg diltiazem hcl coated beads cap sr 24hr 300 1 mg diltiazem hcl coated beads cap sr 24hr 360 1 mg diltiazem hcl extended release beads cap sr1 24hr 120 mg diltiazem hcl extended release beads cap sr1 24hr 180 mg diltiazem hcl extended release beads cap sr1 24hr 240 mg diltiazem hcl extended release beads cap sr1 24hr 300 mg diltiazem hcl extended release beads cap sr1 24hr 360 mg diltiazem hcl extended release beads cap sr1 24hr 420 mg

63 Drug Name Drug Tier Requirements/Limits diltiazem hcl iv soln 25 mg/5ml (5 mg/ml) 1 diltiazem hcl tab 30 mg 1 diltiazem hcl tab 60 mg 1 diltiazem hcl tab 90 mg 1 diltiazem hcl tab 120 mg 1 DILTIAZEM INJ 100MG 3 diltzac cap 120mg/24 1 diltzac cap 180mg/24 1 diltzac cap 240mg/24 1 diltzac cap 300mg/24 1 diltzac cap 360mg/24 1 felodipine tab sr 24hr 2.5 mg 1 felodipine tab sr 24hr 5 mg 1 felodipine tab sr 24hr 10 mg 1 isradipine cap 2.5 mg 1 isradipine cap 5 mg 1 matzim la tab 180mg/24 1 matzim la tab 240mg/24 1 matzim la tab 300mg/24 1 matzim la tab 360mg/24 1 matzim la tab 420mg/24 1 nicardipine hcl cap 20 mg 1 nicardipine hcl cap 30 mg 1 nicardipine hcl iv soln 2.5 mg/ml 1 nifediac cc tab 30mg er 1 nifediac cc tab 60mg er 1 nifediac cc tab 90mg er 1 nifedical xl tab 30mg 1 nifedical xl tab 60mg 1 nifedipine tab sr 24hr 30 mg 1 nifedipine tab sr 24hr 60 mg 1 nifedipine tab sr 24hr 90 mg 1 nifedipine tab sr 24hr osmotic 30 mg 1 nifedipine tab sr 24hr osmotic 60 mg 1 nifedipine tab sr 24hr osmotic 90 mg 1 nimodipine cap 30 mg 1 nisoldipine tab sr 24hr 8.5 mg 1 nisoldipine tab sr 24hr 17 mg 1 nisoldipine tab sr 24hr 20 mg 1 nisoldipine tab sr 24hr 25.5 mg 1 nisoldipine tab sr 24hr 30 mg 1 nisoldipine tab sr 24hr 34 mg 1 nisoldipine tab sr 24hr 40 mg 1 taztia xt cap 120mg/24 1 taztia xt cap 180mg/24 1

64 Drug Name Drug Tier Requirements/Limits taztia xt cap 240mg/24 1 taztia xt cap 300mg/24 1 taztia xt cap 360mg/24 1 verapamil hcl cap sr 24hr 100 mg 1 verapamil hcl cap sr 24hr 120 mg 1 verapamil hcl cap sr 24hr 180 mg 1 verapamil hcl cap sr 24hr 200 mg 1 verapamil hcl cap sr 24hr 240 mg 1 verapamil hcl cap sr 24hr 300 mg 1 verapamil hcl cap sr 24hr 360 mg 1 verapamil hcl iv soln 2.5 mg/ml 1 verapamil hcl tab 40 mg 1 verapamil hcl tab 80 mg 1 verapamil hcl tab 120 mg 1 verapamil hcl tab cr 120 mg 1 verapamil hcl tab cr 180 mg 1 verapamil hcl tab cr 240 mg 1 CARDIOTONICS Cardiac Glycosides digoxin inj 0.25 mg/ml 1 digoxin oral soln 0.05 mg/ml 1 digoxin tab 0.25 mg 1 digoxin tab 0.125 mg 1 LANOXIN INJ 0.1MG/ML 3 CARDIOVASCULAR AGENTS - MISC. Impotence Agents CIALIS TAB 2.5MG 3 PA Prostaglandin Vasodilators epoprostenol sodium for inj 0.5 mg 4 PA epoprostenol sodium for inj 1.5 mg 4 PA REMODULIN INJ 1MG/ML 4 PA REMODULIN INJ 2.5MG/ML 4 PA REMODULIN INJ 5MG/ML 4 PA REMODULIN INJ 10MG/ML 4 PA TYVASO START SOL 0.6MG/ML 4 PA VENTAVIS SOL 10MCG/ML 4 PA VENTAVIS SOL 20MCG/ML 4 PA Pulmonary Hypertension - Endothelin Receptor Antagonists LETAIRIS TAB 5MG 4 PA LETAIRIS TAB 10MG 4 PA TRACLEER TAB 62.5MG 4 PA TRACLEER TAB 125MG 4 PA Pulmonary Hypertension - Phosphodiesterase Inhibitors ADCIRCA TAB 20MG 4 PA

65 Drug Name Drug Tier Requirements/Limits REVATIO INJ 4 PA citrate tab 20 mg 4 PA CEPHALOSPORINS Cephalosporins - 1st Generation cefadroxil cap 500 mg 1 cefadroxil for susp 250 mg/5ml 1 cefadroxil for susp 500 mg/5ml 1 cefadroxil tab 1 gm 1 CEFAZOL/DEX SOL 2GM 3 CEFAZOLIN INJ 1GM/50ML 3 cefazolin sodium for inj 1 gm 1 cefazolin sodium for inj 10 gm 1 cefazolin sodium for inj 500 mg 1 cephalexin cap 250 mg 1 cephalexin cap 500 mg 1 cephalexin for susp 125 mg/5ml 1 cephalexin for susp 250 mg/5ml 1 cephalexin tab 250 mg 1 cephalexin tab 500 mg 1 KEFLEX CAP 750MG 2 Cephalosporins - 2nd Generation cefaclor cap 250 mg 1 cefaclor cap 500 mg 1 CEFACLOR ER TAB 500MG 2 cefaclor for susp 125 mg/5ml 1 cefaclor for susp 250 mg/5ml 1 cefaclor for susp 375 mg/5ml 1 CEFOTET/DEX INJ 1-3.58% 3 CEFOTET/DEX INJ 2-2.08% 3 CEFOTETAN INJ 1GM/10ML 3 CEFOTETAN INJ 2GM/20ML 3 CEFOTETAN INJ 10G 3 CEFOXITIN INJ 1GM 3 CEFOXITIN INJ 2GM 3 cefoxitin sodium for inj 1 gm 1 cefoxitin sodium for inj 2 gm 1 cefoxitin sodium for inj 10 gm 1 cefprozil for susp 125 mg/5ml 1 cefprozil for susp 250 mg/5ml 1 cefprozil tab 250 mg 1 cefprozil tab 500 mg 1 CEFTIN SUS 250/5ML 2 CEFUROX/DEXT INJ 1.5GM 3 CEFUROX/DEXT INJ 750MG 3 cefuroxime axetil for susp 125 mg/5ml 1

66 Drug Name Drug Tier Requirements/Limits cefuroxime axetil tab 250 mg 1 cefuroxime axetil tab 500 mg 1 CEFUROXIME INJ 75GM 3 cefuroxime sodium for inj 1.5 gm 1 cefuroxime sodium for inj 7.5 gm 1 cefuroxime sodium for inj 750 mg 1 MEFOXIN INJ 1GM/50ML 3 MEFOXIN INJ 2GM/50ML 3 ZINACEF INJ 750MG 3 ZINACEF/H20 INJ 1.5GM PB 3 Cephalosporins - 3rd Generation CEDAX CAP 400MG 3 cefdinir cap 300 mg 1 cefdinir for susp 125 mg/5ml 1 cefdinir for susp 250 mg/5ml 1 cefditoren pivoxil tab 200 mg (base 1 equivalent) cefotaxime sodium for inj 1 gm 1 cefotaxime sodium for inj 2 gm 1 cefotaxime sodium for inj 10 gm 1 cefotaxime sodium for inj 500 mg 1 cefpodoxime proxetil for susp 50 mg/5ml 1 cefpodoxime proxetil for susp 100 mg/5ml 1 cefpodoxime proxetil tab 100 mg 1 cefpodoxime proxetil tab 200 mg 1 ceftazidime for inj 1 gm 1 ceftazidime for inj 2 gm 1 ceftazidime for inj 6 gm 1 ceftazidime for inj 500 mg 1 CEFTAZIDIME INJ 100GM 3 CEFTAZIDIME/ SOL D5W 1GM 3 CEFTAZIDIME/ SOL D5W 2GM 3 CEFTRIAXONE INJ 100GM 3 ceftriaxone sodium for inj 1 gm 1 ceftriaxone sodium for inj 2 gm 1 ceftriaxone sodium for inj 10 gm 1 ceftriaxone sodium for inj 250 mg 1 ceftriaxone sodium for inj 500 mg 1 ceftriaxone sodium for iv soln 1 gm 1 ceftriaxone sodium for iv soln 2 gm 1 CLAFORAN INJ 1GM 3 CLAFORAN INJ 2GM 3 FORTAZ INJ 1GM 3 FORTAZ INJ 2GM 3 SUPRAX CHW 100MG 2 SUPRAX CHW 200MG 2

67 Drug Name Drug Tier Requirements/Limits SUPRAX SUS 100/5ML 2 SUPRAX SUS 200/5ML 2 SUPRAX TAB 400MG 2 tazicef inj 1gm 1 tazicef inj 2gm 1 tazicef inj 6gm 1 Cephalosporins - 4th Generation cefepime hcl for inj 1 gm 1 cefepime hcl for inj 2 gm 1 CEFEPIME INJ 1GM 3 CEFEPIME INJ 2GM 3 MAXIPIME INJ 1GM 3 MAXIPIME INJ 2GM 3 Cephalosporins - 5th Generation TEFLARO INJ 400MG 3 TEFLARO INJ 600MG 3 CONTRACEPTIVES Combination Contraceptives - Oral altavera tab 0 alyacen tab 1/35 0 alyacen tab 7/7/7 0 amethia tab 0 amethyst tab 90-20mcg 0 apri tab 0 aranelle tab 0 aviane tab 0 azurette tab 28 day 0 BEYAZ TAB 0 caziant pak 0 cesia pak 0 chateal tab 0.15/30 0 cryselle-28 tab 28 tabs 0 cyclafem tab 1/35 0 cyclafem tab 7/7/7 0 dasetta tab 1/35 0 dasetta tab 7/7/7 0 drospirenone-ethinyl estradiol tab 3-0.03 0 mg elinest tab 0 emoquette tab 0 enpresse-28 tab 0 falmina tab 0 GENERESS FE CHW 0 gianvi tab 3-0.02mg 0 gildess fe tab 1.5/30 0

68 Drug Name Drug Tier Requirements/Limits gildess fe tab 1/20 0 gildess tab 1.5/30 0 gildess tab 1/20 0 introvale tab 0 jolessa tab 0 junel 1.5/30 tab 0 junel 1/20 tab 0 junel fe tab 1.5/30 0 junel fe tab 1/20 0 kariva tab 28 day 0 kelnor tab 1/35 0 kurvelo tab 0.15/30 0 leena tab 0 lessina tab 0 levonest tab 0 levonorg-eth est tab 0.1-0.02mg(84) & eth 0 est tab 0.01mg(7) levonorgestrel & ethinyl estradiol (91-day) 0 tab 0.15-0.03 mg levonorgestrel & ethinyl estradiol tab 0.15 0 mg-30 mcg levora-28 tab 0.15/30 0 LO LOESTRIN TAB 0 LOESTRIN 24 TAB FE 0 loryna tab 3-0.02mg 0 low-ogestrel tab 0 lutera tab 0 marlissa tab 0.15/30 0 microgestin tab 1.5/30 0 microgestin tab 1/20 0 microgestin tab fe1.5/30 0 microgestin tab fe 1/20 0 mono-linyah tab 0.25-35 0 mononessa tab 0 myzilra tab 0 NATAZIA TAB 0 necon tab 0.5/35 0 necon tab 1/35 0 necon tab 1/50-28 0 necon tab 7/7/7 0 NECON TAB 10/11-28 0 norgestimate & ethinyl estradiol tab 0.25 0 mg-35 mcg norgestimate-eth estrad tab 0.18- 0 35/0.215-35/0.25-35 mg-mcg norgestrel & ethinyl estradiol tab 0.3 mg- 0 30 mcg

69 Drug Name Drug Tier Requirements/Limits nortrel tab 0.5/35 0 nortrel tab 1/35 0 nortrel tab 7/7/7 0 ocella tab 3-0.03mg 0 ogestrel tab 0 orsythia tab 0 ORTHO TRI- TAB CYCLN LO 0 OVCON 50 TAB 28 0 portia-28 tab 0 previfem tab 0 quasense tab 0 reclipsen tab 0 SAFYRAL TAB 0 solia tab 0 sprintec 28 tab 28 day 0 sronyx tab 0 syeda tab 3-0.03mg 0 tilia fe tab 0 tri-linyah tab 0 tri-lo- tab sprintec 0 tri-previfem tab 0 tri-sprintec tab 0 trinessa tab 0 trivora-28 tab 0 velivet pak 0 vestura tab 3-0.02mg 0 viorele tab 0 wera tab 0.5/35 0 zarah tab 3-0.03mg 0 zenchent tab 0 zeosa chw 0 zovia 1/35e tab 0 zovia 1/50e tab 0 Combination Contraceptives - Transdermal ORTHO EVRA DIS WEEK 0 Combination Contraceptives - Vaginal NUVARING MIS 0 Emergency Contraceptives ELLA TAB 30MG 0 levonorgestrel tab 0.75 mg 0 next choice tab 0.75mg 0 next choice tab 1.5mg 0 Progestin Contraceptives - IUD MIRENA IUD SYSTEM 0 SKYLA IUD 13.5MG 0

70 Drug Name Drug Tier Requirements/Limits Progestin Contraceptives - Implants IMPLANON IMP 68MG 0 NEXPLANON IMP 68MG 0 Progestin Contraceptives - Injectable DEPO-SQ PROV INJ 104 0 medroxyprogesterone acetate im susp 150 0 mg/ml Progestin Contraceptives - Oral camila tab 0.35mg 0 errin tab 0.35mg 0 heather tab 0.35mg 0 jolivette tab 0.35mg 0 nora-be tab 0.35mg 0 norethindrone tab 0.35 mg 0 CORTICOSTEROIDS Glucocorticosteroids a-methapred inj 40mg 1 a-methapred inj 125mg 1 asmalpred sol plus 1 baycadron elx 0.5/5ml 1 budesonide cap sr 24hr 3 mg 1 acetate tab 25 mg 1 DEPO-MEDROL INJ 20MG/ML 3 DEXAMETHASON CON 1MG/ML 2 elixir 0.5 mg/5ml 1 dexamethasone sodium phosphate inj 4 1 mg/ml dexamethasone sodium phosphate inj 10 1 mg/ml dexamethasone soln 0.5 mg/5ml 1 dexamethasone tab 0.5 mg 1 dexamethasone tab 0.75 mg 1 dexamethasone tab 1 mg 1 dexamethasone tab 1.5 mg 1 dexamethasone tab 2 mg 1 dexamethasone tab 4 mg 1 dexamethasone tab 6 mg 1 DEXPAK PAK 6 DAY 3 DEXPAK PAK 10 DAY 3 DEXPAK PAK 13 DAY 3 hydrocortisone tab 5 mg 1 hydrocortisone tab 10 mg 1 hydrocortisone tab 20 mg 1 MEDROL TAB 2MG 2 methylprednisolone sodium succinate for 1 inj 40 mg

71 Drug Name Drug Tier Requirements/Limits methylprednisolone sodium succinate for 1 inj 125 mg methylprednisolone sodium succinate for 1 inj 500 mg methylprednisolone tab 4 mg 1 methylprednisolone tab 4 mg dose pack 1 methylprednisolone tab 8 mg 1 methylprednisolone tab 16 mg 1 methylprednisolone tab 32 mg 1 MILLIPRED DP PAK 5MG 3 MILLIPRED SOL 10MG/5ML 3 MILLIPRED TAB 5MG 3 ORAPRED ODT TAB 10MG 3 ORAPRED ODT TAB 15MG 3 ORAPRED ODT TAB 30MG 3 prednisolone sod phosph oral soln 6.7 1 mg/5ml (5 mg/5ml base) prednisolone sod phosphate oral soln 15 1 mg/5ml (base equiv) prednisolone sodium phosphate oral soln 1 25 mg/5ml (base eq) prednisolone syrup 15 mg/5ml (usp 1 solution equivalent) CON 5MG/ML 2 prednisone oral soln 5 mg/5ml 1 prednisone tab 1 mg 1 prednisone tab 2.5 mg 1 prednisone tab 5 mg 1 prednisone tab 5 mg dose pack 1 prednisone tab 10 mg 1 prednisone tab 10 mg dose pack 1 prednisone tab 20 mg 1 prednisone tab 50 mg 1 SOLU-CORTEF INJ 100MG 3 SOLU-CORTEF INJ 250MG 3 SOLU-CORTEF INJ 500MG 3 SOLU-CORTEF INJ 1000MG 3 SOLU-MEDROL INJ 2GM 3 VERIPRED 20 SOL 20MG/5ML 3 Mineralocorticoids fludrocortisone acetate tab 0.1 mg 1 COUGH/COLD/ Antitussives benzonatate cap 100 mg 1 benzonatate cap 200 mg 1 hydrocodone w/ syrup 5-1.5 1 mg/5ml

72 Drug Name Drug Tier Requirements/Limits hydrocodone w/ homatropine tab 5-1.5 mg 1 hydromet syp 5-1.5/5 1 tussigon tab 5mg 1 Cough/Cold/Allergy Combinations ALLFEN CDX LIQ 2 DEX-TUSS LIQ 300-10/5 2 -codeine liquid 200-10 mg/5ml 1 guaifenesin-codeine liquid 300-10 mg/5ml 1 prometh vc/ syp codeine 1 promethazine w/ codeine syrup 6.25-10 1 mg/5ml promethazine-dm syrup 6.25-15 mg/5ml 1 sudatuss-2 sol 1 sudatuss-sf sol 1 ZODRYL DAC SUS 50 2 ZODRYL DAC SUS 60 2 ZODRYL DAC SUS 80 2 Mucolytics acetylcysteine inhal soln 10% 1 acetylcysteine inhal soln 20% 1 DERMATOLOGICALS Acne Products ACANYA GEL 1.2-2.5% 3 ST adapalene cream 0.1% 1 PA adapalene gel 0.1% 1 PA AKNE-MYCIN OIN 2% 3 amnesteem cap 10mg 1 PA amnesteem cap 20mg 1 PA amnesteem cap 40mg 1 PA ATRALIN GEL 0.05% 3 PA AVAR GEL 10-5% 2 avar-e green cre 10-5% 1 avita cre 0.025% 1 PA avita gel 0.025% 1 PA AZELEX CRE 20% 3 ST BENZAMYCIN GEL PAK 2 BENZASHAVE 5 CRE 5% 2 benzashave cre 10% 1 benzepro aer 5.3% 1 benzepro sc aer 9.8% 1 BENZIQ GEL 5.25% 2 BENZIQ LS GEL 2.75% 2 benziq wash liq 5.25% 1 benzoyl per gel 10% 1 benzoyl per kit 4% wash 1

73 Drug Name Drug Tier Requirements/Limits benzoyl per kit 8% wash 1 benzoyl per liq 2.5%wash 1 benzoyl per liq 4% crem 1 benzoyl per liq 5% wash 1 benzoyl per liq 8% crem 1 benzoyl per liq 10% wash 1 benzoyl per lot 3% 1 benzoyl per lot 4% 1 benzoyl per lot 6% 1 benzoyl per lot 8% 1 benzoyl per lot 9% 1 benzoyl pero kit acne pck 1 benzoyl peroxide cleanser 4.25% 1 benzoyl peroxide cream 3.5% 1 benzoyl peroxide cream 5.5% 1 benzoyl peroxide cream 8.5% 1 benzoyl peroxide foam 5.3% 1 benzoyl peroxide foam 9.8% 1 benzoyl peroxide gel 2.5% 1 benzoyl peroxide pad 3% 1 benzoyl peroxide pad 6% 1 benzoyl peroxide pad 9% 1 benzoyl peroxide-erythromycin gel 5-3% 1 bp 7% wash kit 1 bp gel gel 10% 1 bp wash liq 2.5% 1 bp wash liq 5% 1 bp wash liq 5.25% 1 bp wash liq 7% 1 bp wash liq 10% 1 bpo cloths mis 3% 1 bpo cloths mis 6% 1 bpo cloths mis 9% 1 bpo creamy kit 4% wash 1 BPO GEL 4% 2 BPO GEL 8% 2 bpo-5 wash liq 5% 1 bpo-10 wash liq 10% 1 claravis cap 10mg 1 PA claravis cap 20mg 1 PA claravis cap 30mg 1 PA claravis cap 40mg 1 PA clearplex x gel 10% 1 clenia cre 10-5% 1 CLINAC BPO GEL 7% 2

74 Drug Name Drug Tier Requirements/Limits CLINDACIN KIT PAC 1% 3 clindamax gel 1% 1 clindamax lot 10mg/ml 1 clindamycin phosph-benzoyl peroxide 1 (refrig) gel 1.2 (1)-5% clindamycin phosphate foam 1% 1 clindamycin phosphate gel 1% 1 clindamycin phosphate lotion 1% 1 clindamycin phosphate soln 1% 1 clindamycin phosphate swab 1% 1 clindamycin phosphate-benzoyl peroxide 1 gel 1-5% DELOS LIQ 3.5% 1 DELOS LOT 3.5% 2 DIFFERIN GEL 0.3% 3 PA DIFFERIN LOT 0.1% 3 PA EPIDUO GEL 0.1-2.5% 3 ery pad 2% 1 erythromycin gel 2% 1 erythromycin pads 2% 1 erythromycin soln 2% 1 lavoclen-4 kit acne wsh 1 lavoclen-4 liq crem wsh 1 lavoclen-8 kit acne wsh 1 lavoclen-8 liq crem wsh 1 myorisan cap 10mg 1 PA myorisan cap 20mg 1 PA myorisan cap 40mg 1 PA oscion clnsr lot 6% 1 oscion clnsr lot 9% 1 PACNEX HP PAD 7% 2 PACNEX LP PAD 4.25% 2 pacnex wash liq 7% 1 pr benzoyl liq 7% wash 1 RETIN-A MICR GEL 0.1% 3 PA RETIN-A MICR GEL 0.04%PMP 3 PA se bpo cloth mis 3% 1 se bpo cloth mis 6% 1 se bpo cloth mis 9% 1 se bpo wash liq 7% 1 sotret cap 10mg 1 PA sotret cap 20mg 1 PA sotret cap 30mg 1 PA sulfacetamide sodium lotion 10% (acne) 1 sulfacetamide sodium w/ sulfur cleansing 1 pad 10-4%

75 Drug Name Drug Tier Requirements/Limits sulfacetamide sodium w/ sulfur cream 10- 1 5% sulfacetamide sodium w/ sulfur lotion 10- 1 5% suphera cre 10-5% 1 topisulf cre 10-5% 1 TRETIN-X CRE 0.0375% 3 PA TRETIN-X CRE KIT 0.1% 3 PA TRETIN-X CRE KIT 0.05% 3 PA TRETIN-X CRE KIT 0.025% 3 PA TRETIN-X GEL KIT 0.01% 3 PA TRETIN-X GEL KIT 0.025% 3 PA tretinoin cream 0.1% 1 PA tretinoin cream 0.05% 1 PA tretinoin cream 0.025% 1 PA tretinoin gel 0.01% 1 PA tretinoin gel 0.025% 1 PA VELTIN GEL 3 PA ZIANA GEL 3 PA Agents for External Genital and Perianal Warts VEREGEN OIN 15% 3 Anti-inflammatory Agents - Topical VOLTAREN GEL 1% 3 ST Antibiotics - Topical ALTABAX OIN 1% 3 CENTANY AT KIT 2% 3 centany oin 2% 1 CORTISPORIN CRE 0.5% 3 CORTISPORIN OIN 1% 3 gentamicin sulfate cream 0.1% 1 gentamicin sulfate oint 0.1% 1 mupirocin oint 2% 1 Antifungals - Topical ciclopirox gel 0.77% 1 ciclopirox olamine cream 0.77% (base 1 equiv) ciclopirox olamine susp 0.77% (base 1 equiv) ciclopirox shampoo 1% 1 CLOTRIMAZOLE CRY 3 clotrimazole soln 1% 1 clotrimazole w/ betamethasone cream 1- 1 0.05% econazole nitrate cream 1% 1 ERTACZO CRE 2% 3 EXELDERM CRE 1% 3 EXELDERM SOL 1% 3

76 Drug Name Drug Tier Requirements/Limits ketoconazole cream 2% 1 ketoconazole foam 2% 1 ketoconazole shampoo 2% 1 MENTAX CRE 1% 3 NAFTIN CRE 1% 3 NAFTIN CRE 2% 3 NAFTIN GEL 1% 3 nyamyc pow 100000 1 nystatin cream 100000 unit/gm 1 nystatin oint 100000 unit/gm 1 nystatin topical powder 1 nystatin-triamcinolone cream 100000-0.1 1 unit/gm-% nystatin-triamcinolone oint 100000-0.1 1 unit/gm-% nystop pow 100000 1 OXISTAT CRE 1% 3 OXISTAT LOT 1% 3 pedi-dri pow 100000 1 XOLEGEL GEL 2% 3 Antineoplastic or Premalignant Lesion Agents - Topical CARAC CRE 0.5% 3 FLUOROPLEX CRE 1% 3 fluorouracil cream 5% 1 fluorouracil soln 2% 1 fluorouracil soln 5% 1 PANRETIN GEL 0.1% 3 PICATO GEL 0.05% 3 PICATO GEL 0.015% 3 SOLARAZE GEL 3% W/W 2 TARGRETIN GEL 1% 4 PA - Topical prudoxin cre 5% 1 Antipsoriatics AMEVIVE INJ 15MG 3 calcipotriene cream 0.005% 1 calcipotriene oint 0.005% 1 calcipotriene soln 0.005% (50 mcg/ml) 1 calcitrene oin 0.005% 1 calcitriol oint 3 mcg/gm 1 8-MOP CAP 10MG 3 OXSORALEN-UL CAP 10MG 3 SORIATANE CAP 10MG 3 SORIATANE CAP 17.5MG 3 SORIATANE CAP 25MG 3 STELARA INJ 45MG/0.5 4 PA

77 Drug Name Drug Tier Requirements/Limits STELARA INJ 90MG/ML 4 PA TAZORAC CRE 0.1% 2 PA TAZORAC CRE 0.05% 2 PA TAZORAC GEL 0.1% 2 PA TAZORAC GEL 0.05% 2 PA Antiseborrheic Products selenium sulfide lotion 2.5% 1 Antivirals - Topical DENAVIR CRE 1% 3 ZOVIRAX CRE 5% 3 ZOVIRAX OIN 5% 3 Burn Products silver sulfadiazine cream 1% 1 ssd cre 1% 1 SULFAMYLON CRE 85MG/GM 3 SULFAMYLON PAK 5% 3 thermazene cre 1% 1 Corticosteroids - Topical ala cort cre 1% 1 alclometasone dipropionate cream 0.05% 1 alclometasone dipropionate oint 0.05% 1 alphatrex gel 0.05% 1 amcinonide cream 0.1% 1 amcinonide lotion 0.1% 1 AMCINONIDE OIN 0.1% 2 amcinonide oint 0.1% 1 APEXICON E CRE 0.05% 3 apexicon oin 0.05% 1 betamethasone dipropionate augmented 1 cream 0.05% betamethasone dipropionate augmented 1 lotion 0.05% betamethasone dipropionate augmented 1 oint 0.05% betamethasone dipropionate cream 0.05% 1 betamethasone dipropionate lotion 0.05% 1 betamethasone dipropionate oint 0.05% 1 betamethasone valerate cream 0.1% 1 betamethasone valerate lotion 0.1% 1 betamethasone valerate oint 0.1% 1 CAPEX SHA 0.01% 3 clobetasol propionate cream 0.05% 1 clobetasol propionate foam 0.05% 1 clobetasol propionate gel 0.05% 1 clobetasol propionate lotion 0.05% 1 clobetasol propionate oint 0.05% 1

78 Drug Name Drug Tier Requirements/Limits clobetasol propionate shampoo 0.05% 1 clobetasol propionate soln 0.05% 1 CLOBEX SPR 0.05% 3 CLODERM CRE 0.1% PMP 3 CORDRAN 24X3 TAP 4MCG/CM 3 CORDRAN LOT 0.05% 3 CORDRAN SP CRE 0.05% 3 cormax oin 0.05% 1 DESONATE GEL 0.05% 3 desonide cream 0.05% 1 desonide lotion 0.05% 1 desonide oint 0.05% 1 DESOWEN OINT KIT 0.05% 3 desoximetasone cream 0.05% 1 desoximetasone cream 0.25% 1 desoximetasone gel 0.05% 1 desoximetasone oint 0.25% 1 diflorasone diacetate cream 0.05% 1 diflorasone diacetate oint 0.05% 1 fluocin acet oil body 1 fluocinolone acetonide cream 0.01% 1 fluocinolone acetonide cream 0.025% 1 fluocinolone acetonide oint 0.025% 1 fluocinolone acetonide soln 0.01% 1 fluocinonide cream 0.05% 1 fluocinonide gel 0.05% 1 fluocinonide oint 0.05% 1 fluocinonide soln 0.05% 1 fluticasone propionate cream 0.05% 1 fluticasone propionate lotion 0.05% 1 fluticasone propionate oint 0.005% 1 halobetasol propionate cream 0.05% 1 halobetasol propionate oint 0.05% 1 HALOG CRE 0.1% 3 HALOG OIN 0.1% 3 hydrocortisone butyrate cream 0.1% 1 hydrocortisone butyrate oint 0.1% 1 hydrocortisone butyrate soln 0.1% 1 hydrocortisone cream 1% 1 hydrocortisone cream 2.5% 1 hydrocortisone lotion 2.5% 1 hydrocortisone oint 2.5% 1 hydrocortisone valerate cream 0.2% 1 hydrocortisone valerate oint 0.2% 1 KENALOG AER SPRAY 3

79 Drug Name Drug Tier Requirements/Limits lokara lot 0.05% 1 mometasone furoate cream 0.1% 1 mometasone furoate oint 0.1% 1 mometasone furoate solution 0.1% (lotion) 1 PEDIADERM HC KIT 3 PEDIADERM TA KIT 3 prednicarbate cream 0.1% 1 prednicarbate oint 0.1% 1 scalacort lot 2% 1 TACLONEX OIN 3 TACLONEX SUS 3 TEXACORT SOL 2.5% 3 triamcinolone acetonide cream 0.1% 1 triamcinolone acetonide cream 0.5% 1 triamcinolone acetonide cream 0.025% 1 triamcinolone acetonide lotion 0.1% 1 triamcinolone acetonide lotion 0.025% 1 triamcinolone acetonide oint 0.1% 1 triamcinolone acetonide oint 0.5% 1 triamcinolone acetonide oint 0.025% 1 TRIANEX OIN 0.05% 3 triderm cre 0.1% 1 VANOS CRE 0.1% 2 VERDESO AER 0.05% 3 Emollients laclotion lot 12% 1 lactic acid (ammonium lactate) cream 12% 1 lactic acid (ammonium lactate) lotion 12% 1 Enzymes - Topical SANTYL OIN 250/GM 3 Immunomodulating Agents - Topical imiquimod cream 5% 1 ZYCLARA CRE 3.75% 3 Immunosuppressive Agents - Topical ELIDEL CRE 1% 2 ST PROTOPIC OIN 0.1% 2 ST PROTOPIC OIN 0.03% 2 ST Keratolytic/Antimitotic Agents CONDYLOX GEL 0.5% 3 podofilox soln 0.5% 1 Local Anesthetics - Topical lidocaine hcl cream 3% 1 lidocaine hcl gel 2% 1 lidocaine hcl lotion 3% 1 lidocaine hcl soln 4% 1

80 Drug Name Drug Tier Requirements/Limits lidocaine oint 5% 1 lidocaine-prilocaine cream 2.5-2.5% 1 lidocaine-prilocaine kit 2.5-2.5% 1 LIDODERM DIS 5% 3 pramox gel 1% 1 SYNERA DIS 70-70MG 3 Rosacea Agents FINACEA GEL 15% 3 METROGEL GEL 1% 3 metronidazole cream 0.75% 1 metronidazole gel 0.75% 1 metronidazole lotion 0.75% 1 NORITATE CRE 1% 3 ORACEA CAP 40MG 3 rosadan cre 0.75% 1 vitazol cre 0.75% 1 Scabicides Pediculicides acticin cre 5% 1 EURAX CRE 10% 3 EURAX LOT 10% 3 malathion lotion 0.5% 1 permethrin cream 5% 1 SKLICE LOT 0.5% 3 spinosad susp 0.9% 1 ULESFIA LOT 5% 3 Wound Care Products REGRANEX GEL 0.01% 3 DIAGNOSTIC PRODUCTS Diagnostic Tests ACCU-CHEK TES ACTIVE 2 ACCU-CHEK TES DRUM 2 DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS Dietary Management Products folic acid-pyridoxine-cyanocobalamin tab 1 2.5-25-2 mg DIGESTIVE AIDS Digestive Enzymes CREON CAP 3000UNIT 2 CREON CAP 6000UNIT 2 CREON CAP 12000UNT 2 CREON CAP 24000UNT 2 PANCREAZE CAP 4200UNIT 2 PANCREAZE CAP 10500UNT 2 PANCREAZE CAP 16800UNT 2

81 Drug Name Drug Tier Requirements/Limits PANCREAZE CAP 21000UNT 2 pancrelipase (lip-prot-amyl) dr cap 5000- 1 17000-27000 unit PERTZYE CAP 2 SUCRAID SOL 8500/ML 3 ULTRESA CAP 13800UNT 2 ULTRESA CAP 20700UNT 2 ULTRESA CAP 23000UNT 2 VIOKACE TAB 2 ZENPEP CAP 3000UNIT 2 ZENPEP CAP 10000UNT 2 ZENPEP CAP 15000UNT 2 ZENPEP CAP 20000UNT 2 ZENPEP CAP 25000UNT 2 DIURETICS Carbonic Anhydrase Inhibitors acetazolamide cap sr 12hr 500 mg 1 acetazolamide sodium for inj 500 mg 1 acetazolamide tab 125 mg 1 acetazolamide tab 250 mg 1 methazolamide tab 25 mg 1 methazolamide tab 50 mg 1 Diuretic Combinations ALDACTAZIDE TAB 50/50 2 amiloride & hydrochlorothiazide tab 5-50 1 mg spironolactone & hydrochlorothiazide tab 1 25-25 mg triamterene & hydrochlorothiazide cap 1 37.5-25 mg triamterene & hydrochlorothiazide cap 50- 1 25 mg triamterene & hydrochlorothiazide tab 1 37.5-25 mg triamterene & hydrochlorothiazide tab 75- 1 50 mg Loop Diuretics bumetanide inj 0.25 mg/ml 1 bumetanide tab 0.5 mg 1 bumetanide tab 1 mg 1 bumetanide tab 2 mg 1 EDECRIN TAB 25MG 3 furosemide inj 10 mg/ml 1 furosemide oral soln 10 mg/ml 1 FUROSEMIDE SOL 8MG/ML 2 furosemide tab 20 mg 1 furosemide tab 40 mg 1

82 Drug Name Drug Tier Requirements/Limits furosemide tab 80 mg 1 SOD EDECRIN INJ 50MG 3 TORSEMIDE INJ 20MG/2ML 3 torsemide tab 5 mg 1 torsemide tab 10 mg 1 torsemide tab 20 mg 1 torsemide tab 100 mg 1 Potassium Sparing Diuretics amiloride hcl tab 5 mg 1 DYRENIUM CAP 50MG 3 DYRENIUM CAP 100MG 3 spironolactone tab 25 mg 1 spironolactone tab 50 mg 1 spironolactone tab 100 mg 1 Thiazides and Thiazide-Like Diuretics chlorothiazide sodium for inj 500 mg 1 chlorothiazide tab 250 mg 1 chlorothiazide tab 500 mg 1 chlorthalidone tab 25 mg 1 chlorthalidone tab 50 mg 1 chlorthalidone tab 100 mg 1 DIURIL SUS 250/5ML 3 hydrochlorothiazide cap 12.5 mg 1 hydrochlorothiazide tab 12.5 mg 1 hydrochlorothiazide tab 25 mg 1 hydrochlorothiazide tab 50 mg 1 indapamide tab 1.25 mg 1 indapamide tab 2.5 mg 1 methyclothiazide tab 5 mg 1 metolazone tab 2.5 mg 1 metolazone tab 5 mg 1 metolazone tab 10 mg 1 THALITONE TAB 15MG 2 ENDOCRINE AND METABOLIC AGENTS - MISC. Bone Density Regulators ACTONEL TAB 5MG 3 ST ACTONEL TAB 30MG 3 ST ACTONEL TAB 35MG 3 ST ACTONEL TAB 150MG 3 ST alendronate sodium tab 5 mg 1 alendronate sodium tab 10 mg 1 alendronate sodium tab 35 mg 1 alendronate sodium tab 40 mg 1 alendronate sodium tab 70 mg 1 ATELVIA TAB 3 ST

83 Drug Name Drug Tier Requirements/Limits BONIVA INJ 3MG/3ML 3 calcitonin (salmon) nasal soln 200 unit/act 1 etidronate disodium tab 200 mg 1 etidronate disodium tab 400 mg 1 FORTEO SOL 600/2.4 4 PA FOSAMAX + D TAB 70-2800 3 ST FOSAMAX + D TAB 70-5600 3 ST FOSAMAX SOL 3 ibandronate sodium tab 150 mg (base 1 equivalent) MIACALCIN INJ 200/ML 3 pamidronate disodium for inj 30 mg 4 PA pamidronate disodium for inj 90 mg 4 PA pamidronate disodium iv soln 3 mg/ml 4 PA pamidronate disodium iv soln 9 mg/ml 4 PA PAMIDRONATE INJ 6MG/ML 4 PA PROLIA SOL 60MG/ML 4 PA RECLAST INJ 5/100ML 4 PA SKELID TAB 200MG 3 XGEVA INJ 4 PA ZOMETA INJ 4MG/5ML 4 PA ZOMETA INJ 4MG/100 4 PA Fertility Regulators chorionic gonadotropin for inj 10000 unit 4 PA novarel inj 10000unt 4 PA pregnyl inj 10000unt 4 PA Growth Hormone Receptor Antagonists SOMAVERT INJ 10MG 4 PA SOMAVERT INJ 15MG 4 PA SOMAVERT INJ 20MG 4 PA Growth Hormones GENOTROPIN INJ 0.2MG 4 PA GENOTROPIN INJ 0.4MG 4 PA GENOTROPIN INJ 0.6MG 4 PA GENOTROPIN INJ 0.8MG 4 PA GENOTROPIN INJ 1.2MG 4 PA GENOTROPIN INJ 1.4MG 4 PA GENOTROPIN INJ 1.6MG 4 PA GENOTROPIN INJ 1.8MG 4 PA GENOTROPIN INJ 1MG 4 PA GENOTROPIN INJ 2MG 4 PA GENOTROPIN INJ 5MG 4 PA GENOTROPIN INJ 12MG 4 PA HUMATROPE INJ 5MG 4 PA HUMATROPE INJ 6MG 4 PA HUMATROPE INJ 12MG 4 PA 84 Drug Name Drug Tier Requirements/Limits HUMATROPE INJ 24MG 4 PA NORDITROPIN INJ 5/1.5ML 4 PA NORDITROPIN INJ 10/1.5ML 4 PA NORDITROPIN INJ 15/1.5ML 4 PA NORDITROPIN INJ 30/3ML 4 PA NUTROPIN AQ INJ 10MG/2ML 4 PA NUTROPIN AQ INJ 20MG/2ML 4 PA NUTROPIN AQ INJ NUSPIN 5 4 PA NUTROPIN INJ 10MG 4 PA OMNITROPE INJ 5.8MG 4 PA OMNITROPE INJ 5/1.5ML 4 PA OMNITROPE INJ 10/1.5ML 4 PA SAIZEN INJ 5MG 4 PA SAIZEN INJ 8.8MG 4 PA SEROSTIM INJ 4MG 4 PA SEROSTIM INJ 5MG 4 PA SEROSTIM INJ 6MG 4 PA TEV-TROPIN INJ 5MG 4 PA ZORBTIVE INJ 8.8MG 4 PA Hormone Receptor Modulators EVISTA TAB 60MG 2 Insulin-Like Growth Factors (Somatomedins) INCRELEX INJ 40MG/4ML 4 PA LHRH/GnRH Analog Pituitary Suppressants LUPR DEP-PED INJ 7.5MG 4 PA LUPR DEP-PED INJ 11.25MG 4 PA LUPR DEP-PED INJ 15MG 4 PA LUPR DEP-PED INJ 30MG 4 PA SYNAREL SOL 2MG/ML 2 Metabolic Modifiers ALDURAZYME INJ 2.9MG/5M 4 PA BUPHENYL POW 3 BUPHENYL TAB 500MG 3 calcitriol cap 0.5 mcg 1 calcitriol cap 0.25 mcg 1 calcitriol inj 1 mcg/ml 1 calcitriol oral soln 1 mcg/ml 1 CARBAGLU TAB 200MG 4 PA CYSTADANE POW 3 ELAPRASE INJ 6MG/3ML 4 PA FABRAZYME INJ 5MG 4 PA FABRAZYME INJ 35MG 4 PA HECTOROL CAP 0.5MCG 2 HECTOROL CAP 1MCG 2 HECTOROL CAP 2.5MCG 2

85 Drug Name Drug Tier Requirements/Limits HECTOROL INJ 4MCG/2ML 3 KUVAN TAB 100MG 4 PA MYOZYME INJ 50MG 4 PA NAGLAZYME INJ 1MG/ML 4 PA ORFADIN CAP 2MG 4 PA ORFADIN CAP 5MG 4 PA ORFADIN CAP 10MG 4 PA SENSIPAR TAB 30MG 4 PA SENSIPAR TAB 60MG 4 PA SENSIPAR TAB 90MG 4 PA ZEMPLAR CAP 1MCG 2 ZEMPLAR CAP 2MCG 2 ZEMPLAR CAP 4MCG 2 ZEMPLAR INJ 2MCG/ML 3 ZEMPLAR INJ 5MCG/ML 3 Posterior Pituitary Hormones desmopressin acetate inj 4 mcg/ml 1 desmopressin acetate nasal soln 0.01% 1 (refrigerated) desmopressin acetate nasal spray soln 1 0.01% desmopressin acetate nasal spray soln 1 0.01% (refrigerated) desmopressin acetate tab 0.1 mg 1 desmopressin acetate tab 0.2 mg 1 minirin spr nasal 1 Prolactin Inhibitors tab 0.5 mg 1 Somatostatic Agents acetate inj 50 mcg/ml (0.05 4 PA mg/ml) octreotide acetate inj 100 mcg/ml (0.1 4 PA mg/ml) octreotide acetate inj 200 mcg/ml (0.2 4 PA mg/ml) octreotide acetate inj 500 mcg/ml (0.5 4 PA mg/ml) octreotide acetate inj 1000 mcg/ml (1 4 PA mg/ml) SANDOSTATIN KIT LAR 10MG 4 PA SANDOSTATIN KIT LAR 20MG 4 PA SANDOSTATIN KIT LAR 30MG 4 PA SOMATULINE INJ 60/0.2ML 4 PA SOMATULINE INJ 90/0.3ML 4 PA SOMATULINE INJ 120/.5ML 4 PA Vasopressin Receptor Antagonists SAMSCA TAB 15MG 4 PA SAMSCA TAB 30MG 4 PA 86 Drug Name Drug Tier Requirements/Limits ESTROGENS Estrogen Combinations CLIMARA PRO DIS WEEKLY 2 estradiol & norethindrone acetate tab 0.5- 1 0.1 mg estradiol & norethindrone acetate tab 1-0.51 mg FEMHRT TAB 0.5-2.5 2 FEMHRT TAB 0.5-2.5 3 jevantique tab 1mg-5mcg 1 jinteli tab 1mg-5mcg 1 mimvey tab 1-0.5mg 1 Estrogens ALORA DIS 0.1MG 3 PA; High Risk Medications require PA for members age 65 and older ALORA DIS 0.05MG 3 PA; High Risk Medications require PA for members age 65 and older ALORA DIS 0.025MG 3 PA; High Risk Medications require PA for members age 65 and older ALORA DIS 0.075MG 3 PA; High Risk Medications require PA for members age 65 and older CENESTIN TAB 0.3MG 3 PA; High Risk Medications require PA for members age 65 and older CENESTIN TAB 0.9MG 3 PA; High Risk Medications require PA for members age 65 and older CENESTIN TAB 0.45MG 3 PA; High Risk Medications require PA for members age 65 and older

87 Drug Name Drug Tier Requirements/Limits CENESTIN TAB 0.625MG 3 PA; High Risk Medications require PA for members age 65 and older CENESTIN TAB 1.25MG 3 PA; High Risk Medications require PA for members age 65 and older DELESTROGEN INJ 10MG/ML 3 DEPO-ESTRADI INJ 5MG/ML 3 DIVIGEL GEL 0.25MG 3 ELESTRIN GEL 0.06% 3 ENJUVIA TAB 0.3MG 3 PA; High Risk Medications require PA for members age 65 and older ENJUVIA TAB 0.9MG 3 PA; High Risk Medications require PA for members age 65 and older ENJUVIA TAB 0.45MG 3 PA; High Risk Medications require PA for members age 65 and older ENJUVIA TAB 0.625MG 3 PA; High Risk Medications require PA for members age 65 and older ENJUVIA TAB 1.25MG 3 PA; High Risk Medications require PA for members age 65 and older estradiol tab 0.5 mg 1 PA; High Risk Medications require PA for members age 65 and older estradiol tab 1 mg 1 PA; High Risk Medications require PA for members age 65 and older

88 Drug Name Drug Tier Requirements/Limits estradiol tab 2 mg 1 PA; High Risk Medications require PA for members age 65 and older estradiol td patch weekly 0.1 mg/24hr 1 PA; High Risk Medications require PA for members age 65 and older estradiol td patch weekly 0.05 mg/24hr 1 PA; High Risk Medications require PA for members age 65 and older estradiol td patch weekly 0.06 mg/24hr 1 PA; High Risk Medications require PA for members age 65 and older estradiol td patch weekly 0.025 mg/24hr 1 PA; High Risk Medications require PA for members age 65 and older estradiol td patch weekly 0.075 mg/24hr 1 PA; High Risk Medications require PA for members age 65 and older estradiol td patch weekly 0.0375 mg/24hr 1 PA; High Risk (37.5 mcg/24hr) Medications require PA for members age 65 and older estradiol valerate im in oil 20 mg/ml 1 estradiol valerate im in oil 40 mg/ml 1 ESTROGEL GEL 3 estropipate tab 0.75 mg 1 PA; High Risk Medications require PA for members age 65 and older estropipate tab 1.5 mg 1 PA; High Risk Medications require PA for members age 65 and older estropipate tab 3 mg 1 PA; High Risk Medications require PA for members age 65 and older

89 Drug Name Drug Tier Requirements/Limits EVAMIST SPR 1.53MG 3 MENEST TAB 0.3MG 3 PA; High Risk Medications require PA for members age 65 and older MENEST TAB 0.625MG 3 PA; High Risk Medications require PA for members age 65 and older MENEST TAB 1.25MG 3 PA; High Risk Medications require PA for members age 65 and older MENEST TAB 2.5MG 3 PA; High Risk Medications require PA for members age 65 and older MENOSTAR DIS 14MCG 3 PA; High Risk Medications require PA for members age 65 and older ortho-est tab 0.625 1 PA; High Risk Medications require PA for members age 65 and older ortho-est tab 1.25 1 PA; High Risk Medications require PA for members age 65 and older PREMARIN INJ 25MG 3 PA; High Risk Medications require PA for members age 65 and older PREMARIN TAB 0.3MG 3 PA; High Risk Medications require PA for members age 65 and older PREMARIN TAB 0.9MG 3 PA; High Risk Medications require PA for members age 65 and older

90 Drug Name Drug Tier Requirements/Limits PREMARIN TAB 0.45MG 3 PA; High Risk Medications require PA for members age 65 and older PREMARIN TAB 0.625MG 3 PA; High Risk Medications require PA for members age 65 and older PREMARIN TAB 1.25MG 3 PA; High Risk Medications require PA for members age 65 and older VIVELLE-DOT DIS 0.1MG 3 PA; High Risk Medications require PA for members age 65 and older VIVELLE-DOT DIS 0.05MG 3 PA; High Risk Medications require PA for members age 65 and older VIVELLE-DOT DIS 0.025MG 3 PA; High Risk Medications require PA for members age 65 and older VIVELLE-DOT DIS 0.075MG 3 PA; High Risk Medications require PA for members age 65 and older VIVELLE-DOT DIS 0.0375MG 3 PA; High Risk Medications require PA for members age 65 and older FLUOROQUINOLONES Fluoroquinolones AVELOX ABC TAB 400MG 2 AVELOX INJ 3 AVELOX TAB 400MG 2 CIPRO (5%) SUS 250MG/5 2 CIPRO (10%) SUS 500MG/5 2 200 mg/100ml in d5w 1 ciprofloxacin hcl tab 100 mg (base equiv) 1 ciprofloxacin hcl tab 250 mg (base equiv) 1 ciprofloxacin hcl tab 500 mg (base equiv) 1

91 Drug Name Drug Tier Requirements/Limits ciprofloxacin hcl tab 750 mg (base equiv) 1 ciprofloxacin iv soln 200 mg/20ml (1%) 1 ciprofloxacin-ciprofloxacin hcl tab sr 24hr 1 500 mg (base eq) ciprofloxacin-ciprofloxacin hcl tab sr 24hr 1 1000 mg(base eq) FACTIVE TAB 320MG 3 levofloxacin in d5w iv soln 250 mg/50ml 1 levofloxacin iv soln 25 mg/ml 1 levofloxacin oral soln 25 mg/ml 1 levofloxacin tab 250 mg 1 levofloxacin tab 500 mg 1 levofloxacin tab 750 mg 1 NOROXIN TAB 400MG 3 ofloxacin tab 200 mg 1 ofloxacin tab 300 mg 1 ofloxacin tab 400 mg 1 GASTROINTESTINAL AGENTS - MISC. Gallstone Solubilizing Agents ursodiol cap 300 mg 1 ursodiol tab 250 mg 1 ursodiol tab 500 mg 1 Gastrointestinal Antiallergy Agents cromolyn sodium oral conc 100 mg/5ml 1 Gastrointestinal Chloride Channel Activators AMITIZA CAP 8MCG 2 PA AMITIZA CAP 24MCG 2 PA Gastrointestinal Stimulants hcl inj 5 mg/ml 1 metoclopramide hcl soln 5 mg/5ml (10 1 mg/10ml) metoclopramide hcl tab 5 mg 1 metoclopramide hcl tab 10 mg 1 METOZOLV ODT TAB 5MG 3 METOZOLV ODT TAB 10MG 3 Inflammatory Bowel Agents APRISO CAP 0.375GM 2 ASACOL HD TAB 800MG 3 ASACOL TAB 400MG DR 3 balsalazide disodium cap 750 mg 1 CANASA SUP 1000MG 2 CIMZIA KIT 4 PA CIMZIA KIT 200MG/ML 4 PA DIPENTUM CAP 250MG 3 LIALDA TAB 1.2GM 3

92 Drug Name Drug Tier Requirements/Limits mesalamine rectal enema 4 gm & cleanser 1 wipe kit PENTASA CAP 250MG CR 3 PENTASA CAP 500MG CR 3 REMICADE INJ 100MG 4 PA SFROWASA ENE 4GM 3 sulfasalazine tab 500 mg 1 sulfasalazine tab delayed release 500 mg 1 sulfazine tab 500mg 1 Intestinal Acidifiers enulose sol 10gm/15 1 generlac sol 10gm/15 1 (IBS) Agents LOTRONEX TAB 0.5MG 3 PA LOTRONEX TAB 1MG 3 PA Peripheral Antagonists RELISTOR INJ 12/0.6ML 3 Phosphate Binder Agents calcium acetate (phosphate binder) cap 1 667 mg (169 mg ca) calcium acetate (phosphate binder) tab 1 667 mg FOSRENOL CHW 500MG 3 FOSRENOL CHW 750MG 3 FOSRENOL CHW 1000MG 3 PHOSLYRA SOL 3 RENAGEL TAB 400MG 3 RENAGEL TAB 800MG 3 RENVELA PAK 0.8GM 3 RENVELA PAK 2.4GM 3 RENVELA TAB 800MG 2 GENITOURINARY AGENTS - MISCELLANEOUS Alkalinizers potassium citrate tab cr 5 meq (540 mg) 1 potassium citrate tab cr 10 meq (1080 mg)1 UROCIT-K 15 TAB 2 Cystinosis Agents CYSTAGON CAP 50MG 4 PA CYSTAGON CAP 150MG 4 PA Genitourinary Irrigants sodium chloride irrigation soln 0.9% 1 Interstitial Cystitis Agents ELMIRON CAP 100MG 3 Prostatic Hypertrophy Agents hcl tab sr 24hr 10 mg 1

93 Drug Name Drug Tier Requirements/Limits AVODART CAP 0.5MG 3 ST CARDURA XL TAB 4MG 3 ST CARDURA XL TAB 8MG 3 ST finasteride tab 5 mg 1 JALYN CAP 3 ST RAPAFLO CAP 4MG 3 ST RAPAFLO CAP 8MG 3 ST hcl cap 0.4 mg 1 Urinary Analgesics phenazopyridine hcl tab 100 mg 1 phenazopyridine hcl tab 200 mg 1 GOUT AGENTS Gout Agent Combinations colchicine w/ probenecid tab 0.5-500 mg 1 Gout Agents allopurinol sodium for inj 500 mg 1 allopurinol tab 100 mg 1 allopurinol tab 300 mg 1 COLCRYS TAB 0.6MG 2 ULORIC TAB 40MG 3 ST ULORIC TAB 80MG 3 ST Uricosurics probenecid tab 500 mg 1 HEMATOLOGICAL AGENTS - MISC. Bradykinin B2 Receptor Antagonists FIRAZYR INJ 30MG/3ML 4 PA Hematorheologic Agents pentopak tab 400mg cr 1 tab cr 400 mg 1 Platelet Aggregation Inhibitors AGGRENOX CAP 25-200MG 2 anagrelide hcl cap 0.5 mg 1 anagrelide hcl cap 1 mg 1 BRILINTA TAB 90MG 2 cilostazol tab 50 mg 1 cilostazol tab 100 mg 1 clopidogrel bisulfate tab 75 mg (base 1 equiv) clopidogrel bisulfate tab 300 mg (base 1 equiv) dipyridamole tab 25 mg 1 PA; High Risk Medications require PA for members age 65 and older

94 Drug Name Drug Tier Requirements/Limits dipyridamole tab 50 mg 1 PA; High Risk Medications require PA for members age 65 and older dipyridamole tab 75 mg 1 PA; High Risk Medications require PA for members age 65 and older EFFIENT TAB 5MG 2 EFFIENT TAB 10MG 2 ticlopidine hcl tab 250 mg 1 HEMATOPOIETIC AGENTS Agents for Gaucher Disease CEREZYME INJ 200UNIT 4 PA CEREZYME INJ 400UNIT 4 PA VPRIV INJ 400UNIT 4 PA ZAVESCA CAP 100MG 4 PA Agents for Sickle Cell Anemia DROXIA CAP 200MG 2 DROXIA CAP 300MG 2 DROXIA CAP 400MG 2 Cobalamins cobal-1000 inj 1000mcg 1 cyanocobalamin inj 1000 mcg/ml 1 Folic Acid/Folates FA-8 CAP 800MCG 0 folic acid tab 1 mg 1 folic acid tab 400 mcg 0 folic acid tab 800 mcg 0 Hematopoietic Growth Factors ARANESP INJ 25MCG 4 PA ARANESP INJ 40MCG 4 PA ARANESP INJ 60MCG 4 PA ARANESP INJ 100MCG 4 PA ARANESP INJ 150MCG 4 PA ARANESP INJ 200MCG 4 PA ARANESP INJ 300MCG 4 PA ARANESP INJ 500MCG 4 PA EPOGEN INJ 2000/ML 4 PA EPOGEN INJ 3000/ML 4 PA EPOGEN INJ 4000/ML 4 PA EPOGEN INJ 10000/ML 4 PA EPOGEN INJ 20000/ML 4 PA LEUKINE INJ 250MCG 4 PA

95 Drug Name Drug Tier Requirements/Limits LEUKINE INJ 500 MCG 4 PA NEULASTA INJ 6MG/0.6M 4 PA NEUPOGEN INJ 300/0.5 4 PA NEUPOGEN INJ 300MCG 4 PA NEUPOGEN INJ 480/0.8 4 PA NEUPOGEN INJ 480MCG 4 PA OMONTYS INJ 10MG/ML 4 PA PROCRIT INJ 2000/ML 4 PA PROCRIT INJ 3000/ML 4 PA PROCRIT INJ 4000/ML 4 PA PROCRIT INJ 10000/ML 4 PA PROCRIT INJ 20000/ML 4 PA PROCRIT INJ 40000/ML 4 PA PROMACTA TAB 12.5MG 4 PA PROMACTA TAB 25MG 4 PA PROMACTA TAB 50MG 4 PA PROMACTA TAB 75MG 4 PA Iron FER-IN-SOL DRO 15MG/ML 0 FERROUS SULF DRO 0 FERROUS SULF SYP 300/5ML 0 ferrous sulfate elixir 220 mg/5ml (44 0 mg/5ml elemental fe) ferrous sulfate soln 75 mg/0.6ml (15 0 mg/0.6ml elemental fe) ferrous sulfate soln 75 mg/ml (15 mg/ml 0 elemental fe) ICAR PEDS SUS GRAPE 0 MYKIDZ IRON SUS 15/1.5ML 0 wee care sus 15/1.25 0 Stem Cell Mobilizers MOZOBIL INJ 4 PA HEMOSTATICS Hemostatics - Systemic tranexamic acid inj 100 mg/ml 1 tranexamic acid tab 650 mg 1 Hypnotics tab 15 mg 1 phenobarbital tab 16.2 mg 1 phenobarbital tab 30 mg 1 phenobarbital tab 32.4 mg 1 phenobarbital tab 60 mg 1 phenobarbital tab 64.8 mg 1 phenobarbital tab 97.2 mg 1

96 Drug Name Drug Tier Requirements/Limits phenobarbital tab 100 mg 1 Hypnotics - Tricyclic Agents SILENOR TAB 3MG 3 ST SILENOR TAB 6MG 3 ST Non-Barbiturate Hypnotics EDLUAR SUB 5MG 3 ST EDLUAR SUB 10MG 3 ST INTERMEZZO SUB 1.75MG 3 ST INTERMEZZO SUB 3.5MG 3 ST LUNESTA TAB 1MG 3 ST LUNESTA TAB 2MG 3 ST LUNESTA TAB 3MG 3 ST cap 7.5 mg 1 QL (15 caps / 25 days) temazepam cap 15 mg 1 QL (15 caps / 25 days) temazepam cap 22.5 mg 1 QL (15 caps / 25 days) temazepam cap 30 mg 1 QL (15 caps / 25 days) cap 5 mg 1 QL (15 caps / 25 days) zaleplon cap 10 mg 1 QL (15 caps / 25 days) tartrate tab 5 mg 1 QL (15 tabs / 25 days) zolpidem tartrate tab 10 mg 1 QL (15 tabs / 25 days) zolpidem tartrate tab cr 6.25 mg 1 QL (15 tabs / 25 days) zolpidem tartrate tab cr 12.5 mg 1 QL (15 tabs / 25 days) Selective Receptor Agonists ROZEREM TAB 8MG 3 ST LAXATIVES Laxative Combinations COLYTE/FLAVR SOL PACKS 2 gavilyte-c sol 1 gavilyte-g sol 1 gavilyte-n sol flav pk 1 GOLYTELY SOL 2 MOVIPREP SOL 2 peg 3350-kcl-na bicarb-nacl-na sulfate for 1 soln 236 gm peg 3350-kcl-na bicarb-nacl-na sulfate for 1 soln 240 gm peg 3350-kcl-sod bicarb-nacl for soln 420 1 gm SUPREP BOWEL SOL PREP 3 trilyte sol 1 Laxatives - Miscellaneous constulose sol 10gm/15 1 KRISTALOSE PAK 10GM 3 KRISTALOSE PAK 20GM 3 lactulose solution 10 gm/15ml 1 polyethylene glycol 3350 oral packet 1 97 Drug Name Drug Tier Requirements/Limits Saline Laxatives OSMOPREP TAB 1.5GM 3 VISICOL TAB 1.5GM 3 LOCAL ANESTHETICS-Parenteral Local Anesthetics - Amides LIDO/DEXTROS INJ 5-7.5% 3 lidocaine hcl local inj 0.5% 1 lidocaine hcl local inj 1% 1 lidocaine hcl local inj 1.5% 1 lidocaine hcl local inj 4% 1 MACROLIDES Azithromycin azithromycin for susp 100 mg/5ml 1 azithromycin for susp 200 mg/5ml 1 azithromycin iv for soln 500 mg 1 azithromycin powd pack for susp 1 gm 1 azithromycin tab 250 mg 1 azithromycin tab 500 mg 1 azithromycin tab 600 mg 1 ZMAX SUS 2GM 3 Clarithromycin clarithromycin for susp 125 mg/5ml 1 clarithromycin for susp 250 mg/5ml 1 clarithromycin tab 250 mg 1 clarithromycin tab 500 mg 1 clarithromycin tab sr 24hr 500 mg 1 Erythromycins e.e.s. 400 tab 400mg 1 E.E.S. GRAN SUS 200/5ML 2 ERY-TAB TAB 250MG EC 2 ERY-TAB TAB 333MG EC 2 ERY-TAB TAB 500MG EC 2 ERYPED SUS 200/5ML 2 ERYPED SUS 400/5ML 2 ERYTHROCIN INJ 500MG 3 ERYTHROCIN INJ 1000MG 3 erythrocin tab 250mg 1 erythromycin ethylsuccinate tab 400 mg 1 erythromycin tab 250 mg 1 erythromycin tab 500 mg 1 erythromycin w/ delayed release particles 1 cap 250 mg PCE TAB 333MG EC 3 PCE TAB 500MG EC 3

98 Drug Name Drug Tier Requirements/Limits Fidaxomicin DIFICID TAB 200MG 2 PA MEDICAL DEVICES Contraceptives FEMCAP MIS 22MM 0 FEMCAP MIS 26MM 0 FEMCAP MIS 30MM 0 OMNIFLEX DPR 0 ORTHO COIL DPR KIT 50 0 ORTHO COIL DPR KIT 100 0 ORTHO COIL DPR KIT 105 0 ORTHO FLAT DPR KIT 55 0 ORTHO FLAT DPR KIT 60 0 ORTHO FLAT DPR KIT 65 0 ORTHO FLAT DPR KIT 70 0 ORTHO FLAT DPR KIT 75 0 ORTHO FLAT DPR KIT 80 0 ORTHO FLAT DPR KIT 85 0 ORTHO FLAT DPR KIT 90 0 ORTHO FLAT DPR KIT 95 0 ORTHO FLEX DPR 65MM 0 ORTHO FLEX DPR 70MM 0 ORTHO FLEX DPR 75MM 0 ORTHO FLEX DPR 80MM 0 PARAGARD IUD T380A 0 PRENTIF MIS 22MM 0 PRENTIF MIS 25MM 0 PRENTIF MIS 28MM 0 PRENTIF MIS 31MM 0 PRENTIF MIS FITTING 0 WIDE-SEAL DPR KIT 60 0 WIDE-SEAL DPR KIT 65 0 WIDE-SEAL DPR KIT 70 0 WIDE-SEAL DPR KIT 75 0 WIDE-SEAL DPR KIT 80 0 WIDE-SEAL DPR KIT 85 0 WIDE-SEAL DPR KIT 90 0 WIDE-SEAL DPR KIT 95 0 Diabetic Supplies ACCU-CHEK MIS MLTICLIX 2 ONETOUCH KIT ULTRA 2 2 ONETOUCH US MIS LANCETS 2 PRODUCTS Migraine Combinations

99 Drug Name Drug Tier Requirements/Limits CAFERGOT TAB 1-100MG 2 w/ caffeine tab 1-100 mg 1 Migraine Products mesylate inj 1 mg/ml 1 ERGOMAR SUB 2MG 3 MIGRANAL SPR 4MG/ML 2 QL (8 kits / 25 days) Serotonin Agonists AXERT TAB 6.25MG 3 ST AXERT TAB 12.5MG 3 ST FROVA TAB 2.5MG 3 ST hcl tab 1 mg (base equiv) 1 QL (8 tabs / 25 days) naratriptan hcl tab 2.5 mg (base equiv) 1 QL (8 tabs / 25 days) RELPAX TAB 20MG 3 ST RELPAX TAB 40MG 3 ST benzoate orally disintegrating 1 QL (12 ea / 25 days) tab 5 mg rizatriptan benzoate orally disintegrating 1 QL (12 ea / 25 days) tab 10 mg rizatriptan benzoate tab 5 mg 1 QL (12 tabs / 25 days) rizatriptan benzoate tab 10 mg 1 QL (12 tabs / 25 days) nasal spray 5 mg/act 1 QL (8 / 25 days) sumatriptan nasal spray 20 mg/act 1 QL (8 / 25 days) sumatriptan succinate inj 4 mg/0.5ml 1 QL (4 / 25 days) sumatriptan succinate inj 6 mg/0.5ml 1 QL (5 ml per 25 days) sumatriptan succinate tab 25 mg 1 QL (8 tabs / 25 days) sumatriptan succinate tab 50 mg 1 QL (8 tabs / 25 days) sumatriptan succinate tab 100 mg 1 QL (8 tabs / 25 days) ZOMIG SPR 5MG 3 ST ZOMIG TAB 2.5MG 3 ST ZOMIG TAB 5MG 3 ST ZOMIG ZMT TAB 2.5 MG 3 ST ZOMIG ZMT TAB 5MG 3 ST MINERALS ELECTROLYTES Chloride AMMONIUM CHL INJ 5MEQ/ML 3 Electrolyte Mixtures ISOLYTE-S INJ 3 kcl 20 meq/l (0.15%) in nacl 0.9% inj 1 kcl 20 meq/l (0.15%) in nacl 0.45% inj 1 kcl 40 meq/l (0.3%) in nacl 0.9% inj 1 NORMOSOL -R INJ 3 PLASMA-LYTE INJ -148 3 PLASMA-LYTE INJ -A 3 Fluoride epiflur chw 0.5mg f 0

100 Drug Name Drug Tier Requirements/Limits epiflur chw 0.25mg f 0 epiflur chw 1mg f 1 fluor-a-day dro 0.125mg 0 FLUORABON DRO 0 fluoritab chw 0.5mg f 0 fluoritab chw 2.2mg 1 fluoritab dro 0.125mg 0 flura-drops dro 0.25mg f 0 flura-drops dro 0.125mg 0 ludent chw 0.5mg f 0 ludent chw 0.25mg f 0 ludent chw 1mg f 1 LURIDE CHW 0.5MG F 0 LURIDE CHW 0.25MG F 0 LURIDE DRO 0.5MG/ML 0 nafrinse chw 1mg f 1 sodiphluor dro 1.1mg/ml 0 sodium fluoride chew tab 0.5 mg f (from 0 1.1 mg naf) sodium fluoride chew tab 0.25 mg f (from 0 0.55 mg naf) sodium fluoride chew tab 1 mg f (from 2.2 1 mg naf) sodium fluoride soln 0.5 mg/ml f (from 1.1 0 mg/ml naf) sodium fluoride soln 0.125 mg/drop f 0 (0.275 mg/drop naf) sodium fluoride tab 0.5 mg f (from 1.1 mg 0 naf) sodium fluoride tab 1 mg f (from 2.2 mg 1 naf) Magnesium MAGNESIUM SU INJ 40MG/ML 3 MAGNESIUM SU INJ 80MG/ML 3 magnesium sulfate inj 50% 1 MG SO4/D5W INJ 10MG/ML 3 MG SO4/D5W INJ 20MG/ML 3 Potassium klor-con 8 tab 8meq er 1 klor-con 10 tab 10meq er 1 KLOR-CON M15 TAB 2 klor-con m20 tab 20meq er 1 potassium chloride cap cr 8 meq 1 potassium chloride cap cr 10 meq 1 potassium chloride inj 2 meq/ml 1 potassium chloride inj 10 meq/50 ml 1 potassium chloride inj 10 meq/100 ml 1

101 Drug Name Drug Tier Requirements/Limits potassium chloride inj 20 meq/50 ml 1 potassium chloride inj 30 meq/100 ml 1 potassium chloride microencapsulated crys 1 cr tab 10 meq potassium chloride microencapsulated crys 1 cr tab 20 meq potassium chloride oral liq 10% (20 1 meq/15ml) potassium chloride oral liq 20% (40 1 meq/15ml) potassium chloride tab cr 8 meq (600 mg) 1 potassium chloride tab cr 10 meq 1 Sodium sodium chloride inj 0.9% 1 sodium chloride inj 0.45% 1 sodium chloride inj 2.5 meq/ml (14.6%) 1 sodium chloride inj 3% 1 sodium chloride inj 5% 1 sodium chloride iv soln 0.9% 1 MOUTH/THROAT/DENTAL AGENTS Anesthetics Topical Oral lidocaine hcl viscous soln 2% 1 Anti-infectives - Throat clotrimazole troche 10 mg 1 nystatin susp 100000 unit/ml 1 Antiallergy Agents - Mouth/Throat APHTHASOL PST 5% 3 Antiseptics - Mouth/Throat chlorhexidine gluconate soln 0.12% 1 periogard sol 0.12% 1 Steroids - Mouth/Throat oralone pst 0.1% 1 triamcinolone acetonide dental paste 0.1% 1 Throat Products - Misc. hcl cap 30 mg 1 hcl tab 5 mg 1 pilocarpine hcl tab 7.5 mg 1 MULTIVITAMINS Ped MV w/ Fluoride acd/fluoride dro 0.25mg 1 multi-vit/fl chw 0.5mg 1 multi-vit/fl chw 0.25mg 1 multi-vit/fl chw 1mg 1 multi-vit/fl dro 0.5mg/ml 1 multi-vit/fl dro 0.25mg 1

102 Drug Name Drug Tier Requirements/Limits multivit/fl chw 0.5mg 1 multivit/fl chw 0.25mg 1 multivit/fl chw 1mg 1 phluorivit dro 1 poly-vi-flor chw 0.5mg 1 poly-vi-flor chw 0.25mg 1 poly-vi-flor chw 1mg 1 poly-vit/fl dro 0.25mg 1 polyvit/fl dro 0.5mg/ml 1 tri-vit/fl dro 0.5mg 1 tri-vit/fl dro 0.25mg 1 tri-vit/fluo dro 0.5mg 1 tri-vit/fluo dro 0.25mg 1 tri-vita/fl dro 0.25mg 1 Ped Multi Vitamins w/Fl FE multi-vit/fe dro /fl 0.25 1 multi-vit/fl dro /fe 0.25 1 phluorivit + dro fe 1 poly-vit/fe dro /fl 0.5 1 poly-vit/fe dro /fl 0.25 1 tri-vit/fe dro /fl 0.25 1 Prenatal Vitamins CITRANATAL CAP HARMONY 2 CITRANATAL MIS 90 DHA 2 CITRANATAL MIS B-CALM 2 CITRANATAL PAK ASSURE 2 CITRANATAL PAK DHA 2 CITRANATAL TAB RX 2 MUSCULOSKELETAL THERAPY AGENTS Central Muscle Relaxants AMRIX CAP 15MG 3 PA; High Risk Medications require PA for members age 65 and older AMRIX CAP 30MG 3 PA; High Risk Medications require PA for members age 65 and older tab 10 mg 1 baclofen tab 20 mg 1 tab 250 mg 1 PA; High Risk Medications require PA for members age 65 and older

103 Drug Name Drug Tier Requirements/Limits carisoprodol tab 350 mg 1 PA; High Risk Medications require PA for members age 65 and older chlorzoxazone tab 500 mg 1 hcl tab 5 mg 1 PA; High Risk Medications require PA for members age 65 and older cyclobenzaprine hcl tab 7.5 mg 1 PA; High Risk Medications require PA for members age 65 and older cyclobenzaprine hcl tab 10 mg 1 PA; High Risk Medications require PA for members age 65 and older LORZONE TAB 375MG 3 LORZONE TAB 750MG 3 tab 800 mg 1 PA; High Risk Medications require PA for members age 65 and older tab 500 mg 1 PA; High Risk Medications require PA for members age 65 and older methocarbamol tab 750 mg 1 PA; High Risk Medications require PA for members age 65 and older citrate inj 30 mg/ml 1 orphenadrine citrate tab sr 12hr 100 mg 1 PA; High Risk Medications require PA for members age 65 and older hcl cap 2 mg 1 tizanidine hcl cap 4 mg 1 tizanidine hcl cap 6 mg 1 tizanidine hcl tab 2 mg 1 tizanidine hcl tab 4 mg 1 Direct Muscle Relaxants dantrolene sodium cap 25 mg 1 dantrolene sodium cap 50 mg 1

104 Drug Name Drug Tier Requirements/Limits dantrolene sodium cap 100 mg 1 Combinations orphen cpd tab ds 1 orphenadrine w/ aspirin & caffeine tab 25- 1 PA; High Risk 385-30 mg Medications require PA for members age 65 and older NASAL AGENTS - SYSTEMIC AND TOPICAL Nasal Anti-infectives BACTROBAN OIN NASAL 2% 3 Nasal Antiallergy ASTEPRO SPR 0.15% 3 QL (2 inhalers / 25 days) hcl nasal spray 137 mcg/spray 1 QL (2 / 25 days) (1 mg/ml) PATANASE SPR 0.6% 3 QL (1 inhaler per 25 days) Nasal Anticholinergics nasal soln 0.03% (21 1 mcg/spray) ipratropium bromide nasal soln 0.06% (42 1 mcg/spray) Nasal Steroids BECONASE AQ SUS 0.042% 3 ST flunisolide nasal soln 0.025% 1 QL (2 inhalers per 25 days) flunisolide nasal soln 29 mcg/act (0.025%) 1 QL (2 inhalers per 25 days) fluticasone propionate nasal susp 50 1 QL (1 inhaler per 25 mcg/act days) NASONEX SPR 50MCG/AC 3 QL (2 inhalers / 25 days) OMNARIS SPR 3 ST QNASL AER 80MCG 3 ST RHINOCORT SUS AQUA 3 ST triamcinolone acetonide nasal inhal 55 1 QL (1 inhaler / 25 days) mcg/act VERAMYST SPR 27.5MCG 3 ST Sympathomimetic Decongestants TYZINE PED DRO 0.05% 3 TYZINE SOL 0.1% 3 NEUROMUSCULAR AGENTS ALS Agents RILUTEK TAB 50MG 3 Neuromuscular Blocking Agent - Neurotoxins 105 Drug Name Drug Tier Requirements/Limits BOTOX INJ 100UNIT 4 PA BOTOX INJ 200UNIT 4 PA XEOMIN INJ 50 UNIT 4 PA OPHTHALMIC AGENTS Artificial Tears and Lubricants LACRISERT MIS 5MG OP 3 Beta-blockers - Ophthalmic betaxolol hcl ophth soln 0.5% 1 BETIMOL SOL 0.5% 3 BETIMOL SOL 0.25% 3 BETOPTIC-S SUS 0.25% OP 2 hcl ophth soln 1% 1 COMBIGAN SOL 0.2/0.5% 2 COSOPT PF SOL 3 dorzolamide hcl-timolol maleate ophth soln 1 22.3-6.8 mg/ml ISTALOL SOL 0.5% OP 3 hcl ophth soln 0.5% 1 levobunolol hcl ophth soln 0.25% 1 ophth soln 0.3% 1 timolol maleate ophth gel forming soln 1 0.5% timolol maleate ophth gel forming soln 1 0.25% timolol maleate ophth soln 0.5% 1 timolol maleate ophth soln 0.25% 1 TIMOPTIC OCU SOL 0.5% OP 2 TIMOPTIC OCU SOL 0.25% OP 2 Cycloplegic Mydriatics atropine sulfate ophth oint 1% 1 atropine sulfate ophth soln 1% 1 homatropaire sol 5% op 1 homatropine hbr ophth soln 5% 1 ISO HOMATROP SOL 2% OP 3 ophth soln 0.5% 1 tropicamide ophth soln 1% 1 Miotics PHOSPHOLINE SOL 0.125%OP 3 PILOPINE HS GEL 4% OP 3 Ophthalmic Agents ALPHAGAN P SOL 0.1% 3 hcl ophth soln 0.5% (base 1 equivalent) tartrate ophth soln 0.2% 1 brimonidine tartrate ophth soln 0.15% 1 IOPIDINE SOL 1% OP 3

106 Drug Name Drug Tier Requirements/Limits Ophthalmic Anti-infectives AZASITE SOL 1% 3 bacitracin ophth oint 500 unit/gm 1 bacitracin-polymyxin b ophth oint 1 BESIVANCE SUS 0.6% 3 CILOXAN OIN 0.3% OP 2 ciprofloxacin hcl ophth soln 0.3% 1 erythromycin ophth oint 5 mg/gm 1 garamycin oin 0.3% op 1 gentak oin 0.3% op 1 gentak sol 0.3% op 1 gentamicin sulfate ophth oint 0.3% 1 gentamicin sulfate ophth soln 0.3% 1 gentasol sol 0.3% op 1 ilotycin oin op 1 levofloxacin ophth soln 0.5% 1 MOXEZA SOL 0.5% 3 NATACYN SUS 5% OP 2 neomycin-polymyxin b-gramicidin ophth 1 soln ofloxacin ophth soln 0.3% 1 polycin oin op 1 polymyxin b-trimethoprim ophth soln 1 10000 unit/ml-0.1% romycin oin op 1 sulfacetamide sodium ophth soln 10% 1 tobramycin sulfate ophth soln 0.3% 1 TOBREX OIN 0.3% OP 2 trifluridine ophth soln 1% 1 VIGAMOX DRO 0.5% 2 ZIRGAN GEL 0.15% 3 ZYMAR DRO 0.3% 3 ZYMAXID SOL 0.5% 3 Ophthalmic Decongestants sol 0.1% op 1 hcl ophth soln 2.5% 1 phenylephrine hcl ophth soln 10% 1 Ophthalmic Immunomodulators RESTASIS EMU 0.05% 3 Ophthalmic Local Anesthetics parcaine sol 0.5% op 1 proparacaine hcl ophth soln 0.5% 1 Ophthalmic Steroids ALREX SUS 0.2% 3 bacitracin-polymyxin-neomycin-hc ophth 1 oint 1%

107 Drug Name Drug Tier Requirements/Limits BLEPHAMIDE OIN S.O.P. 2 BLEPHAMIDE SUS OP 2 dexamethasone sodium phosphate ophth 1 soln 0.1% DUREZOL EMU 0.05% 3 FLAREX SUS 0.1% OP 3 fluor-op sus 0.1% op 1 fluorometholone ophth susp 0.1% 1 FML FORTE SUS 0.25% OP 3 FML OIN 0.1% OP 3 LOTEMAX GEL 0.5% 3 LOTEMAX OIN 0.5% 3 LOTEMAX SUS 0.5% 3 MAXIDEX SUS 0.1% OP 3 neo-polycin oin hc 1%op 1 neomycin-polymyxin-dexamethasone 1 ophth oint 0.1% neomycin-polymyxin-dexamethasone 1 ophth susp 0.1% neomycin-polymyxin-hc ophth susp 1 poly-dex oin 0.1% op 1 PRED MILD SUS 0.12% OP 2 PRED SOD PHO SOL 1% OP 2 prednisolone acetate ophth susp 1% 1 sulfacetamide sodium-prednisolone ophth 1 soln 10-0.23(0.25)% TOBRADEX OIN 0.3-0.1% 2 tobramycin-dexamethasone ophth susp 1 0.3-0.1% VEXOL SUS 1% OP 3 Ophthalmics - Misc. ACUVAIL SOL 0.45% 3 ALOCRIL SOL 2% 3 ALOMIDE SOL 0.1% OP 3 azelastine hcl ophth soln 0.05% 1 AZOPT SUS 1% OP 3 BEPREVE DRO 1.5% 3 BROMDAY SOL 0.09% 3 bromfenac sodium ophth soln 0.09% (base 1 equivalent) cromolyn sodium ophth soln 4% 1 diclofenac sodium ophth soln 0.1% 1 dorzolamide hcl ophth soln 2% 1 EMADINE SOL 0.05% OP 3 hcl ophth soln 0.05% 1 flurbiprofen sodium ophth soln 0.03% 1 ILEVRO DRO 0.3% OP 3

108 Drug Name Drug Tier Requirements/Limits ketorolac tromethamine ophth soln 0.4% 1 ketorolac tromethamine ophth soln 0.5% 1 fumarate ophth soln 0.025% 1 (base equiv) LASTACAFT SOL 0.25% 3 NEVANAC SUS 0.1% 3 PATADAY SOL 0.2% 3 PATANOL SOL 0.1% OP 3 Prostaglandins - Ophthalmic latanoprost ophth soln 0.005% 1 LUMIGAN SOL 0.01% 3 ST LUMIGAN SOL 0.03% 3 ST TRAVATAN Z DRO 0.004% 3 ST ZIOPTAN DRO 0.0015% 3 ST OTIC AGENTS Otic Agents - Miscellaneous acetic acid 2% in aluminum acetate otic 1 soln acetic acid otic soln 2% 1 Otic Anti-infectives ofloxacin otic soln 0.3% 1 Otic Combinations CIPRO HC SUS OTIC 3 CIPRODEX SUS 0.3-0.1% 2 CORTISPORIN SUS -TC OTIC 3 cortomycin sol 1% otic 1 cortomycin sus 1% otic 1 neomycin-polymyxin-hc otic soln 1% 1 neomycin-polymyxin-hc otic susp 3.5 1 mg/ml-10000 unit/ml-1% Otic Steroids fluocinolone acetonide (otic) oil 0.01% 1 hydrocortisone w/ acetic acid otic soln 1- 1 2% PASSIVE IMMUNIZING AGENTS Immune Serums CARIMUNE NF INJ 3GM 4 PA FLEBOGAMMA INJ 5% 4 PA FLEBOGAMMA INJ 10% 4 PA GAMASTAN S/D INJ 4 PA GAMMAGARD SD INJ 2.5GM HU 4 PA GAMMAKED INJ 1GM/10ML 4 PA GAMMAPLEX INJ 2.5GM 4 PA GAMUNEX INJ 10% 4 PA HIZENTRA INJ 1GM/5ML 4 PA

109 Drug Name Drug Tier Requirements/Limits OCTAGAM INJ 1GM 4 PA PRIVIGEN INJ 5 GRAMS 4 PA PENICILLINS Aminopenicillins amoxicillin (trihydrate) cap 250 mg 1 amoxicillin (trihydrate) cap 500 mg 1 amoxicillin (trihydrate) chew tab 125 mg 1 amoxicillin (trihydrate) chew tab 200 mg 1 amoxicillin (trihydrate) chew tab 250 mg 1 amoxicillin (trihydrate) for susp 125 1 mg/5ml amoxicillin (trihydrate) for susp 200 1 mg/5ml amoxicillin (trihydrate) for susp 250 1 mg/5ml amoxicillin (trihydrate) for susp 400 1 mg/5ml amoxicillin (trihydrate) tab 500 mg 1 amoxicillin (trihydrate) tab 875 mg 1 ampicillin cap 250 mg 1 ampicillin cap 500 mg 1 ampicillin for susp 125 mg/5ml 1 ampicillin for susp 250 mg/5ml 1 ampicillin sodium for inj 10 gm 1 ampicillin sodium for inj 125 mg 1 ampicillin sodium for inj 250 mg 1 ampicillin sodium for iv soln 1 gm 1 ampicillin sodium for iv soln 2 gm 1 MOXATAG TAB 775MG 3 Natural Penicillins BICILLIN L-A INJ 600000 3 BICILLIN L-A INJ 1200000 3 BICILLIN L-A INJ 2400000 3 PEN G PROC INJ 600000 3 PENICILL GK/ INJ DEX 1MU 3 PENICILL GK/ INJ DEX 2MU 3 PENICILL GK/ INJ DEX 3MU 3 penicillin g potassium for inj 5000000 unit 1 penicillin g sodium for inj 5000000 unit 1 penicillin v potassium for soln 125 mg/5ml 1 penicillin v potassium for soln 250 mg/5ml 1 penicillin v potassium tab 250 mg 1 penicillin v potassium tab 500 mg 1 Penicillin Combinations amoxicillin & k clavulanate chew tab 200- 1 28.5 mg

110 Drug Name Drug Tier Requirements/Limits amoxicillin & k clavulanate chew tab 400- 1 57 mg amoxicillin & k clavulanate for susp 200- 1 28.5 mg/5ml amoxicillin & k clavulanate for susp 250- 1 62.5 mg/5ml amoxicillin & k clavulanate for susp 400-57 1 mg/5ml amoxicillin & k clavulanate for susp 600- 1 42.9 mg/5ml amoxicillin & k clavulanate tab 250-125 mg1 amoxicillin & k clavulanate tab 500-125 mg1 amoxicillin & k clavulanate tab 875-125 mg1 amoxicillin & k clavulanate tab sr 12hr 1 1000-62.5 mg ampicillin & sulbactam sodium for inj 1-0.5 1 gm ampicillin & sulbactam sodium for iv soln 1 1-0.5 gm ampicillin & sulbactam sodium for iv soln 1 10-5 gm AUGMENTIN SUS 125/5ML 2 BICILLIN C-R INJ 900/300 3 BICILLIN C-R INJ 1200000 3 piperacillin sodium-tazobactam sodium for 1 inj 2-0.25 gm piperacillin sodium-tazobactam sodium for 1 inj 3-0.375 gm piperacillin sodium-tazobactam sodium for 1 inj 4-0.5 gm TIMENTIN INJ 3.1GM 3 ZOSYN SOL 2-0.25GM 3 ZOSYN SOL 3-0.375G 3 Penicillinase-Resistant Penicillins BACTOCILL INJ DEX 1GM 3 BACTOCILL INJ DEX 2GM 3 dicloxacillin sodium cap 250 mg 1 dicloxacillin sodium cap 500 mg 1 nafcillin sodium for inj 1 gm 1 nafcillin sodium for inj 10 gm 1 nafcillin sodium for iv soln 2 gm 1 NALLPEN/DEX INJ 1GM/50ML 3 oxacillin sodium for inj 1 gm 1 oxacillin sodium for inj 10 gm 1 PROGESTINS Progestins medroxyprogesterone acetate tab 2.5 mg 1 medroxyprogesterone acetate tab 5 mg 1

111 Drug Name Drug Tier Requirements/Limits medroxyprogesterone acetate tab 10 mg 1 MEGACE ES SUS 625/5ML 3 norethindrone acetate tab 5 mg 1 micronized cap 100 mg 1 progesterone micronized cap 200 mg 1 PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. Agents for Chemical Dependency CAMPRAL TAB 333MG 3 PA disulfiram tab 250 mg 1 disulfiram tab 500 mg 1 Anti-Cataplectic Agents XYREM SOL 500MG/ML 2 PA Antidementia Agents ARICEPT TAB 23MG 2 ST donepezil hydrochloride orally 1 disintegrating tab 5 mg donepezil hydrochloride orally 1 disintegrating tab 10 mg donepezil hydrochloride tab 5 mg 1 donepezil hydrochloride tab 10 mg 1 EXELON DIS 4.6MG/24 3 PA EXELON DIS 9.5MG/24 3 PA EXELON SOL 2MG/ML 2 PA galantamine hydrobromide cap sr 24hr 8 1 mg galantamine hydrobromide cap sr 24hr 16 1 mg galantamine hydrobromide cap sr 24hr 24 1 mg galantamine hydrobromide oral soln 4 1 mg/ml galantamine hydrobromide tab 4 mg 1 galantamine hydrobromide tab 8 mg 1 galantamine hydrobromide tab 12 mg 1 NAMENDA SOL 10MG/5ML 2 PA NAMENDA TAB 5-10MG 3 PA NAMENDA TAB 5MG 2 PA NAMENDA TAB 10MG 2 PA rivastigmine tartrate cap 1.5 mg 1 rivastigmine tartrate cap 3 mg 1 rivastigmine tartrate cap 4.5 mg 1 rivastigmine tartrate cap 6 mg 1 Agents SAVELLA MIS TITR PAK 3 SAVELLA TAB 12.5MG 3 SAVELLA TAB 25MG 3

112 Drug Name Drug Tier Requirements/Limits SAVELLA TAB 50MG 3 SAVELLA TAB 100MG 3 Movement Disorder Drug Therapy XENAZINE TAB 12.5MG 4 PA XENAZINE TAB 25MG 4 PA Multiple Sclerosis Agents AMPYRA TAB 10MG 4 PA AUBAGIO TAB 7MG 4 PA AUBAGIO TAB 14MG 4 PA AVONEX KIT 30MCG 4 PA AVONEX PEN KIT 30MCG 4 PA AVONEX PREFL KIT 30MCG 4 PA BETASERON INJ 0.3MG 4 PA COPAXONE KIT 20MG/ML 4 PA EXTAVIA INJ 0.3MG 4 PA GILENYA CAP 0.5MG 4 PA REBIF INJ 22/0.5 4 PA REBIF INJ 44/0.5 4 PA REBIF TITRTN SOL PACK 4 PA TYSABRI INJ 4 PA Postherpetic Neuralgia (PHN) Agents GRALISE STAR MIS 300/600 3 ST GRALISE TAB 300MG 3 ST GRALISE TAB 600MG 3 ST Premenstrual Dysphoric Disorder (PMDD) Agents SARAFEM TAB 10MG 3 SARAFEM TAB 20MG 3 Pseudobulbar Affect (PBA) Agents NUEDEXTA CAP 20-10MG 3 Psychotherapeutic and Neurological Agents - Misc. mesylates tab 1 mg 1 ORAP TAB 1MG 3 ORAP TAB 2MG 3 Restless Leg Syndrome (RLS) Agents HORIZANT TAB 600MG 3 ST Smoking Deterrents buproban tab 150mg 0 bupropion hcl (smoking deterrent) tab sr 0 12hr 150 mg CHANTIX PAK 0.5& 1MG 0 CHANTIX PAK 1MG 0 CHANTIX TAB 0.5MG 0 CHANTIX TAB 1MG 0 NICODERM CQ DIS 7MG/24HR 0 NICODERM CQ DIS 14MG/24H 0

113 Drug Name Drug Tier Requirements/Limits NICODERM CQ DIS 21MG/24H 0 NICORETTE GUM 2MG ORIG 0 NICORETTE GUM 4MG ORIG 0 NICORETTE LOZ 2MG ORIG 0 NICORETTE LOZ 4MG ORIG 0 polacrilex gum 2 mg 0 nicotine polacrilex gum 4 mg 0 nicotine polacrilex lozenge 2 mg 0 nicotine polacrilex lozenge 4 mg 0 nicotine td patch 24hr 7 mg/24hr 0 nicotine td patch 24hr 14 mg/24hr 0 nicotine td patch 24hr 21 mg/24hr 0 NICOTROL INH 3 NICOTROL NS SPR 10MG/ML 3 sm nicotine dis 7mg/24hr 0 sm nicotine dis 14mg/24h 0 sm nicotine dis 21mg 0 thrive gum 4mg mint 0 ZYBAN TAB 150MG SR 0 RESPIRATORY AGENTS - MISC. Alpha-Proteinase Inhibitor (Human) ARALAST NP INJ 400MG 4 PA ARALAST NP INJ 500MG 4 PA GLASSIA INJ 4 PA PROLASTIN INJ 500MG 4 PA PROLASTIN INJ 1000MG 4 PA PROLASTIN-C INJ 1000MG 4 PA ZEMAIRA INJ 1000MG 4 PA Cystic Fibrosis Agents KALYDECO TAB 150MG 4 PA SULFONAMIDES Sulfonamides SULFADIAZINE TAB 500MG 3 TETRACYCLINES Tetracyclines ALODOX KIT 20MG 3 avidoxy tab 100mg 1 demeclocycline hcl tab 150 mg 1 demeclocycline hcl tab 300 mg 1 DORYX TAB 150MG 3 doxy 100 inj 100mg 1 DOXYCYCL HYC CAP 100MG 3 doxycycline hyclate cap 50 mg 1 doxycycline hyclate cap 100 mg 1

114 Drug Name Drug Tier Requirements/Limits doxycycline hyclate for inj 100 mg 1 doxycycline hyclate tab 20 mg 1 doxycycline hyclate tab 100 mg 1 doxycycline hyclate tab delayed release 75 1 mg doxycycline hyclate tab delayed release 1 100 mg doxycycline monohydrate cap 50 mg 1 doxycycline monohydrate cap 75 mg 1 doxycycline monohydrate cap 100 mg 1 doxycycline monohydrate cap 150 mg 1 doxycycline monohydrate tab 50 mg 1 doxycycline monohydrate tab 75 mg 1 doxycycline monohydrate tab 150 mg 1 minocycline hcl cap 50 mg 1 minocycline hcl cap 75 mg 1 minocycline hcl cap 100 mg 1 minocycline hcl tab 50 mg 1 minocycline hcl tab 75 mg 1 minocycline hcl tab 100 mg 1 minocycline hcl tab sr 24hr 45 mg 1 minocycline hcl tab sr 24hr 90 mg 1 minocycline hcl tab sr 24hr 135 mg 1 morgidox cap 1x100mg 1 MORGIDOX KIT 1X100MG 3 OCUDOX KIT 3 tetracycline hcl cap 250 mg 1 tetracycline hcl cap 500 mg 1 VIBRAMYCIN SUS 25MG/5ML 3 VIBRAMYCIN SYP 50MG/5ML 3 THYROID AGENTS Antithyroid Agents methimazole tab 5 mg 1 methimazole tab 10 mg 1 propylthiouracil tab 50 mg 1 levothroid tab 25mcg 1 levothroid tab 50mcg 1 levothroid tab 75mcg 1 levothroid tab 88mcg 1 levothroid tab 100mcg 1 levothroid tab 112mcg 1 levothroid tab 125mcg 1 levothroid tab 137mcg 1 levothroid tab 150mcg 1

115 Drug Name Drug Tier Requirements/Limits levothroid tab 175mcg 1 levothroid tab 200mcg 1 levothroid tab 300mcg 1 sodium tab 25 mcg 1 levothyroxine sodium tab 50 mcg 1 levothyroxine sodium tab 75 mcg 1 levothyroxine sodium tab 88 mcg 1 levothyroxine sodium tab 100 mcg 1 levothyroxine sodium tab 112 mcg 1 levothyroxine sodium tab 125 mcg 1 levothyroxine sodium tab 137 mcg 1 levothyroxine sodium tab 150 mcg 1 levothyroxine sodium tab 175 mcg 1 levothyroxine sodium tab 200 mcg 1 levothyroxine sodium tab 300 mcg 1 levoxyl tab 25mcg 1 levoxyl tab 50mcg 1 levoxyl tab 75mcg 1 levoxyl tab 88mcg 1 levoxyl tab 100mcg 1 levoxyl tab 112mcg 1 levoxyl tab 125mcg 1 levoxyl tab 137mcg 1 levoxyl tab 150mcg 1 levoxyl tab 175mcg 1 levoxyl tab 200mcg 1 liothyronine sodium iv soln 10 mcg/ml 1 liothyronine sodium tab 5 mcg 1 liothyronine sodium tab 25 mcg 1 liothyronine sodium tab 50 mcg 1 THYROLAR-1 TAB 60MG 3 THYROLAR-1/2 TAB 30MG 3 THYROLAR-1/4 TAB 15MG 3 THYROLAR-2 TAB 120MG 3 THYROLAR-3 TAB 180MG 3 unithroid tab 25mcg 1 unithroid tab 50mcg 1 unithroid tab 75mcg 1 unithroid tab 88mcg 1 unithroid tab 100mcg 1 unithroid tab 112mcg 1 unithroid tab 125mcg 1 unithroid tab 137mcg 1 unithroid tab 150mcg 1 unithroid tab 175mcg 1

116 Drug Name Drug Tier Requirements/Limits unithroid tab 200mcg 1 unithroid tab 300mcg 1 TOXOIDS Toxoid Combinations ADACEL INJ 0 BOOSTRIX INJ 0 DAPTACEL INJ 0 DECAVAC INJ 5-2LF 0 DIP/TET PED INJ 6.7-5LF 0 DIP/TET PED INJ 25-5LFU 0 INFANRIX INJ 0 KINRIX INJ 0 PEDIARIX INJ 0.5ML 0 PENTACEL INJ 0 TENIVAC INJ 5-2LF 0 TET/DIP TOX INJ 2-2 LF 0 TRIHIBIT KIT P/F 0 TRIPEDIA SUS P/F 0 Toxoids TETANUS TOX INJ 5LF ADS 0 ULCER DRUGS Antispasmodics ATROPEN INJ 0.5MG 3 ATROPEN INJ 0.25MG 3 ATROPEN INJ 1MG 3 ATROPEN INJ 2MG 3 atropine sulfate inj 0.1 mg/ml 1 atropine sulfate inj 0.05 mg/ml 1 BENTYL INJ 10MG/ML 3 CANTIL TAB 25MG 3 clidinium & cap 2.5-5 mg 1 CUVPOSA SOL 1MG/5ML 2 dicyclomine hcl cap 10 mg 1 dicyclomine hcl oral soln 10 mg/5ml 1 dicyclomine hcl tab 20 mg 1 ed-spaz tab 0.125mg 1 glycopyrrolate inj 0.4 mg/2ml (0.2 mg/ml) 1 glycopyrrolate tab 1 mg 1 glycopyrrolate tab 2 mg 1 hyomax tab 0.125mg 1 hyomax-ft tab 0.125mg 1 hyomax-sl sub 0.125mg 1 hyomax-sr tab 0.375mg 1 sulfate tab 0.125 mg 1

117 Drug Name Drug Tier Requirements/Limits hyoscyamine sulfate tab disp 0.125 mg 1 hyoscyamine sulfate tab sl 0.125 mg 1 hyoscyamine sulfate tab sr 12hr 0.375 mg 1 methscopolamine bromide tab 2.5 mg 1 methscopolamine bromide tab 5 mg 1 nulev tab 0.125mg 1 oscimin sr tab 0.375mg 1 oscimin sub 0.125mg 1 oscimin tab 0.125mg 1 symax fastab tab 0.125mg 1 symax-sl sub 0.125mg 1 H-2 Antagonists hcl soln 300 mg/5ml 1 cimetidine tab 300 mg 1 cimetidine tab 400 mg 1 cimetidine tab 800 mg 1 for susp 40 mg/5ml 1 famotidine in nacl 0.9% iv soln 20 1 mg/50ml famotidine inj 10 mg/ml 1 famotidine tab 20 mg 1 famotidine tab 40 mg 1 cap 150 mg 1 nizatidine cap 300 mg 1 nizatidine oral soln 15 mg/ml 1 hcl cap 150 mg 1 ranitidine hcl cap 300 mg 1 ranitidine hcl inj 50 mg/2ml (25 mg/ml) 1 ranitidine hcl syrup 15 mg/ml (75 mg/5ml) 1 ranitidine hcl tab 150 mg 1 ranitidine hcl tab 300 mg 1 ZANTAC INJ 50/50ML 3 ZANTAC TAB 25MG EF 3 Misc. Anti-Ulcer CARAFATE SUS 1GM/10ML 3 sucralfate tab 1 gm 1 Proton Pump Inhibitors ACIPHEX TAB 20MG 3 ST DEXILANT CAP 30MG DR 3 ST DEXILANT CAP 60MG DR 3 ST lansoprazole cap delayed release 15 mg 1 QL (30 caps / 25 days) lansoprazole cap delayed release 30 mg 1 QL (30 caps / 25 days) lansoprazole tab delayed release orally 1 QL (30 caps / 25 days) disintegrating 15 mg lansoprazole tab delayed release orally 1 QL (30 caps / 25 days) disintegrating 30 mg

118 Drug Name Drug Tier Requirements/Limits NEXIUM CAP 20MG 3 ST NEXIUM CAP 40MG 3 ST NEXIUM GRA 2.5MG DR 3 ST NEXIUM GRA 5MG DR 3 ST NEXIUM GRA 10MG DR 3 ST NEXIUM GRA 20MG DR 3 ST NEXIUM GRA 40MG DR 3 ST NEXIUM I.V. INJ 20MG 3 NEXIUM I.V. INJ 40MG 3 omeprazole cap delayed release 10 mg 1 QL (30 caps / 25 days) omeprazole cap delayed release 20 mg 1 QL (30 caps / 25 days) omeprazole cap delayed release 40 mg 1 QL (30 caps / 25 days) pantoprazole sodium ec tab 20 mg (base 1 QL (30 tabs / 25 days) equiv) pantoprazole sodium ec tab 40 mg (base 1 QL (30 tabs / 25 days) equiv) PROTONIX PAK 3 QL (30 packets / 25 days) Ulcer Drugs - Prostaglandins misoprostol tab 100 mcg 1 misoprostol tab 200 mcg 1 Ulcer Therapy Combinations omeprazole-sodium bicarbonate cap 40- 1 QL (30 caps / 25 days) 1100 mg URINARY ANTI-INFECTIVES Urinary Anti-infectives MACRODANTIN CAP 25MG 2 PA; High Risk Medications require PA for members age 65 and older methenamine hippurate tab 1 gm 1 MONUROL PAK GRANULES 3 nitrofurantoin macrocrystalline cap 50 mg 1 PA; High Risk Medications require PA for members age 65 and older nitrofurantoin macrocrystalline cap 100 mg 1 PA; High Risk Medications require PA for members age 65 and older nitrofurantoin monohydrate 1 PA; High Risk macrocrystalline cap 100 mg Medications require PA for members age 65 and older

119 Drug Name Drug Tier Requirements/Limits nitrofurantoin susp 25 mg/5ml 1 PA; High Risk Medications require PA for members age 65 and older URINARY ANTISPASMODICS Beta-3 Adrenergic Agonists MYRBETRIQ TAB 25MG 3 ST MYRBETRIQ TAB 50MG 3 ST Urinary Antispasmodics chloride tab 5 mg 1 bethanechol chloride tab 10 mg 1 bethanechol chloride tab 25 mg 1 bethanechol chloride tab 50 mg 1 DETROL LA CAP 2MG 3 ST DETROL LA CAP 4MG 3 ST ENABLEX TAB 7.5MG 3 ST ENABLEX TAB 15MG 3 ST hcl tab 100 mg 1 GELNIQUE GEL 3% 3 ST GELNIQUE GEL 10% 3 ST chloride syrup 5 mg/5ml 1 oxybutynin chloride tab 5 mg 1 oxybutynin chloride tab sr 24hr 5 mg 1 oxybutynin chloride tab sr 24hr 10 mg 1 oxybutynin chloride tab sr 24hr 15 mg 1 OXYTROL DIS 3.9MG/24 3 ST tartrate tab 1 mg 1 tolterodine tartrate tab 2 mg 1 TOVIAZ TAB 4MG 3 ST TOVIAZ TAB 8MG 3 ST cap sr 24hr 60 mg 1 trospium chloride tab 20 mg 1 VESICARE TAB 5MG 3 ST VESICARE TAB 10MG 3 ST VACCINES Bacterial Vaccines ACTHIB INJ 0 HIBERIX SOL 10-25MCG 0 MENACTRA INJ 0 MENHIBRIX INJ 0 MENOMUNE INJ A/C/Y/W 0 MENVEO INJ 0 PEDVAX HIB INJ 0 PNEUMOVAX 23 INJ 25/0.5 0

120 Drug Name Drug Tier Requirements/Limits PREVNAR 13 INJ 0 PREVNAR INJ 0 Mixed Vaccine Combinations COMVAX INJ 0 Viral Vaccines AFLURIA INJ 2009-10 0 AFLURIA INJ 2011-12 0 AFLURIA INJ 2012-13 0 AFLURIA INJ PF 10-11 0 AFLURIA INJ PF 11-12 0 AFLURIA INJ PF 12-13 0 AGRIFLU INJ PF 10-11 0 CERVARIX INJ 0 ENGERIX-B INJ 10/0.5ML 0 ENGERIX-B INJ 20MCG/ML 0 FLUARIX INJ PF 10-11 0 FLUARIX INJ PF 11-12 0 FLUARIX INJ PF 12-13 0 FLUCELVAX INJ 2012-13 0 FLULAVAL INJ 2010-11 0 FLULAVAL INJ 2011-12 0 FLULAVAL INJ 2012-13 0 FLUMIST NASA LIQ 2010-11 0 FLUMIST NASA LIQ 2011-12 0 FLUMIST NASA LIQ 2012-13 0 FLUVIRIN INJ 2010-11 0 FLUVIRIN INJ 2011-12 0 FLUVIRIN INJ 2012-13 0 FLUVIRIN INJ PF 11-12 0 FLUVIRIN INJ PF 12-13 0 FLUZONE HD INJ PF 10-11 0 FLUZONE HD INJ PF 11-12 0 FLUZONE HD INJ PF 12-13 0 FLUZONE INJ INTRADRM 0 FLUZONE INJ PF 10-11 0 FLUZONE INJ PF 11-12 0 FLUZONE INJ PF 12-13 0 FLUZONE PED/ INJ PF 10-11 0 FLUZONE PED/ INJ PF 11-12 0 FLUZONE PED/ INJ PF 12-13 0 FLUZONE SPLT INJ 2010-11 0 GARDASIL INJ 0 HAVRIX INJ 720UNIT 0 HAVRIX INJ 1440UNIT 0 INFLUENZA A INJ 09 H1N1 0

121 Drug Name Drug Tier Requirements/Limits INFLUENZA A INJ PF09H1N1 0 INFLUENZA A SPR 09 H1N1 0 IPOL INJ INACTIVE 0 M-M-R II INJ LIVE 0 PROQUAD INJ 0 RECOMBIVA HB INJ 5MCG/0.5 0 RECOMBIVA HB INJ 10MCG/ML 0 RECOMBIVA-HB INJ 40MCG/ML 0 ROTARIX SUS 0 ROTATEQ SUS 0 TWINRIX INJ 0 VAQTA INJ 25/0.5ML 0 VAQTA INJ 50UNT/ML 0 VARIVAX INJ 0 ZOSTAVAX INJ 0 VAGINAL PRODUCTS Vaginal Anti-infectives CLEOCIN SUP 100MG 2 clindamycin phosphate vaginal cream 2% 1 GYNAZOLE-1 CRE 2% 3 metronidazole vaginal gel 0.75% 1 terconazole vaginal cream 0.4% 1 terconazole vaginal cream 0.8% 1 terconazole vaginal suppos 80 mg 1 vandazole gel 0.75% 1 zazole cre 0.4% 1 zazole cre 0.8% 1 zazole sup 80mg 1 Vaginal Estrogens ESTRACE VAG CRE 0.1MG/GM 2 ESTRING MIS 2MG 3 FEMRING MIS 0.1MG/24 3 FEMRING MIS 0.05/24H 3 PREMARIN VAG CRE 0.625MG 3 VAGIFEM TAB 10MCG 3 Vaginal Progestins CRINONE GEL 4% VAG 2 CRINONE GEL 8% VAG 2 VASOPRESSORS Anaphylaxis Therapy Agents epinephrine inj device 0.3 mg/0.3ml 1 (1:1000) epinephrine inj device 0.15 mg/0.15ml 1 (1:1000) EPIPEN 2-PAK INJ 0.3MG 2

122 Drug Name Drug Tier Requirements/Limits EPIPEN INJ 0.3MG 2 EPIPEN-JR INJ 0.15MG 2 EPIPEN-JR INJ 2-PAK 2 Vasopressors hcl tab 2.5 mg 1 midodrine hcl tab 5 mg 1 midodrine hcl tab 10 mg 1 VITAMINS Oil Soluble Vitamins ergocalciferol cap 50000 unit 1 MEPHYTON TAB 5MG 2

123 ACTHIB INJ120 Index acticin cre 5%81 ACTIMMUNE INJ 2MU/0.550 8 ACTONEL TAB 150MG83 8-MOP CAP 10MG77 ACTONEL TAB 30MG83 ACTONEL TAB 35MG83 A ACTONEL TAB 5MG83 a-methapred inj 125mg71 ACUVAIL SOL 0.45%108 a-methapred inj 40mg71 acyclovir cap 200 mg59 abacavir sulfate tab 300 mg (base acyclovir sodium for inj 500 mg59 equiv)56 acyclovir susp 200 mg/5ml59 ABELCET INJ 5MG/ML37 acyclovir tab 400 mg59 ABILIFY DISC TAB 10MG56 acyclovir tab 800 mg59 ABILIFY DISC TAB 15MG56 ADACEL INJ117 ABILIFY INJ 9.75MG56 ADAGEN INJ 250/ML63 ABILIFY SOL 1MG/ML56 adapalene cream 0.1%73 ABILIFY TAB 10MG56 adapalene gel 0.1%73 ABILIFY TAB 15MG56 ADCIRCA TAB 20MG65 ABILIFY TAB 20MG56 adriamycin inj 10mg48 ABILIFY TAB 2MG56 ADRIAMYCIN INJ 20MG48 ABILIFY TAB 30MG56 adrucil inj 50mg/ml46 ABILIFY TAB 5MG56 ADULT ASA TAB 81MG QM6 ABRAXANE INJ 100MG51 ADVAIR DISKU AER 100/5020 ABSTRAL SUB 100MCG6 afeditab tab 30mg cr63 ABSTRAL SUB 200MCG6 afeditab tab 60mg cr63 ABSTRAL SUB 300MCG6 AFINITOR TAB 10MG49 ABSTRAL SUB 400MCG6 AFINITOR TAB 2.5MG48 ABSTRAL SUB 600MCG6 AFINITOR TAB 5MG49 ABSTRAL SUB 800MCG6 AFINITOR TAB 7.5MG49 ACANYA GEL 1.2-2.5%73 AFLURIA INJ 2009-10121 acarbose tab 100 mg31 AFLURIA INJ 2011-12121 acarbose tab 25 mg31 AFLURIA INJ 2012-13121 acarbose tab 50 mg31 AFLURIA INJ PF 10-11121 ACCU-CHEK MIS MLTICLIX99 AFLURIA INJ PF 11-12121 ACCU-CHEK TES ACTIVE81 AFLURIA INJ PF 12-13121 ACCU-CHEK TES DRUM81 AGGRENOX CAP 25-200MG94 acd/fluoride dro 0.25mg102 AGRIFLU INJ PF 10-11121 acebutolol hcl cap 200 mg61 AKNE-MYCIN OIN 2%73 acebutolol hcl cap 400 mg61 ala cort cre 1%78 acetaminophen w/ codeine soln 120-12 ALBENZA TAB 200MG13 mg/5ml10 albuterol sulfate soln nebu 0.083% (2.5 acetaminophen w/ codeine tab 300-15 mg/3ml)20 mg10 albuterol sulfate soln nebu 0.5% (5 acetaminophen w/ codeine tab 300-30 mg/ml)20 mg10 albuterol sulfate soln nebu 0.63 mg/3ml acetaminophen w/ codeine tab 300-60 (base equiv)20 mg10 albuterol sulfate soln nebu 1.25 mg/3ml acetazolamide cap sr 12hr 500 mg82 (base equiv)20 acetazolamide sodium for inj 500 mg82 albuterol sulfate syrup 2 mg/5ml20 acetazolamide tab 125 mg82 albuterol sulfate tab 2 mg20 acetazolamide tab 250 mg82 albuterol sulfate tab 4 mg20 acetic acid 2% in aluminum acetate otic albuterol sulfate tab sr 12hr 4 mg20 soln109 albuterol sulfate tab sr 12hr 8 mg20 acetic acid otic soln 2%109 alclometasone dipropionate cream acetylcysteine inhal soln 10%73 0.05%78 acetylcysteine inhal soln 20%73 alclometasone dipropionate oint 0.05%78 ACIPHEX TAB 20MG118 ALDACTAZIDE TAB 50/5082 ACTEMRA INJ 200/10ML4 ALDURAZYME INJ 2.9MG/5M85 ACTEMRA INJ 400/20ML4 alendronate sodium tab 10 mg83 ACTEMRA INJ 80MG/4ML4 alendronate sodium tab 35 mg83 124 alendronate sodium tab 40 mg83 amikacin sulfate inj 100 mg/2ml (50 alendronate sodium tab 5 mg83 mg/ml)3 alendronate sodium tab 70 mg83 amikacin sulfate inj 500 mg/2ml (250 ALFERON N INJ 5MU/ML50 mg/ml)3 alfuzosin hcl tab sr 24hr 10 mg93 amiloride & hydrochlorothiazide tab 5-50 ALIMTA INJ 100MG46 mg82 ALIMTA INJ 500MG46 amiloride hcl tab 5 mg83 ALINIA SUS 100MG/5M14 aminophylline inj 25 mg/ml21 ALINIA TAB 500MG14 amiodarone hcl inj 150 mg/3ml (50 ALKERAN TAB 2MG45 mg/ml)18 ALLFEN CDX LIQ73 amiodarone hcl tab 200 mg18 allopurinol sodium for inj 500 mg94 amiodarone hcl tab 400 mg18 allopurinol tab 100 mg94 AMITIZA CAP 24MCG92 allopurinol tab 300 mg94 AMITIZA CAP 8MCG92 ALOCRIL SOL 2%108 amitriptyline hcl tab 10 mg28 ALODOX KIT 20MG114 amitriptyline hcl tab 100 mg28 ALOMIDE SOL 0.1% OP108 amitriptyline hcl tab 150 mg29 ALORA DIS 0.025MG87 amitriptyline hcl tab 25 mg28 ALORA DIS 0.05MG87 amitriptyline hcl tab 50 mg28 ALORA DIS 0.075MG87 amitriptyline hcl tab 75 mg28 ALORA DIS 0.1MG87 amlodipine besylate tab 10 mg63 ALOXI INJ35 amlodipine besylate tab 2.5 mg63 ALOXI INJ 0.25MG/535 amlodipine besylate tab 5 mg63 ALPHAGAN P SOL 0.1%106 amlodipine besylate-benazepril hcl cap 10- alphatrex gel 0.05%78 20 mg43 amlodipine besylate-benazepril hcl cap 10- ALPRAZOLAM CON 1 MG/ML17 alprazolam orally disintegrating tab 0.25 40 mg43 amlodipine besylate-benazepril hcl cap mg17 alprazolam orally disintegrating tab 0.5 2.5-10 mg42 amlodipine besylate-benazepril hcl cap 5- mg17 alprazolam orally disintegrating tab 1 10 mg42 amlodipine besylate-benazepril hcl cap 5- mg17 alprazolam orally disintegrating tab 2 20 mg42 amlodipine besylate-benazepril hcl cap 5- mg17 40 mg42 alprazolam tab 0.25 mg17 AMMONIUM CHL INJ 5MEQ/ML100 alprazolam tab 0.5 mg17 amnesteem cap 10mg73 alprazolam tab 1 mg17 amnesteem cap 20mg73 alprazolam tab 2 mg17 amnesteem cap 40mg73 ALREX SUS 0.2%107 AMOXAPINE TAB 100MG29 ALTABAX OIN 1%76 AMOXAPINE TAB 150MG29 altavera tab68 AMOXAPINE TAB 25MG29 ALTOPREV TAB 20MG ER40 AMOXAPINE TAB 50MG29 ALTOPREV TAB 40MG ER40 amoxicillin & k clavulanate chew tab 200- ALTOPREV TAB 60MG ER40 28.5 mg110 ALVESCO AER 160MCG19 amoxicillin & k clavulanate chew tab 400- ALVESCO AER 80MCG19 57 mg111 alyacen tab 1/3568 amoxicillin & k clavulanate for susp 200- alyacen tab 7/7/768 28.5 mg/5ml111 amantadine hcl cap 100 mg52 amoxicillin & k clavulanate for susp 250- amantadine hcl syrup 50 mg/5ml52 62.5 mg/5ml111 amantadine hcl tab 100 mg52 amoxicillin & k clavulanate for susp 400- AMBISOME INJ 50MG37 57 mg/5ml111 amcinonide cream 0.1%78 amoxicillin & k clavulanate for susp 600- amcinonide lotion 0.1%78 42.9 mg/5ml111 AMCINONIDE OIN 0.1%78 amoxicillin & k clavulanate tab 250-125 amcinonide oint 0.1%78 mg111 amethia tab68 amoxicillin & k clavulanate tab 500-125 amethyst tab 90-20mcg68 mg111 AMEVIVE INJ 15MG77 amoxicillin & k clavulanate tab 875-125 amifostine crystalline for inj 500 mg50 mg111

125 amoxicillin & k clavulanate tab sr 12hr ampicillin sodium for iv soln 1 gm110 1000-62.5 mg111 ampicillin sodium for iv soln 2 gm110 amoxicillin (trihydrate) cap 250 mg110 AMPYRA TAB 10MG113 amoxicillin (trihydrate) cap 500 mg110 AMRIX CAP 15MG103 amoxicillin (trihydrate) chew tab 125 AMRIX CAP 30MG103 mg110 ANADROL-50 TAB 50MG12 amoxicillin (trihydrate) chew tab 200 anagrelide hcl cap 0.5 mg94 mg110 anagrelide hcl cap 1 mg94 amoxicillin (trihydrate) chew tab 250 anastrozole tab 1 mg47 mg110 ANDRODERM DIS 2.5MG/2412 amoxicillin (trihydrate) for susp 125 ANDRODERM DIS 2MG/24HR12 mg/5ml110 ANDRODERM DIS 4MG/24HR12 amoxicillin (trihydrate) for susp 200 ANDRODERM DIS 5MG/24HR12 mg/5ml110 amoxicillin (trihydrate) for susp 250 ANDROGEL GEL 1%(25MG)12 mg/5ml110 ANDROGEL GEL 1.62%12 amoxicillin (trihydrate) for susp 400 android cap 10mg12 mg/5ml110 ANDROXY TAB 10MG13 amoxicillin (trihydrate) tab 500 mg110 ANTIVERT TAB 50MG36 amoxicillin (trihydrate) tab 875 mg110 anucort-hc sup 25mg13 amphetamine-dextroamphetamine cap sr ANZEMET TAB 100MG35 24hr 10 mg1 ANZEMET TAB 50MG35 amphetamine-dextroamphetamine cap sr APEXICON E CRE 0.05%78 24hr 15 mg1 apexicon oin 0.05%78 amphetamine-dextroamphetamine cap sr APHTHASOL PST 5%102 24hr 20 mg1 APIDRA INJ SOLOSTAR33 amphetamine-dextroamphetamine cap sr APIDRA INJ U-10033 24hr 25 mg1 APLENZIN TAB 174MG26 amphetamine-dextroamphetamine cap sr APLENZIN TAB 348MG26 24hr 30 mg1 APLENZIN TAB 522MG26 amphetamine-dextroamphetamine cap sr APOKYN INJ52 24hr 5 mg1 apraclonidine hcl ophth soln 0.5% (base amphetamine-dextroamphetamine tab 10 equivalent)106 mg1 apri tab68 amphetamine-dextroamphetamine tab APRISO CAP 0.375GM92 12.5 mg1 APTIVUS CAP 250MG56 amphetamine-dextroamphetamine tab 15 APTIVUS SOL56 mg1 ARALAST NP INJ 400MG114 amphetamine-dextroamphetamine tab 20 ARALAST NP INJ 500MG114 mg1 aranelle tab68 amphetamine-dextroamphetamine tab 30 ARANESP INJ 100MCG95 mg1 amphetamine-dextroamphetamine tab 5 ARANESP INJ 150MCG95 mg1 ARANESP INJ 200MCG95 amphetamine-dextroamphetamine tab 7.5 ARANESP INJ 25MCG95 mg1 ARANESP INJ 300MCG95 AMPHOTEC INJ 100MG37 ARANESP INJ 40MCG95 AMPHOTEC INJ 50MG37 ARANESP INJ 500MCG95 amphotericin b for inj 50 mg37 ARANESP INJ 60MCG95 ampicillin & sulbactam sodium for inj 1-0.5 arbinoxa liq 4mg/5ml37 gm111 ARCALYST INJ 220MG4 ampicillin & sulbactam sodium for iv soln ARCAPTA CAP 75MCG20 1-0.5 gm111 argatroban inj 100 mg/ml (concentrate for ampicillin & sulbactam sodium for iv soln iv infusion)22 10-5 gm111 ARGATROBAN INJ 125/12522 ampicillin cap 250 mg110 ARICEPT TAB 23MG112 ampicillin cap 500 mg110 ARRANON INJ 5MG/ML46 ampicillin for susp 125 mg/5ml110 ARZERRA CON 100/5ML47 ampicillin for susp 250 mg/5ml110 ASACOL HD TAB 800MG92 ampicillin sodium for inj 10 gm110 ASACOL TAB 400MG DR92 ampicillin sodium for inj 125 mg110 asmalpred sol plus71 ampicillin sodium for inj 250 mg110 ASMANEX 120 AER 220MCG19 126 ASMANEX 14 AER 220MCG19 AVINZA CAP 120MG6 ASMANEX 30 AER 110MCG19 AVINZA CAP 30MG6 ASMANEX 30 AER 220MCG19 AVINZA CAP 45MG6 ASMANEX 60 AER 220MCG19 AVINZA CAP 60MG6 ASMANEX 7 AER 110MCG19 AVINZA CAP 75MG6 aspirin chew tab 81 mg6 AVINZA CAP 90MG6 aspirin low tab 81mg ec6 avita cre 0.025%73 aspirin tab 325 mg6 avita gel 0.025%73 aspirin tab 81 mg6 AVODART CAP 0.5MG94 aspirin tab delayed release 325 mg6 AVONEX KIT 30MCG113 ASTEPRO SPR 0.15%105 AVONEX PEN KIT 30MCG113 astramorph inj 1mg/2ml6 AVONEX PREFL KIT 30MCG113 astramorph inj 2mg/2ml6 AXERT TAB 12.5MG100 ATACAND TAB 16MG41 AXERT TAB 6.25MG100 ATACAND TAB 32MG41 AXIRON SOL 30MG/ACT13 ATACAND TAB 4MG41 AZACTAM/DEX INJ 1GM13 ATACAND TAB 8MG41 AZACTAM/DEX INJ 2GM13 ATELVIA TAB83 AZASAN TAB 100MG60 atenolol & chlorthalidone tab 100-25 mg43 AZASAN TAB 75 MG60 atenolol & chlorthalidone tab 50-25 mg43 AZASITE SOL 1%107 atenolol tab 100 mg61 azathioprine sodium for inj 100 mg60 atenolol tab 25 mg61 azathioprine tab 50 mg60 atenolol tab 50 mg61 azelastine hcl nasal spray 137 mcg/spray ATGAM INJ 250MG60 (1 mg/ml)105 atorvastatin calcium tab 10 mg (base azelastine hcl ophth soln 0.05%108 equivalent)40 AZELEX CRE 20%73 atorvastatin calcium tab 20 mg (base AZILECT TAB 0.5MG53 equivalent)40 AZILECT TAB 1MG53 atorvastatin calcium tab 40 mg (base azithromycin for susp 100 mg/5ml98 equivalent)40 azithromycin for susp 200 mg/5ml98 atorvastatin calcium tab 80 mg (base azithromycin iv for soln 500 mg98 equivalent)40 azithromycin powd pack for susp 1 gm98 atovaquone-proguanil hcl tab 250-100 azithromycin tab 250 mg98 mg44 azithromycin tab 500 mg98 atovaquone-proguanil hcl tab 62.5-25 azithromycin tab 600 mg98 mg44 AZOPT SUS 1% OP108 ATRALIN GEL 0.05%73 aztreonam for inj 1 gm13 ATRIPLA TAB56 aztreonam for inj 2 gm13 ATROPEN INJ 0.25MG117 azurette tab 28 day68 ATROPEN INJ 0.5MG117 ATROPEN INJ 1MG117 ATROPEN INJ 2MG117 B atropine sulfate inj 0.05 mg/ml117 bacitracin ophth oint 500 unit/gm107 atropine sulfate inj 0.1 mg/ml117 bacitracin-polymyxin b ophth oint107 atropine sulfate ophth oint 1%106 bacitracin-polymyxin-neomycin-hc ophth atropine sulfate ophth soln 1%106 oint 1%107 ATROVENT HFA AER 17MCG19 baclofen tab 10 mg103 AUBAGIO TAB 14MG113 baclofen tab 20 mg103 AUBAGIO TAB 7MG113 BACTOCILL INJ DEX 1GM111 AUGMENTIN SUS 125/5ML111 BACTOCILL INJ DEX 2GM111 AVANDIA TAB 2MG33 BACTROBAN OIN NASAL 2%105 AVANDIA TAB 4MG33 balsalazide disodium cap 750 mg92 AVANDIA TAB 8MG33 BANZEL SUS 40MG/ML23 AVAR GEL 10-5%73 BANZEL TAB 200MG23 avar-e green cre 10-5%73 BANZEL TAB 400MG23 AVELOX ABC TAB 400MG91 BARACLUDE SOL .05MG/ML58 AVELOX INJ91 BARACLUDE TAB 0.5MG58 AVELOX TAB 400MG91 BARACLUDE TAB 1MG58 aviane tab68 baycadron elx 0.5/5ml71 avidoxy tab 100mg114 bayer low chw 81mg6 BECONASE AQ SUS 0.042%105 127 benazepril hcl tab 10 mg40 0.05%78 benazepril hcl tab 20 mg40 betamethasone dipropionate oint 0.05%78 benazepril hcl tab 40 mg40 betamethasone valerate cream 0.1%78 benazepril hcl tab 5 mg40 betamethasone valerate lotion 0.1%78 BENICAR TAB 20MG41 betamethasone valerate oint 0.1%78 BENICAR TAB 40MG41 BETASERON INJ 0.3MG113 BENICAR TAB 5MG41 betaxolol hcl ophth soln 0.5%106 BENLYSTA INJ 120MG61 betaxolol hcl tab 10 mg61 BENTYL INJ 10MG/ML117 betaxolol hcl tab 20 mg61 BENZAMYCIN GEL PAK73 bethanechol chloride tab 10 mg120 BENZASHAVE 5 CRE 5%73 bethanechol chloride tab 25 mg120 benzashave cre 10%73 bethanechol chloride tab 5 mg120 benzepro aer 5.3%73 bethanechol chloride tab 50 mg120 benzepro sc aer 9.8%73 BETIMOL SOL 0.25%106 BENZIQ GEL 5.25%73 BETIMOL SOL 0.5%106 BENZIQ LS GEL 2.75%73 BETOPTIC-S SUS 0.25% OP106 benziq wash liq 5.25%73 BEXXAR 131 I INJ 0.61/ML50 benzonatate cap 100 mg72 BEXXAR 131 I INJ 5.6MCI/M50 benzonatate cap 200 mg72 BEXXAR CON 14MG/ML47 benzoyl per gel 10%73 BEYAZ TAB68 benzoyl per kit 4% wash73 bicalutamide tab 50 mg47 benzoyl per kit 8% wash74 BICILLIN C-R INJ 1200000111 benzoyl per liq 10% wash74 BICILLIN C-R INJ 900/300111 benzoyl per liq 2.5%wash74 BICILLIN L-A INJ 1200000110 benzoyl per liq 4% crem74 BICILLIN L-A INJ 2400000110 benzoyl per liq 5% wash74 BICILLIN L-A INJ 600000110 benzoyl per liq 8% crem74 BICNU INJ 100MG45 benzoyl per lot 3%74 BILTRICIDE TAB 600MG13 benzoyl per lot 4%74 BIO-STATIN CAP 100000037 benzoyl per lot 6%74 BIO-STATIN CAP 50000037 benzoyl per lot 8%74 bisoprolol & hydrochlorothiazide tab 10- benzoyl per lot 9%74 6.25 mg43 benzoyl pero kit acne pck74 bisoprolol & hydrochlorothiazide tab 2.5- benzoyl peroxide cleanser 4.25%74 6.25 mg43 benzoyl peroxide cream 3.5%74 bisoprolol & hydrochlorothiazide tab 5- benzoyl peroxide cream 5.5%74 6.25 mg43 benzoyl peroxide cream 8.5%74 bisoprolol fumarate tab 10 mg61 benzoyl peroxide foam 5.3%74 bisoprolol fumarate tab 5 mg61 benzoyl peroxide foam 9.8%74 bleomycin sulfate for inj 15 unit48 benzoyl peroxide gel 2.5%74 bleomycin sulfate for inj 30 unit48 benzoyl peroxide pad 3%74 BLEPHAMIDE OIN S.O.P.108 benzoyl peroxide pad 6%74 BLEPHAMIDE SUS OP108 benzoyl peroxide pad 9%74 BONIVA INJ 3MG/3ML84 benzoyl peroxide-erythromycin gel 5- BOOSTRIX INJ117 3%74 BOSULIF TAB 100MG49 benztropine mesylate inj 1 mg/ml52 BOSULIF TAB 500MG49 benztropine mesylate tab 0.5 mg52 BOTOX INJ 100UNIT106 benztropine mesylate tab 1 mg52 BOTOX INJ 200UNIT106 benztropine mesylate tab 2 mg52 bp 7% wash kit74 BEPREVE DRO 1.5%108 bp gel gel 10%74 BESIVANCE SUS 0.6%107 bp wash liq 10%74 betamethasone dipropionate augmented bp wash liq 2.5%74 cream 0.05%78 bp wash liq 5%74 betamethasone dipropionate augmented bp wash liq 5.25%74 lotion 0.05%78 bp wash liq 7%74 betamethasone dipropionate augmented bpo cloths mis 3%74 oint 0.05%78 bpo cloths mis 6%74 betamethasone dipropionate cream bpo cloths mis 9%74 0.05%78 bpo creamy kit 4% wash74 betamethasone dipropionate lotion BPO GEL 4%74 128 BPO GEL 8%74 BYSTOLIC TAB 10MG61 bpo-10 wash liq 10%74 BYSTOLIC TAB 2.5MG61 bpo-5 wash liq 5%74 BYSTOLIC TAB 20MG62 BRILINTA TAB 90MG94 BYSTOLIC TAB 5MG61 brimonidine tartrate ophth soln 0.15%106 brimonidine tartrate ophth soln 0.2%106 C BROMDAY SOL 0.09%108 cabergoline tab 0.5 mg86 bromfenac sodium ophth soln 0.09% CAFERGOT TAB 1-100MG100 (base equivalent)108 calcipotriene cream 0.005%77 bromocriptine mesylate cap 5 mg52 calcipotriene oint 0.005%77 bromocriptine mesylate tab 2.5 mg52 calcipotriene soln 0.005% (50 mcg/ml)77 brompheniramine tannate chew tab 12 calcitonin (salmon) nasal soln 200 mg37 unit/act84 BROVANA NEB 15MCG20 calcitrene oin 0.005%77 budeprion tab 100mg sr26 calcitriol cap 0.25 mcg85 budeprion tab 150mg sr26 calcitriol cap 0.5 mcg85 budeprion xl tab 150mg26 calcitriol inj 1 mcg/ml85 budeprion xl tab 300mg26 calcitriol oint 3 mcg/gm77 budesonide cap sr 24hr 3 mg71 calcitriol oral soln 1 mcg/ml85 budesonide inhalation susp 0.25 calcium acetate (phosphate binder) cap mg/2ml19 667 mg (169 mg ca)93 budesonide inhalation susp 0.5 mg/2ml19 calcium acetate (phosphate binder) tab bumetanide inj 0.25 mg/ml82 667 mg93 bumetanide tab 0.5 mg82 camila tab 0.35mg71 bumetanide tab 1 mg82 CAMPATH INJ 30MG/ML47 bumetanide tab 2 mg82 CAMPRAL TAB 333MG112 BUPHENYL POW85 CAMPTOSAR INJ 300/15ML51 BUPHENYL TAB 500MG85 CANASA SUP 1000MG92 buprenorphine hcl inj 0.3 mg/ml (base CANCIDAS INJ 50MG36 equiv)12 CANCIDAS INJ 70MG36 buprenorphine hcl sl tab 2 mg (base CANTIL TAB 25MG117 equiv)12 buprenorphine hcl sl tab 8 mg (base CAPASTAT SUL INJ 1GM45 equiv)12 CAPEX SHA 0.01%78 buproban tab 150mg113 CAPITAL/COD SUS 120-12/510 bupropion hcl (smoking deterrent) tab sr CAPRELSA TAB 100MG49 12hr 150 mg113 CAPRELSA TAB 300MG49 bupropion hcl tab 100 mg26 captopril & hydrochlorothiazide tab 25-15 mg43 bupropion hcl tab 75 mg26 captopril & hydrochlorothiazide tab 25-25 bupropion hcl tab sr 12hr 100 mg26 mg43 bupropion hcl tab sr 12hr 150 mg26 captopril & hydrochlorothiazide tab 50-15 bupropion hcl tab sr 12hr 200 mg26 mg43 bupropion hcl tab sr 24hr 150 mg26 captopril & hydrochlorothiazide tab 50-25 bupropion hcl tab sr 24hr 300 mg26 mg43 buspirone hcl tab 10 mg16 captopril tab 100 mg41 buspirone hcl tab 15 mg16 captopril tab 12.5 mg41 buspirone hcl tab 30 mg16 captopril tab 25 mg41 buspirone hcl tab 5 mg16 captopril tab 50 mg41 buspirone hcl tab 7.5 mg16 CARAC CRE 0.5%77 BUSULFEX INJ 6MG/ML45 CARAFATE SUS 1GM/10ML118 butorphanol tartrate inj 1 mg/ml12 CARBAGLU TAB 200MG85 butorphanol tartrate inj 2 mg/ml12 carbamazepine cap sr 12hr 100 mg23 butorphanol tartrate nasal soln 10 carbamazepine cap sr 12hr 200 mg23 mg/ml12 carbamazepine cap sr 12hr 300 mg23 BUTRANS DIS 10MCG/HR12 carbamazepine chew tab 100 mg23 BUTRANS DIS 20MCG/HR12 carbamazepine susp 100 mg/5ml23 BUTRANS DIS 5MCG/HR12 carbamazepine tab 200 mg23 BYDUREON INJ33 carbamazepine tab sr 12hr 200 mg23 BYETTA INJ 10MCG33 carbamazepine tab sr 12hr 400 mg23 BYETTA INJ 5MCG33 carbidopa & levodopa orally disintegrating

129 tab 10-100 mg52 cefadroxil for susp 500 mg/5ml66 carbidopa & levodopa orally disintegrating cefadroxil tab 1 gm66 tab 25-100 mg52 CEFAZOL/DEX SOL 2GM66 carbidopa & levodopa orally disintegrating CEFAZOLIN INJ 1GM/50ML66 tab 25-250 mg52 cefazolin sodium for inj 1 gm66 carbidopa & levodopa tab 10-100 mg52 cefazolin sodium for inj 10 gm66 carbidopa & levodopa tab 25-100 mg52 cefazolin sodium for inj 500 mg66 carbidopa & levodopa tab 25-250 mg52 cefdinir cap 300 mg67 carbidopa & levodopa tab cr 25-100 mg52 cefdinir for susp 125 mg/5ml67 carbidopa & levodopa tab cr 50-200 mg52 cefdinir for susp 250 mg/5ml67 carbidopa-levodopa-entacapone tabs 12.5- cefditoren pivoxil tab 200 mg (base 50-200 mg52 equivalent)67 carbidopa-levodopa-entacapone tabs cefepime hcl for inj 1 gm68 18.75-75-200 mg52 cefepime hcl for inj 2 gm68 carbidopa-levodopa-entacapone tabs 25- CEFEPIME INJ 1GM68 100-200 mg52 CEFEPIME INJ 2GM68 carbidopa-levodopa-entacapone tabs cefotaxime sodium for inj 1 gm67 31.25-125-200 mg52 cefotaxime sodium for inj 10 gm67 carbidopa-levodopa-entacapone tabs 37.5- cefotaxime sodium for inj 2 gm67 150-200 mg52 carbidopa-levodopa-entacapone tabs 50- cefotaxime sodium for inj 500 mg67 200-200 mg52 CEFOTET/DEX INJ 1-3.58%66 carbinoxamine maleate liquid 4 mg/5ml37 CEFOTET/DEX INJ 2-2.08%66 carbinoxamine maleate tab 4 mg38 CEFOTETAN INJ 10G66 carboplatin iv for inj 150 mg45 CEFOTETAN INJ 1GM/10ML66 carboplatin iv soln 150 mg/15ml45 CEFOTETAN INJ 2GM/20ML66 carboplatin iv soln 450 mg/45ml45 CEFOXITIN INJ 1GM66 carboplatin iv soln 50 mg/5ml45 CEFOXITIN INJ 2GM66 carboplatin iv soln 600 mg/60ml45 cefoxitin sodium for inj 1 gm66 CARDENE IV INJ 40/200ML63 cefoxitin sodium for inj 10 gm66 CARDENE IV SOL 20/200ML63 cefoxitin sodium for inj 2 gm66 cefpodoxime proxetil for susp 100 CARDIZEM LA TAB 120MG63 mg/5ml67 CARDURA XL TAB 4MG94 cefpodoxime proxetil for susp 50 CARDURA XL TAB 8MG94 mg/5ml67 CARIMUNE NF INJ 3GM109 cefpodoxime proxetil tab 100 mg67 carisoprodol tab 250 mg103 cefpodoxime proxetil tab 200 mg67 carisoprodol tab 350 mg104 cefprozil for susp 125 mg/5ml66 carteolol hcl ophth soln 1%106 cefprozil for susp 250 mg/5ml66 cartia xt cap 120/24hr63 cefprozil tab 250 mg66 cartia xt cap 180/24hr63 cefprozil tab 500 mg66 cartia xt cap 240/24hr63 ceftazidime for inj 1 gm67 cartia xt cap 300/24hr63 ceftazidime for inj 2 gm67 carvedilol tab 12.5 mg61 ceftazidime for inj 500 mg67 carvedilol tab 25 mg61 ceftazidime for inj 6 gm67 carvedilol tab 3.125 mg61 CEFTAZIDIME INJ 100GM67 carvedilol tab 6.25 mg61 CEFTAZIDIME/ SOL D5W 1GM67 CAYSTON INH 75MG13 CEFTAZIDIME/ SOL D5W 2GM67 caziant pak68 CEFTIN SUS 250/5ML66 CEDAX CAP 400MG67 CEFTRIAXONE INJ 100GM67 CEENU CAP 100MG45 ceftriaxone sodium for inj 1 gm67 CEENU CAP 10MG45 ceftriaxone sodium for inj 10 gm67 CEENU CAP 40MG45 ceftriaxone sodium for inj 2 gm67 cefaclor cap 250 mg66 ceftriaxone sodium for inj 250 mg67 cefaclor cap 500 mg66 ceftriaxone sodium for inj 500 mg67 CEFACLOR ER TAB 500MG66 ceftriaxone sodium for iv soln 1 gm67 cefaclor for susp 125 mg/5ml66 ceftriaxone sodium for iv soln 2 gm67 cefaclor for susp 250 mg/5ml66 CEFUROX/DEXT INJ 1.5GM66 cefaclor for susp 375 mg/5ml66 CEFUROX/DEXT INJ 750MG66 cefadroxil cap 500 mg66 cefuroxime axetil for susp 125 mg/5ml66 cefadroxil for susp 250 mg/5ml66 cefuroxime axetil tab 250 mg67 130 cefuroxime axetil tab 500 mg67 cholestyramine powder 4 gm/dose39 CEFUROXIME INJ 75GM67 cholestyramine powder packets 4 gm39 cefuroxime sodium for inj 1.5 gm67 chorionic gonadotropin for inj 10000 cefuroxime sodium for inj 7.5 gm67 unit84 cefuroxime sodium for inj 750 mg67 CIALIS TAB 2.5MG65 CELEBREX CAP 100MG4 ciclopirox gel 0.77%76 CELEBREX CAP 200MG4 ciclopirox olamine cream 0.77% (base CELEBREX CAP 400MG4 equiv)76 CELEBREX CAP 50MG4 ciclopirox olamine susp 0.77% (base CELLCEPT IV INJ 500MG60 equiv)76 CELLCEPT SUS 200MG/ML60 ciclopirox shampoo 1%76 CELONTIN CAP 300MG25 cidofovir iv inj 75 mg/ml58 CENESTIN TAB 0.3MG87 cilostazol tab 100 mg94 CENESTIN TAB 0.45MG87 cilostazol tab 50 mg94 CENESTIN TAB 0.625MG88 CILOXAN OIN 0.3% OP107 CENESTIN TAB 0.9MG87 cimetidine hcl soln 300 mg/5ml118 CENESTIN TAB 1.25MG88 cimetidine tab 300 mg118 CENTANY AT KIT 2%76 cimetidine tab 400 mg118 centany oin 2%76 cimetidine tab 800 mg118 cephalexin cap 250 mg66 CIMZIA KIT92 cephalexin cap 500 mg66 CIMZIA KIT 200MG/ML92 cephalexin for susp 125 mg/5ml66 CIPRO (10%) SUS 500MG/591 cephalexin for susp 250 mg/5ml66 CIPRO (5%) SUS 250MG/591 cephalexin tab 250 mg66 CIPRO HC SUS OTIC109 cephalexin tab 500 mg66 CIPRODEX SUS 0.3-0.1%109 CEREZYME INJ 200UNIT95 ciprofloxacin 200 mg/100ml in d5w91 CEREZYME INJ 400UNIT95 ciprofloxacin hcl ophth soln 0.3%107 CERVARIX INJ121 ciprofloxacin hcl tab 100 mg (base CESAMET CAP 1MG36 equiv)91 cesia pak68 ciprofloxacin hcl tab 250 mg (base cevimeline hcl cap 30 mg102 equiv)91 ciprofloxacin hcl tab 500 mg (base CHANTIX PAK 0.5& 1MG113 equiv)91 CHANTIX PAK 1MG113 ciprofloxacin hcl tab 750 mg (base CHANTIX TAB 0.5MG113 equiv)92 CHANTIX TAB 1MG113 ciprofloxacin iv soln 200 mg/20ml (1%)92 chateal tab 0.15/3068 ciprofloxacin-ciprofloxacin hcl tab sr 24hr CHEMET CAP 100MG35 1000 mg(base eq)92 chloramphenicol sodium succinate for iv ciprofloxacin-ciprofloxacin hcl tab sr 24hr inj 1 gm14 500 mg (base eq)92 chlorhexidine gluconate soln 0.12%102 cisplatin inj 100 mg/100ml (1 mg/ml)45 chloroquine phosphate tab 250 mg44 cisplatin inj 200 mg/200ml (1 mg/ml)45 chloroquine phosphate tab 500 mg44 cisplatin inj 50 mg/50ml (1 mg/ml)45 chlorothiazide sodium for inj 500 mg83 citalopram hydrobromide oral soln 10 chlorothiazide tab 250 mg83 mg/5ml27 chlorothiazide tab 500 mg83 citalopram hydrobromide tab 10 mg (base CHLORPROMAZ INJ 25MG/ML55 equiv)27 chlorpromazine hcl tab 10 mg55 citalopram hydrobromide tab 20 mg (base chlorpromazine hcl tab 100 mg55 equiv)27 chlorpromazine hcl tab 200 mg55 citalopram hydrobromide tab 40 mg (base chlorpromazine hcl tab 25 mg55 equiv)27 chlorpromazine hcl tab 50 mg55 CITRANATAL CAP HARMONY103 chlorpropamide tab 100 mg34 CITRANATAL MIS 90 DHA103 chlorpropamide tab 250 mg34 CITRANATAL MIS B-CALM103 chlorthalidone tab 100 mg83 CITRANATAL PAK ASSURE103 chlorthalidone tab 25 mg83 CITRANATAL PAK DHA103 chlorthalidone tab 50 mg83 CITRANATAL TAB RX103 chlorzoxazone tab 500 mg104 cladribine inj 1 mg/ml46 cholestyramine light powder 4 gm/dose39 CLAFORAN INJ 1GM67 cholestyramine light powder packets 4 CLAFORAN INJ 2GM67 gm39 claravis cap 10mg74 131 claravis cap 20mg74 clonidine hcl td patch weekly 0.2 claravis cap 30mg74 mg/24hr42 claravis cap 40mg74 clonidine hcl td patch weekly 0.3 CLARINEX SYP 0.5MG/ML38 mg/24hr42 clarithromycin for susp 125 mg/5ml98 clopidogrel bisulfate tab 300 mg (base clarithromycin for susp 250 mg/5ml98 equiv)94 clarithromycin tab 250 mg98 clopidogrel bisulfate tab 75 mg (base clarithromycin tab 500 mg98 equiv)94 clarithromycin tab sr 24hr 500 mg98 clorazepate dipotassium tab 15 mg17 clearplex x gel 10%74 clorazepate dipotassium tab 3.75 mg17 clemastine fumarate syrup 0.67 mg/5ml clorazepate dipotassium tab 7.5 mg17 (0.5 mg/5ml base eq)38 CLOTRIMAZOLE CRY76 clemastine fumarate tab 2.68 mg38 clotrimazole soln 1%76 clenia cre 10-5%74 clotrimazole troche 10 mg102 CLEOCIN SUP 100MG122 clotrimazole w/ betamethasone cream 1- clidinium & chlordiazepoxide cap 2.5-5 0.05%76 mg117 clozapine tab 100 mg54 CLIMARA PRO DIS WEEKLY87 clozapine tab 200 mg55 CLINAC BPO GEL 7%74 clozapine tab 25 mg54 CLINDACIN KIT PAC 1%75 clozapine tab 50 mg54 clindamax gel 1%75 co-gesic tab 5-500mg10 clindamax lot 10mg/ml75 COARTEM TAB 20-120MG44 clindamycin hcl cap 150 mg15 cobal-1000 inj 1000mcg95 clindamycin hcl cap 300 mg15 COCET PLUS TAB 650-60MG10 clindamycin hcl cap 75 mg15 COCET TAB 650-30MG10 clindamycin palmitate hcl for soln 75 CODEINE SULF SOL 30MG/5ML7 mg/5ml (base equiv)15 codeine sulfate tab 15 mg7 clindamycin phosph-benzoyl peroxide codeine sulfate tab 30 mg7 (refrig) gel 1.2 (1)-5%75 codeine sulfate tab 60 mg7 clindamycin phosphate foam 1%75 colchicine w/ probenecid tab 0.5-500 clindamycin phosphate gel 1%75 mg94 clindamycin phosphate inj 300 mg/2ml15 COLCRYS TAB 0.6MG94 clindamycin phosphate lotion 1%75 colestipol hcl granule packets 5 gm39 clindamycin phosphate soln 1%75 colestipol hcl granules 5 gm39 clindamycin phosphate swab 1%75 colestipol hcl tab 1 gm39 clindamycin phosphate vaginal cream colocort ene 100mg13 2%122 COLYTE/FLAVR SOL PACKS97 clindamycin phosphate-benzoyl peroxide COMBIGAN SOL 0.2/0.5%106 gel 1-5%75 COMBIVENT AER RESPIMAT20 clobetasol propionate cream 0.05%78 COMETRIQ KIT 100MG49 clobetasol propionate foam 0.05%78 COMETRIQ KIT 140MG49 clobetasol propionate gel 0.05%78 COMETRIQ KIT 60MG49 clobetasol propionate lotion 0.05%78 COMPLERA TAB56 clobetasol propionate oint 0.05%78 compro sup 25mg55 clobetasol propionate shampoo 0.05%79 COMVAX INJ121 clobetasol propionate soln 0.05%79 CONDYLOX GEL 0.5%80 CLOBEX SPR 0.05%79 constulose sol 10gm/1597 CLODERM CRE 0.1% PMP79 CONZIP CAP 100MG7 CLOLAR INJ 1MG/ML46 CONZIP CAP 200MG7 clomipramine hcl cap 25 mg29 CONZIP CAP 300MG7 clomipramine hcl cap 50 mg29 COPAXONE KIT 20MG/ML113 clomipramine hcl cap 75 mg29 CORDRAN 24X3 TAP 4MCG/CM79 clonazepam tab 0.5 mg23 CORDRAN LOT 0.05%79 clonazepam tab 1 mg23 CORDRAN SP CRE 0.05%79 clonazepam tab 2 mg23 COREG CR CAP 10MG61 clonidine hcl tab 0.1 mg42 COREG CR CAP 20MG61 clonidine hcl tab 0.2 mg42 COREG CR CAP 40MG61 clonidine hcl tab 0.3 mg42 COREG CR CAP 80MG61 clonidine hcl td patch weekly 0.1 cormax oin 0.05%79 mg/24hr42 cortisone acetate tab 25 mg71

132 CORTISPORIN CRE 0.5%76 cytarabine inj pf 20 mg/ml46 CORTISPORIN OIN 1%76 CORTISPORIN SUS -TC OTIC109 D cortomycin sol 1% otic109 dacarbazine for inj 100 mg50 cortomycin sus 1% otic109 dacarbazine for inj 200 mg50 COSOPT PF SOL106 DACOGEN INJ 50MG46 COUMADIN INJ 5 MG21 dactinomycin for inj 0.5 mg48 CREON CAP 12000UNT81 DALIRESP TAB 500MCG19 CREON CAP 24000UNT81 danazol cap 100 mg13 CREON CAP 3000UNIT81 danazol cap 200 mg13 CREON CAP 6000UNIT81 danazol cap 50 mg13 CRESTOR TAB 10MG40 dantrolene sodium cap 100 mg105 CRESTOR TAB 20MG40 dantrolene sodium cap 25 mg104 CRESTOR TAB 40MG40 dantrolene sodium cap 50 mg104 CRESTOR TAB 5MG40 dapsone tab 100 mg15 CRINONE GEL 4% VAG122 dapsone tab 25 mg15 CRINONE GEL 8% VAG122 DAPTACEL INJ117 CRIXIVAN CAP 100MG56 DARAPRIM TAB 25MG44 CRIXIVAN CAP 200MG57 dasetta tab 1/3568 CRIXIVAN CAP 400MG57 dasetta tab 7/7/768 cromolyn sodium ophth soln 4%108 daunorubicin hcl for inj 20 mg48 cromolyn sodium oral conc 100 mg/5ml92 daunorubicin hcl inj 5 mg/ml (base cromolyn sodium soln nebu 20 mg/2ml18 equiv)48 cryselle-28 tab 28 tabs68 DAUNOXOME INJ 2MG/ML48 CUBICIN SOL 500MG14 DAYTRANA DIS 10MG/9HR2 CUVPOSA SOL 1MG/5ML117 DAYTRANA DIS 15MG/9HR2 cyanocobalamin inj 1000 mcg/ml95 DAYTRANA DIS 20MG/9HR2 cyclafem tab 1/3568 DAYTRANA DIS 30MG/9HR2 cyclafem tab 7/7/768 DECAVAC INJ 5-2LF117 cyclobenzaprine hcl tab 10 mg104 DELESTROGEN INJ 10MG/ML88 cyclobenzaprine hcl tab 5 mg104 DELOS LIQ 3.5%75 cyclobenzaprine hcl tab 7.5 mg104 DELOS LOT 3.5%75 CYCLOPHOSPH INJ 1GM45 demeclocycline hcl tab 150 mg114 CYCLOPHOSPH INJ 2GM45 demeclocycline hcl tab 300 mg114 CYCLOPHOSPH INJ 500MG45 DENAVIR CRE 1%78 cyclophosphamide tab 25 mg45 depade tab 50mg35 cyclophosphamide tab 50 mg45 DEPEN TITRA TAB 250MG60 cycloserine cap 250 mg45 DEPO-ESTRADI INJ 5MG/ML88 CYCLOSET TAB 0.8MG33 DEPO-MEDROL INJ 20MG/ML71 cyclosporine cap 100 mg60 DEPO-PROVERA INJ 400/ML47 cyclosporine cap 25 mg60 DEPO-SQ PROV INJ 10471 cyclosporine iv soln 50 mg/ml60 DEPOCYT INJ 50MG/5ML46 cyclosporine modified cap 100 mg60 desipramine hcl tab 10 mg29 cyclosporine modified cap 25 mg60 desipramine hcl tab 100 mg29 cyclosporine modified cap 50 mg60 desipramine hcl tab 150 mg29 cyclosporine modified oral soln 100 desipramine hcl tab 25 mg29 mg/ml60 desipramine hcl tab 50 mg29 CYMBALTA CAP 20MG28 desipramine hcl tab 75 mg29 CYMBALTA CAP 30MG28 desloratadine tab 5 mg38 CYMBALTA CAP 60MG28 desloratadine tab orally disintegrating 2.5 cyproheptadine hcl syrup 2 mg/5ml39 mg38 cyproheptadine hcl tab 4 mg39 desloratadine tab orally disintegrating 5 CYSTADANE POW85 mg38 CYSTAGON CAP 150MG93 desmopressin acetate inj 4 mcg/ml86 CYSTAGON CAP 50MG93 desmopressin acetate nasal soln 0.01% cytarabine for inj 1 gm46 (refrigerated)86 cytarabine for inj 100 mg46 desmopressin acetate nasal spray soln cytarabine for inj 500 mg46 0.01%86 cytarabine inj 100 mg/ml46 desmopressin acetate nasal spray soln cytarabine inj 20 mg/ml46 0.01% (refrigerated)86 133 desmopressin acetate tab 0.1 mg86 diclofenac sodium tab delayed release 25 desmopressin acetate tab 0.2 mg86 mg4 DESONATE GEL 0.05%79 diclofenac sodium tab delayed release 50 desonide cream 0.05%79 mg4 desonide lotion 0.05%79 diclofenac sodium tab delayed release 75 desonide oint 0.05%79 mg4 DESOWEN OINT KIT 0.05%79 diclofenac sodium tab sr 24hr 100 mg4 desoximetasone cream 0.05%79 diclofenac w/ misoprostol tab delayed desoximetasone cream 0.25%79 release 50-0.2 mg4 desoximetasone gel 0.05%79 diclofenac w/ misoprostol tab delayed desoximetasone oint 0.25%79 release 75-0.2 mg4 DETROL LA CAP 2MG120 dicloxacillin sodium cap 250 mg111 DETROL LA CAP 4MG120 dicloxacillin sodium cap 500 mg111 DEX-TUSS LIQ 300-10/573 dicyclomine hcl cap 10 mg117 DEXAMETHASON CON 1MG/ML71 dicyclomine hcl oral soln 10 mg/5ml117 dexamethasone elixir 0.5 mg/5ml71 dicyclomine hcl tab 20 mg117 dexamethasone sodium phosphate inj 10 didanosine delayed release capsule 125 mg/ml71 mg57 dexamethasone sodium phosphate inj 4 didanosine delayed release capsule 200 mg/ml71 mg57 dexamethasone sodium phosphate ophth didanosine delayed release capsule 250 soln 0.1%108 mg57 didanosine delayed release capsule 400 dexamethasone soln 0.5 mg/5ml71 mg57 dexamethasone tab 0.5 mg71 DIFFERIN GEL 0.3%75 dexamethasone tab 0.75 mg71 DIFFERIN LOT 0.1%75 dexamethasone tab 1 mg71 DIFICID TAB 200MG99 dexamethasone tab 1.5 mg71 diflorasone diacetate cream 0.05%79 dexamethasone tab 2 mg71 diflorasone diacetate oint 0.05%79 dexamethasone tab 4 mg71 diflunisal tab 500 mg6 dexamethasone tab 6 mg71 dexchlorpheniramine maleate syrup 2 digoxin inj 0.25 mg/ml65 mg/5ml37 digoxin oral soln 0.05 mg/ml65 DEXILANT CAP 30MG DR118 digoxin tab 0.125 mg65 DEXILANT CAP 60MG DR118 digoxin tab 0.25 mg65 dihydroergotamine mesylate inj 1 dexmethylphenidate hcl tab 10 mg2 mg/ml100 dexmethylphenidate hcl tab 2.5 mg2 DILANTIN CAP 30MG25 dexmethylphenidate hcl tab 5 mg2 DILATRATE SR CAP 40MG15 DEXPAK PAK 10 DAY71 DILAUDID-HP INJ 250MG7 DEXPAK PAK 13 DAY71 dilt-cd cap 120mg63 DEXPAK PAK 6 DAY71 dilt-cd cap 180mg63 dexrazoxane for inj 250 mg50 dilt-cd cap 240mg63 dexrazoxane for inj 500 mg50 dextroamphetamine sulfate cap sr 24hr 10 dilt-cd cap 300mg63 mg1 diltiazem hcl cap sr 12hr 120 mg63 dextroamphetamine sulfate cap sr 24hr 15 diltiazem hcl cap sr 12hr 60 mg63 mg1 diltiazem hcl cap sr 12hr 90 mg63 dextroamphetamine sulfate cap sr 24hr 5 diltiazem hcl cap sr 24hr 120 mg63 mg1 diltiazem hcl cap sr 24hr 180 mg63 dextroamphetamine sulfate tab 10 mg1 diltiazem hcl cap sr 24hr 240 mg63 dextroamphetamine sulfate tab 5 mg1 diltiazem hcl coated beads cap sr 24hr 120 dextrose inj 32 mg/50ml mg63 and ondansetron hcl36 diltiazem hcl coated beads cap sr 24hr 180 DIAZEPAM CON 5MG/ML17 mg63 diazepam soln 1 mg/ml17 diltiazem hcl coated beads cap sr 24hr 240 diazepam tab 10 mg17 mg63 diltiazem hcl coated beads cap sr 24hr 300 diazepam tab 2 mg17 mg63 diazepam tab 5 mg17 diltiazem hcl coated beads cap sr 24hr 360 DIBENZYLINE CAP 10MG41 mg63 diclofenac potassium tab 50 mg4 diltiazem hcl extended release beads cap diclofenac sodium ophth soln 0.1%108 sr 24hr 120 mg63

134 diltiazem hcl extended release beads cap DOCETAXEL INJ 160/16ML51 sr 24hr 180 mg63 DOCETAXEL INJ 20/0.5ML51 diltiazem hcl extended release beads cap DOCETAXEL INJ 20MG/2ML51 sr 24hr 240 mg63 DOCETAXEL INJ 80MG/2ML51 diltiazem hcl extended release beads cap DOCETAXEL INJ 80MG/8ML51 sr 24hr 300 mg63 donepezil hydrochloride orally diltiazem hcl extended release beads cap disintegrating tab 10 mg112 sr 24hr 360 mg63 donepezil hydrochloride orally diltiazem hcl extended release beads cap disintegrating tab 5 mg112 sr 24hr 420 mg63 donepezil hydrochloride tab 10 mg112 diltiazem hcl iv soln 25 mg/5ml (5 donepezil hydrochloride tab 5 mg112 mg/ml)64 DORIBAX INJ 250MG14 diltiazem hcl tab 120 mg64 DORIBAX INJ 500MG14 diltiazem hcl tab 30 mg64 DORYX TAB 150MG114 diltiazem hcl tab 60 mg64 dorzolamide hcl ophth soln 2%108 diltiazem hcl tab 90 mg64 dorzolamide hcl-timolol maleate ophth DILTIAZEM INJ 100MG64 soln 22.3-6.8 mg/ml106 diltzac cap 120mg/2464 doxazosin mesylate tab 1 mg42 diltzac cap 180mg/2464 doxazosin mesylate tab 2 mg42 diltzac cap 240mg/2464 doxazosin mesylate tab 4 mg42 diltzac cap 300mg/2464 doxazosin mesylate tab 8 mg42 diltzac cap 360mg/2464 doxepin hcl cap 10 mg30 dimenhydrinate tab 50 mg36 doxepin hcl cap 100 mg30 DIOVAN TAB 160MG42 doxepin hcl cap 150 mg30 DIOVAN TAB 320MG42 doxepin hcl cap 25 mg30 DIOVAN TAB 40MG41 doxepin hcl cap 50 mg30 DIOVAN TAB 80MG41 doxepin hcl cap 75 mg30 DIP/TET PED INJ 25-5LFU117 doxepin hcl conc 10 mg/ml30 DIP/TET PED INJ 6.7-5LF117 doxorubicin hcl for inj 10 mg48 DIPENTUM CAP 250MG92 doxorubicin hcl for inj 50 mg48 diphenhydramine hcl cap 25 mg38 doxorubicin hcl inj 2 mg/ml48 diphenhydramine hcl cap 50 mg38 doxy 100 inj 100mg114 diphenhydramine hcl elixir 12.5 mg/5ml38 DOXYCYCL HYC CAP 100MG114 diphenhydramine hcl inj 50 mg/ml38 doxycycline hyclate cap 100 mg114 diphenoxylate w/ atropine liq 2.5-0.025 doxycycline hyclate cap 50 mg114 mg/5ml35 doxycycline hyclate for inj 100 mg115 diphenoxylate w/ atropine tab 2.5-0.025 doxycycline hyclate tab 100 mg115 mg35 doxycycline hyclate tab 20 mg115 dipyridamole tab 25 mg94 doxycycline hyclate tab delayed release dipyridamole tab 50 mg95 100 mg115 dipyridamole tab 75 mg95 doxycycline hyclate tab delayed release 75 disopyramide phosphate cap 100 mg18 mg115 disopyramide phosphate cap 150 mg18 doxycycline monohydrate cap 100 mg115 disulfiram tab 250 mg112 doxycycline monohydrate cap 150 mg115 disulfiram tab 500 mg112 doxycycline monohydrate cap 50 mg115 DIURIL SUS 250/5ML83 doxycycline monohydrate cap 75 mg115 divalproex sodium cap sprinkle 125 mg25 doxycycline monohydrate tab 150 mg115 divalproex sodium tab delayed release 125 doxycycline monohydrate tab 50 mg115 mg25 doxycycline monohydrate tab 75 mg115 divalproex sodium tab delayed release 250 dronabinol cap 10 mg36 mg25 dronabinol cap 2.5 mg36 divalproex sodium tab delayed release 500 dronabinol cap 5 mg36 mg25 drospirenone-ethinyl estradiol tab 3-0.03 divalproex sodium tab sr 24 hr 250 mg25 mg68 divalproex sodium tab sr 24 hr 500 mg25 DROXIA CAP 200MG95 DIVIGEL GEL 0.25MG88 DROXIA CAP 300MG95 DOCEFREZ INJ 20MG51 DROXIA CAP 400MG95 DOCEFREZ INJ 80MG51 DULERA AER 100-5MCG20 docetaxel for inj conc 20 mg/ml51 DULERA AER 200-5MCG20 docetaxel for inj conc 80 mg/4ml (20 DUREZOL EMU 0.05%108 mg/ml)51 135 DYRENIUM CAP 100MG83 endocet tab 10-650mg11 DYRENIUM CAP 50MG83 endocet tab 5-325mg10 endocet tab 7.5-32510 E endocet tab 7.5-500m10 e.e.s. 400 tab 400mg98 ENGERIX-B INJ 10/0.5ML121 E.E.S. GRAN SUS 200/5ML98 ENGERIX-B INJ 20MCG/ML121 e.s.p. sus 200-60014 ENJUVIA TAB 0.3MG88 econazole nitrate cream 1%76 ENJUVIA TAB 0.45MG88 ECOTRIN TAB 325MG EC6 ENJUVIA TAB 0.625MG88 ed-spaz tab 0.125mg117 ENJUVIA TAB 0.9MG88 EDARBI TAB 40MG42 ENJUVIA TAB 1.25MG88 EDARBI TAB 80MG42 enoxaparin sodium inj 100 mg/ml22 EDECRIN TAB 25MG82 enoxaparin sodium inj 120 mg/0.8ml22 EDLUAR SUB 10MG97 enoxaparin sodium inj 150 mg/ml22 EDLUAR SUB 5MG97 enoxaparin sodium inj 30 mg/0.3ml22 EDURANT TAB 25MG57 enoxaparin sodium inj 300 mg/3ml22 EFFIENT TAB 10MG95 enoxaparin sodium inj 40 mg/0.4ml22 EFFIENT TAB 5MG95 enoxaparin sodium inj 60 mg/0.6ml22 ELAPRASE INJ 6MG/3ML85 enoxaparin sodium inj 80 mg/0.8ml22 ELESTRIN GEL 0.06%88 enpresse-28 tab68 ELIDEL CRE 1%80 entacapone tab 200 mg52 ELIGARD INJ 22.5MG47 enulose sol 10gm/1593 ELIGARD INJ 30MG47 EPIDUO GEL 0.1-2.5%75 ELIGARD INJ 45MG47 epiflur chw 0.25mg f101 ELIGARD INJ 7.5MG47 epiflur chw 0.5mg f100 elinest tab68 epiflur chw 1mg f101 ELIQUIS TAB 2.5MG22 epinastine hcl ophth soln 0.05%108 ELIQUIS TAB 5MG22 epinephrine hcl inj 0.1 mg/ml20 ELIXOPHYLLIN ELX 80/15ML21 epinephrine hcl inj 1 mg/ml20 ELLA TAB 30MG70 epinephrine inj device 0.15 mg/0.15ml ELMIRON CAP 100MG93 (1:1000)122 ELOXATIN INJ 200MG45 epinephrine inj device 0.3 mg/0.3ml ELSPAR INJ 10000UNT50 (1:1000)122 EMADINE SOL 0.05% OP108 EPIPEN 2-PAK INJ 0.3MG122 EMBEDA CAP 30-1.2MG7 EPIPEN INJ 0.3MG123 EMCYT CAP 140MG47 EPIPEN-JR INJ 0.15MG123 EMEND CAP 125MG36 EPIPEN-JR INJ 2-PAK123 epirubicin hcl inj 10 mg/5ml (2 mg/ml)48 EMEND CAP 40MG36 epirubicin hcl inj 150 mg/75ml (2 EMEND CAP 80MG36 mg/ml)48 EMEND PAK 80 & 12536 epirubicin hcl inj 200 mg/100ml (2 emoquette tab68 mg/ml)48 EMSAM DIS 12MG/24H27 epirubicin hcl inj 50 mg/25ml (2 mg/ml)48 EMSAM DIS 6MG/24HR27 EPIRUBICIN INJ 200MG48 EMSAM DIS 9MG/24HR27 EPIRUBICIN INJ 50MG48 EMTRIVA CAP 200MG57 epitol tab 200mg23 EMTRIVA SOL 10MG/ML57 EPIVIR HBV SOL 5MG/ML57 ENABLEX TAB 15MG120 EPIVIR HBV TAB 100MG57 ENABLEX TAB 7.5MG120 EPIVIR SOL 10MG/ML57 enalapril maleate & hydrochlorothiazide eplerenone tab 25 mg44 tab 10-25 mg43 enalapril maleate & hydrochlorothiazide eplerenone tab 50 mg44 EPOGEN INJ 10000/ML95 tab 5-12.5 mg43 enalapril maleate tab 10 mg41 EPOGEN INJ 2000/ML95 enalapril maleate tab 2.5 mg41 EPOGEN INJ 20000/ML95 enalapril maleate tab 20 mg41 EPOGEN INJ 3000/ML95 enalapril maleate tab 5 mg41 EPOGEN INJ 4000/ML95 ENBREL INJ 25/0.5ML6 epoprostenol sodium for inj 0.5 mg65 ENBREL INJ 25MG6 epoprostenol sodium for inj 1.5 mg65 ENBREL INJ 50MG/ML6 eprosartan mesylate tab 600 mg42 endocet tab 10-325mg10 EPZICOM TAB 600-30057 136 ERAXIS INJ 100MG36 estropipate tab 1.5 mg89 ERAXIS INJ 50MG36 estropipate tab 3 mg89 ERBITUX INJ 100MG47 ethambutol hcl tab 100 mg45 ERBITUX INJ 200MG47 ethambutol hcl tab 400 mg45 ergocalciferol cap 50000 unit123 ethosuximide cap 250 mg25 ergoloid mesylates tab 1 mg113 ethosuximide soln 250 mg/5ml25 ERGOMAR SUB 2MG100 etidronate disodium tab 200 mg84 ergotamine w/ caffeine tab 1-100 mg100 etidronate disodium tab 400 mg84 ERIVEDGE CAP 150MG47 etodolac cap 200 mg4 errin tab 0.35mg71 etodolac cap 300 mg4 ERTACZO CRE 2%76 etodolac tab 400 mg4 ery pad 2%75 etodolac tab 500 mg4 ERY-TAB TAB 250MG EC98 etodolac tab sr 24hr 400 mg4 ERY-TAB TAB 333MG EC98 etodolac tab sr 24hr 500 mg4 ERY-TAB TAB 500MG EC98 etodolac tab sr 24hr 600 mg4 ERYPED SUS 200/5ML98 ETOPOPHOS INJ 100MG51 ERYPED SUS 400/5ML98 etoposide cap 50 mg51 ERYTHROCIN INJ 1000MG98 etoposide inj 20 mg/ml51 ERYTHROCIN INJ 500MG98 EURAX CRE 10%81 erythrocin tab 250mg98 EURAX LOT 10%81 erythromycin ethylsuccinate tab 400 mg98 EVAMIST SPR 1.53MG90 erythromycin gel 2%75 EVISTA TAB 60MG85 erythromycin ophth oint 5 mg/gm107 EXALGO TAB 12MG7 erythromycin pads 2%75 EXALGO TAB 16MG7 erythromycin soln 2%75 EXALGO TAB 32MG7 erythromycin tab 250 mg98 EXALGO TAB 8MG7 erythromycin tab 500 mg98 EXELDERM CRE 1%76 erythromycin w/ delayed release particles EXELDERM SOL 1%76 cap 250 mg98 EXELON DIS 4.6MG/24112 erythromycin-sulfisoxazole for susp 200- EXELON DIS 9.5MG/24112 600 mg/5ml14 EXELON SOL 2MG/ML112 escitalopram oxalate soln 5 mg/5ml (base exemestane tab 25 mg47 equiv)27 EXJADE TAB 125MG35 escitalopram oxalate tab 10 mg (base EXJADE TAB 250MG35 equiv)27 EXJADE TAB 500MG35 escitalopram oxalate tab 20 mg (base EXTAVIA INJ 0.3MG113 equiv)27 escitalopram oxalate tab 5 mg (base equiv)27 F ESTRACE VAG CRE 0.1MG/GM122 FA-8 CAP 800MCG95 estradiol & norethindrone acetate tab 0.5- FABRAZYME INJ 35MG85 0.1 mg87 FABRAZYME INJ 5MG85 estradiol & norethindrone acetate tab 1- FACTIVE TAB 320MG92 0.5 mg87 falmina tab68 estradiol tab 0.5 mg88 famciclovir tab 125 mg59 estradiol tab 1 mg88 famciclovir tab 250 mg59 estradiol tab 2 mg89 famciclovir tab 500 mg59 estradiol td patch weekly 0.025 famotidine for susp 40 mg/5ml118 mg/24hr89 famotidine in nacl 0.9% iv soln 20 estradiol td patch weekly 0.0375 mg/24hr mg/50ml118 (37.5 mcg/24hr)89 famotidine inj 10 mg/ml118 estradiol td patch weekly 0.05 mg/24hr89 famotidine tab 20 mg118 estradiol td patch weekly 0.06 mg/24hr89 famotidine tab 40 mg118 estradiol td patch weekly 0.075 FANAPT PAK53 mg/24hr89 FANAPT TAB 10MG54 estradiol td patch weekly 0.1 mg/24hr89 FANAPT TAB 12MG54 estradiol valerate im in oil 20 mg/ml89 FANAPT TAB 1MG53 estradiol valerate im in oil 40 mg/ml89 FANAPT TAB 2MG53 ESTRING MIS 2MG122 FANAPT TAB 4MG53 ESTROGEL GEL89 FANAPT TAB 6MG54 estropipate tab 0.75 mg89 137 FANAPT TAB 8MG54 flecainide acetate tab 100 mg18 FARESTON TAB 60MG47 flecainide acetate tab 150 mg18 FASLODEX INJ 250MG47 flecainide acetate tab 50 mg18 felbamate susp 600 mg/5ml25 FLOVENT DISK AER 100MCG19 felbamate tab 400 mg25 FLOVENT DISK AER 250MCG19 felbamate tab 600 mg25 FLOVENT DISK AER 50MCG19 felodipine tab sr 24hr 10 mg64 FLOVENT HFA AER 110MCG19 felodipine tab sr 24hr 2.5 mg64 FLOVENT HFA AER 220MCG19 felodipine tab sr 24hr 5 mg64 FLOVENT HFA AER 44MCG19 FEMCAP MIS 22MM99 floxuridine for inj 0.5 gm46 FEMCAP MIS 26MM99 FLUARIX INJ PF 10-11121 FEMCAP MIS 30MM99 FLUARIX INJ PF 11-12121 FEMHRT TAB 0.5-2.587 FLUARIX INJ PF 12-13121 FEMRING MIS 0.05/24H122 FLUCELVAX INJ 2012-13121 FEMRING MIS 0.1MG/24122 fluconazole for susp 10 mg/ml37 fenofibrate micronized cap 134 mg39 fluconazole for susp 40 mg/ml37 fenofibrate micronized cap 200 mg39 fluconazole in dextrose inj 200 fenofibrate micronized cap 67 mg39 mg/100ml37 fenofibrate tab 160 mg39 fluconazole in dextrose inj 400 fenofibrate tab 54 mg39 mg/200ml37 fenofibric acid tab 105 mg39 fluconazole in nacl 0.9% inj 200 fenofibric acid tab 35 mg39 mg/100ml37 FENOGLIDE TAB 40MG39 fluconazole in nacl 0.9% inj 400 fenoprofen calcium tab 600 mg4 mg/200ml37 fentanyl citrate lollipop 1200 mcg7 fluconazole tab 100 mg37 fentanyl citrate lollipop 1600 mcg7 fluconazole tab 150 mg37 fentanyl citrate lollipop 200 mcg7 fluconazole tab 200 mg37 fentanyl citrate lollipop 400 mcg7 fluconazole tab 50 mg37 fentanyl citrate lollipop 600 mcg7 FLUCONAZOLE/ INJ NACL 10037 fentanyl citrate lollipop 800 mcg7 fludarabine phosphate for inj 50 mg46 fentanyl td patch 72hr 100 mcg/hr7 fludarabine phosphate inj 25 mg/ml46 fentanyl td patch 72hr 12 mcg/hr7 fludrocortisone acetate tab 0.1 mg72 fentanyl td patch 72hr 25 mcg/hr7 FLULAVAL INJ 2010-11121 fentanyl td patch 72hr 50 mcg/hr7 FLULAVAL INJ 2011-12121 fentanyl td patch 72hr 75 mcg/hr7 FLULAVAL INJ 2012-13121 FENTORA TAB 100MCG7 FLUMIST NASA LIQ 2010-11121 FENTORA TAB 200MCG7 FLUMIST NASA LIQ 2011-12121 FENTORA TAB 400MCG7 FLUMIST NASA LIQ 2012-13121 FENTORA TAB 600MCG7 flunisolide nasal soln 0.025%105 FENTORA TAB 800MCG7 flunisolide nasal soln 29 mcg/act FER-IN-SOL DRO 15MG/ML96 (0.025%)105 FERRIPROX TAB 500MG35 fluocin acet oil body79 FERROUS SULF DRO96 fluocinolone acetonide (otic) oil 0.01%109 FERROUS SULF SYP 300/5ML96 fluocinolone acetonide cream 0.01%79 ferrous sulfate elixir 220 mg/5ml (44 fluocinolone acetonide cream 0.025%79 mg/5ml elemental fe)96 fluocinolone acetonide oint 0.025%79 ferrous sulfate soln 75 mg/0.6ml (15 fluocinolone acetonide soln 0.01%79 mg/0.6ml elemental fe)96 fluocinonide cream 0.05%79 ferrous sulfate soln 75 mg/ml (15 mg/ml fluocinonide gel 0.05%79 elemental fe)96 fluocinonide oint 0.05%79 FINACEA GEL 15%81 fluocinonide soln 0.05%79 finasteride tab 5 mg94 fluor-a-day dro 0.125mg101 FIRAZYR INJ 30MG/3ML94 fluor-op sus 0.1% op108 FIRMAGON INJ 120MG47 FLUORABON DRO101 FIRMAGON INJ 80MG47 fluoritab chw 0.5mg f101 FLAGYL ER TAB 750MG13 fluoritab chw 2.2mg101 FLAREX SUS 0.1% OP108 fluoritab dro 0.125mg101 flavoxate hcl tab 100 mg120 fluorometholone ophth susp 0.1%108 FLEBOGAMMA INJ 10%109 FLUOROPLEX CRE 1%77 FLEBOGAMMA INJ 5%109 fluorouracil cream 5%77 138 fluorouracil inj 1 gm/20ml (50 mg/ml)46 FOCALIN XR CAP 20MG2 fluorouracil inj 2.5 gm/50ml (50 mg/ml)46 FOCALIN XR CAP 25MG2 fluorouracil inj 5 gm/100ml (50 mg/ml)46 FOCALIN XR CAP 30MG2 fluorouracil inj 500 mg/10ml (50 FOCALIN XR CAP 35MG2 mg/ml)46 FOCALIN XR CAP 40MG2 fluorouracil soln 2%77 FOCALIN XR CAP 5MG2 fluorouracil soln 5%77 folic acid tab 1 mg95 fluoxetine hcl cap 10 mg27 folic acid tab 400 mcg95 fluoxetine hcl cap 20 mg27 folic acid tab 800 mcg95 fluoxetine hcl cap 40 mg27 folic acid-pyridoxine-cyanocobalamin tab fluoxetine hcl cap delayed release 90 2.5-25-2 mg81 mg27 fondaparinux sodium inj 10 mg/0.8ml22 fluoxetine hcl solution 20 mg/5ml27 fondaparinux sodium inj 2.5 mg/0.5ml22 fluoxetine hcl tab 10 mg27 fondaparinux sodium inj 5 mg/0.4ml22 fluoxetine hcl tab 20 mg27 fondaparinux sodium inj 7.5 mg/0.6ml22 FLUOXETINE TAB 60MG27 FORADIL CAP AEROLIZE20 fluphenazine decanoate inj 25 mg/ml55 FORTAZ INJ 1GM67 fluphenazine hcl elixir 2.5 mg/5ml55 FORTAZ INJ 2GM67 fluphenazine hcl inj 2.5 mg/ml55 FORTEO SOL 600/2.484 fluphenazine hcl oral conc 5 mg/ml55 FORTESTA GEL 10MG/ACT13 fluphenazine hcl tab 1 mg55 FOSAMAX + D TAB 70-280084 fluphenazine hcl tab 10 mg55 FOSAMAX + D TAB 70-560084 fluphenazine hcl tab 2.5 mg55 FOSAMAX SOL84 fluphenazine hcl tab 5 mg55 foscarnet sodium inj 24 mg/ml58 flura-drops dro 0.125mg101 fosinopril sodium tab 10 mg41 flura-drops dro 0.25mg f101 fosinopril sodium tab 20 mg41 flurbiprofen sodium ophth soln 0.03%108 fosinopril sodium tab 40 mg41 flurbiprofen tab 100 mg5 fosphenytoin sodium inj 100 mg/2ml flurbiprofen tab 50 mg5 (phenytoin equiv)25 flutamide cap 125 mg47 FOSRENOL CHW 1000MG93 fluticasone propionate cream 0.05%79 FOSRENOL CHW 500MG93 fluticasone propionate lotion 0.05%79 FOSRENOL CHW 750MG93 fluticasone propionate nasal susp 50 FRAGMIN INJ 10000/ML22 mcg/act105 FRAGMIN INJ 12500UNT22 fluticasone propionate oint 0.005%79 FRAGMIN INJ 15000UNT22 fluvastatin sodium cap 20 mg40 FRAGMIN INJ 18000UNT22 fluvastatin sodium cap 40 mg40 FRAGMIN INJ 2500/0.222 FLUVIRIN INJ 2010-11121 FRAGMIN INJ 25000/ML22 FLUVIRIN INJ 2011-12121 FRAGMIN INJ 5000/0.222 FLUVIRIN INJ 2012-13121 FRAGMIN INJ 7500/0.322 FLUVIRIN INJ PF 11-12121 FROVA TAB 2.5MG100 FLUVIRIN INJ PF 12-13121 furosemide inj 10 mg/ml82 fluvoxamine maleate tab 100 mg27 furosemide oral soln 10 mg/ml82 fluvoxamine maleate tab 25 mg27 FUROSEMIDE SOL 8MG/ML82 fluvoxamine maleate tab 50 mg27 furosemide tab 20 mg82 FLUZONE HD INJ PF 10-11121 furosemide tab 40 mg82 FLUZONE HD INJ PF 11-12121 furosemide tab 80 mg83 FLUZONE HD INJ PF 12-13121 FUZEON INJ 90MG57 FLUZONE INJ INTRADRM121 FUZEON KIT57 FLUZONE INJ PF 10-11121 FLUZONE INJ PF 11-12121 G FLUZONE INJ PF 12-13121 gabapentin cap 100 mg23 FLUZONE PED/ INJ PF 10-11121 gabapentin cap 300 mg23 FLUZONE PED/ INJ PF 11-12121 gabapentin cap 400 mg23 FLUZONE PED/ INJ PF 12-13121 gabapentin oral soln 250 mg/5ml23 FLUZONE SPLT INJ 2010-11121 gabapentin tab 600 mg23 FML FORTE SUS 0.25% OP108 gabapentin tab 800 mg23 FML OIN 0.1% OP108 GABITRIL TAB 12MG25 FOCALIN XR CAP 10MG2 GABITRIL TAB 16MG25 FOCALIN XR CAP 15MG2 galantamine hydrobromide cap sr 24hr 16 139 mg112 gentasol sol 0.3% op107 galantamine hydrobromide cap sr 24hr 24 GEODON INJ 20MG53 mg112 gianvi tab 3-0.02mg68 galantamine hydrobromide cap sr 24hr 8 gildess fe tab 1.5/3068 mg112 gildess fe tab 1/2069 galantamine hydrobromide oral soln 4 gildess tab 1.5/3069 mg/ml112 gildess tab 1/2069 galantamine hydrobromide tab 12 mg112 GILENYA CAP 0.5MG113 galantamine hydrobromide tab 4 mg112 GLASSIA INJ114 galantamine hydrobromide tab 8 mg112 GLEEVEC TAB 100MG49 GAMASTAN S/D INJ109 GLEEVEC TAB 400MG49 GAMMAGARD SD INJ 2.5GM HU109 GLIADEL WAF 7.7MG45 GAMMAKED INJ 1GM/10ML109 glimepiride tab 1 mg34 GAMMAPLEX INJ 2.5GM109 glimepiride tab 2 mg34 GAMUNEX INJ 10%109 glimepiride tab 4 mg34 ganciclovir cap 250 mg58 glipizide tab 10 mg34 ganciclovir cap 500 mg58 glipizide tab 5 mg34 garamycin oin 0.3% op107 glipizide tab sr 24hr 10 mg34 GARDASIL INJ121 glipizide tab sr 24hr 2.5 mg34 gavilyte-c sol97 glipizide tab sr 24hr 5 mg34 gavilyte-g sol97 glipizide-metformin hcl tab 2.5-250 mg31 gavilyte-n sol flav pk97 glipizide-metformin hcl tab 2.5-500 mg31 GELNIQUE GEL 10%120 glipizide-metformin hcl tab 5-500 mg32 GELNIQUE GEL 3%120 GLUCAGEN INJ HYPOKIT32 gemcitabine hcl for inj 1 gm46 GLUCAGON KIT 1MG32 gemcitabine hcl for inj 2 gm46 glyburide micronized tab 1.5 mg34 gemcitabine hcl for inj 200 mg46 glyburide micronized tab 3 mg34 gemfibrozil tab 600 mg39 glyburide micronized tab 6 mg34 GENERESS FE CHW68 glyburide tab 1.25 mg34 generlac sol 10gm/1593 glyburide tab 2.5 mg34 gengraf cap 100mg60 glyburide tab 5 mg34 gengraf cap 25mg60 glyburide-metformin tab 1.25-250 mg32 gengraf sol 100mg/ml60 glyburide-metformin tab 2.5-500 mg32 GENOTROPIN INJ 0.2MG84 glyburide-metformin tab 5-500 mg32 GENOTROPIN INJ 0.4MG84 glycopyrrolate inj 0.4 mg/2ml (0.2 GENOTROPIN INJ 0.6MG84 mg/ml)117 GENOTROPIN INJ 0.8MG84 glycopyrrolate tab 1 mg117 GENOTROPIN INJ 1.2MG84 glycopyrrolate tab 2 mg117 GENOTROPIN INJ 1.4MG84 glycron tab 1.5mg34 GENOTROPIN INJ 1.6MG84 glycron tab 3mg34 GENOTROPIN INJ 1.8MG84 GLYCRON TAB 4.5MG35 GENOTROPIN INJ 12MG84 glycron tab 6mg35 GENOTROPIN INJ 1MG84 GLYSET TAB 100MG31 GENOTROPIN INJ 2MG84 GLYSET TAB 25MG31 GENOTROPIN INJ 5MG84 GLYSET TAB 50MG31 gentak oin 0.3% op107 GOLYTELY SOL97 gentak sol 0.3% op107 GRALISE STAR MIS 300/600113 GENTAM/NACL INJ 0.9MG/ML3 GRALISE TAB 300MG113 GENTAM/NACL INJ 1.4MG/ML3 GRALISE TAB 600MG113 gentamicin in saline inj 0.8 mg/ml3 granisetron hcl inj 0.1 mg/ml35 gentamicin in saline inj 1 mg/ml3 granisetron hcl inj 1 mg/ml35 gentamicin in saline inj 1.2 mg/ml3 granisetron hcl tab 1 mg35 gentamicin in saline inj 1.6 mg/ml3 GRANISOL SOL 2MG/10ML35 gentamicin in saline inj 2 mg/ml3 griseofulvin microsize susp 125 mg/5ml37 gentamicin sulfate cream 0.1%76 griseofulvin microsize tab 500 mg37 gentamicin sulfate inj 10 mg/ml3 griseofulvin ultramicrosize tab 125 mg37 gentamicin sulfate inj 40 mg/ml3 griseofulvin ultramicrosize tab 250 mg37 gentamicin sulfate oint 0.1%76 guaifenesin-codeine liquid 200-10 gentamicin sulfate ophth oint 0.3%107 mg/5ml73 gentamicin sulfate ophth soln 0.3%107 guaifenesin-codeine liquid 300-10 140 mg/5ml73 HUMULIN R INJ U-50033 guanfacine hcl tab 1 mg42 HYCAMTIN CAP 0.25MG51 guanfacine hcl tab 2 mg42 HYCAMTIN CAP 1MG51 GUANIDINE TAB 125MG44 hydralazine hcl inj 20 mg/ml44 GYNAZOLE-1 CRE 2%122 hydralazine hcl tab 10 mg44 hydralazine hcl tab 100 mg44 H hydralazine hcl tab 25 mg44 HALFAN TAB 250MG44 hydralazine hcl tab 50 mg44 HALFPRIN TAB 162MG EC6 hydrochlorothiazide cap 12.5 mg83 halobetasol propionate cream 0.05%79 hydrochlorothiazide tab 12.5 mg83 halobetasol propionate oint 0.05%79 hydrochlorothiazide tab 25 mg83 HALOG CRE 0.1%79 hydrochlorothiazide tab 50 mg83 HALOG OIN 0.1%79 HYDROCO/APAP SOL 10-325MG11 haloperidol decanoate im soln 100 hydrocodone w/ homatropine syrup 5-1.5 mg/ml54 mg/5ml72 haloperidol decanoate im soln 50 mg/ml54 hydrocodone w/ homatropine tab 5-1.5 haloperidol lactate inj 5 mg/ml54 mg73 haloperidol lactate oral conc 2 mg/ml54 hydrocodone-acetaminophen soln 7.5-325 mg/15ml11 haloperidol tab 0.5 mg54 hydrocodone-acetaminophen soln 7.5-500 haloperidol tab 1 mg54 mg/15ml11 haloperidol tab 10 mg54 hydrocodone-acetaminophen tab 10-300 haloperidol tab 2 mg54 mg11 haloperidol tab 20 mg54 hydrocodone-acetaminophen tab 10-325 haloperidol tab 5 mg54 mg11 HAVRIX INJ 1440UNIT121 hydrocodone-acetaminophen tab 10-500 HAVRIX INJ 720UNIT121 mg11 heather tab 0.35mg71 hydrocodone-acetaminophen tab 10-650 HECTOROL CAP 0.5MCG85 mg11 HECTOROL CAP 1MCG85 hydrocodone-acetaminophen tab 10-660 HECTOROL CAP 2.5MCG85 mg11 HECTOROL INJ 4MCG/2ML86 hydrocodone-acetaminophen tab 10-750 hemril-30 sup 30mg13 mg11 heparin sodium (porcine) inj 1000 hydrocodone-acetaminophen tab 2.5-500 unit/ml22 mg11 heparin sodium (porcine) inj 10000 hydrocodone-acetaminophen tab 5-300 unit/ml22 mg11 HEPSERA TAB 10MG58 hydrocodone-acetaminophen tab 5-325 HEXALEN CAP 50MG45 mg11 HIBERIX SOL 10-25MCG120 hydrocodone-acetaminophen tab 5-500 HIZENTRA INJ 1GM/5ML109 mg11 homatropaire sol 5% op106 hydrocodone-acetaminophen tab 7.5-300 homatropine hbr ophth soln 5%106 mg11 HORIZANT TAB 600MG113 hydrocodone-acetaminophen tab 7.5-325 HUMALOG INJ 100/ML33 mg11 HUMALOG MIX INJ 50/5033 hydrocodone-acetaminophen tab 7.5-500 mg11 HUMALOG MIX INJ 50/50KWP33 hydrocodone-acetaminophen tab 7.5-650 HUMALOG MIX INJ 75/25KWP33 mg11 HUMALOG MIX SUS 75/2533 hydrocodone-acetaminophen tab 7.5-750 HUMATROPE INJ 12MG84 mg11 HUMATROPE INJ 24MG85 hydrocortisone acetate suppos 25 mg13 HUMATROPE INJ 5MG84 hydrocortisone acetate suppos 30 mg13 HUMATROPE INJ 6MG84 hydrocortisone butyrate cream 0.1%79 HUMIRA KIT 20MG/0.44 hydrocortisone butyrate oint 0.1%79 HUMIRA KIT 40MG/0.84 hydrocortisone butyrate soln 0.1%79 HUMIRA PEN KIT CROHNS4 hydrocortisone cream 1%79 HUMULIN INJ 70/3033 hydrocortisone cream 2.5%79 HUMULIN N INJ U-10033 hydrocortisone enema 100 mg/60ml13 HUMULIN N PN INJ U-10033 hydrocortisone lotion 2.5%79 HUMULIN PEN INJ 70/3033 hydrocortisone oint 2.5%79 HUMULIN R INJ U-10033 141 hydrocortisone tab 10 mg71 idarubicin hcl iv inj 5 mg/5ml (1 mg/ml)48 hydrocortisone tab 20 mg71 ifosfamide & mesna inj kit 1000-1000 hydrocortisone tab 5 mg71 mg48 hydrocortisone valerate cream 0.2%79 ifosfamide for inj 1 gm45 hydrocortisone valerate oint 0.2%79 ifosfamide iv inj 1 gm/20ml (50 mg/ml)45 hydrocortisone w/ acetic acid otic soln 1- ifosfamide iv inj 3 gm/60ml (50 mg/ml)45 2%109 ILEVRO DRO 0.3% OP108 hydrogesic cap 5-500mg11 ilotycin oin op107 hydromet syp 5-1.5/573 imipenem-cilastatin intravenous for soln HYDROMORPHON SUP 3MG7 250 mg14 hydromorphone hcl inj 1 mg/ml7 imipenem-cilastatin intravenous for soln hydromorphone hcl inj 10 mg/ml7 500 mg14 hydromorphone hcl inj 2 mg/ml7 imipramine hcl tab 10 mg30 hydromorphone hcl liqd 1 mg/ml7 imipramine hcl tab 25 mg30 hydromorphone hcl preservative free (pf) imipramine hcl tab 50 mg30 inj 1 mg/ml7 imipramine pamoate cap 100 mg30 hydromorphone hcl preservative free (pf) imipramine pamoate cap 125 mg30 inj 10 mg/ml8 imipramine pamoate cap 150 mg30 hydromorphone hcl preservative free (pf) imipramine pamoate cap 75 mg30 inj 2 mg/ml8 imiquimod cream 5%80 hydromorphone hcl preservative free (pf) IMPLANON IMP 68MG71 inj 4 mg/ml8 INCIVEK TAB 375MG58 hydromorphone hcl tab 2 mg8 INCRELEX INJ 40MG/4ML85 hydromorphone hcl tab 4 mg8 indapamide tab 1.25 mg83 hydromorphone hcl tab 8 mg8 indapamide tab 2.5 mg83 hydroxychloroquine sulfate tab 200 mg44 INDOCIN SUS 25MG/5ML5 hydroxyurea cap 500 mg50 indomethacin cap 25 mg5 hydroxyzine hcl im soln 25 mg/ml16 indomethacin cap 50 mg5 hydroxyzine hcl im soln 50 mg/ml16 indomethacin cap cr 75 mg5 hydroxyzine hcl syrup 10 mg/5ml16 INFANRIX INJ117 hydroxyzine hcl tab 10 mg16 INFERGEN INJ 15MCG58 hydroxyzine hcl tab 25 mg17 INFERGEN INJ 9MCG58 hydroxyzine hcl tab 50 mg17 INFLUENZA A INJ 09 H1N1121 hydroxyzine pamoate cap 100 mg17 INFLUENZA A INJ PF09H1N1122 hydroxyzine pamoate cap 25 mg17 INFLUENZA A SPR 09 H1N1122 hydroxyzine pamoate cap 50 mg17 INLYTA TAB 1MG49 hyomax tab 0.125mg117 INLYTA TAB 5MG49 hyomax-ft tab 0.125mg117 INTELENCE TAB 100MG57 hyomax-sl sub 0.125mg117 INTELENCE TAB 200MG57 hyomax-sr tab 0.375mg117 INTELENCE TAB 25MG57 hyoscyamine sulfate tab 0.125 mg117 INTERMEZZO SUB 1.75MG97 hyoscyamine sulfate tab disp 0.125 mg118 INTERMEZZO SUB 3.5MG97 hyoscyamine sulfate tab sl 0.125 mg118 INTRON-A INJ 10MU50 hyoscyamine sulfate tab sr 12hr 0.375 INTRON-A INJ 10MU PEN50 mg118 INTRON-A INJ 18MU50 INTRON-A INJ 25MU50 I INTRON-A INJ 3MU PEN50 ibandronate sodium tab 150 mg (base INTRON-A INJ 50MU50 equivalent)84 INTRON-A INJ 5MU PEN50 ibuprofen sus 100/5ml5 introvale tab69 ibuprofen tab 400 mg5 INTUNIV TAB 1MG1 ibuprofen tab 600 mg5 INTUNIV TAB 2MG1 ibuprofen tab 800 mg5 INTUNIV TAB 3MG1 ICAR PEDS SUS GRAPE96 INTUNIV TAB 4MG2 ICLUSIG TAB 15MG49 INVANZ INJ 1GM14 ICLUSIG TAB 45MG49 INVEGA SUST INJ 117/0.7554 idarubicin hcl iv inj 10 mg/10ml (1 INVEGA SUST INJ 156MG/ML54 mg/ml)48 INVEGA SUST INJ 234/1.554 idarubicin hcl iv inj 20 mg/20ml (1 INVEGA SUST INJ 39/0.2554 mg/ml)48 INVEGA SUST INJ 78/0.5ML54 142 INVEGA TAB 1.5MG54 JAKAFI TAB 25MG49 INVEGA TAB 3MG54 JAKAFI TAB 5MG49 INVEGA TAB 6MG54 JALYN CAP94 INVEGA TAB 9MG54 jantoven tab 10mg21 INVIRASE CAP 200MG57 jantoven tab 1mg21 INVIRASE TAB 500MG57 jantoven tab 2.5mg21 IOPIDINE SOL 1% OP106 jantoven tab 2mg21 IPOL INJ INACTIVE122 jantoven tab 3mg21 ipratropium bromide inhal soln 0.02%19 jantoven tab 4mg21 ipratropium bromide nasal soln 0.03% (21 jantoven tab 5mg21 mcg/spray)105 jantoven tab 6mg21 ipratropium bromide nasal soln 0.06% (42 jantoven tab 7.5mg21 mcg/spray)105 JANUMET TAB 50-100032 ipratropium-albuterol nebu soln 0.5-2.5(3) JANUMET TAB 50-500MG32 mg/3ml20 JANUMET XR TAB 100-100032 irbesartan tab 150 mg42 JANUMET XR TAB 50-100032 irbesartan tab 300 mg42 JANUMET XR TAB 50-500MG32 irbesartan tab 75 mg42 JANUVIA TAB 100MG32 irinotecan hcl inj 100 mg/5ml (20 JANUVIA TAB 25MG32 mg/ml)51 JANUVIA TAB 50MG32 irinotecan hcl inj 40 mg/2ml (20 mg/ml)51 JENTADUETO TAB 2.5-100032 irinotecan hcl inj 500 mg/25ml (20 JENTADUETO TAB 2.5-50032 mg/ml)51 JENTADUETO TAB 2.5-85032 ISENTRESS CHW 100MG57 jevantique tab 1mg-5mcg87 ISENTRESS CHW 25MG57 jinteli tab 1mg-5mcg87 ISENTRESS TAB 400MG57 jolessa tab69 ISO HOMATROP SOL 2% OP106 jolivette tab 0.35mg71 isochron tab 40mg cr15 junel 1.5/30 tab69 isoditrate tab 40mg er15 junel 1/20 tab69 ISOLYTE-S INJ100 junel fe tab 1.5/3069 isonarif cap44 junel fe tab 1/2069 isoniazid inj 100 mg/ml45 isoniazid syrup 50 mg/5ml45 isoniazid tab 100 mg45 K isoniazid tab 300 mg45 KADIAN CAP 10MG CR8 ISORDIL TAB 40MG15 KADIAN CAP 200MG CR8 isosorbide dinitrate sl tab 2.5 mg15 KALETRA SOL57 isosorbide dinitrate sl tab 5 mg15 KALETRA TAB 100-25MG57 isosorbide dinitrate tab 10 mg15 KALETRA TAB 200-50MG57 isosorbide dinitrate tab 20 mg15 KALYDECO TAB 150MG114 isosorbide dinitrate tab 30 mg15 kanamycin sulfate inj 333 mg/ml3 isosorbide dinitrate tab 5 mg15 kariva tab 28 day69 isosorbide dinitrate tab cr 40 mg15 kcl 20 meq/l (0.15%) in nacl 0.45% inj100 isosorbide mononitrate tab 10 mg15 kcl 20 meq/l (0.15%) in nacl 0.9% inj100 isosorbide mononitrate tab 20 mg15 kcl 40 meq/l (0.3%) in nacl 0.9% inj100 isosorbide mononitrate tab sr 24hr 120 KEFLEX CAP 750MG66 mg15 kelnor tab 1/3569 isosorbide mononitrate tab sr 24hr 30 KENALOG AER SPRAY79 mg15 KEPIVANCE INJ 6.25MG50 isosorbide mononitrate tab sr 24hr 60 KETEK TAB 300MG15 mg15 KETEK TAB 400MG15 isradipine cap 2.5 mg64 ketoconazole cream 2%77 isradipine cap 5 mg64 ketoconazole foam 2%77 ISTALOL SOL 0.5% OP106 ketoconazole shampoo 2%77 itraconazole cap 100 mg37 ketoconazole tab 200 mg37 ketoprofen cap 50 mg5 J ketoprofen cap 75 mg5 JAKAFI TAB 10MG49 ketoprofen cap sr 24hr 200 mg5 JAKAFI TAB 15MG49 ketorolac tromethamine im inj 30 mg/ml5 JAKAFI TAB 20MG49 ketorolac tromethamine im inj 60 mg/2ml

143 (30 mg/ml)5 mg23 ketorolac tromethamine inj 15 mg/ml5 lamotrigine tab sr 24hr 100 mg23 ketorolac tromethamine inj 30 mg/ml5 lamotrigine tab sr 24hr 200 mg24 ketorolac tromethamine inj 300 mg/10ml lamotrigine tab sr 24hr 25 mg23 (30 mg/ml)5 lamotrigine tab sr 24hr 250 mg24 ketorolac tromethamine inj 60 mg/2ml (30 lamotrigine tab sr 24hr 300 mg24 mg/ml)5 lamotrigine tab sr 24hr 50 mg23 ketorolac tromethamine ophth soln LANOXIN INJ 0.1MG/ML65 0.4%109 lansoprazole cap delayed release 15 ketorolac tromethamine ophth soln mg118 0.5%109 lansoprazole cap delayed release 30 ketorolac tromethamine tab 10 mg5 mg118 ketotifen fumarate ophth soln 0.025% lansoprazole tab delayed release orally (base equiv)109 disintegrating 15 mg118 KINERET INJ4 lansoprazole tab delayed release orally KINRIX INJ117 disintegrating 30 mg118 kionex sus 15gm/6061 LANTUS INJ 100/ML33 klor-con 10 tab 10meq er101 LANTUS INJ SOLOSTAR33 klor-con 8 tab 8meq er101 LASTACAFT SOL 0.25%109 KLOR-CON M15 TAB101 latanoprost ophth soln 0.005%109 klor-con m20 tab 20meq er101 LATUDA TAB 120MG53 KRISTALOSE PAK 10GM97 LATUDA TAB 20MG53 KRISTALOSE PAK 20GM97 LATUDA TAB 40MG53 kurvelo tab 0.15/3069 LATUDA TAB 80MG53 KUVAN TAB 100MG86 lavoclen-4 kit acne wsh75 lavoclen-4 liq crem wsh75 L lavoclen-8 kit acne wsh75 labetalol hcl iv soln 5 mg/ml61 lavoclen-8 liq crem wsh75 labetalol hcl tab 100 mg61 LAZANDA SPR 100MCG8 labetalol hcl tab 200 mg61 LAZANDA SPR 400MCG8 labetalol hcl tab 300 mg61 leena tab69 laclotion lot 12%80 leflunomide tab 10 mg6 LACRISERT MIS 5MG OP106 leflunomide tab 20 mg6 lactic acid (ammonium lactate) cream LESCOL XL TAB 80MG40 12%80 lessina tab69 lactic acid (ammonium lactate) lotion LETAIRIS TAB 10MG65 12%80 LETAIRIS TAB 5MG65 lactulose solution 10 gm/15ml97 letrozole tab 2.5 mg47 LAMICTAL CHW 2MG23 leucovorin calcium for inj 100 mg50 LAMICTAL KIT START 3523 leucovorin calcium for inj 200 mg50 LAMICTAL KIT START 4923 leucovorin calcium for inj 350 mg50 LAMICTAL KIT START 9823 leucovorin calcium for inj 50 mg50 LAMICTAL ODT KIT23 leucovorin calcium inj 10 mg/ml50 LAMICTAL ODT TAB 100MG23 leucovorin calcium tab 10 mg50 LAMICTAL ODT TAB 200MG23 leucovorin calcium tab 15 mg51 LAMICTAL ODT TAB 25MG23 leucovorin calcium tab 25 mg51 LAMICTAL ODT TAB 50MG23 leucovorin calcium tab 5 mg50 LAMICTAL XR KIT23 LEUCOVORIN INJ CALCIUM51 LAMISIL GRA 125MG37 LEUKERAN TAB 2MG46 LAMISIL GRA 187.5MG37 LEUKINE INJ 250MCG95 lamivudine tab 150 mg57 LEUKINE INJ 500 MCG96 lamivudine tab 300 mg57 leuprolide acetate inj kit 5 mg/ml47 lamivudine-zidovudine tab 150-300 mg57 levalbuterol hcl soln nebu 0.31 mg/3ml lamotrigine tab 100 mg23 (base equiv)20 lamotrigine tab 150 mg23 levalbuterol hcl soln nebu 0.63 mg/3ml lamotrigine tab 200 mg23 (base equiv)20 lamotrigine tab 25 mg23 levalbuterol hcl soln nebu conc 1.25 lamotrigine tab chewable dispersible 25 mg/0.5ml (base equiv)20 mg23 LEVATOL TAB 20MG62 lamotrigine tab chewable dispersible 5 LEVEMIR INJ33

144 LEVEMIR INJ FLEXPEN33 levoxyl tab 112mcg116 LEVETIRACETA INJ 10MG/ML24 levoxyl tab 125mcg116 LEVETIRACETA INJ 15MG/ML24 levoxyl tab 137mcg116 LEVETIRACETA INJ 5MG/ML24 levoxyl tab 150mcg116 levetiracetam inj 500 mg/5ml (100 levoxyl tab 175mcg116 mg/ml)24 levoxyl tab 200mcg116 levetiracetam oral soln 100 mg/ml24 levoxyl tab 25mcg116 levetiracetam tab 1000 mg24 levoxyl tab 50mcg116 levetiracetam tab 250 mg24 levoxyl tab 75mcg116 levetiracetam tab 500 mg24 levoxyl tab 88mcg116 levetiracetam tab 750 mg24 LEXIVA SUS 50MG/ML57 levetiracetam tab sr 24hr 500 mg24 LEXIVA TAB 700MG57 levetiracetam tab sr 24hr 750 mg24 LIALDA TAB 1.2GM92 levobunolol hcl ophth soln 0.25%106 LIDO/DEXTROS INJ 5-7.5%98 levobunolol hcl ophth soln 0.5%106 lidocaine hcl cream 3%80 levocetirizine dihydrochloride soln 2.5 lidocaine hcl gel 2%80 mg/5ml (0.5 mg/ml)38 lidocaine hcl iv inj 20 mg/ml18 levocetirizine dihydrochloride tab 5 mg38 lidocaine hcl local inj 0.5%98 levofloxacin in d5w iv soln 250 mg/50ml92 lidocaine hcl local inj 1%98 levofloxacin iv soln 25 mg/ml92 lidocaine hcl local inj 1.5%98 levofloxacin ophth soln 0.5%107 lidocaine hcl local inj 4%98 levofloxacin oral soln 25 mg/ml92 lidocaine hcl lotion 3%80 levofloxacin tab 250 mg92 lidocaine hcl soln 4%80 levofloxacin tab 500 mg92 lidocaine hcl viscous soln 2%102 levofloxacin tab 750 mg92 lidocaine iv infusion in d5w inj 4 mg/ml18 levonest tab69 lidocaine iv infusion in d5w inj 8 mg/ml18 levonorg-eth est tab 0.1-0.02mg(84) & lidocaine oint 5%81 eth est tab 0.01mg(7)69 lidocaine-prilocaine cream 2.5-2.5%81 levonorgestrel & ethinyl estradiol (91-day) lidocaine-prilocaine kit 2.5-2.5%81 tab 0.15-0.03 mg69 LIDODERM DIS 5%81 levonorgestrel & ethinyl estradiol tab 0.15 LINCOCIN INJ 300MG/ML15 mg-30 mcg69 liothyronine sodium iv soln 10 mcg/ml116 levonorgestrel tab 0.75 mg70 liothyronine sodium tab 25 mcg116 levora-28 tab 0.15/3069 liothyronine sodium tab 5 mcg116 levorphanol tartrate tab 2 mg8 liothyronine sodium tab 50 mcg116 levothroid tab 100mcg115 lipodox 50 inj 2mg/ml48 levothroid tab 112mcg115 lipodox inj 2mg/ml48 levothroid tab 125mcg115 LIPOFEN CAP 150MG39 levothroid tab 137mcg115 LIPOFEN CAP 50MG39 levothroid tab 150mcg115 lisinopril & hydrochlorothiazide tab 10- levothroid tab 175mcg116 12.5 mg43 levothroid tab 200mcg116 lisinopril & hydrochlorothiazide tab 20- levothroid tab 25mcg115 12.5 mg43 levothroid tab 300mcg116 lisinopril & hydrochlorothiazide tab 20-25 levothroid tab 50mcg115 mg43 levothroid tab 75mcg115 lisinopril tab 10 mg41 levothroid tab 88mcg115 lisinopril tab 2.5 mg41 levothyroxine sodium tab 100 mcg116 lisinopril tab 20 mg41 levothyroxine sodium tab 112 mcg116 lisinopril tab 30 mg41 levothyroxine sodium tab 125 mcg116 lisinopril tab 40 mg41 levothyroxine sodium tab 137 mcg116 lisinopril tab 5 mg41 levothyroxine sodium tab 150 mcg116 lithium carbonate cap 150 mg53 levothyroxine sodium tab 175 mcg116 lithium carbonate cap 300 mg53 levothyroxine sodium tab 200 mcg116 lithium carbonate cap 600 mg53 levothyroxine sodium tab 25 mcg116 lithium carbonate tab 300 mg53 levothyroxine sodium tab 300 mcg116 lithium carbonate tab cr 300 mg53 levothyroxine sodium tab 50 mcg116 lithium carbonate tab cr 450 mg53 levothyroxine sodium tab 75 mcg116 LITHIUM CITR SOL 8MEQ/5ML53 levothyroxine sodium tab 88 mcg116 LIVALO TAB 1MG40 levoxyl tab 100mcg116 LIVALO TAB 2MG40 145 LIVALO TAB 4MG40 LUVOX CR CAP 100MG27 LO LOESTRIN TAB69 LUVOX CR CAP 150MG27 LODOSYN TAB 25MG52 LYRICA CAP 100MG24 LOESTRIN 24 TAB FE69 LYRICA CAP 150MG24 lokara lot 0.05%80 LYRICA CAP 200MG24 loperamide hcl cap 2 mg35 LYRICA CAP 225MG24 loperamide hcl tab 2 mg35 LYRICA CAP 25MG24 lorazepam conc 2 mg/ml17 LYRICA CAP 300MG24 lorazepam tab 0.5 mg17 LYRICA CAP 50MG24 lorazepam tab 1 mg17 LYRICA CAP 75MG24 lorazepam tab 2 mg17 LYRICA SOL 20MG/ML24 loryna tab 3-0.02mg69 LYSODREN TAB 500MG47 LORZONE TAB 375MG104 LORZONE TAB 750MG104 M losartan potassium & hydrochlorothiazide M-M-R II INJ LIVE122 tab 100-12.5 mg43 MACRODANTIN CAP 25MG119 losartan potassium & hydrochlorothiazide MAGNACET TAB 7.5-40011 tab 100-25 mg43 losartan potassium & hydrochlorothiazide MAGNESIUM SU INJ 40MG/ML101 tab 50-12.5 mg43 MAGNESIUM SU INJ 80MG/ML101 losartan potassium tab 100 mg42 magnesium sulfate inj 50%101 losartan potassium tab 25 mg42 malathion lotion 0.5%81 losartan potassium tab 50 mg42 maprotiline hcl tab 25 mg26 LOTEMAX GEL 0.5%108 maprotiline hcl tab 50 mg26 LOTEMAX OIN 0.5%108 maprotiline hcl tab 75 mg26 LOTEMAX SUS 0.5%108 margesic-h cap 5-500mg11 LOTRONEX TAB 0.5MG93 marlissa tab 0.15/3069 LOTRONEX TAB 1MG93 MARPLAN TAB 10MG27 lovastatin tab 10 mg40 MATULANE CAP 50MG50 lovastatin tab 20 mg40 matzim la tab 180mg/2464 lovastatin tab 40 mg40 matzim la tab 240mg/2464 LOVAZA CAP 1GM39 matzim la tab 300mg/2464 low-ogestrel tab69 matzim la tab 360mg/2464 loxapine succinate cap 10 mg55 matzim la tab 420mg/2464 loxapine succinate cap 25 mg55 MAXAIR AUTOH AER 200MCG20 loxapine succinate cap 5 mg55 MAXIDEX SUS 0.1% OP108 loxapine succinate cap 50 mg55 MAXIPIME INJ 1GM68 ludent chw 0.25mg f101 MAXIPIME INJ 2GM68 ludent chw 0.5mg f101 mebendazole chew tab 100 mg13 ludent chw 1mg f101 meclizine hcl tab 12.5 mg36 LUFYLLIN TAB 200MG21 meclizine hcl tab 25 mg36 LUFYLLIN TAB 400MG21 meclofenamate sodium cap 100 mg5 LUMIGAN SOL 0.01%109 meclofenamate sodium cap 50 mg5 MEDROL TAB 2MG71 LUMIGAN SOL 0.03%109 medroxyprogesterone acetate im susp 150 LUNESTA TAB 1MG97 mg/ml71 LUNESTA TAB 2MG97 medroxyprogesterone acetate tab 10 LUNESTA TAB 3MG97 mg112 LUPR DEP-PED INJ 11.25MG85 medroxyprogesterone acetate tab 2.5 LUPR DEP-PED INJ 15MG85 mg111 LUPR DEP-PED INJ 30MG85 medroxyprogesterone acetate tab 5 LUPR DEP-PED INJ 7.5MG85 mg111 LUPRON DEPOT INJ 11.25MG47 mefenamic acid cap 250 mg5 LUPRON DEPOT INJ 22.5MG47 mefloquine hcl tab 250 mg44 LUPRON DEPOT INJ 3.75MG47 MEFOXIN INJ 1GM/50ML67 LUPRON DEPOT INJ 30MG47 MEFOXIN INJ 2GM/50ML67 LUPRON DEPOT INJ 45MG47 MEGACE ES SUS 625/5ML112 LURIDE CHW 0.25MG F101 megestrol acetate susp 40 mg/ml47 LURIDE CHW 0.5MG F101 megestrol acetate tab 20 mg47 LURIDE DRO 0.5MG/ML101 megestrol acetate tab 40 mg48 lutera tab69 meloxicam susp 7.5 mg/5ml5 146 meloxicam tab 15 mg5 methocarbamol tab 500 mg104 meloxicam tab 7.5 mg5 methocarbamol tab 750 mg104 melphalan hcl for inj 50 mg (base methotrexate sodium for inj 1 gm46 equiv)46 methotrexate sodium inj 25 mg/ml46 MENACTRA INJ120 methotrexate sodium inj pf 25 mg/ml47 MENEST TAB 0.3MG90 methotrexate sodium tab 2.5 mg (base MENEST TAB 0.625MG90 equiv)47 MENEST TAB 1.25MG90 methscopolamine bromide tab 2.5 mg118 MENEST TAB 2.5MG90 methscopolamine bromide tab 5 mg118 MENHIBRIX INJ120 methyclothiazide tab 5 mg83 MENOMUNE INJ A/C/Y/W120 methyldopa tab 250 mg42 MENOSTAR DIS 14MCG90 methyldopa tab 500 mg42 MENTAX CRE 1%77 methyldopate hcl inj 250 mg/5ml42 MENVEO INJ120 METHYLIN CHW 10MG2 meperidine hcl oral soln 50 mg/5ml8 METHYLIN CHW 2.5MG2 meperidine hcl tab 100 mg8 METHYLIN CHW 5MG2 meperidine hcl tab 50 mg8 methylin tab 10mg3 MEPHYTON TAB 5MG123 methylin tab 10mg er3 meprobamate tab 200 mg17 methylin tab 20mg3 meprobamate tab 400 mg17 methylin tab 20mg er3 MEPRON SUS14 methylin tab 5mg2 mercaptopurine tab 50 mg46 methylphenidate hcl cap sr 24hr 20 mg3 meropenem iv for soln 500 mg14 methylphenidate hcl cap sr 24hr 30 mg3 mesalamine rectal enema 4 gm & cleanser methylphenidate hcl cap sr 24hr 40 mg3 wipe kit93 methylphenidate hcl soln 10 mg/5ml3 mesna inj 100 mg/ml51 methylphenidate hcl soln 5 mg/5ml3 MESNEX TAB 400MG51 methylphenidate hcl tab 10 mg3 MESTINON SYP 60MG/5ML44 methylphenidate hcl tab 20 mg3 MESTINON TAB TIMESPAN44 methylphenidate hcl tab 5 mg3 metadate tab 20mg er2 methylphenidate hcl tab cr 10 mg3 metaproterenol sulfate syrup 10 methylphenidate hcl tab cr 20 mg3 mg/5ml20 methylphenidate hcl tab sa osm 18 mg3 metaproterenol sulfate tab 10 mg20 methylphenidate hcl tab sa osm 27 mg3 metaproterenol sulfate tab 20 mg20 methylphenidate hcl tab sa osm 36 mg3 metaxalone tab 800 mg104 methylphenidate hcl tab sa osm 54 mg3 metformin hcl tab 1000 mg32 methylprednisolone sodium succinate for metformin hcl tab 500 mg32 inj 125 mg72 metformin hcl tab 850 mg32 methylprednisolone sodium succinate for metformin hcl tab sr 24hr 500 mg32 inj 40 mg71 metformin hcl tab sr 24hr 750 mg32 methylprednisolone sodium succinate for metformin hcl tab sr 24hr osmotic 1000 inj 500 mg72 mg32 methylprednisolone tab 16 mg72 methadone hcl conc 10 mg/ml8 methylprednisolone tab 32 mg72 methadone hcl soln 10 mg/5ml8 methylprednisolone tab 4 mg72 methadone hcl soln 5 mg/5ml8 methylprednisolone tab 4 mg dose pack72 methadone hcl tab 10 mg8 methylprednisolone tab 8 mg72 methadone hcl tab 5 mg8 metipranolol ophth soln 0.3%106 methadone hcl tab for oral susp 40 mg8 metoclopramide hcl inj 5 mg/ml92 METHADONE INJ 10MG/ML8 metoclopramide hcl soln 5 mg/5ml (10 methadose con 10mg/ml8 mg/10ml)92 methadose tab 10mg8 metoclopramide hcl tab 10 mg92 methadose tab 40mg8 metoclopramide hcl tab 5 mg92 methadose tab 5mg8 metolazone tab 10 mg83 methamphetamine hcl tab 5 mg1 metolazone tab 2.5 mg83 methazolamide tab 25 mg82 metolazone tab 5 mg83 methazolamide tab 50 mg82 metoprolol & hydrochlorothiazide tab 100- methenamine hippurate tab 1 gm119 25 mg43 methimazole tab 10 mg115 metoprolol & hydrochlorothiazide tab 100- methimazole tab 5 mg115 50 mg43 METHITEST TAB 10MG13 metoprolol & hydrochlorothiazide tab 50-

147 25 mg43 MIRAPEX ER TAB 0.375MG52 metoprolol succinate tab sr 24hr 100 MIRAPEX ER TAB 0.75MG52 mg62 MIRAPEX ER TAB 1.5MG52 metoprolol succinate tab sr 24hr 200 MIRAPEX ER TAB 2.25MG52 mg62 MIRAPEX ER TAB 3.75MG52 metoprolol succinate tab sr 24hr 25 mg62 MIRAPEX ER TAB 3MG53 metoprolol succinate tab sr 24hr 50 mg62 MIRAPEX ER TAB 4.5MG53 metoprolol tartrate inj 1 mg/ml62 MIRENA IUD SYSTEM70 metoprolol tartrate tab 100 mg62 mirtazapine orally disintegrating tab 15 metoprolol tartrate tab 25 mg62 mg26 metoprolol tartrate tab 50 mg62 mirtazapine orally disintegrating tab 30 METOZOLV ODT TAB 10MG92 mg26 METOZOLV ODT TAB 5MG92 mirtazapine orally disintegrating tab 45 METROGEL GEL 1%81 mg26 metronidazole cap 375 mg13 mirtazapine tab 15 mg26 metronidazole cream 0.75%81 mirtazapine tab 30 mg26 metronidazole gel 0.75%81 mirtazapine tab 45 mg26 metronidazole in nacl 0.79% iv soln 500 mirtazapine tab 7.5 mg26 mg/100ml13 misoprostol tab 100 mcg119 metronidazole lotion 0.75%81 misoprostol tab 200 mcg119 metronidazole tab 250 mg14 mitomycin for inj 20 mg48 metronidazole tab 500 mg14 mitomycin for inj 40 mg48 metronidazole vaginal gel 0.75%122 mitomycin for inj 5 mg48 mexiletine hcl cap 150 mg18 mitoxantrone hcl inj conc 20 mg/10ml (2 mexiletine hcl cap 200 mg18 mg/ml)48 mexiletine hcl cap 250 mg18 mitoxantrone hcl inj conc 25 mg/12.5ml (2 MG SO4/D5W INJ 10MG/ML101 mg/ml)48 MG SO4/D5W INJ 20MG/ML101 mitoxantrone hcl inj conc 30 mg/15ml (2 MIACALCIN INJ 200/ML84 mg/ml)48 MICARDIS TAB 20MG42 modafinil tab 100 mg3 MICARDIS TAB 40MG42 modafinil tab 200 mg3 MICARDIS TAB 80MG42 moexipril hcl tab 15 mg41 microgestin tab 1.5/3069 moexipril hcl tab 7.5 mg41 microgestin tab 1/2069 mometasone furoate cream 0.1%80 microgestin tab fe 1/2069 mometasone furoate oint 0.1%80 microgestin tab fe1.5/3069 mometasone furoate solution 0.1% midodrine hcl tab 10 mg123 (lotion)80 midodrine hcl tab 2.5 mg123 mono-linyah tab 0.25-3569 midodrine hcl tab 5 mg123 mononessa tab69 MIGRANAL SPR 4MG/ML100 montelukast sodium chew tab 4 mg (base MILLIPRED DP PAK 5MG72 equiv)19 montelukast sodium chew tab 5 mg (base MILLIPRED SOL 10MG/5ML72 equiv)19 MILLIPRED TAB 5MG72 montelukast sodium oral granules packet mimvey tab 1-0.5mg87 4 mg (base equiv)19 minirin spr nasal86 montelukast sodium tab 10 mg (base minitran dis 0.1mg/hr15 equiv)19 minitran dis 0.2mg/hr15 MONUROL PAK GRANULES119 minitran dis 0.4mg/hr15 morgidox cap 1x100mg115 minitran dis 0.6mg/hr16 MORGIDOX KIT 1X100MG115 minocycline hcl cap 100 mg115 MORPHINE SUL INJ 4MG/ML8 minocycline hcl cap 50 mg115 MORPHINE SUL INJ 5MG/ML8 minocycline hcl cap 75 mg115 MORPHINE SUL SUP 30MG8 minocycline hcl tab 100 mg115 morphine sulfate (concentrate) oral soln minocycline hcl tab 50 mg115 20 mg/ml8 minocycline hcl tab 75 mg115 morphine sulfate cap sr 24hr 100 mg9 minocycline hcl tab sr 24hr 135 mg115 morphine sulfate cap sr 24hr 20 mg8 minocycline hcl tab sr 24hr 45 mg115 morphine sulfate cap sr 24hr 30 mg8 minocycline hcl tab sr 24hr 90 mg115 morphine sulfate cap sr 24hr 50 mg8 minoxidil tab 10 mg44 morphine sulfate cap sr 24hr 60 mg8 minoxidil tab 2.5 mg44 morphine sulfate cap sr 24hr 80 mg8 148 morphine sulfate inj 10 mg/ml9 nadolol tab 160 mg62 morphine sulfate inj 15 mg/ml9 nadolol tab 20 mg62 morphine sulfate inj 2 mg/ml9 nadolol tab 40 mg62 morphine sulfate inj 8 mg/ml9 nadolol tab 80 mg62 morphine sulfate inj pf 0.5 mg/ml9 nafcillin sodium for inj 1 gm111 morphine sulfate inj pf 1 mg/ml9 nafcillin sodium for inj 10 gm111 morphine sulfate oral soln 10 mg/5ml9 nafcillin sodium for iv soln 2 gm111 morphine sulfate oral soln 20 mg/5ml9 nafrinse chw 1mg f101 morphine sulfate suppos 10 mg9 NAFTIN CRE 1%77 morphine sulfate suppos 20 mg9 NAFTIN CRE 2%77 morphine sulfate suppos 5 mg9 NAFTIN GEL 1%77 morphine sulfate tab 15 mg9 NAGLAZYME INJ 1MG/ML86 morphine sulfate tab 30 mg9 nalbuphine hcl inj 10 mg/ml12 morphine sulfate tab cr 100 mg9 nalbuphine hcl inj 20 mg/ml12 morphine sulfate tab cr 15 mg9 NALFON CAP 200MG5 morphine sulfate tab cr 200 mg9 NALFON CAP 400MG5 morphine sulfate tab cr 30 mg9 NALLPEN/DEX INJ 1GM/50ML111 morphine sulfate tab sr 12hr 60 mg9 naloxone hcl inj 0.4 mg/ml35 MOTOFEN TAB35 naloxone hcl inj 1 mg/ml35 MOVIPREP SOL97 naltrexone hcl tab 50 mg35 MOXATAG TAB 775MG110 NAMENDA SOL 10MG/5ML112 MOXEZA SOL 0.5%107 NAMENDA TAB 10MG112 MOZOBIL INJ96 NAMENDA TAB 5-10MG112 MULTAQ TAB 400MG18 NAMENDA TAB 5MG112 multi-vit/fe dro /fl 0.25103 naphazoline sol 0.1% op107 multi-vit/fl chw 0.25mg102 naproxen dr tab 375mg5 multi-vit/fl chw 0.5mg102 naproxen dr tab 500mg5 multi-vit/fl chw 1mg102 naproxen sodium tab 275 mg5 multi-vit/fl dro /fe 0.25103 naproxen sodium tab 550 mg5 multi-vit/fl dro 0.25mg102 naproxen susp 125 mg/5ml5 multi-vit/fl dro 0.5mg/ml102 naproxen tab 250 mg5 multivit/fl chw 0.25mg103 naproxen tab 375 mg5 multivit/fl chw 0.5mg103 naproxen tab 500 mg5 multivit/fl chw 1mg103 naratriptan hcl tab 1 mg (base equiv)100 mupirocin oint 2%76 naratriptan hcl tab 2.5 mg (base MYCAMINE INJ 100MG37 equiv)100 MYCAMINE INJ 50MG36 NASONEX SPR 50MCG/AC105 MYCOBUTIN CAP 150MG45 NATACYN SUS 5% OP107 mycophenolate mofetil cap 250 mg60 NATAZIA TAB69 mycophenolate mofetil tab 500 mg60 nateglinide tab 120 mg33 MYFORTIC TAB 180MG60 nateglinide tab 60 mg33 MYFORTIC TAB 360MG60 NAVANE CAP 20MG56 MYKIDZ IRON SUS 15/1.5ML96 NEBUPENT INH 300MG14 MYLERAN TAB 2MG46 necon tab 0.5/3569 myorisan cap 10mg75 necon tab 1/3569 myorisan cap 20mg75 necon tab 1/50-2869 myorisan cap 40mg75 NECON TAB 10/11-2869 MYOZYME INJ 50MG86 necon tab 7/7/769 MYRBETRIQ TAB 25MG120 nefazodone hcl tab 100 mg26 MYRBETRIQ TAB 50MG120 nefazodone hcl tab 200 mg26 MYTELASE TAB 10MG44 nefazodone hcl tab 250 mg26 myzilra tab69 NEO-FRADIN SOL 125/5ML3 neo-polycin oin hc 1%op108 N neomycin sulfate tab 500 mg3 nabumetone tab 500 mg5 neomycin-polymyxin b-gramicidin ophth nabumetone tab 750 mg5 soln107 nadolol & bendroflumethiazide tab 40-5 neomycin-polymyxin-dexamethasone mg43 ophth oint 0.1%108 nadolol & bendroflumethiazide tab 80-5 neomycin-polymyxin-dexamethasone mg43 ophth susp 0.1%108 149 neomycin-polymyxin-hc ophth susp108 nimodipine cap 30 mg64 neomycin-polymyxin-hc otic soln 1%109 nisoldipine tab sr 24hr 17 mg64 neomycin-polymyxin-hc otic susp 3.5 nisoldipine tab sr 24hr 20 mg64 mg/ml-10000 unit/ml-1%109 nisoldipine tab sr 24hr 25.5 mg64 NEULASTA INJ 6MG/0.6M96 nisoldipine tab sr 24hr 30 mg64 NEUPOGEN INJ 300/0.596 nisoldipine tab sr 24hr 34 mg64 NEUPOGEN INJ 300MCG96 nisoldipine tab sr 24hr 40 mg64 NEUPOGEN INJ 480/0.896 nisoldipine tab sr 24hr 8.5 mg64 NEUPOGEN INJ 480MCG96 NITRO-BID OIN 2%16 NEVANAC SUS 0.1%109 NITRO-DUR DIS 0.3MG/HR16 nevirapine susp 50 mg/5ml57 NITRO-DUR DIS 0.8MG/HR16 nevirapine tab 200 mg57 nitrofurantoin macrocrystalline cap 100 NEXAVAR TAB 200MG49 mg119 NEXIUM CAP 20MG119 nitrofurantoin macrocrystalline cap 50 NEXIUM CAP 40MG119 mg119 NEXIUM GRA 10MG DR119 nitrofurantoin monohydrate NEXIUM GRA 2.5MG DR119 macrocrystalline cap 100 mg119 NEXIUM GRA 20MG DR119 nitrofurantoin susp 25 mg/5ml120 NEXIUM GRA 40MG DR119 NITROGLYCER INJ 5MG/ML16 NEXIUM GRA 5MG DR119 nitroglycerin iv soln 100 mcg/ml in d5w16 NEXIUM I.V. INJ 20MG119 nitroglycerin iv soln 200 mcg/ml in d5w16 NEXIUM I.V. INJ 40MG119 nitroglycerin iv soln 400 mcg/ml in d5w16 NEXPLANON IMP 68MG71 nitroglycerin td patch 24hr 0.1 mg/hr16 next choice tab 0.75mg70 nitroglycerin td patch 24hr 0.2 mg/hr16 next choice tab 1.5mg70 nitroglycerin td patch 24hr 0.4 mg/hr16 NEXTERONE INJ18 nitroglycerin td patch 24hr 0.6 mg/hr16 NIASPAN TAB 1000 ER40 nitroglycerin tl soln 0.4 mg/spray (400 NIASPAN TAB 500MG ER40 mcg/spray)16 NIASPAN TAB 750MG ER40 NITROMIST AER 400MCG16 nicardipine hcl cap 20 mg64 NITROSTAT SUB 0.3MG16 nicardipine hcl cap 30 mg64 NITROSTAT SUB 0.4MG16 nicardipine hcl iv soln 2.5 mg/ml64 NITROSTAT SUB 0.6MG16 NICODERM CQ DIS 14MG/24H113 nizatidine cap 150 mg118 NICODERM CQ DIS 21MG/24H114 nizatidine cap 300 mg118 NICODERM CQ DIS 7MG/24HR113 nizatidine oral soln 15 mg/ml118 NICORETTE GUM 2MG ORIG114 nora-be tab 0.35mg71 NICORETTE GUM 4MG ORIG114 NORDITROPIN INJ 10/1.5ML85 NICORETTE LOZ 2MG ORIG114 NORDITROPIN INJ 15/1.5ML85 NICORETTE LOZ 4MG ORIG114 NORDITROPIN INJ 30/3ML85 nicotine polacrilex gum 2 mg114 NORDITROPIN INJ 5/1.5ML85 nicotine polacrilex gum 4 mg114 norethindrone acetate tab 5 mg112 nicotine polacrilex lozenge 2 mg114 norethindrone tab 0.35 mg71 nicotine polacrilex lozenge 4 mg114 norgestimate & ethinyl estradiol tab 0.25 nicotine td patch 24hr 14 mg/24hr114 mg-35 mcg69 nicotine td patch 24hr 21 mg/24hr114 norgestimate-eth estrad tab 0.18- nicotine td patch 24hr 7 mg/24hr114 35/0.215-35/0.25-35 mg-mcg69 norgestrel & ethinyl estradiol tab 0.3 mg- NICOTROL INH114 30 mcg69 NICOTROL NS SPR 10MG/ML114 NORITATE CRE 1%81 nifediac cc tab 30mg er64 NORMOSOL -R INJ100 nifediac cc tab 60mg er64 NOROXIN TAB 400MG92 nifediac cc tab 90mg er64 NORPACE CAP 100MG CR18 nifedical xl tab 30mg64 NORPACE CAP 150MG CR18 nifedical xl tab 60mg64 nortrel tab 0.5/3570 nifedipine tab sr 24hr 30 mg64 nortrel tab 1/3570 nifedipine tab sr 24hr 60 mg64 nortrel tab 7/7/770 nifedipine tab sr 24hr 90 mg64 nortriptyline hcl cap 10 mg30 nifedipine tab sr 24hr osmotic 30 mg64 nortriptyline hcl cap 25 mg31 nifedipine tab sr 24hr osmotic 60 mg64 nortriptyline hcl cap 50 mg31 nifedipine tab sr 24hr osmotic 90 mg64 nortriptyline hcl cap 75 mg31 NILANDRON TAB 150MG48 150 nortriptyline hcl soln 10 mg/5ml31 ofloxacin otic soln 0.3%109 NORVIR CAP 100MG57 ofloxacin tab 200 mg92 NORVIR SOL 80MG/ML57 ofloxacin tab 300 mg92 NORVIR TAB 100MG57 ofloxacin tab 400 mg92 novarel inj 10000unt84 ogestrel tab70 NOVOLIN INJ 70/3033 olanzapine for im inj 10 mg55 NOVOLIN N INJ U-10033 olanzapine orally disintegrating tab 10 NOVOLIN R INJ U-10033 mg55 NOVOLOG INJ 100/ML33 olanzapine orally disintegrating tab 15 NOVOLOG INJ PENFILL33 mg55 NOVOLOG MIX INJ 70/3033 olanzapine orally disintegrating tab 20 NOVOLOG MIX INJ FLEXPEN33 mg55 NOXAFIL SUS 40MG/ML37 olanzapine orally disintegrating tab 5 NUCYNTA ER TAB 100MG9 mg55 NUCYNTA ER TAB 150MG9 olanzapine tab 10 mg55 NUCYNTA ER TAB 200MG9 olanzapine tab 15 mg55 NUCYNTA ER TAB 250MG9 olanzapine tab 2.5 mg55 NUCYNTA ER TAB 50MG9 olanzapine tab 20 mg55 NUCYNTA TAB 100MG9 olanzapine tab 5 mg55 NUCYNTA TAB 50MG9 olanzapine tab 7.5 mg55 NUCYNTA TAB 75MG9 OLEPTRO TAB 24HR15026 NUEDEXTA CAP 20-10MG113 OLEPTRO TAB 24HR30026 nulev tab 0.125mg118 omeprazole cap delayed release 10 mg119 NULOJIX INJ 250MG60 omeprazole cap delayed release 20 mg119 NUTROPIN AQ INJ 10MG/2ML85 omeprazole cap delayed release 40 mg119 NUTROPIN AQ INJ 20MG/2ML85 omeprazole-sodium bicarbonate cap 40- NUTROPIN AQ INJ NUSPIN 585 1100 mg119 NUTROPIN INJ 10MG85 OMNARIS SPR105 NUVARING MIS70 OMNIFLEX DPR99 NUVIGIL TAB 150MG3 OMNITROPE INJ 10/1.5ML85 NUVIGIL TAB 250MG3 OMNITROPE INJ 5.8MG85 NUVIGIL TAB 50MG3 OMNITROPE INJ 5/1.5ML85 nyamyc pow 10000077 OMONTYS INJ 10MG/ML96 nystatin cream 100000 unit/gm77 ONCASPAR INJ 750/ML50 ondansetron hcl nystatin oint 100000 unit/gm77 and dextrose inj 32 mg/50ml36 nystatin oral powder37 ondansetron hcl inj 4 mg/2ml (2 mg/ml)36 nystatin susp 100000 unit/ml102 ondansetron hcl oral soln 4 mg/5ml36 nystatin tab 500000 unit37 ondansetron hcl tab 24 mg36 nystatin topical powder77 nystatin-triamcinolone cream 100000-0.1 ondansetron hcl tab 4 mg36 unit/gm-%77 ondansetron hcl tab 8 mg36 nystatin-triamcinolone oint 100000-0.1 ondansetron orally disintegrating tab 4 unit/gm-%77 mg36 ondansetron orally disintegrating tab 8 nystop pow 10000077 mg36 ONETOUCH KIT ULTRA 299 O ONETOUCH US MIS LANCETS99 ocella tab 3-0.03mg70 ONFI TAB 10MG23 OCTAGAM INJ 1GM110 ONFI TAB 20MG23 octreotide acetate inj 100 mcg/ml (0.1 ONFI TAB 5MG23 mg/ml)86 ONGLYZA TAB 2.5MG32 octreotide acetate inj 1000 mcg/ml (1 ONGLYZA TAB 5MG32 mg/ml)86 ONSOLIS MIS 1200MCG9 octreotide acetate inj 200 mcg/ml (0.2 ONSOLIS MIS 200MCG9 mg/ml)86 octreotide acetate inj 50 mcg/ml (0.05 ONSOLIS MIS 400MCG9 mg/ml)86 ONSOLIS MIS 600MCG9 octreotide acetate inj 500 mcg/ml (0.5 ONSOLIS MIS 800MCG9 mg/ml)86 ONTAK INJ 150/ML50 OCUDOX KIT115 OPANA ER TAB 10MG9 ofloxacin ophth soln 0.3%107 OPANA ER TAB 15MG9 151 OPANA ER TAB 20MG9 oxazepam cap 15 mg18 OPANA ER TAB 30MG9 oxazepam cap 30 mg18 OPANA ER TAB 40MG9 oxcarbazepine susp 300 mg/5ml (60 OPANA ER TAB 5MG9 mg/ml)24 OPANA ER TAB 7.5MG9 oxcarbazepine tab 150 mg24 ORACEA CAP 40MG81 oxcarbazepine tab 300 mg24 oralone pst 0.1%102 oxcarbazepine tab 600 mg24 ORAP TAB 1MG113 OXECTA TAB 5MG9 ORAP TAB 2MG113 OXECTA TAB 7.5MG9 ORAPRED ODT TAB 10MG72 OXISTAT CRE 1%77 ORAPRED ODT TAB 15MG72 OXISTAT LOT 1%77 ORAPRED ODT TAB 30MG72 OXSORALEN-UL CAP 10MG77 ORENCIA INJ 250MG6 oxybutynin chloride syrup 5 mg/5ml120 ORFADIN CAP 10MG86 oxybutynin chloride tab 5 mg120 ORFADIN CAP 2MG86 oxybutynin chloride tab sr 24hr 10 mg120 ORFADIN CAP 5MG86 oxybutynin chloride tab sr 24hr 15 mg120 orphen cpd tab ds105 oxybutynin chloride tab sr 24hr 5 mg120 orphenadrine citrate inj 30 mg/ml104 oxycodone hcl cap 5 mg9 orphenadrine citrate tab sr 12hr 100 oxycodone hcl conc 20 mg/ml10 mg104 oxycodone hcl soln 5 mg/5ml10 orphenadrine w/ aspirin & caffeine tab 25- oxycodone hcl tab 10 mg10 385-30 mg105 oxycodone hcl tab 15 mg10 orsythia tab70 oxycodone hcl tab 20 mg10 ORTHO COIL DPR KIT 10099 oxycodone hcl tab 30 mg10 ORTHO COIL DPR KIT 10599 oxycodone hcl tab 5 mg10 ORTHO COIL DPR KIT 5099 oxycodone w/ acetaminophen cap 5-500 ORTHO EVRA DIS WEEK70 mg11 ORTHO FLAT DPR KIT 5599 oxycodone w/ acetaminophen tab 10-325 ORTHO FLAT DPR KIT 6099 mg11 ORTHO FLAT DPR KIT 6599 oxycodone w/ acetaminophen tab 10-650 ORTHO FLAT DPR KIT 7099 mg11 ORTHO FLAT DPR KIT 7599 oxycodone w/ acetaminophen tab 2.5-325 ORTHO FLAT DPR KIT 8099 mg11 ORTHO FLAT DPR KIT 8599 oxycodone w/ acetaminophen tab 5-325 ORTHO FLAT DPR KIT 9099 mg11 ORTHO FLAT DPR KIT 9599 oxycodone w/ acetaminophen tab 7.5-325 ORTHO FLEX DPR 65MM99 mg11 oxycodone w/ acetaminophen tab 7.5-500 ORTHO FLEX DPR 70MM99 mg11 ORTHO FLEX DPR 75MM99 oxycodone-ibuprofen tab 5-400 mg11 ORTHO FLEX DPR 80MM99 OXYCONTIN TAB 10MG CR10 ORTHO TRI- TAB CYCLN LO70 OXYCONTIN TAB 15MG CR10 ortho-est tab 0.62590 OXYCONTIN TAB 20MG CR10 ortho-est tab 1.2590 OXYCONTIN TAB 30MG CR10 oscimin sr tab 0.375mg118 OXYCONTIN TAB 40MG CR10 oscimin sub 0.125mg118 OXYCONTIN TAB 60MG CR10 oscimin tab 0.125mg118 OXYCONTIN TAB 80MG CR10 oscion clnsr lot 6%75 oxymorphone hcl tab 10 mg10 oscion clnsr lot 9%75 oxymorphone hcl tab 5 mg10 OSMOPREP TAB 1.5GM98 oxymorphone hcl tab sr 12hr 10 mg10 OVCON 50 TAB 2870 oxymorphone hcl tab sr 12hr 15 mg10 oxacillin sodium for inj 1 gm111 oxymorphone hcl tab sr 12hr 20 mg10 oxacillin sodium for inj 10 gm111 oxymorphone hcl tab sr 12hr 30 mg10 oxaliplatin for iv inj 100 mg46 oxymorphone hcl tab sr 12hr 40 mg10 oxaliplatin for iv inj 50 mg46 oxymorphone hcl tab sr 12hr 5 mg10 oxaliplatin iv soln 100 mg/20ml46 oxymorphone hcl tab sr 12hr 7.5 mg10 oxaliplatin iv soln 50 mg/10ml46 OXYTROL DIS 3.9MG/24120 oxandrolone tab 10 mg12 oxandrolone tab 2.5 mg12 oxaprozin tab 600 mg5 P oxazepam cap 10 mg18 PACERONE TAB 100MG18 152 pacerone tab 200mg18 PEG-INTRON KIT 50MCG58 paclitaxel iv conc 100 mg/16.7ml (6 PEG-INTRON KIT 50MCG RP59 mg/ml)51 PEG-INTRON KIT 80MCG59 paclitaxel iv conc 150 mg/25ml (6 PEG-INTRON KIT 80MCG RP59 mg/ml)51 PEGANONE TAB 250MG25 paclitaxel iv conc 30 mg/5ml (6 mg/ml)51 PEGASYS INJ59 paclitaxel iv conc 300 mg/50ml (6 PEGASYS INJ 180MCG/M59 mg/ml)51 PEGASYS INJ PROCLICK59 PACNEX HP PAD 7%75 PEGASYS KIT59 PACNEX LP PAD 4.25%75 PEN G PROC INJ 600000110 pacnex wash liq 7%75 PENICILL GK/ INJ DEX 1MU110 pamidronate disodium for inj 30 mg84 PENICILL GK/ INJ DEX 2MU110 pamidronate disodium for inj 90 mg84 PENICILL GK/ INJ DEX 3MU110 pamidronate disodium iv soln 3 mg/ml84 penicillin g potassium for inj 5000000 pamidronate disodium iv soln 9 mg/ml84 unit110 PAMIDRONATE INJ 6MG/ML84 penicillin g sodium for inj 5000000 unit110 PANCREAZE CAP 10500UNT81 penicillin v potassium for soln 125 PANCREAZE CAP 16800UNT81 mg/5ml110 PANCREAZE CAP 21000UNT82 penicillin v potassium for soln 250 PANCREAZE CAP 4200UNIT81 mg/5ml110 pancrelipase (lip-prot-amyl) dr cap 5000- penicillin v potassium tab 250 mg110 17000-27000 unit82 penicillin v potassium tab 500 mg110 PANRETIN GEL 0.1%77 PENTACEL INJ117 pantoprazole sodium ec tab 20 mg (base PENTAM 300 INJ 300MG14 equiv)119 PENTASA CAP 250MG CR93 pantoprazole sodium ec tab 40 mg (base PENTASA CAP 500MG CR93 equiv)119 pentopak tab 400mg cr94 PARAGARD IUD T380A99 pentostatin for inj 10 mg50 parcaine sol 0.5% op107 pentoxifylline tab cr 400 mg94 paromomycin sulfate cap 250 mg3 PERFOROMIST NEB 20MCG20 paroxetine hcl oral susp 10 mg/5ml (base perindopril erbumine tab 2 mg41 equiv)27 perindopril erbumine tab 4 mg41 paroxetine hcl tab 10 mg27 perindopril erbumine tab 8 mg41 paroxetine hcl tab 20 mg27 periogard sol 0.12%102 paroxetine hcl tab 30 mg27 permethrin cream 5%81 paroxetine hcl tab 40 mg27 perphenazine tab 16 mg56 paroxetine hcl tab sr 24hr 12.5 mg27 perphenazine tab 2 mg56 paroxetine hcl tab sr 24hr 25 mg27 perphenazine tab 4 mg56 paroxetine hcl tab sr 24hr 37.5 mg27 perphenazine tab 8 mg56 PASER GRA 4GM45 PERTZYE CAP82 PATADAY SOL 0.2%109 PEXEVA TAB 10MG28 PATANASE SPR 0.6%105 PEXEVA TAB 20MG28 PATANOL SOL 0.1% OP109 PEXEVA TAB 30MG28 PAXIL SUS 10MG/5ML27 PEXEVA TAB 40MG28 PCE TAB 333MG EC98 phenadoz sup 12.5mg38 PCE TAB 500MG EC98 phenadoz sup 25mg38 pedi-dri pow 10000077 phenazopyridine hcl tab 100 mg94 PEDIADERM HC KIT80 phenazopyridine hcl tab 200 mg94 PEDIADERM TA KIT80 phenelzine sulfate tab 15 mg27 PEDIARIX INJ 0.5ML117 phenobarbital tab 100 mg97 PEDVAX HIB INJ120 phenobarbital tab 15 mg96 peg 3350-kcl-na bicarb-nacl-na sulfate for phenobarbital tab 16.2 mg96 soln 236 gm97 phenobarbital tab 30 mg96 peg 3350-kcl-na bicarb-nacl-na sulfate for phenobarbital tab 32.4 mg96 soln 240 gm97 peg 3350-kcl-sod bicarb-nacl for soln 420 phenobarbital tab 60 mg96 gm97 phenobarbital tab 64.8 mg96 PEG-INTRON KIT 120 RP59 phenobarbital tab 97.2 mg96 PEG-INTRON KIT 120MCG59 phenylephrine hcl ophth soln 10%107 PEG-INTRON KIT 150 RP59 phenylephrine hcl ophth soln 2.5%107 PEG-INTRON KIT 150MCG59 phenytoin chew tab 50 mg25 153 phenytoin sodium extended cap 100 mg25 potassium chloride inj 2 meq/ml101 phenytoin sodium extended cap 200 mg25 potassium chloride inj 20 meq/50 ml102 phenytoin sodium extended cap 300 mg25 potassium chloride inj 30 meq/100 ml102 phenytoin sodium inj 50 mg/ml25 potassium chloride microencapsulated crys phenytoin susp 125 mg/5ml25 cr tab 10 meq102 PHISOHEX LIQ 3%56 potassium chloride microencapsulated crys phluorivit + dro fe103 cr tab 20 meq102 phluorivit dro103 potassium chloride oral liq 10% (20 PHOSLYRA SOL93 meq/15ml)102 PHOSPHOLINE SOL 0.125%OP106 potassium chloride oral liq 20% (40 PHOTOFRIN INJ 75MG50 meq/15ml)102 physiolyte sol61 potassium chloride tab cr 10 meq102 physiosol sol irrigat61 potassium chloride tab cr 8 meq (600 PICATO GEL 0.015%77 mg)102 potassium citrate tab cr 10 meq (1080 PICATO GEL 0.05%77 mg)93 pilocarpine hcl tab 5 mg102 potassium citrate tab cr 5 meq (540 pilocarpine hcl tab 7.5 mg102 mg)93 PILOPINE HS GEL 4% OP106 POTIGA TAB 200MG24 pindolol tab 10 mg62 POTIGA TAB 300MG24 pindolol tab 5 mg62 POTIGA TAB 400MG24 pioglitazone hcl tab 15 mg (base equiv)33 POTIGA TAB 50MG24 pioglitazone hcl tab 30 mg (base equiv)33 pr benzoyl liq 7% wash75 pioglitazone hcl tab 45 mg (base equiv)33 PRADAXA CAP 150MG22 pioglitazone hcl-glimepiride tab 30-2 mg32 PRADAXA CAP 75MG22 pioglitazone hcl-glimepiride tab 30-4 mg32 pramipexole dihydrochloride tab 0.125 pioglitazone hcl-metformin hcl tab 15-500 mg53 mg32 pramipexole dihydrochloride tab 0.25 pioglitazone hcl-metformin hcl tab 15-850 mg53 mg32 pramipexole dihydrochloride tab 0.5 mg53 piperacillin sodium-tazobactam sodium for pramipexole dihydrochloride tab 0.75 inj 2-0.25 gm111 mg53 piperacillin sodium-tazobactam sodium for pramipexole dihydrochloride tab 1 mg53 inj 3-0.375 gm111 piperacillin sodium-tazobactam sodium for pramipexole dihydrochloride tab 1.5 mg53 inj 4-0.5 gm111 pramox gel 1%81 piroxicam cap 10 mg5 PRANDIN TAB 0.5MG33 piroxicam cap 20 mg5 PRANDIN TAB 1MG33 PLASMA-LYTE INJ -148100 PRANDIN TAB 2MG34 PLASMA-LYTE INJ -A100 pravastatin sodium tab 10 mg40 PNEUMOVAX 23 INJ 25/0.5120 pravastatin sodium tab 20 mg40 podofilox soln 0.5%80 pravastatin sodium tab 40 mg40 poly-dex oin 0.1% op108 pravastatin sodium tab 80 mg40 poly-vi-flor chw 0.25mg103 prazosin hcl cap 1 mg42 poly-vi-flor chw 0.5mg103 prazosin hcl cap 2 mg42 poly-vi-flor chw 1mg103 prazosin hcl cap 5 mg42 poly-vit/fe dro /fl 0.25103 PRED MILD SUS 0.12% OP108 poly-vit/fe dro /fl 0.5103 PRED SOD PHO SOL 1% OP108 poly-vit/fl dro 0.25mg103 prednicarbate cream 0.1%80 polycin oin op107 prednicarbate oint 0.1%80 polyethylene glycol 3350 oral packet97 prednisolone acetate ophth susp 1%108 prednisolone sod phosph oral soln 6.7 polygesic cap 5-500mg12 mg/5ml (5 mg/5ml base)72 polymyxin b sulfate for inj 500000 unit15 prednisolone sod phosphate oral soln 15 polymyxin b-trimethoprim ophth soln mg/5ml (base equiv)72 10000 unit/ml-0.1%107 prednisolone sodium phosphate oral soln polyvit/fl dro 0.5mg/ml103 25 mg/5ml (base eq)72 portia-28 tab70 prednisolone syrup 15 mg/5ml (usp potassium chloride cap cr 10 meq101 solution equivalent)72 potassium chloride cap cr 8 meq101 PREDNISONE CON 5MG/ML72 potassium chloride inj 10 meq/100 ml101 prednisone oral soln 5 mg/5ml72 potassium chloride inj 10 meq/50 ml101 prednisone tab 1 mg72 154 prednisone tab 10 mg72 PROGLYCEM SUS 50MG/ML32 prednisone tab 10 mg dose pack72 PROGRAF INJ 5MG/ML60 prednisone tab 2.5 mg72 PROLASTIN INJ 1000MG114 prednisone tab 20 mg72 PROLASTIN INJ 500MG114 prednisone tab 5 mg72 PROLASTIN-C INJ 1000MG114 prednisone tab 5 mg dose pack72 PROLIA SOL 60MG/ML84 prednisone tab 50 mg72 PROMACTA TAB 12.5MG96 pregnyl inj 10000unt84 PROMACTA TAB 25MG96 PREMARIN INJ 25MG90 PROMACTA TAB 50MG96 PREMARIN TAB 0.3MG90 PROMACTA TAB 75MG96 PREMARIN TAB 0.45MG91 prometh vc/ syp codeine73 PREMARIN TAB 0.625MG91 promethazine hcl inj 25 mg/ml38 PREMARIN TAB 0.9MG90 promethazine hcl inj 50 mg/ml38 PREMARIN TAB 1.25MG91 promethazine hcl suppos 12.5 mg38 PREMARIN VAG CRE 0.625MG122 promethazine hcl suppos 25 mg38 PRENTIF MIS 22MM99 promethazine hcl syrup 6.25 mg/5ml38 PRENTIF MIS 25MM99 promethazine hcl tab 12.5 mg38 PRENTIF MIS 28MM99 promethazine hcl tab 25 mg38 PRENTIF MIS 31MM99 promethazine hcl tab 50 mg39 PRENTIF MIS FITTING99 promethazine w/ codeine syrup 6.25-10 prevalite pow 4gm39 mg/5ml73 previfem tab70 promethazine-dm syrup 6.25-15 PREVNAR 13 INJ121 mg/5ml73 PREVNAR INJ121 promethegan sup 12.5mg39 PREZISTA TAB 150MG57 promethegan sup 25mg39 PREZISTA TAB 400MG57 promethegan sup 50mg39 PREZISTA TAB 600MG57 propafenone hcl cap sr 12hr 225 mg18 PREZISTA TAB 75MG57 propafenone hcl cap sr 12hr 325 mg18 PREZISTA TAB 800MG57 propafenone hcl cap sr 12hr 425 mg18 PRIFTIN TAB 150MG45 propafenone hcl tab 150 mg18 PRIMAQUINE TAB 26.3MG44 propafenone hcl tab 225 mg18 primidone tab 250 mg24 propafenone hcl tab 300 mg18 primidone tab 50 mg24 proparacaine hcl ophth soln 0.5%107 PRIMLEV TAB 10-300MG12 propranolol & hydrochlorothiazide tab 40- PRIMLEV TAB 5-300MG12 25 mg43 PRIMLEV TAB 7.5-30012 propranolol & hydrochlorothiazide tab 80- PRIMSOL SOL 50MG/5ML14 25 mg43 PRISTIQ TAB 100MG28 propranolol hcl cap sr 24hr 120 mg62 PRISTIQ TAB 50MG28 propranolol hcl cap sr 24hr 160 mg62 PRIVIGEN INJ 5 GRAMS110 propranolol hcl cap sr 24hr 60 mg62 PROAIR HFA AER20 propranolol hcl cap sr 24hr 80 mg62 probenecid tab 500 mg94 propranolol hcl inj 1 mg/ml62 procainamide hcl inj 100 mg/ml18 propranolol hcl oral soln 20 mg/5ml62 PROCAINAMIDE INJ 500MG/ML18 propranolol hcl oral soln 40 mg/5ml62 prochlorperazine edisylate inj 5 mg/ml56 propranolol hcl tab 10 mg62 prochlorperazine maleate tab 10 mg56 propranolol hcl tab 20 mg62 prochlorperazine maleate tab 5 mg56 propranolol hcl tab 40 mg62 prochlorperazine suppos 25 mg56 propranolol hcl tab 60 mg62 PROCRIT INJ 10000/ML96 propranolol hcl tab 80 mg62 PROCRIT INJ 2000/ML96 propylthiouracil tab 50 mg115 PROCRIT INJ 20000/ML96 PROQUAD INJ122 PROCRIT INJ 3000/ML96 PROTONIX PAK119 PROCRIT INJ 4000/ML96 PROTOPIC OIN 0.03%80 PROCRIT INJ 40000/ML96 PROTOPIC OIN 0.1%80 procto-pak cre 1%13 protriptyline hcl tab 10 mg31 proctocream cre -hc 2.5%13 protriptyline hcl tab 5 mg31 proctosol hc cre 2.5%13 PROVENTIL AER HFA20 proctozone cre -hc 2.5%13 prudoxin cre 5%77 progesterone micronized cap 100 mg112 PULMICORT INH 180MCG20 progesterone micronized cap 200 mg112 PULMICORT INH 90MCG20 155 PULMICORT SUS 1MG/2ML20 RELPAX TAB 20MG100 pyrazinamide tab 500 mg45 RELPAX TAB 40MG100 pyridostigmine bromide tab 60 mg44 REMICADE INJ 100MG93 REMODULIN INJ 10MG/ML65 Q REMODULIN INJ 1MG/ML65 QNASL AER 80MCG105 REMODULIN INJ 2.5MG/ML65 QUADRAMET INJ50 REMODULIN INJ 5MG/ML65 quasense tab70 RENAGEL TAB 400MG93 quetiapine fumarate tab 100 mg55 RENAGEL TAB 800MG93 quetiapine fumarate tab 200 mg55 RENVELA PAK 0.8GM93 quetiapine fumarate tab 25 mg55 RENVELA PAK 2.4GM93 quetiapine fumarate tab 300 mg55 RENVELA TAB 800MG93 quetiapine fumarate tab 400 mg55 RESCRIPTOR TAB 100 MG57 quetiapine fumarate tab 50 mg55 RESCRIPTOR TAB 200MG57 quinapril hcl tab 10 mg41 RESTASIS EMU 0.05%107 quinapril hcl tab 20 mg41 RETIN-A MICR GEL 0.04%PMP75 quinapril hcl tab 40 mg41 RETIN-A MICR GEL 0.1%75 quinapril hcl tab 5 mg41 RETROVIR INJ 10MG/ML57 quinidine gluconate tab cr 324 mg18 REVATIO INJ66 quinidine sulfate tab cr 300 mg18 REVLIMID CAP 10MG60 quinine sulfate cap 324 mg44 REVLIMID CAP 15MG60 QVAR AER 40MCG20 REVLIMID CAP 2.5MG60 QVAR AER 80MCG20 REVLIMID CAP 25MG60 REVLIMID CAP 5MG60 REYATAZ CAP 100MG57 R REYATAZ CAP 150MG58 ramipril cap 1.25 mg41 REYATAZ CAP 200MG58 ramipril cap 10 mg41 REYATAZ CAP 300MG58 ramipril cap 2.5 mg41 RHEUMATREX TAB 2.5MG4 ramipril cap 5 mg41 RHINOCORT SUS AQUA105 RANEXA TAB 1000MG15 RIBAPAK MIS 600/DAY59 RANEXA TAB 500MG15 RIBAPAK PAK 1000/DAY59 ranitidine hcl cap 150 mg118 ribasphere cap 200mg59 ranitidine hcl cap 300 mg118 ribasphere tab 200mg59 ranitidine hcl inj 50 mg/2ml (25 ribasphere tab 400mg59 mg/ml)118 ranitidine hcl syrup 15 mg/ml (75 ribasphere tab 600mg59 mg/5ml)118 RIBATAB PAK 1000/DAY59 ranitidine hcl tab 150 mg118 ribavirin cap 200 mg59 ranitidine hcl tab 300 mg118 ribavirin tab 200 mg59 RAPAFLO CAP 4MG94 rifampin cap 150 mg45 RAPAFLO CAP 8MG94 rifampin cap 300 mg45 RAPAMUNE SOL 1MG/ML60 rifampin for inj 600 mg45 RAPAMUNE TAB 0.5MG60 RIFATER TAB45 RAPAMUNE TAB 1MG60 RILUTEK TAB 50MG105 RAPAMUNE TAB 2MG60 rimantadine hydrochloride tab 100 mg59 REBETOL SOL 40MG/ML59 RIOMET SOL32 REBIF INJ 22/0.5113 RISPERDAL INJ 12.5MG54 REBIF INJ 44/0.5113 RISPERDAL INJ 25MG54 REBIF TITRTN SOL PACK113 RISPERDAL INJ 37.5MG54 RECLAST INJ 5/100ML84 RISPERDAL INJ 50MG54 risperidone orally disintegrating tab 0.25 reclipsen tab70 mg54 RECOMBIVA HB INJ 10MCG/ML122 risperidone orally disintegrating tab 0.5 RECOMBIVA HB INJ 5MCG/0.5122 mg54 RECOMBIVA-HB INJ 40MCG/ML122 risperidone orally disintegrating tab 1 RECTIV OIN 0.4%13 mg54 REGONOL INJ 5MG/ML44 risperidone orally disintegrating tab 2 REGRANEX GEL 0.01%81 mg54 RELENZA MIS DISKHALE59 risperidone orally disintegrating tab 3 RELISTOR INJ 12/0.6ML93 mg54

156 risperidone orally disintegrating tab 4 scalacort lot 2%80 mg54 se bpo cloth mis 3%75 risperidone soln 1 mg/ml54 se bpo cloth mis 6%75 risperidone tab 0.25 mg54 se bpo cloth mis 9%75 risperidone tab 0.5 mg54 se bpo wash liq 7%75 risperidone tab 1 mg54 selegiline hcl cap 5 mg53 risperidone tab 2 mg54 selegiline hcl tab 5 mg53 risperidone tab 3 mg54 selenium sulfide lotion 2.5%78 risperidone tab 4 mg54 SELZENTRY TAB 150MG58 RITALIN LA CAP 10MG3 SELZENTRY TAB 300MG58 RITUXAN INJ 100MG47 SENSIPAR TAB 30MG86 rivastigmine tartrate cap 1.5 mg112 SENSIPAR TAB 60MG86 rivastigmine tartrate cap 3 mg112 SENSIPAR TAB 90MG86 rivastigmine tartrate cap 4.5 mg112 SEREVENT DIS AER 50MCG21 rivastigmine tartrate cap 6 mg112 SEROQUEL XR TAB 150MG55 rizatriptan benzoate orally disintegrating SEROQUEL XR TAB 200MG55 tab 10 mg100 SEROQUEL XR TAB 300MG55 rizatriptan benzoate orally disintegrating SEROQUEL XR TAB 400MG55 tab 5 mg100 SEROQUEL XR TAB 50MG55 rizatriptan benzoate tab 10 mg100 SEROSTIM INJ 4MG85 rizatriptan benzoate tab 5 mg100 SEROSTIM INJ 5MG85 romycin oin op107 SEROSTIM INJ 6MG85 ropinirole hydrochloride tab 0.25 mg53 sertraline hcl oral conc 20 mg/ml28 ropinirole hydrochloride tab 0.5 mg53 sertraline hcl tab 100 mg28 ropinirole hydrochloride tab 1 mg53 sertraline hcl tab 25 mg28 ropinirole hydrochloride tab 2 mg53 sertraline hcl tab 50 mg28 ropinirole hydrochloride tab 3 mg53 SFROWASA ENE 4GM93 ropinirole hydrochloride tab 4 mg53 sildenafil citrate tab 20 mg66 ropinirole hydrochloride tab 5 mg53 SILENOR TAB 3MG97 rosadan cre 0.75%81 SILENOR TAB 6MG97 ROTARIX SUS122 silver sulfadiazine cream 1%78 ROTATEQ SUS122 SIMPONI INJ 50MG4 ROXICET SOL 5-325/512 SIMULECT INJ 10MG60 roxicet tab 5-325mg12 SIMULECT INJ 20MG60 ROXICET TAB 5-500MG12 simvastatin tab 10 mg40 ROZEREM TAB 8MG97 simvastatin tab 20 mg40 simvastatin tab 40 mg40 S simvastatin tab 5 mg40 SABRIL POW 500MG25 simvastatin tab 80 mg40 SABRIL TAB 500MG25 SKELID TAB 200MG84 SAFYRAL TAB70 SKLICE LOT 0.5%81 SAIZEN INJ 5MG85 SKYLA IUD 13.5MG70 SAIZEN INJ 8.8MG85 sm nicotine dis 14mg/24h114 SAMSCA TAB 15MG86 sm nicotine dis 21mg114 SAMSCA TAB 30MG86 sm nicotine dis 7mg/24hr114 SANCUSO DIS 3.1MG36 SOD EDECRIN INJ 50MG83 SANDIMMUNE SOL 100MG/ML60 sodiphluor dro 1.1mg/ml101 SANDOSTATIN KIT LAR 10MG86 sodium chloride inj 0.45%102 SANDOSTATIN KIT LAR 20MG86 sodium chloride inj 0.9%102 SANDOSTATIN KIT LAR 30MG86 sodium chloride inj 2.5 meq/ml SANTYL OIN 250/GM80 (14.6%)102 SAPHRIS SUB 10MG55 sodium chloride inj 3%102 SAPHRIS SUB 5MG55 sodium chloride inj 5%102 SARAFEM TAB 10MG113 sodium chloride irrigation soln 0.9%93 SARAFEM TAB 20MG113 sodium chloride iv soln 0.9%102 SAVELLA MIS TITR PAK112 sodium fluoride chew tab 0.25 mg f (from SAVELLA TAB 100MG113 0.55 mg naf)101 SAVELLA TAB 12.5MG112 sodium fluoride chew tab 0.5 mg f (from SAVELLA TAB 25MG112 1.1 mg naf)101 SAVELLA TAB 50MG113 sodium fluoride chew tab 1 mg f (from 2.2 157 mg naf)101 sronyx tab70 sodium fluoride soln 0.125 mg/drop f ssd cre 1%78 (0.275 mg/drop naf)101 ST JOSEPH CHW 75MG ADU6 sodium fluoride soln 0.5 mg/ml f (from 1.1 stagesic cap 5-500mg12 mg/ml naf)101 stavudine cap 15 mg58 sodium fluoride tab 0.5 mg f (from 1.1 mg stavudine cap 20 mg58 naf)101 stavudine cap 30 mg58 sodium fluoride tab 1 mg f (from 2.2 mg stavudine cap 40 mg58 naf)101 stavudine for oral soln 1 mg/ml58 sodium polystyrene sulfonate oral susp 15 STAVZOR CAP 125MG25 gm/60ml61 STAVZOR CAP 250MG25 sodium polystyrene sulfonate rectal susp STAVZOR CAP 500MG26 30 gm/120ml61 STELARA INJ 45MG/0.577 SOLARAZE GEL 3% W/W77 STELARA INJ 90MG/ML78 solia tab70 STIVARGA TAB 40MG49 SOLU-CORTEF INJ 1000MG72 STRATTERA CAP 100MG2 SOLU-CORTEF INJ 100MG72 STRATTERA CAP 10MG2 SOLU-CORTEF INJ 250MG72 STRATTERA CAP 18MG2 SOLU-CORTEF INJ 500MG72 STRATTERA CAP 25MG2 SOLU-MEDROL INJ 2GM72 STRATTERA CAP 40MG2 SOMATULINE INJ 120/.5ML86 STRATTERA CAP 60MG2 SOMATULINE INJ 60/0.2ML86 STRATTERA CAP 80MG2 SOMATULINE INJ 90/0.3ML86 streptomycin sulfate for inj 1 gm3 SOMAVERT INJ 10MG84 STRIANT MIS 30MG13 SOMAVERT INJ 15MG84 STROMECTOL TAB 3MG13 SOMAVERT INJ 20MG84 SUBOXONE MIS 12-3MG12 SORIATANE CAP 10MG77 SUBOXONE MIS 2-0.5MG12 SORIATANE CAP 17.5MG77 SUBOXONE MIS 4-1MG12 SORIATANE CAP 25MG77 SUBOXONE MIS 8-2MG12 sorine tab 120mg62 SUBSYS SPR 100MCG10 sorine tab 160mg62 SUBSYS SPR 200MCG10 sorine tab 240mg62 SUBSYS SPR 400MCG10 sorine tab 80mg62 SUBSYS SPR 600MCG10 sotalol hcl (afib/afl) tab 120 mg62 SUBSYS SPR 800MCG10 sotalol hcl (afib/afl) tab 160 mg62 SUCRAID SOL 8500/ML82 sotalol hcl (afib/afl) tab 80 mg62 sucralfate tab 1 gm118 SOTALOL HCL INJ 150/10ML62 sudatuss-2 sol73 sotalol hcl tab 120 mg62 sudatuss-sf sol73 sotalol hcl tab 160 mg62 sulfacetamide sodium lotion 10% (acne)75 sotalol hcl tab 240 mg62 sulfacetamide sodium ophth soln 10%107 sotalol hcl tab 80 mg62 sulfacetamide sodium w/ sulfur cleansing sotret cap 10mg75 pad 10-4%75 sotret cap 20mg75 sulfacetamide sodium w/ sulfur cream 10- sotret cap 30mg75 5%76 spinosad susp 0.9%81 sulfacetamide sodium w/ sulfur lotion 10- SPIRIVA CAP HANDIHLR19 5%76 spironolactone & hydrochlorothiazide tab sulfacetamide sodium-prednisolone ophth 25-25 mg82 soln 10-0.23(0.25)%108 spironolactone tab 100 mg83 SULFADIAZINE TAB 500MG114 spironolactone tab 25 mg83 sulfamethoxazole-trimethoprim iv soln spironolactone tab 50 mg83 400-80 mg/5ml14 SPORANOX SOL 10MG/ML37 sulfamethoxazole-trimethoprim susp 200- sprintec 28 tab 28 day70 40 mg/5ml14 SPRIX SPR 15.75MG5 sulfamethoxazole-trimethoprim tab 400- SPRYCEL TAB 100MG49 80 mg14 SPRYCEL TAB 140MG49 sulfamethoxazole-trimethoprim tab 800- SPRYCEL TAB 20MG49 160 mg14 SPRYCEL TAB 50MG49 SULFAMYLON CRE 85MG/GM78 SPRYCEL TAB 70MG49 SULFAMYLON PAK 5%78 SPRYCEL TAB 80MG49 sulfasalazine tab 500 mg93

158 sulfasalazine tab delayed release 500 TARGRETIN GEL 1%77 mg93 TASIGNA CAP 150MG49 sulfazine tab 500mg93 TASIGNA CAP 200MG49 sulindac tab 150 mg6 TASMAR TAB 100MG52 sulindac tab 200 mg6 TAXOTERE INJ 20/0.5ML51 sumatriptan nasal spray 20 mg/act100 TAXOTERE INJ 80MG/2ML51 sumatriptan nasal spray 5 mg/act100 tazicef inj 1gm68 sumatriptan succinate inj 4 mg/0.5ml100 tazicef inj 2gm68 sumatriptan succinate inj 6 mg/0.5ml100 tazicef inj 6gm68 sumatriptan succinate tab 100 mg100 TAZORAC CRE 0.05%78 sumatriptan succinate tab 25 mg100 TAZORAC CRE 0.1%78 sumatriptan succinate tab 50 mg100 TAZORAC GEL 0.05%78 suphera cre 10-5%76 TAZORAC GEL 0.1%78 SUPRAX CHW 100MG67 taztia xt cap 120mg/2464 SUPRAX CHW 200MG67 taztia xt cap 180mg/2464 SUPRAX SUS 100/5ML68 taztia xt cap 240mg/2465 SUPRAX SUS 200/5ML68 taztia xt cap 300mg/2465 SUPRAX TAB 400MG68 taztia xt cap 360mg/2465 SUPREP BOWEL SOL PREP97 TEFLARO INJ 400MG68 SUSTIVA CAP 200MG58 TEFLARO INJ 600MG68 SUSTIVA CAP 50MG58 TEGRETOL XR TAB 100MG24 SUSTIVA TAB 600MG58 TEKTURNA TAB 150MG44 SUTENT CAP 12.5MG49 TEKTURNA TAB 300MG44 SUTENT CAP 25MG49 temazepam cap 15 mg97 SUTENT CAP 50MG49 temazepam cap 22.5 mg97 syeda tab 3-0.03mg70 temazepam cap 30 mg97 symax fastab tab 0.125mg118 temazepam cap 7.5 mg97 symax-sl sub 0.125mg118 TEMODAR CAP 100MG46 SYMBICORT AER 160-4.521 TEMODAR CAP 140MG46 SYMBICORT AER 80-4.521 TEMODAR CAP 180MG46 SYMLIN INJ 600MCG31 TEMODAR CAP 20MG46 SYMLINPEN 60 INJ 1000MCG31 TEMODAR CAP 250MG46 SYMLNPEN 120 INJ 1000MCG31 TEMODAR CAP 5MG46 SYNAREL SOL 2MG/ML85 TEMODAR INJ 100MG46 SYNERA DIS 70-70MG81 TENIVAC INJ 5-2LF117 SYNRIBO INJ 3.5MG50 terazosin hcl cap 1 mg42 SYPRINE CAP 250MG60 terazosin hcl cap 10 mg42 terazosin hcl cap 2 mg42 T terazosin hcl cap 5 mg42 TABLOID TAB 40MG47 terbinafine hcl tab 250 mg37 TACLONEX OIN80 terbutaline sulfate inj 1 mg/ml21 TACLONEX SUS80 terbutaline sulfate tab 2.5 mg21 tacrolimus cap 0.5 mg60 terbutaline sulfate tab 5 mg21 tacrolimus cap 1 mg61 terconazole vaginal cream 0.4%122 tacrolimus cap 5 mg61 terconazole vaginal cream 0.8%122 TALWIN INJ 30MG/ML12 terconazole vaginal suppos 80 mg122 TAMIFLU CAP 30MG59 TESTIM GEL 1%(50MG)13 TAMIFLU CAP 45MG59 testosterone cypionate im in oil 100 TAMIFLU CAP 75MG59 mg/ml13 TAMIFLU SUS 12MG/ML59 testosterone cypionate im in oil 200 TAMIFLU SUS 6MG/ML59 mg/ml13 tamoxifen citrate tab 10 mg (base testosterone enanthate im in oil 200 equivalent)48 mg/ml13 tamoxifen citrate tab 20 mg (base TET/DIP TOX INJ 2-2 LF117 equivalent)48 TETANUS TOX INJ 5LF ADS117 tamsulosin hcl cap 0.4 mg94 tetracycline hcl cap 250 mg115 TARCEVA TAB 100MG49 tetracycline hcl cap 500 mg115 TARCEVA TAB 150MG49 TEV-TROPIN INJ 5MG85 TARCEVA TAB 25MG49 TEVETEN TAB 400MG42 TARGRETIN CAP 75MG50 TEXACORT SOL 2.5%80 159 THALITONE TAB 15MG83 tis-u-sol sol61 THALOMID CAP 100MG60 tizanidine hcl cap 2 mg104 THALOMID CAP 150MG60 tizanidine hcl cap 4 mg104 THALOMID CAP 200MG60 tizanidine hcl cap 6 mg104 THALOMID CAP 50MG60 tizanidine hcl tab 2 mg104 THEO-24 CAP 100MG CR21 tizanidine hcl tab 4 mg104 THEO-24 CAP 200MG CR21 TOBI NEB 300/5ML3 THEO-24 CAP 300MG CR21 TOBRA/NACL INJ 60/0.94 THEO-24 CAP 400MG ER21 TOBRA/NACL INJ 80/0.94 theochron tab 100mg cr21 TOBRADEX OIN 0.3-0.1%108 theochron tab 200mg cr21 tobramycin sulfate inj 10 mg/ml4 theochron tab 300mg cr21 tobramycin sulfate inj 80 mg/2ml (40 theophylline soln 80 mg/15ml21 mg/ml)4 theophylline tab sr 12hr 100 mg21 tobramycin sulfate ophth soln 0.3%107 theophylline tab sr 12hr 200 mg21 tobramycin-dexamethasone ophth susp theophylline tab sr 12hr 300 mg21 0.3-0.1%108 theophylline tab sr 12hr 450 mg21 TOBREX OIN 0.3% OP107 theophylline tab sr 24hr 400 mg21 tolazamide tab 250 mg35 theophylline tab sr 24hr 600 mg21 tolazamide tab 500 mg35 THERACYS INJ50 tolbutamide tab 500 mg35 thermazene cre 1%78 tolmetin sodium cap 400 mg6 thioridazine hcl tab 10 mg56 tolmetin sodium tab 200 mg6 thioridazine hcl tab 100 mg56 tolmetin sodium tab 600 mg6 thioridazine hcl tab 25 mg56 tolterodine tartrate tab 1 mg120 thioridazine hcl tab 50 mg56 tolterodine tartrate tab 2 mg120 thiotepa for inj 15 mg46 topiragen tab 100mg24 THIOTEPA INJ 15MG46 topiragen tab 200mg24 thiothixene cap 1 mg56 topiragen tab 25mg24 thiothixene cap 10 mg56 topiragen tab 50mg24 thiothixene cap 2 mg56 topiramate sprinkle cap 15 mg24 thiothixene cap 5 mg56 topiramate sprinkle cap 25 mg24 thrive gum 4mg mint114 topiramate tab 100 mg24 THYMOGLOBULN INJ 25MG61 topiramate tab 200 mg24 THYROLAR-1 TAB 60MG116 topiramate tab 25 mg24 THYROLAR-1/2 TAB 30MG116 topiramate tab 50 mg24 THYROLAR-1/4 TAB 15MG116 topisulf cre 10-5%76 THYROLAR-2 TAB 120MG116 toposar inj 100/5ml51 THYROLAR-3 TAB 180MG116 topotecan hcl for inj 4 mg51 tiagabine hcl tab 2 mg25 TOPOTECAN INJ 4MG/4ML51 tiagabine hcl tab 4 mg25 TORISEL SOL 25MG/ML49 TICE BCG INJ50 TORSEMIDE INJ 20MG/2ML83 ticlopidine hcl tab 250 mg95 torsemide tab 10 mg83 TIKOSYN CAP 125MCG18 torsemide tab 100 mg83 TIKOSYN CAP 250MCG18 torsemide tab 20 mg83 TIKOSYN CAP 500MCG18 torsemide tab 5 mg83 tilia fe tab70 TOVIAZ TAB 4MG120 TIMENTIN INJ 3.1GM111 TOVIAZ TAB 8MG120 timolol maleate ophth gel forming soln TRACLEER TAB 125MG65 0.25%106 TRACLEER TAB 62.5MG65 timolol maleate ophth gel forming soln TRADJENTA TAB 5MG33 0.5%106 tramadol hcl tab 50 mg10 timolol maleate ophth soln 0.25%106 tramadol hcl tab sr 24hr 100 mg10 timolol maleate ophth soln 0.5%106 tramadol hcl tab sr 24hr 200 mg10 timolol maleate tab 10 mg62 tramadol hcl tab sr 24hr 300 mg10 timolol maleate tab 20 mg62 trandolapril tab 1 mg41 timolol maleate tab 5 mg62 trandolapril tab 2 mg41 TIMOPTIC OCU SOL 0.25% OP106 trandolapril tab 4 mg41 TIMOPTIC OCU SOL 0.5% OP106 tranexamic acid inj 100 mg/ml96 tinidazole tab 250 mg14 tranexamic acid tab 650 mg96 tinidazole tab 500 mg14 TRANSDERM-SC DIS 1.5MG36 160 tranylcypromine sulfate tab 10 mg27 trifluoperazine hcl tab 2 mg56 TRAVATAN Z DRO 0.004%109 trifluoperazine hcl tab 5 mg56 trazodone hcl tab 100 mg26 trifluridine ophth soln 1%107 trazodone hcl tab 150 mg26 TRIGLIDE TAB 50MG39 trazodone hcl tab 300 mg26 trihexyphenidyl hcl elixir 0.4 mg/ml52 trazodone hcl tab 50 mg26 trihexyphenidyl hcl tab 2 mg52 TRECATOR TAB 250MG45 trihexyphenidyl hcl tab 5 mg52 TRELSTAR DEP INJ 3.75MG48 TRIHIBIT KIT P/F117 TRELSTAR LA INJ 11.25MG48 TRILIPIX CAP 135MG39 TRELSTAR MIX INJ 22.5MG48 TRILIPIX CAP 45MG39 TRETIN-X CRE 0.0375%76 trilyte sol97 TRETIN-X CRE KIT 0.025%76 trimethobenzamide hcl cap 300 mg36 TRETIN-X CRE KIT 0.05%76 trimethobenzamide hcl inj 100 mg/ml36 TRETIN-X CRE KIT 0.1%76 trimethoprim tab 100 mg14 TRETIN-X GEL KIT 0.01%76 trimipramine maleate cap 100 mg31 TRETIN-X GEL KIT 0.025%76 trimipramine maleate cap 25 mg31 tretinoin cap 10 mg50 trimipramine maleate cap 50 mg31 tretinoin cream 0.025%76 trinessa tab70 tretinoin cream 0.05%76 TRIPEDIA SUS P/F117 tretinoin cream 0.1%76 TRISENOX SOL 10MG/10M50 tretinoin gel 0.01%76 trivora-28 tab70 tretinoin gel 0.025%76 TRIZIVIR TAB58 TREXALL TAB 10MG47 tropicamide ophth soln 0.5%106 TREXALL TAB 15MG47 tropicamide ophth soln 1%106 TREXALL TAB 5MG47 trospium chloride cap sr 24hr 60 mg120 TREXALL TAB 7.5MG47 trospium chloride tab 20 mg120 tri-linyah tab70 TRUVADA TAB 200-30058 tri-lo- tab sprintec70 tussigon tab 5mg73 tri-previfem tab70 TWINRIX INJ122 tri-sprintec tab70 TYGACIL INJ 50MG15 tri-vit/fe dro /fl 0.25103 TYKERB TAB 250MG49 tri-vit/fl dro 0.25mg103 TYSABRI INJ113 tri-vit/fl dro 0.5mg103 TYVASO START SOL 0.6MG/ML65 tri-vit/fluo dro 0.25mg103 TYZEKA TAB 600MG59 tri-vit/fluo dro 0.5mg103 TYZINE PED DRO 0.05%105 tri-vita/fl dro 0.25mg103 TYZINE SOL 0.1%105 triamcinolone acetonide cream 0.025%80 triamcinolone acetonide cream 0.1%80 U triamcinolone acetonide cream 0.5%80 ULESFIA LOT 5%81 triamcinolone acetonide dental paste ULORIC TAB 40MG94 0.1%102 ULORIC TAB 80MG94 triamcinolone acetonide lotion 0.025%80 ULTRESA CAP 13800UNT82 triamcinolone acetonide lotion 0.1%80 ULTRESA CAP 20700UNT82 triamcinolone acetonide nasal inhal 55 ULTRESA CAP 23000UNT82 mcg/act105 unithroid tab 100mcg116 triamcinolone acetonide oint 0.025%80 unithroid tab 112mcg116 triamcinolone acetonide oint 0.1%80 unithroid tab 125mcg116 triamcinolone acetonide oint 0.5%80 triamterene & hydrochlorothiazide cap unithroid tab 137mcg116 37.5-25 mg82 unithroid tab 150mcg116 triamterene & hydrochlorothiazide cap 50- unithroid tab 175mcg116 25 mg82 unithroid tab 200mcg117 triamterene & hydrochlorothiazide tab unithroid tab 25mcg116 37.5-25 mg82 unithroid tab 300mcg117 triamterene & hydrochlorothiazide tab 75- unithroid tab 50mcg116 50 mg82 unithroid tab 75mcg116 TRIANEX OIN 0.05%80 unithroid tab 88mcg116 triderm cre 0.1%80 univert tab 32mg36 trifluoperazine hcl tab 1 mg56 UROCIT-K 15 TAB93 trifluoperazine hcl tab 10 mg56 ursodiol cap 300 mg92

161 ursodiol tab 250 mg92 VERAMYST SPR 27.5MCG105 ursodiol tab 500 mg92 verapamil hcl cap sr 24hr 100 mg65 UVADEX INJ 20MCG/ML50 verapamil hcl cap sr 24hr 120 mg65 verapamil hcl cap sr 24hr 180 mg65 V verapamil hcl cap sr 24hr 200 mg65 VAGIFEM TAB 10MCG122 verapamil hcl cap sr 24hr 240 mg65 valacyclovir hcl tab 1 gm59 verapamil hcl cap sr 24hr 300 mg65 valacyclovir hcl tab 500 mg59 verapamil hcl cap sr 24hr 360 mg65 VALCYTE SOL 50MG/ML58 verapamil hcl iv soln 2.5 mg/ml65 VALCYTE TAB 450MG58 verapamil hcl tab 120 mg65 valproate sodium inj 100 mg/ml26 verapamil hcl tab 40 mg65 valproate sodium syrup 250 mg/5ml (base verapamil hcl tab 80 mg65 equiv)26 verapamil hcl tab cr 120 mg65 valproic acid cap 250 mg26 verapamil hcl tab cr 180 mg65 valsartan-hydrochlorothiazide tab 160- verapamil hcl tab cr 240 mg65 12.5 mg43 VERDESO AER 0.05%80 valsartan-hydrochlorothiazide tab 160-25 VEREGEN OIN 15%76 mg44 VERIPRED 20 SOL 20MG/5ML72 valsartan-hydrochlorothiazide tab 320- VESICARE TAB 10MG120 12.5 mg44 VESICARE TAB 5MG120 valsartan-hydrochlorothiazide tab 320-25 vestura tab 3-0.02mg70 mg44 VEXOL SUS 1% OP108 valsartan-hydrochlorothiazide tab 80-12.5 VFEND SUS 40MG/ML37 mg43 VIBATIV INJ 250MG14 vancomycin hcl cap 125 mg14 VIBRAMYCIN SUS 25MG/5ML115 vancomycin hcl cap 250 mg14 VIBRAMYCIN SYP 50MG/5ML115 vancomycin hcl for inj 10 gm14 vicodin es tab 7.5-30012 vancomycin hcl for inj 1000 mg14 vicodin hp tab 10-300mg12 vancomycin hcl for inj 500 mg14 vicodin hp tab 10-660mg12 vandazole gel 0.75%122 vicodin tab 5-300mg12 VANDETANIB TAB 100MG49 VICTOZA INJ 18MG/3ML33 VANDETANIB TAB 300MG49 VICTRELIS CAP 200MG59 VANOS CRE 0.1%80 VIDAZA INJ 100MG47 VAQTA INJ 25/0.5ML122 VIDEX SOL 2GM58 VAQTA INJ 50UNT/ML122 VIDEX SOL 4GM58 VARIVAX INJ122 VIGAMOX DRO 0.5%107 velivet pak70 VIIBRYD KIT26 VELTIN GEL76 VIIBRYD TAB 10MG26 venlafaxine hcl cap sr 24hr 150 mg (base VIIBRYD TAB 20MG26 equivalent)28 VIIBRYD TAB 40MG27 venlafaxine hcl cap sr 24hr 37.5 mg (base VIMPAT INJ 200MG/2024 equivalent)28 VIMPAT SOL 10MG/ML25 venlafaxine hcl cap sr 24hr 75 mg (base VIMPAT TAB 100MG25 equivalent)28 VIMPAT TAB 150MG25 venlafaxine hcl tab 100 mg28 VIMPAT TAB 200MG25 venlafaxine hcl tab 25 mg28 VIMPAT TAB 50MG25 venlafaxine hcl tab 37.5 mg28 VINBLASTINE INJ 10MG51 venlafaxine hcl tab 50 mg28 vinblastine sulfate inj 1 mg/ml51 venlafaxine hcl tab 75 mg28 venlafaxine hcl tab sr 24hr 150 mg (base vincasar pfs inj 1mg/ml51 equivalent)28 vincristine sulfate iv soln 1 mg/ml51 venlafaxine hcl tab sr 24hr 225 mg (base vinorelbine tartrate inj 10 mg/ml51 equivalent)28 vinorelbine tartrate inj 50 mg/5ml (10 venlafaxine hcl tab sr 24hr 37.5 mg (base mg/ml)51 equivalent)28 VIOKACE TAB82 venlafaxine hcl tab sr 24hr 75 mg (base viorele tab70 equivalent)28 VIRACEPT TAB 250MG58 VENTAVIS SOL 10MCG/ML65 VIRACEPT TAB 625MG58 VENTAVIS SOL 20MCG/ML65 VIRAMUNE XR TAB 400MG58 VENTOLIN HFA AER21 VIRAZOLE INH 6GM59 VIREAD POW 40MG/GM58 162 VIREAD TAB 150MG58 XELODA TAB 500MG47 VIREAD TAB 200MG58 XENAZINE TAB 12.5MG113 VIREAD TAB 250MG58 XENAZINE TAB 25MG113 VIREAD TAB 300MG58 XEOMIN INJ 50 UNIT106 VISICOL TAB 1.5GM98 XGEVA INJ84 vitazol cre 0.75%81 XIFAXAN TAB 200MG14 VIVELLE-DOT DIS 0.025MG91 XIFAXAN TAB 550MG14 VIVELLE-DOT DIS 0.0375MG91 XOLEGEL GEL 2%77 VIVELLE-DOT DIS 0.05MG91 XOLOX TAB 10-500MG12 VIVELLE-DOT DIS 0.075MG91 XOPENEX HFA AER21 VIVELLE-DOT DIS 0.1MG91 XTANDI CAP 40MG48 VIVITROL INJ 380MG35 XYREM SOL 500MG/ML112 VOLTAREN GEL 1%76 voriconazole tab 200 mg37 Y voriconazole tab 50 mg37 YERVOY INJ 50MG47 VOTRIENT TAB 200MG49 VPRIV INJ 400UNIT95 VUMON INJ 50MG/5ML51 Z VYTORIN TAB 10-10MG39 zafirlukast tab 10 mg19 VYTORIN TAB 10-20MG39 zafirlukast tab 20 mg19 VYTORIN TAB 10-40MG39 zaleplon cap 10 mg97 VYTORIN TAB 10-80MG39 zaleplon cap 5 mg97 VYVANSE CAP 20MG1 ZAMICET SOL 10-325MG12 VYVANSE CAP 30MG1 ZANOSAR INJ 1GM46 VYVANSE CAP 40MG1 ZANTAC INJ 50/50ML118 VYVANSE CAP 50MG1 ZANTAC TAB 25MG EF118 VYVANSE CAP 60MG1 zarah tab 3-0.03mg70 VYVANSE CAP 70MG1 ZAVESCA CAP 100MG95 zazole cre 0.4%122 zazole cre 0.8%122 W zazole sup 80mg122 warfarin sodium tab 1 mg21 ZELAPAR TAB 1.25MG53 warfarin sodium tab 10 mg22 ZELBORAF TAB 240MG49 warfarin sodium tab 2 mg21 ZEMAIRA INJ 1000MG114 warfarin sodium tab 2.5 mg21 ZEMPLAR CAP 1MCG86 warfarin sodium tab 3 mg21 ZEMPLAR CAP 2MCG86 warfarin sodium tab 4 mg21 ZEMPLAR CAP 4MCG86 warfarin sodium tab 5 mg22 ZEMPLAR INJ 2MCG/ML86 warfarin sodium tab 6 mg22 ZEMPLAR INJ 5MCG/ML86 warfarin sodium tab 7.5 mg22 zenchent tab70 wee care sus 15/1.2596 ZENPEP CAP 10000UNT82 WELCHOL PAK 3.75GM39 ZENPEP CAP 15000UNT82 WELCHOL TAB 625MG39 ZENPEP CAP 20000UNT82 wera tab 0.5/3570 ZENPEP CAP 25000UNT82 WIDE-SEAL DPR KIT 6099 ZENPEP CAP 3000UNIT82 WIDE-SEAL DPR KIT 6599 zeosa chw70 WIDE-SEAL DPR KIT 7099 ZETIA TAB 10MG40 WIDE-SEAL DPR KIT 7599 ZIAGEN SOL 20MG/ML58 WIDE-SEAL DPR KIT 8099 ZIANA GEL76 WIDE-SEAL DPR KIT 8599 zidovudine cap 100 mg58 WIDE-SEAL DPR KIT 9099 zidovudine syrup 10 mg/ml58 WIDE-SEAL DPR KIT 9599 zidovudine tab 300 mg58 ZINACEF INJ 750MG67 X ZINACEF/H20 INJ 1.5GM PB67 XALKORI CAP 200MG49 ZIOPTAN DRO 0.0015%109 XALKORI CAP 250MG49 ziprasidone hcl cap 20 mg53 XARELTO TAB 10MG22 ziprasidone hcl cap 40 mg53 XARELTO TAB 15MG22 ziprasidone hcl cap 60 mg53 XARELTO TAB 20MG22 ziprasidone hcl cap 80 mg53 XELODA TAB 150MG47 ZIPSOR CAP 25MG6

163 ZIRGAN GEL 0.15%107 ZMAX SUS 2GM98 ZODRYL DAC SUS 5073 ZODRYL DAC SUS 6073 ZODRYL DAC SUS 8073 ZOLINZA CAP 100MG50 zolpidem tartrate tab 10 mg97 zolpidem tartrate tab 5 mg97 zolpidem tartrate tab cr 12.5 mg97 zolpidem tartrate tab cr 6.25 mg97 ZOMETA INJ 4MG/10084 ZOMETA INJ 4MG/5ML84 ZOMIG SPR 5MG100 ZOMIG TAB 2.5MG100 ZOMIG TAB 5MG100 ZOMIG ZMT TAB 2.5 MG100 ZOMIG ZMT TAB 5MG100 zonisamide cap 100 mg25 zonisamide cap 25 mg25 zonisamide cap 50 mg25 ZORBTIVE INJ 8.8MG85 ZORTRESS TAB 0.25MG61 ZORTRESS TAB 0.5MG61 ZORTRESS TAB 0.75MG61 ZOSTAVAX INJ122 ZOSYN SOL 2-0.25GM111 ZOSYN SOL 3-0.375G111 zovia 1/35e tab70 zovia 1/50e tab70 ZOVIRAX CRE 5%78 ZOVIRAX OIN 5%78 ZUPLENZ MIS 4MG36 ZUPLENZ MIS 8MG36 ZYBAN TAB 150MG SR114 ZYCLARA CRE 3.75%80 ZYFLO CR TAB 600MG19 ZYMAR DRO 0.3%107 ZYMAXID SOL 0.5%107 ZYTIGA TAB 250MG48 ZYVOX SOL 2MG/ML15 ZYVOX SUS 100MG/5M15 ZYVOX TAB 600MG15

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