Tufts Health Together Programa de farmacia y Lista de Medicamentos Preferidos 1 de octubre de 2016

Introducción

Programa de farmacia Tratamos de proporcionar opciones de alta calidad y bajo costo para la terapia con medicamentos. Trabajamos con sus proveedores médicos y farmacéuticos para estar seguros de que cubrimos los medicamentos más útiles e importantes para una variedad de enfermedades y condiciones. Cubrimos ambas, las primeras recetas de medicamentos y recetas adicionales. También cubrimos algunos medicamentos de venta libre (OTC, por sus siglas en inglés) si su proveedor le entrega una receta y la compra en una farmacia.

Nuestro programa de farmacia no cubre todos los medicamentos y recetas. Algunos medicamentos deben cumplir algunas pautas clínicas antes de que los podamos cubrir. Su proveedor debe solicitarnos la autorización previa antes de que cubramos estos medicamentos.

Lista de Medicamentos Preferidos (PDL , por sus siglas en inglés) Listamos todos los medicamentos según su categoría terapéutica y clase de droga, seguido por el nombre genérico o de marca. Use el índice para encontrar un medicamento según su nombre genérico o de marca. Cubrimos medicamentos de marca solamente cuando un medicamento genérico no esté disponible o si brindamos la autorización previa para usar el medicamento de marca.

Con la receta de un médico, los medicamentos cubiertos están a disposición de los miembros menores de 21 años de edad gratis y de los miembros de 21 años o mayores por un pequeño copago. Algunos miembros de 21 años o más no necesitan pagar el copago. Para determinar si no necesita pagar un copago, consulte su Manual del Miembro .

Copagos: La mayoría de los miembros que tienen 21 años de edad o más deben pagar los siguientes copagos de farmacia: • $1 por ciertos medicamentos genéricos cubiertos usados principalmente para la diabetes, la hipertensión arterial y el alto nivel de colesterol. Estos medicamentos se llaman antihiperglicémicos (como metaformina), antihipertensivos (como lisinopril) y antihiperlipidémicos (como simvastatin) • $3.65 por ciertos medicamentos de venta libre (OTC, por sus siglas en inglés) para los cuales tiene una receta del medico • $3.65 por la primera receta y recetas adicionales de ciertos medicamentos genéricos cubiertos y de venta libre

• $3.65 por la primera receta y recetas adicionales de medicamentos cubiertos de marca

La PDL se aplica solamente a medicamentos que recibe en farmacias minoristas y de especialidades. La PDL no se aplica a medicamentos que recibe si está en el hospital. Los medicamentos que usted recibe mientras está en el hospital están cubiertos como parte de su estadía.

Para obtener la información más actualizada sobre la PDL , por favor visite tuftshealthplan.com o llámenos al 888.257.1985 (TTY: 888.391.5535).

Autorización previa Algunos medicamentos siempre requieren autorización previa, lo que quiere decir que su proveedor debe solicitarnos la aprobación antes de que nosotros paguemos por el medicamento. Uno de nuestros clínicos evaluará esta solicitud. Nosotros cubriremos el medicamento de acuerdo a nuestras directrices clínicas si: • Existe una justificación médica por la que necesita un medicamento en particular • Dependiendo del medicamento, otros medicamentos de la PDL no han sido útiles

Si no aprobamos la solicitud de autorización previa, usted o su representante autorizado, si identifica a uno, puede apelar la decisión. Vea su Manual del Miembro para obtener información sobre las quejas y apelaciones.

Programa de terapia escalonada Cubrimos algunos tipos de medicamentos solamente a través de nuestro programa de terapia escalonada. Nuestro programa de terapia escalonada requiere que usted pruebe medicamentos de primer nivel antes de que cubramos otro medicamento de dicho tipo. Si usted y su proveedor piensan que cierto medicamento no es apropiado para tratar su enfermedad, su proveedor puede solicitarnos la autorización previa para usar el otro medicamento. Uno de nuestros clínicos evaluará la solicitud. Nosotros cubriremos el medicamento de acuerdo a nuestras directrices clínicas. Si no aprobamos la solicitud de autorización previa, usted o su representante autorizado, si identifica a uno, puede apelar la decisión. Vea su Manual del Miembro para obtener información sobre las quejas y apelaciones.

Límite a la cantidad Para asegurar que los medicamentos que toma son seguros y que recibe la cantidad apropiada, podríamos limitar cuánto recibe en cada oportunidad. Su proveedor puede pedirnos la autorización previa si usted necesita más de lo que cubrimos. Uno de nuestros clínicos evaluará la solicitud. Nosotros cubriremos el medicamento de acuerdo a nuestras directrices clínicas si existe una razón médica por la que se necesita esta cantidad en particular. Si no aprobamos la solicitud de autorización previa, usted o su representante autorizado, si identifica a uno, puede apelar la decisión. Vea su Manual del Miembro para obtener información sobre las quejas y apelaciones.

Medicamentos genéricos Los medicamentos genéricos tienen los mismos ingredientes activos y funcionan de la misma manera que los medicamentos de marca. Cuando hay medicamentos genéricos disponibles, no cubrimos el medicamento de marca sin autorización previa. Si usted y su proveedor piensan que un medicamento genérico no es apropiado para tratar su enfermedad y que un medicamento de marca es médicamente necesario, su proveedor puede solicitarnos la autorización previa. Uno de nuestros clínicos evaluará la solicitud. Si no aprobamos la solicitud de autorización previa, usted o su representante autorizado, si identifica a uno, puede apelar la decisión. Vea su Manual del Miembro

para obtener información sobre las quejas y apelaciones.

Medicamentos nuevos en el mercado Nosotros evaluamos nuevos medicamentos para determinar su eficacia y seguridad antes de agregarlos a nuestra PDL . Un proveedor que piensa que un medicamento nuevo en el mercado es médicamente necesario para usted antes de que lo hayamos evaluado, puede presentar una solicitud de autorización previa. Uno de nuestros clínicos evaluará esta solicitud. Si aprobamos la solicitud, cubriremos el medicamento de acuerdo a nuestras directrices clínicas. Si no aprobamos la solicitud, usted o su representante autorizado, si identifica a uno, puede apelar la decisión. Vea su Manual del Miembro para obtener información sobre las quejas y apelaciones.

Límites a la cobertura La columna Requisitos/Límites en la PDL indica cuando un medicamento tiene un cierto requisito o límite para la cobertura. Los límites a la cobertura incluyen: • AGE (edad, en inglés) — Se puede aplicar restricción a la edad Este medicamento requiere autorización previa, si el medicamento no está cubierto basado en la edad del miembro. Su proveedor deberá solicitarnos la autorización previa si el medicamento es médicamente necesario. • PA (por sus siglas en inglés) — Autorización previa Este medicamento requiere autorización previa. Su proveedor puede recetar un medicamento diferente de la PDL o enviarnos una solicitud de autorización previa. • QL (por sus siglas en inglés) — Límite a la cantidad Este medicamento se limita a una cantidad específica. Si una mayor cantidad es médicamente necesaria, su proveedor deberá enviar una solicitud de autorización previa. • SP (por sus siglas en inglés) — Medicamento de especialidad Este medicamento está disponible solamente a través de nuestro proveedor de farmacia de especialidades, CVS/specialty. • ST (por sus siglas en inglés) — Terapia escalonada Este medicamento requiere una autorización previa si todavía no ha usado un medicamento de primera línea de la PDL. Su proveedor puede recetar otro medicamento de la PDL o enviarnos una solicitud de autorización previa.

Medicare Parte D Si tiene la cobertura de Medicare, su cobertura de medicamentos recetados de Medicare (Parte D) cubrirá gran parte de sus medicamentos recetados. Debería tener una tarjeta de identificación adicional para su cobertura de medicamentos recetados de Medicare. Por favor, muéstrele a su farmacéutico su tarjeta de identificación de Medicare Parte D cuando compra un medicamento recetado.

Aunque tenga Medicare Parte D, nosotros cubriremos algunos medicamentos, tales como ciertos medicamentos OTC. Los montos del copago y las excepciones se siguen aplicando a estos medicamentos cubiertos. Para más información, por favor llámenos al 888.257.1985 (TTY: 888.391.5535). También puede encontrar más información sobre su cobertura de medicamentos recetados de Medicare llamando a Medicare al 800.633.4227 (TTY: 877.486.2048), visitando el sitio web de Medicare en medicare.gov o consultando su manual Medicare y Usted . Recuerde llevar todas sus tarjetas de identificación con usted cuando visita la farmacia. Cuando compra un medicamento recetado, por favor muestre su tarjeta de identificación como miembro de Tufts Health Together y MassHealth así como sus tarjetas de identificación para medicamentos recetados de Medicare.

Programa de farmacia de especialidades Una farmacia de especialidades necesita entregarle ciertos medicamentos, como medicamentos inyectables y por vía intravenosa (IV, por sus siglas en inglés), que a menudo se usan para tratar enfermedades crónicas como la hepatitis C o la esclerosis múltiple. Estos tipos de medicamentos necesitan apoyo y conocimiento adicional. Las farmacias de especialidades tienen conocimientos en estos campos. Estas farmacias pueden brindar apoyo adicional a miembros y proveedores.

CVS/specialty es nuestra farmacia de especialidades y puede entregarle estos medicamentos. Además de proporcionar medicamentos específicos de especialidad, CVS/specialty: • Entregará los medicamentos a su domicilio, consultorio de su proveedor o cualquier dirección que elija (excepto una casilla de correos) • Responderá sus respuestas y ofrecerá ayuda con sus medicamentos • Le brindará información, materiales y apoyo continuo para ayudarle a atender su enfermedad y a tomar los medicamentos de la manera correcta • Tendrá farmacéuticos que pueden ayudarle las 24 horas al día, siete días a la semana, en el 800.237.2767

Synagis Cada año, desde el 1 de noviembre al 31 de marzo, CVS/specialty proporcionará a los miembros de Tufts Health Together con Synagis, que se usa para prevenir una enfermedad respiratoria seria causada por el virus respiratorio sincitial (RSV, por sus siglas en inglés). Evaluaremos las solicitudes de Synagis según las directrices más recientes de la American Academy of Pediatrics.

Tufts Health Plan cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, color, nacionalidad, edad, discapacidad o sexo . Tufts Health Plan no excluye a las personas ni las trata de forma diferente debido a su raza, color, nacionalidad, edad, discapacidad o sexo . Tufts Health Plan:

Proporciona asistencia y servicios gratuitos a las personas con discapacidades para que se comuniquen de manera eficaz con nosotros, como los siguientes :

— Información escrita en otros formatos (letra grande, audio, formatos electrónicos accesibles, otros formatos)

Proporciona servicios lingüísticos gratuitos a personas cuya lengua materna no es el inglés, como los siguientes : — Intérpretes capacitados

— Información escrita en otros idiomas

Si necesita recibir estos servicios, comuníquese con Servicios para Miembros de Tufts Health Plan a 888.257.1985. Si considera que Tufts Health Plan no le proporcionó estos servicios o lo discriminó de otra manera por motivos de raza, color, nacionalidad, edad, discapacidad o sexo, puede presentar un reclamo a la siguiente persona:

Tufts Health Plan Attention: Civil Rights Coordinator, Legal Dept. 705 Mount Auburn St. Watertown, MA 02472 Phone: 888.880.8699 ext. 48000, [TTY number— 866-930-9252] Fax: 617.972.9048 Email: [email protected]

Puede presentar el reclamo en persona o por correo postal, fax o correo electrónico. Si necesita ayuda para hacerlo, el coordinador de derechos civiles con Tufts Health Plan está a su disposición para brindársela.

También puede presentar un reclamo de derechos civiles ante la Office for Civil Rights (Oficina de Derechos Civiles) del Department of Health and Human Services (Departamento de Salud y Servicios Humanos) de EE. UU. de manera electrónica a través de Office for Civil Rights Complaint Portal, disponible en https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, o bien, por correo postal a la siguiente dirección o por teléfono a los números que figuran a continuación:

U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 Phone: 800.368.1019, 800.537.7697 (TDD)

Puede obtener los formularios de reclamo en el sitio web http://www.hhs.gov/ocr/office/file/index.html. tuftshealthplan.com | 888.257.1985

For no cost translation in English, call the number on your ID card. ل ا ا ا، ال ا اون ا ا . Arabic Chinese 若需免費的中文版本，請撥打ID 卡上的電話號碼。 French Pour demander une traduction gratuite en français, composez le numéro indiqué sur votre carte d’identité. German Um eine kostenlose deutsche Übersetzung zu erhalten, rufen Sie bitte die Telefonnummer auf Ihrer Ausweiskarte an. Greek Για δωρεάν μετάφραση στα Ελληνικά, καλέστε τον αριθμό που αναγράφεται στην αναγνωριστική κάρτας σας. Haitian Creole Pou jwenn tradiksyon gratis nan lang Kreyòl Ayisyen, rele nimewo ki sou kat ID ou. Italian Per la traduzione in italiano senza costi aggiuntivi, è possibile chiamare il numero indicato sulla tessera identificativa. Japanese 日本語の無料翻訳についてはID カードに書いてある番号に電話してください。 Khmer (Cambodian) សប់េសបកែបេយឥតគិតៃថ ែខរ សូមទូរស័ពេន់េលខែដលនេេលប័ណសល់សូមទូរស័ពេន់េលខែដលនេេលប័ណសល់សជិកសជិកសជិករបស់អក។របស់អក។

Korean 한국어로 무료 통역을 원하시면, ID 카드에 있는 번호로 연락하십시오.

Laotian ໍສາລັ ບການແປພາສາເປັ ນພາສາລາວທີ່ ໍ່ບໄດ້ ເສຍຄ່ າໃຊ້ ຈ່ າຍ , ໃຫ້ ໂທຫາເບີ ີ່ທຢູ່ ເທິ ງບັ ດປະຈໍ າຕົ ວຂອງທ່ ານ . Navajo رای ر را ر ره ن درج در رت ن ز زد. Persian Polish Aby uzyskać bezpłatne tłumaczenie w języku polskim, należy zadzwonić na numer znajdujący się na Pana/i dowodzie tożsamości. Portuguese Para tradução grátis para português, ligue para o número no seu cartão de identificação. Russian Для получения услуг бесплатного перевода на русский язык позвоните по номеру, указанному на идентификационной карточке. Spanish Por servicio de traducción gratuito en español, llame al número de su tarjeta de miembro. Tagalog Para sa walang bayad na pagsasalin sa Tagalog, tawagan ang numero na nasa inyong ID card. Vietnamese Để có bản dịch tiếng Việt không phải trả phí, gọi theo số trên thẻ căn cước của bạn.

Table of Contents T a b l e o f C n t s BLOOD DISORDER ...... 3 CHRONIC LUNG OR BREATHING PASSAGE PROBLEM ...... 8 COLD SYMPTOMS ...... 12 CONDITION RESULTING FROM A DEFECTIVE IMMUNE SYSTEM ...... 13 DISEASE AFFECTING THE BODY'S METABOLISM ...... 18 DISEASE OF THE HEART AND BLOOD VESSELS ...... 27 DISEASE OF THE NERVES ...... 37 DISEASE OF THE URINARY TRACT ...... 46 DISORDER OF REPRODUCTIVE SYSTEM ...... 51 DISORDER OF THE CONNECTIVE TISSUE ...... 59 DISORDER OF THE DIGESTIVE SYSTEM ...... 61 DISORDER OF THE ENDOCRINE GLANDS ...... 69 EAR PROBLEM ...... 77 EYE DISORDER ...... 77 FEVER ...... 81 INFECTION ...... 81 INFLAMMATION OF THE SEROUS MEMBRANES IN THE BODY ...... 90 INJURY ...... 90 INJURY TO A MUCOUS MEMBRANE ...... 90 LUNG DISEASE ...... 92 MUSCLE OR BONE DISORDER ...... 97 NEUROPSYCHIATRIC DISORDER ...... 106 OTHER OVER-THE-COUNTER DRUGS ...... 115 OTHER PRESCRIPTION DRUGS ...... 120 OVERDOSE ...... 140 PAIN ...... 140 PATIENT DEMOGRAPHICS ...... 149 POOR NUTRITION ...... 150 PREGNANCY ...... 151 REACTION DUE TO AN ALLERGEN ...... 152 RECENT OPERATION ...... 153 SKIN CONDITION ...... 156 TUMOR ...... 165

1 2 Drug Status Notes BLOOD DISORDER ACTIMMUNE SUBCUTANEOUS* $1 PA; SP SOLUTION ADEMPAS ORAL TABLET $1 PA; SP ADVATE INTRAVENOUS* SOLUTION $1 SP RECONSTITUTED adynovate intravenous* solution reconstituted $1 SP AFSTYLA INTRAVENOUS* KIT $1 SP ALKERAN ORAL TABLET $1 ALPHANATE/VWF COMPLEX/HUMAN INTRAVENOUS* SOLUTION $1 SP RECONSTITUTED ALPHANINE SD INTRAVENOUS* $1 SP SOLUTION RECONSTITUTED ALPROLIX INTRAVENOUS* SOLUTION $1 SP RECONSTITUTED ANADROL-50 ORAL TABLET $1 PA anagrelide hcl oral capsule $1 ARANESP (ALBUMIN FREE) INJECTION $1 SP; QL (4 mL per 30 days) ARANESP (ALBUMIN FREE) INJECTION SOLUTION 10 MCG/0.4ML, 100 MCG/ML, $1 SP; QL (4 mL per 30 days) 200 MCG/ML, 25 MCG/ML, 300 MCG/ML, 40 MCG/ML, 60 MCG/ML ARZERRA INTRAVENOUS* $1 SP CONCENTRATE aspirin-dipyridamole er oral capsule extended $1 PA; QL (60 EA per 30 days) release 12 hour azacitidine injection suspension reconstituted $1 SP BEBULIN INTRAVENOUS* SOLUTION $1 SP RECONSTITUTED BENEFIX INTRAVENOUS* SOLUTION $1 SP RECONSTITUTED

^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 3 Drug Status Notes BOSULIF ORAL TABLET $1 SP BRILINTA ORAL TABLET $1 PA; QL (60 EA per 30 days) CARIMUNE NF INTRAVENOUS* SOLUTION RECONSTITUTED 12 GM, 6 $1 PA; SP GM clopidogrel bisulfate oral tablet $1 COAGADEX INTRAVENOUS* SOLUTION $1 RECONSTITUTED CORIFACT INTRAVENOUS* KIT $1 SP DACOGEN INTRAVENOUS* SOLUTION $1 SP RECONSTITUTED decitabine intravenous* solution reconstituted $1 SP dipyridamole oral tablet $1 DROXIA ORAL CAPSULE $1 EFFIENT ORAL TABLET $1 ELIQUIS ORAL TABLET $1 QL (30 EA per 30 days) ELOCTATE INTRAVENOUS* SOLUTION $1 SP RECONSTITUTED ELSPAR INJECTION SOLUTION $1 SP RECONSTITUTED enoxaparin sodium injection solution $1 enoxaparin sodium subcutaneous* solution $1 EPOGEN INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 20000 UNIT/ML, $1 SP 3000 UNIT/ML, 4000 UNIT/ML EVOMELA INTRAVENOUS* SOLUTION $1 RECONSTITUTED EYLEA INTRAOCULAR SOLUTION $1 SP FARYDAK ORAL CAPSULE $1 PA; SP FEIBA INTRAVENOUS* SOLUTION $1 SP RECONSTITUTED folic acid oral tablet 1 mg $1 fondaparinux sodium subcutaneous* solution $1 FRAGMIN SUBCUTANEOUS* SOLUTION 10000 UNIT/ML, 12500 UNIT/0.5ML, 15000 UNIT/0.6ML, 18000 UNT/0.72ML, 2500 $1 UNIT/0.2ML, 5000 UNIT/0.2ML, 7500 UNIT/0.3ML FUSILEV INTRAVENOUS* SOLUTION $1 SP RECONSTITUTED ^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 4 Drug Status Notes GAMMAGARD S/D LESS IGA INTRAVENOUS* SOLUTION $1 PA; SP RECONSTITUTED GAMUNEX-C INJECTION SOLUTION $1 PA; SP GAZYVA INTRAVENOUS* SOLUTION $1 SP GRANIX SUBCUTANEOUS* $1 SP HELIXATE FS INTRAVENOUS* KIT $1 SP HEMOFIL M INTRAVENOUS* SOLUTION RECONSTITUTED 1000 UNIT, 1700 UNIT, $1 SP 250 UNIT, 500 UNIT heparin sodium (porcine) injection solution $1 10000 unit/ml, 20000 unit/ml, 5000 unit/ml HUMATE-P INTRAVENOUS* SOLUTION RECONSTITUTED 1000-2400 UNIT, 250-600 $1 SP UNIT, 500-1200 UNIT IMBRUVICA ORAL CAPSULE $1 IXINITY INTRAVENOUS* SOLUTION $1 SP RECONSTITUTED JAKAFI ORAL TABLET $1 SP JANTOVEN ORAL TABLET $1 KOATE-DVI INTRAVENOUS* SOLUTION $1 SP RECONSTITUTED KOGENATE FS BIO-SET INTRAVENOUS* $1 SP KIT KOGENATE FS INTRAVENOUS* KIT $1 SP KOVALTRY INTRAVENOUS* SOLUTION $1 SP RECONSTITUTED leucovorin calcium oral tablet $1 LEUKERAN ORAL TABLET $1 LUCENTIS INTRAOCULAR SOLUTION $1 SP LUPRON DEPOT INTRAMUSCULAR* KIT $1 PA; SP 11.25 MG, 3.75 MG MEPHYTON ORAL TABLET $1 MIRCERA INJECTION $1 QL (2 Syringes per 28 days) mitoxantrone hcl intravenous* concentrate $1 PA; SP MONOCLATE-P INTRAVENOUS* KIT 1000 $1 SP UNIT, 1500 UNIT MONONINE INTRAVENOUS* SOLUTION $1 SP RECONSTITUTED 1000 UNIT

^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 5 Drug Status Notes NEULASTA DELIVERY KIT $1 SP SUBCUTANEOUS* NEULASTA DELIVERY KIT $1 SP SUBCUTANEOUS* SOLUTION NEULASTA ONPRO SUBCUTANEOUS* $1 SP NEULASTA SUBCUTANEOUS* $1 SP NEULASTA SUBCUTANEOUS* SOLUTION $1 SP NEUMEGA SUBCUTANEOUS* SOLUTION $1 SP RECONSTITUTED NEUPOGEN INJECTION $1 SP NEUPOGEN INJECTION SOLUTION $1 SP NINLARO ORAL CAPSULE $1 PA; SP NOVOEIGHT INTRAVENOUS* SOLUTION $1 SP RECONSTITUTED NOVOSEVEN RT INTRAVENOUS* $1 SP SOLUTION RECONSTITUTED NPLATE SUBCUTANEOUS* SOLUTION $1 PA; SP RECONSTITUTED NUWIQ INTRAVENOUS* KIT $1 SP NUWIQ INTRAVENOUS* SOLUTION $1 SP RECONSTITUTED obizur intravenous* solution reconstituted $1 SP OCTAGAM INTRAVENOUS* SOLUTION 10 GM/100ML, 2 GM/20ML, 20 GM/200ML, 5 $1 PA; SP GM/50ML ONCASPAR INJECTION SOLUTION $1 SP ONCASPAR INTRAMUSCULAR* $1 SP SOLUTION POMALYST ORAL CAPSULE $1 SP PRADAXA ORAL CAPSULE $1 QL (60 EA per 30 days) PRIVIGEN INTRAVENOUS* SOLUTION $1 PA; SP PROCRIT INJECTION SOLUTION $1 SP PROFILNINE INTRAVENOUS* SOLUTION $1 SP RECONSTITUTED PROFILNINE SD INTRAVENOUS* $1 SP SOLUTION RECONSTITUTED PROMACTA ORAL TABLET $1 PA; SP RECOMBINATE INTRAVENOUS* $1 SP SOLUTION RECONSTITUTED

^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 6 Drug Status Notes REVLIMID ORAL CAPSULE $1 SP RHOPHYLAC INJECTION $1 SP RHOPHYLAC INJECTION SOLUTION $1 SP RIASTAP INTRAVENOUS* SOLUTION $1 SP RECONSTITUTED rixubis intravenous* solution reconstituted $1 SP SOLIRIS INTRAVENOUS* SOLUTION $1 PA; SP SPRYCEL ORAL TABLET $1 SP STIMATE NASAL SOLUTION $1 SP SYNRIBO SUBCUTANEOUS* SOLUTION $1 SP RECONSTITUTED TABLOID ORAL TABLET $1 TASIGNA ORAL CAPSULE $1 SP THALOMID ORAL CAPSULE $1 SP TREANDA INTRAVENOUS* SOLUTION $1 SP RECONSTITUTED tretinoin oral capsule $1 TRETTEN INTRAVENOUS* SOLUTION $1 SP RECONSTITUTED VELCADE INJECTION SOLUTION $1 SP RECONSTITUTED VENCLEXTA ORAL TABLET $1 PA VENCLEXTA STARTING PACK ORAL $1 PA VIDAZA INJECTION SUSPENSION $1 SP RECONSTITUTED warfarin sodium oral tablet $1 WILATE INTRAVENOUS* KIT $1 SP WILATE INTRAVENOUS* SOLUTION RECONSTITUTED 1000-1000 UNIT, 500-500 $1 SP UNIT WINRHO SDF INJECTION SOLUTION $1 SP XARELTO ORAL TABLET $1 QL (30 EA per 30 days) XARELTO STARTER PACK ORAL $1 QL (42 EA per 21 days) XYNTHA INTRAVENOUS* KIT $1 SP XYNTHA SOLOFUSE INTRAVENOUS* KIT $1 SP ZARXIO INJECTION $1 SP zoledronic acid intravenous* concentrate $1 QL (5 vials per 21 days) zoledronic acid intravenous* solution 4 mg/100ml $1 QL (1 vial per 21 days) ^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 7 Drug Status Notes zoledronic acid intravenous* solution $1 QL (1 vial per 21 days) reconstituted ZONTIVITY ORAL TABLET $1 ZYDELIG ORAL TABLET $1 CHRONIC LUNG OR BREATHING PASSAGE PROBLEM ADCIRCA ORAL TABLET $1 PA; SP; QL (60 EA per 30 days) ADEMPAS ORAL TABLET $1 PA; SP ADVAIR DISKUS INHALATION AEROSOL PA; Age Limit (Min 4 Years and POWDER, BREATH ACTIVATED 100-50 $1 Max 11 Years) MCG/DOSE ADVAIR DISKUS INHALATION AEROSOL POWDER, BREATH ACTIVATED 250-50 $1 PA MCG/DOSE, 500-50 MCG/DOSE ADVAIR HFA INHALATION AEROSOL† $1 PA AEROSPAN INHALATION AEROSOL, $1 SOLUTION albuterol sulfate er oral tablet extended release $1 12 hr* albuterol sulfate inhalation nebulization solution $1 albuterol sulfate oral syrup $1 albuterol sulfate oral tablet $1 ALVESCO INHALATION AEROSOL, $1 SOLUTION ANORO ELLIPTA INHALATION AEROSOL POWDER, BREATH $1 PA ACTIVATED ARALAST NP INTRAVENOUS* SOLUTION $1 SP RECONSTITUTED 1000 MG, 500 MG ARCAPTA NEOHALER INHALATION $1 QL (1 EA per 30 days) CAPSULE ASMANEX 120 METERED DOSES INHALATION AEROSOL POWDER, $1 BREATH ACTIVATED ASMANEX 14 METERED DOSES INHALATION AEROSOL POWDER, $1 BREATH ACTIVATED ASMANEX 30 METERED DOSES INHALATION AEROSOL POWDER, $1 BREATH ACTIVATED

^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 8 Drug Status Notes ASMANEX 60 METERED DOSES INHALATION AEROSOL POWDER, $1 BREATH ACTIVATED ASMANEX 7 METERED DOSES INHALATION AEROSOL POWDER, $1 BREATH ACTIVATED ASMANEX HFA INHALATION AEROSOL† $1 atovaquone oral suspension $1 ATROVENT HFA INHALATION $1 AEROSOL, SOLUTION azelastine hcl nasal solution 0.1 % $1 BECONASE AQ NASAL SUSPENSION $1 PA BREO ELLIPTA INHALATION AEROSOL $1 PA; QL (1 EA per 30 days) POWDER, BREATH ACTIVATED budesonide inhalation suspension $1 CAYSTON INHALATION SOLUTION $1 RECONSTITUTED CLARINEX-D 12 HOUR ORAL TABLET $1 PA EXTENDED RELEASE 12 HR* COMBIVENT RESPIMAT INHALATION $1 AEROSOL, SOLUTION cromolyn sodium inhalation nebulization solution $1 DALIRESP ORAL TABLET $1 STPA DULERA INHALATION AEROSOL† $1 ELIXOPHYLLIN ORAL ELIXIR $1 epoprostenol sodium intravenous* solution $1 PA; SP; QL (4 EA per 30 days) reconstituted 0.5 mg epoprostenol sodium intravenous* solution $1 PA; SP; QL (2 EA per 30 days) reconstituted 1.5 mg ESBRIET ORAL CAPSULE $1 PA; SP; QL (270 EA per 30 days) FLOVENT DISKUS INHALATION AEROSOL POWDER, BREATH $1 ACTIVATED FLOVENT HFA INHALATION AEROSOL† $1 fluticasone propionate nasal suspension $1 FORADIL AEROLIZER INHALATION $1 CAPSULE GLASSIA INTRAVENOUS* SOLUTION $1 SP ipratropium bromide inhalation solution $1

^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 9 Drug Status Notes ipratropium-albuterol inhalation solution $1 KALYDECO ORAL PACKET $1 PA; SP; QL (60 EA per 30 days) KALYDECO ORAL TABLET $1 PA; SP; QL (60 EA per 30 days) LETAIRIS ORAL TABLET $1 PA; SP; QL (30 EA per 30 days) levalbuterol hcl inhalation nebulization solution $1 0.31 mg/3ml, 0.63 mg/3ml, 1.25 mg/3ml metaproterenol sulfate oral syrup $1 metaproterenol sulfate oral tablet $1 montelukast sodium oral packet $1 STPA; QL (30 EA per 30 days) montelukast sodium oral tablet $1 QL (30 EA per 30 days) montelukast sodium oral tablet chewable $1 QL (30 EA per 30 days) NEBUPENT INHALATION SOLUTION $1 RECONSTITUTED OFEV ORAL CAPSULE $1 PA; QL (60 EA per 30 days) OMNARIS NASAL SUSPENSION $1 PA OPSUMIT ORAL TABLET $1 PA; SP ORENITRAM ORAL TABLET $1 PA; SP EXTENDEDRELEASE* ORKAMBI ORAL TABLET $1 PA; SP; QL (120 EA per 30 days) PERFOROMIST INHALATION $1 NEBULIZATION SOLUTION PROAIR HFA INHALATION AEROSOL, $1 PA SOLUTION PROAIR RESPICLICK INHALATION AEROSOL POWDER, BREATH $1 PA ACTIVATED PROVENTIL HFA INHALATION $1 PA AEROSOL, SOLUTION PULMICORT FLEXHALER INHALATION AEROSOL POWDER, BREATH $1 ACTIVATED PULMOZYME INHALATION SOLUTION $1 SP QVAR INHALATION AEROSOL, $1 SOLUTION 40 MCG/ACT, 80 MCG/ACT REMODULIN INJECTION SOLUTION $1 PA; SP REVATIO ORAL SUSPENSION $1 PA; SP RECONSTITUTED

^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 10 Drug Status Notes SEREVENT DISKUS INHALATION AEROSOL POWDER, BREATH $1 ACTIVATED sildenafil citrate intravenous* solution $1 PA; SP; QL (90 ML per 30 days) sildenafil citrate oral tablet $1 PA; SP; QL (90 EA per 30 days) SPIRIVA HANDIHALER INHALATION $1 CAPSULE SPIRIVA RESPIMAT INHALATION $1 AEROSOL, SOLUTION STRIVERDI RESPIMAT INHALATION $1 AEROSOL, SOLUTION SYMBICORT INHALATION AEROSOL† $1 THEO-24 ORAL CAPSULE EXTENDED $1 RELEASE 24 HOUR 300 MG, 400 MG THEOCHRON ORAL TABLET EXTENDED $1 RELEASE 12 HR* 100 MG, 200 MG, 300 MG theophylline er oral tablet extended release 12 $1 hr* theophylline er oral tablet extended release 24 $1 hr* theophylline oral solution $1 TOBI PODHALER INHALATION CAPSULE $1 PA; SP; QL (1 EA per 60 days) tobramycin inhalation nebulization solution $1 SP TRACLEER ORAL TABLET $1 PA; SP; QL (60 EA per 30 days) TUDORZA PRESSAIR INHALATION AEROSOL POWDER, BREATH $1 ACTIVATED 400 MCG/ACT TYVASO INHALATION SOLUTION $1 PA; SP TYVASO REFILL INHALATION $1 PA; SP SOLUTION TYVASO STARTER INHALATION $1 PA; SP SOLUTION UPTRAVI ORAL $1 PA; SP UPTRAVI ORAL TABLET $1 PA; SP VELETRI INTRAVENOUS* SOLUTION $1 PA RECONSTITUTED VENTAVIS INHALATION SOLUTION $1 PA; SP; QL (9 Vials per 1 day) VENTOLIN HFA INHALATION AEROSOL, $1 SOLUTION

^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 11 Drug Status Notes XOLAIR SUBCUTANEOUS* SOLUTION $1 PA; SP; QL (6 vials per 28 days) RECONSTITUTED XOPENEX HFA INHALATION AEROSOL† $1 PA zafirlukast oral tablet $1 ZETONNA NASAL AEROSOL, SOLUTION $1 PA COLD SYMPTOMS azelastine hcl nasal solution 0.1 % $1 BECONASE AQ NASAL SUSPENSION $1 PA benzonatate oral capsule 100 mg, 200 mg $1 budesonide nasal suspension $1 PA cetirizine hcl oral solution $1 PA cetirizine hcl oral syrup 1 mg/ml $1 PA CLARINEX ORAL SYRUP $1 PA CLARINEX-D 12 HOUR ORAL TABLET $1 PA EXTENDED RELEASE 12 HR* clemastine fumarate oral tablet 2.68 mg $1 cyproheptadine hcl oral syrup $1 cyproheptadine hcl oral tablet $1 desloratadine oral tablet $1 PA flunisolide nasal solution 25 mcg/act (0.025%) $1 fluticasone propionate nasal suspension $1 GILPHEX TR ORAL TABLET $1 guaifenesin er oral tablet extended release 12 hr* $1 600 mg hydrocod polst-cpm polst er oral $1 hydrocodone-homatropine oral syrup $1 hydrocodone-homatropine oral tablet $1 hydromet oral syrup $1 ipratropium bromide nasal solution $1 levocetirizine dihydrochloride oral solution $1 PA levocetirizine dihydrochloride oral tablet $1 PA mometasone furoate nasal suspension $1 PA montelukast sodium oral packet $1 STPA; QL (30 EA per 30 days) montelukast sodium oral tablet $1 QL (30 EA per 30 days) montelukast sodium oral tablet chewable $1 QL (30 EA per 30 days) OMNARIS NASAL SUSPENSION $1 PA phenyleph-promethazine-cod oral syrup $1 ^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 12 Drug Status Notes promethazine vc plain oral syrup $1 promethazine vc/codeine oral syrup $1 promethazine-codeine oral syrup $1 promethazine-dm oral syrup $1 promethazine-phenylephrine oral syrup $1 pseudoephedrine hcl oral tablet 60 mg $1 QNASL CHILDRENS NASAL AEROSOL, $1 PA SOLUTION QNASL NASAL AEROSOL, SOLUTION $1 PA SEMPREX-D ORAL CAPSULE $1 PA triamcinolone acetonide nasal aerosol† $1 TUSSIGON ORAL TABLET $1 VERAMYST NASAL SUSPENSION $1 PA ZETONNA NASAL AEROSOL, SOLUTION $1 PA CONDITION RESULTING FROM A DEFECTIVE IMMUNE SYSTEM abacavir sulfate oral tablet $1 abacavir-lamivudine-zidovudine oral tablet $1 ACTIMMUNE SUBCUTANEOUS* $1 PA; SP SOLUTION ALPHANATE/VWF COMPLEX/HUMAN INTRAVENOUS* SOLUTION $1 SP RECONSTITUTED APTIVUS ORAL CAPSULE $1 APTIVUS ORAL SOLUTION $1 ARCALYST SUBCUTANEOUS* SOLUTION $1 PA; SP RECONSTITUTED ASTAGRAF XL ORAL CAPSULE $1 PA; QL (30 EA per 30 days) EXTENDED RELEASE 24 HOUR ATRIPLA ORAL TABLET $1 azathioprine oral tablet $1 BERINERT INTRAVENOUS* KIT $1 SP CARIMUNE NF INTRAVENOUS* SOLUTION RECONSTITUTED 12 GM, 6 $1 PA; SP GM cevimeline hcl oral capsule $1 COMPLERA ORAL TABLET $1 cortisone acetate oral tablet $1

^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 13 Drug Status Notes CRIXIVAN ORAL CAPSULE 200 MG, 400 $1 MG cromolyn sodium oral concentrate $1 cyclosporine modified oral capsule $1 cyclosporine modified oral solution $1 cyclosporine oral capsule $1 CYTOGAM INTRAVENOUS* INJECTABLE $1 SP didanosine oral capsule delayed release $1 dronabinol oral capsule $1 EDURANT ORAL TABLET $1 EGRIFTA SUBCUTANEOUS* SOLUTION $1 PA; SP RECONSTITUTED EMTRIVA ORAL CAPSULE $1 EMTRIVA ORAL SOLUTION $1 EPZICOM ORAL TABLET $1 EVOMELA INTRAVENOUS* SOLUTION $1 RECONSTITUTED EVOTAZ ORAL TABLET $1 FIRAZYR SUBCUTANEOUS* SOLUTION $1 PA; SP FLEBOGAMMA DIF INTRAVENOUS* $1 PA; SP SOLUTION FUZEON SUBCUTANEOUS* SOLUTION $1 SP RECONSTITUTED GAMMAGARD INJECTION SOLUTION $1 PA; SP GAMMAGARD S/D LESS IGA INTRAVENOUS* SOLUTION $1 PA; SP RECONSTITUTED GAMUNEX-C INJECTION SOLUTION $1 PA; SP GENGRAF ORAL CAPSULE 100 MG, 25 $1 MG GENGRAF ORAL SOLUTION $1 GENVOYA ORAL TABLET $1 GRANIX SUBCUTANEOUS* $1 SP guanidine hcl oral tablet $1 PA HIZENTRA SUBCUTANEOUS* SOLUTION $1 PA; SP HUMATE-P INTRAVENOUS* SOLUTION RECONSTITUTED 1000-2400 UNIT, 250-600 $1 SP UNIT, 500-1200 UNIT

^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 14 Drug Status Notes hydrocortisone oral tablet $1 HYQVIA SUBCUTANEOUS* KIT $1 PA; SP ILARIS SUBCUTANEOUS* SOLUTION $1 PA; SP RECONSTITUTED INTELENCE ORAL TABLET $1 INVIRASE ORAL CAPSULE $1 INVIRASE ORAL TABLET $1 ISENTRESS ORAL PACKET $1 QL (60 EA per 30 days) ISENTRESS ORAL TABLET $1 ISENTRESS ORAL TABLET CHEWABLE $1 KALETRA ORAL SOLUTION $1 KALETRA ORAL TABLET $1 KENALOG INJECTION SUSPENSION 40 $1 MG/ML KINERET SUBCUTANEOUS* $1 PA; QL (28 Syringes per 28 days) lamivudine oral solution $1 lamivudine oral tablet 150 mg, 300 mg $1 lamivudine-zidovudine oral tablet $1 LEXIVA ORAL SUSPENSION $1 LEXIVA ORAL TABLET $1 MEDROL ORAL TABLET 2 MG $1 megestrol acetate oral suspension 40 mg/ml, 400 $1 mg/10ml, 625 mg/5ml MESTINON ORAL SYRUP $1 methylprednisolone oral $1 methylprednisolone oral tablet $1 methylprednisolone sodium succ injection $1 solution reconstituted 125 mg, 40 mg MILLIPRED DP ORAL $1 MILLIPRED ORAL TABLET $1 mycophenolate mofetil oral capsule $1 mycophenolate mofetil oral suspension $1 reconstituted mycophenolate mofetil oral tablet $1 mycophenolic acid oral tablet delayed release $1 MYLERAN ORAL TABLET $1

^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 15 Drug Status Notes NEBUPENT INHALATION SOLUTION $1 RECONSTITUTED NEULASTA DELIVERY KIT $1 SP SUBCUTANEOUS* NEULASTA DELIVERY KIT $1 SP SUBCUTANEOUS* SOLUTION NEULASTA ONPRO SUBCUTANEOUS* $1 SP NEULASTA SUBCUTANEOUS* $1 SP NEULASTA SUBCUTANEOUS* SOLUTION $1 SP NEUPOGEN INJECTION $1 SP NEUPOGEN INJECTION SOLUTION $1 SP nevirapine er oral tablet extended release 24 hr* $1 nevirapine oral suspension $1 nevirapine oral tablet $1 NORDITROPIN FLEXPRO $1 PA; SP SUBCUTANEOUS* SOLUTION NORVIR ORAL CAPSULE $1 NORVIR ORAL SOLUTION $1 NORVIR ORAL TABLET $1 NOXAFIL ORAL SUSPENSION $1 PA NOXAFIL ORAL TABLET DELAYED $1 PA RELEASE NPLATE SUBCUTANEOUS* SOLUTION $1 PA; SP RECONSTITUTED obizur intravenous* solution reconstituted $1 SP OCTAGAM INTRAVENOUS* SOLUTION $1 PA; SP ODEFSEY ORAL TABLET $1 pilocarpine hcl oral tablet $1 prednisolone oral solution $1 prednisolone oral syrup 15 mg/5ml $1 prednisolone sodium phosphate oral solution 15 $1 mg/5ml, 25 mg/5ml, 6.7 (5 base) mg/5ml prednisolone sodium phosphate oral tablet $1 dispersible PREZCOBIX ORAL TABLET $1 PREZISTA ORAL SUSPENSION $1 PREZISTA ORAL TABLET 150 MG, 600 $1 MG, 75 MG, 800 MG

^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 16 Drug Status Notes PRIVIGEN INTRAVENOUS* SOLUTION $1 PA; SP PROMACTA ORAL TABLET $1 PA; SP pyridostigmine bromide er oral tablet $1 extendedrelease* pyridostigmine bromide oral tablet $1 RAPAMUNE ORAL SOLUTION $1 RESCRIPTOR ORAL TABLET $1 REYATAZ ORAL CAPSULE 150 MG, 200 $1 MG, 300 MG REYATAZ ORAL PACKET $1 RHOPHYLAC INJECTION $1 SP RHOPHYLAC INJECTION SOLUTION $1 SP RUCONEST INTRAVENOUS* SOLUTION $1 SP RECONSTITUTED SANDIMMUNE ORAL SOLUTION $1 SELZENTRY ORAL TABLET $1 SEROSTIM SUBCUTANEOUS* SOLUTION $1 PA; SP RECONSTITUTED 4 MG, 5 MG, 6 MG sirolimus oral tablet $1 SOLU-CORTEF INJECTION SOLUTION $1 RECONSTITUTED 100 MG, 1000 MG stavudine oral capsule $1 stavudine oral solution reconstituted $1 STRIBILD ORAL TABLET $1 SUSTIVA ORAL CAPSULE $1 SUSTIVA ORAL TABLET $1 tacrolimus oral capsule $1 TIVICAY ORAL TABLET $1 TRIUMEQ ORAL TABLET $1 TRUVADA ORAL TABLET 200-300 MG $1 TYBOST ORAL TABLET $1 VALCYTE ORAL SOLUTION $1 RECONSTITUTED valganciclovir hcl oral tablet $1 VIDEX ORAL SOLUTION $1 RECONSTITUTED VIRACEPT ORAL TABLET $1 VIREAD ORAL POWDER $1 ^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 17 Drug Status Notes VIREAD ORAL TABLET $1 VITEKTA ORAL TABLET $1 WILATE INTRAVENOUS* KIT $1 SP WILATE INTRAVENOUS* SOLUTION RECONSTITUTED 1000-1000 UNIT, 500-500 $1 SP UNIT WINRHO SDF INJECTION SOLUTION $1 SP ZARXIO INJECTION $1 SP ZIAGEN ORAL SOLUTION $1 zidovudine oral capsule $1 zidovudine oral syrup $1 zidovudine oral tablet $1 ZORBTIVE SUBCUTANEOUS* SOLUTION $1 PA; SP RECONSTITUTED ZORTRESS ORAL TABLET $1 SP DISEASE AFFECTING THE BODY'S METABOLISM acarbose oral tablet $1 acetazolamide oral tablet $1 ACTOPLUS MET XR ORAL TABLET $1 EXTENDED RELEASE 24 HR* ADVICOR ORAL TABLET EXTENDED $1 RELEASE 24 HR* ALDACTAZIDE ORAL TABLET 50-50 MG $1 ALDURAZYME INTRAVENOUS* $1 SP SOLUTION alendronate sodium oral tablet 40 mg $1 QL (1 EA per 6 Months) allopurinol oral tablet $1 alogliptin benzoate oral tablet $1 PA; QL (30 EA per 30 days) alogliptin-metformin hcl oral tablet $1 PA; QL (60 EA per 30 days) alogliptin-pioglitazone oral tablet $1 PA; QL (30 EA per 30 days) ALTOPREV ORAL TABLET EXTENDED $1 RELEASE 24 HR* amiloride hcl oral tablet $1 amlodipine-atorvastatin oral tablet $1 PA; QL (30 EA per 30 days) ANTARA ORAL CAPSULE 30 MG, 90 MG $1 PA; QL (30 EA per 30 days) APIDRA INJECTION SOLUTION $1 APIDRA SOLOSTAR SUBCUTANEOUS* $1 ^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 18 Drug Status Notes ARALAST NP INTRAVENOUS* SOLUTION $1 SP RECONSTITUTED 1000 MG, 500 MG ARCALYST SUBCUTANEOUS* SOLUTION $1 PA; SP RECONSTITUTED atorvastatin calcium oral tablet $1 AURYXIA ORAL TABLET $1 PA AVANDAMET ORAL TABLET $1 AVANDARYL ORAL TABLET $1 AVANDIA ORAL TABLET $1 BERINERT INTRAVENOUS* KIT $1 SP bumetanide oral tablet $1 BYDUREON SUBCUTANEOUS* $1 BYETTA 10 MCG PEN SUBCUTANEOUS* $1 BYETTA 10 MCG PEN SUBCUTANEOUS* $1 SOLUTION BYETTA 5 MCG PEN SUBCUTANEOUS* $1 BYETTA 5 MCG PEN SUBCUTANEOUS* $1 SOLUTION calcitriol oral capsule $1 calcitriol oral solution $1 calcium acetate (phos binder) oral capsule $1 calcium acetate (phos binder) oral tablet $1 captopril oral tablet $1 CARBAGLU ORAL TABLET $1 PA CAYSTON INHALATION SOLUTION $1 RECONSTITUTED CERDELGA ORAL CAPSULE $1 PA; QL (30 EA per 30 days) CEREZYME INTRAVENOUS* SOLUTION $1 PA; SP RECONSTITUTED 400 UNIT cetirizine hcl oral solution $1 PA cetirizine hcl oral syrup 1 mg/ml $1 PA chlorothiazide oral tablet $1 chlorothiazide sodium intravenous* solution $1 reconstituted chlorpropamide oral tablet $1 chlorthalidone oral tablet 25 mg, 50 mg $1 CHOLBAM ORAL CAPSULE $1 PA cholestyramine light oral packet $1 ^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 19 Drug Status Notes cholestyramine light oral powder $1 cholestyramine oral packet $1 cholestyramine oral powder $1 CINRYZE INTRAVENOUS* SOLUTION $1 PA; SP RECONSTITUTED colchicine oral tablet $1 colchicine-probenecid oral tablet $1 colestipol hcl oral packet $1 colestipol hcl oral tablet $1 constulose oral solution $1 CUPRIMINE ORAL CAPSULE 250 MG $1 CYSTAGON ORAL CAPSULE $1 PA; SP danazol oral capsule $1 DEPEN TITRATABS ORAL TABLET $1 desmopressin ace rhinal tube nasal solution $1 desmopressin ace spray refrig nasal solution $1 desmopressin acetate oral tablet $1 desmopressin acetate spray nasal solution $1 DIABETA ORAL TABLET $1 DIURIL ORAL SUSPENSION $1 dronabinol oral capsule $1 DYRENIUM ORAL CAPSULE $1 EDECRIN ORAL TABLET $1 PA EGRIFTA SUBCUTANEOUS* SOLUTION $1 PA; SP RECONSTITUTED ELAPRASE INTRAVENOUS* SOLUTION $1 SP enulose oral solution $1 ethacrynate sodium intravenous* solution $1 reconstituted etidronate disodium oral tablet $1 EYLEA INTRAOCULAR SOLUTION $1 SP FARXIGA ORAL TABLET $1 PA; QL (30 EA per 30 days) fenofibrate micronized oral capsule 130 mg, 43 $1 PA; QL (30 EA per 30 days) mg fenofibrate micronized oral capsule 134 mg, 200 $1 QL (30 EA per 30 days) mg, 67 mg fenofibrate oral capsule $1 PA; QL (30 EA per 30 days)

^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 20 Drug Status Notes fenofibrate oral tablet 120 mg, 145 mg, 40 mg, 48 $1 PA; QL (30 EA per 30 days) mg fenofibrate oral tablet 160 mg, 54 mg $1 QL (30 EA per 30 days) fenofibric acid oral capsule delayed release $1 PA; QL (30 EA per 30 days) fenofibric acid oral tablet $1 PA; QL (30 EA per 30 days) FIRAZYR SUBCUTANEOUS* SOLUTION $1 PA; SP fluvastatin sodium er oral tablet extended release $1 PA; QL (30 EA per 30 days) 24 hr* fluvastatin sodium oral capsule $1 PA; QL (30 EA per 30 days) FOSRENOL ORAL PACKET $1 FOSRENOL ORAL TABLET CHEWABLE $1 1000 MG, 500 MG, 750 MG furosemide injection solution 10 mg/ml $1 furosemide oral solution 10 mg/ml, 8 mg/ml $1 furosemide oral tablet $1 gemfibrozil oral tablet $1 generlac oral solution $1 GLASSIA INTRAVENOUS* SOLUTION $1 SP glimepiride oral tablet $1 glipizide er oral tablet extended release 24 hr* $1 glipizide oral tablet $1 glipizide xl oral tablet extended release 24 hr* $1 glipizide-metformin hcl oral tablet $1 GLUCAGEN HYPOKIT INJECTION $1 SOLUTION RECONSTITUTED GLUCAGON EMERGENCY INJECTION $1 KIT glyburide micronized oral tablet $1 glyburide oral tablet $1 glyburide-metformin oral tablet $1 GLYSET ORAL TABLET $1 HUMALOG KWIKPEN SUBCUTANEOUS* $1 100 UNIT/ML, 200 UNIT/ML HUMALOG MIX 50/50 KWIKPEN $1 SUBCUTANEOUS* HUMALOG MIX 50/50 SUBCUTANEOUS* $1 SUSPENSION

^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 21 Drug Status Notes HUMALOG MIX 75/25 KWIKPEN $1 SUBCUTANEOUS* HUMALOG MIX 75/25 SUBCUTANEOUS* $1 SUSPENSION HUMALOG SUBCUTANEOUS* $1 HUMALOG SUBCUTANEOUS* SOLUTION $1 HUMULIN 70/30 KWIKPEN $1 SUBCUTANEOUS* HUMULIN 70/30 SUBCUTANEOUS* $1 SUSPENSION HUMULIN N KWIKPEN SUBCUTANEOUS* $1 HUMULIN N SUBCUTANEOUS* $1 SUSPENSION HUMULIN R INJECTION SOLUTION $1 HUMULIN R U-500 (CONCENTRATED) $1 SUBCUTANEOUS* SOLUTION HUMULIN R U-500 KWIKPEN $1 SUBCUTANEOUS* HUMULIN R U-500 KWIKPEN $1 SUBCUTANEOUS* SOLUTION ILARIS SUBCUTANEOUS* SOLUTION $1 PA; SP RECONSTITUTED indapamide oral tablet $1 INVOKAMET ORAL TABLET $1 STPA; QL (60 EA per 30 days) INVOKANA ORAL TABLET 100 MG $1 STPA; QL (30 EA per 30 days) INVOKANA ORAL TABLET 300 MG $1 STPA; QL (60 EA per 30 days) JANUMET ORAL TABLET $1 STPA; QL (60 EA per 30 days) JANUMET XR ORAL TABLET EXTENDED $1 STPA; QL (30 EA per 30 days) RELEASE 24 HR* JANUVIA ORAL TABLET $1 STPA; QL (30 EA per 30 days) JENTADUETO ORAL TABLET $1 STPA; QL (60 EA per 30 days) JUXTAPID ORAL CAPSULE $1 PA; QL (30 EA per 30 days) KALYDECO ORAL PACKET $1 PA; SP; QL (60 EA per 30 days) KALYDECO ORAL TABLET $1 PA; SP; QL (60 EA per 30 days) KAZANO ORAL TABLET $1 PA; QL (60 EA per 30 days) KIONEX ORAL POWDER $1 KIONEX ORAL SUSPENSION $1 KLOR-CON M15 ORAL TABLET $1 EXTENDEDRELEASE* ^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 22 Drug Status Notes KORLYM ORAL TABLET $1 PA KRYSTEXXA INTRAVENOUS* SOLUTION $1 PA; SP KUVAN ORAL TABLET SOLUBLE $1 PA; SP KYNAMRO SUBCUTANEOUS* $1 PA; SP; QL (4 EA per 28 days) KYNAMRO SUBCUTANEOUS* SOLUTION $1 PA; SP; QL (4 EA per 28 days) lactulose encephalopathy oral solution $1 lactulose oral solution $1 LANTUS SOLOSTAR SUBCUTANEOUS* $1 LANTUS SUBCUTANEOUS* SOLUTION $1 LEVEMIR FLEXPEN SUBCUTANEOUS* $1 LEVEMIR FLEXTOUCH $1 SUBCUTANEOUS* LEVEMIR SUBCUTANEOUS* SOLUTION $1 levocetirizine dihydrochloride oral solution $1 PA levocetirizine dihydrochloride oral tablet $1 PA LIVALO ORAL TABLET $1 PA; QL (30 EA per 30 days) lovastatin oral tablet $1 LUCENTIS INTRAOCULAR SOLUTION $1 SP LUMIZYME INTRAVENOUS* SOLUTION $1 SP RECONSTITUTED LYRICA ORAL CAPSULE $1 PA; QL (60 EA per 30 days) LYRICA ORAL SOLUTION $1 PA; QL (900 ML per 30 days) megestrol acetate oral suspension 40 mg/ml, 400 $1 mg/10ml, 625 mg/5ml metformin hcl er (mod) oral tablet extended $1 release 24 hr* 1000 mg metformin hcl er oral tablet extended release 24 $1 hr* metformin hcl oral tablet $1 PA; ¥ (PA applies to members less methamphetamine hcl oral tablet $1 than 3 years old or 25 and older); QL (150 EA per 30 days) methyclothiazide oral tablet $1 metoclopramide hcl oral solution 10 mg/10ml, 5 $1 mg/5ml metoclopramide hcl oral tablet $1 metolazone oral tablet $1 micronized colestipol hcl oral tablet $1 ^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 23 Drug Status Notes MYALEPT SUBCUTANEOUS* SOLUTION $1 PA; QL (30 Vials per 30 days) RECONSTITUTED MYOZYME INTRAVENOUS* SOLUTION $1 SP RECONSTITUTED NAGLAZYME INTRAVENOUS* $1 SP SOLUTION nateglinide oral tablet $1 PA; SP; QL (2 Cartridges per 21 NATPARA SUBCUTANEOUS* $1 days) NESINA ORAL TABLET $1 PA; QL (30 EA per 30 days) niacin er (antihyperlipidemic) oral tablet $1 extendedrelease* niacin er oral capsule extended release* $1 NIACOR ORAL TABLET $1 NORDITROPIN FLEXPRO $1 PA; SP SUBCUTANEOUS* SOLUTION NOVOLIN 70/30 RELION $1 SUBCUTANEOUS* SUSPENSION NOVOLIN 70/30 SUBCUTANEOUS* $1 SUSPENSION NOVOLIN N RELION SUBCUTANEOUS* $1 SUSPENSION NOVOLIN N SUBCUTANEOUS* $1 SUSPENSION NOVOLIN R INJECTION SOLUTION $1 NOVOLIN R RELION INJECTION $1 SOLUTION NOVOLOG FLEXPEN SUBCUTANEOUS* $1 NOVOLOG MIX 70/30 FLEXPEN $1 SUBCUTANEOUS* NOVOLOG MIX 70/30 SUBCUTANEOUS* $1 SUSPENSION NOVOLOG PENFILL SUBCUTANEOUS* $1 NOVOLOG SUBCUTANEOUS* SOLUTION $1 NUCYNTA ER ORAL TABLET EXTENDED $1 PA RELEASE 12 HR* octreotide acetate injection solution 100 mcg/ml, 1000 mcg/ml, 200 mcg/ml, 50 mcg/ml, 500 $1 PA; SP; QL (30 ML per 30 days) mcg/ml ONGLYZA ORAL TABLET $1 PA; QL (30 EA per 30 days) ^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 24 Drug Status Notes ORKAMBI ORAL TABLET $1 PA; SP; QL (120 EA per 30 days) OSENI ORAL TABLET $1 PA; QL (30 EA per 30 days) oxandrolone oral tablet 10 mg $1 PA; QL (60 EA per 30 days) oxandrolone oral tablet 2.5 mg $1 PA; QL (240 EA per 30 days) pamidronate disodium intravenous* solution $1 pamidronate disodium intravenous* solution $1 reconstituted PHOSLYRA ORAL SOLUTION $1 PHOSPHA 250 NEUTRAL ORAL TABLET $1 pioglitazone hcl oral tablet $1 pioglitazone hcl-glimepiride oral tablet $1 pioglitazone hcl-metformin hcl oral tablet $1 pot bicarb-pot chloride oral tablet effervescent $1 potassium bicarbonate oral tablet effervescent $1 potassium chloride crys er oral tablet $1 extendedrelease* potassium chloride er oral capsule extended $1 release* potassium chloride er oral tablet $1 extendedrelease* potassium chloride oral packet $1 potassium chloride oral solution 20 meq/15ml $1 (10%), 40 meq/15ml (20%) PRALUENT SUBCUTANEOUS* 150 $1 PA; SP; QL (2 ML per 28 days) MG/ML, 75 MG/ML pravastatin sodium oral tablet $1 probenecid oral tablet $1 PROGLYCEM ORAL SUSPENSION $1 PA PULMOZYME INHALATION SOLUTION $1 SP RAVICTI ORAL LIQUID† $1 PA; SP REGRANEX EXTERNAL GEL $1 RENAGEL ORAL TABLET $1 RENVELA ORAL TABLET $1 repaglinide oral tablet $1 repaglinide-metformin hcl oral tablet $1 REPATHA PUSHTRONEX SYSTEM PA; SP; # (Preferred product); QL $1 SUBCUTANEOUS* (1 ML per 28 days)

^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 25 Drug Status Notes PA; SP; # (Preferred product); QL REPATHA SUBCUTANEOUS* $1 (2 ML per 28 days) PA; SP; # (Preferred product); QL REPATHA SURECLICK SUBCUTANEOUS* $1 (2 ML per 28 days) RIOMET ORAL SOLUTION $1 risedronate sodium oral tablet 30 mg $1 PA; QL (30 EA per 30 days) rosuvastatin calcium oral tablet $1 PA; QL (30 EA per 30 days) RUCONEST INTRAVENOUS* SOLUTION $1 SP RECONSTITUTED SAMSCA ORAL TABLET 15 MG $1 SP; QL (30 EA per 30 days) SAMSCA ORAL TABLET 30 MG $1 SP; QL (60 EA per 30 days) SANDOSTATIN LAR DEPOT $1 PA; SP; QL (1 vial per 28 days) INTRAMUSCULAR* KIT SEROSTIM SUBCUTANEOUS* SOLUTION $1 PA; SP RECONSTITUTED 4 MG, 5 MG, 6 MG SIMCOR ORAL TABLET EXTENDED $1 RELEASE 24 HR* simvastatin oral tablet $1 sodium polystyrene sulfonate oral powder $1 sodium polystyrene sulfonate oral suspension $1 sodium polystyrene sulfonate suspension $1 SOMATULINE DEPOT SUBCUTANEOUS* $1 PA; SP; QL (1 ML per 28 days) SOLUTION SOMAVERT SUBCUTANEOUS* $1 PA; SP; QL (30 EA per 30 days) SOLUTION RECONSTITUTED spironolactone oral tablet $1 spironolactone-hctz oral tablet $1 SPS ORAL SUSPENSION $1 STRENSIQ SUBCUTANEOUS* SOLUTION $1 PA SYMLINPEN 120 SUBCUTANEOUS* $1 SYMLINPEN 60 SUBCUTANEOUS* $1 SYPRINE ORAL CAPSULE $1 PA TANZEUM SUBCUTANEOUS* $1 TOBI PODHALER INHALATION CAPSULE $1 PA; SP; QL (1 EA per 60 days) tobramycin inhalation nebulization solution $1 SP tolazamide oral tablet $1 tolbutamide oral tablet $1 torsemide oral tablet $1 ^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 26 Drug Status Notes TOUJEO SOLOSTAR SUBCUTANEOUS* $1 TRADJENTA ORAL TABLET $1 STPA; QL (30 EA per 30 days) TRESIBA FLEXTOUCH SUBCUTANEOUS* $1 triamterene-hctz oral capsule $1 triamterene-hctz oral tablet $1 TRIGLIDE ORAL TABLET 160 MG $1 PA; QL (30 EA per 30 days) TRULICITY SUBCUTANEOUS* $1 ULORIC ORAL TABLET $1 PA; QL (30 EA per 30 days) VELTASSA ORAL PACKET $1 VICTOZA SUBCUTANEOUS* $1 VPRIV INTRAVENOUS* SOLUTION $1 PA; SP RECONSTITUTED VYTORIN ORAL TABLET $1 PA; QL (30 EA per 30 days) WELCHOL ORAL TABLET $1 PA XGEVA SUBCUTANEOUS* SOLUTION $1 SP; QL (1 vial per 30 days) XIFAXAN ORAL TABLET 200 MG $1 QL (9 EA per 30 days) XIFAXAN ORAL TABLET 550 MG $1 QL (6 EA per 30 days) XIGDUO XR ORAL TABLET EXTENDED $1 PA RELEASE 24 HR* XOLAIR SUBCUTANEOUS* SOLUTION $1 PA; SP; QL (6 vials per 28 days) RECONSTITUTED ZETIA ORAL TABLET $1 PA; QL (30 EA per 30 days) zoledronic acid intravenous* concentrate $1 QL (5 vials per 21 days) zoledronic acid intravenous* solution 4 mg/100ml $1 QL (1 vial per 21 days) zoledronic acid intravenous* solution $1 QL (1 vial per 21 days) reconstituted ZORBTIVE SUBCUTANEOUS* SOLUTION $1 PA; SP RECONSTITUTED DISEASE OF THE HEART AND BLOOD VESSELS acebutolol hcl oral capsule $1 ADCIRCA ORAL TABLET $1 PA; SP; QL (60 EA per 30 days) ADEMPAS ORAL TABLET $1 PA; SP ADRENALIN INJECTION SOLUTION $1 ADVICOR ORAL TABLET EXTENDED $1 RELEASE 24 HR* AFEDITAB CR ORAL TABLET EXTENDED $1 RELEASE 24 HR* ^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 27 Drug Status Notes ALDACTAZIDE ORAL TABLET 50-50 MG $1 almotriptan malate oral tablet $1 PA; QL (9 EA per 30 days) ALPHANATE/VWF COMPLEX/HUMAN INTRAVENOUS* SOLUTION $1 SP RECONSTITUTED AMICAR ORAL SYRUP $1 AMICAR ORAL TABLET $1 amiloride-hydrochlorothiazide oral tablet $1 amiodarone hcl oral tablet $1 amlodipine besy-benazepril hcl oral capsule $1 QL (30 EA per 30 days) amlodipine besylate oral tablet $1 amlodipine besylate-valsartan oral tablet $1 PA; QL (30 EA per 30 days) amlodipine-atorvastatin oral tablet $1 PA; QL (30 EA per 30 days) amlodipine-valsartan-hctz oral tablet $1 PA; QL (30 EA per 30 days) anucort-hc suppository $1 ANUSOL-HC SUPPOSITORY $1 aspirin-dipyridamole er oral capsule extended $1 PA; QL (60 EA per 30 days) release 12 hour atenolol oral tablet $1 atenolol-chlorthalidone oral tablet $1 AZOR ORAL TABLET $1 PA benazepril hcl oral tablet $1 benazepril-hydrochlorothiazide oral tablet $1 BENICAR HCT ORAL TABLET $1 STPA BENICAR ORAL TABLET $1 STPA betaxolol hcl oral tablet $1 BIDIL ORAL TABLET $1 PA bisoprolol fumarate oral tablet $1 bisoprolol-hydrochlorothiazide oral tablet $1 BOTOX INJECTION SOLUTION $1 PA; SP RECONSTITUTED BRILINTA ORAL TABLET $1 PA; QL (60 EA per 30 days) bumetanide oral tablet $1 BYSTOLIC ORAL TABLET $1 STPA; QL (30 EA per 30 days) CAFERGOT ORAL TABLET $1 candesartan cilexetil oral tablet $1 PA captopril oral tablet $1 ^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 28 Drug Status Notes captopril-hydrochlorothiazide oral tablet $1 CARDENE IV INTRAVENOUS* SOLUTION $1 20-0.86 MG/200ML-%, 20-4.8 MG/200ML-% CARDENE SR ORAL CAPSULE EXTENDED RELEASE 12 HOUR 30 MG, 60 $1 MG CARDIZEM LA ORAL TABLET $1 PA EXTENDED RELEASE 24 HR* 120 MG CARIMUNE NF INTRAVENOUS* SOLUTION RECONSTITUTED 12 GM, 6 $1 PA; SP GM CARTIA XT ORAL CAPSULE EXTENDED $1 RELEASE 24 HOUR carvedilol oral tablet $1 cilostazol oral tablet $1 clonidine hcl oral tablet $1 clonidine hcl transdermal patch weekly $1 clopidogrel bisulfate oral tablet $1 CLORPRES ORAL TABLET $1 COREG CR ORAL CAPSULE EXTENDED $1 STPA; QL (30 EA per 30 days) RELEASE 24 HOUR CORLANOR ORAL TABLET $1 PA DEFITELIO INTRAVENOUS* SOLUTION $1 DEMSER ORAL CAPSULE $1 DIGITEK ORAL TABLET $1 DIGOX ORAL TABLET $1 digoxin oral solution $1 digoxin oral tablet $1 dihydroergotamine mesylate nasal solution $1 DILATRATE-SR ORAL CAPSULE $1 EXTENDED RELEASE* dilt-cd oral capsule extended release 24 hour $1 diltiazem cd oral capsule extended release 24 $1 hour 120 mg, 180 mg, 240 mg diltiazem hcl er beads oral capsule extended $1 release 24 hour diltiazem hcl er coated beads oral capsule $1 extended release 24 hour

^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 29 Drug Status Notes diltiazem hcl er coated beads oral tablet extended $1 release 24 hr* diltiazem hcl er oral capsule extended release 12 $1 hour diltiazem hcl er oral capsule extended release 24 $1 hour 120 mg, 180 mg, 240 mg diltiazem hcl oral tablet $1 dilt-xr oral capsule extended release 24 hour $1 diltzac oral capsule extended release 24 hour $1 disopyramide phosphate oral capsule $1 divalproex sodium er oral tablet extended release $1 24 hr* divalproex sodium oral tablet delayed release $1 doxazosin mesylate oral tablet $1 EDARBI ORAL TABLET $1 PA EDECRIN ORAL TABLET $1 PA EFFIENT ORAL TABLET $1 ELIQUIS ORAL TABLET $1 QL (30 EA per 30 days) enalapril maleate oral tablet $1 enalapril-hydrochlorothiazide oral tablet $1 enoxaparin sodium injection solution $1 enoxaparin sodium subcutaneous* solution $1 ENTRESTO ORAL TABLET $1 PA EPANED ORAL SOLUTION $1 RECONSTITUTED epinephrine hcl injection solution 1 mg/ml $1 eplerenone oral tablet $1 PA; QL (60 EA per 30 days) epoprostenol sodium intravenous* solution $1 PA; SP; QL (4 EA per 30 days) reconstituted 0.5 mg epoprostenol sodium intravenous* solution $1 PA; SP; QL (2 EA per 30 days) reconstituted 1.5 mg eprosartan mesylate oral tablet $1 PA ERGOMAR SUBLINGUAL TABLET $1 SUBLINGUAL ethacrynate sodium intravenous* solution $1 reconstituted EYLEA INTRAOCULAR SOLUTION $1 SP

^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 30 Drug Status Notes FEIBA INTRAVENOUS* SOLUTION $1 SP RECONSTITUTED felodipine er oral tablet extended release 24 hr* $1 flecainide acetate oral tablet $1 fosinopril sodium oral tablet $1 fosinopril sodium-hctz oral tablet $1 FRAGMIN SUBCUTANEOUS* SOLUTION 10000 UNIT/ML, 12500 UNIT/0.5ML, 15000 UNIT/0.6ML, 18000 UNT/0.72ML, 2500 $1 UNIT/0.2ML, 5000 UNIT/0.2ML, 7500 UNIT/0.3ML frovatriptan succinate oral tablet $1 PA; QL (9 EA per 30 days) furosemide injection solution 10 mg/ml $1 furosemide oral solution 10 mg/ml, 8 mg/ml $1 furosemide oral tablet $1 GAMMAGARD S/D LESS IGA INTRAVENOUS* SOLUTION $1 PA; SP RECONSTITUTED GAMUNEX-C INJECTION SOLUTION $1 PA; SP guanfacine hcl oral tablet $1 HEMMOREX-HC SUPPOSITORY $1 HUMATE-P INTRAVENOUS* SOLUTION RECONSTITUTED 1000-2400 UNIT, 250-600 $1 SP UNIT, 500-1200 UNIT hydralazine hcl oral tablet $1 hydrochlorothiazide oral capsule $1 hydrochlorothiazide oral tablet $1 hydrocortisone ace-pramoxine cream $1 hydrocortisone ace-pramoxine external cream $1 2.5-1 % hydrocortisone acetate suppository $1 hydroxyprogesterone caproate intramuscular* oil $1 indapamide oral tablet $1 INNOPRAN XL ORAL CAPSULE $1 EXTENDED RELEASE 24 HOUR irbesartan oral tablet $1 STPA irbesartan-hydrochlorothiazide oral tablet $1 STPA ISORDIL TITRADOSE ORAL TABLET 40 $1 MG ^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 31 Drug Status Notes isosorbide dinitrate er oral tablet $1 extendedrelease* isosorbide dinitrate oral tablet $1 isosorbide mononitrate er oral tablet extended $1 release 24 hr* isosorbide mononitrate oral tablet $1 isradipine oral capsule $1 PA JANTOVEN ORAL TABLET $1 labetalol hcl oral tablet $1 LANOXIN ORAL TABLET 187.5 MCG, 62.5 $1 MCG LETAIRIS ORAL TABLET $1 PA; SP; QL (30 EA per 30 days) LEVATOL ORAL TABLET $1 PA lisinopril oral tablet $1 lisinopril-hydrochlorothiazide oral tablet $1 losartan potassium oral tablet $1 losartan potassium-hctz oral tablet $1 LUCENTIS INTRAOCULAR SOLUTION $1 SP LUMIZYME INTRAVENOUS* SOLUTION $1 SP RECONSTITUTED LUPRON DEPOT INTRAMUSCULAR* KIT $1 PA; SP 11.25 MG, 3.75 MG MATZIM LA ORAL TABLET EXTENDED $1 PA RELEASE 24 HR* meclizine hcl oral tablet $1 medroxyprogesterone acetate oral tablet $1 mesna intravenous* solution $1 MESNEX ORAL TABLET $1 methyldopa oral tablet $1 methyldopa-hydrochlorothiazide oral tablet $1 methylergonovine maleate oral tablet $1 metoprolol succinate er oral tablet extended $1 release 24 hr* metoprolol tartrate oral tablet 100 mg, 25 mg, 50 $1 mg metoprolol tartrate oral tablet 37.5 mg, 75 mg $1 PA metoprolol-hydrochlorothiazide oral tablet $1 mexiletine hcl oral capsule $1 ^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 32 Drug Status Notes midodrine hcl oral tablet $1 MIGERGOT SUPPOSITORY $1 MINITRAN TRANSDERMAL PATCH 24 HR $1 minoxidil oral tablet $1 moexipril hcl oral tablet $1 moexipril-hydrochlorothiazide oral tablet $1 MULTAQ ORAL TABLET $1 MYOZYME INTRAVENOUS* SOLUTION $1 SP RECONSTITUTED nadolol oral tablet 20 mg, 40 mg, 80 mg $1 nadolol-bendroflumethiazide oral tablet $1 naratriptan hcl oral tablet $1 STPA; QL (9 EA per 30 days) NATAZIA ORAL TABLET $1 nicardipine hcl oral capsule $1 NIFEDICAL XL ORAL TABLET $1 EXTENDED RELEASE 24 HR* nifedipine er oral tablet extended release 24 hr* $1 nifedipine er osmotic release oral tablet extended $1 release 24 hr* nifedipine oral capsule $1 nimodipine oral capsule $1 PA nisoldipine er oral tablet extended release 24 hr* $1 NITRO-BID TRANSDERMAL OINTMENT $1 NITRO-DUR TRANSDERMAL PATCH 24 $1 HR 0.3 MG/HR, 0.8 MG/HR nitroglycerin transdermal patch 24 hr $1 nitroglycerin translingual aerosol, solution $1 nitroglycerin translingual solution $1 NITROSTAT SUBLINGUAL TABLET $1 SUBLINGUAL norethindrone acetate oral tablet $1 NORPACE CR ORAL CAPSULE $1 EXTENDED RELEASE 12 HOUR NORTHERA ORAL CAPSULE $1 PA NOVOSEVEN RT INTRAVENOUS* $1 SP SOLUTION RECONSTITUTED NPLATE SUBCUTANEOUS* SOLUTION $1 PA; SP RECONSTITUTED ^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 33 Drug Status Notes obizur intravenous* solution reconstituted $1 SP OCTAGAM INTRAVENOUS* SOLUTION 10 GM/100ML, 2 GM/20ML, 20 GM/200ML, 5 $1 PA; SP GM/50ML OPSUMIT ORAL TABLET $1 PA; SP ORENITRAM ORAL TABLET $1 PA; SP EXTENDEDRELEASE* PACERONE ORAL TABLET 100 MG, 200 $1 MG, 400 MG pentoxifylline er oral tablet extendedrelease* $1 perindopril erbumine oral tablet $1 phenoxybenzamine hcl oral capsule $1 pindolol oral tablet $1 PRADAXA ORAL CAPSULE $1 QL (60 EA per 30 days) PRALUENT SUBCUTANEOUS* 150 $1 PA; SP; QL (2 ML per 28 days) MG/ML, 75 MG/ML pramcort cream $1 prazosin hcl oral capsule $1 PRIVIGEN INTRAVENOUS* SOLUTION $1 PA; SP PROCTOFOAM HC FOAM $1 progesterone intramuscular* oil $1 PA PROMACTA ORAL TABLET $1 PA; SP propafenone hcl er oral capsule extended release $1 12 hour propafenone hcl oral tablet $1 propranolol hcl er oral capsule extended release $1 24 hour propranolol-hctz oral tablet $1 quinapril hcl oral tablet $1 quinapril-hydrochlorothiazide oral tablet $1 quinidine gluconate er oral tablet $1 extendedrelease* quinidine sulfate er oral tablet extendedrelease* $1 quinidine sulfate oral tablet $1 ramipril oral capsule $1 RANEXA ORAL TABLET EXTENDED $1 PA; QL (60 EA per 30 days) RELEASE 12 HR* ranitidine hcl oral capsule $1

^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 34 Drug Status Notes ranitidine hcl oral syrup $1 ranitidine hcl oral tablet 150 mg, 300 mg $1 RELPAX ORAL TABLET $1 PA; QL (9 EA per 30 days) REMODULIN INJECTION SOLUTION $1 PA; SP REPATHA PUSHTRONEX SYSTEM PA; SP; # (Preferred product); QL $1 SUBCUTANEOUS* (1 ML per 28 days) PA; SP; # (Preferred product); QL REPATHA SUBCUTANEOUS* $1 (2 ML per 28 days) PA; SP; # (Preferred product); QL REPATHA SURECLICK SUBCUTANEOUS* $1 (2 ML per 28 days) reserpine oral tablet $1 REVATIO ORAL SUSPENSION $1 PA; SP RECONSTITUTED RHOPHYLAC INJECTION $1 SP RHOPHYLAC INJECTION SOLUTION $1 SP rizatriptan benzoate oral tablet $1 STPA; QL (9 EA per 30 days) rizatriptan benzoate oral tablet dispersible $1 STPA; QL (9 EA per 30 days) sildenafil citrate intravenous* solution $1 PA; SP; QL (90 ML per 30 days) sildenafil citrate oral tablet $1 PA; SP; QL (90 EA per 30 days) SORINE ORAL TABLET $1 sotalol hcl (af) oral tablet 120 mg, 80 mg $1 sotalol hcl oral tablet $1 SOTYLIZE ORAL SOLUTION $1 spironolactone oral tablet $1 spironolactone-hctz oral tablet $1 sumatriptan nasal solution $1 QL (6 Units per 30 days) sumatriptan succinate oral tablet $1 QL (9 EA per 30 days) sumatriptan succinate refill subcutaneous* $1 QL (5 EA per 30 days) sumatriptan succinate subcutaneous* 4 mg/0.5ml, $1 QL (5 EA per 30 days) 6 mg/0.5ml sumatriptan succinate subcutaneous* solution 6 $1 QL (5 EA per 30 days) mg/0.5ml TAZTIA XT ORAL CAPSULE EXTENDED $1 RELEASE 24 HOUR TEKTURNA HCT ORAL TABLET $1 PA; QL (30 EA per 30 days) TEKTURNA ORAL TABLET $1 PA; QL (30 EA per 30 days) telmisartan oral tablet $1 PA

^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 35 Drug Status Notes telmisartan-hctz oral tablet 40-12.5 mg, 80-12.5 $1 mg terazosin hcl oral capsule $1 TIKOSYN ORAL CAPSULE $1 SP timolol maleate oral tablet $1 topiramate oral capsule sprinkle 15 mg $1 topiramate oral capsule sprinkle 25 mg $1 QL (180 EA per 30 days) topiramate oral tablet 100 mg, 50 mg $1 QL (90 EA per 30 days) topiramate oral tablet 200 mg $1 topiramate oral tablet 25 mg $1 QL (180 EA per 30 days) torsemide oral tablet $1 TRACLEER ORAL TABLET $1 PA; SP; QL (60 EA per 30 days) trandolapril oral tablet $1 trandolapril-verapamil hcl er oral tablet $1 extendedrelease* tranexamic acid oral tablet $1 PA triamterene-hctz oral capsule $1 triamterene-hctz oral tablet $1 TYVASO INHALATION SOLUTION $1 PA; SP TYVASO REFILL INHALATION $1 PA; SP SOLUTION TYVASO STARTER INHALATION $1 PA; SP SOLUTION UPTRAVI ORAL $1 PA; SP UPTRAVI ORAL TABLET $1 PA; SP valsartan oral tablet $1 STPA valsartan-hydrochlorothiazide oral tablet $1 STPA VELETRI INTRAVENOUS* SOLUTION $1 PA RECONSTITUTED VENTAVIS INHALATION SOLUTION $1 PA; SP; QL (9 Vials per 1 day) verapamil hcl er oral capsule extended release 24 $1 hour verapamil hcl er oral tablet extendedrelease* 120 $1 mg, 180 mg, 240 mg verapamil hcl oral tablet $1 warfarin sodium oral tablet $1 WILATE INTRAVENOUS* KIT $1 SP

^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 36 Drug Status Notes WILATE INTRAVENOUS* SOLUTION RECONSTITUTED 1000-1000 UNIT, 500-500 $1 SP UNIT WINRHO SDF INJECTION SOLUTION $1 SP XARELTO ORAL TABLET $1 QL (30 EA per 30 days) XARELTO STARTER PACK ORAL $1 QL (42 EA per 21 days) ZEGERID ORAL PACKET $1 PA zolmitriptan oral tablet $1 STPA; QL (9 EA per 30 days) zolmitriptan oral tablet dispersible $1 STPA; QL (9 EA per 30 days) ZOMIG NASAL SOLUTION $1 STPA; QL (6 Units per 30 days) ZONTIVITY ORAL TABLET $1 DISEASE OF THE NERVES AFINITOR DISPERZ ORAL TABLET $1 SP SOLUBLE almotriptan malate oral tablet $1 PA; QL (9 EA per 30 days) amantadine hcl oral capsule $1 amantadine hcl oral syrup $1 amantadine hcl oral tablet $1 amlodipine-atorvastatin oral tablet $1 PA; QL (30 EA per 30 days) PA; ¥ (PA applies to members less amphetamine-dextroamphet er oral capsule $1 than 3 years old or 25 and older); extended release 24 hour QL (60 EA per 30 days) PA; ¥ (PA applies to members less amphetamine-dextroamphetamine oral tablet $1 than 3 years old or 25 and older); QL (90 EA per 30 days) AMPYRA ORAL TABLET EXTENDED PA; SP; QL (60 Tablets per 30 $1 RELEASE 12 HR* days) APOKYN SUBCUTANEOUS* SOLUTION $1 SP; QL (15 ML per 30 days) APTIOM ORAL TABLET $1 PA aspirin-dipyridamole er oral capsule extended $1 PA; QL (60 EA per 30 days) release 12 hour atropine sulfate ophthalmic ointment $1 atropine sulfate ophthalmic solution $1 AUBAGIO ORAL TABLET $1 PA; SP; QL (30 EA per 30 days) AVONEX INTRAMUSCULAR* KIT $1 SP AVONEX PEN INTRAMUSCULAR* $1 SP AVONEX PREFILLED INTRAMUSCULAR* $1 SP AZILECT ORAL TABLET $1

^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 37 Drug Status Notes baclofen oral tablet $1 BELSOMRA ORAL TABLET $1 PA benztropine mesylate oral tablet $1 BETASERON SUBCUTANEOUS* KIT $1 SP BETASERON SUBCUTANEOUS* $1 SP SOLUTION RECONSTITUTED BOTOX INJECTION SOLUTION $1 PA; SP RECONSTITUTED bromocriptine mesylate oral capsule $1 bromocriptine mesylate oral tablet $1 CAFERGOT ORAL TABLET $1 carbamazepine er oral capsule extended release $1 12 hour carbamazepine er oral tablet extended release 12 $1 hr* carbamazepine oral suspension $1 carbamazepine oral tablet $1 carbamazepine oral tablet chewable $1 carbidopa oral tablet $1 carbidopa-levodopa er oral tablet $1 extendedrelease* 25-100 mg, 50-200 mg carbidopa-levodopa oral tablet $1 carbidopa-levodopa oral tablet dispersible $1 carbidopa-levodopa-entacapone oral tablet $1 CELONTIN ORAL CAPSULE $1 chlordiazepoxide hcl oral capsule $1 clonazepam oral tablet $1 clonidine hcl er oral tablet extended release 12 $1 PA; QL (60 EA per 30 days) hr* clorazepate dipotassium oral tablet $1 constulose oral solution $1 COPAXONE SUBCUTANEOUS* $1 SP COPAXONE SUBCUTANEOUS* KIT $1 SP CUPRIMINE ORAL CAPSULE 250 MG $1 dantrolene sodium oral capsule $1 DAYTRANA TRANSDERMAL PATCH $1 PA; QL (30 patches per 30 days) DEPEN TITRATABS ORAL TABLET $1

^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 38 Drug Status Notes PA; ¥ (PA applies to members less DEXEDRINE ORAL TABLET $1 than 3 years old or 25 and older); QL (90 EA per 30 days) PA; ¥ (PA applies to members less dexmethylphenidate hcl er oral capsule extended $1 than 3 years old or 25 and older); release 24 hour QL (30 EA per 30 days) PA; ¥ (PA applies to members less dexmethylphenidate hcl oral tablet $1 than 3 years old or 25 and older); QL (60 EA per 30 days) PA; ¥ (PA applies to members less dextroamphetamine sulfate er oral capsule $1 than 3 years old or 25 and older); extended release 24 hour QL (90 EA per 30 days) PA; ¥ (PA applies to members less dextroamphetamine sulfate oral solution $1 than 3 years old or 25 and older); QL (1200 mL per 30 days) PA; ¥ (PA applies to members less dextroamphetamine sulfate oral tablet $1 than 3 years old or 25 and older); QL (90 EA per 30 days) diazepam gel $1 QL (1 System per 1 Rx) diazepam oral solution 1 mg/ml $1 diazepam oral tablet $1 dihydroergotamine mesylate nasal solution $1 DILANTIN ORAL CAPSULE 30 MG $1 diphenhydramine hcl oral capsule $1 diphenhydramine hcl oral elixir $1 divalproex sodium er oral tablet extended release $1 24 hr* divalproex sodium oral $1 divalproex sodium oral tablet delayed release $1 donepezil hcl oral tablet 10 mg, 5 mg $1 donepezil hcl oral tablet dispersible $1 DYSPORT (GLABELLAR LINES) INTRAMUSCULAR* SOLUTION $1 PA; SP RECONSTITUTED DYSPORT INTRAMUSCULAR* SOLUTION $1 PA; SP RECONSTITUTED EDLUAR SUBLINGUAL TABLET $1 PA; QL (30 EA per 30 days) SUBLINGUAL entacapone oral tablet $1 enulose oral solution $1

^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 39 Drug Status Notes EPITOL ORAL TABLET $1 ergoloid mesylates oral tablet $1 ERGOMAR SUBLINGUAL TABLET $1 SUBLINGUAL estazolam oral tablet 1 mg $1 eszopiclone oral tablet $1 PA; QL (30 EA per 30 days) ethosuximide oral capsule $1 ethosuximide oral solution $1 EXTAVIA SUBCUTANEOUS* KIT $1 SP EXTAVIA SUBCUTANEOUS* SOLUTION $1 SP RECONSTITUTED felbamate oral suspension $1 PA felbamate oral tablet $1 PA flurazepam hcl oral capsule $1 FOCALIN XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 25 MG, 35 $1 PA; QL (30 EA per 30 days) MG frovatriptan succinate oral tablet $1 PA; QL (9 EA per 30 days) FYCOMPA ORAL SUSPENSION $1 FYCOMPA ORAL TABLET $1 PA gabapentin oral capsule $1 gabapentin oral solution 250 mg/5ml $1 gabapentin oral tablet $1 GABITRIL ORAL TABLET 12 MG, 16 MG $1 galantamine hydrobromide er oral capsule $1 extended release 24 hour galantamine hydrobromide oral solution $1 galantamine hydrobromide oral tablet $1 GAMMAGARD INJECTION SOLUTION $1 PA; SP generlac oral solution $1 STPA; SP; QL (30 EA per 30 GILENYA ORAL CAPSULE $1 days) GLATOPA SUBCUTANEOUS* $1 SP GRALISE ORAL TABLET $1 PA; QL (90 EA per 30 days) GRALISE STARTER ORAL $1 PA guanfacine hcl er oral tablet extended release 24 $1 STPA; QL (30 EA per 30 days) hr* guanidine hcl oral tablet $1 PA ^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 40 Drug Status Notes HETLIOZ ORAL CAPSULE $1 PA; QL (30 EA per 30 days) HORIZANT ORAL TABLET $1 PA; QL (60 EA per 30 days) EXTENDEDRELEASE* HP ACTHAR INJECTION GEL $1 PA; SP hydroxyzine hcl oral syrup $1 hydroxyzine hcl oral tablet $1 hydroxyzine pamoate oral capsule $1 INCRELEX SUBCUTANEOUS* SOLUTION $1 PA; SP INNOPRAN XL ORAL CAPSULE $1 EXTENDED RELEASE 24 HOUR lactulose encephalopathy oral solution $1 lactulose oral solution $1 lamotrigine er oral tablet extended release 24 hr* $1 PA; QL (90 EA per 30 days) lamotrigine odt oral tablet dispersible $1 lamotrigine oral tablet 100 mg, 150 mg $1 QL (90 EA per 30 days) lamotrigine oral tablet 200 mg $1 lamotrigine oral tablet 25 mg $1 QL (180 EA per 30 days) lamotrigine oral tablet chewable $1 QL (180 EA per 30 days) lamotrigine oral tablet dispersible $1 levetiracetam er oral tablet extended release 24 $1 PA; QL (180 EA per 30 days) hr* 500 mg levetiracetam er oral tablet extended release 24 $1 PA; QL (120 EA per 30 days) hr* 750 mg levetiracetam oral solution $1 levetiracetam oral tablet $1 lidocaine external patch 5 % $1 LYRICA ORAL CAPSULE $1 PA; QL (60 EA per 30 days) LYRICA ORAL SOLUTION $1 PA; QL (900 ML per 30 days) meclizine hcl oral tablet $1 memantine hcl oral solution $1 memantine hcl oral tablet $1 MESTINON ORAL SYRUP $1 PA; ¥ (PA applies to members less methamphetamine hcl oral tablet $1 than 3 years old or 25 and older); QL (150 EA per 30 days) PA; ¥ (PA applies to members less methylphenidate hcl er (cd) oral capsule extended $1 than 3 years old or 25 and older); release* 10 mg, 20 mg, 40 mg, 50 mg, 60 mg QL (30 EA per 30 days) ^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 41 Drug Status Notes PA; ¥ (PA applies to members less methylphenidate hcl er (cd) oral capsule extended $1 than 3 years old or 25 and older); release* 30 mg QL (60 EA per 30 days) PA; ¥ (PA applies to members less methylphenidate hcl er (la) oral capsule extended $1 than 3 years old or 25 and older); release 24 hour 20 mg, 40 mg QL (30 EA per 30 days) PA; ¥ (PA applies to members less methylphenidate hcl er (la) oral capsule extended $1 than 3 years old or 25 and older); release 24 hour 30 mg QL (60 EA per 30 days) PA; ¥ (PA applies to members less methylphenidate hcl er oral tablet extended $1 than 3 years old or 25 and older); release 24 hr* QL (30 EA per 30 days) methylphenidate hcl er oral tablet PA; ¥ (PA applies to members less extendedrelease* 10 mg, 18 mg, 20 mg, 27 mg, 54 $1 than 3 years old or 25 and older); mg QL (30 EA per 30 days) PA; ¥ (PA applies to members less methylphenidate hcl er oral tablet $1 than 3 years old or 25 and older); extendedrelease* 36 mg QL (60 EA per 30 days) PA; ¥ (PA applies to members less methylphenidate hcl oral solution $1 than 3 years old or 25 and older); QL (900 mL per 30 days) PA; ¥ (PA applies to members less methylphenidate hcl oral tablet $1 than 3 years old or 25 and older); QL (90 EA per 30 days) PA; ¥ (PA applies to members less methylphenidate hcl oral tablet chewable $1 than 3 years old or 25 and older); QL (90 EA per 30 days) MIGERGOT SUPPOSITORY $1 MIRAPEX ER ORAL TABLET EXTENDED $1 RELEASE 24 HR* 3.75 MG mitoxantrone hcl intravenous* concentrate $1 PA; SP modafinil oral tablet $1 PA; QL (30 EA per 30 days) MYOBLOC INTRAMUSCULAR* $1 PA; SP SOLUTION NAMENDA XR ORAL CAPSULE $1 EXTENDED RELEASE 24 HOUR NAMENDA XR TITRATION PACK ORAL $1 CAPSULE EXTENDED RELEASE 24 HOUR naratriptan hcl oral tablet $1 STPA; QL (9 EA per 30 days) NEUPRO TRANSDERMAL PATCH 24 HR $1 PA; QL (30 EA per 30 days) nimodipine oral capsule $1 PA

^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 42 Drug Status Notes NUCYNTA ER ORAL TABLET EXTENDED $1 PA RELEASE 12 HR* NUVIGIL ORAL TABLET 150 MG, 200 MG, $1 PA; QL (30 EA per 30 days) 250 MG NUVIGIL ORAL TABLET 50 MG $1 PA; QL (60 EA per 30 days) octreotide acetate injection solution 100 mcg/ml, 1000 mcg/ml, 200 mcg/ml, 50 mcg/ml, 500 $1 PA; SP; QL (30 ML per 30 days) mcg/ml ONFI ORAL SUSPENSION $1 PA ONFI ORAL TABLET 10 MG, 20 MG $1 PA; QL (60 EA per 30 days) oxazepam oral capsule $1 oxcarbazepine oral suspension $1 oxcarbazepine oral tablet $1 OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR* 150 MG, 300 $1 PA; QL (30 EA per 30 days) MG OXTELLAR XR ORAL TABLET $1 PA; QL (120 EA per 30 days) EXTENDED RELEASE 24 HR* 600 MG PEGANONE ORAL TABLET $1 PA PHENYTOIN INFATABS ORAL TABLET $1 CHEWABLE phenytoin oral suspension 125 mg/5ml $1 phenytoin oral tablet chewable $1 phenytoin sodium extended oral capsule $1 pimozide oral tablet $1 PA POTIGA ORAL TABLET $1 PA pramipexole dihydrochloride er oral tablet extended release 24 hr* 0.375 mg, 0.75 mg, 1.5 $1 mg, 2.25 mg, 3 mg, 4.5 mg pramipexole dihydrochloride oral tablet $1 propranolol hcl er oral capsule extended release $1 24 hour propranolol hcl oral solution $1 propranolol hcl oral tablet $1 pyridostigmine bromide er oral tablet $1 extendedrelease* pyridostigmine bromide oral tablet $1 QUILLIVANT XR ORAL SUSPENSION $1 PA; QL (360 mL per 30 days) RECONSTITUTED

^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 43 Drug Status Notes REBIF REBIDOSE SUBCUTANEOUS* $1 SP REBIF REBIDOSE SUBCUTANEOUS* $1 SP SOLUTION REBIF REBIDOSE TITRATION PACK $1 SP SUBCUTANEOUS* REBIF REBIDOSE TITRATION PACK $1 SP SUBCUTANEOUS* SOLUTION REBIF SUBCUTANEOUS* $1 SP REBIF SUBCUTANEOUS* SOLUTION $1 SP REBIF TITRATION PACK $1 SP SUBCUTANEOUS* REBIF TITRATION PACK $1 SP SUBCUTANEOUS* SOLUTION REGRANEX EXTERNAL GEL $1 RELPAX ORAL TABLET $1 PA; QL (9 EA per 30 days) riluzole oral tablet $1 RITALIN LA ORAL CAPSULE EXTENDED $1 PA; QL (30 EA per 30 days) RELEASE 24 HOUR 10 MG, 60 MG rivastigmine tartrate oral capsule $1 rivastigmine transdermal patch 24 hr $1 rizatriptan benzoate oral tablet $1 STPA; QL (9 EA per 30 days) rizatriptan benzoate oral tablet dispersible $1 STPA; QL (9 EA per 30 days) ropinirole hcl er oral tablet extended release 24 $1 hr* ropinirole hcl oral tablet $1 ROZEREM ORAL TABLET $1 PA; QL (30 EA per 30 days) SABRIL ORAL PACKET $1 PA; SP; QL (180 EA per 30 days) SABRIL ORAL TABLET $1 PA; SP; QL (180 EA per 30 days) SANDOSTATIN LAR DEPOT $1 PA; SP; QL (1 vial per 28 days) INTRAMUSCULAR* KIT selegiline hcl oral capsule $1 selegiline hcl oral tablet $1 SOMATULINE DEPOT SUBCUTANEOUS* $1 PA; SP; QL (1 ML per 28 days) SOLUTION SOMAVERT SUBCUTANEOUS* $1 PA; SP; QL (30 EA per 30 days) SOLUTION RECONSTITUTED SPRITAM ORAL $1 PA; QL (60 EA per 30 days) STRATTERA ORAL CAPSULE $1 PA; QL (60 EA per 30 days)

^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 44 Drug Status Notes sumatriptan nasal solution $1 QL (6 Units per 30 days) sumatriptan succinate oral tablet $1 QL (9 EA per 30 days) sumatriptan succinate refill subcutaneous* $1 QL (5 EA per 30 days) sumatriptan succinate subcutaneous* 4 mg/0.5ml, $1 QL (5 EA per 30 days) 6 mg/0.5ml sumatriptan succinate subcutaneous* solution 6 $1 QL (5 EA per 30 days) mg/0.5ml SYPRINE ORAL CAPSULE $1 PA TECFIDERA ORAL $1 PA; SP; QL (60 EA per 30 days) TECFIDERA ORAL CAPSULE DELAYED $1 PA; SP; QL (60 EA per 30 days) RELEASE temazepam oral capsule $1 TEMODAR INTRAVENOUS* SOLUTION $1 SP RECONSTITUTED temozolomide oral capsule $1 SP tetrabenazine oral tablet 12.5 mg $1 PA; SP; QL (240 EA per 30 days) tetrabenazine oral tablet 25 mg $1 PA; SP; QL (120 EA per 30 days) tiagabine hcl oral tablet $1 tolcapone oral tablet $1 PA; QL (180 EA per 30 days) topiramate er oral $1 PA topiramate oral capsule sprinkle 15 mg $1 topiramate oral capsule sprinkle 25 mg $1 QL (180 EA per 30 days) topiramate oral tablet 100 mg, 50 mg $1 QL (90 EA per 30 days) topiramate oral tablet 200 mg $1 topiramate oral tablet 25 mg $1 QL (180 EA per 30 days) trihexyphenidyl hcl oral elixir $1 trihexyphenidyl hcl oral tablet $1 TROKENDI XR ORAL CAPSULE $1 PA EXTENDED RELEASE 24 HOUR TYSABRI INTRAVENOUS* $1 PA; SP; QL (1 vial per 28 days) CONCENTRATE valproic acid oral capsule $1 valproic acid oral solution $1 valproic acid oral syrup $1 VIMPAT ORAL SOLUTION $1 PA; QL (1200 ML per 30 days) VIMPAT ORAL TABLET $1 PA; QL (60 EA per 30 days) VYVANSE ORAL CAPSULE $1 PA; QL (30 EA per 30 days)

^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 45 Drug Status Notes XEOMIN INTRAMUSCULAR* SOLUTION $1 PA; SP RECONSTITUTED XIFAXAN ORAL TABLET 200 MG $1 QL (9 EA per 30 days) XIFAXAN ORAL TABLET 550 MG $1 QL (6 EA per 30 days) XYREM ORAL SOLUTION $1 PA zaleplon oral capsule $1 QL (30 EA per 30 days) ZELAPAR ORAL TABLET DISPERSIBLE $1 PA; QL (60 EA per 30 days) PA; ¥ (PA applies to members less ZENZEDI ORAL TABLET 10 MG, 5 MG $1 than 3 years old or 25 and older); QL (90 EA per 30 days) zolmitriptan oral tablet $1 STPA; QL (9 EA per 30 days) zolmitriptan oral tablet dispersible $1 STPA; QL (9 EA per 30 days) zolpidem tartrate er oral tablet extendedrelease* $1 PA; QL (30 EA per 30 days) zolpidem tartrate oral tablet $1 QL (30 EA per 30 days) zolpidem tartrate sublingual tablet sublingual $1 PA; QL (30 EA per 30 days) ZOMIG NASAL SOLUTION $1 STPA; QL (6 Units per 30 days) zonisamide oral capsule $1 ZONTIVITY ORAL TABLET $1 DISEASE OF THE URINARY TRACT AFINITOR ORAL TABLET $1 SP alfuzosin hcl er oral tablet extended release 24 $1 hr* ARANESP (ALBUMIN FREE) INJECTION $1 SP; QL (4 mL per 30 days) ARANESP (ALBUMIN FREE) INJECTION SOLUTION 10 MCG/0.4ML, 100 MCG/ML, $1 SP; QL (4 mL per 30 days) 200 MCG/ML, 25 MCG/ML, 300 MCG/ML, 40 MCG/ML, 60 MCG/ML ASTAGRAF XL ORAL CAPSULE $1 PA; QL (30 EA per 30 days) EXTENDED RELEASE 24 HOUR AURYXIA ORAL TABLET $1 PA AVASTIN INTRAVENOUS* SOLUTION $1 SP AVC VAGINAL VAGINAL CREAM $1 azathioprine oral tablet $1 bethanechol chloride oral tablet $1 bicalutamide oral tablet $1 CABOMETYX ORAL TABLET $1 PA; SP calcium acetate (phos binder) oral capsule $1 calcium acetate (phos binder) oral tablet $1 ^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 46 Drug Status Notes captopril oral tablet $1 CARDURA XL ORAL TABLET EXTENDED $1 RELEASE 24 HR* CIALIS ORAL TABLET 5 MG $1 PA; QL (30 EA per 30 days) ciprofloxacin hcl oral tablet 100 mg $1 ciprofloxacin-ciproflox hcl er oral tablet extended $1 release 24 hr* CLEOCIN VAGINAL SUPPOSITORY $1 clindamycin phosphate vaginal cream $1 cyclosporine modified oral capsule $1 cyclosporine modified oral solution $1 cyclosporine oral capsule $1 darifenacin hydrobromide er oral tablet extended $1 PA release 24 hr* DEPO-PROVERA INTRAMUSCULAR* $1 SUSPENSION 400 MG/ML desmopressin acetate oral tablet $1 DIVIGEL TRANSDERMAL GEL $1 PA doxazosin mesylate oral tablet $1 doxercalciferol oral capsule $1 dutasteride oral capsule $1 PA; QL (30 EA per 30 days) dutasteride-tamsulosin hcl oral capsule $1 PA; QL (30 EA per 30 days) ELESTRIN TRANSDERMAL GEL $1 PA ELIGARD SUBCUTANEOUS* KIT $1 PA; SP ELMIRON ORAL CAPSULE $1 EMCYT ORAL CAPSULE $1 EPOGEN INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 20000 UNIT/ML, $1 SP 3000 UNIT/ML, 4000 UNIT/ML ESTRACE VAGINAL CREAM $1 ESTRING VAGINAL RING $1 ESTROGEL TRANSDERMAL GEL $1 PA FEMRING VAGINAL RING $1 finasteride oral tablet 5 mg $1 FIRMAGON SUBCUTANEOUS* $1 SP SOLUTION RECONSTITUTED FLAGYL ER ORAL TABLET EXTENDED $1 RELEASE 24 HR* ^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 47 Drug Status Notes flavoxate hcl oral tablet $1 flutamide oral capsule $1 FOSRENOL ORAL PACKET $1 FOSRENOL ORAL TABLET CHEWABLE $1 1000 MG, 500 MG, 750 MG GELNIQUE TRANSDERMAL GEL $1 PA GENGRAF ORAL CAPSULE 100 MG, 25 $1 MG GENGRAF ORAL SOLUTION $1 GLYDO EXTERNAL GEL $1 GYNAZOLE-1 VAGINAL CREAM $1 hydroxyprogesterone caproate intramuscular* oil $1 imipramine hcl oral tablet $1 INLYTA ORAL TABLET $1 SP JEVTANA INTRAVENOUS* SOLUTION $1 SP LENVIMA 10 MG DAILY DOSE ORAL $1 PA LENVIMA 14 MG DAILY DOSE ORAL $1 PA LENVIMA 20 MG DAILY DOSE ORAL $1 PA LENVIMA 24 MG DAILY DOSE ORAL $1 PA leuprolide acetate injection kit $1 PA; SP lidocaine hcl external gel 2 % $1 LUPRON DEPOT INTRAMUSCULAR* KIT $1 PA; SP 22.5 MG, 30 MG, 45 MG, 7.5 MG medroxyprogesterone acetate oral tablet $1 mesna intravenous* solution $1 MESNEX ORAL TABLET $1 methenamine hippurate oral tablet $1 methenamine mandelate oral tablet $1 metolazone oral tablet $1 metronidazole vaginal gel $1 miconazole 3 vaginal suppository $1 MIRCERA INJECTION $1 QL (2 Syringes per 28 days) mitoxantrone hcl intravenous* concentrate $1 PA; SP MONUROL ORAL PACKET $1 mycophenolate mofetil oral capsule $1 mycophenolate mofetil oral suspension $1 reconstituted ^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 48 Drug Status Notes mycophenolate mofetil oral tablet $1 mycophenolic acid oral tablet delayed release $1 MYRBETRIQ ORAL TABLET EXTENDED $1 PA RELEASE 24 HR* NATAZIA ORAL TABLET $1 NEXAVAR ORAL TABLET $1 SP NILANDRON ORAL TABLET $1 nitrofurantoin macrocrystal oral capsule $1 nitrofurantoin monohyd macro oral capsule $1 nitrofurantoin oral suspension $1 norethindrone acetate oral tablet $1 OSPHENA ORAL TABLET $1 PA oxybutynin chloride er oral tablet extended $1 release 24 hr* oxybutynin chloride oral syrup $1 oxybutynin chloride oral tablet $1 OXYTROL TRANSDERMAL PATCH $1 PA BIWEEKLY paricalcitol oral capsule $1 PA phenazopyridine hcl oral tablet 100 mg, 200 mg $1 PHOSLYRA ORAL SOLUTION $1 PREMARIN VAGINAL CREAM $1 PREMPHASE ORAL TABLET $1 PREMPRO ORAL TABLET $1 PROCRIT INJECTION SOLUTION $1 SP progesterone intramuscular* oil $1 PA PROLEUKIN INTRAVENOUS* SOLUTION $1 SP RECONSTITUTED RAPAFLO ORAL CAPSULE $1 PA RAPAMUNE ORAL SOLUTION $1 RENAGEL ORAL TABLET $1 RENVELA ORAL TABLET $1 SANDIMMUNE ORAL SOLUTION $1 SENSIPAR ORAL TABLET $1 STPA; SP sirolimus oral tablet $1 SUTENT ORAL CAPSULE $1 SP tacrolimus oral capsule $1 ^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 49 Drug Status Notes tamsulosin hcl oral capsule $1 TECENTRIQ INTRAVENOUS* SOLUTION $1 terazosin hcl oral capsule $1 terconazole vaginal cream $1 terconazole vaginal suppository $1 tinidazole oral tablet $1 tolterodine tartrate er oral capsule extended $1 release 24 hour tolterodine tartrate oral tablet $1 TORISEL INTRAVENOUS* SOLUTION $1 SP TOVIAZ ORAL TABLET EXTENDED $1 RELEASE 24 HR* tranexamic acid oral tablet $1 PA TRELSTAR DEPOT INTRAMUSCULAR* $1 SP SUSPENSION RECONSTITUTED TRELSTAR INTRAMUSCULAR* $1 SP SUSPENSION RECONSTITUTED TRELSTAR LA INTRAMUSCULAR* $1 SP SUSPENSION RECONSTITUTED TRELSTAR MIXJECT INTRAMUSCULAR* $1 SP SUSPENSION RECONSTITUTED trimethoprim oral tablet $1 trospium chloride er oral capsule extended $1 release 24 hour trospium chloride oral tablet $1 VAGIFEM VAGINAL TABLET 10 MCG $1 VALCYTE ORAL SOLUTION $1 RECONSTITUTED valganciclovir hcl oral tablet $1 VALSTAR INTRAVESICAL SOLUTION $1 SP VANDAZOLE VAGINAL GEL $1 VANTAS SUBCUTANEOUS* KIT $1 PA; SP VESICARE ORAL TABLET $1 PA VOTRIENT ORAL TABLET $1 SP XTANDI ORAL CAPSULE $1 SP ZOLADEX SUBCUTANEOUS* IMPLANT PA; SP; QL (1 Implant per 84 $1 10.8 MG days)

^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 50 Drug Status Notes ZOLADEX SUBCUTANEOUS* IMPLANT PA; SP; QL (1 Implant per 28 $1 3.6 MG days) ZORTRESS ORAL TABLET $1 SP ZYTIGA ORAL TABLET $1 SP DISORDER OF REPRODUCTIVE SYSTEM AFINITOR ORAL TABLET $1 SP alendronate sodium oral tablet 10 mg, 5 mg $1 QL (30 EA per 30 days) alendronate sodium oral tablet 35 mg, 70 mg $1 QL (4 EA per 28 days) ALKERAN ORAL TABLET $1 ALTAVERA ORAL TABLET $1 alyacen 1/35 oral tablet $1 alyacen 7/7/7 oral tablet $1 AMETHIA LO ORAL TABLET $1 AMETHIA ORAL TABLET $1 AMETHYST ORAL TABLET $1 anastrozole oral tablet $1 ANDRODERM TRANSDERMAL PATCH 24 $1 PA HR 2 MG/24HR, 4 MG/24HR ANDROGEL PUMP TRANSDERMAL GEL $1 PA 20.25 MG/ACT (1.62%) ANDROGEL TRANSDERMAL GEL 20.25 MG/1.25GM (1.62%), 40.5 MG/2.5GM $1 PA (1.62%), 50 MG/5GM (1%) ANDROXY ORAL TABLET $1 APRI ORAL TABLET $1 ARANELLE ORAL TABLET $1 ASHLYNA ORAL TABLET $1 AUBRA ORAL TABLET $1 AVC VAGINAL VAGINAL CREAM $1 AVIANE ORAL TABLET $1 AXIRON TRANSDERMAL SOLUTION $1 PA AZURETTE ORAL TABLET $1 BALZIVA ORAL TABLET $1 BEKYREE ORAL TABLET $1 BEYAZ ORAL TABLET $1 BLISOVI 24 FE ORAL TABLET $1 BLISOVI FE 1.5/30 ORAL TABLET $1

^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 51 Drug Status Notes BLISOVI FE 1/20 ORAL TABLET $1 briellyn oral tablet $1 calcitonin (salmon) nasal solution $1 CAMILA ORAL TABLET $1 CAMRESE LO ORAL TABLET $1 CAMRESE ORAL TABLET $1 capecitabine oral tablet $1 SP CAZIANT ORAL TABLET $1 CHATEAL ORAL TABLET $1 CIALIS ORAL TABLET 5 MG $1 PA; QL (30 EA per 30 days) CLEOCIN VAGINAL SUPPOSITORY $1 CLIMARA PRO TRANSDERMAL PATCH $1 WEEKLY clindamycin phosphate vaginal cream $1 clomiphene citrate oral tablet $1 PA COMBIPATCH TRANSDERMAL PATCH $1 BIWEEKLY CRINONE VAGINAL GEL 8 % $1 PA CRYSELLE-28 ORAL TABLET $1 CYCLAFEM 1/35 ORAL TABLET $1 CYCLAFEM 7/7/7 ORAL TABLET $1 CYRED ORAL TABLET $1 danazol oral capsule $1 DASETTA 1/35 ORAL TABLET $1 DASETTA 7/7/7 ORAL TABLET $1 DAYSEE ORAL TABLET $1 DEBLITANE ORAL TABLET $1 DELYLA ORAL TABLET $1 DEPO-PROVERA INTRAMUSCULAR* $1 SUSPENSION 400 MG/ML DEPO-SUBQ PROVERA 104 $1 SUBCUTANEOUS* SUSPENSION DEPO-TESTOSTERONE INTRAMUSCULAR* SOLUTION 100 $1 PA MG/ML desogestrel-ethinyl estradiol oral tablet $1 DIVIGEL TRANSDERMAL GEL $1 PA

^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 52 Drug Status Notes drospirenone-ethinyl estradiol oral tablet $1 DUAVEE ORAL TABLET $1 PA ELESTRIN TRANSDERMAL GEL $1 PA ELINEST ORAL TABLET $1 ELLA ORAL TABLET $1 EMOQUETTE ORAL TABLET $1 ENPRESSE-28 ORAL TABLET $1 ENSKYCE ORAL TABLET $1 ERRIN ORAL TABLET $1 ESTARYLLA ORAL TABLET $1 ESTRACE VAGINAL CREAM $1 estradiol oral tablet $1 estradiol transdermal patch biweekly $1 estradiol transdermal patch weekly $1 ESTRING VAGINAL RING $1 ESTROGEL TRANSDERMAL GEL $1 PA estropipate oral tablet $1 EVAMIST TRANSDERMAL SOLUTION $1 PA exemestane oral tablet $1 FALMINA ORAL TABLET $1 FARESTON ORAL TABLET $1 FEMRING VAGINAL RING $1 FLAGYL ER ORAL TABLET EXTENDED $1 RELEASE 24 HR* FORTEO SUBCUTANEOUS* SOLUTION $1 PA; SP; QL (1 vial per 30 days) 600 MCG/2.4ML FORTICAL NASAL SOLUTION $1 FOSAMAX PLUS D ORAL TABLET $1 PA; QL (4 EA per 28 days) GIANVI ORAL TABLET $1 GILDAGIA ORAL TABLET $1 GILDESS 1.5/30 ORAL TABLET $1 GILDESS 1/20 ORAL TABLET $1 GILDESS 24 FE ORAL TABLET $1 GILDESS FE 1.5/30 ORAL TABLET $1 GILDESS FE 1/20 ORAL TABLET $1 GYNAZOLE-1 VAGINAL CREAM $1

^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 53 Drug Status Notes HALAVEN INTRAVENOUS* SOLUTION $1 SP HEATHER ORAL TABLET $1 HERCEPTIN INTRAVENOUS* SOLUTION $1 SP RECONSTITUTED HEXALEN ORAL CAPSULE $1 hydroxyprogesterone caproate intramuscular* oil $1 ibandronate sodium intravenous* solution 3 $1 PA; QL (3 ML per 90 days) mg/3ml ibandronate sodium oral tablet $1 PA; QL (1 EA per 28 days) IBRANCE ORAL CAPSULE $1 PA; SP INTROVALE ORAL TABLET $1 IXEMPRA KIT INTRAVENOUS* $1 SP SOLUTION RECONSTITUTED JENCYCLA ORAL TABLET $1 JOLESSA ORAL TABLET $1 JOLIVETTE ORAL TABLET $1 JULEBER ORAL TABLET $1 JUNEL 1.5/30 ORAL TABLET $1 JUNEL 1/20 ORAL TABLET $1 JUNEL FE 1.5/30 ORAL TABLET $1 JUNEL FE 1/20 ORAL TABLET $1 JUNEL FE 24 ORAL TABLET $1 KADCYLA INTRAVENOUS* SOLUTION $1 SP RECONSTITUTED KAITLIB FE ORAL TABLET CHEWABLE $1 KARIVA ORAL TABLET $1 KELNOR 1/35 ORAL TABLET $1 KIMIDESS ORAL TABLET $1 KURVELO ORAL TABLET $1 LARIN 1.5/30 ORAL TABLET $1 LARIN 1/20 ORAL TABLET $1 LARIN 24 FE ORAL TABLET $1 LARIN FE 1.5/30 ORAL TABLET $1 LARIN FE 1/20 ORAL TABLET $1 LAYOLIS FE ORAL TABLET CHEWABLE $1 LEENA ORAL TABLET $1 LESSINA ORAL TABLET $1 ^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 54 Drug Status Notes letrozole oral tablet $1 LEVONEST ORAL TABLET $1 levonorgest-eth estrad 91-day oral tablet $1 levonorgestrel oral tablet $1 levonorgestrel-ethinyl estrad oral tablet $1 levonorg-eth estrad triphasic oral tablet $1 LEVORA 0.15/30 (28) ORAL TABLET $1 LO LOESTRIN FE ORAL TABLET $1 LOMEDIA 24 FE ORAL TABLET $1 LORYNA ORAL TABLET $1 LOW-OGESTREL ORAL TABLET $1 LUPRON DEPOT INTRAMUSCULAR* KIT $1 PA; SP 11.25 MG, 3.75 MG LUTERA ORAL TABLET $1 LYNPARZA ORAL CAPSULE $1 PA LYZA ORAL TABLET $1 marlissa oral tablet $1 medroxyprogesterone acetate oral tablet $1 mefenamic acid oral capsule $1 PA megestrol acetate oral tablet $1 MENEST ORAL TABLET $1 mesna intravenous* solution $1 MESNEX ORAL TABLET $1 methitest oral tablet $1 PA methyltestosterone oral capsule $1 metronidazole vaginal gel $1 MIACALCIN INJECTION SOLUTION $1 miconazole 3 vaginal suppository $1 MICROGESTIN 1.5/30 ORAL TABLET $1 MICROGESTIN 1/20 ORAL TABLET $1 MICROGESTIN 24 FE ORAL TABLET $1 MICROGESTIN FE 1.5/30 ORAL TABLET $1 MICROGESTIN FE 1/20 ORAL TABLET $1 MINASTRIN 24 FE ORAL TABLET $1 CHEWABLE MONO-LINYAH ORAL TABLET $1

^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 55 Drug Status Notes MONONESSA ORAL TABLET $1 MY WAY ORAL TABLET $1 MYZILRA ORAL TABLET $1 NATAZIA ORAL TABLET $1 NECON 0.5/35 (28) ORAL TABLET $1 NECON 1/35 (28) ORAL TABLET $1 NECON 1/50 (28) ORAL TABLET $1 NECON 10/11 (28) ORAL TABLET $1 NECON 7/7/7 ORAL TABLET $1 NEXT CHOICE ONE DOSE ORAL TABLET $1 NIKKI ORAL TABLET $1 NORA-BE ORAL TABLET $1 norethin ace-eth estrad-fe oral tablet $1 norethindrone acetate oral tablet $1 norethindrone acet-ethinyl est oral tablet $1 norethindrone oral tablet $1 norethindrone-eth estradiol oral tablet $1 norethin-eth estradiol-fe oral tablet chewable $1 norgestimate-eth estradiol oral tablet 0.25-35 $1 mg-mcg norgestim-eth estrad triphasic oral tablet $1 NORLYROC ORAL TABLET $1 NORTREL 0.5/35 (28) ORAL TABLET $1 NORTREL 1/35 (21) ORAL TABLET $1 NORTREL 1/35 (28) ORAL TABLET $1 NORTREL 7/7/7 ORAL TABLET $1 NUVARING VAGINAL RING $1 OCELLA ORAL TABLET $1 OGESTREL ORAL TABLET $1 ORSYTHIA ORAL TABLET $1 OSPHENA ORAL TABLET $1 PA PERJETA INTRAVENOUS* SOLUTION $1 SP PHILITH ORAL TABLET $1 PIMTREA ORAL TABLET $1 PIRMELLA 1/35 ORAL TABLET $1 PIRMELLA 7/7/7 ORAL TABLET $1

^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 56 Drug Status Notes PORTIA-28 ORAL TABLET $1 PREMARIN ORAL TABLET $1 PREMARIN VAGINAL CREAM $1 PREMPHASE ORAL TABLET $1 PREMPRO ORAL TABLET $1 PREVIFEM ORAL TABLET $1 progesterone intramuscular* oil $1 PA PROLIA SUBCUTANEOUS* SOLUTION $1 SP; QL (1 syringe per 180 days) QUARTETTE ORAL TABLET $1 QUASENSE ORAL TABLET $1 raloxifene hcl oral tablet $1 RECLIPSEN ORAL TABLET $1 risedronate sodium oral tablet 150 mg $1 PA; QL (1 EA per 30 days) risedronate sodium oral tablet 35 mg $1 PA; QL (4 EA per 28 days) risedronate sodium oral tablet 5 mg $1 PA; QL (30 EA per 30 days) risedronate sodium oral tablet delayed release $1 PA; QL (4 EA per 28 days) SAFYRAL ORAL TABLET $1 SEROPHENE ORAL TABLET $1 PA SETLAKIN ORAL TABLET $1 SHAROBEL ORAL TABLET $1 SOLTAMOX ORAL SOLUTION $1 SPRINTEC 28 ORAL TABLET $1 SRONYX ORAL TABLET $1 STRIANT BUCCAL $1 PA SYEDA ORAL TABLET $1 SYNAREL NASAL SOLUTION $1 PA tamoxifen citrate oral tablet $1 TARINA FE 1/20 ORAL TABLET $1 terconazole vaginal cream $1 terconazole vaginal suppository $1 TESTOPEL IMPLANT PELLET $1 PA testosterone cypionate intramuscular* solution $1 PA 100 mg/ml, 200 mg/ml testosterone enanthate intramuscular* solution $1 PA testosterone transdermal gel 10 mg/act (2%), 12.5 $1 PA mg/act (1%), 25 mg/2.5gm (1%), 50 mg/5gm (1%)

^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 57 Drug Status Notes TILIA FE ORAL TABLET $1 tinidazole oral tablet $1 tranexamic acid oral tablet $1 PA TRI-ESTARYLLA ORAL TABLET $1 TRI-LEGEST FE ORAL TABLET $1 TRI-LINYAH ORAL TABLET $1 TRI-LO-ESTARYLLA ORAL TABLET $1 TRI-LO-MARZIA ORAL TABLET $1 TRI-LO-SPRINTEC ORAL TABLET $1 TRINESSA (28) ORAL TABLET $1 TRINESSA LO ORAL TABLET $1 TRI-PREVIFEM ORAL TABLET $1 TRI-SPRINTEC ORAL TABLET $1 TRIVORA (28) ORAL TABLET $1 TYKERB ORAL TABLET $1 SP VAGIFEM VAGINAL TABLET 10 MCG $1 VANDAZOLE VAGINAL GEL $1 VELIVET ORAL TABLET $1 VESTURA ORAL TABLET $1 VIENVA ORAL TABLET $1 viorele oral tablet $1 VYFEMLA ORAL TABLET $1 WERA ORAL TABLET $1 WYMZYA FE ORAL TABLET CHEWABLE $1 XIAFLEX INJECTION SOLUTION Medical Benefit PA RECONSTITUTED XULANE TRANSDERMAL PATCH $1 WEEKLY ZARAH ORAL TABLET $1 ZENCHENT FE ORAL TABLET $1 CHEWABLE ZENCHENT ORAL TABLET $1 ZOLADEX SUBCUTANEOUS* IMPLANT PA; SP; QL (1 Implant per 28 $1 3.6 MG days) zoledronic acid intravenous* solution 5 mg/100ml $1 QL (1 vial per 1 Year) ZOVIA 1/35E (28) ORAL TABLET $1 ZOVIA 1/50E (28) ORAL TABLET $1 ^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 58 Drug Status Notes DISORDER OF THE CONNECTIVE TISSUE ACTEMRA INTRAVENOUS* SOLUTION $1 PA; SP; QL (4 vials per 28 days) 200 MG/10ML ACTEMRA INTRAVENOUS* SOLUTION $1 PA; SP; QL (2 vials per 28 days) 400 MG/20ML ACTEMRA INTRAVENOUS* SOLUTION 80 $1 PA; SP; QL (10 vials per 28 days) MG/4ML PA; SP; QL (4 syringes per 28 ACTEMRA SUBCUTANEOUS* $1 days) azathioprine oral tablet $1 BENLYSTA INTRAVENOUS* SOLUTION $1 PA; SP RECONSTITUTED celecoxib oral capsule $1 STPA; QL (60 EA per 30 days) CIMZIA PREFILLED SUBCUTANEOUS* $1 PA; SP; QL (2 EA per 28 days) KIT CIMZIA STARTER KIT SUBCUTANEOUS* $1 PA; SP KIT CIMZIA SUBCUTANEOUS* KIT 2 X 200 $1 PA; SP; QL (2 EA per 28 days) MG diclofenac sodium er oral tablet extended release $1 24 hr* EGRIFTA SUBCUTANEOUS* SOLUTION $1 PA; SP RECONSTITUTED PA; SP; QL (8 syringes per 28 ENBREL SUBCUTANEOUS* 25 MG/0.5ML $1 days) PA; SP; QL (4 syringes per 28 ENBREL SUBCUTANEOUS* 50 MG/ML $1 days) ENBREL SUBCUTANEOUS* SOLUTION PA; SP; QL (8 syringes per 28 $1 RECONSTITUTED days) PA; SP; QL (4 syringes per 28 ENBREL SURECLICK SUBCUTANEOUS* $1 days) ENBREL SURECLICK SUBCUTANEOUS* PA; SP; QL (4 syringes per 28 $1 SOLUTION days) etodolac er oral tablet extended release 24 hr* $1 flurbiprofen oral tablet $1 HALAVEN INTRAVENOUS* SOLUTION $1 SP HP ACTHAR INJECTION GEL $1 PA; SP HUMIRA PEDIATRIC CROHNS START $1 PA; SP; ¥ (1 Fill per life of plan) SUBCUTANEOUS* 40 MG/0.8ML HUMIRA PEN SUBCUTANEOUS* $1 PA; SP; QL (2 EA per 28 days) ^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 59 Drug Status Notes HUMIRA PEN-CROHNS STARTER $1 PA; SP; ¥ (1 Fill per life of plan) SUBCUTANEOUS* HUMIRA PEN-PSORIASIS STARTER $1 PA; SP; ¥ (1 Fill per life of plan) SUBCUTANEOUS* HUMIRA SUBCUTANEOUS* $1 PA; SP; QL (2 EA per 28 days) hydroxychloroquine sulfate oral tablet $1 KENALOG INJECTION SUSPENSION 10 $1 MG/ML ketoprofen er oral capsule extended release 24 $1 hour KINERET SUBCUTANEOUS* $1 PA; QL (28 Syringes per 28 days) leflunomide oral tablet $1 meloxicam oral suspension $1 meloxicam oral tablet $1 methotrexate oral tablet $1 MYALEPT SUBCUTANEOUS* SOLUTION $1 PA; QL (30 Vials per 30 days) RECONSTITUTED nabumetone oral tablet $1 ORENCIA CLICKJECT SUBCUTANEOUS* $1 PA; SP; QL (4 ML per 28 days) ORENCIA INTRAVENOUS* SOLUTION PA; SP; QL (4 VIALS per 28 $1 RECONSTITUTED days) ORENCIA SUBCUTANEOUS* $1 PA; SP; QL (4 ML per 28 days) oxaprozin oral tablet $1 PANRETIN EXTERNAL GEL $1 PA piroxicam oral capsule $1 REMICADE INTRAVENOUS* SOLUTION $1 PA; SP RECONSTITUTED RHEUMATREX ORAL TABLET 2.5 MG $1 RITUXAN INTRAVENOUS* $1 SP CONCENTRATE RITUXAN INTRAVENOUS* SOLUTION $1 SP salsalate oral tablet $1 SIMPONI ARIA INTRAVENOUS* $1 PA; SP; QL (5 vials per 8 Weeks) SOLUTION PA; SP; QL (1 syringe per 28 SIMPONI SUBCUTANEOUS* $1 days) sulfasalazine oral tablet delayed release $1 tolmetin sodium oral capsule $1

^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 60 Drug Status Notes tolmetin sodium oral tablet $1 TREXALL ORAL TABLET $1 VOTRIENT ORAL TABLET $1 SP XELJANZ ORAL TABLET $1 PA; SP; QL (60 EA per 30 days) XELJANZ XR ORAL TABLET EXTENDED $1 PA; SP; QL (30 EA per 30 days) RELEASE 24 HR* DISORDER OF THE DIGESTIVE SYSTEM ACIPHEX SPRINKLE ORAL CAPSULE $1 PA SPRINKLE adefovir dipivoxil oral tablet $1 AFINITOR ORAL TABLET $1 SP AKYNZEO ORAL CAPSULE $1 QL (1 EA per 1 Fill) ALINIA ORAL SUSPENSION $1 RECONSTITUTED ALINIA ORAL TABLET $1 alosetron hcl oral tablet $1 PA; QL (60 EA per 30 days) ALOXI INTRAVENOUS* SOLUTION 0.25 $1 QL (20 ML per 1 Rx) MG/5ML AMITIZA ORAL CAPSULE $1 PA; QL (60 EA per 30 days) amoxicill-clarithro-lansopraz oral $1 anucort-hc suppository $1 ANUSOL-HC SUPPOSITORY $1 ANZEMET ORAL TABLET 100 MG $1 QL (10 EA per 1 fill) ANZEMET ORAL TABLET 50 MG $1 QL (5 EA per 1 fill) APRISO ORAL CAPSULE EXTENDED $1 RELEASE 24 HOUR ASACOL HD ORAL TABLET DELAYED $1 RELEASE AVASTIN INTRAVENOUS* SOLUTION $1 SP balsalazide disodium oral capsule $1 BARACLUDE ORAL SOLUTION $1 BILTRICIDE ORAL TABLET $1 budesonide oral capsule delayed release particles $1 CANASA SUPPOSITORY $1 CANTIL ORAL TABLET $1 PA capecitabine oral tablet $1 SP CARAFATE ORAL SUSPENSION $1

^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 61 Drug Status Notes CESAMET ORAL CAPSULE $1 PA cevimeline hcl oral capsule $1 chlorhexidine gluconate mouth/throat solution $1 CHOLBAM ORAL CAPSULE $1 PA cimetidine hcl oral solution $1 cimetidine oral tablet $1 CIMZIA PREFILLED SUBCUTANEOUS* $1 PA; SP; QL (2 EA per 28 days) KIT CIMZIA STARTER KIT SUBCUTANEOUS* $1 PA; SP KIT CIMZIA SUBCUTANEOUS* KIT 2 X 200 $1 PA; SP; QL (2 EA per 28 days) MG CLINPRO 5000 DENTAL PASTE $1 COLOCORT ENEMA $1 COMPAZINE SUPPOSITORY $1 COMPRO SUPPOSITORY $1 constulose oral solution $1 CORTIFOAM FOAM $1 CREON ORAL CAPSULE DELAYED $1 RELEASE PARTICLES CUPRIMINE ORAL CAPSULE 250 MG $1 CUVPOSA ORAL SOLUTION $1 cyclosporine modified oral capsule $1 cyclosporine modified oral solution $1 cyclosporine oral capsule $1 PA; SP; QL (30 TABS per 30 DAKLINZA ORAL TABLET $1 days) DEFITELIO INTRAVENOUS* SOLUTION $1 DELZICOL ORAL CAPSULE DELAYED $1 RELEASE DENAVIR EXTERNAL CREAM $1 PA; QL (5 GM per 1 Fill) DENTA 5000 PLUS DENTAL CREAM $1 DENTAGEL DENTAL GEL $1 DEPEN TITRATABS ORAL TABLET $1 DEXILANT ORAL CAPSULE DELAYED $1 PA RELEASE 60 MG DICLEGIS ORAL TABLET DELAYED $1 PA RELEASE ^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 62 Drug Status Notes dicyclomine hcl oral capsule $1 dicyclomine hcl oral solution $1 dicyclomine hcl oral tablet $1 DIFICID ORAL TABLET $1 QL (20 EA per 1 Fill) dimenhydrinate oral tablet $1 DIPENTUM ORAL CAPSULE $1 diphenoxylate-atropine oral liquid† $1 diphenoxylate-atropine oral tablet $1 dronabinol oral capsule $1 ELAPRASE INTRAVENOUS* SOLUTION $1 SP EMEND ORAL CAPSULE $1 QL (6 EA per 1 Rx) entecavir oral tablet $1 ENTYVIO INTRAVENOUS* SOLUTION $1 PA; SP; QL (1 vial per 8 Weeks) RECONSTITUTED enulose oral solution $1 ERBITUX INTRAVENOUS* SOLUTION $1 SP ESCAVITE D ORAL TABLET CHEWABLE $1 Age Limit (Max 6 Years) ESCAVITE ORAL TABLET CHEWABLE $1 Age Limit (Max 6 Years) esomeprazole magnesium oral capsule delayed $1 PA release famotidine oral suspension reconstituted $1 famotidine oral tablet 20 mg, 40 mg $1 FLUORABON ORAL SOLUTION $1 FLUOR-A-DAY ORAL SOLUTION $1 FLUOR-A-DAY ORAL TABLET $1 CHEWABLE FLUORIDEX DAILY DEFENSE DENTAL $1 GEL FLUORIDEX SENSITIVITY RELIEF $1 DENTAL PASTE FLURA-DROPS ORAL SOLUTION 0.55 $1 (0.25 F) MG/DROP FUSILEV INTRAVENOUS* SOLUTION $1 SP RECONSTITUTED GAMASTAN S/D INTRAMUSCULAR* $1 PA; SP INJECTABLE

^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 63 Drug Status Notes GAMMAGARD S/D LESS IGA INTRAVENOUS* SOLUTION $1 PA; SP RECONSTITUTED GATTEX SUBCUTANEOUS* KIT $1 PA; SP; QL (1 Kit per 1 day) GAVILYTE-C ORAL SOLUTION $1 RECONSTITUTED GAVILYTE-G ORAL SOLUTION $1 RECONSTITUTED GAVILYTE-H ORAL KIT $1 generlac oral solution $1 GENGRAF ORAL CAPSULE 100 MG, 25 $1 MG GENGRAF ORAL SOLUTION $1 GIAZO ORAL TABLET $1 PA GOLYTELY ORAL SOLUTION $1 RECONSTITUTED 227.1 GM granisetron hcl oral tablet $1 QL (14 EA per 1 Fill) HARVONI ORAL TABLET $1 PA; SP HEMMOREX-HC SUPPOSITORY $1 HERCEPTIN INTRAVENOUS* SOLUTION $1 SP RECONSTITUTED HUMIRA PEDIATRIC CROHNS START $1 PA; SP; ¥ (1 Fill per life of plan) SUBCUTANEOUS* 40 MG/0.8ML HUMIRA PEN SUBCUTANEOUS* $1 PA; SP; QL (2 EA per 28 days) HUMIRA PEN-CROHNS STARTER $1 PA; SP; ¥ (1 Fill per life of plan) SUBCUTANEOUS* HUMIRA PEN-PSORIASIS STARTER $1 PA; SP; ¥ (1 Fill per life of plan) SUBCUTANEOUS* HUMIRA SUBCUTANEOUS* $1 PA; SP; QL (2 EA per 28 days) hydrocortisone ace-pramoxine cream $1 hydrocortisone ace-pramoxine external cream $1 2.5-1 % hydrocortisone acetate suppository $1 hydrocortisone enema $1 INTRON A INJECTION SOLUTION $1 SP INTRON A INJECTION SOLUTION $1 SP RECONSTITUTED irinotecan hcl intravenous* solution 40 mg/2ml, $1 500 mg/25ml

^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 64 Drug Status Notes ivermectin oral tablet $1 lactulose encephalopathy oral solution $1 lactulose oral solution $1 lamivudine oral tablet 100 mg $1 lansoprazole oral capsule delayed release $1 PA LIALDA ORAL TABLET DELAYED $1 STPA; QL (120 EA per 30 days) RELEASE LINZESS ORAL CAPSULE $1 PA; QL (30 EA per 30 days) LONSURF ORAL TABLET $1 PA; SP loperamide hcl oral capsule $1 meclizine hcl oral tablet $1 mesalamine enema $1 methscopolamine bromide oral tablet $1 PA metoclopramide hcl oral solution 10 mg/10ml, 5 $1 mg/5ml metoclopramide hcl oral tablet $1 misoprostol oral tablet $1 MODERIBA ORAL TABLET $1 QL (210 EA per 30 days) MOVANTIK ORAL TABLET $1 PA MOVIPREP ORAL SOLUTION $1 RECONSTITUTED multi vitamin/fluoride oral tablet chewable $1 multi-vit/fluoride oral solution $1 multi-vit/fluoride/iron oral solution $1 multi-vitamin/fluoride oral tablet chewable 0.5 $1 mg multivitamin/fluoride oral tablet chewable 1 mg $1 mycophenolate mofetil oral capsule $1 mycophenolate mofetil oral suspension $1 reconstituted mycophenolate mofetil oral tablet $1 NAFRINSE DAILY/NEUTRAL MOUTH/THROAT SOLUTION $1 RECONSTITUTED neomycin sulfate oral tablet $1 neutral sodium fluoride mouth/throat solution $1 NEXAVAR ORAL TABLET $1 SP NEXIUM ORAL PACKET $1 PA ^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 65 Drug Status Notes nizatidine oral capsule $1 nizatidine oral solution $1 PA; SP; QL (30 TABS per 30 OCALIVA ORAL TABLET $1 days) octreotide acetate injection solution 100 mcg/ml, 1000 mcg/ml, 200 mcg/ml, 50 mcg/ml, 500 $1 PA; SP; QL (30 ML per 30 days) mcg/ml omeprazole oral capsule delayed release $1 ondansetron hcl injection solution 4 mg/2ml, 40 $1 mg/20ml ondansetron hcl oral solution $1 QL (105 ML per 1 Fill) ondansetron hcl oral tablet $1 QL (21 EA per 1 Fill) ondansetron oral tablet dispersible $1 QL (21 EA per 1 Fill) ORALONE MOUTH/THROAT PASTE $1 OSMOPREP ORAL TABLET $1 QL (32 EA per 1 Fill) PANCREAZE ORAL CAPSULE DELAYED $1 RELEASE PARTICLES paregoric oral tincture $1 PAROEX MOUTH/THROAT SOLUTION $1 paromomycin sulfate oral capsule $1 peg 3350/electrolytes oral solution reconstituted $1 peg 3350-kcl-na bicarb-nacl oral solution $1 reconstituted peg-3350/electrolytes oral solution reconstituted $1 PEGASYS PROCLICK SUBCUTANEOUS* $1 SP; QL (4 ML per 28 days) SOLUTION PEGASYS SUBCUTANEOUS* SOLUTION $1 SP; QL (4 ML per 28 days) PEG-INTRON REDIPEN PAK 4 $1 SP; QL (4 EA per 28 days) SUBCUTANEOUS* KIT 120 MCG/0.5ML PEG-INTRON REDIPEN SUBCUTANEOUS* $1 SP; QL (4 EA per 28 days) KIT PEGINTRON SUBCUTANEOUS* KIT $1 SP; QL (4 EA per 28 days) PEG-INTRON SUBCUTANEOUS* KIT $1 SP; QL (4 EA per 28 days) PENTASA ORAL CAPSULE EXTENDED $1 RELEASE* PERIOGARD MOUTH/THROAT $1 SOLUTION PERTZYE ORAL CAPSULE DELAYED $1 RELEASE PARTICLES ^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 66 Drug Status Notes PHENADOZ SUPPOSITORY $1 PHENERGAN SUPPOSITORY $1 pilocarpine hcl oral tablet $1 polyethylene glycol 3350 oral packet $1 PA polyethylene glycol 3350 oral powder $1 POLY-VI-FLOR ORAL SUSPENSION $1 pramcort cream $1 PREPOPIK ORAL PACKET $1 PREVACID SOLUTAB ORAL TABLET $1 PA; Age Limit (Max 2 Years) DISPERSIBLE PRILOSEC ORAL PACKET $1 PA prochlorperazine edisylate injection solution $1 prochlorperazine maleate oral tablet $1 prochlorperazine suppository $1 PROCTOFOAM HC FOAM $1 PROGLYCEM ORAL SUSPENSION $1 PA PROMACTA ORAL TABLET $1 PA; SP promethazine hcl oral solution $1 promethazine hcl oral syrup $1 promethazine hcl oral tablet $1 promethazine hcl suppository $1 PROMETHEGAN SUPPOSITORY $1 PYLERA ORAL CAPSULE $1 rabeprazole sodium oral tablet delayed release $1 PA ranitidine hcl oral capsule $1 ranitidine hcl oral syrup $1 ranitidine hcl oral tablet 150 mg, 300 mg $1 REBETOL ORAL SOLUTION $1 SP; QL (35 ML per 1 day) RELISTOR SUBCUTANEOUS* SOLUTION $1 PA 12 MG/0.6ML, 8 MG/0.4ML REMICADE INTRAVENOUS* SOLUTION $1 PA; SP RECONSTITUTED RIBASPHERE ORAL CAPSULE $1 QL (210 EA per 30 days) RIBASPHERE ORAL TABLET 200 MG $1 QL (210 EA per 30 days) ribavirin oral capsule $1 SP; QL (210 EA per 30 days) ribavirin oral tablet 200 mg $1 SP; QL (210 EA per 30 days) SANCUSO TRANSDERMAL PATCH $1 PA ^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 67 Drug Status Notes SANDIMMUNE ORAL SOLUTION $1 SANDOSTATIN LAR DEPOT $1 PA; SP; QL (1 vial per 28 days) INTRAMUSCULAR* KIT sf 5000 plus dental cream $1 sf dental gel $1 SFROWASA ENEMA $1 sodium fluoride oral solution $1 sodium fluoride oral tablet 1.1 (0.5 f) mg $1 sodium fluoride oral tablet chewable $1 SOVALDI ORAL TABLET $1 PA; SP spironolactone oral tablet $1 STIVARGA ORAL TABLET $1 SP sucralfate oral tablet $1 sulfasalazine oral tablet $1 sulfasalazine oral tablet delayed release $1 SUPREP BOWEL PREP ORAL SOLUTION $1 SUTENT ORAL CAPSULE $1 SP SYPRINE ORAL CAPSULE $1 PA tacrolimus oral capsule $1 tinidazole oral tablet $1 TRANSDERM-SCOP (1.5 MG) $1 TRANSDERMAL PATCH 72 HR triamcinolone acetonide mouth/throat paste $1 TRILYTE ORAL SOLUTION $1 RECONSTITUTED trimethobenzamide hcl oral capsule $1 tri-vit/fluoride/iron oral solution $1 tri-vitamin/fluoride oral solution $1 TYSABRI INTRAVENOUS* $1 PA; SP; QL (1 vial per 28 days) CONCENTRATE TYZEKA ORAL TABLET $1 UCERIS FOAM $1 PA UCERIS ORAL TABLET EXTENDED $1 PA RELEASE 24 HR* ursodiol oral capsule $1 ursodiol oral tablet $1 vancomycin hcl oral capsule $1 QL (40 EA per 10 days)

^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 68 Drug Status Notes VECTIBIX INTRAVENOUS* SOLUTION $1 SP 100 MG/5ML, 400 MG/20ML VIBERZI ORAL TABLET $1 VIEKIRA PAK ORAL $1 PA VIREAD ORAL POWDER $1 VIREAD ORAL TABLET $1 XIFAXAN ORAL TABLET 200 MG $1 QL (9 EA per 30 days) XIFAXAN ORAL TABLET 550 MG $1 QL (6 EA per 30 days) ZALTRAP INTRAVENOUS* SOLUTION $1 SP ZEGERID ORAL PACKET $1 PA ZENPEP ORAL CAPSULE DELAYED $1 RELEASE PARTICLES ZORTRESS ORAL TABLET $1 SP ZOVIRAX EXTERNAL CREAM $1 PA; QL (5 GM per 1 Rx) DISORDER OF THE ENDOCRINE GLANDS acarbose oral tablet $1 ACTOPLUS MET XR ORAL TABLET $1 EXTENDED RELEASE 24 HR* ALDURAZYME INTRAVENOUS* $1 SP SOLUTION alendronate sodium oral tablet 10 mg, 5 mg $1 QL (30 EA per 30 days) alendronate sodium oral tablet 35 mg, 70 mg $1 QL (4 EA per 28 days) alogliptin benzoate oral tablet $1 PA; QL (30 EA per 30 days) alogliptin-metformin hcl oral tablet $1 PA; QL (60 EA per 30 days) alogliptin-pioglitazone oral tablet $1 PA; QL (30 EA per 30 days) ANDRODERM TRANSDERMAL PATCH 24 $1 PA HR 2 MG/24HR, 4 MG/24HR ANDROGEL PUMP TRANSDERMAL GEL $1 PA 20.25 MG/ACT (1.62%) ANDROGEL TRANSDERMAL GEL 20.25 MG/1.25GM (1.62%), 40.5 MG/2.5GM $1 PA (1.62%), 50 MG/5GM (1%) ANDROXY ORAL TABLET $1 APIDRA INJECTION SOLUTION $1 APIDRA SOLOSTAR SUBCUTANEOUS* $1 AURYXIA ORAL TABLET $1 PA AVANDAMET ORAL TABLET $1 AVANDARYL ORAL TABLET $1 ^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 69 Drug Status Notes AVANDIA ORAL TABLET $1 AXIRON TRANSDERMAL SOLUTION $1 PA bromocriptine mesylate oral capsule $1 bromocriptine mesylate oral tablet $1 BYDUREON SUBCUTANEOUS* $1 BYETTA 10 MCG PEN SUBCUTANEOUS* $1 BYETTA 10 MCG PEN SUBCUTANEOUS* $1 SOLUTION BYETTA 5 MCG PEN SUBCUTANEOUS* $1 BYETTA 5 MCG PEN SUBCUTANEOUS* $1 SOLUTION cabergoline oral tablet $1 calcitonin (salmon) nasal solution $1 calcium acetate (phos binder) oral capsule $1 calcium acetate (phos binder) oral tablet $1 CAPRELSA ORAL TABLET $1 captopril oral tablet $1 chlorpropamide oral tablet $1 CLIMARA PRO TRANSDERMAL PATCH $1 WEEKLY COMBIPATCH TRANSDERMAL PATCH $1 BIWEEKLY COMETRIQ (100 MG DAILY DOSE) ORAL $1 KIT COMETRIQ (140 MG DAILY DOSE) ORAL $1 KIT COMETRIQ (60 MG DAILY DOSE) ORAL $1 KIT cortisone acetate oral tablet $1 CRINONE VAGINAL GEL 8 % $1 PA DEPO-TESTOSTERONE INTRAMUSCULAR* SOLUTION 100 $1 PA MG/ML desmopressin ace rhinal tube nasal solution $1 desmopressin ace spray refrig nasal solution $1 desmopressin acetate oral tablet $1 desmopressin acetate spray nasal solution $1

^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 70 Drug Status Notes DEXAMETHASONE INTENSOL ORAL $1 CONCENTRATE dexamethasone oral elixir $1 dexamethasone oral solution $1 dexamethasone oral tablet $1 DEXPAK 10 DAY ORAL $1 DEXPAK 13 DAY ORAL $1 DEXPAK 6 DAY ORAL $1 DIABETA ORAL TABLET $1 DIVIGEL TRANSDERMAL GEL $1 PA doxercalciferol oral capsule $1 ELAPRASE INTRAVENOUS* SOLUTION $1 SP ELESTRIN TRANSDERMAL GEL $1 PA ESTRACE VAGINAL CREAM $1 estradiol transdermal patch biweekly $1 estradiol transdermal patch weekly $1 ESTRING VAGINAL RING $1 ESTROGEL TRANSDERMAL GEL $1 PA estropipate oral tablet $1 EYLEA INTRAOCULAR SOLUTION $1 SP FARXIGA ORAL TABLET $1 PA; QL (30 EA per 30 days) FEMRING VAGINAL RING $1 fludrocortisone acetate oral tablet $1 FORTEO SUBCUTANEOUS* SOLUTION $1 PA; SP; QL (1 vial per 30 days) 600 MCG/2.4ML FORTICAL NASAL SOLUTION $1 FOSAMAX PLUS D ORAL TABLET $1 PA; QL (4 EA per 28 days) FOSRENOL ORAL PACKET $1 FOSRENOL ORAL TABLET CHEWABLE $1 1000 MG, 500 MG, 750 MG glimepiride oral tablet $1 glipizide er oral tablet extended release 24 hr* $1 glipizide oral tablet $1 glipizide xl oral tablet extended release 24 hr* $1 glipizide-metformin hcl oral tablet $1 GLUCAGEN HYPOKIT INJECTION $1 SOLUTION RECONSTITUTED ^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 71 Drug Status Notes GLUCAGON EMERGENCY INJECTION $1 KIT glyburide micronized oral tablet $1 glyburide oral tablet $1 glyburide-metformin oral tablet $1 GLYSET ORAL TABLET $1 HUMALOG KWIKPEN SUBCUTANEOUS* $1 100 UNIT/ML, 200 UNIT/ML HUMALOG MIX 50/50 KWIKPEN $1 SUBCUTANEOUS* HUMALOG MIX 50/50 SUBCUTANEOUS* $1 SUSPENSION HUMALOG MIX 75/25 KWIKPEN $1 SUBCUTANEOUS* HUMALOG MIX 75/25 SUBCUTANEOUS* $1 SUSPENSION HUMALOG SUBCUTANEOUS* $1 HUMALOG SUBCUTANEOUS* SOLUTION $1 HUMULIN 70/30 KWIKPEN $1 SUBCUTANEOUS* HUMULIN 70/30 SUBCUTANEOUS* $1 SUSPENSION HUMULIN N KWIKPEN SUBCUTANEOUS* $1 HUMULIN N SUBCUTANEOUS* $1 SUSPENSION HUMULIN R INJECTION SOLUTION $1 HUMULIN R U-500 (CONCENTRATED) $1 SUBCUTANEOUS* SOLUTION HUMULIN R U-500 KWIKPEN $1 SUBCUTANEOUS* HUMULIN R U-500 KWIKPEN $1 SUBCUTANEOUS* SOLUTION hydrocortisone oral tablet $1 hydroxyprogesterone caproate intramuscular* oil $1 ibandronate sodium intravenous* solution 3 $1 PA; QL (3 ML per 90 days) mg/3ml ibandronate sodium oral tablet $1 PA; QL (1 EA per 28 days) INCRELEX SUBCUTANEOUS* SOLUTION $1 PA; SP INVOKAMET ORAL TABLET $1 STPA; QL (60 EA per 30 days)

^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 72 Drug Status Notes INVOKANA ORAL TABLET 100 MG $1 STPA; QL (30 EA per 30 days) INVOKANA ORAL TABLET 300 MG $1 STPA; QL (60 EA per 30 days) JANUMET ORAL TABLET $1 STPA; QL (60 EA per 30 days) JANUMET XR ORAL TABLET EXTENDED $1 STPA; QL (30 EA per 30 days) RELEASE 24 HR* JANUVIA ORAL TABLET $1 STPA; QL (30 EA per 30 days) JENTADUETO ORAL TABLET $1 STPA; QL (60 EA per 30 days) KAZANO ORAL TABLET $1 PA; QL (60 EA per 30 days) KENALOG INJECTION SUSPENSION 40 $1 MG/ML KORLYM ORAL TABLET $1 PA LANTUS SOLOSTAR SUBCUTANEOUS* $1 LANTUS SUBCUTANEOUS* SOLUTION $1 LENVIMA 10 MG DAILY DOSE ORAL $1 PA LENVIMA 14 MG DAILY DOSE ORAL $1 PA LENVIMA 20 MG DAILY DOSE ORAL $1 PA LENVIMA 24 MG DAILY DOSE ORAL $1 PA leuprolide acetate injection kit $1 PA; SP LEVEMIR FLEXPEN SUBCUTANEOUS* $1 LEVEMIR FLEXTOUCH $1 SUBCUTANEOUS* LEVEMIR SUBCUTANEOUS* SOLUTION $1 LEVO-T ORAL TABLET $1 levothyroxine sodium oral tablet $1 LEVOXYL ORAL TABLET $1 liothyronine sodium oral tablet $1 LUCENTIS INTRAOCULAR SOLUTION $1 SP LUPRON DEPOT-PED INTRAMUSCULAR* $1 PA; SP KIT LYRICA ORAL CAPSULE $1 PA; QL (60 EA per 30 days) LYRICA ORAL SOLUTION $1 PA; QL (900 ML per 30 days) LYSODREN ORAL TABLET $1 MEDROL ORAL TABLET 2 MG $1 medroxyprogesterone acetate oral tablet $1 MENEST ORAL TABLET $1 metformin hcl er (mod) oral tablet extended $1 release 24 hr* 1000 mg

^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 73 Drug Status Notes metformin hcl er oral tablet extended release 24 $1 hr* metformin hcl oral tablet $1 methimazole oral tablet $1 methitest oral tablet $1 PA methylprednisolone oral $1 methylprednisolone oral tablet $1 methylprednisolone sodium succ injection $1 solution reconstituted 125 mg, 40 mg methyltestosterone oral capsule $1 metoclopramide hcl oral solution 10 mg/10ml, 5 $1 mg/5ml metoclopramide hcl oral tablet $1 MIACALCIN INJECTION SOLUTION $1 MILLIPRED DP ORAL $1 MILLIPRED ORAL TABLET $1 NAGLAZYME INTRAVENOUS* $1 SP SOLUTION nateglinide oral tablet $1 PA; SP; QL (2 Cartridges per 21 NATPARA SUBCUTANEOUS* $1 days) NESINA ORAL TABLET $1 PA; QL (30 EA per 30 days) NEXAVAR ORAL TABLET $1 SP NORDITROPIN FLEXPRO $1 PA; SP SUBCUTANEOUS* SOLUTION norethindrone acetate oral tablet $1 norethindrone-eth estradiol oral tablet $1 NOVOLIN 70/30 RELION $1 SUBCUTANEOUS* SUSPENSION NOVOLIN 70/30 SUBCUTANEOUS* $1 SUSPENSION NOVOLIN N RELION SUBCUTANEOUS* $1 SUSPENSION NOVOLIN N SUBCUTANEOUS* $1 SUSPENSION NOVOLIN R INJECTION SOLUTION $1 NOVOLIN R RELION INJECTION $1 SOLUTION NOVOLOG FLEXPEN SUBCUTANEOUS* $1 ^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 74 Drug Status Notes NOVOLOG MIX 70/30 FLEXPEN $1 SUBCUTANEOUS* NOVOLOG MIX 70/30 SUBCUTANEOUS* $1 SUSPENSION NOVOLOG PENFILL SUBCUTANEOUS* $1 NOVOLOG SUBCUTANEOUS* SOLUTION $1 NUCYNTA ER ORAL TABLET EXTENDED $1 PA RELEASE 12 HR* octreotide acetate injection solution 100 mcg/ml, 1000 mcg/ml, 200 mcg/ml, 50 mcg/ml, 500 $1 PA; SP; QL (30 ML per 30 days) mcg/ml ONGLYZA ORAL TABLET $1 PA; QL (30 EA per 30 days) OSENI ORAL TABLET $1 PA; QL (30 EA per 30 days) OSPHENA ORAL TABLET $1 PA paricalcitol oral capsule $1 PA PHOSLYRA ORAL SOLUTION $1 pioglitazone hcl oral tablet $1 pioglitazone hcl-glimepiride oral tablet $1 pioglitazone hcl-metformin hcl oral tablet $1 prednisolone oral solution $1 prednisolone oral syrup 15 mg/5ml $1 prednisolone sodium phosphate oral solution 15 $1 mg/5ml, 25 mg/5ml, 6.7 (5 base) mg/5ml prednisolone sodium phosphate oral tablet $1 dispersible PREMARIN ORAL TABLET $1 PREMARIN VAGINAL CREAM $1 PREMPHASE ORAL TABLET $1 PREMPRO ORAL TABLET $1 progesterone intramuscular* oil $1 PA PROGLYCEM ORAL SUSPENSION $1 PA PROLIA SUBCUTANEOUS* SOLUTION $1 SP; QL (1 syringe per 180 days) propylthiouracil oral tablet $1 raloxifene hcl oral tablet $1 REGRANEX EXTERNAL GEL $1 RENAGEL ORAL TABLET $1 RENVELA ORAL TABLET $1 repaglinide oral tablet $1 ^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 75 Drug Status Notes repaglinide-metformin hcl oral tablet $1 RIOMET ORAL SOLUTION $1 risedronate sodium oral tablet 150 mg $1 PA; QL (1 EA per 30 days) risedronate sodium oral tablet 35 mg $1 PA; QL (4 EA per 28 days) risedronate sodium oral tablet 5 mg $1 PA; QL (30 EA per 30 days) risedronate sodium oral tablet delayed release $1 PA; QL (4 EA per 28 days) SAMSCA ORAL TABLET 15 MG $1 SP; QL (30 EA per 30 days) SAMSCA ORAL TABLET 30 MG $1 SP; QL (60 EA per 30 days) SANDOSTATIN LAR DEPOT $1 PA; SP; QL (1 vial per 28 days) INTRAMUSCULAR* KIT SENSIPAR ORAL TABLET $1 STPA; SP SEROSTIM SUBCUTANEOUS* SOLUTION $1 PA; SP RECONSTITUTED 4 MG, 5 MG, 6 MG SIGNIFOR SUBCUTANEOUS* SOLUTION $1 PA; QL (60 ML per 30 days) SOLU-CORTEF INJECTION SOLUTION $1 RECONSTITUTED 100 MG, 1000 MG SOMATULINE DEPOT SUBCUTANEOUS* $1 PA; SP; QL (1 ML per 28 days) SOLUTION SOMAVERT SUBCUTANEOUS* $1 PA; SP; QL (30 EA per 30 days) SOLUTION RECONSTITUTED STRIANT BUCCAL $1 PA SUPPRELIN LA SUBCUTANEOUS* KIT $1 PA; SP SYMLINPEN 120 SUBCUTANEOUS* $1 SYMLINPEN 60 SUBCUTANEOUS* $1 SYNAREL NASAL SOLUTION $1 PA TANZEUM SUBCUTANEOUS* $1 TESTOPEL IMPLANT PELLET $1 PA testosterone cypionate intramuscular* solution $1 PA 100 mg/ml, 200 mg/ml testosterone enanthate intramuscular* solution $1 PA testosterone transdermal gel 10 mg/act (2%), 12.5 $1 PA mg/act (1%), 25 mg/2.5gm (1%), 50 mg/5gm (1%) THYROGEN INTRAMUSCULAR* $1 SP SOLUTION RECONSTITUTED THYROLAR-1 ORAL TABLET $1 THYROLAR-1/2 ORAL TABLET $1 THYROLAR-1/4 ORAL TABLET $1 THYROLAR-2 ORAL TABLET $1 ^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 76 Drug Status Notes THYROLAR-3 ORAL TABLET $1 tolazamide oral tablet $1 tolbutamide oral tablet $1 TOUJEO SOLOSTAR SUBCUTANEOUS* $1 TRADJENTA ORAL TABLET $1 STPA; QL (30 EA per 30 days) TRESIBA FLEXTOUCH SUBCUTANEOUS* $1 TRULICITY SUBCUTANEOUS* $1 UNITHROID ORAL TABLET $1 VAGIFEM VAGINAL TABLET 10 MCG $1 VICTOZA SUBCUTANEOUS* $1 XIGDUO XR ORAL TABLET EXTENDED $1 PA RELEASE 24 HR* zoledronic acid intravenous* solution 5 mg/100ml $1 QL (1 vial per 1 Year) ZORBTIVE SUBCUTANEOUS* SOLUTION $1 PA; SP RECONSTITUTED EAR PROBLEM ACETASOL HC OTIC SOLUTION $1 acetic acid otic solution $1 acetic acid-aluminum acetate otic solution $1 ARCALYST SUBCUTANEOUS* SOLUTION $1 PA; SP RECONSTITUTED CIPRO HC OTIC SUSPENSION $1 CIPRODEX OTIC SUSPENSION $1 dexamethasone sodium phosphate ophthalmic $1 solution fluocinolone acetonide otic oil $1 hydrocortisone-acetic acid otic solution $1 ILARIS SUBCUTANEOUS* SOLUTION $1 PA; SP RECONSTITUTED neomycin-polymyxin-hc otic solution $1 neomycin-polymyxin-hc otic suspension $1 ofloxacin otic solution $1 EYE DISORDER acetazolamide oral tablet $1 ADRENALIN INJECTION SOLUTION 1 $1 MG/ML ALOCRIL OPHTHALMIC SOLUTION $1 PA

^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 77 Drug Status Notes ALPHAGAN P OPHTHALMIC SOLUTION $1 PA 0.1 % ALREX OPHTHALMIC SUSPENSION $1 atropine sulfate ophthalmic ointment $1 atropine sulfate ophthalmic solution $1 AZASITE OPHTHALMIC SOLUTION $1 QL (2.5 mL per 1 fill) azelastine hcl ophthalmic solution $1 PA AZOPT OPHTHALMIC SUSPENSION $1 PA bacitracin ophthalmic ointment $1 bacitracin-polymyxin b ophthalmic ointment $1 500-10000 unit/gm BEPREVE OPHTHALMIC SOLUTION $1 PA BESIVANCE OPHTHALMIC SUSPENSION $1 betaxolol hcl ophthalmic solution $1 BETIMOL OPHTHALMIC SOLUTION $1 BETOPTIC-S OPHTHALMIC SUSPENSION $1 bimatoprost ophthalmic solution $1 PA BLEPHAMIDE OPHTHALMIC $1 SUSPENSION BLEPHAMIDE S.O.P. OPHTHALMIC $1 OINTMENT brimonidine tartrate ophthalmic solution 0.15 % $1 PA brimonidine tartrate ophthalmic solution 0.2 % $1 bromfenac sodium (once-daily) ophthalmic $1 solution bromfenac sodium ophthalmic solution $1 carteolol hcl ophthalmic solution $1 cevimeline hcl oral capsule $1 CILOXAN OPHTHALMIC OINTMENT $1 ciprofloxacin hcl ophthalmic solution $1 COMBIGAN OPHTHALMIC SOLUTION $1 PA COSOPT PF OPHTHALMIC SOLUTION $1 cromolyn sodium ophthalmic solution $1 cyclopentolate hcl ophthalmic solution $1 QL (2 ML per 30 days) dexamethasone sodium phosphate ophthalmic $1 solution diclofenac sodium ophthalmic solution $1

^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 78 Drug Status Notes dorzolamide hcl ophthalmic solution $1 dorzolamide hcl-timolol mal ophthalmic solution $1 DUREZOL OPHTHALMIC EMULSION $1 EMADINE OPHTHALMIC SOLUTION $1 PA epinastine hcl ophthalmic solution $1 PA erythromycin ophthalmic ointment $1 EYLEA INTRAOCULAR SOLUTION $1 SP FLAREX OPHTHALMIC SUSPENSION $1 fluorometholone ophthalmic suspension $1 flurbiprofen sodium ophthalmic solution $1 FML FORTE OPHTHALMIC SUSPENSION $1 FML OPHTHALMIC OINTMENT $1 GAMMAGARD S/D LESS IGA INTRAVENOUS* SOLUTION $1 PA; SP RECONSTITUTED gatifloxacin ophthalmic solution $1 GENTAK OPHTHALMIC OINTMENT $1 gentamicin sulfate ophthalmic ointment $1 gentamicin sulfate ophthalmic solution $1 HOMATROPAIRE OPHTHALMIC $1 SOLUTION homatropine hbr ophthalmic solution $1 ILEVRO OPHTHALMIC SUSPENSION $1 ILOTYCIN OPHTHALMIC OINTMENT $1 ISOPTO CARBACHOL OPHTHALMIC $1 SOLUTION ketorolac tromethamine ophthalmic solution $1 ketotifen fumarate ophthalmic solution $1 LASTACAFT OPHTHALMIC SOLUTION $1 PA latanoprost ophthalmic solution $1 levobunolol hcl ophthalmic solution $1 levofloxacin ophthalmic solution $1 LOTEMAX OPHTHALMIC GEL $1 LOTEMAX OPHTHALMIC OINTMENT $1 LOTEMAX OPHTHALMIC SUSPENSION $1 LUCENTIS INTRAOCULAR SOLUTION $1 SP

^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 79 Drug Status Notes LUMIGAN OPHTHALMIC SOLUTION 0.01 $1 PA % MACUGEN INTRAOCULAR SOLUTION $1 SP MAXIDEX OPHTHALMIC SUSPENSION $1 methazolamide oral tablet $1 metipranolol ophthalmic solution $1 MOXEZA OPHTHALMIC SOLUTION $1 naphazoline hcl ophthalmic solution $1 NATACYN OPHTHALMIC SUSPENSION $1 PA neomycin-bacitracin zn-polymyx ophthalmic $1 ointment neomycin-polymyxin-gramicidin ophthalmic $1 solution 1.75-10000-.025 neomycin-polymyxin-hc ophthalmic suspension $1 3.5-10000-1 NEO-POLYCIN OPHTHALMIC $1 OINTMENT NEVANAC OPHTHALMIC SUSPENSION $1 ofloxacin ophthalmic solution $1 olopatadine hcl ophthalmic solution $1 PA PATADAY OPHTHALMIC SOLUTION $1 PA PHOSPHOLINE IODIDE OPHTHALMIC $1 SOLUTION RECONSTITUTED pilocarpine hcl ophthalmic solution 1 %, 2 %, 4 $1 % pilocarpine hcl oral tablet $1 POLYCIN OPHTHALMIC OINTMENT $1 polymyxin b-trimethoprim ophthalmic solution $1 polyvinyl alcohol ophthalmic solution $1 PRED MILD OPHTHALMIC SUSPENSION $1 PRED-G OPHTHALMIC SUSPENSION $1 PRED-G S.O.P. OPHTHALMIC OINTMENT $1 prednisolone acetate ophthalmic suspension $1 prednisolone sodium phosphate ophthalmic $1 solution proparacaine hcl ophthalmic solution $1 RESCULA OPHTHALMIC SOLUTION $1 PA RESTASIS OPHTHALMIC EMULSION $1 PA; QL (60 EA per 30 days) ^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 80 Drug Status Notes SIMBRINZA OPHTHALMIC SUSPENSION $1 PA sulfacetamide sodium ophthalmic ointment $1 sulfacetamide sodium ophthalmic solution $1 sulfacetamide-prednisolone ophthalmic solution $1 timolol maleate ophthalmic gel forming solution $1 timolol maleate ophthalmic solution $1 TIMOPTIC OCUDOSE OPHTHALMIC $1 SOLUTION 0.25 % TOBRADEX OPHTHALMIC OINTMENT $1 tobramycin ophthalmic solution $1 tobramycin-dexamethasone ophthalmic $1 suspension TOBREX OPHTHALMIC OINTMENT $1 TRAVATAN Z OPHTHALMIC SOLUTION $1 PA TRIESENCE INTRAOCULAR SUSPENSION $1 trifluridine ophthalmic solution $1 tropicamide ophthalmic solution $1 VALCYTE ORAL SOLUTION $1 RECONSTITUTED valganciclovir hcl oral tablet $1 VEXOL OPHTHALMIC SUSPENSION $1 VIGAMOX OPHTHALMIC SOLUTION $1 VISUDYNE INTRAVENOUS* SOLUTION $1 SP RECONSTITUTED XEOMIN INTRAMUSCULAR* SOLUTION $1 PA; SP RECONSTITUTED ZIOPTAN OPHTHALMIC SOLUTION $1 PA ZIRGAN OPHTHALMIC GEL $1 PA ZYLET OPHTHALMIC SUSPENSION $1 QL (5 mL per 30 days) FEVER dantrolene sodium oral capsule $1 GAMMAGARD S/D LESS IGA INTRAVENOUS* SOLUTION $1 PA; SP RECONSTITUTED INFECTION abacavir sulfate oral tablet $1 abacavir-lamivudine-zidovudine oral tablet $1 acyclovir external ointment $1 ^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 81 Drug Status Notes acyclovir oral tablet 800 mg $1 adefovir dipivoxil oral tablet $1 ADRENALIN INJECTION SOLUTION $1 ALFERON N INJECTION SOLUTION $1 SP ALINIA ORAL SUSPENSION $1 RECONSTITUTED ALINIA ORAL TABLET $1 ALTABAX EXTERNAL OINTMENT $1 STPA; QL (15 GM per 1 Fill) amantadine hcl oral capsule $1 amantadine hcl oral syrup $1 amantadine hcl oral tablet $1 amoxicill-clarithro-lansopraz oral $1 APTIVUS ORAL CAPSULE $1 APTIVUS ORAL SOLUTION $1 atovaquone oral suspension $1 atovaquone-proguanil hcl oral tablet $1 ATRIPLA ORAL TABLET $1 AVC VAGINAL VAGINAL CREAM $1 AZASITE OPHTHALMIC SOLUTION $1 QL (2.5 mL per 1 fill) azithromycin oral tablet 600 mg $1 bacitracin ophthalmic ointment $1 bacitracin-polymyxin b ophthalmic ointment $1 500-10000 unit/gm BACTROBAN NASAL NASAL OINTMENT $1 BARACLUDE ORAL SOLUTION $1 BESIVANCE OPHTHALMIC SUSPENSION $1 BILTRICIDE ORAL TABLET $1 CENTANY EXTERNAL OINTMENT $1 chlorhexidine gluconate mouth/throat solution $1 chloroquine phosphate oral tablet $1 CICLODAN EXTERNAL CREAM $1 CICLODAN EXTERNAL SOLUTION $1 ciclopirox external gel $1 ciclopirox external solution $1 ciclopirox olamine external cream $1 ciclopirox olamine external suspension $1 PA

^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 82 Drug Status Notes CILOXAN OPHTHALMIC OINTMENT $1 CIPRODEX OTIC SUSPENSION $1 ciprofloxacin hcl ophthalmic solution $1 ciprofloxacin hcl oral tablet 100 mg $1 ciprofloxacin-ciproflox hcl er oral tablet extended $1 release 24 hr* CLEOCIN VAGINAL SUPPOSITORY $1 clindamycin phosphate vaginal cream $1 clotrimazole anti-fungal external cream $1 clotrimazole external cream $1 clotrimazole external solution $1 clotrimazole mouth/throat lozenge $1 clotrimazole mouth/throat troche $1 clotrimazole-betamethasone external cream $1 clotrimazole-betamethasone external lotion $1 COARTEM ORAL TABLET $1 QL (24 EA per 30 days) COMPLERA ORAL TABLET $1 CONDYLOX EXTERNAL GEL $1 CORTISPORIN EXTERNAL CREAM $1 CRESEMBA ORAL CAPSULE $1 CRIXIVAN ORAL CAPSULE 200 MG, 400 $1 MG cycloserine oral capsule $1 CYTOGAM INTRAVENOUS* INJECTABLE $1 SP PA; SP; QL (30 TABS per 30 DAKLINZA ORAL TABLET $1 days) DENAVIR EXTERNAL CREAM $1 PA; QL (5 GM per 1 Fill) didanosine oral capsule delayed release $1 DIFICID ORAL TABLET $1 QL (20 EA per 1 Fill) dronabinol oral capsule $1 econazole nitrate external cream $1 ECOZA EXTERNAL FOAM $1 PA EDURANT ORAL TABLET $1 EGRIFTA SUBCUTANEOUS* SOLUTION $1 PA; SP RECONSTITUTED EMTRIVA ORAL CAPSULE $1 EMTRIVA ORAL SOLUTION $1 ^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 83 Drug Status Notes entecavir oral tablet $1 epinephrine hcl injection solution 1 mg/ml $1 EPZICOM ORAL TABLET $1 erythromycin ophthalmic ointment $1 ethambutol hcl oral tablet $1 EURAX EXTERNAL CREAM $1 EURAX EXTERNAL LOTION $1 EVOTAZ ORAL TABLET $1 EXELDERM EXTERNAL CREAM $1 PA EXELDERM EXTERNAL SOLUTION $1 PA FLAGYL ER ORAL TABLET EXTENDED $1 RELEASE 24 HR* FUZEON SUBCUTANEOUS* SOLUTION $1 SP RECONSTITUTED gabapentin oral capsule $1 gabapentin oral solution 250 mg/5ml $1 gabapentin oral tablet $1 GAMASTAN S/D INTRAMUSCULAR* $1 PA; SP INJECTABLE gatifloxacin ophthalmic solution $1 GENTAK OPHTHALMIC OINTMENT $1 gentamicin sulfate external cream $1 gentamicin sulfate external ointment $1 gentamicin sulfate ophthalmic ointment $1 gentamicin sulfate ophthalmic solution $1 GENVOYA ORAL TABLET $1 GRALISE ORAL TABLET $1 PA; QL (90 EA per 30 days) GRALISE STARTER ORAL $1 PA griseofulvin microsize oral suspension $1 griseofulvin microsize oral tablet $1 griseofulvin ultramicrosize oral tablet $1 GYNAZOLE-1 VAGINAL CREAM $1 HARVONI ORAL TABLET $1 PA; SP ILOTYCIN OPHTHALMIC OINTMENT $1 imiquimod external cream $1 IMPAVIDO ORAL CAPSULE $1 INTELENCE ORAL TABLET $1 ^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 84 Drug Status Notes INTRON A INJECTION SOLUTION $1 SP INTRON A INJECTION SOLUTION $1 SP RECONSTITUTED INVIRASE ORAL CAPSULE $1 INVIRASE ORAL TABLET $1 ISENTRESS ORAL PACKET $1 QL (60 EA per 30 days) ISENTRESS ORAL TABLET $1 ISENTRESS ORAL TABLET CHEWABLE $1 isoniazid oral syrup $1 isoniazid oral tablet $1 ivermectin oral tablet $1 JUBLIA EXTERNAL SOLUTION $1 PA KALETRA ORAL SOLUTION $1 KALETRA ORAL TABLET $1 ketoconazole external cream $1 ketoconazole external shampoo $1 kp clotrimazole external cream $1 PA; ¥ (Max of 6 weeks); QL (2 LAMISIL ORAL PACKET $1 Packets per 1 day) lamivudine oral solution $1 lamivudine oral tablet $1 lamivudine-zidovudine oral tablet $1 levofloxacin ophthalmic solution $1 LEXIVA ORAL SUSPENSION $1 LEXIVA ORAL TABLET $1 lidocaine external patch 5 % $1 lindane external lotion $1 lindane external shampoo $1 LUZU EXTERNAL CREAM $1 PA malathion external lotion $1 mefloquine hcl oral tablet $1 megestrol acetate oral suspension 40 mg/ml, 400 $1 mg/10ml, 625 mg/5ml methenamine hippurate oral tablet $1 methenamine mandelate oral tablet $1 metronidazole vaginal gel $1 miconazole 3 vaginal suppository $1 ^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 85 Drug Status Notes MODERIBA ORAL TABLET $1 QL (210 EA per 30 days) MONUROL ORAL PACKET $1 MOXEZA OPHTHALMIC SOLUTION $1 mupirocin calcium external cream $1 PA mupirocin external ointment $1 naftifine hcl external cream $1 PA NAFTIN EXTERNAL GEL 1 % $1 PA NATACYN OPHTHALMIC SUSPENSION $1 PA NEBUPENT INHALATION SOLUTION $1 RECONSTITUTED neomycin-bacitracin zn-polymyx ophthalmic $1 ointment neomycin-polymyxin-gramicidin ophthalmic $1 solution 1.75-10000-.025 neomycin-polymyxin-hc ophthalmic suspension $1 3.5-10000-1 NEO-POLYCIN OPHTHALMIC $1 OINTMENT nevirapine er oral tablet extended release 24 hr* $1 nevirapine oral suspension $1 nevirapine oral tablet $1 nitrofurantoin macrocrystal oral capsule $1 nitrofurantoin monohyd macro oral capsule $1 nitrofurantoin oral suspension $1 NORDITROPIN FLEXPRO $1 PA; SP SUBCUTANEOUS* SOLUTION NORVIR ORAL CAPSULE $1 NORVIR ORAL SOLUTION $1 NORVIR ORAL TABLET $1 NOXAFIL ORAL SUSPENSION $1 PA NOXAFIL ORAL TABLET DELAYED $1 PA RELEASE NYAMYC EXTERNAL POWDER $1 nystatin external cream $1 nystatin external ointment $1 nystatin external powder $1 nystatin mouth/throat suspension $1 nystatin oral powder $1 ^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 86 Drug Status Notes nystatin oral tablet $1 nystatin-triamcinolone external cream $1 nystatin-triamcinolone external ointment $1 NYSTOP EXTERNAL POWDER $1 ODEFSEY ORAL TABLET $1 ofloxacin ophthalmic solution $1 oxiconazole nitrate external cream $1 PA OXISTAT EXTERNAL LOTION $1 PA PAROEX MOUTH/THROAT SOLUTION $1 paromomycin sulfate oral capsule $1 PASER ORAL PACKET $1 PA PEGASYS PROCLICK SUBCUTANEOUS* $1 SP; QL (4 ML per 28 days) SOLUTION PEGASYS SUBCUTANEOUS* SOLUTION $1 SP; QL (4 ML per 28 days) PEG-INTRON REDIPEN PAK 4 $1 SP; QL (4 EA per 28 days) SUBCUTANEOUS* KIT 120 MCG/0.5ML PEG-INTRON REDIPEN SUBCUTANEOUS* $1 SP; QL (4 EA per 28 days) KIT PEGINTRON SUBCUTANEOUS* KIT $1 SP; QL (4 EA per 28 days) PEG-INTRON SUBCUTANEOUS* KIT $1 SP; QL (4 EA per 28 days) PERIOGARD MOUTH/THROAT $1 SOLUTION permethrin external cream $1 podofilox external solution $1 POLYCIN OPHTHALMIC OINTMENT $1 polymyxin b-trimethoprim ophthalmic solution $1 PRED-G OPHTHALMIC SUSPENSION $1 PRED-G S.O.P. OPHTHALMIC OINTMENT $1 PREZCOBIX ORAL TABLET $1 PREZISTA ORAL SUSPENSION $1 PREZISTA ORAL TABLET 150 MG, 600 $1 MG, 75 MG, 800 MG PRIFTIN ORAL TABLET $1 PA primaquine phosphate oral tablet $1 PROMACTA ORAL TABLET $1 PA; SP PYLERA ORAL CAPSULE $1 pyrazinamide oral tablet $1

^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 87 Drug Status Notes REBETOL ORAL SOLUTION $1 SP; QL (35 ML per 1 day) RELENZA DISKHALER INHALATION ¥ (Max of 2 fills per year); QL (20 AEROSOL POWDER, BREATH $1 Blisters per 1 Rx) ACTIVATED RESCRIPTOR ORAL TABLET $1 REYATAZ ORAL CAPSULE 150 MG, 200 $1 MG, 300 MG REYATAZ ORAL PACKET $1 RIBASPHERE ORAL CAPSULE $1 QL (210 EA per 30 days) RIBASPHERE ORAL TABLET 200 MG $1 QL (210 EA per 30 days) ribavirin oral capsule $1 SP; QL (210 EA per 30 days) ribavirin oral tablet 200 mg $1 SP; QL (210 EA per 30 days) rifabutin oral capsule $1 RIFAMATE ORAL CAPSULE $1 rifampin oral capsule $1 RIFATER ORAL TABLET $1 rimantadine hcl oral tablet $1 SELZENTRY ORAL TABLET $1 SEROSTIM SUBCUTANEOUS* SOLUTION $1 PA; SP RECONSTITUTED 4 MG, 5 MG, 6 MG silver sulfadiazine external cream $1 SIRTURO ORAL TABLET $1 PA SIVEXTRO ORAL TABLET $1 QL (6 EA per 365 days) SKLICE EXTERNAL LOTION $1 STPA; QL (117 GM per 1 day) SOVALDI ORAL TABLET $1 PA; SP spinosad external suspension $1 STPA; QL (120 ML per 1 Fill) SSD EXTERNAL CREAM $1 stavudine oral capsule $1 stavudine oral solution reconstituted $1 STRIBILD ORAL TABLET $1 sulfacetamide sodium ophthalmic ointment $1 sulfacetamide sodium ophthalmic solution $1 SULFAMYLON EXTERNAL CREAM $1 PA SUSTIVA ORAL CAPSULE $1 SUSTIVA ORAL TABLET $1 SYNAGIS INTRAMUSCULAR* SOLUTION $1 PA; SP; QL (5 ML per 1 Season)

^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 88 Drug Status Notes ¥ (Max of 2 fills per year); QL (20 TAMIFLU ORAL CAPSULE 30 MG $1 EA per 1 Fill) ¥ (Max of 2 fills per year); QL (10 TAMIFLU ORAL CAPSULE 45 MG, 75 MG $1 EA per 1 Fill) TAMIFLU ORAL SUSPENSION ¥ (Max of 2 fills per year); QL $1 RECONSTITUTED 6 MG/ML (180 ML per 1 Fill) ¥ (Max of 90 tablets per 365 days); terbinafine hcl oral tablet $1 QL (30 EA per 30 days) terconazole vaginal cream $1 terconazole vaginal suppository $1 tinidazole oral tablet $1 TIVICAY ORAL TABLET $1 TOBI PODHALER INHALATION CAPSULE $1 PA; SP; QL (1 EA per 60 days) TOBRADEX OPHTHALMIC OINTMENT $1 tobramycin inhalation nebulization solution $1 SP tobramycin ophthalmic solution $1 tobramycin-dexamethasone ophthalmic $1 suspension TOBREX OPHTHALMIC OINTMENT $1 TRECATOR ORAL TABLET $1 PA trifluridine ophthalmic solution $1 trimethoprim oral tablet $1 TRIUMEQ ORAL TABLET $1 TRUVADA ORAL TABLET 200-300 MG $1 TYBOST ORAL TABLET $1 TYZEKA ORAL TABLET $1 ULESFIA EXTERNAL LOTION $1 QL (12 Bottles per 1 Rx) valacyclovir hcl oral tablet $1 VALCYTE ORAL SOLUTION $1 RECONSTITUTED valganciclovir hcl oral tablet $1 vancomycin hcl oral capsule $1 QL (40 EA per 10 days) VANDAZOLE VAGINAL GEL $1 VEREGEN EXTERNAL OINTMENT $1 PA VIDEX ORAL SOLUTION $1 RECONSTITUTED VIEKIRA PAK ORAL $1 PA VIGAMOX OPHTHALMIC SOLUTION $1 ^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 89 Drug Status Notes VIRACEPT ORAL TABLET $1 VIRAZOLE INHALATION SOLUTION $1 RECONSTITUTED VIREAD ORAL POWDER $1 VIREAD ORAL TABLET $1 VITEKTA ORAL TABLET $1 XIFAXAN ORAL TABLET 200 MG $1 QL (9 EA per 30 days) XIFAXAN ORAL TABLET 550 MG $1 QL (6 EA per 30 days) ZIAGEN ORAL SOLUTION $1 zidovudine oral capsule $1 zidovudine oral syrup $1 zidovudine oral tablet $1 ZIRGAN OPHTHALMIC GEL $1 PA ZMAX ORAL SUSPENSION $1 RECONSTITUTED ZORBTIVE SUBCUTANEOUS* SOLUTION $1 PA; SP RECONSTITUTED ZOVIRAX EXTERNAL CREAM $1 PA; QL (5 GM per 1 Rx) ZYLET OPHTHALMIC SUSPENSION $1 QL (5 mL per 30 days) INFLAMMATION OF THE SEROUS MEMBRANES IN THE BODY spironolactone oral tablet $1 INJURY PA; ¥ (Max of 3 months); QL (60 FLECTOR TRANSDERMAL PATCH $1 Patches per 30 days) lidocaine hcl external cream $1 lidocaine hcl external lotion $1 lidopin external cream 3 % $1 nimodipine oral capsule $1 PA SANTYL EXTERNAL OINTMENT $1 QL (30 GM per 1 Rx) silver sulfadiazine external cream $1 SSD EXTERNAL CREAM $1 SULFAMYLON EXTERNAL CREAM $1 PA INJURY TO A MUCOUS MEMBRANE ALOCRIL OPHTHALMIC SOLUTION $1 PA ALREX OPHTHALMIC SUSPENSION $1 AZASITE OPHTHALMIC SOLUTION $1 QL (2.5 mL per 1 fill)

^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 90 Drug Status Notes azelastine hcl ophthalmic solution $1 PA BECONASE AQ NASAL SUSPENSION $1 PA BEPREVE OPHTHALMIC SOLUTION $1 PA BESIVANCE OPHTHALMIC SUSPENSION $1 chlorhexidine gluconate mouth/throat solution $1 CILOXAN OPHTHALMIC OINTMENT $1 ciprofloxacin hcl ophthalmic solution $1 clotrimazole mouth/throat lozenge $1 clotrimazole mouth/throat troche $1 cromolyn sodium ophthalmic solution $1 DIVIGEL TRANSDERMAL GEL $1 PA doxycycline hyclate oral tablet 20 mg $1 ELESTRIN TRANSDERMAL GEL $1 PA EMADINE OPHTHALMIC SOLUTION $1 PA epinastine hcl ophthalmic solution $1 PA ESTRACE VAGINAL CREAM $1 ESTRING VAGINAL RING $1 ESTROGEL TRANSDERMAL GEL $1 PA FEMRING VAGINAL RING $1 GAMMAGARD S/D LESS IGA INTRAVENOUS* SOLUTION $1 PA; SP RECONSTITUTED gatifloxacin ophthalmic solution $1 GENTAK OPHTHALMIC OINTMENT $1 gentamicin sulfate ophthalmic ointment $1 gentamicin sulfate ophthalmic solution $1 ketotifen fumarate ophthalmic solution $1 LASTACAFT OPHTHALMIC SOLUTION $1 PA levofloxacin ophthalmic solution $1 MOXEZA OPHTHALMIC SOLUTION $1 NATACYN OPHTHALMIC SUSPENSION $1 PA NOXAFIL ORAL SUSPENSION $1 PA nystatin mouth/throat suspension $1 nystatin oral powder $1 nystatin oral tablet $1 ofloxacin ophthalmic solution $1

^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 91 Drug Status Notes olopatadine hcl ophthalmic solution $1 PA OSPHENA ORAL TABLET $1 PA PAROEX MOUTH/THROAT SOLUTION $1 PATADAY OPHTHALMIC SOLUTION $1 PA PERIOGARD MOUTH/THROAT $1 SOLUTION polymyxin b-trimethoprim ophthalmic solution $1 PRED-G OPHTHALMIC SUSPENSION $1 PRED-G S.O.P. OPHTHALMIC OINTMENT $1 PREMARIN VAGINAL CREAM $1 PREMPHASE ORAL TABLET $1 PREMPRO ORAL TABLET $1 RESTASIS OPHTHALMIC EMULSION $1 PA; QL (60 EA per 30 days) sulfacetamide sodium ophthalmic ointment $1 sulfacetamide sodium ophthalmic solution $1 tobramycin ophthalmic solution $1 TOBREX OPHTHALMIC OINTMENT $1 trifluridine ophthalmic solution $1 VAGIFEM VAGINAL TABLET 10 MCG $1 VIGAMOX OPHTHALMIC SOLUTION $1 LUNG DISEASE acetazolamide oral tablet $1 acetylcysteine inhalation solution $1 ADCIRCA ORAL TABLET $1 PA; SP; QL (60 EA per 30 days) ADEMPAS ORAL TABLET $1 PA; SP ADVAIR DISKUS INHALATION AEROSOL PA; Age Limit (Min 4 Years and POWDER, BREATH ACTIVATED 100-50 $1 Max 11 Years) MCG/DOSE ADVAIR DISKUS INHALATION AEROSOL POWDER, BREATH ACTIVATED 250-50 $1 PA MCG/DOSE, 500-50 MCG/DOSE ADVAIR HFA INHALATION AEROSOL† $1 PA AEROSPAN INHALATION AEROSOL, $1 SOLUTION albuterol sulfate er oral tablet extended release $1 12 hr* albuterol sulfate inhalation nebulization solution $1 albuterol sulfate oral syrup $1 ^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 92 Drug Status Notes albuterol sulfate oral tablet $1 ALECENSA ORAL CAPSULE $1 PA; SP ALVESCO INHALATION AEROSOL, $1 SOLUTION ANORO ELLIPTA INHALATION AEROSOL POWDER, BREATH $1 PA ACTIVATED ARALAST NP INTRAVENOUS* SOLUTION $1 SP RECONSTITUTED 1000 MG, 500 MG ARCAPTA NEOHALER INHALATION $1 QL (1 EA per 30 days) CAPSULE ASMANEX 120 METERED DOSES INHALATION AEROSOL POWDER, $1 BREATH ACTIVATED ASMANEX 14 METERED DOSES INHALATION AEROSOL POWDER, $1 BREATH ACTIVATED ASMANEX 30 METERED DOSES INHALATION AEROSOL POWDER, $1 BREATH ACTIVATED ASMANEX 60 METERED DOSES INHALATION AEROSOL POWDER, $1 BREATH ACTIVATED ASMANEX 7 METERED DOSES INHALATION AEROSOL POWDER, $1 BREATH ACTIVATED ASMANEX HFA INHALATION AEROSOL† $1 atovaquone oral suspension $1 ATROVENT HFA INHALATION $1 AEROSOL, SOLUTION AVASTIN INTRAVENOUS* SOLUTION $1 SP benzonatate oral capsule 100 mg, 200 mg $1 BREO ELLIPTA INHALATION AEROSOL $1 PA; QL (1 EA per 30 days) POWDER, BREATH ACTIVATED budesonide inhalation suspension $1 CAYSTON INHALATION SOLUTION $1 RECONSTITUTED chlorpromazine hcl oral tablet $1 COMBIVENT RESPIMAT INHALATION $1 AEROSOL, SOLUTION cromolyn sodium inhalation nebulization solution $1 ^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 93 Drug Status Notes DALIRESP ORAL TABLET $1 STPA DULERA INHALATION AEROSOL† $1 ELIQUIS ORAL TABLET $1 QL (30 EA per 30 days) ELIXOPHYLLIN ORAL ELIXIR $1 epoprostenol sodium intravenous* solution $1 PA; SP; QL (4 EA per 30 days) reconstituted 0.5 mg epoprostenol sodium intravenous* solution $1 PA; SP; QL (2 EA per 30 days) reconstituted 1.5 mg ESBRIET ORAL CAPSULE $1 PA; SP; QL (270 EA per 30 days) FLOVENT DISKUS INHALATION AEROSOL POWDER, BREATH $1 ACTIVATED FLOVENT HFA INHALATION AEROSOL† $1 FORADIL AEROLIZER INHALATION $1 CAPSULE GLASSIA INTRAVENOUS* SOLUTION $1 SP guaifenesin er oral tablet extended release 12 hr* $1 600 mg HYCAMTIN ORAL CAPSULE $1 SP hydrocod polst-cpm polst er oral $1 hydrocodone-homatropine oral syrup $1 hydrocodone-homatropine oral tablet $1 hydromet oral syrup $1 ipratropium bromide inhalation solution $1 ipratropium-albuterol inhalation solution $1 IRESSA ORAL TABLET $1 PA KALYDECO ORAL PACKET $1 PA; SP; QL (60 EA per 30 days) KALYDECO ORAL TABLET $1 PA; SP; QL (60 EA per 30 days) LETAIRIS ORAL TABLET $1 PA; SP; QL (30 EA per 30 days) levalbuterol hcl inhalation nebulization solution $1 0.31 mg/3ml, 0.63 mg/3ml, 1.25 mg/3ml LUMIZYME INTRAVENOUS* SOLUTION $1 SP RECONSTITUTED metaproterenol sulfate oral syrup $1 metaproterenol sulfate oral tablet $1 modafinil oral tablet $1 PA; QL (30 EA per 30 days) montelukast sodium oral packet $1 STPA; QL (30 EA per 30 days) montelukast sodium oral tablet $1 QL (30 EA per 30 days) ^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 94 Drug Status Notes montelukast sodium oral tablet chewable $1 QL (30 EA per 30 days) MYOZYME INTRAVENOUS* SOLUTION $1 SP RECONSTITUTED NEBUPENT INHALATION SOLUTION $1 RECONSTITUTED NOXAFIL ORAL SUSPENSION $1 PA NOXAFIL ORAL TABLET DELAYED $1 PA RELEASE NUVIGIL ORAL TABLET 150 MG, 200 MG, $1 PA; QL (30 EA per 30 days) 250 MG NUVIGIL ORAL TABLET 50 MG $1 PA; QL (60 EA per 30 days) OFEV ORAL CAPSULE $1 PA; QL (60 EA per 30 days) OPSUMIT ORAL TABLET $1 PA; SP ORENITRAM ORAL TABLET $1 PA; SP EXTENDEDRELEASE* ORKAMBI ORAL TABLET $1 PA; SP; QL (120 EA per 30 days) PASER ORAL PACKET $1 PA PERFOROMIST INHALATION $1 NEBULIZATION SOLUTION phenyleph-promethazine-cod oral syrup $1 PRIFTIN ORAL TABLET $1 PA PROAIR HFA INHALATION AEROSOL, $1 PA SOLUTION PROAIR RESPICLICK INHALATION AEROSOL POWDER, BREATH $1 PA ACTIVATED promethazine vc/codeine oral syrup $1 promethazine-codeine oral syrup $1 promethazine-dm oral syrup $1 PROVENTIL HFA INHALATION $1 PA AEROSOL, SOLUTION PULMICORT FLEXHALER INHALATION AEROSOL POWDER, BREATH $1 ACTIVATED PULMOZYME INHALATION SOLUTION $1 SP QVAR INHALATION AEROSOL, $1 SOLUTION 40 MCG/ACT, 80 MCG/ACT RAPAMUNE ORAL SOLUTION $1 REMODULIN INJECTION SOLUTION $1 PA; SP

^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 95 Drug Status Notes REVATIO ORAL SUSPENSION $1 PA; SP RECONSTITUTED RIFATER ORAL TABLET $1 SEREVENT DISKUS INHALATION AEROSOL POWDER, BREATH $1 ACTIVATED sildenafil citrate intravenous* solution $1 PA; SP; QL (90 ML per 30 days) sildenafil citrate oral tablet $1 PA; SP; QL (90 EA per 30 days) sirolimus oral tablet $1 SIRTURO ORAL TABLET $1 PA SPIRIVA HANDIHALER INHALATION $1 CAPSULE SPIRIVA RESPIMAT INHALATION $1 AEROSOL, SOLUTION STRIVERDI RESPIMAT INHALATION $1 AEROSOL, SOLUTION SYMBICORT INHALATION AEROSOL† $1 SYNAGIS INTRAMUSCULAR* SOLUTION $1 PA; SP; QL (5 ML per 1 Season) TAGRISSO ORAL TABLET $1 PA TARCEVA ORAL TABLET $1 SP THEO-24 ORAL CAPSULE EXTENDED $1 RELEASE 24 HOUR 300 MG, 400 MG THEOCHRON ORAL TABLET EXTENDED $1 RELEASE 12 HR* 100 MG, 200 MG, 300 MG theophylline er oral tablet extended release 12 $1 hr* theophylline er oral tablet extended release 24 $1 hr* theophylline oral solution $1 TOBI PODHALER INHALATION CAPSULE $1 PA; SP; QL (1 EA per 60 days) tobramycin inhalation nebulization solution $1 SP TRACLEER ORAL TABLET $1 PA; SP; QL (60 EA per 30 days) TUDORZA PRESSAIR INHALATION AEROSOL POWDER, BREATH $1 ACTIVATED 400 MCG/ACT TUSSIGON ORAL TABLET $1 TYVASO INHALATION SOLUTION $1 PA; SP TYVASO REFILL INHALATION $1 PA; SP SOLUTION

^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 96 Drug Status Notes TYVASO STARTER INHALATION $1 PA; SP SOLUTION UPTRAVI ORAL $1 PA; SP UPTRAVI ORAL TABLET $1 PA; SP VELETRI INTRAVENOUS* SOLUTION $1 PA RECONSTITUTED VENTAVIS INHALATION SOLUTION $1 PA; SP; QL (9 Vials per 1 day) VENTOLIN HFA INHALATION AEROSOL, $1 SOLUTION XALKORI ORAL CAPSULE $1 SP XARELTO ORAL TABLET $1 QL (30 EA per 30 days) XARELTO STARTER PACK ORAL $1 QL (42 EA per 21 days) XOLAIR SUBCUTANEOUS* SOLUTION $1 PA; SP; QL (6 vials per 28 days) RECONSTITUTED XOPENEX HFA INHALATION AEROSOL† $1 PA zafirlukast oral tablet $1 ZMAX ORAL SUSPENSION $1 RECONSTITUTED ZYKADIA ORAL CAPSULE $1 SP MUSCLE OR BONE DISORDER ACTEMRA INTRAVENOUS* SOLUTION $1 PA; SP; QL (4 vials per 28 days) 200 MG/10ML ACTEMRA INTRAVENOUS* SOLUTION $1 PA; SP; QL (2 vials per 28 days) 400 MG/20ML ACTEMRA INTRAVENOUS* SOLUTION 80 $1 PA; SP; QL (10 vials per 28 days) MG/4ML PA; SP; QL (4 syringes per 28 ACTEMRA SUBCUTANEOUS* $1 days) ACTIMMUNE SUBCUTANEOUS* $1 PA; SP SOLUTION alendronate sodium oral tablet 10 mg, 5 mg $1 QL (30 EA per 30 days) alendronate sodium oral tablet 35 mg, 70 mg $1 QL (4 EA per 28 days) alendronate sodium oral tablet 40 mg $1 QL (1 EA per 6 Months) PA; ¥ (PA applies to members less amphetamine-dextroamphet er oral capsule $1 than 3 years old or 25 and older); extended release 24 hour QL (60 EA per 30 days) PA; ¥ (PA applies to members less amphetamine-dextroamphetamine oral tablet $1 than 3 years old or 25 and older); QL (90 EA per 30 days)

^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 97 Drug Status Notes AMPYRA ORAL TABLET EXTENDED PA; SP; QL (60 Tablets per 30 $1 RELEASE 12 HR* days) atropine sulfate ophthalmic ointment $1 atropine sulfate ophthalmic solution $1 AURYXIA ORAL TABLET $1 PA azathioprine oral tablet $1 baclofen oral tablet $1 calcitonin (salmon) nasal solution $1 calcium acetate (phos binder) oral capsule $1 calcium acetate (phos binder) oral tablet $1 carbamazepine oral suspension $1 carbamazepine oral tablet $1 carbamazepine oral tablet chewable $1 carisoprodol oral tablet 350 mg $1 carisoprodol-aspirin oral tablet $1 celecoxib oral capsule $1 STPA; QL (60 EA per 30 days) chlorzoxazone oral tablet 500 mg $1 choline-mag trisalicylate oral liquid† $1 cilostazol oral tablet $1 CIMZIA PREFILLED SUBCUTANEOUS* $1 PA; SP; QL (2 EA per 28 days) KIT CIMZIA STARTER KIT SUBCUTANEOUS* $1 PA; SP KIT CIMZIA SUBCUTANEOUS* KIT 2 X 200 $1 PA; SP; QL (2 EA per 28 days) MG CLIMARA PRO TRANSDERMAL PATCH $1 WEEKLY clonazepam oral tablet $1 clonidine hcl er oral tablet extended release 12 $1 PA; QL (60 EA per 30 days) hr* colchicine-probenecid oral tablet $1 COSENTYX SENSOREADY PEN $1 PA; SP SUBCUTANEOUS* 150 MG/ML COSENTYX SUBCUTANEOUS* $1 PA; SP CUPRIMINE ORAL CAPSULE 250 MG $1 cyclobenzaprine hcl oral tablet 10 mg, 5 mg $1 dantrolene sodium oral capsule $1

^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 98 Drug Status Notes darifenacin hydrobromide er oral tablet extended $1 PA release 24 hr* DAYTRANA TRANSDERMAL PATCH $1 PA; QL (30 patches per 30 days) DEPEN TITRATABS ORAL TABLET $1 PA; ¥ (PA applies to members less DEXEDRINE ORAL TABLET $1 than 3 years old or 25 and older); QL (90 EA per 30 days) PA; ¥ (PA applies to members less dexmethylphenidate hcl er oral capsule extended $1 than 3 years old or 25 and older); release 24 hour QL (30 EA per 30 days) PA; ¥ (PA applies to members less dexmethylphenidate hcl oral tablet $1 than 3 years old or 25 and older); QL (60 EA per 30 days) PA; ¥ (PA applies to members less dextroamphetamine sulfate er oral capsule $1 than 3 years old or 25 and older); extended release 24 hour QL (90 EA per 30 days) PA; ¥ (PA applies to members less dextroamphetamine sulfate oral solution $1 than 3 years old or 25 and older); QL (1200 mL per 30 days) PA; ¥ (PA applies to members less dextroamphetamine sulfate oral tablet $1 than 3 years old or 25 and older); QL (90 EA per 30 days) diazepam oral solution 1 mg/ml $1 diazepam oral tablet $1 diclofenac potassium oral tablet $1 diclofenac sodium er oral tablet extended release $1 24 hr* diclofenac sodium transdermal gel 1 % $1 STPA diclofenac sodium transdermal solution $1 PA DUAVEE ORAL TABLET $1 PA duloxetine hcl oral capsule delayed release $1 STPA; QL (60 EA per 30 days) particles 20 mg, 60 mg duloxetine hcl oral capsule delayed release $1 STPA; QL (30 EA per 30 days) particles 30 mg DYSPORT (GLABELLAR LINES) INTRAMUSCULAR* SOLUTION $1 PA; SP RECONSTITUTED DYSPORT INTRAMUSCULAR* SOLUTION $1 PA; SP RECONSTITUTED PA; SP; QL (8 syringes per 28 ENBREL SUBCUTANEOUS* 25 MG/0.5ML $1 days) ^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 99 Drug Status Notes PA; SP; QL (4 syringes per 28 ENBREL SUBCUTANEOUS* 50 MG/ML $1 days) ENBREL SUBCUTANEOUS* SOLUTION PA; SP; QL (8 syringes per 28 $1 RECONSTITUTED days) PA; SP; QL (4 syringes per 28 ENBREL SURECLICK SUBCUTANEOUS* $1 days) ENBREL SURECLICK SUBCUTANEOUS* PA; SP; QL (4 syringes per 28 $1 SOLUTION days) EPITOL ORAL TABLET $1 etidronate disodium oral tablet $1 etodolac er oral tablet extended release 24 hr* $1 etodolac oral capsule $1 etodolac oral tablet $1 EUFLEXXA INTRA-ARTICULAR* $1 PA; SP PA; ¥ (Max of 3 months); QL (60 FLECTOR TRANSDERMAL PATCH $1 Patches per 30 days) flurbiprofen oral tablet $1 FOCALIN XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 25 MG, 35 $1 PA; QL (30 EA per 30 days) MG FORTEO SUBCUTANEOUS* SOLUTION $1 PA; SP; QL (1 vial per 30 days) 600 MCG/2.4ML FORTICAL NASAL SOLUTION $1 FOSAMAX PLUS D ORAL TABLET $1 PA; QL (4 EA per 28 days) FOSRENOL ORAL PACKET $1 FOSRENOL ORAL TABLET CHEWABLE $1 1000 MG, 500 MG, 750 MG FYCOMPA ORAL SUSPENSION $1 FYCOMPA ORAL TABLET $1 PA GAMMAGARD INJECTION SOLUTION $1 PA; SP GELNIQUE TRANSDERMAL GEL $1 PA GLYDO EXTERNAL GEL $1 guanfacine hcl er oral tablet extended release 24 $1 STPA; QL (30 EA per 30 days) hr* guanidine hcl oral tablet $1 PA HP ACTHAR INJECTION GEL $1 PA; SP HUMIRA PEDIATRIC CROHNS START $1 PA; SP; ¥ (1 Fill per life of plan) SUBCUTANEOUS* 40 MG/0.8ML HUMIRA PEN SUBCUTANEOUS* $1 PA; SP; QL (2 EA per 28 days) ^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 100 Drug Status Notes HUMIRA PEN-CROHNS STARTER $1 PA; SP; ¥ (1 Fill per life of plan) SUBCUTANEOUS* HUMIRA PEN-PSORIASIS STARTER $1 PA; SP; ¥ (1 Fill per life of plan) SUBCUTANEOUS* HUMIRA SUBCUTANEOUS* $1 PA; SP; QL (2 EA per 28 days) hydroxychloroquine sulfate oral tablet $1 ibandronate sodium intravenous* solution 3 $1 PA; QL (3 ML per 90 days) mg/3ml ibandronate sodium oral tablet $1 PA; QL (1 EA per 28 days) ibuprofen oral suspension $1 ibuprofen oral tablet 400 mg, 600 mg, 800 mg $1 ILARIS SUBCUTANEOUS* SOLUTION $1 PA; SP RECONSTITUTED INDOCIN ORAL SUSPENSION $1 indomethacin er oral capsule extended release* $1 indomethacin oral capsule $1 KENALOG INJECTION SUSPENSION 10 $1 MG/ML ketoprofen er oral capsule extended release 24 $1 hour ketoprofen oral capsule $1 KINERET SUBCUTANEOUS* $1 PA; QL (28 Syringes per 28 days) lamotrigine odt oral tablet dispersible $1 lamotrigine oral tablet 100 mg, 150 mg $1 QL (90 EA per 30 days) lamotrigine oral tablet 200 mg $1 lamotrigine oral tablet 25 mg $1 QL (180 EA per 30 days) lamotrigine oral tablet chewable $1 QL (180 EA per 30 days) lamotrigine oral tablet dispersible $1 leflunomide oral tablet $1 levetiracetam oral solution $1 levetiracetam oral tablet $1 lidocaine hcl external gel 2 % $1 meclofenamate sodium oral capsule $1 meloxicam oral suspension $1 meloxicam oral tablet $1 MESTINON ORAL SYRUP $1 metaxalone oral tablet 800 mg $1 STPA; QL (120 EA per 30 days)

^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 101 Drug Status Notes PA; ¥ (PA applies to members less methamphetamine hcl oral tablet $1 than 3 years old or 25 and older); QL (150 EA per 30 days) methocarbamol oral tablet $1 methotrexate oral tablet $1 PA; ¥ (PA applies to members less methylphenidate hcl er (cd) oral capsule extended $1 than 3 years old or 25 and older); release* 10 mg, 20 mg, 40 mg, 50 mg, 60 mg QL (30 EA per 30 days) PA; ¥ (PA applies to members less methylphenidate hcl er (cd) oral capsule extended $1 than 3 years old or 25 and older); release* 30 mg QL (60 EA per 30 days) PA; ¥ (PA applies to members less methylphenidate hcl er (la) oral capsule extended $1 than 3 years old or 25 and older); release 24 hour 20 mg, 40 mg QL (30 EA per 30 days) PA; ¥ (PA applies to members less methylphenidate hcl er (la) oral capsule extended $1 than 3 years old or 25 and older); release 24 hour 30 mg QL (60 EA per 30 days) PA; ¥ (PA applies to members less methylphenidate hcl er oral tablet extended $1 than 3 years old or 25 and older); release 24 hr* QL (30 EA per 30 days) methylphenidate hcl er oral tablet PA; ¥ (PA applies to members less extendedrelease* 10 mg, 18 mg, 20 mg, 27 mg, 54 $1 than 3 years old or 25 and older); mg QL (30 EA per 30 days) PA; ¥ (PA applies to members less methylphenidate hcl er oral tablet $1 than 3 years old or 25 and older); extendedrelease* 36 mg QL (60 EA per 30 days) PA; ¥ (PA applies to members less methylphenidate hcl oral solution $1 than 3 years old or 25 and older); QL (900 mL per 30 days) PA; ¥ (PA applies to members less methylphenidate hcl oral tablet $1 than 3 years old or 25 and older); QL (90 EA per 30 days) PA; ¥ (PA applies to members less methylphenidate hcl oral tablet chewable $1 than 3 years old or 25 and older); QL (90 EA per 30 days) MIACALCIN INJECTION SOLUTION $1 MYOBLOC INTRAMUSCULAR* $1 PA; SP SOLUTION MYRBETRIQ ORAL TABLET EXTENDED $1 PA RELEASE 24 HR* nabumetone oral tablet $1 naproxen dr oral tablet delayed release $1 ^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 102 Drug Status Notes naproxen oral suspension $1 naproxen oral tablet $1 naproxen sodium oral tablet $1 norethindrone-eth estradiol oral tablet $1 octreotide acetate injection solution 100 mcg/ml, 1000 mcg/ml, 200 mcg/ml, 50 mcg/ml, 500 $1 PA; SP; QL (30 ML per 30 days) mcg/ml ORENCIA CLICKJECT SUBCUTANEOUS* $1 PA; SP; QL (4 ML per 28 days) ORENCIA INTRAVENOUS* SOLUTION PA; SP; QL (4 VIALS per 28 $1 RECONSTITUTED days) ORENCIA SUBCUTANEOUS* $1 PA; SP; QL (4 ML per 28 days) orphenadrine citrate er oral tablet extended $1 release 12 hr* orphenadrine-aspirin-caffeine oral tablet $1 25-385-30 mg OTEZLA ORAL 10 & 20 & 30 MG $1 PA; SP; QL (60 EA per 30 days) OTEZLA ORAL TABLET $1 PA; SP; QL (60 EA per 30 days) oxaprozin oral tablet $1 oxybutynin chloride er oral tablet extended $1 release 24 hr* oxybutynin chloride oral syrup $1 oxybutynin chloride oral tablet $1 OXYTROL TRANSDERMAL PATCH $1 PA BIWEEKLY PEGANONE ORAL TABLET $1 PA PENNSAID TRANSDERMAL SOLUTION 2 $1 PA % pentoxifylline er oral tablet extendedrelease* $1 PHOSLYRA ORAL SOLUTION $1 pimozide oral tablet $1 PA piroxicam oral capsule $1 PROLIA SUBCUTANEOUS* SOLUTION $1 SP; QL (1 syringe per 180 days) propranolol hcl oral solution $1 propranolol hcl oral tablet $1 pyridostigmine bromide er oral tablet $1 extendedrelease* pyridostigmine bromide oral tablet $1

^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 103 Drug Status Notes QUILLIVANT XR ORAL SUSPENSION $1 PA; QL (360 mL per 30 days) RECONSTITUTED raloxifene hcl oral tablet $1 REMICADE INTRAVENOUS* SOLUTION $1 PA; SP RECONSTITUTED RENAGEL ORAL TABLET $1 RENVELA ORAL TABLET $1 RHEUMATREX ORAL TABLET 2.5 MG $1 riluzole oral tablet $1 risedronate sodium oral tablet 150 mg $1 PA; QL (1 EA per 30 days) risedronate sodium oral tablet 30 mg, 5 mg $1 PA; QL (30 EA per 30 days) risedronate sodium oral tablet 35 mg $1 PA; QL (4 EA per 28 days) risedronate sodium oral tablet delayed release $1 PA; QL (4 EA per 28 days) RITALIN LA ORAL CAPSULE EXTENDED $1 PA; QL (30 EA per 30 days) RELEASE 24 HOUR 10 MG, 60 MG RITUXAN INTRAVENOUS* $1 SP CONCENTRATE RITUXAN INTRAVENOUS* SOLUTION $1 SP SABRIL ORAL PACKET $1 PA; SP; QL (180 EA per 30 days) SABRIL ORAL TABLET $1 PA; SP; QL (180 EA per 30 days) salsalate oral tablet $1 SANDOSTATIN LAR DEPOT $1 PA; SP; QL (1 vial per 28 days) INTRAMUSCULAR* KIT SAVELLA ORAL TABLET $1 STPA; QL (60 EA per 30 days) SAVELLA TITRATION PACK ORAL $1 STPA; QL (60 EA per 30 days) SIMPONI ARIA INTRAVENOUS* $1 PA; SP; QL (5 vials per 8 Weeks) SOLUTION PA; SP; QL (1 syringe per 28 SIMPONI SUBCUTANEOUS* $1 days) SOMATULINE DEPOT SUBCUTANEOUS* $1 PA; SP; QL (1 ML per 28 days) SOLUTION SOMAVERT SUBCUTANEOUS* $1 PA; SP; QL (30 EA per 30 days) SOLUTION RECONSTITUTED SPRITAM ORAL $1 PA; QL (60 EA per 30 days) STELARA SUBCUTANEOUS* $1 PA; SP; QL (1 ML per 28 days) STRATTERA ORAL CAPSULE $1 PA; QL (60 EA per 30 days) sulfasalazine oral tablet delayed release $1 sulindac oral tablet $1

^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 104 Drug Status Notes SYPRINE ORAL CAPSULE $1 PA tetrabenazine oral tablet 12.5 mg $1 PA; SP; QL (240 EA per 30 days) tetrabenazine oral tablet 25 mg $1 PA; SP; QL (120 EA per 30 days) tizanidine hcl oral tablet $1 tolmetin sodium oral capsule $1 tolmetin sodium oral tablet $1 tolterodine tartrate er oral capsule extended $1 release 24 hour tolterodine tartrate oral tablet $1 TOVIAZ ORAL TABLET EXTENDED $1 RELEASE 24 HR* tramadol hcl er (biphasic) oral tablet extended $1 PA release 24 hr* 100 mg, 300 mg tramadol hcl er oral tablet extended release 24 $1 PA; QL (30 EA per 30 days) hr* TREXALL ORAL TABLET $1 trospium chloride er oral capsule extended $1 release 24 hour trospium chloride oral tablet $1 VESICARE ORAL TABLET $1 PA VOLTAREN TRANSDERMAL GEL $1 STPA; QL (32 GM per 1 day) VYVANSE ORAL CAPSULE $1 PA; QL (30 EA per 30 days) XELJANZ ORAL TABLET $1 PA; SP; QL (60 EA per 30 days) XELJANZ XR ORAL TABLET EXTENDED $1 PA; SP; QL (30 EA per 30 days) RELEASE 24 HR* XEOMIN INTRAMUSCULAR* SOLUTION $1 PA; SP RECONSTITUTED XGEVA SUBCUTANEOUS* SOLUTION $1 SP; QL (1 vial per 30 days) XIAFLEX INJECTION SOLUTION Medical Benefit PA RECONSTITUTED XYREM ORAL SOLUTION $1 PA PA; ¥ (PA applies to members less ZENZEDI ORAL TABLET 10 MG, 5 MG $1 than 3 years old or 25 and older); QL (90 EA per 30 days) zoledronic acid intravenous* concentrate $1 QL (5 vials per 21 days) zoledronic acid intravenous* solution 4 mg/100ml $1 QL (1 vial per 21 days) zoledronic acid intravenous* solution 5 mg/100ml $1 QL (1 vial per 1 Year) zoledronic acid intravenous* solution $1 QL (1 vial per 21 days) reconstituted ^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 105 Drug Status Notes NEUROPSYCHIATRIC DISORDER ABILIFY MAINTENA INTRAMUSCULAR* SUSPENSION RECONSTITUTED 300 MG, $1 PA 400 MG acamprosate calcium oral tablet delayed release $1 QL (180 EA per 30 days) ALPRAZOLAM INTENSOL ORAL $1 CONCENTRATE alprazolam oral tablet $1 amoxapine oral tablet $1 PA; ¥ (PA applies to members less amphetamine-dextroamphet er oral capsule $1 than 3 years old or 25 and older); extended release 24 hour QL (60 EA per 30 days) PA; ¥ (PA applies to members less amphetamine-dextroamphetamine oral tablet $1 than 3 years old or 25 and older); QL (90 EA per 30 days) aripiprazole oral solution $1 PA; QL (750 ML per 30 days) aripiprazole oral tablet $1 PA; QL (30 EA per 30 days) aripiprazole oral tablet dispersible $1 PA; QL (30 EA per 30 days) ARISTADA INTRAMUSCULAR* $1 PA ASCOMP-CODEINE ORAL CAPSULE $1 QL (180 EA per 30 days) BEYAZ ORAL TABLET $1 PA; ¥ (Max of 32 mg/day for the BUNAVAIL BUCCAL FILM 2.1-0.3 MG, $1 first 6 months); QL (30 EA per 30 6.3-1 MG days) PA; ¥ (Max of 32 mg/day for the BUNAVAIL BUCCAL FILM 4.2-0.7 MG $1 first 6 months); QL (60 EA per 30 days) buprenorphine hcl sublingual tablet sublingual $1 PA buprenorphine hcl-naloxone hcl sublingual tablet ¥ (Max of 32 mg/day for the first 6 $1 sublingual 2-0.5 mg months); QL (90 EA per 30 days) buprenorphine hcl-naloxone hcl sublingual tablet ¥ (Max of 32 mg/day for the first 6 $1 sublingual 8-2 mg months); QL (60 EA per 30 days) BUPROBAN ORAL TABLET EXTENDED $1 RELEASE 12 HR* bupropion hcl er (smoking det) oral tablet $1 extended release 12 hr* bupropion hcl er (sr) oral tablet extended release $1 12 hr* bupropion hcl er (xl) oral tablet extended release $1 24 hr*

^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 106 Drug Status Notes bupropion hcl oral tablet $1 buspirone hcl oral tablet 10 mg, 15 mg, 5 mg, 7.5 $1 mg buspirone hcl oral tablet 30 mg $1 PA butalbital-acetaminophen oral tablet $1 QL (180 EA per 30 days) butalbital-apap-caffeine oral capsule 50-325-40 $1 QL (180 EA per 30 days) mg butalbital-apap-caffeine oral tablet 50-325-40 mg $1 QL (180 EA per 30 days) butalbital-aspirin-caffeine oral capsule $1 QL (180 EA per 30 days) CAPACET ORAL CAPSULE $1 QL (180 EA per 30 days) carbamazepine er oral capsule extended release $1 12 hour carbamazepine er oral tablet extended release 12 $1 hr* carbamazepine oral tablet $1 CHANTIX CONTINUING MONTH PAK $1 QL (60 EA per 30 days) ORAL TABLET CHANTIX ORAL TABLET $1 QL (60 EA per 30 days) CHANTIX STARTING MONTH PAK ORAL $1 QL (60 EA per 30 days) TABLET chlordiazepoxide hcl oral capsule $1 chlorpromazine hcl oral tablet $1 citalopram hydrobromide oral solution $1 citalopram hydrobromide oral tablet $1 clomipramine hcl oral capsule $1 clonazepam oral tablet $1 clonidine hcl er oral tablet extended release 12 $1 PA; QL (60 EA per 30 days) hr* clorazepate dipotassium oral tablet $1 clozapine oral tablet $1 clozapine oral tablet dispersible $1 QL (60 EA per 30 days) DAYTRANA TRANSDERMAL PATCH $1 PA; QL (30 patches per 30 days) desipramine hcl oral tablet $1 desvenlafaxine er oral tablet extended release 24 $1 STPA hr* desvenlafaxine fumarate er oral tablet extended $1 STPA release 24 hr*

^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 107 Drug Status Notes PA; ¥ (PA applies to members less DEXEDRINE ORAL TABLET $1 than 3 years old or 25 and older); QL (90 EA per 30 days) PA; ¥ (PA applies to members less dexmethylphenidate hcl er oral capsule extended $1 than 3 years old or 25 and older); release 24 hour QL (30 EA per 30 days) PA; ¥ (PA applies to members less dexmethylphenidate hcl oral tablet $1 than 3 years old or 25 and older); QL (60 EA per 30 days) PA; ¥ (PA applies to members less dextroamphetamine sulfate er oral capsule $1 than 3 years old or 25 and older); extended release 24 hour QL (90 EA per 30 days) PA; ¥ (PA applies to members less dextroamphetamine sulfate oral solution $1 than 3 years old or 25 and older); QL (1200 mL per 30 days) PA; ¥ (PA applies to members less dextroamphetamine sulfate oral tablet $1 than 3 years old or 25 and older); QL (90 EA per 30 days) diazepam oral solution 1 mg/ml $1 diazepam oral tablet $1 disulfiram oral tablet $1 divalproex sodium er oral tablet extended release $1 24 hr* divalproex sodium oral tablet delayed release $1 donepezil hcl oral tablet 10 mg, 5 mg $1 donepezil hcl oral tablet dispersible $1 doxepin hcl oral capsule $1 doxepin hcl oral concentrate $1 drospirenone-ethinyl estradiol oral tablet 3-0.02 $1 mg duloxetine hcl oral capsule delayed release $1 STPA; QL (60 EA per 30 days) particles 20 mg, 60 mg duloxetine hcl oral capsule delayed release $1 STPA; QL (30 EA per 30 days) particles 30 mg EMSAM TRANSDERMAL PATCH 24 HR $1 PA; QL (30 EA per 30 days) eq nicotine mouth/throat lozenge $1 eq nicotine polacrilex mouth/throat gum $1 eq nicotine polacrilex mouth/throat lozenge $1 eq nicotine step 3 transdermal patch 24 hr $1

^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 108 Drug Status Notes eq nicotine transdermal patch 24 hr 14 mg/24hr, $1 21 mg/24hr eql nicotine polacrilex mouth/throat gum $1 eql nicotine polacrilex mouth/throat lozenge $1 eql nicotine transdermal patch 24 hr $1 ergoloid mesylates oral tablet $1 escitalopram oxalate oral solution $1 escitalopram oxalate oral tablet $1 FANAPT ORAL TABLET $1 PA; QL (60 EA per 30 days) FANAPT TITRATION PACK ORAL $1 PA TABLET FETZIMA ORAL CAPSULE EXTENDED $1 PA; QL (30 EA per 30 days) RELEASE 24 HOUR FETZIMA TITRATION ORAL $1 PA; QL (28 EA per 28 days) fluoxetine hcl oral capsule $1 fluoxetine hcl oral solution $1 fluoxetine hcl oral tablet 10 mg $1 fluoxetine hcl oral tablet 20 mg $1 PA fluphenazine decanoate injection solution $1 fluphenazine hcl oral concentrate $1 fluphenazine hcl oral elixir $1 fluphenazine hcl oral tablet $1 fluvoxamine maleate er oral capsule extended $1 PA; QL (30 EA per 30 days) release 24 hour fluvoxamine maleate oral tablet $1 FOCALIN XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 25 MG, 35 $1 PA; QL (30 EA per 30 days) MG galantamine hydrobromide er oral capsule $1 extended release 24 hour galantamine hydrobromide oral solution $1 galantamine hydrobromide oral tablet $1 GEODON INTRAMUSCULAR* SOLUTION $1 RECONSTITUTED GIANVI ORAL TABLET $1 gnp nicotine mini mouth/throat lozenge $1 gnp nicotine polacrilex mouth/throat gum $1 gnp nicotine polacrilex mouth/throat lozenge $1 ^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 109 Drug Status Notes guanfacine hcl er oral tablet extended release 24 $1 STPA; QL (30 EA per 30 days) hr* haloperidol decanoate intramuscular* solution $1 haloperidol lactate injection solution $1 haloperidol lactate oral concentrate $1 haloperidol oral tablet $1 hm nicotine polacrilex mouth/throat gum $1 hm nicotine polacrilex mouth/throat lozenge $1 hm nicotine transdermal patch 24 hr $1 hydroxyzine hcl oral syrup $1 hydroxyzine hcl oral tablet $1 hydroxyzine pamoate oral capsule $1 imipramine hcl oral tablet $1 imipramine pamoate oral capsule $1 PA INVEGA SUSTENNA INTRAMUSCULAR* PA; ¥ (2 vials for first month); QL $1 SUSPENSION (1 vial per 30 days) INVEGA TRINZA INTRAMUSCULAR* $1 PA SUSPENSION lamotrigine odt oral tablet dispersible $1 lamotrigine oral tablet 100 mg, 150 mg $1 QL (90 EA per 30 days) lamotrigine oral tablet 200 mg $1 lamotrigine oral tablet 25 mg $1 QL (180 EA per 30 days) lamotrigine oral tablet chewable $1 QL (180 EA per 30 days) lamotrigine oral tablet dispersible $1 LATUDA ORAL TABLET $1 PA; QL (30 EA per 30 days) lithium carbonate er oral tablet extendedrelease* $1 lithium carbonate oral capsule $1 lithium carbonate oral tablet $1 lithium oral solution $1 LORAZEPAM INTENSOL ORAL $1 CONCENTRATE lorazepam oral concentrate $1 lorazepam oral tablet $1 LORYNA ORAL TABLET $1 loxapine succinate oral capsule $1 maprotiline hcl oral tablet $1 margesic oral capsule $1 QL (180 EA per 30 days) ^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 110 Drug Status Notes marten-tab oral tablet $1 QL (180 EA per 30 days) memantine hcl oral solution $1 memantine hcl oral tablet $1 meprobamate oral tablet $1 PA METHADONE HCL INTENSOL ORAL $1 QL (6 ML per 1 day) CONCENTRATE methadone hcl oral concentrate $1 QL (6 ML per 1 day) methadone hcl oral solution 10 mg/5ml $1 QL (30 ML per 1 day) methadone hcl oral solution 5 mg/5ml $1 QL (60 ML per 1 day) methadone hcl oral tablet 10 mg $1 QL (6 EA per 1 day) methadone hcl oral tablet 5 mg $1 QL (12 EA per 1 day) methadone hcl oral tablet soluble $1 QL (1.5 EA per 1 day) METHADOSE ORAL TABLET SOLUBLE $1 QL (1.5 EA per 1 day) PA; ¥ (PA applies to members less methamphetamine hcl oral tablet $1 than 3 years old or 25 and older); QL (150 EA per 30 days) PA; ¥ (PA applies to members less methylphenidate hcl er (cd) oral capsule extended $1 than 3 years old or 25 and older); release* 10 mg, 20 mg, 40 mg, 50 mg, 60 mg QL (30 EA per 30 days) PA; ¥ (PA applies to members less methylphenidate hcl er (cd) oral capsule extended $1 than 3 years old or 25 and older); release* 30 mg QL (60 EA per 30 days) PA; ¥ (PA applies to members less methylphenidate hcl er (la) oral capsule extended $1 than 3 years old or 25 and older); release 24 hour 20 mg, 40 mg QL (30 EA per 30 days) PA; ¥ (PA applies to members less methylphenidate hcl er (la) oral capsule extended $1 than 3 years old or 25 and older); release 24 hour 30 mg QL (60 EA per 30 days) PA; ¥ (PA applies to members less methylphenidate hcl er oral tablet extended $1 than 3 years old or 25 and older); release 24 hr* QL (30 EA per 30 days) methylphenidate hcl er oral tablet PA; ¥ (PA applies to members less extendedrelease* 10 mg, 18 mg, 20 mg, 27 mg, 54 $1 than 3 years old or 25 and older); mg QL (30 EA per 30 days) PA; ¥ (PA applies to members less methylphenidate hcl er oral tablet $1 than 3 years old or 25 and older); extendedrelease* 36 mg QL (60 EA per 30 days) PA; ¥ (PA applies to members less methylphenidate hcl oral solution $1 than 3 years old or 25 and older); QL (900 mL per 30 days)

^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 111 Drug Status Notes PA; ¥ (PA applies to members less methylphenidate hcl oral tablet $1 than 3 years old or 25 and older); QL (90 EA per 30 days) PA; ¥ (PA applies to members less methylphenidate hcl oral tablet chewable $1 than 3 years old or 25 and older); QL (90 EA per 30 days) mirtazapine oral tablet $1 mirtazapine oral tablet dispersible $1 naltrexone hcl oral tablet $1 NAMENDA XR ORAL CAPSULE $1 EXTENDED RELEASE 24 HOUR NAMENDA XR TITRATION PACK ORAL $1 CAPSULE EXTENDED RELEASE 24 HOUR nefazodone hcl oral tablet $1 NICORELIEF MOUTH/THROAT GUM $1 nicotine mini mouth/throat lozenge $1 nicotine polacrilex mouth/throat gum $1 nicotine polacrilex mouth/throat lozenge $1 nicotine step 1 transdermal patch 24 hr $1 nicotine step 2 transdermal patch 24 hr $1 nicotine step 3 transdermal patch 24 hr $1 nicotine transdermal patch 24 hr $1 NICOTROL INHALATION INHALER $1 NICOTROL NS NASAL SOLUTION $1 NIKKI ORAL TABLET $1 nortriptyline hcl oral capsule $1 nortriptyline hcl oral solution $1 NUEDEXTA ORAL CAPSULE $1 PA olanzapine intramuscular* solution reconstituted $1 olanzapine oral tablet $1 QL (30 EA per 30 days) olanzapine oral tablet dispersible $1 QL (30 EA per 30 days) olanzapine-fluoxetine hcl oral capsule $1 PA; QL (30 EA per 30 days) OLEPTRO ORAL TABLET EXTENDED $1 STPA RELEASE 24 HR* oxazepam oral capsule $1 paliperidone er oral tablet extended release 24 $1 PA; QL (30 EA per 30 days) hr*

^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 112 Drug Status Notes paroxetine hcl er oral tablet extended release 24 $1 PA; QL (30 EA per 30 days) hr* paroxetine hcl oral tablet $1 PAXIL ORAL SUSPENSION $1 perphenazine oral tablet $1 phenelzine sulfate oral tablet $1 pimozide oral tablet $1 PA PRISTIQ ORAL TABLET EXTENDED $1 STPA RELEASE 24 HR* 100 MG, 50 MG protriptyline hcl oral tablet $1 PA quetiapine fumarate oral tablet $1 QL (90 EA per 30 days) QUILLIVANT XR ORAL SUSPENSION $1 PA; QL (360 mL per 30 days) RECONSTITUTED ra mini nicotine mouth/throat lozenge $1 ra nicotine mouth/throat gum $1 ra nicotine polacrilex mouth/throat gum $1 ra nicotine polacrilex mouth/throat lozenge $1 ra nicotine transdermal patch 24 hr $1 REXULTI ORAL TABLET $1 PA; QL (30 EA per 30 days) RISPERDAL CONSTA INTRAMUSCULAR* $1 QL (2 injections per 28 days) SUSPENSION RECONSTITUTED RISPERIDONE M-TAB ORAL TABLET $1 DISPERSIBLE risperidone oral solution $1 risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 $1 QL (60 EA per 30 days) mg, 3 mg risperidone oral tablet 4 mg $1 risperidone oral tablet dispersible $1 RITALIN LA ORAL CAPSULE EXTENDED $1 PA; QL (30 EA per 30 days) RELEASE 24 HOUR 10 MG, 60 MG rivastigmine tartrate oral capsule $1 rivastigmine transdermal patch 24 hr $1 SAPHRIS SUBLINGUAL TABLET $1 PA; QL (60 EA per 30 days) SUBLINGUAL SARAFEM ORAL TABLET 10 MG, 20 MG $1 PA SEROQUEL XR ORAL TABLET $1 PA EXTENDED RELEASE 24 HR* sertraline hcl oral concentrate $1

^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 113 Drug Status Notes sertraline hcl oral tablet $1 sm nicotine mouth/throat gum $1 sm nicotine mouth/throat lozenge $1 sm nicotine polacrilex mouth/throat gum $1 sm nicotine polacrilex mouth/throat lozenge $1 sm nicotine transdermal patch 24 hr $1 STRATTERA ORAL CAPSULE $1 PA; QL (60 EA per 30 days) PA; ¥ (Max of 32 mg/day for the SUBOXONE SUBLINGUAL FILM 12-3 MG, $1 first 6 months); QL (30 EA per 30 4-1 MG days) PA; ¥ (Max of 32 mg/day for the SUBOXONE SUBLINGUAL FILM 2-0.5 MG $1 first 6 months); QL (90 EA per 30 days) PA; ¥ (Max of 32 mg/day for the SUBOXONE SUBLINGUAL FILM 8-2 MG $1 first 6 months); QL (60 EA per 30 days) sw nicotine polacrilex mouth/throat gum $1 sw nicotine polacrilex mouth/throat lozenge $1 TENCON ORAL TABLET 50-325 MG $1 QL (180 EA per 30 days) tetrabenazine oral tablet 12.5 mg $1 PA; SP; QL (240 EA per 30 days) tetrabenazine oral tablet 25 mg $1 PA; SP; QL (120 EA per 30 days) tgt nicotine mouth/throat gum 4 mg $1 tgt nicotine polacrilex mouth/throat gum $1 tgt nicotine polacrilex mouth/throat lozenge $1 tgt nicotine step one transdermal patch 24 hr $1 tgt nicotine step three transdermal patch 24 hr $1 tgt nicotine step two transdermal patch 24 hr $1 thioridazine hcl oral tablet $1 thiothixene oral capsule $1 tranylcypromine sulfate oral tablet $1 trazodone hcl oral tablet $1 trifluoperazine hcl oral tablet $1 trimipramine maleate oral capsule $1 PA venlafaxine hcl er oral capsule extended release $1 24 hour venlafaxine hcl er oral tablet extended release 24 $1 STPA hr* venlafaxine hcl oral tablet $1 ^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 114 Drug Status Notes VERSACLOZ ORAL SUSPENSION $1 VESTURA ORAL TABLET $1 VIIBRYD ORAL TABLET $1 PA; QL (30 EA per 30 days) VIIBRYD STARTER PACK ORAL KIT $1 PA VIVITROL INTRAMUSCULAR* $1 SUSPENSION RECONSTITUTED VRAYLAR ORAL $1 PA VRAYLAR ORAL CAPSULE $1 PA VYVANSE ORAL CAPSULE $1 PA; QL (30 EA per 30 days) PA; ¥ (PA applies to members less ZENZEDI ORAL TABLET 10 MG, 5 MG $1 than 3 years old or 25 and older); QL (90 EA per 30 days) ziprasidone hcl oral capsule $1 QL (60 EA per 30 days) ZUBSOLV SUBLINGUAL TABLET PA; ¥ (Max of 32 mg/day for the SUBLINGUAL 1.4-0.36 MG, 2.9-0.71 MG, $1 first 6 months); QL (60 EA per 30 5.7-1.4 MG days) PA; ¥ (Max of 32 mg/day for the ZUBSOLV SUBLINGUAL TABLET $1 first 6 months); QL (30 EA per 30 SUBLINGUAL 11.4-2.9 MG, 8.6-2.1 MG days) ZYPREXA RELPREVV INTRAMUSCULAR* SUSPENSION $1 QL (2 vials per 28 days) RECONSTITUTED 210 MG, 300 MG ZYPREXA RELPREVV INTRAMUSCULAR* SUSPENSION $1 QL (1 vial per 28 days) RECONSTITUTED 405 MG OTHER OVER-THE-COUNTER DRUGS ACCU-CHEK SAFE-T PRO LANCETS $1 ACCU-CHEK SOFT TOUCH LANCETS $1 ACCU-CHEK SOFTCLIX LANCETS $1 AT LAST LANCETS $1 BD INSULIN SYRINGE 25G X 1" 1 ML, 25G X 5/8" 1 ML, 26G X 1/2" 1 ML, 27.5G X 5/8" 2 ML, 27G X 1/2" 1 ML, 28G X 1/2" 1 ML, $1 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 29G X 1/2" 2 ML, U-100 1 ML BD INSULIN SYRINGE MICROFINE $1 BD INSULIN SYRINGE ULTRAFINE 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 $1 ML, 30G X 1/2" 0.3 ML, 30G X 1/2" 0.5 ML, 30G X 1/2" 1 ML

^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 115 Drug Status Notes BD LANCET ULTRAFINE 33G $1 BD SAFETY-LOK INSULIN SYRINGE $1 BD SYRINGE SLIP TIP 3 ML $1 CLEANLET LANCETS 28G $1 clotrimazole anti-fungal external cream $1 comfort lancets $1 COPASIL EXTERNAL GEL $1 daily multi oral tablet $1 diphenhydramine hcl oral capsule 25 mg $1 eq nicotine mouth/throat gum 4 mg $1 eq nicotine polacrilex mouth/throat lozenge $1 eq nicotine step 3 transdermal patch 24 hr $1 eq nicotine transdermal patch 24 hr 7 mg/24hr $1 EZ-LETS LANCETS 26G $1 ferrous sulfate granules $1 FINGERSTIX LANCETS $1 FREESTYLE INSULINX TEST IN VITRO $1 QL (150 strips per 30 days) STRIP FREESTYLE LANCETS $1 FREESTYLE LITE TEST IN VITRO STRIP $1 QL (150 strips per 30 days) FREESTYLE PRECISION NEO TEST IN $1 QL (150 strips per 30 days) VITRO STRIP FREESTYLE TEST IN VITRO STRIP $1 QL (150 strips per 30 days) GENTLE-LET GP LANCETS $1 GENTLE-LET LANCETS $1 GLUCOSOURCE LANCETS $1 gnp lancets $1 gnp ultra com insulin syringe 28g x 1/2" 0.5 ml, 28g x 1/2" 1 ml, 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 $1 ml, 29g x 1/2" 1 ml guaifenesin er oral tablet extended release 12 hr* $1 600 mg HAEMOLANCE LOW FLOW LANCETS $1 hm nicotine transdermal patch 24 hr 7 mg/24hr $1 hydrocortisone external cream 1 % $1 hydrocortisone external lotion 1 % $1 hydrocortisone external ointment 1 % $1

^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 116 Drug Status Notes HY-VEE LANCETS $1 hy-vee thin lancets $1 insulin syringe 28g x 1/2" 0.5 ml, 28g x 1/2" 1 ml, 29g x 1" 0.3 ml, 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 $1 ml, 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml insulin syringe 29g x 1/2" 1 ml, 30g x 5/16" 1 ml $1 insulin syringe/needle $1 kinney lancets $1 kinney thin lancets $1 kinray insulin syringe 29g x 1/2" 0.5 ml $1 lancets $1 lancets thin $1 lavare wound wash external gel $1 LIFESCAN UNISTIK II LANCETS $1 lite touch lancets $1 longs lancets thin $1 MEDISENSE THIN LANCETS $1 MEIJER LANCETS $1 MICROTAINER SAFETY FLOW LANCET $1 MONOJECT FILTER ASPIRATOR $1 MONOJECT INSULIN SYRINGE 25G X 5/8" 1 ML, 27G X 1/2" 1 ML, 28G X 1/2" 1 ML, $1 29G X 1/2" 0.3 ML, 30G X 5/16" 1 ML, U-100 1 ML MONOJECT INSULIN SYRINGE 28G X 1/2" $1 0.5 ML MONOJECT PHARMACY TRAY 20 ML , 3 $1 ML , 35 ML , 6 ML , 60 ML MONOJECT PISTON SYRINGE $1 MONOJECT SAFETY SYRINGE/SHIELD 12 ML , 20G X 1-1/2" 12 ML, 21G X 1" 3 ML, $1 21G X 1-1/2" 3 ML, 3 ML

^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 117 Drug Status Notes MONOJECT SYRINGE 12 ML , 18G X 1" 12 ML, 20G X 1" 3 ML, 20G X 1-1/2" 12 ML, 20G X 1-1/2" 3 ML, 20G X 1-1/2" 6 ML, 20G X 3/4" 3 ML, 21G X 1" 12 ML, 21G X 1" 3 ML, 21G X 1" 6 ML, 21G X 1-1/2" 12 ML, $1 21G X 1-1/2" 3 ML, 21G X 1-1/2" 6 ML, 22G X 1" 3 ML, 22G X 1-1/2" 3 ML, 23G X 1" 3 ML, 25G X 1" 3 ML, 25G X 1-1/4" 3 ML, 25G X 5/8" 3 ML, 27G X 1-1/4" 3 ML, 3 ML MONOJECT SYRINGE CATH TIP $1 MONOJECT SYRINGE ECC LUER 35 ML $1 MONOJECT SYRINGE LUER LOCK $1 MONOJECT SYRINGE REG LUER 12 ML , $1 20 ML , 3 ML , 35 ML , 6 ML MONOJECT TB SAFETY SYRINGE 28G X $1 1/2" 1 ML MONOJECT TB SYRINGE 25G X 5/8" 1 ML, $1 26G X 3/8" 1 ML, 28G X 1/2" 1 ML MONOJECT ULTRA COMFORT SYRINGE $1 28G X 1/2" 0.5 ML MONOLET LANCETS $1 MULTI COMPLETE ORAL CAPSULE $1 multi vitamin/minerals oral tablet $1 n-acetyl-l-cysteine oral capsule $1 ONETOUCH CLUB LANCETS FINE PT $1 ONETOUCH FINEPOINT LANCETS $1 ONETOUCH LANCETS $1 ONETOUCH ULTRASOFT LANCETS $1 potassium bicarbonate granules $1 potassium chloride granules $1 potassium citrate monohydrate granules $1 PRECISION SURE-DOSE SYRINGE 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.5 $1 ML PRECISION THIN LANCETS $1 PRECISION THINS GP LANCETS $1 PRECISION ULTRA LANCET $1 PRECISION XTRA BLOOD GLUCOSE IN $1 QL (150 strips per 30 days) VITRO STRIP preferred plus lancets colored $1 ^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 118 Drug Status Notes preferred plus lancets thin $1 prenatal 19 oral tablet $1 prenatal 19 oral tablet chewable $1 PSS SELECT GP LANCETS $1 PSS SELECT SAFETY LANCETS $1 qc nicotine polacrilex mouth/throat gum $1 reality lancets $1 reality trigger lancets $1 sb lancets thin $1 sb lancets ultra thin $1 sr nicotine mouth/throat gum $1 super thin lancets $1 sure comfort insulin syringe 28g x 1/2" 0.5 ml, 28g x 1/2" 1 ml, 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 $1 ml, 29g x 1/2" 1 ml, 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml SURELITE LANCETS $1 tb syringe 1 ml $1 TECHLITE LANCETS $1 tgt nicotine mouth/throat gum $1 THINLETS GP LANCETS $1 THINLETS LANCET $1 topco insulin syringe $1 ULTILET CLASSIC LANCETS $1 ULTILET LANCETS $1 ULTRA-THIN II AUTO LANCET $1 ULTRA-THIN II LANCETS $1 UNILET COMFORTOUCH LANCET $1 UNILET G.P. LANCET $1 UNILET G.P. SUPERLITE LANCET $1 UNILET LANCET $1 UNILET SUPERLITE LANCET $1 UNISTIK 1 $1 VITALET PRO LANCETS $1 VITALET PRO PLUS LANCETS $1 W&F LANCETS 26G $1 W&F LANCETS COLORED 21G $1 ^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 119 Drug Status Notes OTHER PRESCRIPTION DRUGS abacavir-lamivudine-zidovudine oral tablet $1 acamprosate calcium oral tablet delayed release $1 QL (180 EA per 30 days) ¥ (Max of 4 g of acetaminophen or acetaminophen-codeine oral tablet $1 360 mg of codeine) acetazolamide er oral capsule extended release $1 12 hour ACIPHEX SPRINKLE ORAL CAPSULE $1 PA SPRINKLE acitretin oral capsule $1 QL (60 EA per 30 days) PA; SP; QL (4 syringes per 28 ACTEMRA SUBCUTANEOUS* $1 days) acyclovir oral capsule $1 acyclovir oral suspension $1 acyclovir oral tablet 400 mg $1 adefovir dipivoxil oral tablet $1 ADEMPAS ORAL TABLET $1 PA; SP ADRENALIN NASAL SOLUTION $1 AEROSPAN INHALATION AEROSOL, $1 SOLUTION ala cort external cream $1 ALBENZA ORAL TABLET $1 alclometasone dipropionate external cream $1 alclometasone dipropionate external ointment $1 almotriptan malate oral tablet $1 PA; QL (9 EA per 30 days) alogliptin benzoate oral tablet $1 PA; QL (30 EA per 30 days) alogliptin-metformin hcl oral tablet $1 PA; QL (60 EA per 30 days) alogliptin-pioglitazone oral tablet 12.5-15 mg, $1 PA; QL (30 EA per 30 days) 12.5-30 mg, 25-30 mg, 25-45 mg ALOMIDE OPHTHALMIC SOLUTION $1 PA alosetron hcl oral tablet 0.5 mg $1 PA; QL (60 EA per 30 days) alphatrex external gel $1 amcinonide external cream $1 PA amcinonide external lotion $1 PA amcinonide external ointment $1 PA amiodarone hcl oral tablet 100 mg $1 amitriptyline hcl oral tablet $1

^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 120 Drug Status Notes amlodipine besylate-valsartan oral tablet $1 PA; QL (30 EA per 30 days) amlodipine-valsartan-hctz oral tablet $1 PA; QL (30 EA per 30 days) amoxicill-clarithro-lansopraz oral $1 amoxicillin oral capsule $1 amoxicillin oral suspension reconstituted $1 amoxicillin oral tablet $1 amoxicillin oral tablet chewable 125 mg, 250 mg $1 amoxicillin-pot clavulanate er oral tablet $1 extended release 12 hr* amoxicillin-pot clavulanate oral suspension $1 reconstituted amoxicillin-pot clavulanate oral tablet $1 amoxicillin-pot clavulanate oral tablet chewable $1 PA; ¥ (PA applies to members less amphetamine-dextroamphetamine oral tablet 12.5 $1 than 3 years old or 25 and older); mg, 15 mg, 7.5 mg QL (90 EA per 30 days) ampicillin oral capsule $1 ampicillin oral suspension reconstituted $1 ANALPRAM-HC LOTION 1-2.5 % $1 ANORO ELLIPTA INHALATION AEROSOL POWDER, BREATH $1 PA ACTIVATED ANTARA ORAL CAPSULE 30 MG, 90 MG $1 PA; QL (30 EA per 30 days) antipyrine-benzocaine otic solution 5.4-1.4 %, $1 54-14 mg/ml APEXICON E EXTERNAL CREAM $1 PA APIDRA OPTICLIK SUBCUTANEOUS* $1 APIDRA OPTICLIK SUBCUTANEOUS* $1 SOLUTION APPFORMIN-D ORAL $1 APTIOM ORAL TABLET $1 PA aripiprazole oral tablet 2 mg $1 PA; QL (30 EA per 30 days) aripiprazole oral tablet dispersible $1 PA; QL (30 EA per 30 days) ARMOUR THYROID ORAL TABLET 120 $1 MG, 15 MG, 180 MG, 240 MG, 300 MG aspirin-dipyridamole er oral capsule extended $1 PA; QL (60 EA per 30 days) release 12 hour ASTAGRAF XL ORAL CAPSULE $1 PA; QL (30 EA per 30 days) EXTENDED RELEASE 24 HOUR ^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 121 Drug Status Notes atovaquone oral suspension $1 atropine sulfate ophthalmic solution $1 AUBRA ORAL TABLET $1 AUGMENTIN ORAL SUSPENSION $1 RECONSTITUTED 125-31.25 MG/5ML AURYXIA ORAL TABLET $1 PA AVAR CLEANSER EXTERNAL EMULSION $1 avidoxy oral tablet $1 azacitidine injection suspension reconstituted $1 SP azithromycin oral packet $1 azithromycin oral suspension reconstituted $1 azithromycin oral tablet 250 mg, 500 mg $1 bacitra-neomycin-polymyxin-hc ophthalmic $1 ointment BANZEL ORAL SUSPENSION $1 PA BANZEL ORAL TABLET $1 PA betamethasone dipropionate aug external cream $1 betamethasone dipropionate aug external gel $1 betamethasone dipropionate aug external lotion $1 betamethasone dipropionate aug external $1 ointment betamethasone dipropionate external cream $1 betamethasone dipropionate external lotion $1 betamethasone dipropionate external ointment $1 betamethasone valerate external cream $1 betamethasone valerate external lotion $1 betamethasone valerate external ointment $1 bexarotene oral capsule $1 SP BICILLIN L-A INTRAMUSCULAR* SUSPENSION 1200000 UNIT/2ML, 2400000 $1 UNIT/4ML BICNU INTRAVENOUS* SOLUTION $1 RECONSTITUTED bimatoprost ophthalmic solution $1 PA bp multinatal plus oral tablet $1 bp multinatal plus oral tablet chewable $1 BRINTELLIX ORAL TABLET $1 PA; QL (30 EA per 30 days)

^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 122 Drug Status Notes bromfenac sodium (once-daily) ophthalmic $1 solution budesonide inhalation suspension 1 mg/2ml $1 butalbital-aspirin-caffeine oral capsule $1 QL (180 EA per 30 days) BUTRANS TRANSDERMAL PATCH $1 PA; QL (4 EA per 28 days) WEEKLY 15 MCG/HR caffeine citrate oral solution $1 calcipotriene-betameth diprop external ointment $1 PA capecitabine oral tablet $1 SP carbamazepine er oral tablet extended release 12 $1 hr* 100 mg carbidopa oral tablet $1 CARDENE SR ORAL CAPSULE $1 EXTENDED RELEASE 12 HOUR 45 MG CAVAREST DENTAL GEL $1 CAVIRINSE MOUTH/THROAT SOLUTION $1 CEDAX ORAL SUSPENSION $1 RECONSTITUTED 90 MG/5ML cefaclor er oral tablet extended release 12 hr* $1 cefaclor oral capsule $1 cefaclor oral suspension reconstituted 125 $1 mg/5ml, 250 mg/5ml cefadroxil oral capsule $1 cefadroxil oral suspension reconstituted $1 cefadroxil oral tablet $1 cefdinir oral capsule $1 cefdinir oral suspension reconstituted $1 cefditoren pivoxil oral tablet $1 cefixime oral suspension reconstituted $1 cefpodoxime proxetil oral suspension $1 reconstituted cefpodoxime proxetil oral tablet $1 cefprozil oral suspension reconstituted $1 cefprozil oral tablet $1 ceftibuten oral capsule $1 CEFTIN ORAL SUSPENSION $1 RECONSTITUTED

^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 123 Drug Status Notes ceftriaxone sodium injection solution $1 reconstituted 1 gm, 250 mg, 500 mg cefuroxime axetil oral tablet $1 celecoxib oral capsule $1 STPA; QL (60 EA per 30 days) cephalexin oral capsule $1 cephalexin oral suspension reconstituted $1 cephalexin oral tablet $1 CEREZYME INTRAVENOUS* SOLUTION $1 PA; SP RECONSTITUTED 200 UNIT CEROVEL EXTERNAL LOTION $1 chlordiazepoxide-clidinium oral capsule $1 chlorthalidone oral tablet 100 mg $1 choline & mag trisalicylate oral tablet 1000 mg $1 CIDALEAZE EXTERNAL CREAM $1 ciprofloxacin hcl oral tablet 250 mg, 500 mg, 750 $1 mg ciprofloxacin oral suspension reconstituted $1 clarithromycin er oral tablet extended release 24 $1 hr* clarithromycin oral suspension reconstituted $1 clarithromycin oral tablet $1 CLEARPLEX X EXTERNAL GEL $1 CLINDAMAX EXTERNAL GEL $1 clindamycin hcl oral capsule $1 clindamycin palmitate hcl oral solution $1 reconstituted clobetasol propionate external liquid† $1 PA clocortolone pivalate external cream $1 PA clocortolone pivalate pump external cream $1 PA clonidine hcl er oral tablet extended release 12 $1 PA; QL (60 EA per 30 days) hr* clozapine oral tablet dispersible 150 mg, 200 mg $1 QL (60 EA per 30 days) COMPAZINE SUPPOSITORY $1 CONTROLRX DENTAL CREAM $1 COPAXONE SUBCUTANEOUS* 40 MG/ML $1 SP COPAXONE SUBCUTANEOUS* KIT $1 SP CORDRAN EXTERNAL LOTION $1 PA

^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 124 Drug Status Notes CORDRAN EXTERNAL OINTMENT $1 PA CORDRAN EXTERNAL TAPE $1 PA CORTISPORIN-TC OTIC SUSPENSION $1 COVERA-HS ORAL TABLET EXTENDED $1 RELEASE 24 HR* cyclopentolate hcl ophthalmic solution 0.5 % $1 QL (2 ML per 30 days) cyclophosphamide oral capsule $1 cycloserine oral capsule $1 cytra-2 oral solution $1 dapsone oral tablet $1 darifenacin hydrobromide er oral tablet extended $1 PA release 24 hr* decitabine intravenous* solution reconstituted $1 SP DELTASONE ORAL TABLET $1 demeclocycline hcl oral tablet $1 PA DEPRIZINE FUSEPAQ ORAL SUSPENSION $1 RECONSTITUTED desogestrel-ethinyl estradiol oral tablet $1 desonide external cream $1 PA desonide external lotion $1 PA desonide external ointment $1 PA desoximetasone external cream 0.05 % $1 PA desoximetasone external cream 0.25 % $1 desoximetasone external gel $1 desoximetasone external ointment 0.05 % $1 PA desoximetasone external ointment 0.25 % $1 PA; ¥ (PA applies to members less dexmethylphenidate hcl er oral capsule extended $1 than 3 years old or 25 and older); release 24 hour QL (30 EA per 30 days) diclofenac sodium oral tablet delayed release $1 diclofenac sodium transdermal gel 1 % $1 STPA diclofenac sodium transdermal gel 3 % $1 QL (1 Tube per 1 fill) diclofenac sodium transdermal solution $1 PA dicloxacillin sodium oral capsule $1 DICOPANOL FUSEPAQ ORAL $1 SUSPENSION RECONSTITUTED dicyclomine hcl oral solution $1

^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 125 Drug Status Notes diflorasone diacetate external cream $1 PA diflorasone diacetate external ointment $1 PA diltiazem hcl er coated beads oral tablet extended $1 release 24 hr* DONNATAL ORAL ELIXIR $1 doxepin hcl external cream $1 QL (45 grams per 1 Fill) doxercalciferol oral capsule $1 doxycycline hyclate oral capsule $1 doxycycline hyclate oral tablet 100 mg $1 doxycycline monohydrate oral capsule 100 mg, $1 50 mg doxycycline monohydrate oral suspension $1 reconstituted doxycycline monohydrate oral tablet 100 mg, 50 $1 mg DRITHO-CREME HP EXTERNAL CREAM $1 drospirenone-ethinyl estradiol oral tablet 3-0.02 $1 mg DUAVEE ORAL TABLET $1 PA duloxetine hcl oral capsule delayed release $1 STPA; QL (60 EA per 30 days) particles 20 mg, 60 mg duloxetine hcl oral capsule delayed release $1 STPA; QL (30 EA per 30 days) particles 30 mg dutasteride oral capsule $1 PA; QL (30 EA per 30 days) dutasteride-tamsulosin hcl oral capsule $1 PA; QL (30 EA per 30 days) DYNACIRC CR ORAL TABLET $1 EXTENDED RELEASE 24 HR* E.E.S. 400 ORAL TABLET $1 E.E.S. GRANULES ORAL SUSPENSION $1 RECONSTITUTED EASYGEL DENTAL GEL $1 ECOZA EXTERNAL FOAM $1 PA ELITE-OB ORAL TABLET $1 entecavir oral tablet $1 EPANED ORAL SOLUTION $1 RECONSTITUTED epirubicin hcl intravenous* solution 50 mg/25ml $1 ERYPED 200 ORAL SUSPENSION $1 RECONSTITUTED ^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 126 Drug Status Notes ERYPED 400 ORAL SUSPENSION $1 RECONSTITUTED ERY-TAB ORAL TABLET DELAYED $1 RELEASE ERYTHROCIN STEARATE ORAL TABLET $1 250 MG erythromycin base oral capsule delayed release $1 particles erythromycin base oral tablet $1 erythromycin ethylsuccinate oral tablet $1 esomeprazole magnesium oral capsule delayed $1 PA release est estrogens-methyltest hs oral tablet $1 est estrogens-methyltest oral tablet $1 estradiol transdermal patch biweekly $1 estradiol-norethindrone acet oral tablet $1 ethacrynate sodium intravenous* solution $1 reconstituted etoposide intravenous* solution 1 gm/50ml, 100 $1 mg/5ml, 500 mg/25ml etoposide oral capsule $1 FABIOR EXTERNAL FOAM $1 PA FACTIVE ORAL TABLET $1 famciclovir oral tablet $1 FARXIGA ORAL TABLET $1 PA; QL (30 EA per 30 days) fenofibrate oral capsule $1 PA; QL (30 EA per 30 days) fenofibrate oral tablet 120 mg, 40 mg $1 PA; QL (30 EA per 30 days) fenofibric acid oral capsule delayed release $1 PA; QL (30 EA per 30 days) FETZIMA ORAL CAPSULE EXTENDED $1 PA; QL (30 EA per 30 days) RELEASE 24 HOUR FETZIMA TITRATION ORAL $1 PA; QL (28 EA per 28 days) FIRST-BXN MOUTHWASH $1 MOUTH/THROAT SUSPENSION FIRST-DUKES MOUTHWASH $1 MOUTH/THROAT SUSPENSION FIRST-HYDROCORTISONE EXTERNAL $1 GEL FIRST-LANSOPRAZOLE ORAL $1 Age Limit (Max 12 Years) SUSPENSION ^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 127 Drug Status Notes FIRST-MARYS MOUTHWASH $1 MOUTH/THROAT SUSPENSION FIRST-MOUTHWASH BLM $1 MOUTH/THROAT SUSPENSION FIRST-OMEPRAZOLE ORAL $1 Age Limit (Max 13 Years) SUSPENSION FIRST-PROGESTERONE VGS 100 $1 VAGINAL SUPPOSITORY FIRST-PROGESTERONE VGS 200 $1 VAGINAL SUPPOSITORY FIRST-PROGESTERONE VGS 25 VAGINAL $1 SUPPOSITORY FIRST-PROGESTERONE VGS 400 $1 VAGINAL SUPPOSITORY FIRST-PROGESTERONE VGS 50 VAGINAL $1 SUPPOSITORY FIRST-TESTOSTERONE MC $1 TRANSDERMAL CREAM FIRST-TESTOSTERONE TRANSDERMAL $1 OINTMENT FIRST-VANCOMYCIN 25 ORAL $1 SOLUTION FIRST-VANCOMYCIN 50 ORAL $1 SOLUTION fluconazole oral suspension reconstituted $1 fluconazole oral tablet $1 flucytosine oral capsule $1 PA fluocinolone acetonide external cream $1 fluocinolone acetonide external ointment $1 fluocinolone acetonide external solution $1 fluocinonide external cream 0.05 % $1 fluocinonide external cream 0.1 % $1 PA fluocinonide external gel $1 fluocinonide external ointment $1 fluocinonide external solution $1 FLUORIDEX ENHANCED WHITENING $1 DENTAL GEL FLUORIDEX SENSITIVITY RELIEF $1 DENTAL GEL

^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 128 Drug Status Notes flurandrenolide external cream $1 PA fluticasone propionate external cream $1 fluticasone propionate external lotion $1 fluticasone propionate external ointment $1 fluvastatin sodium er oral tablet extended release $1 PA; QL (30 EA per 30 days) 24 hr* frovatriptan succinate oral tablet $1 PA; QL (9 EA per 30 days) FYCOMPA ORAL TABLET $1 PA gatifloxacin ophthalmic solution $1 GAZYVA INTRAVENOUS* SOLUTION $1 SP GEBAUERS PAIN EASE EXTERNAL $1 AEROSOL† GEBAUERS SPRAY AND STRETCH $1 EXTERNAL AEROSOL† gentamicin sulfate ophthalmic solution $1 GLEOSTINE ORAL CAPSULE 10 MG, 100 $1 MG, 40 MG glycopyrrolate oral tablet $1 glycron oral tablet 1.5 mg, 3 mg, 6 mg $1 GORDONS UREA EXTERNAL OINTMENT $1 40 % GRANIX SUBCUTANEOUS* $1 SP halobetasol propionate external cream $1 PA halobetasol propionate external ointment $1 PA HALOG EXTERNAL CREAM $1 PA HALOG EXTERNAL OINTMENT $1 PA HEMOFIL M INTRAVENOUS* SOLUTION RECONSTITUTED 1000 UNIT, 1700 UNIT, $1 SP 250 UNIT, 500 UNIT heparin sodium (porcine) injection solution 2500 $1 unit/ml HIZENTRA SUBCUTANEOUS* SOLUTION $1 PA; SP 10 GM/50ML HUMALOG MIX 50/50 PEN $1 SUBCUTANEOUS* HUMALOG MIX 50/50 PEN $1 SUBCUTANEOUS* SUSPENSION HUMALOG MIX 75/25 PEN $1 SUBCUTANEOUS* ^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 129 Drug Status Notes HUMALOG MIX 75/25 PEN $1 SUBCUTANEOUS* SUSPENSION HUMALOG PEN SUBCUTANEOUS* $1 HUMALOG PEN SUBCUTANEOUS* $1 SOLUTION hydrocodone-acetaminophen oral solution 2.5-108 mg/5ml, 5-217 mg/10ml, 7.5-325 $1 QL (480 ML per 1 day) mg/15ml hydrocortisone butyrate external cream $1 PA hydrocortisone butyrate external ointment $1 PA hydrocortisone butyrate external solution $1 PA hydrocortisone cream $1 hydrocortisone external cream 2.5 % $1 hydrocortisone external lotion 2.5 % $1 hydrocortisone external ointment 1 %, 2.5 % $1 hydrocortisone valerate external cream $1 hydrocortisone valerate external ointment $1 hydroxyprogesterone caproate intramuscular* oil $1 HYOPHEN ORAL TABLET $1 hyoscyamine sulfate er oral tablet extended $1 release 12 hr* hyoscyamine sulfate oral elixir $1 hyoscyamine sulfate oral solution $1 hyoscyamine sulfate oral tablet $1 hyoscyamine sulfate oral tablet dispersible $1 hyoscyamine sulfate sublingual tablet sublingual $1 hyosyne oral elixir $1 hyosyne oral solution $1 HYPERSAL INHALATION $1 NEBULIZATION SOLUTION 3.5 % ibandronate sodium intravenous* solution 3 $1 PA; QL (3 ML per 90 days) mg/3ml ICLUSIG ORAL TABLET $1 SP imatinib mesylate oral tablet $1 IMBRUVICA ORAL CAPSULE $1 INTROL ORAL SOLUTION $1 isometheptene-dichloral-apap oral capsule $1 QL (300 EA per 30 days)

^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 130 Drug Status Notes ISOPTO HYOSCINE OPHTHALMIC $1 SOLUTION itraconazole oral capsule $1 ivermectin oral tablet $1 K.B.G.L IN TERODERM EXTERNAL $1 CREAM KARIGEL DENTAL GEL $1 KARIGEL-N DENTAL GEL $1 KETEK ORAL TABLET $1 ketoconazole oral tablet $1 KOGENATE FS INTRAVENOUS* KIT $1 SP K-PHOS NO 2 ORAL TABLET $1 K-PHOS ORAL TABLET $1 LAMISIL SPRAY EXTERNAL SOLUTION $1 lamivudine oral solution $1 lamivudine oral tablet 100 mg $1 LANOXIN ORAL TABLET 187.5 MCG, 62.5 $1 MCG LANTUS FOR OPTICLIK $1 SUBCUTANEOUS* LANTUS FOR OPTICLIK $1 SUBCUTANEOUS* SOLUTION LARIN FE 1.5/30 ORAL TABLET $1 LARIN FE 1/20 ORAL TABLET $1 LATRIX EXTERNAL SUSPENSION $1 LATUDA ORAL TABLET 60 MG $1 PA; QL (30 EA per 30 days) LEUKINE INTRAVENOUS* SOLUTION $1 SP RECONSTITUTED levofloxacin oral solution $1 levofloxacin oral tablet $1 levonorgest-eth estrad 91-day oral tablet $1 0.15-0.03 &0.01 mg levonorgestrel oral tablet 1.5 mg $1 levonorgestrel-ethinyl estrad oral tablet 90-20 $1 mcg levonorg-eth estrad triphasic oral tablet $1 lidocaine external patch 5 % $1 LIDOPROFEN EXTERNAL CREAM $1 ^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 131 Drug Status Notes linezolid oral suspension reconstituted $1 QL (840 ML per 14 days) linezolid oral tablet $1 QL (28 EA per 14 days) LOCOID EXTERNAL LOTION $1 lofene oral tablet $1 LOKARA EXTERNAL LOTION $1 PA LOMEDIA 24 FE ORAL TABLET $1 lomustine oral capsule $1 LOZI-FLUR MOUTH/THROAT LOZENGE $1 LUFYLLIN ORAL TABLET 400 MG $1 PA LUZU EXTERNAL CREAM $1 PA LYZA ORAL TABLET $1 MATULANE ORAL CAPSULE $1 me/naphos/mb/hyo1 oral tablet $1 megestrol acetate oral suspension 625 mg/5ml $1 memantine hcl oral solution $1 memantine hcl oral tablet $1 meperidine hcl oral tablet 100 mg $1 QL (12 EA per 1 day) mercaptopurine oral tablet $1 metformin hcl er (mod) oral tablet extended $1 release 24 hr* 1000 mg methoxsalen rapid oral capsule $1 PA; ¥ (PA applies to members less methylphenidate hcl oral tablet chewable $1 than 3 years old or 25 and older); QL (90 EA per 30 days) methyltestosterone oral capsule $1 metronidazole oral capsule $1 metronidazole oral tablet $1 MICROCYN EXTERNAL GEL $1 MICROCYN SKIN AND WOUND $1 EXTERNAL GEL migragesic ida oral capsule $1 QL (300 EA per 30 days) MILLIPRED DP 12-DAY ORAL $1 minocycline hcl oral capsule $1 MIRVASO EXTERNAL GEL $1 PA MODERIBA ORAL TABLET $1 QL (210 EA per 30 days) mometasone furoate external cream $1 mometasone furoate external ointment $1 ^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 132 Drug Status Notes mometasone furoate external solution $1 mometasone furoate nasal suspension $1 PA MONDOXYNE NL ORAL CAPSULE 100 $1 MG, 50 MG MONOCLATE-P INTRAVENOUS* KIT 1500 $1 SP UNIT, 250 UNIT MONOJECT CONTROL SYRINGE $1 MONOJECT INSULIN SYRINGE 28G X 1/2" 0.5 ML, 29G X 1/2" 0.5 ML, 30G X 5/16" 0.3 $1 ML, 30G X 5/16" 0.5 ML MONOJECT SAFETY SYRINGE/SHIELD $1 21G X 1-1/2" 12 ML, 22G X 1-1/2" 3 ML MONOJECT SYRINGE 22G X 1-1/2" 12 ML, $1 22G X 1-1/2" 6 ML, 3 ML , 6 ML MONOJECT SYRINGE LUER LOCK 6 ML , $1 60 ML MONOJECT SYRINGE REG LUER 12 ML $1 MONONINE INTRAVENOUS* SOLUTION $1 SP RECONSTITUTED 250 UNIT, 500 UNIT MORGIDOX ORAL CAPSULE 100 MG $1 morphine sulfate er beads oral capsule extended $1 PA; QL (2 EA per 1 day) release 24 hour 120 mg, 90 mg morphine sulfate er beads oral capsule extended $1 PA; QL (8 EA per 1 day) release 24 hour 30 mg morphine sulfate er beads oral capsule extended $1 PA; QL (5 EA per 1 day) release 24 hour 45 mg morphine sulfate er beads oral capsule extended $1 PA; QL (4 EA per 1 day) release 24 hour 60 mg morphine sulfate er beads oral capsule extended $1 PA; QL (3 EA per 1 day) release 24 hour 75 mg morphine sulfate er oral capsule extended release $1 PA; QL (24 EA per 1 day) 24 hour 10 mg moxifloxacin hcl oral tablet $1 multi-vit/fluoride oral solution $1 multi-vit/fluoride/iron oral solution $1 multivitamin/fluoride oral tablet chewable 1 mg $1 mycophenolate mofetil oral suspension $1 reconstituted mycophenolic acid oral tablet delayed release $1

^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 133 Drug Status Notes NAFRINSE DAILY ACIDULATED MOUTH/THROAT SOLUTION $1 RECONSTITUTED NAFRINSE WEEKLY MOUTH/THROAT $1 SOLUTION RECONSTITUTED naftifine hcl external cream $1 PA napro external cream $1 NATURE-THROID ORAL TABLET $1 NEBUSAL INHALATION NEBULIZATION $1 SOLUTION 6 % neomycin-polymyxin-dexameth ophthalmic $1 ointment neomycin-polymyxin-dexameth ophthalmic $1 suspension 3.5-10000-0.1 neomycin-polymyxin-hc otic solution 1 % $1 NEO-POLYCIN HC OPHTHALMIC $1 OINTMENT NEUTRAGARD ADVANCED DENTAL GEL $1 nevirapine er oral tablet extended release 24 hr* $1 400 mg NEXT CHOICE ORAL TABLET $1 niacin er (antihyperlipidemic) oral tablet $1 extendedrelease* NIFEDIAC CC ORAL TABLET EXTENDED $1 RELEASE 24 HR* 30 MG, 60 MG nitrofurantoin macrocrystal oral capsule 25 mg $1 NODOLOR ORAL CAPSULE $1 QL (300 EA per 30 days) norethin ace-eth estrad-fe oral tablet $1 norethindrone acet-ethinyl est oral tablet $1 norethindrone-eth estradiol oral tablet $1 norethin-eth estradiol-fe oral tablet chewable $1 norgestim-eth estrad triphasic oral tablet $1 0.18/0.215/0.25 mg-25 mcg norgestrel-ethinyl estradiol oral tablet $1 nortuss-ex oral liquid† $1 NOXAFIL ORAL TABLET DELAYED $1 PA RELEASE np thyroid oral tablet $1 NUVIGIL ORAL TABLET 200 MG $1 PA; QL (30 EA per 30 days) ^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 134 Drug Status Notes nystatin external powder $1 ofloxacin oral tablet 400 mg $1 olopatadine hcl ophthalmic solution $1 PA OMEPRAZOLE+SYRSPEND SF ALKA $1 ORAL SUSPENSION ONFI ORAL SUSPENSION $1 PA ONFI ORAL TABLET 10 MG, 20 MG $1 PA; QL (60 EA per 30 days) opium oral tincture $1 OPSUMIT ORAL TABLET $1 PA; SP OSCION CLEANSER EXTERNAL LOTION $1 PA 6 % otic care otic solution $1 oxiconazole nitrate external cream $1 PA OXSORALEN EXTERNAL LOTION $1 oxycodone hcl er oral 10 mg, 20 mg, 40 mg, 80 $1 QL (90 EA per 30 days) mg OXYCONTIN ORAL 15 MG $1 QL (90 EA per 30 days) paclitaxel intravenous* concentrate 100 $1 mg/16.7ml, 150 mg/25ml, 300 mg/50ml paliperidone er oral tablet extended release 24 $1 PA; QL (30 EA per 30 days) hr* PANDEL EXTERNAL CREAM $1 pantoprazole sodium oral tablet delayed release $1 paricalcitol oral capsule $1 PA PCE ORAL TABLET DELAYED RELEASE $1 PEGANONE ORAL TABLET $1 PA penicillin g procaine intramuscular* suspension $1 penicillin v potassium oral solution reconstituted $1 penicillin v potassium oral tablet $1 PENNSAID TRANSDERMAL SOLUTION 2 $1 PA % phenobarbital oral elixir $1 phenobarbital oral solution $1 phenobarbital oral tablet $1 PHENOHYTRO ORAL TABLET $1 phenoxybenzamine hcl oral capsule $1 phenyleph-promethazine-cod oral syrup $1

^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 135 Drug Status Notes phenylephrine-guaifenesin oral liquid† $1 PHOS-FLUR DENTAL GEL $1 PHOSPHASAL ORAL TABLET $1 pimozide oral tablet 2 mg $1 PA PIMTREA ORAL TABLET $1 PIRMELLA 7/7/7 ORAL TABLET $1 potassium chloride er oral tablet $1 extendedrelease* 20 meq potassium chloride oral packet $1 potassium citrate er oral tablet extendedrelease* $1 pramipexole dihydrochloride er oral tablet extended release 24 hr* 0.375 mg, 0.75 mg, 1.5 $1 mg, 2.25 mg, 3 mg, 4.5 mg PRASCION EXTERNAL EMULSION $1 prednicarbate external cream $1 prednisolone sodium phosphate oral tablet $1 dispersible PREDNISONE INTENSOL ORAL $1 CONCENTRATE prednisone oral $1 prednisone oral solution $1 prednisone oral tablet $1 premium lidocaine external ointment $1 primidone oral tablet $1 PRIMSOL ORAL SOLUTION $1 PROCTOZONE-HC CREAM $1 progesterone micronized oral capsule $1 progesterone micronized transdermal cream $1 promethazine hcl suppository 50 mg $1 promethazine-phenylephrine oral syrup $1 PROTONIX ORAL PACKET $1 PA psorcon external cream $1 PA PULMOSAL INHALATION $1 NEBULIZATION SOLUTION PURIXAN ORAL SUSPENSION $1 pyridostigmine bromide er oral tablet $1 extendedrelease* quinaretic oral tablet 10-12.5 mg, 20-25 mg $1 ^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 136 Drug Status Notes quinine sulfate oral capsule $1 PA rabeprazole sodium oral tablet delayed release $1 PA raloxifene hcl oral tablet $1 REA LO 40 EXTERNAL CREAM $1 REA LO 40 EXTERNAL LOTION $1 REGRANEX EXTERNAL GEL $1 REMEVEN EXTERNAL CREAM $1 repaglinide oral tablet $1 repaglinide-metformin hcl oral tablet $1 rexaphenac transdermal cream $1 rifabutin oral capsule $1 risedronate sodium oral tablet 150 mg $1 PA; QL (1 EA per 30 days) risedronate sodium oral tablet 30 mg, 5 mg $1 PA; QL (30 EA per 30 days) risedronate sodium oral tablet 35 mg $1 PA; QL (4 EA per 28 days) risedronate sodium oral tablet delayed release $1 PA; QL (4 EA per 28 days) RISPERIDONE M-TAB ORAL TABLET $1 DISPERSIBLE rivastigmine transdermal patch 24 hr 4.6 $1 mg/24hr, 9.5 mg/24hr rixubis intravenous* solution reconstituted $1 SP ROSANIL CLEANSER EXTERNAL $1 EMULSION rosuvastatin calcium oral tablet $1 PA; QL (30 EA per 30 days) selenium sulfide external lotion $1 SELRX EXTERNAL SHAMPOO $1 sildenafil citrate intravenous* solution $1 PA; SP; QL (90 ML per 30 days) SIMPONI ARIA INTRAVENOUS* $1 PA; SP; QL (5 vials per 8 Weeks) SOLUTION sirolimus oral tablet $1 sodium chloride irrigation solution 0.9 % $1 PA sodium fluoride oral tablet 2.2 (1 f) mg $1 sodium polystyrene sulfonate oral powder $1 SOVALDI ORAL TABLET $1 PA; SP SPORANOX ORAL SOLUTION $1 sulfacetamide sodium ophthalmic solution $1 sulfacetamide sodium-sulfur external emulsion $1

^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 137 Drug Status Notes sulfacetamide sodium-sulfur external lotion 10-5 $1 % sulfadiazine oral tablet $1 sulfamethoxazole-trimethoprim oral suspension $1 200-40 mg/5ml sulfamethoxazole-trimethoprim oral tablet $1 sulfasalazine oral tablet delayed release $1 SULFATRIM PEDIATRIC ORAL $1 SUSPENSION SUPRAX ORAL CAPSULE $1 SUPRAX ORAL SUSPENSION $1 RECONSTITUTED 500 MG/5ML SUPRAX ORAL TABLET CHEWABLE $1 SYNALAR (CREAM) EXTERNAL KIT $1 PA SYNALAR (OINTMENT) EXTERNAL KIT $1 PA tacrolimus external ointment $1 PA telmisartan oral tablet $1 PA telmisartan-hctz oral tablet 40-12.5 mg, 80-12.5 $1 mg temozolomide oral capsule $1 SP terbutaline sulfate oral tablet $1 testosterone transdermal gel 10 mg/act (2%), 25 $1 PA mg/2.5gm (1%), 50 mg/5gm (1%) tetrabenazine oral tablet 12.5 mg $1 PA; SP; QL (240 EA per 30 days) tetrabenazine oral tablet 25 mg $1 PA; SP; QL (120 EA per 30 days) tetracycline hcl oral capsule $1 THALITONE ORAL TABLET $1 theophylline er oral tablet extended release 24 $1 hr* TIVICAY ORAL TABLET 50 MG $1 tobramycin inhalation nebulization solution $1 SP tolcapone oral tablet $1 PA; QL (180 EA per 30 days) tolterodine tartrate er oral capsule extended $1 release 24 hour tretinoin external gel 0.05 % $1 PA; Age Limit (Max 26 Years) triamcinolone acetonide external aerosol, $1 PA solution triamcinolone acetonide external cream $1

^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 138 Drug Status Notes triamcinolone acetonide external lotion $1 triamcinolone acetonide external ointment $1 TRIDERM EXTERNAL CREAM $1 TRI-LO-SPRINTEC ORAL TABLET $1 TRILYTE ORAL SOLUTION $1 RECONSTITUTED TROKENDI XR ORAL CAPSULE $1 PA EXTENDED RELEASE 24 HOUR U-KERA E EXTERNAL CREAM $1 UMECTA EXTERNAL EMULSION $1 UNITHROID DIRECT ORAL TABLET $1 UNITHROID ORAL TABLET 137 MCG $1 urea external cream 40 %, 50 % $1 urea external lotion 40 % $1 urea external suspension $1 urea nail film external suspension $1 urea-c40 external lotion $1 ure-k external cream $1 URETRON D/S ORAL TABLET $1 URIMAR-T ORAL TABLET $1 UROLET MB ORAL TABLET $1 UROPHEN MB ORAL TABLET $1 URYL ORAL TABLET $1 VALCHLOR EXTERNAL GEL $1 valganciclovir hcl oral tablet $1 valsartan oral tablet $1 STPA VERSACLOZ ORAL SUSPENSION $1 voriconazole oral suspension reconstituted $1 PA voriconazole oral tablet $1 PA; QL (180 EA per 30 days) VYFEMLA ORAL TABLET $1 WESTHROID ORAL TABLET 130 MG, 195 $1 MG, 32.5 MG, 65 MG, 97.5 MG WILATE INTRAVENOUS* SOLUTION $1 SP RECONSTITUTED WP THYROID ORAL TABLET $1 WYMZYA FE ORAL TABLET CHEWABLE $1 ZAZOLE VAGINAL CREAM 0.8 % $1 ^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 139 Drug Status Notes ZAZOLE VAGINAL SUPPOSITORY $1 zoledronic acid intravenous* solution 4 mg/100ml $1 QL (1 vial per 21 days) ZOMIG NASAL SOLUTION 2.5 MG $1 STPA; QL (6 Units per 30 days) PA; ¥ (Max of 32 mg/day for the ZUBSOLV SUBLINGUAL TABLET $1 first 6 months); QL (60 EA per 30 SUBLINGUAL 1.4-0.36 MG, 5.7-1.4 MG days) OVERDOSE acetylcysteine inhalation solution $1 AMITIZA ORAL CAPSULE $1 PA; QL (60 EA per 30 days) CHEMET ORAL CAPSULE $1 PA; ¥ (Max of 4 units per 30 EVZIO INJECTION $1 days); QL (2 Units per 1 Rx) EXJADE ORAL TABLET SOLUBLE $1 SP FERRIPROX ORAL SOLUTION $1 PA FERRIPROX ORAL TABLET $1 PA FUSILEV INTRAVENOUS* SOLUTION $1 SP RECONSTITUTED JADENU ORAL TABLET $1 SP leucovorin calcium oral tablet $1 MOVANTIK ORAL TABLET $1 PA naloxone hcl injection solution $1 ¥ (Max of 4 units per 30 days); QL NARCAN NASAL LIQUID† $1 (2 Units per 1 Rx) RELISTOR SUBCUTANEOUS* SOLUTION $1 PA 12 MG/0.6ML, 8 MG/0.4ML VISTOGARD ORAL PACKET $1 QL (20 EA per 30 days) PAIN ABSTRAL SUBLINGUAL TABLET $1 PA SUBLINGUAL ¥ (Max of 4 g of acetaminophen or acetaminophen-codeine #2 oral tablet $1 360 mg of codeine) ¥ (Max of 4 g of acetaminophen or acetaminophen-codeine #3 oral tablet $1 360 mg of codeine) ¥ (Max of 4 g of acetaminophen or acetaminophen-codeine #4 oral tablet $1 360 mg of codeine) ¥ (Max of 4 g of acetaminophen or acetaminophen-codeine oral solution $1 360 mg of codeine) ¥ (Max of 4 g of acetaminophen or acetaminophen-codeine oral tablet $1 360 mg of codeine) ^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 140 Drug Status Notes AFEDITAB CR ORAL TABLET EXTENDED $1 RELEASE 24 HR* almotriptan malate oral tablet $1 PA; QL (9 EA per 30 days) amlodipine besylate oral tablet $1 ASCOMP-CODEINE ORAL CAPSULE $1 QL (180 EA per 30 days) atenolol oral tablet $1 BELBUCA BUCCAL FILM $1 PA BOTOX INJECTION SOLUTION $1 PA; SP RECONSTITUTED BRILINTA ORAL TABLET $1 PA; QL (60 EA per 30 days) bromfenac sodium (once-daily) ophthalmic $1 solution bromfenac sodium ophthalmic solution $1 butalbital-acetaminophen oral tablet $1 QL (180 EA per 30 days) butalbital-apap-caffeine oral capsule 50-325-40 $1 QL (180 EA per 30 days) mg butalbital-apap-caffeine oral tablet 50-325-40 mg $1 QL (180 EA per 30 days) butalbital-aspirin-caffeine oral capsule $1 QL (180 EA per 30 days) butorphanol tartrate injection solution $1 butorphanol tartrate nasal solution $1 BUTRANS TRANSDERMAL PATCH $1 PA; QL (4 EA per 28 days) WEEKLY CAFERGOT ORAL TABLET $1 CAPACET ORAL CAPSULE $1 QL (180 EA per 30 days) ¥ (Max of 4 g of acetaminophen or CAPITAL/CODEINE ORAL SUSPENSION $1 360 mg of codeine) CARDIZEM LA ORAL TABLET $1 PA EXTENDED RELEASE 24 HR* 120 MG CARTIA XT ORAL CAPSULE EXTENDED $1 RELEASE 24 HOUR cilostazol oral tablet $1 cimetidine oral tablet 200 mg $1 clopidogrel bisulfate oral tablet $1 codeine sulfate oral tablet $1 QL (360 mg per 1 day) diclofenac potassium oral tablet $1 diflunisal oral tablet $1 dihydroergotamine mesylate nasal solution $1

^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 141 Drug Status Notes DILATRATE-SR ORAL CAPSULE $1 EXTENDED RELEASE* dilt-cd oral capsule extended release 24 hour $1 diltiazem cd oral capsule extended release 24 $1 hour 120 mg, 180 mg, 240 mg diltiazem hcl er beads oral capsule extended $1 release 24 hour diltiazem hcl er coated beads oral capsule $1 extended release 24 hour diltiazem hcl er coated beads oral tablet extended $1 release 24 hr* diltiazem hcl er oral capsule extended release 12 $1 hour diltiazem hcl er oral capsule extended release 24 $1 hour 120 mg, 180 mg, 240 mg diltiazem hcl oral tablet $1 dilt-xr oral capsule extended release 24 hour $1 diltzac oral capsule extended release 24 hour $1 divalproex sodium er oral tablet extended release $1 24 hr* divalproex sodium oral tablet delayed release $1 duloxetine hcl oral capsule delayed release $1 STPA; QL (60 EA per 30 days) particles 20 mg, 60 mg duloxetine hcl oral capsule delayed release $1 STPA; QL (30 EA per 30 days) particles 30 mg DUREZOL OPHTHALMIC EMULSION $1 EMBEDA ORAL CAPSULE EXTENDED $1 PA; QL (2 EA per 1 day) RELEASE* 100-4 MG EMBEDA ORAL CAPSULE EXTENDED $1 PA; QL (12 EA per 1 day) RELEASE* 20-0.8 MG EMBEDA ORAL CAPSULE EXTENDED $1 PA; QL (8 EA per 1 day) RELEASE* 30-1.2 MG EMBEDA ORAL CAPSULE EXTENDED $1 PA; QL (4 EA per 1 day) RELEASE* 50-2 MG, 60-2.4 MG EMBEDA ORAL CAPSULE EXTENDED $1 PA; QL (3 EA per 1 day) RELEASE* 80-3.2 MG ENDOCET ORAL TABLET 10-325 MG, ¥ (Max of 4 g of acetaminophen or $1 2.5-325 MG, 5-325 MG, 7.5-325 MG 160 mg of oxycodone ) ERGOMAR SUBLINGUAL TABLET $1 SUBLINGUAL

^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 142 Drug Status Notes etodolac oral capsule $1 etodolac oral tablet $1 famotidine oral suspension reconstituted $1 famotidine oral tablet 20 mg, 40 mg $1 fenoprofen calcium oral tablet $1 fentanyl citrate buccal lollipop $1 PA; QL (120 EA per 30 days) fentanyl transdermal patch 72 hr 100 mcg/hr $1 PA fentanyl transdermal patch 72 hr 12 mcg/hr, 25 $1 QL (10 EA per 30 days) mcg/hr, 50 mcg/hr, 75 mcg/hr fentanyl transdermal patch 72 hr 37.5 mcg/hr, $1 PA; QL (10 EA per 30 days) 62.5 mcg/hr, 87.5 mcg/hr FENTORA BUCCAL TABLET 100 MCG, 200 $1 PA; QL (4 EA per 1 day) MCG, 400 MCG, 600 MCG, 800 MCG flavoxate hcl oral tablet $1 FRAGMIN SUBCUTANEOUS* SOLUTION 10000 UNIT/ML, 12500 UNIT/0.5ML, 15000 UNIT/0.6ML, 18000 UNT/0.72ML, 2500 $1 UNIT/0.2ML, 5000 UNIT/0.2ML, 7500 UNIT/0.3ML frovatriptan succinate oral tablet $1 PA; QL (9 EA per 30 days) gabapentin oral capsule $1 gabapentin oral solution 250 mg/5ml $1 gabapentin oral tablet $1 GLYDO EXTERNAL GEL $1 GRALISE ORAL TABLET $1 PA; QL (90 EA per 30 days) GRALISE STARTER ORAL $1 PA hydrocodone-acetaminophen oral solution 2.5-108 mg/5ml, 5-217 mg/10ml, 7.5-325 $1 QL (480 ML per 1 day) mg/15ml hydrocodone-acetaminophen oral tablet 10-325 $1 QL (12 EA per 1 day) mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg hydrocodone-ibuprofen oral tablet 10-200 mg, $1 QL (5 EA per 1 day) 5-200 mg, 7.5-200 mg hydromorphone hcl er oral $1 PA; QL (64 mg per 1 day) hydromorphone hcl oral liquid† $1 QL (120 mg per 1 day) hydromorphone hcl oral tablet $1 QL (120 mg per 1 day) hydromorphone hcl suppository $1 IBUDONE ORAL TABLET $1 QL (5 EA per 1 day) ibuprofen oral suspension $1 ^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 143 Drug Status Notes ibuprofen oral tablet 400 mg, 600 mg, 800 mg $1 ILEVRO OPHTHALMIC SUSPENSION $1 INNOPRAN XL ORAL CAPSULE $1 EXTENDED RELEASE 24 HOUR ISORDIL TITRADOSE ORAL TABLET 40 $1 MG isosorbide dinitrate er oral tablet $1 extendedrelease* isosorbide dinitrate oral tablet $1 isosorbide mononitrate er oral tablet extended $1 release 24 hr* isosorbide mononitrate oral tablet $1 KADIAN ORAL CAPSULE EXTENDED $1 PA; QL (1 EA per 1 day) RELEASE 24 HOUR 200 MG KADIAN ORAL CAPSULE EXTENDED $1 PA; QL (6 EA per 1 day) RELEASE 24 HOUR 40 MG ketoprofen oral capsule $1 ketorolac tromethamine injection solution 15 ¥ (Max of 5 days per Rx); QL (120 $1 mg/ml, 30 mg/ml mg per 1 day) ketorolac tromethamine intramuscular* solution ¥ (Max of 5 days per Rx); QL (120 $1 60 mg/2ml mg per 1 day) ketorolac tromethamine ophthalmic solution $1 ketorolac tromethamine oral tablet $1 QL (20 EA per 30 days) lidocaine external patch 5 % $1 lidocaine hcl external cream $1 lidocaine hcl external gel 2 % $1 lidocaine hcl external lotion $1 lidopin external cream 3 % $1 LORCET HD ORAL TABLET $1 QL (12 EA per 1 day) LORCET ORAL TABLET $1 QL (12 EA per 1 day) LORCET PLUS ORAL TABLET 7.5-325 MG $1 QL (12 EA per 1 day) LORTAB ORAL TABLET 10-325 MG, 5-325 $1 QL (12 EA per 1 day) MG, 7.5-325 MG margesic oral capsule $1 QL (180 EA per 30 days) marten-tab oral tablet $1 QL (180 EA per 30 days) MATZIM LA ORAL TABLET EXTENDED $1 PA RELEASE 24 HR* meclofenamate sodium oral capsule $1

^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 144 Drug Status Notes mefenamic acid oral capsule $1 PA meperidine hcl oral solution $1 QL (120 ML per 1 day) meperidine hcl oral tablet 100 mg $1 QL (12 EA per 1 day) meperidine hcl oral tablet 50 mg $1 QL (24 EA per 1 day) METHADONE HCL INTENSOL ORAL $1 QL (6 ML per 1 day) CONCENTRATE methadone hcl oral concentrate $1 QL (6 ML per 1 day) methadone hcl oral solution 10 mg/5ml $1 QL (30 ML per 1 day) methadone hcl oral solution 5 mg/5ml $1 QL (60 ML per 1 day) methadone hcl oral tablet 10 mg $1 QL (6 EA per 1 day) methadone hcl oral tablet 5 mg $1 QL (12 EA per 1 day) methadone hcl oral tablet soluble $1 QL (1.5 EA per 1 day) METHADOSE ORAL TABLET SOLUBLE $1 QL (1.5 EA per 1 day) metoprolol succinate er oral tablet extended $1 release 24 hr* metoprolol tartrate oral tablet 100 mg, 25 mg, 50 $1 mg metoprolol tartrate oral tablet 37.5 mg, 75 mg $1 PA MIGERGOT SUPPOSITORY $1 MINITRAN TRANSDERMAL PATCH 24 HR $1 morphine sulfate (concentrate) oral solution 100 $1 QL (12 ML per 1 day) mg/5ml morphine sulfate er beads oral capsule extended $1 PA; QL (2 EA per 1 day) release 24 hour 120 mg, 90 mg morphine sulfate er beads oral capsule extended $1 PA; QL (8 EA per 1 day) release 24 hour 30 mg morphine sulfate er beads oral capsule extended $1 PA; QL (5 EA per 1 day) release 24 hour 45 mg morphine sulfate er beads oral capsule extended $1 PA; QL (4 EA per 1 day) release 24 hour 60 mg morphine sulfate er beads oral capsule extended $1 PA; QL (3 EA per 1 day) release 24 hour 75 mg morphine sulfate er oral capsule extended release $1 PA; QL (24 EA per 1 day) 24 hour 10 mg morphine sulfate er oral capsule extended release $1 PA; QL (2 EA per 1 day) 24 hour 100 mg morphine sulfate er oral capsule extended release $1 PA; QL (12 EA per 1 day) 24 hour 20 mg

^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 145 Drug Status Notes morphine sulfate er oral capsule extended release $1 PA; QL (8 EA per 1 day) 24 hour 30 mg morphine sulfate er oral capsule extended release $1 PA; QL (4 EA per 1 day) 24 hour 50 mg, 60 mg morphine sulfate er oral capsule extended release $1 PA; QL (3 EA per 1 day) 24 hour 80 mg morphine sulfate er oral tablet extendedrelease* $1 QL (2 EA per 1 day) 100 mg morphine sulfate er oral tablet extendedrelease* $1 QL (16 EA per 1 day) 15 mg morphine sulfate er oral tablet extendedrelease* $1 QL (1 EA per 1 day) 200 mg morphine sulfate er oral tablet extendedrelease* $1 QL (8 EA per 1 day) 30 mg morphine sulfate er oral tablet extendedrelease* $1 QL (4 EA per 1 day) 60 mg morphine sulfate oral solution 10 mg/5ml $1 QL (120 ML per 1 day) morphine sulfate oral solution 20 mg/5ml $1 QL (60 ML per 1 day) morphine sulfate oral tablet 15 mg $1 QL (16 EA per 1 day) morphine sulfate oral tablet 30 mg $1 QL (8 EA per 1 day) nadolol oral tablet 20 mg, 40 mg, 80 mg $1 naproxen oral suspension $1 naproxen oral tablet $1 naproxen sodium oral tablet $1 naratriptan hcl oral tablet $1 STPA; QL (9 EA per 30 days) NEVANAC OPHTHALMIC SUSPENSION $1 nicardipine hcl oral capsule $1 NIFEDICAL XL ORAL TABLET $1 EXTENDED RELEASE 24 HR* nifedipine er oral tablet extended release 24 hr* $1 nifedipine er osmotic release oral tablet extended $1 release 24 hr* nifedipine oral capsule $1 NITRO-BID TRANSDERMAL OINTMENT $1 NITRO-DUR TRANSDERMAL PATCH 24 $1 HR 0.3 MG/HR, 0.8 MG/HR nitroglycerin transdermal patch 24 hr $1 nitroglycerin translingual aerosol, solution $1 nitroglycerin translingual solution $1 ^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 146 Drug Status Notes NITROSTAT SUBLINGUAL TABLET $1 SUBLINGUAL NUCYNTA ER ORAL TABLET EXTENDED $1 PA RELEASE 12 HR* NUCYNTA ORAL TABLET $1 PA OPANA ER ORAL $1 PA; QL (80 mg per 1 day) OSPHENA ORAL TABLET $1 PA oxycodone hcl er oral $1 QL (90 EA per 30 days) oxycodone hcl oral capsule $1 QL (160 mg per 1 day) oxycodone hcl oral concentrate 100 mg/5ml $1 QL (160 mg per 1 day) oxycodone hcl oral solution $1 oxycodone hcl oral tablet $1 QL (160 mg per 1 day) oxycodone-acetaminophen oral tablet 10-325 mg, ¥ (Max of 4 g of acetaminophen or $1 2.5-325 mg, 5-325 mg, 7.5-325 mg 160 mg of oxycodone ) oxycodone-aspirin oral tablet 4.8355-325 mg $1 oxycodone-ibuprofen oral tablet $1 PA OXYCONTIN ORAL $1 QL (90 EA per 30 days) oxymorphone hcl er oral tablet extended release $1 PA; QL (80 mg per 1 day) 12 hr* oxymorphone hcl oral tablet $1 PA; QL (80 mg per 1 day) pentoxifylline er oral tablet extendedrelease* $1 PHENADOZ SUPPOSITORY $1 phenazopyridine hcl oral tablet 100 mg, 200 mg $1 PHENERGAN SUPPOSITORY $1 PREMARIN VAGINAL CREAM $1 promethazine hcl oral solution $1 promethazine hcl oral syrup $1 promethazine hcl oral tablet $1 promethazine hcl suppository $1 PROMETHEGAN SUPPOSITORY $1 propranolol hcl er oral capsule extended release $1 24 hour RANEXA ORAL TABLET EXTENDED $1 PA; QL (60 EA per 30 days) RELEASE 12 HR* RELPAX ORAL TABLET $1 PA; QL (9 EA per 30 days) REPREXAIN ORAL TABLET 10-200 MG $1 QL (5 EA per 1 day) rizatriptan benzoate oral tablet $1 STPA; QL (9 EA per 30 days)

^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 147 Drug Status Notes rizatriptan benzoate oral tablet dispersible $1 STPA; QL (9 EA per 30 days) ¥ (Max of 4 g of acetaminophen or ROXICET ORAL SOLUTION $1 160 mg of oxycodone ) ¥ (Max of 4 g of acetaminophen or ROXICET ORAL TABLET 5-325 MG $1 160 mg of oxycodone ) SAVELLA ORAL TABLET $1 STPA; QL (60 EA per 30 days) SAVELLA TITRATION PACK ORAL $1 STPA; QL (60 EA per 30 days) PA; ¥ (Max of 5 days per Rx); QL SPRIX NASAL SOLUTION $1 (4 units per 1 day) sumatriptan nasal solution $1 QL (6 Units per 30 days) sumatriptan succinate oral tablet $1 QL (9 EA per 30 days) sumatriptan succinate refill subcutaneous* $1 QL (5 EA per 30 days) sumatriptan succinate subcutaneous* 4 mg/0.5ml, $1 QL (5 EA per 30 days) 6 mg/0.5ml sumatriptan succinate subcutaneous* solution 6 $1 QL (5 EA per 30 days) mg/0.5ml TAZTIA XT ORAL CAPSULE EXTENDED $1 RELEASE 24 HOUR TENCON ORAL TABLET 50-325 MG $1 QL (180 EA per 30 days) topiramate oral capsule sprinkle 15 mg $1 topiramate oral capsule sprinkle 25 mg $1 QL (180 EA per 30 days) topiramate oral tablet 100 mg, 50 mg $1 QL (90 EA per 30 days) topiramate oral tablet 200 mg $1 topiramate oral tablet 25 mg $1 QL (180 EA per 30 days) tramadol hcl er (biphasic) oral tablet extended $1 PA release 24 hr* 100 mg, 300 mg tramadol hcl er oral tablet extended release 24 $1 PA; QL (30 EA per 30 days) hr* tramadol hcl oral tablet $1 QL (240 EA per 30 days) tramadol-acetaminophen oral tablet $1 QL (240 EA per 30 days) verapamil hcl oral tablet $1 VERDROCET ORAL TABLET $1 QL (12 EA per 1 day) XYLON ORAL TABLET $1 QL (5 EA per 1 day) ZAMICET ORAL SOLUTION $1 ZOHYDRO ER ORAL $1 PA; QL (120 mg per 1 day) zolmitriptan oral tablet $1 STPA; QL (9 EA per 30 days) zolmitriptan oral tablet dispersible $1 STPA; QL (9 EA per 30 days) ZOMIG NASAL SOLUTION $1 STPA; QL (6 Units per 30 days) ^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 148 Drug Status Notes PATIENT DEMOGRAPHICS BUPROBAN ORAL TABLET EXTENDED $1 RELEASE 12 HR* bupropion hcl er (smoking det) oral tablet $1 extended release 12 hr* CHANTIX CONTINUING MONTH PAK $1 QL (60 EA per 30 days) ORAL TABLET CHANTIX ORAL TABLET $1 QL (60 EA per 30 days) CHANTIX STARTING MONTH PAK ORAL $1 QL (60 EA per 30 days) TABLET eq nicotine mouth/throat lozenge $1 eq nicotine polacrilex mouth/throat gum $1 eq nicotine polacrilex mouth/throat lozenge $1 eq nicotine step 3 transdermal patch 24 hr $1 eq nicotine transdermal patch 24 hr 14 mg/24hr, $1 21 mg/24hr eql nicotine polacrilex mouth/throat gum $1 eql nicotine polacrilex mouth/throat lozenge $1 eql nicotine transdermal patch 24 hr $1 gnp nicotine mini mouth/throat lozenge $1 gnp nicotine polacrilex mouth/throat gum $1 gnp nicotine polacrilex mouth/throat lozenge $1 hm nicotine polacrilex mouth/throat gum $1 hm nicotine polacrilex mouth/throat lozenge $1 hm nicotine transdermal patch 24 hr $1 NICORELIEF MOUTH/THROAT GUM $1 nicotine mini mouth/throat lozenge $1 nicotine polacrilex mouth/throat gum $1 nicotine polacrilex mouth/throat lozenge $1 nicotine step 1 transdermal patch 24 hr $1 nicotine step 2 transdermal patch 24 hr $1 nicotine step 3 transdermal patch 24 hr $1 nicotine transdermal patch 24 hr $1 NICOTROL INHALATION INHALER $1 NICOTROL NS NASAL SOLUTION $1 ra mini nicotine mouth/throat lozenge $1 ra nicotine mouth/throat gum $1

^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 149 Drug Status Notes ra nicotine polacrilex mouth/throat gum $1 ra nicotine polacrilex mouth/throat lozenge $1 ra nicotine transdermal patch 24 hr $1 sm nicotine mouth/throat gum $1 sm nicotine mouth/throat lozenge $1 sm nicotine polacrilex mouth/throat gum $1 sm nicotine polacrilex mouth/throat lozenge $1 sm nicotine transdermal patch 24 hr $1 sw nicotine polacrilex mouth/throat gum $1 sw nicotine polacrilex mouth/throat lozenge $1 tgt nicotine mouth/throat gum 4 mg $1 tgt nicotine polacrilex mouth/throat gum $1 tgt nicotine polacrilex mouth/throat lozenge $1 tgt nicotine step one transdermal patch 24 hr $1 tgt nicotine step three transdermal patch 24 hr $1 tgt nicotine step two transdermal patch 24 hr $1 POOR NUTRITION AURYXIA ORAL TABLET $1 PA calcium acetate (phos binder) oral capsule $1 calcium acetate (phos binder) oral tablet $1 cyanocobalamin injection solution $1 ergocalciferol oral capsule $1 ESCAVITE D ORAL TABLET CHEWABLE $1 Age Limit (Max 6 Years) ESCAVITE ORAL TABLET CHEWABLE $1 Age Limit (Max 6 Years) folbee oral tablet $1 folic acid oral tablet 1 mg $1 FOSRENOL ORAL PACKET $1 FOSRENOL ORAL TABLET CHEWABLE $1 1000 MG, 500 MG, 750 MG FUSILEV INTRAVENOUS* SOLUTION $1 SP RECONSTITUTED leucovorin calcium oral tablet $1 levocarnitine oral solution $1 levocarnitine oral tablet $1 megestrol acetate oral suspension 40 mg/ml, 400 $1 mg/10ml, 625 mg/5ml multi vitamin/fluoride oral tablet chewable $1 ^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 150 Drug Status Notes multi-vit/fluoride oral solution $1 multi-vit/fluoride/iron oral solution $1 multi-vitamin/fluoride oral tablet chewable 0.5 $1 mg multivitamin/fluoride oral tablet chewable 1 mg $1 MYKIDZ IRON FL ORAL SUSPENSION $1 mynephrocaps oral capsule $1 NEPHROCAPS QT ORAL TABLET $1 DISPERSIBLE NORDITROPIN FLEXPRO $1 PA; SP SUBCUTANEOUS* SOLUTION PHOSLYRA ORAL SOLUTION $1 POLY-VI-FLOR ORAL SUSPENSION $1 RENAGEL ORAL TABLET $1 RENAL ORAL CAPSULE $1 RENVELA ORAL TABLET $1 SEROSTIM SUBCUTANEOUS* SOLUTION $1 PA; SP RECONSTITUTED 4 MG, 5 MG, 6 MG tri-vit/fluoride/iron oral solution $1 tri-vitamin/fluoride oral solution $1 vitamin d (ergocalciferol) oral capsule $1 ZORBTIVE SUBCUTANEOUS* SOLUTION $1 PA; SP RECONSTITUTED PREGNANCY bp folinatal plus b oral tablet $1 DICLEGIS ORAL TABLET DELAYED $1 PA RELEASE INATAL ADVANCE ORAL TABLET $1 MAKENA INTRAMUSCULAR* OIL $1 PA methylergonovine maleate oral tablet $1 OBSTETRIX EC ORAL TABLET $1 pnv folic acid + iron oral tablet $1 prenatabs fa oral tablet $1 PRENATABS RX ORAL TABLET $1 prenatal 19 oral tablet $1 prenatal 19 oral tablet chewable $1 prenatal oral tablet 27-0.8 mg $1

^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 151 Drug Status Notes RHOPHYLAC INJECTION $1 SP RHOPHYLAC INJECTION SOLUTION $1 SP TRINATE ORAL TABLET $1 WINRHO SDF INJECTION SOLUTION $1 SP REACTION DUE TO AN ALLERGEN ADRENALIN INJECTION SOLUTION $1 ALOCRIL OPHTHALMIC SOLUTION $1 PA ALREX OPHTHALMIC SUSPENSION $1 azelastine hcl nasal solution 0.1 % $1 azelastine hcl ophthalmic solution $1 PA BECONASE AQ NASAL SUSPENSION $1 PA BEPREVE OPHTHALMIC SOLUTION $1 PA BERINERT INTRAVENOUS* KIT $1 SP budesonide nasal suspension $1 PA cetirizine hcl oral solution $1 PA cetirizine hcl oral syrup 1 mg/ml $1 PA CLARINEX ORAL SYRUP $1 PA CLARINEX-D 12 HOUR ORAL TABLET $1 PA EXTENDED RELEASE 12 HR* clemastine fumarate oral tablet 2.68 mg $1 cromolyn sodium ophthalmic solution $1 cyproheptadine hcl oral syrup $1 cyproheptadine hcl oral tablet $1 desloratadine oral tablet $1 PA diphenhydramine hcl oral capsule $1 diphenhydramine hcl oral elixir $1 EMADINE OPHTHALMIC SOLUTION $1 PA epinastine hcl ophthalmic solution $1 PA epinephrine hcl injection solution 1 mg/ml $1 epinephrine injection 0.15 mg/0.15ml, 0.3 $1 QL (2 EA per 1 Fill) mg/0.3ml EPIPEN 2-PAK INJECTION $1 PA; QL (2 EA per 1 Fill) EPIPEN JR 2-PAK INJECTION $1 PA; QL (2 EA per 1 Fill) FIRAZYR SUBCUTANEOUS* SOLUTION $1 PA; SP flunisolide nasal solution 25 mcg/act (0.025%) $1 hydrocod polst-cpm polst er oral $1

^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 152 Drug Status Notes ipratropium bromide nasal solution $1 ketotifen fumarate ophthalmic solution $1 LASTACAFT OPHTHALMIC SOLUTION $1 PA levocetirizine dihydrochloride oral solution $1 PA levocetirizine dihydrochloride oral tablet $1 PA mometasone furoate nasal suspension $1 PA montelukast sodium oral packet $1 STPA; QL (30 EA per 30 days) montelukast sodium oral tablet $1 QL (30 EA per 30 days) montelukast sodium oral tablet chewable $1 QL (30 EA per 30 days) olopatadine hcl ophthalmic solution $1 PA OMNARIS NASAL SUSPENSION $1 PA PATADAY OPHTHALMIC SOLUTION $1 PA promethazine vc plain oral syrup $1 promethazine-codeine oral syrup $1 promethazine-dm oral syrup $1 promethazine-phenylephrine oral syrup $1 QNASL CHILDRENS NASAL AEROSOL, $1 PA SOLUTION QNASL NASAL AEROSOL, SOLUTION $1 PA RUCONEST INTRAVENOUS* SOLUTION $1 SP RECONSTITUTED SEMPREX-D ORAL CAPSULE $1 PA triamcinolone acetonide nasal aerosol† $1 VERAMYST NASAL SUSPENSION $1 PA XOLAIR SUBCUTANEOUS* SOLUTION $1 PA; SP; QL (6 vials per 28 days) RECONSTITUTED ZETONNA NASAL AEROSOL, SOLUTION $1 PA RECENT OPERATION ADRENALIN INJECTION SOLUTION 1 $1 MG/ML ALOXI INTRAVENOUS* SOLUTION 0.25 $1 QL (20 ML per 1 Rx) MG/5ML ALPHANATE/VWF COMPLEX/HUMAN INTRAVENOUS* SOLUTION $1 SP RECONSTITUTED AMICAR ORAL SYRUP $1 AMICAR ORAL TABLET $1

^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 153 Drug Status Notes ASTAGRAF XL ORAL CAPSULE $1 PA; QL (30 EA per 30 days) EXTENDED RELEASE 24 HOUR azathioprine oral tablet $1 BRILINTA ORAL TABLET $1 PA; QL (60 EA per 30 days) bromfenac sodium (once-daily) ophthalmic $1 solution bromfenac sodium ophthalmic solution $1 clopidogrel bisulfate oral tablet $1 cyclosporine modified oral capsule $1 cyclosporine modified oral solution $1 cyclosporine oral capsule $1 CYTOGAM INTRAVENOUS* INJECTABLE $1 SP dexamethasone sodium phosphate ophthalmic $1 solution diclofenac sodium ophthalmic solution $1 DUREZOL OPHTHALMIC EMULSION $1 EFFIENT ORAL TABLET $1 EMEND ORAL CAPSULE $1 QL (6 EA per 1 Rx) EVOMELA INTRAVENOUS* SOLUTION $1 RECONSTITUTED flurbiprofen sodium ophthalmic solution $1 fondaparinux sodium subcutaneous* solution $1 GATTEX SUBCUTANEOUS* KIT $1 PA; SP; QL (1 Kit per 1 day) GENGRAF ORAL CAPSULE 100 MG, 25 $1 MG GENGRAF ORAL SOLUTION $1 GLYDO EXTERNAL GEL $1 HUMATE-P INTRAVENOUS* SOLUTION RECONSTITUTED 1000-2400 UNIT, 250-600 $1 SP UNIT, 500-1200 UNIT hydroxyzine hcl oral syrup $1 hydroxyzine hcl oral tablet $1 hydroxyzine pamoate oral capsule $1 ILEVRO OPHTHALMIC SUSPENSION $1 ketorolac tromethamine injection solution 15 ¥ (Max of 5 days per Rx); QL (120 $1 mg/ml, 30 mg/ml mg per 1 day) ketorolac tromethamine intramuscular* solution ¥ (Max of 5 days per Rx); QL (120 $1 60 mg/2ml mg per 1 day)

^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 154 Drug Status Notes ketorolac tromethamine ophthalmic solution $1 ketorolac tromethamine oral tablet $1 QL (20 EA per 30 days) lidocaine external ointment $1 lidocaine hcl (pf) injection solution 4 % $1 lidocaine hcl external cream $1 lidocaine hcl external gel 2 % $1 lidocaine hcl external lotion $1 lidocaine hcl external solution $1 lidocaine hcl injection solution 0.5 %, 1 %, 1.5 %, $1 2 % lidocaine viscous mouth/throat solution $1 lidocaine-prilocaine external cream $1 lidocaine-prilocaine external kit $1 lidopin external cream 3 % $1 mycophenolate mofetil oral capsule $1 mycophenolate mofetil oral suspension $1 reconstituted mycophenolate mofetil oral tablet $1 mycophenolic acid oral tablet delayed release $1 MYLERAN ORAL TABLET $1 neomycin sulfate oral tablet $1 NEVANAC OPHTHALMIC SUSPENSION $1 ondansetron hcl injection solution 4 mg/2ml, 40 $1 mg/20ml oxycodone-ibuprofen oral tablet $1 PA PHENADOZ SUPPOSITORY $1 PHENERGAN SUPPOSITORY $1 pilocarpine hcl ophthalmic solution 1 %, 2 %, 4 $1 % promethazine hcl oral solution $1 promethazine hcl oral syrup $1 promethazine hcl oral tablet $1 promethazine hcl suppository $1 PROMETHEGAN SUPPOSITORY $1 proparacaine hcl ophthalmic solution $1 RAPAMUNE ORAL SOLUTION $1 SANDIMMUNE ORAL SOLUTION $1 ^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 155 Drug Status Notes silver sulfadiazine external cream $1 sirolimus oral tablet $1 PA; ¥ (Max of 5 days per Rx); QL SPRIX NASAL SOLUTION $1 (4 units per 1 day) SSD EXTERNAL CREAM $1 SULFAMYLON EXTERNAL CREAM $1 PA tacrolimus oral capsule $1 TRIESENCE INTRAOCULAR SUSPENSION $1 VALCYTE ORAL SOLUTION $1 RECONSTITUTED valganciclovir hcl oral tablet $1 VEXOL OPHTHALMIC SUSPENSION $1 WILATE INTRAVENOUS* KIT $1 SP WILATE INTRAVENOUS* SOLUTION RECONSTITUTED 1000-1000 UNIT, 500-500 $1 SP UNIT ZONTIVITY ORAL TABLET $1 ZORTRESS ORAL TABLET $1 SP SKIN CONDITION 8-MOP ORAL CAPSULE $1 ABSORICA ORAL CAPSULE $1 PA acitretin oral capsule $1 QL (60 EA per 30 days) acne medication 5 external gel $1 ACZONE EXTERNAL GEL 5 % $1 PA; QL (60 GM per 30 days) ACZONE EXTERNAL GEL 7.5 % $1 PA; QL (30 GM per 30 days) adapalene external cream $1 STPA adapalene external gel $1 STPA adapalene external lotion $1 STPA ALFERON N INJECTION SOLUTION $1 SP ALTABAX EXTERNAL OINTMENT $1 STPA; QL (15 GM per 1 Fill) ammonium lactate external cream $1 ammonium lactate external lotion $1 ANALPRAM-HC LOTION 2.5-1 % $1 AVITA EXTERNAL CREAM $1 PA; Age Limit (Max 26 Years) AVITA EXTERNAL GEL $1 PA; Age Limit (Max 26 Years) AZELEX EXTERNAL CREAM $1 QL (30 grams per 1 fill)

^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 156 Drug Status Notes BENLYSTA INTRAVENOUS* SOLUTION $1 PA; SP RECONSTITUTED benzoyl peroxide external gel 10 %, 5 % $1 benzoyl peroxide wash external liquid† 10 % $1 benzoyl peroxide-erythromycin external gel $1 QL (23 GM per 30 days) BERINERT INTRAVENOUS* KIT $1 SP betamethasone valerate external foam $1 bexarotene oral capsule $1 SP BEYAZ ORAL TABLET $1 BLISOVI 24 FE ORAL TABLET $1 BLISOVI FE 1.5/30 ORAL TABLET $1 BLISOVI FE 1/20 ORAL TABLET $1 BOTOX INJECTION SOLUTION $1 PA; SP RECONSTITUTED bp foaming wash external liquid† $1 bp wash external liquid† 2.5 % $1 bpo external gel $1 PA calcipotriene external cream $1 calcipotriene external ointment $1 calcipotriene external solution $1 calcipotriene-betameth diprop external ointment $1 PA CALCITRENE EXTERNAL OINTMENT $1 calcitriol external ointment $1 CAPEX EXTERNAL SHAMPOO $1 PA CENTANY EXTERNAL OINTMENT $1 cetirizine hcl oral solution $1 PA cetirizine hcl oral syrup 1 mg/ml $1 PA CICLODAN EXTERNAL CREAM $1 CICLODAN EXTERNAL SOLUTION $1 ciclopirox external gel $1 ciclopirox external shampoo $1 PA ciclopirox external solution $1 ciclopirox olamine external cream $1 ciclopirox olamine external suspension $1 PA CIMZIA PREFILLED SUBCUTANEOUS* $1 PA; SP; QL (2 EA per 28 days) KIT

^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 157 Drug Status Notes CIMZIA STARTER KIT SUBCUTANEOUS* $1 PA; SP KIT CIMZIA SUBCUTANEOUS* KIT 2 X 200 $1 PA; SP; QL (2 EA per 28 days) MG PA; ¥ (Max of 5 months); QL (60 CLARAVIS ORAL CAPSULE $1 EA per 30 days) clemastine fumarate oral tablet 2.68 mg $1 CLINDAGEL EXTERNAL GEL $1 PA clindamycin phos-benzoyl perox external gel $1 PA; QL (50 GM per 30 days) clindamycin phosphate external foam $1 PA clindamycin phosphate external gel $1 clindamycin phosphate external lotion $1 clindamycin phosphate external solution $1 clobetasol propionate e external cream $1 clobetasol propionate external cream $1 PA clobetasol propionate external foam $1 clobetasol propionate external gel $1 PA clobetasol propionate external liquid† $1 PA clobetasol propionate external lotion $1 clobetasol propionate external ointment $1 PA clobetasol propionate external shampoo $1 clobetasol propionate external solution $1 PA CLODAN EXTERNAL SHAMPOO $1 clotrimazole anti-fungal external cream $1 clotrimazole external cream $1 clotrimazole external solution $1 clotrimazole-betamethasone external cream $1 clotrimazole-betamethasone external lotion $1 CONDYLOX EXTERNAL GEL $1 CORMAX SCALP APPLICATION $1 PA EXTERNAL SOLUTION CORTISPORIN EXTERNAL CREAM $1 COSENTYX SENSOREADY PEN $1 PA; SP SUBCUTANEOUS* 150 MG/ML COSENTYX SUBCUTANEOUS* $1 PA; SP COTELLIC ORAL TABLET $1 PA; SP cyproheptadine hcl oral syrup $1

^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 158 Drug Status Notes cyproheptadine hcl oral tablet $1 DENAVIR EXTERNAL CREAM $1 PA; QL (5 GM per 1 Fill) diclofenac sodium transdermal gel 3 % $1 QL (1 Tube per 1 fill) drospirenone-ethinyl estradiol oral tablet 3-0.02 $1 mg DRYSOL EXTERNAL SOLUTION $1 DYSPORT (GLABELLAR LINES) INTRAMUSCULAR* SOLUTION $1 PA; SP RECONSTITUTED DYSPORT INTRAMUSCULAR* SOLUTION $1 PA; SP RECONSTITUTED econazole nitrate external cream $1 ECOZA EXTERNAL FOAM $1 PA ELIDEL EXTERNAL CREAM $1 PA PA; SP; QL (8 syringes per 28 ENBREL SUBCUTANEOUS* 25 MG/0.5ML $1 days) PA; SP; QL (4 syringes per 28 ENBREL SUBCUTANEOUS* 50 MG/ML $1 days) ENBREL SUBCUTANEOUS* SOLUTION PA; SP; QL (8 syringes per 28 $1 RECONSTITUTED days) PA; SP; QL (4 syringes per 28 ENBREL SURECLICK SUBCUTANEOUS* $1 days) ENBREL SURECLICK SUBCUTANEOUS* PA; SP; QL (4 syringes per 28 $1 SOLUTION days) EPIFOAM EXTERNAL FOAM $1 ERBITUX INTRAVENOUS* SOLUTION $1 SP ERIVEDGE ORAL CAPSULE $1 SP erythromycin external gel $1 erythromycin external solution $1 EURAX EXTERNAL CREAM $1 EURAX EXTERNAL LOTION $1 EXELDERM EXTERNAL CREAM $1 PA EXELDERM EXTERNAL SOLUTION $1 PA FABIOR EXTERNAL FOAM $1 PA FINACEA EXTERNAL FOAM $1 QL (50 GM per 1 Rx) FINACEA EXTERNAL GEL $1 QL (50 GM per 1 Rx) FIRAZYR SUBCUTANEOUS* SOLUTION $1 PA; SP fluocinolone acetonide body external oil $1

^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 159 Drug Status Notes fluocinolone acetonide otic oil $1 fluocinolone acetonide scalp external oil $1 fluocinonide external cream 0.1 % $1 PA FLUOROPLEX EXTERNAL CREAM $1 fluorouracil external cream $1 fluorouracil external solution $1 GAMMAGARD S/D LESS IGA INTRAVENOUS* SOLUTION $1 PA; SP RECONSTITUTED gentamicin sulfate external cream $1 gentamicin sulfate external ointment $1 GIANVI ORAL TABLET $1 GILDESS 1.5/30 ORAL TABLET $1 GILDESS 1/20 ORAL TABLET $1 GILDESS 24 FE ORAL TABLET $1 GILDESS FE 1.5/30 ORAL TABLET $1 GILDESS FE 1/20 ORAL TABLET $1 griseofulvin microsize oral suspension $1 griseofulvin microsize oral tablet $1 griseofulvin ultramicrosize oral tablet $1 HUMIRA PEDIATRIC CROHNS START $1 PA; SP; ¥ (1 Fill per life of plan) SUBCUTANEOUS* 40 MG/0.8ML HUMIRA PEN SUBCUTANEOUS* $1 PA; SP; QL (2 EA per 28 days) HUMIRA PEN-CROHNS STARTER $1 PA; SP; ¥ (1 Fill per life of plan) SUBCUTANEOUS* HUMIRA PEN-PSORIASIS STARTER $1 PA; SP; ¥ (1 Fill per life of plan) SUBCUTANEOUS* HUMIRA SUBCUTANEOUS* $1 PA; SP; QL (2 EA per 28 days) hydrocortisone ace-pramoxine external cream $1 2.5-1 % hydrocortisone cream $1 hydrocortisone external cream 1 %, 2.5 % $1 hydroxychloroquine sulfate oral tablet $1 hydroxyurea oral capsule $1 imiquimod external cream $1 IMPAVIDO ORAL CAPSULE $1 INTRON A INJECTION SOLUTION $1 SP

^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 160 Drug Status Notes INTRON A INJECTION SOLUTION $1 SP RECONSTITUTED ISTODAX INTRAVENOUS* SOLUTION $1 SP RECONSTITUTED JUBLIA EXTERNAL SOLUTION $1 PA JUNEL 1.5/30 ORAL TABLET $1 JUNEL 1/20 ORAL TABLET $1 JUNEL FE 1.5/30 ORAL TABLET $1 JUNEL FE 1/20 ORAL TABLET $1 JUNEL FE 24 ORAL TABLET $1 ketoconazole external cream $1 ketoconazole external foam $1 ketoconazole external shampoo $1 KETODAN EXTERNAL FOAM $1 kp clotrimazole external cream $1 PA; ¥ (Max of 6 weeks); QL (2 LAMISIL ORAL PACKET $1 Packets per 1 day) LARIN 1.5/30 ORAL TABLET $1 LARIN 1/20 ORAL TABLET $1 LARIN 24 FE ORAL TABLET $1 LARIN FE 1.5/30 ORAL TABLET $1 LARIN FE 1/20 ORAL TABLET $1 levocetirizine dihydrochloride oral solution $1 PA levocetirizine dihydrochloride oral tablet $1 PA lidocaine external ointment $1 lidocaine hcl external cream $1 lidocaine hcl external lotion $1 lidopin external cream 3 % $1 lindane external lotion $1 lindane external shampoo $1 LO LOESTRIN FE ORAL TABLET $1 LOMEDIA 24 FE ORAL TABLET $1 LORYNA ORAL TABLET $1 LUZU EXTERNAL CREAM $1 PA malathion external lotion $1 MEKINIST ORAL TABLET $1 SP methotrexate oral tablet $1 ^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 161 Drug Status Notes methoxsalen rapid oral capsule $1 metronidazole external cream $1 metronidazole external gel 0.75 % $1 metronidazole external gel 1 % $1 PA metronidazole external lotion $1 MICROGESTIN 1.5/30 ORAL TABLET $1 MICROGESTIN 1/20 ORAL TABLET $1 MICROGESTIN 24 FE ORAL TABLET $1 MICROGESTIN FE 1.5/30 ORAL TABLET $1 MICROGESTIN FE 1/20 ORAL TABLET $1 MINASTRIN 24 FE ORAL TABLET $1 CHEWABLE MIRVASO EXTERNAL GEL $1 PA mupirocin calcium external cream $1 PA mupirocin external ointment $1 MYORISAN ORAL CAPSULE $1 PA naftifine hcl external cream $1 PA NAFTIN EXTERNAL GEL 1 % $1 PA NEUAC EXTERNAL GEL $1 PA NIKKI ORAL TABLET $1 norethin ace-eth estrad-fe oral tablet $1 norethindrone acet-ethinyl est oral tablet $1 NORITATE EXTERNAL CREAM $1 PA NYAMYC EXTERNAL POWDER $1 nystatin external cream $1 nystatin external ointment $1 nystatin external powder $1 nystatin-triamcinolone external cream $1 nystatin-triamcinolone external ointment $1 NYSTOP EXTERNAL POWDER $1 ODOMZO ORAL CAPSULE $1 PA OTEZLA ORAL 10 & 20 & 30 MG $1 PA; SP; QL (60 EA per 30 days) OTEZLA ORAL TABLET $1 PA; SP; QL (60 EA per 30 days) oxiconazole nitrate external cream $1 PA OXISTAT EXTERNAL LOTION $1 PA PANRETIN EXTERNAL GEL $1 PA

^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 162 Drug Status Notes permethrin external cream $1 PICATO EXTERNAL GEL $1 PA; QL (1 Box per 1 Rx) podofilox external solution $1 PRAMOSONE E EXTERNAL CREAM $1 PRAMOSONE EXTERNAL CREAM 1-1 % $1 PRAMOSONE EXTERNAL LOTION $1 PRAMOSONE EXTERNAL OINTMENT $1 PROCTO-PAK CREAM $1 PROCTOSOL HC CREAM $1 PROCTOZONE-HC CREAM $1 PROLEUKIN INTRAVENOUS* SOLUTION $1 SP RECONSTITUTED REGRANEX EXTERNAL GEL $1 REMICADE INTRAVENOUS* SOLUTION $1 PA; SP RECONSTITUTED RETIN-A MICRO PUMP EXTERNAL GEL $1 PA; Age Limit (Max 26 Years) 0.08 % RHEUMATREX ORAL TABLET 2.5 MG $1 ROSADAN EXTERNAL CREAM $1 ROSADAN EXTERNAL GEL $1 RUCONEST INTRAVENOUS* SOLUTION $1 SP RECONSTITUTED SANTYL EXTERNAL OINTMENT $1 QL (30 GM per 1 Rx) selenium sulfide external lotion $1 selenium sulfide external shampoo $1 selenium sulf-pyrithione-urea external shampoo $1 SELRX EXTERNAL SHAMPOO $1 silver sulfadiazine external cream $1 SIVEXTRO ORAL TABLET $1 QL (6 EA per 365 days) ¥ (Max of 90 days per year); QL (1 SOLARAZE TRANSDERMAL GEL $1 tube per 1 Rx) SOOLANTRA EXTERNAL CREAM $1 PA spinosad external suspension $1 STPA; QL (120 ML per 1 Fill) SSD EXTERNAL CREAM $1 STELARA SUBCUTANEOUS* $1 PA; SP; QL (1 ML per 28 days) sulfacetamide sodium (acne) external lotion $1 sulfacetamide sodium external suspension $1

^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 163 Drug Status Notes SYLATRON SUBCUTANEOUS* KIT 200 MCG, 296 MCG, 300 MCG, 4 X 296 MCG, 4 $1 SP X 444 MCG, 444 MCG, 600 MCG, 888 MCG TACLONEX EXTERNAL SUSPENSION $1 PA tacrolimus external ointment $1 PA TAFINLAR ORAL CAPSULE $1 SP TARGRETIN EXTERNAL GEL $1 TARINA FE 1/20 ORAL TABLET $1 TAZORAC EXTERNAL CREAM $1 STPA TAZORAC EXTERNAL GEL $1 STPA ¥ (Max of 90 tablets per 365 days); terbinafine hcl oral tablet $1 QL (30 EA per 30 days) TERSI EXTERNAL FOAM $1 TILIA FE ORAL TABLET $1 tretinoin external cream $1 PA; Age Limit (Max 26 Years) tretinoin external gel $1 PA; Age Limit (Max 26 Years) tretinoin microsphere external gel $1 PA; Age Limit (Max 26 Years) tretinoin microsphere pump external gel $1 PA; Age Limit (Max 26 Years) TREXALL ORAL TABLET $1 TRI-LEGEST FE ORAL TABLET $1 ULESFIA EXTERNAL LOTION $1 QL (12 Bottles per 1 Rx) VALCHLOR EXTERNAL GEL $1 VEREGEN EXTERNAL OINTMENT $1 PA VESTURA ORAL TABLET $1 XEOMIN INTRAMUSCULAR* SOLUTION $1 PA; SP RECONSTITUTED XERAC AC EXTERNAL SOLUTION $1 XOLAIR SUBCUTANEOUS* SOLUTION $1 PA; SP; QL (6 vials per 28 days) RECONSTITUTED XOLEGEL EXTERNAL GEL $1 YERVOY INTRAVENOUS* SOLUTION $1 SP ZELBORAF ORAL TABLET $1 SP ZENATANE ORAL CAPSULE $1 PA ZOLINZA ORAL CAPSULE $1 SP ZOVIRAX EXTERNAL CREAM $1 PA; QL (5 GM per 1 Rx) ZYCLARA EXTERNAL CREAM $1 PA; QL (28 EA per 14 days) ZYCLARA PUMP EXTERNAL CREAM $1 PA; QL (2 Pumps per 1 day)

^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 164 Drug Status Notes TUMOR ABSTRAL SUBLINGUAL TABLET $1 PA SUBLINGUAL AFINITOR DISPERZ ORAL TABLET $1 SP SOLUBLE AFINITOR ORAL TABLET $1 SP AKYNZEO ORAL CAPSULE $1 QL (1 EA per 1 Fill) ALECENSA ORAL CAPSULE $1 PA; SP alfuzosin hcl er oral tablet extended release 24 $1 hr* ALKERAN ORAL TABLET $1 ALOXI INTRAVENOUS* SOLUTION 0.25 $1 QL (20 ML per 1 Rx) MG/5ML anagrelide hcl oral capsule $1 anastrozole oral tablet $1 ANZEMET ORAL TABLET 100 MG $1 QL (10 EA per 1 fill) ANZEMET ORAL TABLET 50 MG $1 QL (5 EA per 1 fill) ARANESP (ALBUMIN FREE) INJECTION $1 SP; QL (4 mL per 30 days) ARANESP (ALBUMIN FREE) INJECTION SOLUTION 10 MCG/0.4ML, 100 MCG/ML, $1 SP; QL (4 mL per 30 days) 200 MCG/ML, 25 MCG/ML, 300 MCG/ML, 40 MCG/ML, 60 MCG/ML ARZERRA INTRAVENOUS* $1 SP CONCENTRATE AVASTIN INTRAVENOUS* SOLUTION $1 SP azacitidine injection suspension reconstituted $1 SP bexarotene oral capsule $1 SP bicalutamide oral tablet $1 BOSULIF ORAL TABLET $1 SP CABOMETYX ORAL TABLET $1 PA; SP capecitabine oral tablet $1 SP CAPRELSA ORAL TABLET $1 CARDURA XL ORAL TABLET EXTENDED $1 RELEASE 24 HR* CESAMET ORAL CAPSULE $1 PA CIALIS ORAL TABLET 5 MG $1 PA; QL (30 EA per 30 days) COMETRIQ (100 MG DAILY DOSE) ORAL $1 KIT

^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 165 Drug Status Notes COMETRIQ (140 MG DAILY DOSE) ORAL $1 KIT COMETRIQ (60 MG DAILY DOSE) ORAL $1 KIT COTELLIC ORAL TABLET $1 PA; SP DACOGEN INTRAVENOUS* SOLUTION $1 SP RECONSTITUTED decitabine intravenous* solution reconstituted $1 SP DEMSER ORAL CAPSULE $1 DEPO-PROVERA INTRAMUSCULAR* $1 SUSPENSION 400 MG/ML doxazosin mesylate oral tablet $1 dronabinol oral capsule $1 dutasteride oral capsule $1 PA; QL (30 EA per 30 days) dutasteride-tamsulosin hcl oral capsule $1 PA; QL (30 EA per 30 days) ELIGARD SUBCUTANEOUS* KIT $1 PA; SP ELSPAR INJECTION SOLUTION $1 SP RECONSTITUTED EMCYT ORAL CAPSULE $1 EMEND ORAL CAPSULE $1 QL (6 EA per 1 Rx) EPOGEN INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 20000 UNIT/ML, $1 SP 3000 UNIT/ML, 4000 UNIT/ML ERBITUX INTRAVENOUS* SOLUTION $1 SP ERIVEDGE ORAL CAPSULE $1 SP EVOMELA INTRAVENOUS* SOLUTION $1 RECONSTITUTED exemestane oral tablet $1 FARESTON ORAL TABLET $1 FARYDAK ORAL CAPSULE $1 PA; SP fentanyl citrate buccal lollipop $1 PA; QL (120 EA per 30 days) FENTORA BUCCAL TABLET 100 MCG, 200 $1 PA; QL (4 EA per 1 day) MCG, 400 MCG, 600 MCG, 800 MCG finasteride oral tablet 5 mg $1 FIRMAGON SUBCUTANEOUS* $1 SP SOLUTION RECONSTITUTED fluorouracil external cream 5 % $1 fluorouracil external solution 5 % $1

^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 166 Drug Status Notes flutamide oral capsule $1 FUSILEV INTRAVENOUS* SOLUTION $1 SP RECONSTITUTED GAZYVA INTRAVENOUS* SOLUTION $1 SP granisetron hcl oral tablet $1 QL (14 EA per 1 Fill) GRANIX SUBCUTANEOUS* $1 SP HALAVEN INTRAVENOUS* SOLUTION $1 SP HERCEPTIN INTRAVENOUS* SOLUTION $1 SP RECONSTITUTED HEXALEN ORAL CAPSULE $1 HYCAMTIN ORAL CAPSULE $1 SP hydroxyprogesterone caproate intramuscular* oil $1 hydroxyurea oral capsule $1 IBRANCE ORAL CAPSULE $1 PA; SP IMBRUVICA ORAL CAPSULE $1 imiquimod external cream $1 INLYTA ORAL TABLET $1 SP INTRON A INJECTION SOLUTION $1 SP INTRON A INJECTION SOLUTION $1 SP RECONSTITUTED IRESSA ORAL TABLET $1 PA irinotecan hcl intravenous* solution 40 mg/2ml, $1 500 mg/25ml ISTODAX INTRAVENOUS* SOLUTION $1 SP RECONSTITUTED IXEMPRA KIT INTRAVENOUS* $1 SP SOLUTION RECONSTITUTED JAKAFI ORAL TABLET $1 SP JEVTANA INTRAVENOUS* SOLUTION $1 SP KADCYLA INTRAVENOUS* SOLUTION $1 SP RECONSTITUTED LENVIMA 10 MG DAILY DOSE ORAL $1 PA LENVIMA 14 MG DAILY DOSE ORAL $1 PA LENVIMA 20 MG DAILY DOSE ORAL $1 PA LENVIMA 24 MG DAILY DOSE ORAL $1 PA letrozole oral tablet $1 LEUKERAN ORAL TABLET $1 leuprolide acetate injection kit $1 PA; SP ^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 167 Drug Status Notes LONSURF ORAL TABLET $1 PA; SP LUPRON DEPOT INTRAMUSCULAR* KIT $1 PA; SP LYNPARZA ORAL CAPSULE $1 PA LYSODREN ORAL TABLET $1 megestrol acetate oral tablet $1 MEKINIST ORAL TABLET $1 SP mesna intravenous* solution $1 MESNEX ORAL TABLET $1 mitoxantrone hcl intravenous* concentrate $1 PA; SP NEULASTA DELIVERY KIT $1 SP SUBCUTANEOUS* NEULASTA DELIVERY KIT $1 SP SUBCUTANEOUS* SOLUTION NEULASTA ONPRO SUBCUTANEOUS* $1 SP NEULASTA SUBCUTANEOUS* $1 SP NEULASTA SUBCUTANEOUS* SOLUTION $1 SP NEUMEGA SUBCUTANEOUS* SOLUTION $1 SP RECONSTITUTED NEUPOGEN INJECTION $1 SP NEUPOGEN INJECTION SOLUTION $1 SP NEXAVAR ORAL TABLET $1 SP NILANDRON ORAL TABLET $1 NINLARO ORAL CAPSULE $1 PA; SP octreotide acetate injection solution 100 mcg/ml, 1000 mcg/ml, 200 mcg/ml, 50 mcg/ml, 500 $1 PA; SP; QL (30 ML per 30 days) mcg/ml ODOMZO ORAL CAPSULE $1 PA ONCASPAR INJECTION SOLUTION $1 SP ONCASPAR INTRAMUSCULAR* $1 SP SOLUTION ondansetron hcl injection solution 4 mg/2ml, 40 $1 mg/20ml ondansetron hcl oral solution $1 QL (105 ML per 1 Fill) ondansetron hcl oral tablet $1 QL (21 EA per 1 Fill) ondansetron oral tablet dispersible $1 QL (21 EA per 1 Fill) pamidronate disodium intravenous* solution $1 pamidronate disodium intravenous* solution $1 reconstituted ^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 168 Drug Status Notes PANRETIN EXTERNAL GEL $1 PA PERJETA INTRAVENOUS* SOLUTION $1 SP phenoxybenzamine hcl oral capsule $1 pilocarpine hcl oral tablet $1 POMALYST ORAL CAPSULE $1 SP PROCRIT INJECTION SOLUTION $1 SP PROGLYCEM ORAL SUSPENSION $1 PA PROLEUKIN INTRAVENOUS* SOLUTION $1 SP RECONSTITUTED raloxifene hcl oral tablet $1 RAPAFLO ORAL CAPSULE $1 PA REVLIMID ORAL CAPSULE $1 SP RITUXAN INTRAVENOUS* $1 SP CONCENTRATE RITUXAN INTRAVENOUS* SOLUTION $1 SP SANCUSO TRANSDERMAL PATCH $1 PA SANDOSTATIN LAR DEPOT $1 PA; SP; QL (1 vial per 28 days) INTRAMUSCULAR* KIT SOLTAMOX ORAL SOLUTION $1 SOMATULINE DEPOT SUBCUTANEOUS* $1 PA; SP; QL (1 ML per 28 days) SOLUTION SPRYCEL ORAL TABLET $1 SP STIVARGA ORAL TABLET $1 SP SUTENT ORAL CAPSULE $1 SP SYLATRON SUBCUTANEOUS* KIT 200 MCG, 296 MCG, 300 MCG, 4 X 296 MCG, 4 $1 SP X 444 MCG, 444 MCG, 600 MCG, 888 MCG SYNRIBO SUBCUTANEOUS* SOLUTION $1 SP RECONSTITUTED TABLOID ORAL TABLET $1 TAFINLAR ORAL CAPSULE $1 SP TAGRISSO ORAL TABLET $1 PA tamoxifen citrate oral tablet $1 tamsulosin hcl oral capsule $1 TARCEVA ORAL TABLET $1 SP TARGRETIN EXTERNAL GEL $1 TASIGNA ORAL CAPSULE $1 SP TECENTRIQ INTRAVENOUS* SOLUTION $1 ^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 169 Drug Status Notes TEMODAR INTRAVENOUS* SOLUTION $1 SP RECONSTITUTED temozolomide oral capsule $1 SP terazosin hcl oral capsule $1 THALOMID ORAL CAPSULE $1 SP THYROGEN INTRAMUSCULAR* $1 SP SOLUTION RECONSTITUTED TORISEL INTRAVENOUS* SOLUTION $1 SP TREANDA INTRAVENOUS* SOLUTION $1 SP RECONSTITUTED TRELSTAR DEPOT INTRAMUSCULAR* $1 SP SUSPENSION RECONSTITUTED TRELSTAR INTRAMUSCULAR* $1 SP SUSPENSION RECONSTITUTED TRELSTAR LA INTRAMUSCULAR* $1 SP SUSPENSION RECONSTITUTED TRELSTAR MIXJECT INTRAMUSCULAR* $1 SP SUSPENSION RECONSTITUTED tretinoin oral capsule $1 TYKERB ORAL TABLET $1 SP VALCHLOR EXTERNAL GEL $1 VALSTAR INTRAVESICAL SOLUTION $1 SP VANTAS SUBCUTANEOUS* KIT $1 PA; SP VECTIBIX INTRAVENOUS* SOLUTION $1 SP 100 MG/5ML, 400 MG/20ML VELCADE INJECTION SOLUTION $1 SP RECONSTITUTED VENCLEXTA ORAL TABLET $1 PA VENCLEXTA STARTING PACK ORAL $1 PA VIDAZA INJECTION SUSPENSION $1 SP RECONSTITUTED VOTRIENT ORAL TABLET $1 SP XALKORI ORAL CAPSULE $1 SP XGEVA SUBCUTANEOUS* SOLUTION $1 SP; QL (1 vial per 30 days) XTANDI ORAL CAPSULE $1 SP YERVOY INTRAVENOUS* SOLUTION $1 SP ZALTRAP INTRAVENOUS* SOLUTION $1 SP ZARXIO INJECTION $1 SP

^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 170 Drug Status Notes ZELBORAF ORAL TABLET $1 SP ZOLADEX SUBCUTANEOUS* IMPLANT PA; SP; QL (1 Implant per 84 $1 10.8 MG days) ZOLADEX SUBCUTANEOUS* IMPLANT PA; SP; QL (1 Implant per 28 $1 3.6 MG days) zoledronic acid intravenous* concentrate $1 QL (5 vials per 21 days) zoledronic acid intravenous* solution 4 mg/100ml $1 QL (1 vial per 21 days) zoledronic acid intravenous* solution $1 QL (1 vial per 21 days) reconstituted ZOLINZA ORAL CAPSULE $1 SP ZYDELIG ORAL TABLET $1 ZYKADIA ORAL CAPSULE $1 SP ZYTIGA ORAL TABLET $1 SP

^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 171 ^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 172 Index

I n d e x I n d e x I n d e x 8-MOP ...... 156 AKYNZEO ...... 61, 165 amiloride-hydrochlorothiazide .... 28 abacavir sulfate ...... 13, 81 ala cort ...... 120 amiodarone hcl ...... 28, 120 abacavir-lamivudine-zidovudine ALBENZA ...... 120 AMITIZA ...... 61, 140 ...... 13, 81, 120 albuterol sulfate ...... 8, 92, 93 amitriptyline hcl ...... 120 ABILIFY MAINTENA ...... 106 albuterol sulfate er ...... 8, 92 amlodipine besy-benazepril hcl ABSORICA ...... 156 alclometasone dipropionate ...... 120 ...... 28 ABSTRAL ...... 140, 165 ALDACTAZIDE ...... 18, 28 amlodipine besylate ...... 28, 141 acamprosate calcium ...... 106, 120 ALDURAZYME ...... 18, 69 amlodipine besylate-valsartan acarbose ...... 18, 69 ALECENSA ...... 93, 165 ...... 28, 121 ACCU-CHEK SAFE-T PRO alendronate sodium ... 18, 51, 69, 97 amlodipine-atorvastatin LANCETS ...... 115 ALFERON N ...... 82, 156 ...... 18, 28, 37 ACCU-CHEK SOFT TOUCH alfuzosin hcl er ...... 46, 165 amlodipine-valsartan-hctz LANCETS ...... 115 ALINIA ...... 61, 82 ...... 28, 121 ACCU-CHEK SOFTCLIX ALKERAN ...... 3, 51, 165 ammonium lactate ...... 156 LANCETS ...... 115 allopurinol ...... 18 amoxapine ...... 106 acebutolol hcl ...... 27 almotriptan malate amoxicill-clarithro-lansopraz acetaminophen-codeine ...... 120, 140 ...... 28, 37, 120, 141 ...... 61, 82, 121 acetaminophen-codeine #2 ...... 140 ALOCRIL ...... 77, 90, 152 amoxicillin ...... 121 acetaminophen-codeine #3 ...... 140 alogliptin benzoate ...... 18, 69, 120 amoxicillin-pot clavulanate ...... 121 acetaminophen-codeine #4 ...... 140 alogliptin-metformin hcl amoxicillin-pot clavulanate er ACETASOL HC ...... 77 ...... 18, 69, 120 ...... 121 acetazolamide ...... 18, 77, 92 alogliptin-pioglitazone amphetamine-dextroamphet er acetazolamide er ...... 120 ...... 18, 69, 120 ...... 37, 97, 106 acetic acid ...... 77 ALOMIDE ...... 120 amphetamine-dextroamphetamine acetic acid-aluminum acetate ...... 77 alosetron hcl ...... 61, 120 ...... 37, 97, 106, 121 acetylcysteine ...... 92, 140 ALOXI ...... 61, 153, 165 ampicillin ...... 121 ACIPHEX SPRINKLE ...... 61, 120 ALPHAGAN P ...... 78 AMPYRA ...... 37, 98 acitretin ...... 120, 156 ALPHANATE/VWF ANADROL-50 ...... 3 acne medication 5 ...... 156 COMPLEX/HUMAN anagrelide hcl ...... 3, 165 ACTEMRA ...... 59, 97, 120 ...... 3, 13, 28, 153 ANALPRAM-HC ...... 121, 156 ACTIMMUNE ...... 3, 13, 97 ALPHANINE SD ...... 3 anastrozole ...... 51, 165 ACTOPLUS MET XR ...... 18, 69 alphatrex ...... 120 ANDRODERM ...... 51, 69 acyclovir ...... 81, 82, 120 alprazolam ...... 106 ANDROGEL ...... 51, 69 ACZONE ...... 156 ALPRAZOLAM INTENSOL ANDROGEL PUMP ...... 51, 69 adapalene ...... 156 ...... 106 ANDROXY ...... 51, 69 ADCIRCA ...... 8, 27, 92 ALPROLIX ...... 3 ANORO ELLIPTA ...... 8, 93, 121 adefovir dipivoxil ...... 61, 82, 120 ALREX ...... 78, 90, 152 ANTARA ...... 18, 121 ADEMPAS ...... 3, 8, 27, 92, 120 ALTABAX ...... 82, 156 antipyrine-benzocaine ...... 121 ADRENALIN ...... ALTAVERA ...... 51 anucort-hc ...... 28, 61 27, 77, 82, 120, 152, 153 ALTOPREV ...... 18 ANUSOL-HC ...... 28, 61 ADVAIR DISKUS ...... 8, 92 ALVESCO ...... 8, 93 ANZEMET ...... 61, 165 ADVAIR HFA ...... 8, 92 alyacen 1/35 ...... 51 APEXICON E ...... 121 ADVATE ...... 3 alyacen 7/7/7 ...... 51 APIDRA ...... 18, 69 ADVICOR ...... 18, 27 amantadine hcl ...... 37, 82 APIDRA OPTICLIK ...... 121 adynovate ...... 3 amcinonide ...... 120 APIDRA SOLOSTAR ...... 18, 69 AEROSPAN ...... 8, 92, 120 AMETHIA ...... 51 APOKYN ...... 37 AFEDITAB CR ...... 27, 141 AMETHIA LO ...... 51 APPFORMIN-D ...... 121 AFINITOR ...... 46, 51, 61, 165 AMETHYST ...... 51 APRI ...... 51 AFINITOR DISPERZ ...... 37, 165 AMICAR ...... 28, 153 APRISO ...... 61 AFSTYLA ...... 3 amiloride hcl ...... 18 APTIOM ...... 37, 121

^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 173

I n d e x I n d e x I n d e x APTIVUS ...... 13, 82 AVONEX ...... 37 BEPREVE ...... 78, 91, 152 ARALAST NP ...... 8, 19, 93 AVONEX PEN ...... 37 BERINERT ...... 13, 19, 152, 157 ARANELLE ...... 51 AVONEX PREFILLED ...... 37 BESIVANCE ...... 78, 82, 91 ARANESP (ALBUMIN FREE) AXIRON ...... 51, 70 betamethasone dipropionate ...... 122 ...... 3, 46, 165 azacitidine ...... 3, 122, 165 betamethasone dipropionate aug ARCALYST ...... 13, 19, 77 AZASITE ...... 78, 82, 90 ...... 122 ARCAPTA NEOHALER ...... 8, 93 azathioprine ...... 13, 46, 59, 98, 154 betamethasone valerate ...... 122, 157 aripiprazole ...... 106, 121 azelastine hcl ...... 9, 12, 78, 91, 152 BETASERON ...... 38 ARISTADA ...... 106 AZELEX ...... 156 betaxolol hcl ...... 28, 78 ARMOUR THYROID ...... 121 AZILECT ...... 37 bethanechol chloride ...... 46 ARZERRA ...... 3, 165 azithromycin ...... 82, 122 BETIMOL ...... 78 ASACOL HD ...... 61 AZOPT ...... 78 BETOPTIC-S ...... 78 ASCOMP-CODEINE ...... 106, 141 AZOR ...... 28 bexarotene ...... 122, 157, 165 ASHLYNA ...... 51 AZURETTE ...... 51 BEYAZ ...... 51, 106, 157 ASMANEX 120 METERED bacitracin ...... 78, 82 bicalutamide ...... 46, 165 DOSES ...... 8, 93 bacitracin-polymyxin b ...... 78, 82 BICILLIN L-A ...... 122 ASMANEX 14 METERED bacitra-neomycin-polymyxin-hc BICNU ...... 122 DOSES ...... 8, 93 ...... 122 BIDIL ...... 28 ASMANEX 30 METERED baclofen ...... 38, 98 BILTRICIDE ...... 61, 82 DOSES ...... 8, 93 BACTROBAN NASAL ...... 82 bimatoprost ...... 78, 122 ASMANEX 60 METERED balsalazide disodium ...... 61 bisoprolol fumarate ...... 28 DOSES ...... 9, 93 BALZIVA ...... 51 bisoprolol-hydrochlorothiazide ASMANEX 7 METERED BANZEL ...... 122 ...... 28 DOSES ...... 9, 93 BARACLUDE ...... 61, 82 BLEPHAMIDE ...... 78 ASMANEX HFA ...... 9, 93 BD INSULIN SYRINGE ...... 115 BLEPHAMIDE S.O.P...... 78 aspirin-dipyridamole er BD INSULIN SYRINGE BLISOVI 24 FE ...... 51, 157 ...... 3, 28, 37, 121 MICROFINE ...... 115 BLISOVI FE 1.5/30 ...... 51, 157 ASTAGRAF XL BD INSULIN SYRINGE BLISOVI FE 1/20 ...... 52, 157 ...... 13, 46, 121, 154 ULTRAFINE ...... 115 BOSULIF ...... 4, 165 AT LAST LANCETS ...... 115 BD LANCET ULTRAFINE 33G BOTOX ...... 28, 38, 141, 157 atenolol ...... 28, 141 ...... 116 bp foaming wash ...... 157 atenolol-chlorthalidone ...... 28 BD SAFETY-LOK INSULIN bp folinatal plus b ...... 151 atorvastatin calcium ...... 19 SYRINGE ...... 116 bp multinatal plus ...... 122 atovaquone ...... 9, 82, 93, 122 BD SYRINGE SLIP TIP ...... 116 bp wash ...... 157 atovaquone-proguanil hcl ...... 82 BEBULIN ...... 3 bpo ...... 157 ATRIPLA ...... 13, 82 BECONASE AQ ...... 9, 12, 91, 152 BREO ELLIPTA ...... 9, 93 atropine sulfate ...... 37, 78, 98, 122 BEKYREE ...... 51 briellyn ...... 52 ATROVENT HFA ...... 9, 93 BELBUCA ...... 141 BRILINTA ...... 4, 28, 141, 154 AUBAGIO ...... 37 BELSOMRA ...... 38 brimonidine tartrate ...... 78 AUBRA ...... 51, 122 benazepril hcl ...... 28 BRINTELLIX ...... 122 AUGMENTIN ...... 122 benazepril-hydrochlorothiazide bromfenac sodium ...... 78, 141, 154 AURYXIA ...... 28 bromfenac sodium (once-daily) 19, 46, 69, 98, 122, 150 BENEFIX ...... 3 ...... 78, 123, 141, 154 AVANDAMET ...... 19, 69 BENICAR ...... 28 bromocriptine mesylate ...... 38, 70 AVANDARYL ...... 19, 69 BENICAR HCT ...... 28 budesonide ...... AVANDIA ...... 19, 70 BENLYSTA ...... 59, 157 9, 12, 61, 93, 123, 152 AVAR CLEANSER ...... 122 benzonatate ...... 12, 93 bumetanide ...... 19, 28 AVASTIN ...... 46, 61, 93, 165 benzoyl peroxide ...... 157 BUNAVAIL ...... 106 AVC VAGINAL ...... 46, 51, 82 benzoyl peroxide wash ...... 157 buprenorphine hcl ...... 106 AVIANE ...... 51 benzoyl peroxide-erythromycin buprenorphine hcl-naloxone hcl avidoxy ...... 122 ...... 157 ...... 106 AVITA ...... 156 benztropine mesylate ...... 38 BUPROBAN ...... 106, 149 ^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 174

I n d e x I n d e x I n d e x bupropion hcl ...... 107 CARDENE SR ...... 29, 123 chlorthalidone ...... 19, 124 bupropion hcl er (smoking det) CARDIZEM LA ...... 29, 141 chlorzoxazone ...... 98 ...... 106, 149 CARDURA XL ...... 47, 165 CHOLBAM ...... 19, 62 bupropion hcl er (sr) ...... 106 CARIMUNE NF ...... 4, 13, 29 cholestyramine ...... 20 bupropion hcl er (xl) ...... 106 carisoprodol ...... 98 cholestyramine light ...... 19, 20 buspirone hcl ...... 107 carisoprodol-aspirin ...... 98 choline & mag trisalicylate ...... 124 butalbital-acetaminophen carteolol hcl ...... 78 choline-mag trisalicylate ...... 98 ...... 107, 141 CARTIA XT ...... 29, 141 CIALIS ...... 47, 52, 165 butalbital-apap-caffeine ..... 107, 141 carvedilol ...... 29 CICLODAN ...... 82, 157 butalbital-aspirin-caffeine CAVAREST ...... 123 ciclopirox ...... 82, 157 ...... 107, 123, 141 CAVIRINSE ...... 123 ciclopirox olamine ...... 82, 157 butorphanol tartrate ...... 141 CAYSTON ...... 9, 19, 93 CIDALEAZE ...... 124 BUTRANS ...... 123, 141 CAZIANT ...... 52 cilostazol ...... 29, 98, 141 BYDUREON ...... 19, 70 CEDAX ...... 123 CILOXAN ...... 78, 83, 91 BYETTA 10 MCG PEN ...... 19, 70 cefaclor ...... 123 cimetidine ...... 62, 141 BYETTA 5 MCG PEN ...... 19, 70 cefaclor er ...... 123 cimetidine hcl ...... 62 BYSTOLIC ...... 28 cefadroxil ...... 123 CIMZIA ...... 59, 62, 98, 158 cabergoline ...... 70 cefdinir ...... 123 CIMZIA PREFILLED CABOMETYX ...... 46, 165 cefditoren pivoxil ...... 123 ...... 59, 62, 98, 157 CAFERGOT ...... 28, 38, 141 cefixime ...... 123 CIMZIA STARTER KIT caffeine citrate ...... 123 cefpodoxime proxetil ...... 123 ...... 59, 62, 98, 158 calcipotriene ...... 157 cefprozil ...... 123 CINRYZE ...... 20 calcipotriene-betameth diprop ceftibuten ...... 123 CIPRO HC ...... 77 ...... 123, 157 CEFTIN ...... 123 CIPRODEX ...... 77, 83 calcitonin (salmon) ...... 52, 70, 98 ceftriaxone sodium ...... 124 ciprofloxacin ...... 124 CALCITRENE ...... 157 cefuroxime axetil ...... 124 ciprofloxacin hcl ...... calcitriol ...... 19, 157 celecoxib ...... 59, 98, 124 47, 78, 83, 91, 124 calcium acetate (phos binder) CELONTIN ...... 38 ciprofloxacin-ciproflox hcl er ...... 19, 46, 70, 98, 150 CENTANY ...... 82, 157 ...... 47, 83 CAMILA ...... 52 cephalexin ...... 124 citalopram hydrobromide ...... 107 CAMRESE ...... 52 CERDELGA ...... 19 CLARAVIS ...... 158 CAMRESE LO ...... 52 CEREZYME ...... 19, 124 CLARINEX ...... 12, 152 CANASA ...... 61 CEROVEL ...... 124 CLARINEX-D 12 HOUR candesartan cilexetil ...... 28 CESAMET ...... 62, 165 ...... 9, 12, 152 CANTIL ...... 61 cetirizine hcl ...... 12, 19, 152, 157 clarithromycin ...... 124 CAPACET ...... 107, 141 cevimeline hcl ...... 13, 62, 78 clarithromycin er ...... 124 capecitabine ...... 52, 61, 123, 165 CHANTIX ...... 107, 149 CLEANLET LANCETS 28G CAPEX ...... 157 CHANTIX CONTINUING ...... 116 CAPITAL/CODEINE ...... 141 MONTH PAK ...... 107, 149 CLEARPLEX X ...... 124 CAPRELSA ...... 70, 165 CHANTIX STARTING clemastine fumarate ..... 12, 152, 158 captopril ...... 19, 28, 47, 70 MONTH PAK ...... 107, 149 CLEOCIN ...... 47, 52, 83 captopril-hydrochlorothiazide ..... 29 CHATEAL ...... 52 CLIMARA PRO ...... 52, 70, 98 CARAFATE ...... 61 CHEMET ...... 140 CLINDAGEL ...... 158 CARBAGLU ...... 19 chlordiazepoxide hcl ...... 38, 107 CLINDAMAX ...... 124 carbamazepine ...... 38, 98, 107 chlordiazepoxide-clidinium ...... 124 clindamycin hcl ...... 124 carbamazepine er ...... 38, 107, 123 chlorhexidine gluconate clindamycin palmitate hcl ...... 124 carbidopa ...... 38, 123 ...... 62, 82, 91 clindamycin phos-benzoyl perox carbidopa-levodopa ...... 38 chloroquine phosphate ...... 82 ...... 158 carbidopa-levodopa er ...... 38 chlorothiazide ...... 19 clindamycin phosphate carbidopa-levodopa-entacapone chlorothiazide sodium ...... 19 ...... 47, 52, 83, 158 ...... 38 chlorpromazine hcl ...... 93, 107 CLINPRO 5000 ...... 62 CARDENE IV ...... 29 chlorpropamide ...... 19, 70 clobetasol propionate ...... 124, 158 ^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 175

I n d e x I n d e x I n d e x clobetasol propionate e ...... 158 cortisone acetate ...... 13, 70 DELZICOL ...... 62 clocortolone pivalate ...... 124 CORTISPORIN ...... 83, 158 demeclocycline hcl ...... 125 clocortolone pivalate pump ...... 124 CORTISPORIN-TC ...... 125 DEMSER ...... 29, 166 CLODAN ...... 158 COSENTYX ...... 98, 158 DENAVIR ...... 62, 83, 159 clomiphene citrate ...... 52 COSENTYX SENSOREADY DENTA 5000 PLUS ...... 62 clomipramine hcl ...... 107 PEN ...... 98, 158 DENTAGEL ...... 62 clonazepam ...... 38, 98, 107 COSOPT PF ...... 78 DEPEN TITRATABS clonidine hcl ...... 29 COTELLIC ...... 158, 166 ...... 20, 38, 62, 99 clonidine hcl er ...... 38, 98, 107, 124 COVERA-HS ...... 125 DEPO-PROVERA ...... 47, 52, 166 clopidogrel bisulfate CREON ...... 62 DEPO-SUBQ PROVERA 104 ...... 4, 29, 141, 154 CRESEMBA ...... 83 ...... 52 clorazepate dipotassium ...... 38, 107 CRINONE ...... 52, 70 DEPO-TESTOSTERONE CLORPRES ...... 29 CRIXIVAN ...... 14, 83 ...... 52, 70 clotrimazole ...... 83, 91, 158 cromolyn sodium ...... DEPRIZINE FUSEPAQ ...... 125 clotrimazole anti-fungal 9, 14, 78, 91, 93, 152 desipramine hcl ...... 107 ...... 83, 116, 158 CRYSELLE-28 ...... 52 desloratadine ...... 12, 152 clotrimazole-betamethasone CUPRIMINE ...... 20, 38, 62, 98 desmopressin ace rhinal tube ...... 83, 158 CUVPOSA ...... 62 ...... 20, 70 clozapine ...... 107, 124 cyanocobalamin ...... 150 desmopressin ace spray refrig COAGADEX ...... 4 CYCLAFEM 1/35 ...... 52 ...... 20, 70 COARTEM ...... 83 CYCLAFEM 7/7/7 ...... 52 desmopressin acetate ...... 20, 47, 70 codeine sulfate ...... 141 cyclobenzaprine hcl ...... 98 desmopressin acetate spray colchicine ...... 20 cyclopentolate hcl ...... 78, 125 ...... 20, 70 colchicine-probenecid ...... 20, 98 cyclophosphamide ...... 125 desogestrel-ethinyl estradiol colestipol hcl ...... 20 cycloserine ...... 83, 125 ...... 52, 125 COLOCORT ...... 62 cyclosporine ...... 14, 47, 62, 154 desonide ...... 125 COMBIGAN ...... 78 cyclosporine modified desoximetasone ...... 125 COMBIPATCH ...... 52, 70 ...... 14, 47, 62, 154 desvenlafaxine er ...... 107 COMBIVENT RESPIMAT cyproheptadine hcl desvenlafaxine fumarate er ...... 107 ...... 9, 93 ...... 12, 152, 158, 159 dexamethasone ...... 71 COMETRIQ (100 MG DAILY CYRED ...... 52 DEXAMETHASONE DOSE) ...... 70, 165 CYSTAGON ...... 20 INTENSOL ...... 71 COMETRIQ (140 MG DAILY CYTOGAM ...... 14, 83, 154 dexamethasone sodium phosphate DOSE) ...... 70, 166 cytra-2 ...... 125 ...... 77, 78, 154 COMETRIQ (60 MG DAILY DACOGEN ...... 4, 166 DEXEDRINE ...... 39, 99, 108 DOSE) ...... 70, 166 daily multi ...... 116 DEXILANT ...... 62 comfort lancets ...... 116 DAKLINZA ...... 62, 83 dexmethylphenidate hcl COMPAZINE ...... 62, 124 DALIRESP ...... 9, 94 ...... 39, 99, 108 COMPLERA ...... 13, 83 danazol ...... 20, 52 dexmethylphenidate hcl er COMPRO ...... 62 dantrolene sodium ...... 38, 81, 98 ...... 39, 99, 108, 125 CONDYLOX ...... 83, 158 dapsone ...... 125 DEXPAK 10 DAY ...... 71 constulose ...... 20, 38, 62 darifenacin hydrobromide er DEXPAK 13 DAY ...... 71 CONTROLRX ...... 124 ...... 47, 99, 125 DEXPAK 6 DAY ...... 71 COPASIL ...... 116 DASETTA 1/35 ...... 52 dextroamphetamine sulfate COPAXONE ...... 38, 124 DASETTA 7/7/7 ...... 52 ...... 39, 99, 108 CORDRAN ...... 124, 125 DAYSEE ...... 52 dextroamphetamine sulfate er COREG CR ...... 29 DAYTRANA ...... 38, 99, 107 ...... 39, 99, 108 CORIFACT ...... 4 DEBLITANE ...... 52 DIABETA ...... 20, 71 CORLANOR ...... 29 decitabine ...... 4, 125, 166 diazepam ...... 39, 99, 108 CORMAX SCALP DEFITELIO ...... 29, 62 DICLEGIS ...... 62, 151 APPLICATION ...... 158 DELTASONE ...... 125 diclofenac potassium ...... 99, 141 CORTIFOAM ...... 62 DELYLA ...... 52 ^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 176

I n d e x I n d e x I n d e x diclofenac sodium ...... DROXIA ...... 4 ENSKYCE ...... 53 78, 99, 125, 154, 159 DRYSOL ...... 159 entacapone ...... 39 diclofenac sodium er ...... 59, 99 DUAVEE ...... 53, 99, 126 entecavir ...... 63, 84, 126 dicloxacillin sodium ...... 125 DULERA ...... 9, 94 ENTRESTO ...... 30 DICOPANOL FUSEPAQ ...... 125 duloxetine hcl ...... 99, 108, 126, 142 ENTYVIO ...... 63 dicyclomine hcl ...... 63, 125 DUREZOL ...... 79, 142, 154 enulose ...... 20, 39, 63 didanosine ...... 14, 83 dutasteride ...... 47, 126, 166 EPANED ...... 30, 126 DIFICID ...... 63, 83 dutasteride-tamsulosin hcl EPIFOAM ...... 159 diflorasone diacetate ...... 126 ...... 47, 126, 166 epinastine hcl ...... 79, 91, 152 diflunisal ...... 141 DYNACIRC CR ...... 126 epinephrine ...... 152 DIGITEK ...... 29 DYRENIUM ...... 20 epinephrine hcl ...... 30, 84, 152 DIGOX ...... 29 DYSPORT ...... 39, 99, 159 EPIPEN 2-PAK ...... 152 digoxin ...... 29 DYSPORT (GLABELLAR EPIPEN JR 2-PAK ...... 152 dihydroergotamine mesylate LINES) ...... 39, 99, 159 epirubicin hcl ...... 126 ...... 29, 39, 141 E.E.S. 400 ...... 126 EPITOL ...... 40, 100 DILANTIN ...... 39 E.E.S. GRANULES ...... 126 eplerenone ...... 30 DILATRATE-SR ...... 29, 142 EASYGEL ...... 126 EPOGEN ...... 4, 47, 166 dilt-cd ...... 29, 142 econazole nitrate ...... 83, 159 epoprostenol sodium ...... 9, 30, 94 diltiazem cd ...... 29, 142 ECOZA ...... 83, 126, 159 eprosartan mesylate ...... 30 diltiazem hcl ...... 30, 142 EDARBI ...... 30 EPZICOM ...... 14, 84 diltiazem hcl er ...... 30, 142 EDECRIN ...... 20, 30 eq nicotine ...... 108, 109, 116, 149 diltiazem hcl er beads ...... 29, 142 EDLUAR ...... 39 eq nicotine polacrilex diltiazem hcl er coated beads EDURANT ...... 14, 83 ...... 108, 116, 149 ...... 29, 30, 126, 142 EFFIENT ...... 4, 30, 154 eq nicotine step 3 ...... 108, 116, 149 dilt-xr ...... 30, 142 EGRIFTA ...... 14, 20, 59, 83 eql nicotine ...... 109, 149 diltzac ...... 30, 142 ELAPRASE ...... 20, 63, 71 eql nicotine polacrilex ...... 109, 149 dimenhydrinate ...... 63 ELESTRIN ...... 47, 53, 71, 91 ERBITUX ...... 63, 159, 166 DIPENTUM ...... 63 ELIDEL ...... 159 ergocalciferol ...... 150 diphenhydramine hcl ... 39, 116, 152 ELIGARD ...... 47, 166 ergoloid mesylates ...... 40, 109 diphenoxylate-atropine ...... 63 ELINEST ...... 53 ERGOMAR ...... 30, 40, 142 dipyridamole ...... 4 ELIQUIS ...... 4, 30, 94 ERIVEDGE ...... 159, 166 disopyramide phosphate ...... 30 ELITE-OB ...... 126 ERRIN ...... 53 disulfiram ...... 108 ELIXOPHYLLIN ...... 9, 94 ERYPED 200 ...... 126 DIURIL ...... 20 ELLA ...... 53 ERYPED 400 ...... 127 divalproex sodium ELMIRON ...... 47 ERY-TAB ...... 127 ...... 30, 39, 108, 142 ELOCTATE ...... 4 ERYTHROCIN STEARATE divalproex sodium er ELSPAR ...... 4, 166 ...... 127 ...... 30, 39, 108, 142 EMADINE ...... 79, 91, 152 erythromycin ...... 79, 84, 159 DIVIGEL ...... 47, 52, 71, 91 EMBEDA ...... 142 erythromycin base ...... 127 donepezil hcl ...... 39, 108 EMCYT ...... 47, 166 erythromycin ethylsuccinate ...... 127 DONNATAL ...... 126 EMEND ...... 63, 154, 166 ESBRIET ...... 9, 94 dorzolamide hcl ...... 79 EMOQUETTE ...... 53 ESCAVITE ...... 63, 150 dorzolamide hcl-timolol mal ...... 79 EMSAM ...... 108 ESCAVITE D ...... 63, 150 doxazosin mesylate ...... 30, 47, 166 EMTRIVA ...... 14, 83 escitalopram oxalate ...... 109 doxepin hcl ...... 108, 126 enalapril maleate ...... 30 esomeprazole magnesium .... 63, 127 doxercalciferol ...... 47, 71, 126 enalapril-hydrochlorothiazide ..... 30 est estrogens-methyltest ...... 127 doxycycline hyclate ...... 91, 126 ENBREL ...... 59, 99, 100, 159 est estrogens-methyltest hs ...... 127 doxycycline monohydrate ...... 126 ENBREL SURECLICK ESTARYLLA ...... 53 DRITHO-CREME HP ...... 126 ...... 59, 100, 159 estazolam ...... 40 dronabinol ...... 14, 20, 63, 83, 166 ENDOCET ...... 142 ESTRACE ...... 47, 53, 71, 91 drospirenone-ethinyl estradiol enoxaparin sodium ...... 4, 30 estradiol ...... 53, 71, 127 ...... 53, 108, 126, 159 ENPRESSE-28 ...... 53 estradiol-norethindrone acet ...... 127 ^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 177

I n d e x I n d e x I n d e x ESTRING ...... 47, 53, 71, 91 FINGERSTIX LANCETS ...... 116 FLUORIDEX ENHANCED ESTROGEL ...... 47, 53, 71, 91 FIRAZYR ...... 14, 21, 152, 159 WHITENING ...... 128 estropipate ...... 53, 71 FIRMAGON ...... 47, 166 FLUORIDEX SENSITIVITY eszopiclone ...... 40 FIRST-BXN MOUTHWASH RELIEF ...... 63, 128 ethacrynate sodium ...... 20, 30, 127 ...... 127 fluorometholone ...... 79 ethambutol hcl ...... 84 FIRST-DUKES MOUTHWASH FLUOROPLEX ...... 160 ethosuximide ...... 40 ...... 127 fluorouracil ...... 160, 166 etidronate disodium ...... 20, 100 FIRST-HYDROCORTISONE fluoxetine hcl ...... 109 etodolac ...... 100, 143 ...... 127 fluphenazine decanoate ...... 109 etodolac er ...... 59, 100 FIRST-LANSOPRAZOLE ...... 127 fluphenazine hcl ...... 109 etoposide ...... 127 FIRST-MARYS MOUTHWASH FLURA-DROPS ...... 63 EUFLEXXA ...... 100 ...... 128 flurandrenolide ...... 129 EURAX ...... 84, 159 FIRST-MOUTHWASH BLM flurazepam hcl ...... 40 EVAMIST ...... 53 ...... 128 flurbiprofen ...... 59, 100 EVOMELA ...... 4, 14, 154, 166 FIRST-OMEPRAZOLE ...... 128 flurbiprofen sodium ...... 79, 154 EVOTAZ ...... 14, 84 FIRST-PROGESTERONE VGS flutamide ...... 48, 167 EVZIO ...... 140 100 ...... 128 fluticasone propionate ...... 9, 12, 129 EXELDERM ...... 84, 159 FIRST-PROGESTERONE VGS fluvastatin sodium ...... 21 exemestane ...... 53, 166 200 ...... 128 fluvastatin sodium er ...... 21, 129 EXJADE ...... 140 FIRST-PROGESTERONE VGS fluvoxamine maleate ...... 109 EXTAVIA ...... 40 25 ...... 128 fluvoxamine maleate er ...... 109 EYLEA ...... 4, 20, 30, 71, 79 FIRST-PROGESTERONE VGS FML ...... 79 EZ-LETS LANCETS 26G ...... 116 400 ...... 128 FML FORTE ...... 79 FABIOR ...... 127, 159 FIRST-PROGESTERONE VGS FOCALIN XR ...... 40, 100, 109 FACTIVE ...... 127 50 ...... 128 folbee ...... 150 FALMINA ...... 53 FIRST-TESTOSTERONE ...... 128 folic acid ...... 4, 150 famciclovir ...... 127 FIRST-TESTOSTERONE MC fondaparinux sodium ...... 4, 154 famotidine ...... 63, 143 ...... 128 FORADIL AEROLIZER ...... 9, 94 FANAPT ...... 109 FIRST-VANCOMYCIN 25 ..... 128 FORTEO ...... 53, 71, 100 FANAPT TITRATION PACK FIRST-VANCOMYCIN 50 ..... 128 FORTICAL ...... 53, 71, 100 ...... 109 FLAGYL ER ...... 47, 53, 84 FOSAMAX PLUS D .... 53, 71, 100 FARESTON ...... 53, 166 FLAREX ...... 79 fosinopril sodium ...... 31 FARXIGA ...... 20, 71, 127 flavoxate hcl ...... 48, 143 fosinopril sodium-hctz ...... 31 FARYDAK ...... 4, 166 FLEBOGAMMA DIF ...... 14 FOSRENOL ...... FEIBA ...... 4, 31 flecainide acetate ...... 31 21, 48, 71, 100, 150 felbamate ...... 40 FLECTOR ...... 90, 100 FRAGMIN ...... 4, 31, 143 felodipine er ...... 31 FLOVENT DISKUS ...... 9, 94 FREESTYLE INSULINX TEST FEMRING ...... 47, 53, 71, 91 FLOVENT HFA ...... 9, 94 ...... 116 fenofibrate ...... 20, 21, 127 fluconazole ...... 128 FREESTYLE LANCETS ...... 116 fenofibrate micronized ...... 20 flucytosine ...... 128 FREESTYLE LITE TEST ...... 116 fenofibric acid ...... 21, 127 fludrocortisone acetate ...... 71 FREESTYLE PRECISION NEO fenoprofen calcium ...... 143 flunisolide ...... 12, 152 TEST ...... 116 fentanyl ...... 143 fluocinolone acetonide FREESTYLE TEST ...... 116 fentanyl citrate ...... 143, 166 ...... 77, 128, 160 frovatriptan succinate FENTORA ...... 143, 166 fluocinolone acetonide body ...... 159 ...... 31, 40, 129, 143 FERRIPROX ...... 140 fluocinolone acetonide scalp ...... 160 furosemide ...... 21, 31 ferrous sulfate ...... 116 fluocinonide ...... 128, 160 FUSILEV ...... 4, 63, 140, 150, 167 FETZIMA ...... 109, 127 FLUORABON ...... 63 FUZEON ...... 14, 84 FETZIMA TITRATION FLUOR-A-DAY ...... 63 FYCOMPA ...... 40, 100, 129 ...... 109, 127 FLUORIDEX DAILY gabapentin ...... 40, 84, 143 FINACEA ...... 159 DEFENSE ...... 63 GABITRIL ...... 40 finasteride ...... 47, 166 ^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 178

I n d e x I n d e x I n d e x galantamine hydrobromide GLUCOSOURCE LANCETS HUMALOG ...... 22, 72 ...... 40, 109 ...... 116 HUMALOG KWIKPEN ...... 21, 72 galantamine hydrobromide er glyburide ...... 21, 72 HUMALOG MIX 50/50 ...... 21, 72 ...... 40, 109 glyburide micronized ...... 21, 72 HUMALOG MIX 50/50 GAMASTAN S/D ...... 63, 84 glyburide-metformin ...... 21, 72 KWIKPEN ...... 21, 72 GAMMAGARD ...... 14, 40, 100 glycopyrrolate ...... 129 HUMALOG MIX 50/50 PEN GAMMAGARD S/D LESS IGA glycron ...... 129 ...... 129 ...... 5, 14, 31, 64, 79, 81, 91, 160 GLYDO ...... 48, 100, 143, 154 HUMALOG MIX 75/25 ...... 22, 72 GAMUNEX-C ...... 5, 14, 31 GLYSET ...... 21, 72 HUMALOG MIX 75/25 gatifloxacin ...... 79, 84, 91, 129 gnp lancets ...... 116 KWIKPEN ...... 22, 72 GATTEX ...... 64, 154 gnp nicotine mini ...... 109, 149 HUMALOG MIX 75/25 PEN GAVILYTE-C ...... 64 gnp nicotine polacrilex ...... 109, 149 ...... 129, 130 GAVILYTE-G ...... 64 gnp ultra com insulin syringe .... 116 HUMALOG PEN ...... 130 GAVILYTE-H ...... 64 GOLYTELY ...... 64 HUMATE-P ...... 5, 14, 31, 154 GAZYVA ...... 5, 129, 167 GORDONS UREA ...... 129 HUMIRA ...... 60, 64, 101, 160 GEBAUERS PAIN EASE ...... 129 GRALISE ...... 40, 84, 143 HUMIRA PEDIATRIC GEBAUERS SPRAY AND GRALISE STARTER CROHNS START STRETCH ...... 129 ...... 40, 84, 143 ...... 59, 64, 100, 160 GELNIQUE ...... 48, 100 granisetron hcl ...... 64, 167 HUMIRA PEN ...... 59, 64, 100, 160 gemfibrozil ...... 21 GRANIX ...... 5, 14, 129, 167 HUMIRA PEN-CROHNS generlac ...... 21, 40, 64 griseofulvin microsize ...... 84, 160 STARTER ...... 60, 64, 101, 160 GENGRAF ...... 14, 48, 64, 154 griseofulvin ultramicrosize HUMIRA PEN-PSORIASIS GENTAK ...... 79, 84, 91 ...... 84, 160 STARTER ...... 60, 64, 101, 160 gentamicin sulfate ...... guaifenesin er ...... 12, 94, 116 HUMULIN 70/30 ...... 22, 72 79, 84, 91, 129, 160 guanfacine hcl ...... 31 HUMULIN 70/30 KWIKPEN GENTLE-LET GP LANCETS guanfacine hcl er ...... 40, 100, 110 ...... 22, 72 ...... 116 guanidine hcl ...... 14, 40, 100 HUMULIN N ...... 22, 72 GENTLE-LET LANCETS ...... 116 GYNAZOLE-1 ...... 48, 53, 84 HUMULIN N KWIKPEN GENVOYA ...... 14, 84 HAEMOLANCE LOW FLOW ...... 22, 72 GEODON ...... 109 LANCETS ...... 116 HUMULIN R ...... 22, 72 GIANVI ...... 53, 109, 160 HALAVEN ...... 54, 59, 167 HUMULIN R U-500 GIAZO ...... 64 halobetasol propionate ...... 129 (CONCENTRATED) ...... 22, 72 GILDAGIA ...... 53 HALOG ...... 129 HUMULIN R U-500 KWIKPEN GILDESS 1.5/30 ...... 53, 160 haloperidol ...... 110 ...... 22, 72 GILDESS 1/20 ...... 53, 160 haloperidol decanoate ...... 110 HYCAMTIN ...... 94, 167 GILDESS 24 FE ...... 53, 160 haloperidol lactate ...... 110 hydralazine hcl ...... 31 GILDESS FE 1.5/30 ...... 53, 160 HARVONI ...... 64, 84 hydrochlorothiazide ...... 31 GILDESS FE 1/20 ...... 53, 160 HEATHER ...... 54 hydrocod polst-cpm polst er GILENYA ...... 40 HELIXATE FS ...... 5 ...... 12, 94, 152 GILPHEX TR ...... 12 HEMMOREX-HC ...... 31, 64 hydrocodone-acetaminophen GLASSIA ...... 9, 21, 94 HEMOFIL M ...... 5, 129 ...... 130, 143 GLATOPA ...... 40 heparin sodium (porcine) ...... 5, 129 hydrocodone-homatropine ..... 12, 94 GLEOSTINE ...... 129 HERCEPTIN ...... 54, 64, 167 hydrocodone-ibuprofen ...... 143 glimepiride ...... 21, 71 HETLIOZ ...... 41 hydrocortisone ...... glipizide ...... 21, 71 HEXALEN ...... 54, 167 15, 64, 72, 116, 130, 160 glipizide er ...... 21, 71 HIZENTRA ...... 14, 129 hydrocortisone ace-pramoxine glipizide xl ...... 21, 71 hm nicotine ...... 110, 116, 149 ...... 31, 64, 160 glipizide-metformin hcl ...... 21, 71 hm nicotine polacrilex ...... 110, 149 hydrocortisone acetate ...... 31, 64 GLUCAGEN HYPOKIT .... 21, 71 HOMATROPAIRE ...... 79 hydrocortisone butyrate ...... 130 GLUCAGON EMERGENCY homatropine hbr ...... 79 hydrocortisone valerate ...... 130 ...... 21, 72 HORIZANT ...... 41 hydrocortisone-acetic acid ...... 77 HP ACTHAR ...... 41, 59, 100 hydromet ...... 12, 94 ^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 179

I n d e x I n d e x I n d e x hydromorphone hcl ...... 143 ipratropium bromide KARIVA ...... 54 hydromorphone hcl er ...... 143 ...... 9, 12, 94, 153 KAZANO ...... 22, 73 hydroxychloroquine sulfate ipratropium-albuterol ...... 10, 94 KELNOR 1/35 ...... 54 ...... 60, 101, 160 irbesartan ...... 31 KENALOG ...... 15, 60, 73, 101 hydroxyprogesterone caproate irbesartan-hydrochlorothiazide KETEK ...... 131 ...... 31, 48, 54, 72, 130, 167 ...... 31 ketoconazole ...... 85, 131, 161 hydroxyurea ...... 160, 167 IRESSA ...... 94, 167 KETODAN ...... 161 hydroxyzine hcl ...... 41, 110, 154 irinotecan hcl ...... 64, 167 ketoprofen ...... 101, 144 hydroxyzine pamoate ISENTRESS ...... 15, 85 ketoprofen er ...... 60, 101 ...... 41, 110, 154 isometheptene-dichloral-apap ketorolac tromethamine HYOPHEN ...... 130 ...... 130 ...... 79, 144, 154, 155 hyoscyamine sulfate ...... 130 isoniazid ...... 85 ketotifen fumarate ...... 79, 91, 153 hyoscyamine sulfate er ...... 130 ISOPTO CARBACHOL ...... 79 KIMIDESS ...... 54 hyosyne ...... 130 ISOPTO HYOSCINE ...... 131 KINERET ...... 15, 60, 101 HYPERSAL ...... 130 ISORDIL TITRADOSE ... 31, 144 kinney lancets ...... 117 HYQVIA ...... 15 isosorbide dinitrate ...... 32, 144 kinney thin lancets ...... 117 HY-VEE LANCETS ...... 117 isosorbide dinitrate er ...... 32, 144 kinray insulin syringe ...... 117 hy-vee thin lancets ...... 117 isosorbide mononitrate ...... 32, 144 KIONEX ...... 22 ibandronate sodium isosorbide mononitrate er ... 32, 144 KLOR-CON M15 ...... 22 ...... 54, 72, 101, 130 isradipine ...... 32 KOATE-DVI ...... 5 IBRANCE ...... 54, 167 ISTODAX ...... 161, 167 KOGENATE FS ...... 5, 131 IBUDONE ...... 143 itraconazole ...... 131 KOGENATE FS BIO-SET ...... 5 ibuprofen ...... 101, 143, 144 ivermectin ...... 65, 85, 131 KORLYM ...... 23, 73 ICLUSIG ...... 130 IXEMPRA KIT ...... 54, 167 KOVALTRY ...... 5 ILARIS ...... 15, 22, 77, 101 IXINITY ...... 5 kp clotrimazole ...... 85, 161 ILEVRO ...... 79, 144, 154 JADENU ...... 140 K-PHOS ...... 131 ILOTYCIN ...... 79, 84 JAKAFI ...... 5, 167 K-PHOS NO 2 ...... 131 imatinib mesylate ...... 130 JANTOVEN ...... 5, 32 KRYSTEXXA ...... 23 IMBRUVICA ...... 5, 130, 167 JANUMET ...... 22, 73 KURVELO ...... 54 imipramine hcl ...... 48, 110 JANUMET XR ...... 22, 73 KUVAN ...... 23 imipramine pamoate ...... 110 JANUVIA ...... 22, 73 KYNAMRO ...... 23 imiquimod ...... 84, 160, 167 JENCYCLA ...... 54 labetalol hcl ...... 32 IMPAVIDO ...... 84, 160 JENTADUETO ...... 22, 73 lactulose ...... 23, 41, 65 INATAL ADVANCE ...... 151 JEVTANA ...... 48, 167 lactulose encephalopathy INCRELEX ...... 41, 72 JOLESSA ...... 54 ...... 23, 41, 65 indapamide ...... 22, 31 JOLIVETTE ...... 54 LAMISIL ...... 85, 161 INDOCIN ...... 101 JUBLIA ...... 85, 161 LAMISIL SPRAY ...... 131 indomethacin ...... 101 JULEBER ...... 54 lamivudine ...... 15, 65, 85, 131 indomethacin er ...... 101 JUNEL 1.5/30 ...... 54, 161 lamivudine-zidovudine ...... 15, 85 INLYTA ...... 48, 167 JUNEL 1/20 ...... 54, 161 lamotrigine ...... 41, 101, 110 INNOPRAN XL ...... 31, 41, 144 JUNEL FE 1.5/30 ...... 54, 161 lamotrigine er ...... 41 insulin syringe ...... 117 JUNEL FE 1/20 ...... 54, 161 lamotrigine odt ...... 41, 101, 110 insulin syringe/needle ...... 117 JUNEL FE 24 ...... 54, 161 lancets ...... 117 INTELENCE ...... 15, 84 JUXTAPID ...... 22 lancets thin ...... 117 INTROL ...... 130 K.B.G.L IN TERODERM ...... 131 LANOXIN ...... 32, 131 INTRON A ... 64, 85, 160, 161, 167 KADCYLA ...... 54, 167 lansoprazole ...... 65 INTROVALE ...... 54 KADIAN ...... 144 LANTUS ...... 23, 73 INVEGA SUSTENNA ...... 110 KAITLIB FE ...... 54 LANTUS FOR OPTICLIK ..... 131 INVEGA TRINZA ...... 110 KALETRA ...... 15, 85 LANTUS SOLOSTAR ...... 23, 73 INVIRASE ...... 15, 85 KALYDECO ...... 10, 22, 94 LARIN 1.5/30 ...... 54, 161 INVOKAMET ...... 22, 72 KARIGEL ...... 131 LARIN 1/20 ...... 54, 161 INVOKANA ...... 22, 73 KARIGEL-N ...... 131 LARIN 24 FE ...... 54, 161 ^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 180

I n d e x I n d e x I n d e x LARIN FE 1.5/30 ...... 54, 131, 161 lidocaine ...... LUTERA ...... 55 LARIN FE 1/20 ...... 54, 131, 161 41, 85, 131, 144, 155, 161 LUZU ...... 85, 132, 161 LASTACAFT ...... 79, 91, 153 lidocaine hcl ...... LYNPARZA ...... 55, 168 latanoprost ...... 79 48, 90, 101, 144, 155, 161 LYRICA ...... 23, 41, 73 LATRIX ...... 131 lidocaine hcl (pf) ...... 155 LYSODREN ...... 73, 168 LATUDA ...... 110, 131 lidocaine viscous ...... 155 LYZA ...... 55, 132 lavare wound wash ...... 117 lidocaine-prilocaine ...... 155 MACUGEN ...... 80 LAYOLIS FE ...... 54 lidopin ...... 90, 144, 155, 161 MAKENA ...... 151 LEENA ...... 54 LIDOPROFEN ...... 131 malathion ...... 85, 161 leflunomide ...... 60, 101 LIFESCAN UNISTIK II maprotiline hcl ...... 110 LENVIMA 10 MG DAILY LANCETS ...... 117 margesic ...... 110, 144 DOSE ...... 48, 73, 167 lindane ...... 85, 161 marlissa ...... 55 LENVIMA 14 MG DAILY linezolid ...... 132 marten-tab ...... 111, 144 DOSE ...... 48, 73, 167 LINZESS ...... 65 MATULANE ...... 132 LENVIMA 20 MG DAILY liothyronine sodium ...... 73 MATZIM LA ...... 32, 144 DOSE ...... 48, 73, 167 lisinopril ...... 32 MAXIDEX ...... 80 LENVIMA 24 MG DAILY lisinopril-hydrochlorothiazide ..... 32 me/naphos/mb/hyo1 ...... 132 DOSE ...... 48, 73, 167 lite touch lancets ...... 117 meclizine hcl ...... 32, 41, 65 LESSINA ...... 54 lithium ...... 110 meclofenamate sodium ...... 101, 144 LETAIRIS ...... 10, 32, 94 lithium carbonate ...... 110 MEDISENSE THIN LANCETS letrozole ...... 55, 167 lithium carbonate er ...... 110 ...... 117 leucovorin calcium ...... 5, 140, 150 LIVALO ...... 23 MEDROL ...... 15, 73 LEUKERAN ...... 5, 167 LO LOESTRIN FE ...... 55, 161 medroxyprogesterone acetate LEUKINE ...... 131 LOCOID ...... 132 ...... 32, 48, 55, 73 leuprolide acetate ...... 48, 73, 167 lofene ...... 132 mefenamic acid ...... 55, 145 levalbuterol hcl ...... 10, 94 LOKARA ...... 132 mefloquine hcl ...... 85 LEVATOL ...... 32 LOMEDIA 24 FE ...... 55, 132, 161 megestrol acetate ...... LEVEMIR ...... 23, 73 lomustine ...... 132 15, 23, 55, 85, 132, 150, 168 LEVEMIR FLEXPEN ...... 23, 73 longs lancets thin ...... 117 MEIJER LANCETS ...... 117 LEVEMIR FLEXTOUCH LONSURF ...... 65, 168 MEKINIST ...... 161, 168 ...... 23, 73 loperamide hcl ...... 65 meloxicam ...... 60, 101 levetiracetam ...... 41, 101 lorazepam ...... 110 memantine hcl ...... 41, 111, 132 levetiracetam er ...... 41 LORAZEPAM INTENSOL ... 110 MENEST ...... 55, 73 levobunolol hcl ...... 79 LORCET ...... 144 meperidine hcl ...... 132, 145 levocarnitine ...... 150 LORCET HD ...... 144 MEPHYTON ...... 5 levocetirizine dihydrochloride LORCET PLUS ...... 144 meprobamate ...... 111 ...... 12, 23, 153, 161 LORTAB ...... 144 mercaptopurine ...... 132 levofloxacin ...... 79, 85, 91, 131 LORYNA ...... 55, 110, 161 mesalamine ...... 65 LEVONEST ...... 55 losartan potassium ...... 32 mesna ...... 32, 48, 55, 168 levonorgest-eth estrad 91-day losartan potassium-hctz ...... 32 MESNEX ...... 32, 48, 55, 168 ...... 55, 131 LOTEMAX ...... 79 MESTINON ...... 15, 41, 101 levonorgestrel ...... 55, 131 lovastatin ...... 23 metaproterenol sulfate ...... 10, 94 levonorgestrel-ethinyl estrad LOW-OGESTREL ...... 55 metaxalone ...... 101 ...... 55, 131 loxapine succinate ...... 110 metformin hcl ...... 23, 74 levonorg-eth estrad triphasic LOZI-FLUR ...... 132 metformin hcl er ...... 23, 74 ...... 55, 131 LUCENTIS ...... 5, 23, 32, 73, 79 metformin hcl er (mod) LEVORA 0.15/30 (28) ...... 55 LUFYLLIN ...... 132 ...... 23, 73, 132 LEVO-T ...... 73 LUMIGAN ...... 80 methadone hcl ...... 111, 145 levothyroxine sodium ...... 73 LUMIZYME ...... 23, 32, 94 METHADONE HCL LEVOXYL ...... 73 LUPRON DEPOT INTENSOL ...... 111, 145 LEXIVA ...... 15, 85 ...... 5, 32, 48, 55, 168 METHADOSE ...... 111, 145 LIALDA ...... 65 LUPRON DEPOT-PED ...... 73 ^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 181

I n d e x I n d e x I n d e x methamphetamine hcl MICROTAINER SAFETY MONOJECT ULTRA ...... 23, 41, 102, 111 FLOW LANCET ...... 117 COMFORT SYRINGE ...... 118 methazolamide ...... 80 midodrine hcl ...... 33 MONOLET LANCETS ...... 118 methenamine hippurate ...... 48, 85 MIGERGOT ...... 33, 42, 145 MONO-LINYAH ...... 55 methenamine mandelate ...... 48, 85 migragesic ida ...... 132 MONONESSA ...... 56 methimazole ...... 74 MILLIPRED ...... 15, 74 MONONINE ...... 5, 133 methitest ...... 55, 74 MILLIPRED DP ...... 15, 74 montelukast sodium methocarbamol ...... 102 MILLIPRED DP 12-DAY ...... 132 ...... 10, 12, 94, 95, 153 methotrexate ...... 60, 102, 161 MINASTRIN 24 FE ...... 55, 162 MONUROL ...... 48, 86 methoxsalen rapid ...... 132, 162 MINITRAN ...... 33, 145 MORGIDOX ...... 133 methscopolamine bromide ...... 65 minocycline hcl ...... 132 morphine sulfate ...... 146 methyclothiazide ...... 23 minoxidil ...... 33 morphine sulfate (concentrate) methyldopa ...... 32 MIRAPEX ER ...... 42 ...... 145 methyldopa-hydrochlorothiazide MIRCERA ...... 5, 48 morphine sulfate er .... 133, 145, 146 ...... 32 mirtazapine ...... 112 morphine sulfate er beads methylergonovine maleate MIRVASO ...... 132, 162 ...... 133, 145 ...... 32, 151 misoprostol ...... 65 MOVANTIK ...... 65, 140 methylphenidate hcl ...... mitoxantrone hcl ...... 5, 42, 48, 168 MOVIPREP ...... 65 42, 102, 111, 112, 132 modafinil ...... 42, 94 MOXEZA ...... 80, 86, 91 methylphenidate hcl er MODERIBA ...... 65, 86, 132 moxifloxacin hcl ...... 133 ...... 42, 102, 111 moexipril hcl ...... 33 MULTAQ ...... 33 methylphenidate hcl er (cd) moexipril-hydrochlorothiazide .... 33 MULTI COMPLETE ...... 118 ...... 41, 42, 102, 111 mometasone furoate multi vitamin/fluoride ...... 65, 150 methylphenidate hcl er (la) ...... 12, 132, 133, 153 multi vitamin/minerals ...... 118 ...... 42, 102, 111 MONDOXYNE NL ...... 133 multi-vit/fluoride ...... 65, 133, 151 methylprednisolone ...... 15, 74 MONOCLATE-P ...... 5, 133 multi-vit/fluoride/iron methylprednisolone sodium succ MONOJECT CONTROL ...... 65, 133, 151 ...... 15, 74 SYRINGE ...... 133 multivitamin/fluoride methyltestosterone ...... 55, 74, 132 MONOJECT FILTER ...... 65, 133, 151 metipranolol ...... 80 ASPIRATOR ...... 117 multi-vitamin/fluoride ...... 65, 151 metoclopramide hcl ...... 23, 65, 74 MONOJECT INSULIN mupirocin ...... 86, 162 metolazone ...... 23, 48 SYRINGE ...... 117, 133 mupirocin calcium ...... 86, 162 metoprolol succinate er ...... 32, 145 MONOJECT PHARMACY MY WAY ...... 56 metoprolol tartrate ...... 32, 145 TRAY ...... 117 MYALEPT ...... 24, 60 metoprolol-hydrochlorothiazide MONOJECT PISTON mycophenolate mofetil ...... 32 SYRINGE ...... 117 15, 48, 49, 65, 133, 155 metronidazole ...... MONOJECT SAFETY mycophenolic acid 48, 55, 85, 132, 162 SYRINGE/SHIELD ...... 117, 133 ...... 15, 49, 133, 155 mexiletine hcl ...... 32 MONOJECT SYRINGE MYKIDZ IRON FL ...... 151 MIACALCIN ...... 55, 74, 102 ...... 118, 133 MYLERAN ...... 15, 155 miconazole 3 ...... 48, 55, 85 MONOJECT SYRINGE CATH mynephrocaps ...... 151 MICROCYN ...... 132 TIP ...... 118 MYOBLOC ...... 42, 102 MICROCYN SKIN AND MONOJECT SYRINGE ECC MYORISAN ...... 162 WOUND ...... 132 LUER ...... 118 MYOZYME ...... 24, 33, 95 MICROGESTIN 1.5/30 ..... 55, 162 MONOJECT SYRINGE LUER MYRBETRIQ ...... 49, 102 MICROGESTIN 1/20 ...... 55, 162 LOCK ...... 118, 133 MYZILRA ...... 56 MICROGESTIN 24 FE ..... 55, 162 MONOJECT SYRINGE REG nabumetone ...... 60, 102 MICROGESTIN FE 1.5/30 LUER ...... 118, 133 n-acetyl-l-cysteine ...... 118 ...... 55, 162 MONOJECT TB SAFETY nadolol ...... 33, 146 MICROGESTIN FE 1/20 SYRINGE ...... 118 nadolol-bendroflumethiazide ...... 33 ...... 55, 162 MONOJECT TB SYRINGE NAFRINSE DAILY micronized colestipol hcl ...... 23 ...... 118 ACIDULATED ...... 134 ^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 182

I n d e x I n d e x I n d e x NAFRINSE DAILY/NEUTRAL NEUTRAGARD ADVANCED norethindrone ...... 56 ...... 65 ...... 134 norethindrone acetate NAFRINSE WEEKLY ...... 134 neutral sodium fluoride ...... 65 ...... 33, 49, 56, 74 naftifine hcl ...... 86, 134, 162 NEVANAC ...... 80, 146, 155 norethindrone acet-ethinyl est NAFTIN ...... 86, 162 nevirapine ...... 16, 86 ...... 56, 134, 162 NAGLAZYME ...... 24, 74 nevirapine er ...... 16, 86, 134 norethindrone-eth estradiol naloxone hcl ...... 140 NEXAVAR ...... 49, 65, 74, 168 ...... 56, 74, 103, 134 naltrexone hcl ...... 112 NEXIUM ...... 65 norethin-eth estradiol-fe ...... 56, 134 NAMENDA XR ...... 42, 112 NEXT CHOICE ...... 134 norgestimate-eth estradiol ...... 56 NAMENDA XR TITRATION NEXT CHOICE ONE DOSE norgestim-eth estrad triphasic PACK ...... 42, 112 ...... 56 ...... 56, 134 naphazoline hcl ...... 80 niacin er ...... 24 norgestrel-ethinyl estradiol ...... 134 napro ...... 134 niacin er (antihyperlipidemic) NORITATE ...... 162 naproxen ...... 103, 146 ...... 24, 134 NORLYROC ...... 56 naproxen dr ...... 102 NIACOR ...... 24 NORPACE CR ...... 33 naproxen sodium ...... 103, 146 nicardipine hcl ...... 33, 146 NORTHERA ...... 33 naratriptan hcl ...... 33, 42, 146 NICORELIEF ...... 112, 149 NORTREL 0.5/35 (28) ...... 56 NARCAN ...... 140 nicotine ...... 112, 149 NORTREL 1/35 (21) ...... 56 NATACYN ...... 80, 86, 91 nicotine mini ...... 112, 149 NORTREL 1/35 (28) ...... 56 NATAZIA ...... 33, 49, 56 nicotine polacrilex ...... 112, 149 NORTREL 7/7/7 ...... 56 nateglinide ...... 24, 74 nicotine step 1 ...... 112, 149 nortriptyline hcl ...... 112 NATPARA ...... 24, 74 nicotine step 2 ...... 112, 149 nortuss-ex ...... 134 NATURE-THROID ...... 134 nicotine step 3 ...... 112, 149 NORVIR ...... 16, 86 NEBUPENT ...... 10, 16, 86, 95 NICOTROL ...... 112, 149 NOVOEIGHT ...... 6 NEBUSAL ...... 134 NICOTROL NS ...... 112, 149 NOVOLIN 70/30 ...... 24, 74 NECON 0.5/35 (28) ...... 56 NIFEDIAC CC ...... 134 NOVOLIN 70/30 RELION NECON 1/35 (28) ...... 56 NIFEDICAL XL ...... 33, 146 ...... 24, 74 NECON 1/50 (28) ...... 56 nifedipine ...... 33, 146 NOVOLIN N ...... 24, 74 NECON 10/11 (28) ...... 56 nifedipine er ...... 33, 146 NOVOLIN N RELION ...... 24, 74 NECON 7/7/7 ...... 56 nifedipine er osmotic release NOVOLIN R ...... 24, 74 nefazodone hcl ...... 112 ...... 33, 146 NOVOLIN R RELION ...... 24, 74 neomycin sulfate ...... 65, 155 NIKKI ...... 56, 112, 162 NOVOLOG ...... 24, 75 neomycin-bacitracin zn-polymyx NILANDRON ...... 49, 168 NOVOLOG FLEXPEN ...... 24, 74 ...... 80, 86 nimodipine ...... 33, 42, 90 NOVOLOG MIX 70/30 ...... 24, 75 neomycin-polymyxin-dexameth NINLARO ...... 6, 168 NOVOLOG MIX 70/30 ...... 134 nisoldipine er ...... 33 FLEXPEN ...... 24, 75 neomycin-polymyxin-gramicidin NITRO-BID ...... 33, 146 NOVOLOG PENFILL ...... 24, 75 ...... 80, 86 NITRO-DUR ...... 33, 146 NOVOSEVEN RT ...... 6, 33 neomycin-polymyxin-hc nitrofurantoin ...... 49, 86 NOXAFIL ...... 16, 86, 91, 95, 134 ...... 77, 80, 86, 134 nitrofurantoin macrocrystal np thyroid ...... 134 NEO-POLYCIN ...... 80, 86 ...... 49, 86, 134 NPLATE ...... 6, 16, 33 NEO-POLYCIN HC ...... 134 nitrofurantoin monohyd macro NUCYNTA ...... 147 NEPHROCAPS QT ...... 151 ...... 49, 86 NUCYNTA ER ...... 24, 43, 75, 147 NESINA ...... 24, 74 nitroglycerin ...... 33, 146 NUEDEXTA ...... 112 NEUAC ...... 162 NITROSTAT ...... 33, 147 NUVARING ...... 56 NEULASTA ...... 6, 16, 168 nizatidine ...... 66 NUVIGIL ...... 43, 95, 134 NEULASTA DELIVERY KIT NODOLOR ...... 134 NUWIQ ...... 6 ...... 6, 16, 168 NORA-BE ...... 56 NYAMYC ...... 86, 162 NEULASTA ONPRO .... 6, 16, 168 NORDITROPIN FLEXPRO nystatin ...... 86, 87, 91, 135, 162 NEUMEGA ...... 6, 168 ...... 16, 24, 74, 86, 151 nystatin-triamcinolone ...... 87, 162 NEUPOGEN ...... 6, 16, 168 norethin ace-eth estrad-fe NYSTOP ...... 87, 162 NEUPRO ...... 42 ...... 56, 134, 162 obizur ...... 6, 16, 34 ^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 183

I n d e x I n d e x I n d e x OBSTETRIX EC ...... 151 oxazepam ...... 43, 112 PERFOROMIST ...... 10, 95 OCALIVA ...... 66 oxcarbazepine ...... 43 perindopril erbumine ...... 34 OCELLA ...... 56 oxiconazole nitrate ...... 87, 135, 162 PERIOGARD ...... 66, 87, 92 OCTAGAM ...... 6, 16, 34 OXISTAT ...... 87, 162 PERJETA ...... 56, 169 octreotide acetate ...... OXSORALEN ...... 135 permethrin ...... 87, 163 24, 43, 66, 75, 103, 168 OXTELLAR XR ...... 43 perphenazine ...... 113 ODEFSEY ...... 16, 87 oxybutynin chloride ...... 49, 103 PERTZYE ...... 66 ODOMZO ...... 162, 168 oxybutynin chloride er ...... 49, 103 PHENADOZ ...... 67, 147, 155 OFEV ...... 10, 95 oxycodone hcl ...... 147 phenazopyridine hcl ...... 49, 147 ofloxacin ...... 77, 80, 87, 91, 135 oxycodone hcl er ...... 135, 147 phenelzine sulfate ...... 113 OGESTREL ...... 56 oxycodone-acetaminophen ...... 147 PHENERGAN ...... 67, 147, 155 olanzapine ...... 112 oxycodone-aspirin ...... 147 phenobarbital ...... 135 olanzapine-fluoxetine hcl ...... 112 oxycodone-ibuprofen ...... 147, 155 PHENOHYTRO ...... 135 OLEPTRO ...... 112 OXYCONTIN ...... 135, 147 phenoxybenzamine hcl olopatadine hcl ...... 80, 92, 135, 153 oxymorphone hcl ...... 147 ...... 34, 135, 169 omeprazole ...... 66 oxymorphone hcl er ...... 147 phenyleph-promethazine-cod OMEPRAZOLE+SYRSPEND OXYTROL ...... 49, 103 ...... 12, 95, 135 SF ALKA ...... 135 PACERONE ...... 34 phenylephrine-guaifenesin ...... 136 OMNARIS ...... 10, 12, 153 paclitaxel ...... 135 phenytoin ...... 43 ONCASPAR ...... 6, 168 paliperidone er ...... 112, 135 PHENYTOIN INFATABS ...... 43 ondansetron ...... 66, 168 pamidronate disodium ...... 25, 168 phenytoin sodium extended ...... 43 ondansetron hcl ...... 66, 155, 168 PANCREAZE ...... 66 PHILITH ...... 56 ONETOUCH CLUB LANCETS PANDEL ...... 135 PHOS-FLUR ...... 136 FINE PT ...... 118 PANRETIN ...... 60, 162, 169 PHOSLYRA ...... ONETOUCH FINEPOINT pantoprazole sodium ...... 135 25, 49, 75, 103, 151 LANCETS ...... 118 paregoric ...... 66 PHOSPHA 250 NEUTRAL ...... 25 ONETOUCH LANCETS ...... 118 paricalcitol ...... 49, 75, 135 PHOSPHASAL ...... 136 ONETOUCH ULTRASOFT PAROEX ...... 66, 87, 92 PHOSPHOLINE IODIDE ...... 80 LANCETS ...... 118 paromomycin sulfate ...... 66, 87 PICATO ...... 163 ONFI ...... 43, 135 paroxetine hcl ...... 113 pilocarpine hcl ...... ONGLYZA ...... 24, 75 paroxetine hcl er ...... 113 16, 67, 80, 155, 169 OPANA ER ...... 147 PASER ...... 87, 95 pimozide ...... 43, 103, 113, 136 opium ...... 135 PATADAY ...... 80, 92, 153 PIMTREA ...... 56, 136 OPSUMIT ...... 10, 34, 95, 135 PAXIL ...... 113 pindolol ...... 34 ORALONE ...... 66 PCE ...... 135 pioglitazone hcl ...... 25, 75 ORENCIA ...... 60, 103 peg 3350/electrolytes ...... 66 pioglitazone hcl-glimepiride ORENCIA CLICKJECT peg 3350-kcl-na bicarb-nacl ...... 66 ...... 25, 75 ...... 60, 103 peg-3350/electrolytes ...... 66 pioglitazone hcl-metformin hcl ORENITRAM ...... 10, 34, 95 PEGANONE ...... 43, 103, 135 ...... 25, 75 ORKAMBI ...... 10, 25, 95 PEGASYS ...... 66, 87 PIRMELLA 1/35 ...... 56 orphenadrine citrate er ...... 103 PEGASYS PROCLICK ...... 66, 87 PIRMELLA 7/7/7 ...... 56, 136 orphenadrine-aspirin-caffeine PEGINTRON ...... 66, 87 piroxicam ...... 60, 103 ...... 103 PEG-INTRON ...... 66, 87 pnv folic acid + iron ...... 151 ORSYTHIA ...... 56 PEG-INTRON REDIPEN podofilox ...... 87, 163 OSCION CLEANSER ...... 135 ...... 66, 87 POLYCIN ...... 80, 87 OSENI ...... 25, 75 PEG-INTRON REDIPEN PAK polyethylene glycol 3350 ...... 67 OSMOPREP ...... 66 4 ...... 66, 87 polymyxin b-trimethoprim OSPHENA ...... 49, 56, 75, 92, 147 penicillin g procaine ...... 135 ...... 80, 87, 92 OTEZLA ...... 103, 162 penicillin v potassium ...... 135 POLY-VI-FLOR ...... 67, 151 otic care ...... 135 PENNSAID ...... 103, 135 polyvinyl alcohol ...... 80 oxandrolone ...... 25 PENTASA ...... 66 POMALYST ...... 6, 169 oxaprozin ...... 60, 103 pentoxifylline er ...... 34, 103, 147 PORTIA-28 ...... 57 ^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 184

I n d e x I n d e x I n d e x pot bicarb-pot chloride ...... 25 PREPOPIK ...... 67 PSS SELECT GP LANCETS potassium bicarbonate ...... 25, 118 PREVACID SOLUTAB ...... 67 ...... 119 potassium chloride ...... 25, 118, 136 PREVIFEM ...... 57 PSS SELECT SAFETY potassium chloride crys er ...... 25 PREZCOBIX ...... 16, 87 LANCETS ...... 119 potassium chloride er ...... 25, 136 PREZISTA ...... 16, 87 PULMICORT FLEXHALER potassium citrate er ...... 136 PRIFTIN ...... 87, 95 ...... 10, 95 potassium citrate monohydrate PRILOSEC ...... 67 PULMOSAL ...... 136 ...... 118 primaquine phosphate ...... 87 PULMOZYME ...... 10, 25, 95 POTIGA ...... 43 primidone ...... 136 PURIXAN ...... 136 PRADAXA ...... 6, 34 PRIMSOL ...... 136 PYLERA ...... 67, 87 PRALUENT ...... 25, 34 PRISTIQ ...... 113 pyrazinamide ...... 87 pramcort ...... 34, 67 PRIVIGEN ...... 6, 17, 34 pyridostigmine bromide pramipexole dihydrochloride ...... 43 PROAIR HFA ...... 10, 95 ...... 17, 43, 103 pramipexole dihydrochloride er PROAIR RESPICLICK ...... 10, 95 pyridostigmine bromide er ...... 43, 136 probenecid ...... 25 ...... 17, 43, 103, 136 PRAMOSONE ...... 163 prochlorperazine ...... 67 qc nicotine polacrilex ...... 119 PRAMOSONE E ...... 163 prochlorperazine edisylate ...... 67 QNASL ...... 13, 153 PRASCION ...... 136 prochlorperazine maleate ...... 67 QNASL CHILDRENS ...... 13, 153 pravastatin sodium ...... 25 PROCRIT ...... 6, 49, 169 QUARTETTE ...... 57 prazosin hcl ...... 34 PROCTOFOAM HC ...... 34, 67 QUASENSE ...... 57 PRECISION SURE-DOSE PROCTO-PAK ...... 163 quetiapine fumarate ...... 113 SYRINGE ...... 118 PROCTOSOL HC ...... 163 QUILLIVANT XR ..... 43, 104, 113 PRECISION THIN LANCETS PROCTOZONE-HC ...... 136, 163 quinapril hcl ...... 34 ...... 118 PROFILNINE ...... 6 quinapril-hydrochlorothiazide ..... 34 PRECISION THINS GP PROFILNINE SD ...... 6 quinaretic ...... 136 LANCETS ...... 118 progesterone ...... 34, 49, 57, 75 quinidine gluconate er ...... 34 PRECISION ULTRA LANCET progesterone micronized ...... 136 quinidine sulfate ...... 34 ...... 118 PROGLYCEM ...... 25, 67, 75, 169 quinidine sulfate er ...... 34 PRECISION XTRA BLOOD PROLEUKIN ...... 49, 163, 169 quinine sulfate ...... 137 GLUCOSE ...... 118 PROLIA ...... 57, 75, 103 QVAR ...... 10, 95 PRED MILD ...... 80 PROMACTA ...... 6, 17, 34, 67, 87 ra mini nicotine ...... 113, 149 PRED-G ...... 80, 87, 92 promethazine hcl ...... ra nicotine ...... 113, 149, 150 PRED-G S.O.P...... 80, 87, 92 67, 136, 147, 155 ra nicotine polacrilex ...... 113, 150 prednicarbate ...... 136 promethazine vc plain ...... 13, 153 rabeprazole sodium ...... 67, 137 prednisolone ...... 16, 75 promethazine vc/codeine ...... 13, 95 raloxifene hcl ...... prednisolone acetate ...... 80 promethazine-codeine ... 13, 95, 153 57, 75, 104, 137, 169 prednisolone sodium phosphate promethazine-dm ...... 13, 95, 153 ramipril ...... 34 ...... 16, 75, 80, 136 promethazine-phenylephrine RANEXA ...... 34, 147 prednisone ...... 136 ...... 13, 136, 153 ranitidine hcl ...... 34, 35, 67 PREDNISONE INTENSOL PROMETHEGAN ...... 67, 147, 155 RAPAFLO ...... 49, 169 ...... 136 propafenone hcl ...... 34 RAPAMUNE ...... 17, 49, 95, 155 preferred plus lancets colored propafenone hcl er ...... 34 RAVICTI ...... 25 ...... 118 proparacaine hcl ...... 80, 155 REA LO 40 ...... 137 preferred plus lancets thin ...... 119 propranolol hcl ...... 43, 103 reality lancets ...... 119 PREMARIN ...... 49, 57, 75, 92, 147 propranolol hcl er ...... 34, 43, 147 reality trigger lancets ...... 119 premium lidocaine ...... 136 propranolol-hctz ...... 34 REBETOL ...... 67, 88 PREMPHASE ...... 49, 57, 75, 92 propylthiouracil ...... 75 REBIF ...... 44 PREMPRO ...... 49, 57, 75, 92 PROTONIX ...... 136 REBIF REBIDOSE ...... 44 prenatabs fa ...... 151 protriptyline hcl ...... 113 REBIF REBIDOSE PRENATABS RX ...... 151 PROVENTIL HFA ...... 10, 95 TITRATION PACK ...... 44 prenatal ...... 151 pseudoephedrine hcl ...... 13 REBIF TITRATION PACK ..... 44 prenatal 19 ...... 119, 151 psorcon ...... 136 RECLIPSEN ...... 57 ^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 185

I n d e x I n d e x I n d e x RECOMBINATE ...... 6 rivastigmine tartrate ...... 44, 113 SIMPONI ARIA ...... 60, 104, 137 REGRANEX ...... rixubis ...... 7, 137 simvastatin ...... 26 25, 44, 75, 137, 163 rizatriptan benzoate sirolimus ...... 17, 49, 96, 137, 156 RELENZA DISKHALER ...... 88 ...... 35, 44, 147, 148 SIRTURO ...... 88, 96 RELISTOR ...... 67, 140 ropinirole hcl ...... 44 SIVEXTRO ...... 88, 163 RELPAX ...... 35, 44, 147 ropinirole hcl er ...... 44 SKLICE ...... 88 REMEVEN ...... 137 ROSADAN ...... 163 sm nicotine ...... 114, 150 REMICADE ...... 60, 67, 104, 163 ROSANIL CLEANSER ...... 137 sm nicotine polacrilex ...... 114, 150 REMODULIN ...... 10, 35, 95 rosuvastatin calcium ...... 26, 137 sodium chloride ...... 137 RENAGEL ...... 25, 49, 75, 104, 151 ROXICET ...... 148 sodium fluoride ...... 68, 137 RENAL ...... 151 ROZEREM ...... 44 sodium polystyrene sulfonate RENVELA ...... 25, 49, 75, 104, 151 RUCONEST ...... 17, 26, 153, 163 ...... 26, 137 repaglinide ...... 25, 75, 137 SABRIL ...... 44, 104 SOLARAZE ...... 163 repaglinide-metformin hcl SAFYRAL ...... 57 SOLIRIS ...... 7 ...... 25, 76, 137 salsalate ...... 60, 104 SOLTAMOX ...... 57, 169 REPATHA ...... 26, 35 SAMSCA ...... 26, 76 SOLU-CORTEF ...... 17, 76 REPATHA PUSHTRONEX SANCUSO ...... 67, 169 SOMATULINE DEPOT SYSTEM ...... 25, 35 SANDIMMUNE ..... 17, 49, 68, 155 ...... 26, 44, 76, 104, 169 REPATHA SURECLICK SANDOSTATIN LAR DEPOT SOMAVERT ...... 26, 44, 76, 104 ...... 26, 35 ...... 26, 44, 68, 76, 104, 169 SOOLANTRA ...... 163 REPREXAIN ...... 147 SANTYL ...... 90, 163 SORINE ...... 35 RESCRIPTOR ...... 17, 88 SAPHRIS ...... 113 sotalol hcl ...... 35 RESCULA ...... 80 SARAFEM ...... 113 sotalol hcl (af) ...... 35 reserpine ...... 35 SAVELLA ...... 104, 148 SOTYLIZE ...... 35 RESTASIS ...... 80, 92 SAVELLA TITRATION PACK SOVALDI ...... 68, 88, 137 RETIN-A MICRO PUMP ...... 163 ...... 104, 148 spinosad ...... 88, 163 REVATIO ...... 10, 35, 96 sb lancets thin ...... 119 SPIRIVA HANDIHALER REVLIMID ...... 7, 169 sb lancets ultra thin ...... 119 ...... 11, 96 rexaphenac ...... 137 selegiline hcl ...... 44 SPIRIVA RESPIMAT ...... 11, 96 REXULTI ...... 113 selenium sulfide ...... 137, 163 spironolactone ...... 26, 35, 68, 90 REYATAZ ...... 17, 88 selenium sulf-pyrithione-urea ... 163 spironolactone-hctz ...... 26, 35 RHEUMATREX ...... 60, 104, 163 SELRX ...... 137, 163 SPORANOX ...... 137 RHOPHYLAC ...... 7, 17, 35, 152 SELZENTRY ...... 17, 88 SPRINTEC 28 ...... 57 RIASTAP ...... 7 SEMPREX-D ...... 13, 153 SPRITAM ...... 44, 104 RIBASPHERE ...... 67, 88 SENSIPAR ...... 49, 76 SPRIX ...... 148, 156 ribavirin ...... 67, 88 SEREVENT DISKUS ...... 11, 96 SPRYCEL ...... 7, 169 rifabutin ...... 88, 137 SEROPHENE ...... 57 SPS ...... 26 RIFAMATE ...... 88 SEROQUEL XR ...... 113 sr nicotine ...... 119 rifampin ...... 88 SEROSTIM ...... 17, 26, 76, 88, 151 SRONYX ...... 57 RIFATER ...... 88, 96 sertraline hcl ...... 113, 114 SSD ...... 88, 90, 156, 163 riluzole ...... 44, 104 SETLAKIN ...... 57 stavudine ...... 17, 88 rimantadine hcl ...... 88 sf ...... 68 STELARA ...... 104, 163 RIOMET ...... 26, 76 sf 5000 plus ...... 68 STIMATE ...... 7 risedronate sodium ...... SFROWASA ...... 68 STIVARGA ...... 68, 169 26, 57, 76, 104, 137 SHAROBEL ...... 57 STRATTERA ...... 44, 104, 114 RISPERDAL CONSTA ...... 113 SIGNIFOR ...... 76 STRENSIQ ...... 26 risperidone ...... 113 sildenafil citrate ...... 11, 35, 96, 137 STRIANT ...... 57, 76 RISPERIDONE M-TAB silver sulfadiazine STRIBILD ...... 17, 88 ...... 113, 137 ...... 88, 90, 156, 163 STRIVERDI RESPIMAT RITALIN LA ...... 44, 104, 113 SIMBRINZA ...... 81 ...... 11, 96 RITUXAN ...... 60, 104, 169 SIMCOR ...... 26 SUBOXONE ...... 114 rivastigmine ...... 44, 113, 137 SIMPONI ...... 60, 104 sucralfate ...... 68 ^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 186

I n d e x I n d e x I n d e x sulfacetamide sodium TAZTIA XT ...... 35, 148 tizanidine hcl ...... 105 ...... 81, 88, 92, 137, 163 tb syringe 1 ml ...... 119 TOBI PODHALER sulfacetamide sodium (acne) ...... 163 TECENTRIQ ...... 50, 169 ...... 11, 26, 89, 96 sulfacetamide sodium-sulfur TECFIDERA ...... 45 TOBRADEX ...... 81, 89 ...... 137, 138 TECHLITE LANCETS ...... 119 tobramycin ...... sulfacetamide-prednisolone ...... 81 TEKTURNA ...... 35 11, 26, 81, 89, 92, 96, 138 sulfadiazine ...... 138 TEKTURNA HCT ...... 35 tobramycin-dexamethasone sulfamethoxazole-trimethoprim telmisartan ...... 35, 138 ...... 81, 89 ...... 138 telmisartan-hctz ...... 36, 138 TOBREX ...... 81, 89, 92 SULFAMYLON ...... 88, 90, 156 temazepam ...... 45 tolazamide ...... 26, 77 sulfasalazine ...... 60, 68, 104, 138 TEMODAR ...... 45, 170 tolbutamide ...... 26, 77 SULFATRIM PEDIATRIC ... 138 temozolomide ...... 45, 138, 170 tolcapone ...... 45, 138 sulindac ...... 104 TENCON ...... 114, 148 tolmetin sodium ...... 60, 61, 105 sumatriptan ...... 35, 45, 148 terazosin hcl ...... 36, 50, 170 tolterodine tartrate ...... 50, 105 sumatriptan succinate ... 35, 45, 148 terbinafine hcl ...... 89, 164 tolterodine tartrate er sumatriptan succinate refill terbutaline sulfate ...... 138 ...... 50, 105, 138 ...... 35, 45, 148 terconazole ...... 50, 57, 89 topco insulin syringe ...... 119 super thin lancets ...... 119 TERSI ...... 164 topiramate ...... 36, 45, 148 SUPPRELIN LA ...... 76 TESTOPEL ...... 57, 76 topiramate er ...... 45 SUPRAX ...... 138 testosterone ...... 57, 76, 138 TORISEL ...... 50, 170 SUPREP BOWEL PREP ...... 68 testosterone cypionate ...... 57, 76 torsemide ...... 26, 36 sure comfort insulin syringe ...... 119 testosterone enanthate ...... 57, 76 TOUJEO SOLOSTAR ...... 27, 77 SURELITE LANCETS ...... 119 tetrabenazine ...... 45, 105, 114, 138 TOVIAZ ...... 50, 105 SUSTIVA ...... 17, 88 tetracycline hcl ...... 138 TRACLEER ...... 11, 36, 96 SUTENT ...... 49, 68, 169 tgt nicotine ...... 114, 119, 150 TRADJENTA ...... 27, 77 sw nicotine polacrilex ...... 114, 150 tgt nicotine polacrilex ...... 114, 150 tramadol hcl ...... 148 SYEDA ...... 57 tgt nicotine step one ...... 114, 150 tramadol hcl er ...... 105, 148 SYLATRON ...... 164, 169 tgt nicotine step three ...... 114, 150 tramadol hcl er (biphasic) SYMBICORT ...... 11, 96 tgt nicotine step two ...... 114, 150 ...... 105, 148 SYMLINPEN 120 ...... 26, 76 THALITONE ...... 138 tramadol-acetaminophen ...... 148 SYMLINPEN 60 ...... 26, 76 THALOMID ...... 7, 170 trandolapril ...... 36 SYNAGIS ...... 88, 96 THEO-24 ...... 11, 96 trandolapril-verapamil hcl er ...... 36 SYNALAR (CREAM) ...... 138 THEOCHRON ...... 11, 96 tranexamic acid ...... 36, 50, 58 SYNALAR (OINTMENT) ...... 138 theophylline ...... 11, 96 TRANSDERM-SCOP (1.5 MG) SYNAREL ...... 57, 76 theophylline er ...... 11, 96, 138 ...... 68 SYNRIBO ...... 7, 169 THINLETS GP LANCETS .... 119 tranylcypromine sulfate ...... 114 SYPRINE ...... 26, 45, 68, 105 THINLETS LANCET ...... 119 TRAVATAN Z ...... 81 TABLOID ...... 7, 169 thioridazine hcl ...... 114 trazodone hcl ...... 114 TACLONEX ...... 164 thiothixene ...... 114 TREANDA ...... 7, 170 tacrolimus ...... THYROGEN ...... 76, 170 TRECATOR ...... 89 17, 49, 68, 138, 156, 164 THYROLAR-1 ...... 76 TRELSTAR ...... 50, 170 TAFINLAR ...... 164, 169 THYROLAR-1/2 ...... 76 TRELSTAR DEPOT ...... 50, 170 TAGRISSO ...... 96, 169 THYROLAR-1/4 ...... 76 TRELSTAR LA ...... 50, 170 TAMIFLU ...... 89 THYROLAR-2 ...... 76 TRELSTAR MIXJECT .... 50, 170 tamoxifen citrate ...... 57, 169 THYROLAR-3 ...... 77 TRESIBA FLEXTOUCH tamsulosin hcl ...... 50, 169 tiagabine hcl ...... 45 ...... 27, 77 TANZEUM ...... 26, 76 TIKOSYN ...... 36 tretinoin ...... 7, 138, 164, 170 TARCEVA ...... 96, 169 TILIA FE ...... 58, 164 tretinoin microsphere ...... 164 TARGRETIN ...... 164, 169 timolol maleate ...... 36, 81 tretinoin microsphere pump ...... 164 TARINA FE 1/20 ...... 57, 164 TIMOPTIC OCUDOSE ...... 81 TRETTEN ...... 7 TASIGNA ...... 7, 169 tinidazole ...... 50, 58, 68, 89 TREXALL ...... 61, 105, 164 TAZORAC ...... 164 TIVICAY ...... 17, 89, 138 ^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 187

I n d e x I n d e x I n d e x triamcinolone acetonide ULTRA-THIN II LANCETS verapamil hcl er ...... 36 ...... 13, 68, 138, 139, 153 ...... 119 VERDROCET ...... 148 triamterene-hctz ...... 27, 36 UMECTA ...... 139 VEREGEN ...... 89, 164 TRIDERM ...... 139 UNILET COMFORTOUCH VERSACLOZ ...... 115, 139 TRIESENCE ...... 81, 156 LANCET ...... 119 VESICARE ...... 50, 105 TRI-ESTARYLLA ...... 58 UNILET G.P. LANCET ...... 119 VESTURA ...... 58, 115, 164 trifluoperazine hcl ...... 114 UNILET G.P. SUPERLITE VEXOL ...... 81, 156 trifluridine ...... 81, 89, 92 LANCET ...... 119 VIBERZI ...... 69 TRIGLIDE ...... 27 UNILET LANCET ...... 119 VICTOZA ...... 27, 77 trihexyphenidyl hcl ...... 45 UNILET SUPERLITE LANCET VIDAZA ...... 7, 170 TRI-LEGEST FE ...... 58, 164 ...... 119 VIDEX ...... 17, 89 TRI-LINYAH ...... 58 UNISTIK 1 ...... 119 VIEKIRA PAK ...... 69, 89 TRI-LO-ESTARYLLA ...... 58 UNITHROID ...... 77, 139 VIENVA ...... 58 TRI-LO-MARZIA ...... 58 UNITHROID DIRECT ...... 139 VIGAMOX ...... 81, 89, 92 TRI-LO-SPRINTEC ...... 58, 139 UPTRAVI ...... 11, 36, 97 VIIBRYD ...... 115 TRILYTE ...... 68, 139 urea ...... 139 VIIBRYD STARTER PACK trimethobenzamide hcl ...... 68 urea nail film ...... 139 ...... 115 trimethoprim ...... 50, 89 urea-c40 ...... 139 VIMPAT ...... 45 trimipramine maleate ...... 114 ure-k ...... 139 viorele ...... 58 TRINATE ...... 152 URETRON D/S ...... 139 VIRACEPT ...... 17, 90 TRINESSA (28) ...... 58 URIMAR-T ...... 139 VIRAZOLE ...... 90 TRINESSA LO ...... 58 UROLET MB ...... 139 VIREAD ...... 17, 18, 69, 90 TRI-PREVIFEM ...... 58 UROPHEN MB ...... 139 VISTOGARD ...... 140 TRI-SPRINTEC ...... 58 ursodiol ...... 68 VISUDYNE ...... 81 TRIUMEQ ...... 17, 89 URYL ...... 139 VITALET PRO LANCETS .... 119 tri-vit/fluoride/iron ...... 68, 151 VAGIFEM ...... 50, 58, 77, 92 VITALET PRO PLUS tri-vitamin/fluoride ...... 68, 151 valacyclovir hcl ...... 89 LANCETS ...... 119 TRIVORA (28) ...... 58 VALCHLOR ...... 139, 164, 170 vitamin d (ergocalciferol) ...... 151 TROKENDI XR ...... 45, 139 VALCYTE ...... 17, 50, 81, 89, 156 VITEKTA ...... 18, 90 tropicamide ...... 81 valganciclovir hcl ...... VIVITROL ...... 115 trospium chloride ...... 50, 105 17, 50, 81, 89, 139, 156 VOLTAREN ...... 105 trospium chloride er ...... 50, 105 valproic acid ...... 45 voriconazole ...... 139 TRULICITY ...... 27, 77 valsartan ...... 36, 139 VOTRIENT ...... 50, 61, 170 TRUVADA ...... 17, 89 valsartan-hydrochlorothiazide ..... 36 VPRIV ...... 27 TUDORZA PRESSAIR ...... 11, 96 VALSTAR ...... 50, 170 VRAYLAR ...... 115 TUSSIGON ...... 13, 96 vancomycin hcl ...... 68, 89 VYFEMLA ...... 58, 139 TYBOST ...... 17, 89 VANDAZOLE ...... 50, 58, 89 VYTORIN ...... 27 TYKERB ...... 58, 170 VANTAS ...... 50, 170 VYVANSE ...... 45, 105, 115 TYSABRI ...... 45, 68 VECTIBIX ...... 69, 170 W&F LANCETS 26G ...... 119 TYVASO ...... 11, 36, 96 VELCADE ...... 7, 170 W&F LANCETS COLORED TYVASO REFILL ...... 11, 36, 96 VELETRI ...... 11, 36, 97 21G ...... 119 TYVASO STARTER ..... 11, 36, 97 VELIVET ...... 58 warfarin sodium ...... 7, 36 TYZEKA ...... 68, 89 VELTASSA ...... 27 WELCHOL ...... 27 UCERIS ...... 68 VENCLEXTA ...... 7, 170 WERA ...... 58 U-KERA E ...... 139 VENCLEXTA STARTING WESTHROID ...... 139 ULESFIA ...... 89, 164 PACK ...... 7, 170 WILATE ..... 7, 18, 36, 37, 139, 156 ULORIC ...... 27 venlafaxine hcl ...... 114 WINRHO SDF ...... 7, 18, 37, 152 ULTILET CLASSIC LANCETS venlafaxine hcl er ...... 114 WP THYROID ...... 139 ...... 119 VENTAVIS ...... 11, 36, 97 WYMZYA FE ...... 58, 139 ULTILET LANCETS ...... 119 VENTOLIN HFA ...... 11, 97 XALKORI ...... 97, 170 ULTRA-THIN II AUTO VERAMYST ...... 13, 153 XARELTO ...... 7, 37, 97 LANCET ...... 119 verapamil hcl ...... 36, 148 ^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 188

I n d e x I n d e x

XARELTO STARTER PACK zonisamide ...... 46 ...... 7, 37, 97 ZONTIVITY ...... 8, 37, 46, 156 XELJANZ ...... 61, 105 ZORBTIVE ...... 18, 27, 77, 90, 151 XELJANZ XR ...... 61, 105 ZORTRESS ...... 18, 51, 69, 156 XEOMIN ...... 46, 81, 105, 164 ZOVIA 1/35E (28) ...... 58 XERAC AC ...... 164 ZOVIA 1/50E (28) ...... 58 XGEVA ...... 27, 105, 170 ZOVIRAX ...... 69, 90, 164 XIAFLEX ...... 58, 105 ZUBSOLV ...... 115, 140 XIFAXAN ...... 27, 46, 69, 90 ZYCLARA ...... 164 XIGDUO XR ...... 27, 77 ZYCLARA PUMP ...... 164 XOLAIR ...... 12, 27, 97, 153, 164 ZYDELIG ...... 8, 171 XOLEGEL ...... 164 ZYKADIA ...... 97, 171 XOPENEX HFA ...... 12, 97 ZYLET ...... 81, 90 XTANDI ...... 50, 170 ZYPREXA RELPREVV ...... 115 XULANE ...... 58 ZYTIGA ...... 51, 171 XYLON ...... 148 XYNTHA ...... 7 XYNTHA SOLOFUSE ...... 7 XYREM ...... 46, 105 YERVOY ...... 164, 170 zafirlukast ...... 12, 97 zaleplon ...... 46 ZALTRAP ...... 69, 170 ZAMICET ...... 148 ZARAH ...... 58 ZARXIO ...... 7, 18, 170 ZAZOLE ...... 139, 140 ZEGERID ...... 37, 69 ZELAPAR ...... 46 ZELBORAF ...... 164, 171 ZENATANE ...... 164 ZENCHENT ...... 58 ZENCHENT FE ...... 58 ZENPEP ...... 69 ZENZEDI ...... 46, 105, 115 ZETIA ...... 27 ZETONNA ...... 12, 13, 153 ZIAGEN ...... 18, 90 zidovudine ...... 18, 90 ZIOPTAN ...... 81 ziprasidone hcl ...... 115 ZIRGAN ...... 81, 90 ZMAX ...... 90, 97 ZOHYDRO ER ...... 148 ZOLADEX ...... 50, 51, 58, 171 zoledronic acid ...... 7, 8, 27, 58, 77, 105, 140, 171 ZOLINZA ...... 164, 171 zolmitriptan ...... 37, 46, 148 zolpidem tartrate ...... 46 zolpidem tartrate er ...... 46 ZOMIG ...... 37, 46, 140, 148 ^ = Mandates May Apply ¥ = Additional Limits May Apply # = Drug specific notes 189